[Congressional Record Volume 163, Number 77 (Thursday, May 4, 2017)]
[House]
[Pages H4149-H4170]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                    AMERICAN HEALTH CARE ACT OF 2017

  The SPEAKER pro tempore. Pursuant to clause 1(c) of rule XIX, 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, will now resume.
  The Clerk read the title of the bill.
  The SPEAKER pro tempore. Pursuant to House Resolution 308, the 
further amendments printed in House Report 115-109 are considered as 
adopted.
  When consideration was postponed on Friday, March 24, 2017, 41\3/4\ 
minutes of the debate remained on the bill.
  The gentlewoman from Tennessee (Mrs. Black) has 19\1/2\ minutes 
remaining. The gentleman from Virginia (Mr. Scott) has 22\1/4\ minutes 
remaining.
  The Chair recognizes the gentlewoman from Tennessee.


                             General Leave

  Mrs. BLACK. Mr. Speaker, I ask unanimous consent that all Members may 
have 5 legislative days in which to revise and extend their remarks on 
H.R. 1628, the American Health Care Act of 2017.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentlewoman from Tennessee?
  There was no objection.
  Mrs. BLACK. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, I rise today in favor of the American Health Care Act, a 
bill that repeals the worst parts of ObamaCare and begins to repair the 
damage it has caused. This bill brings choice and competition back into 
the healthcare marketplace and puts healthcare decisions back into the 
hands of patients and doctors where it belongs.
  It has been a winding road to get to this point, but we are here 
today to fulfill the promise that we made to the American people. I 
will point out right now to those who say we should have just moved on 
from healthcare reform, American families and individuals are suffering 
from rising costs and barriers to getting the care that they need right 
now.
  Under ObamaCare, the situation is getting worse every day. In Iowa, 
just yesterday, one of the last remaining insurers announced that it 
will pull out of the ObamaCare exchanges, leaving nearly all of the 
State's residents with no--and, yes, I will say again, nearly all of 
the residents with no available health insurance plan for the purchase 
under ObamaCare.

                              {time}  1230

  And in a few of the Iowa counties which are the remaining insurers, 
even that company is saying it might stop offering plans, leaving the 
entire State without an insurance plan available under ObamaCare. That 
is happening this very week. We can't wait a moment longer than 
necessary to provide relief for the American people by repealing and 
replacing ObamaCare.
  I applaud the Members of this body who stuck with us during this 
process and worked hard to make the bill better. I, myself, had 
concerns about the bill as it was introduced. I worked hard to make 
sure that the bill truly reflected my ideals and the views and desires 
of my constituents. And when the bill came before the Budget Committee, 
which I chair, I urged my members to stay in the fight and work to 
improve the bill rather than stop it in its tracks.
  And do you know what? Our members did just that, making some 
recommendations that were eventually included in the various 
amendments. That message was heard loud and clear by all of the members 
of our Conference who have worked tirelessly to finalize a bill that 
truly reflects our vision for healthcare reform.
  Throughout this process, our commitment to undoing the damage done by 
ObamaCare has remained steadfast. Day after day, my constituents call 
my office begging us to do something to save them from ObamaCare, and 
it is because ObamaCare is collapsing.
  In my State of Tennessee, families are suffering. Premiums have 
increased by 60 percent, while deductibles are so high that, even if 
someone has an insurance card, it doesn't mean they have guaranteed 
care.
  There are parts of my State in Tennessee that don't have a single 
insurance provider in the marketplace, and two-thirds of the counties 
have only one provider. That is not competition. That is called a 
monopoly.
  While no legislation is perfect, this bill makes some important 
changes to help American families get quality, affordable health 
insurance: It zeros out the mandates, it repeals the taxes, and it 
repeals the subsidies; it allows people to choose health insurance 
plans to meet the unique needs of their families instead of purchasing 
a one-size-fits-all plan mandated by a Washington bureaucrat; and it 
modernizes Medicaid, a once-in-a-lifetime entitlement reform.
  Ending Medicaid's open-ended funding structure will play an important 
role in addressing our future budget deficits and our growing national 
debt.
  This is a particularly proud moment for me. I was working as a nurse 
in Nashville in the 1990s when the Clinton administration pushed a 
single-payer pilot program in Tennessee called TennCare. I saw 
firsthand the negative impact government-run health care has on patient 
care. I saw costs rise and the quality of care fall. It inspired me to 
get involved in public service.
  When in 2009 and 2010 I saw those same principles being debated and, 
eventually, implemented on the national level, I thought my experience 
in Tennessee could be valuable in the national debate; so, in 2011, I 
sponsored the first piece of legislation that repealed a part of 
ObamaCare. Today, we take the largest step yet in rescuing the American 
people from this damaging, government-run healthcare system.
  I, and many other Members of this body, have worked hard to make sure 
that this bill truly reflects our visions for healthcare reform. I, for 
one, cannot sit idly by and let this opportunity go to waste. Governing 
is hard, but our constituents did not elect us to do what is easy. They 
elected us to do what is right.
  I urge my colleagues to join me in voting ``yes'' on the American 
Health Care Act to rescue the American people from ObamaCare.
  Mr. Speaker, I reserve the balance of my time.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield myself such time as I may 
consume, and I remind my colleague that her vote for this bill could 
increase premiums for people with breast cancer in Tennessee by over 
$38,000.
  Mr. Speaker, let's begin with a few facts:
  Since the passage of the Affordable Care Act, costs have gone up at 
the lowest rate in 50 years;
  Those with preexisting conditions get insurance at the standard rate;
  Instead of millions of people losing their insurance every year, 20 
million more people have insurance;
  Personal bankruptcies are down 50 percent.

[[Page H4150]]

  Still, all we hear are complaints, press releases, and promises about 
something better. But CBO has debunked this proposal by pointing out 
that 24 million fewer people will have insurance, that costs will go 
up, and insurance will cover less.
  So, whatever you think about the Affordable Care Act, this bill makes 
things worse--except for millionaires, who get a tax cut.
  Mr. Speaker, I reserve the balance of my time.
  Mrs. BLACK. Mr. Speaker, it is my honor to yield 1\1/2\ minutes to 
the gentleman from Tennessee (Mr. Roe), a physician and the chair of 
the Veterans' Affairs Committee.
  Mr. ROE of Tennessee. Mr. Speaker, 7 years ago, I stood right in this 
well to debate the ACA, which the premise was to increase access and 
decrease costs. We all agree with that. But that is not exactly what 
happened.
  In my district, in the State of Tennessee, over one-third of the 
counties have no place they can buy insurance; and multiple counties in 
my State, including the third largest, have no access. Premiums have 
soared over 60 percent. Eighteen of the 23 co-ops went bankrupt, 
including one in my State, which required people to search for other 
coverage.
  No matter what verbiage you hear, nothing in this bill changes how 
veterans are treated under the law--nothing. The criticisms are flat-
out wrong. I am a veteran, doctor, and chairman of the Veterans' 
Affairs Committee, and it ain't gonna happen.
  In my State, and where I practiced medicine for over 30 years, listen 
to this: 60 to 70 percent of the uncollectible debt now are people with 
insurance.
  So why do I support this bill?
  One, it protects preexisting conditions;
  Two, it puts patients ahead of special interests and restores a 
physician-patient relationship;
  Three, it reforms Medicaid so that first-class people don't get 
second-class care; and
  Four, it repeals individual mandates so that 160,000 Tennesseans 
don't get fined for a product they cannot afford.
  Mr. Speaker, this bill isn't perfect, but it is a huge improvement 
over ObamaCare, and it is worthy of every Member's support.
  Mr. SCOTT of Virginia. Mr. Speaker, I remind my colleague that his 
vote for this bill could take healthcare protections away from over a 
million people in Tennessee with preexisting conditions.
  Mr. Speaker, I yield 1 minute to the gentlewoman from Oregon (Ms. 
Bonamici), the vice ranking member of the Committee on Education and 
the Workforce.
  Ms. BONAMICI. Mr. Speaker, today the House is voting on a harmful 
bill that puts the most vulnerable members of our community at risk. We 
know that millions will lose coverage. And the Affordable Care Act 
protects people with preexisting conditions--this bill does not. High-
risk pools don't work.
  My constituents are scared, and so are people across this country.
  Arden from Gearhart, Oregon, wrote to me, distraught, because she and 
her daughter, Selah, could lose coverage. Arden took the loving step of 
adopting a child with special needs, and now the support program they 
rely on is at risk of being terminated by this bill.
  This is a critical vote. I implore my colleagues to think about all 
of the people like Arden and Selah in their communities. Think about 
the millions across this country who risk losing coverage.
  I implore my colleagues to do no harm. Vote ``no'' on this harmful 
bill.
  Mrs. BLACK. Mr. Speaker, I yield 4 minutes to the gentleman from 
Oregon (Mr. Walden), the chair of the Energy and Commerce Committee, 
who has worked tirelessly on this bill.
  Mr. WALDEN. Mr. Speaker, I yield to the gentleman from Florida (Mr. 
Webster), my colleague, for the purpose of a colloquy.
  Mr. WEBSTER of Florida. I thank the chairman for yielding.
  I have heard from my Governor, State officials, and providers about 
the challenges on the ground in Florida and what they are facing. The 
demographic issues in Florida raise significant challenges for the 
State of Florida, and it is the Medicaid program.
  Particularly, the State Medicaid program and providers face 
challenges relating to the costs of caring for the most disadvantaged 
and the elderly in Florida's nursing home program, as well as the 
rising costs associated with Florida's aging population.
  As the process moves forward, Florida's unique challenges must be 
recognized and accounted for as we reallocate dollars for this 
important safety net program.
  Mr. WALDEN. I thank the gentleman from Florida for not only raising 
this issue, but being a real partner in this legislation. I met with 
your Governor as well, who has been very helpful in the discussions.
  We believe that accounting for aging demographics of the Medicaid 
program and broader population is an important factor we must consider 
to ensure that any Medicaid reform is successfully implemented. I am 
committed to working with the gentleman from Florida, our colleagues in 
the Senate, and the Trump administration to ensure Florida's unique 
challenges related to an aging Medicaid demographic are recognized and 
accounted for appropriately.
  Mr. Speaker, in the remaining part of my time, I would just like to 
thank my colleagues for their work on this measure.
  Making sure that people have access to affordable health care is 
essential. It is something I would say that we all care about. We all 
care about family members who have suffered from cancer or other 
debilitating diseases or afflictions. We are trying to find a place 
here that works for all Americans, where we have insurance markets that 
are actually available where you can get an insurance product that 
works for you that is affordable for you.
  We know that today, in America, the insurance market and the 
individual market--that is a very small segment, 7 percent of insurance 
in America; that is what we are talking about here today--that that 
market is collapsing before our eyes. In fact, in Iowa, I think they 
just announced 94 in 99 counties, people there won't even have an 
insurance product they can try to purchase on the exchange.
  We have met with Governors and we have met with insurers. We have 
said: What do we need to do to intercede to get this market back to 
where it works? The proposals contained in our legislation are designed 
to do exactly that: to get back to where consumers have choices when 
they are required to buy insurance to take care of their families. 
Those choices need to be affordable. They are not now, today.
  In my own State of Oregon, premiums have gone up 50 percent in the 
last 2 years. Meanwhile, the number of options that you have to choose 
from has gone down--and continues to go down. Now, we haven't gone as 
far as some States where you have either no option in most areas of the 
State or just one, but how far off is it when insurers are failing, 
people losing their opportunity to get affordable health insurance?
  We take care of the disabled. We take care of the elderly. In fact, 
we plus-up to medical CPI plus 1 to make sure that we take care of the 
elderly and the disabled in our Medicaid program.
  By the way, that is probably more than most States are spending 
today.
  So we have thought this through carefully. We care about people and 
their medical condition and their families because we are all in this 
together as Americans.
  I think the bill we have before us today works. It works to take care 
of those most in need. It works to make sure that the people can get 
access to insurance.

  I will tell you what. It is a first step in a many-step process to 
also look at families who are dealing with opioid addition and what we 
can do there. There are efforts at NIH, which we just supported 
yesterday, to fund medical research so that we can get cures for those 
who have diseases and other afflictions. We are fully committed to 
improving health care not only for Americans, but around the globe, 
through innovation and scientific discovery.
  Mr. SCOTT of Virginia. Mr. Speaker, I remind my colleague that his 
vote for this healthcare bill will take away protections for over 
600,000 people in Oregon with preexisting conditions.
  Mr. Speaker, I yield 1 minute to the gentleman from California (Mr. 
Takano).

[[Page H4151]]

  (Mr. TAKANO asked and was given permission to revise and extend his 
remarks.)
  Mr. TAKANO. Mr. Speaker, I include in the Record a letter from the 
Consortium for Citizens with Disabilities, which states that this 
legislation will dramatically cut Medicaid services that are vital to 
people with disabilities and seniors.

                                           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 but 
     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; 
     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; Laura Weidner, National Multiple 
     Sclerosis Society.
  Mr. TAKANO. Mr. Speaker, there are 7 million veterans who are 
eligible for VA care but not enrolled at the VA. All of them could be 
denied access to the tax credits in this bill, and each in this Chamber 
needs to understand how.
  On page 10, line 6 of manager's amendment No. 4, it states that an 
individual is not eligible for tax credits if they are eligible for 
care, as defined by U.S. Code 5000A(f)(1)(A). This code specifically 
includes VA care. So this means that those 7 million veterans who are 
eligible for VA care, even if they are not enrolled, would not have 
access to the tax credits in this law.
  This is not fear-mongering. This is not hyperbole. This is the text 
of the bill we are voting on today. This bill jeopardizes health care 
for up to 7 million veterans, and everyone should oppose it.

                              {time}  1245

  Mrs. BLACK. Mr. Speaker, I reserve the balance of my time.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield 3 minutes to the 
gentleman from Maryland (Mr. Hoyer), the Democratic whip.
  (Mr. HOYER asked and was given permission to revise and extend his 
remarks.)
  Mr. HOYER. Mr. Speaker, Republicans now control all of our 
government. Whatever happens to our healthcare system will be their 
responsibility, including what has already happened since January with 
the destabilizing of our insurance markets and health plans announcing 
rate hikes due to uncertainty.
  They will be held accountable for what happens. Today, Americans will 
have an opportunity to see exactly where their Representatives stand. 
This vote is a simple one. It votes to kick 24 million Americans off of 
their health insurance coverage. I don't say that; CBO says that, which 
is perhaps why we don't have a CBO report on the amendment. It includes 
7 million people who are covered through their employers.
  It is a vote to make coverage unaffordable for one in four Americans 
with preexisting conditions and ration care through high-risk pools.
  It is a vote to impose an age tax on older Americans, some $1,700 to 
$14,600. That is quite a hike.
  It is a vote to force Americans to pay more for less, to raise 
premiums 24 to 29 percent, on average, over each of the next 2 years. 
CBO says that, not me.
  And no matter how Republicans try to spin it, healthcare advocates 
from the AMA to AARP, to everybody that follows, have said that it ends 
protections for those with preexisting conditions.
  I repeat: It ends protections for those with preexisting conditions.
  I repeat again: It ends protections for those with preexisting 
conditions.
  It takes away essential health benefits, like doctor visits, 
emergency room visits, and prescription drugs. So this, Mr. Speaker, 
will be a very instructive vote. It will show the American people if 
Republicans stand with those who don't want to lose their coverage, 
some 55 percent now and 75 percent saying fix it, don't repeal it--or 
if they stand with a President who wants to claim a victory, but 
doesn't even seem to know what his own TrumpCare bill says.
  I recommend, as a political strategist who is concerned about 2018, 
that you once again withdraw this bill. Instead, we ought to work 
together to make sure that the Affordable Care Act works for all 
Americans, and deliver on the promise that President Trump made--and 
made from that rostrum--when he said that he wanted ``insurance for 
everybody;'' not kick 24 million off, ``for everybody;'' not make 
seniors pay more, ``for everybody;'' not to put Medicaid at risk, ``for 
everybody'' that is ``far less expensive and far better.''
  Mr. Speaker, I urge my colleagues: Come to your senses, defeat this 
bill.
  Mrs. BLACK. Mr. Speaker, I would like to remind the other side that 
if they read the bill, they will see under section 137 it says:

       No limiting access to coverage for individuals with 
     preexisting conditions. Nothing in this act shall be 
     construed as permitting health insurance insurers to limit 
     access to health coverage for individuals with preexisting 
     conditions.

  Mr. Speaker, it is my honor to yield 4 minutes to the gentleman from 
Texas (Mr. Brady), the chairman of the Ways and Means Committee.
  Mr. BRADY of Texas. Mr. Speaker, I first want to thank Chairwoman 
Black for her leadership on this effort, as well as Chairman Walden of 
the Energy and Commerce Committee for incredible work.
  As chairman on behalf of the Ways and Means Committee who work 
alongside you, I am honored to speak in support of the American Health 
Care Act because it guarantees coverage for those with preexisting 
illnesses.
  It guarantees coverage for those with preexisting illnesses. In fact, 
this bill takes decisive action to repeal all of the bad parts, all of 
the damage done by ObamaCare, and begin a thoughtful step-by-step 
process to deliver a patient-centered healthcare system, not a 
Washington-centered healthcare system, to the American people.
  While ObamaCare has helped some, far more have been hurt by this law. 
And more ObamaCare failures are piling up every day. Just yesterday, 
Aetna announced it will exit Virginia's individual health market next 
year. And it is not just the State's ObamaCare exchanges they are 
leaving behind. Aetna will not offer any plans next year in the 
individual market in Virginia.
  The same thing is happening in Iowa. And my friends on the Democratic 
aisle have done nothing to stop this--

[[Page H4152]]

nothing. But today, because of this bill, thousands of people will have 
hope for a new plan to provide the healthcare coverage they need. 
Millions of Americans throughout the country are facing just terrible 
options.
  People of Texas have been hit particularly hard. Between last year 
and this year, nine healthcare insurers have exited ObamaCare exchanges 
in the Lone Star State. No other State saw more insurers leave. For my 
family, the failures of this law have come to mean some incredibly 
tough choices. They have had to accept, under ObamaCare, you can't 
access affordable coverage that is tailored to what they need. They 
have had to learn how to get by as their monthly health premiums just 
skyrocket each and every year--bigger than their mortgage payments. 
They have had to choose between paying out of pocket for the care they 
need or not getting care at all.
  Under ObamaCare, the ability to receive treatment from a doctor you 
know and who knows you has become a luxury that too many can't afford. 
Today, with the American Health Care Act, the Republicans propose we 
have an opportunity to provide immediate relief from this failing law. 
More than that, we can provide Americans with real choices in health 
care, not the painful decision they are forced to live with under 
ObamaCare.
  Under the Ways and Means Committee area, this starts by repealing the 
law's crushing taxes and mandates, and that is where Ways and Means 
takes action. Under ObamaCare, the individual and employer mandate 
penalties allow Washington to strong-arm you, to strong-arm Americans 
into ObamaCare plans you do not want and cannot afford.

  Not anymore. Under the Republican plan, we repeal the individual and 
employer mandate tax penalties so Americans have the freedom to make 
the healthcare choices that are right for them. Under ObamaCare, over 
$1 trillion of taxes were imposed on the American people. Under the 
Republican plan, those taxes are gone that burden American small 
businesses and families.
  Under our plan, we provide increased health savings accounts so 
Americans can save easier for the out-of-pocket costs that hit them 
under any health care; and then we create a personal individual tax 
credit so Americans can buy plans that are right for them, not what is 
right for government.
  Healthcare premiums, they can choose a plan that can go with them 
from job to job, State to State, home to start a business, or a family, 
and even into those preretirement years.
  Today is about taking on a collapsing ObamaCare and replacing for the 
American people health care that they want, that they can use, and that 
they can afford; driven not by what Washington wants, but driven by 
what American families need in their health care.
  Mr. Speaker, I urge the support of this bill.
  Mr. SCOTT of Virginia. Mr. Speaker, I remind my colleague that his 
vote for this bill could take away protections of over 4.5 million 
people with preexisting conditions in Texas who might have access to 
coverage, but if they have diabetes, their rates could go up $5,000.
  Mr. Speaker, I yield 1 minute to the gentlewoman from North Carolina 
(Ms. Adams).
  Ms. ADAMS. Mr. Speaker, I thank the gentleman for yielding.
  After his latest failed attempt to roll back the ACA, Speaker Ryan 
declared to the American people ``ObamaCare is the law of the land.'' 
Less than 50 days later, Paul Ryan shamefully is going against his word 
trying to ram TrumpCare down our throats.
  It is an embarrassment that we are wasting taxpayer dollars to again 
consider TrumpCare--or as I called it ``Trump don't care''--a reckless 
plan that does nothing to make health care better.
  TrumpCare gives the rich and big corporations a $600 billion tax 
break. It forces families to pay higher premiums and deductions, 
placing health care out of their reach. TrumpCare forces seniors to pay 
higher costs and changes Medicare as we know it. It strips essential 
health benefits and protections for people with preexisting conditions.
  What a pitiful display of partisan politics. TrumpCare is so bad, 
Republicans have exempted themselves from it. They don't want 
TrumpCare. The medical industry doesn't want TrumpCare. Democrats don't 
want TrumpCare.
  Why don't House Republicans listen?
  The people don't want it, and I won't support it.
  Mrs. BLACK. Mr. Speaker, I reserve the balance of my time.
  Mr. SCOTT of Virginia. Mr. Speaker, I include in the Record a letter 
from Common Sense Kids Action that explains that: ``This jeopardizes 
the health and well-being of America's kids and will alarm any parent 
who understands the importance of health insurance for their children 
and family.''


                                     common sense kids action,

                                                   April 25, 2017.
     Re H.R. 1628--OPPOSE.
     Hon. Diane Black,
     Chairwoman, House Budget Committee,
     House of Representatives, Washington, DC.
       Dear Representative Black: On behalf of the millions of 
     American kids and families who rely on comprehensive, 
     dependable health insurance to stay healthy and to get 
     medical treatment when they need it, we are writing to 
     respectfully express our strong opposition to your bill, H.R. 
     1628, the American Health Care Act (AHCA). We have added this 
     bill to our Common Sense Legislative Ratings Tool as an 
     ``Against Kids'' bill and will communicate our position to 
     our parent and teacher members.
       Common Sense is the nation's leading independent nonprofit 
     organization dedicated to helping kids thrive in a rapidly 
     changing world. We empower parents, teachers, and 
     policymakers by providing unbiased information, trusted 
     advice, and innovative tools to help them harness the power 
     of media and technology as a positive force in all kids' 
     lives. The policy arm, Common Sense Kids Action, is building 
     a movement of parents, teachers, business leaders, and others 
     dedicated to making kids our nation's top priority by 
     supporting policies at the state and federal level that 
     contribute to the building blocks of opportunity for kids. 
     Access to affordable and quality medical care for kids is 
     certainly one of those key building blocks.
       Thanks to current law, including the Affordable Care Act, 
     Medicaid, and the Children's Health Insurance Program (CHIP), 
     95% of young children in the U.S. today have health 
     insurance. That's a remarkable achievement. With health 
     insurance, parents are more likely to seek medical care for 
     themselves and for their children, helping to prevent 
     illnesses from developing and shortening their duration when 
     they occur. However, the AHCA will result in 24 million fewer 
     Americans having coverage, including millions of children. 
     This jeopardizes the health and well-being of America's kids 
     and will alarm any parent who understands the importance of 
     health insurance for their children and family. The 
     Affordable Care Act certainly needs to be fixed, but if 
     Congress has the goal of making sure that all families and 
     businesses have access to affordable and comprehensive health 
     insurance, it could improve the law for everyone without 
     forcing millions of kids and their parents to lose access to 
     critical medical care.
       As Congress continues to grapple with this issue, health 
     insurance programs, we think these facts about children's 
     health insurance from the Congressional Budget Office and the 
     Georgetown University Center for Children and Families are 
     important to keep in mind:
       Ninety-five percent of children age 0-5 are insured today.
       Forty-five million of those children access health care 
     through two programs: about 37 million through Medicaid (a 
     federal-state program) and 8 million through CHIP, the 
     Children's Health Insurance Program.
       Children are the single-largest group of persons covered 
     under Medicaid.
       Under the Affordable Care Act, as you know, many states 
     expanded Medicaid with help from the federal government, 
     increasing coverage for kids and families, including coverage 
     for mental health care.
       Changes being considered, including under the AHCA, would 
     cut funding to Medicaid by as much as $880 billion over the 
     next 10 years.
       The AHCA, when compared with current law, would result in 
     24 million fewer Americans with health insurance by the year 
     2026.
       Even with changes recently suggested to your bill, 
     America's kids will be best served by strengthening the 
     Affordable Care Act and preserving Medicaid and CHIP, not by 
     repealing the Affordable Care Act and block granting or 
     establishing a per capita cap on Medicaid. We urge you to 
     keep our children's future foremost in your thinking, 
     withdraw your bill, and work on a bipartisan basis to support 
     measures that protect and strengthen children's health care. 
     Thank you for your consideration of our views and we would be 
     happy to talk with you at any time about this and other 
     issues that matter to America's children and families.
           Sincerely,

                                                  Danny Weiss,

                                   Vice President, Federal Policy,
                                   Common Sense Media/Kids Action.

  Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the gentleman 
from New York (Mr. Jeffries).
  (Mr. JEFFRIES asked and was given permission to revise and extend his 
remarks.)

[[Page H4153]]

  

  Mr. JEFFRIES. Mr. Speaker, I include in the Record a letter from 
SEIU, which states:

       This legislation will leave millions without health 
     insurance, and decimate the Medicare program.


                                                         SEIU,

                                                      May 2, 2017.
       Dear Representative: On behalf of the 2 million members of 
     the Service Employees International Union (SEIU), America's 
     largest healthcare union, I write to voice strong opposition 
     to the American Health Care Act (AHCA). New provisions in the 
     legislation manage to make a bad bill worse. Not only does 
     the bill cause millions to lose insurance coverage, face 
     higher costs, and end Medicaid as we know it, but now it also 
     strips essential protections for those with pre-existing 
     conditions. The AHCA will leave millions of men, women, and 
     children without access to high quality, affordable health 
     care. The AHCA legislation unequivocally jeopardizes working 
     families' safety, health, and financial security.
       The AHCA will leave millions of Americans without health 
     insurance and therefore without access to healthcare. The 
     last available estimate from the nonpartisan Congressional 
     Budget Office (CBO) estimated about 14 million fewer people 
     will have health insurance in 2018, and by 2026, 24 million 
     fewer people will have coverage compared to the current 
     baseline under the ACA. Unfortunately, we do not have more up 
     to date information. Despite the importance that healthcare 
     plays in the lives of working families, Congressional leaders 
     have indicated that they intend to hold a vote on the 
     legislation without knowing its impact.
       The AHCA also decimates the Medicaid program, rationing and 
     endangering healthcare for children, seniors, people with 
     disabilities, and their families as well as for those who 
     have gained coverage as a result of the Medicaid expansion. 
     According to CBO, the legislation will cut federal funding 
     for Medicaid by $880 billion over ten years. Americans know 
     that Medicaid is working and realize the key role that the 
     program plays in helping families afford care--including 
     nursing home care and home and community-based services for 
     elderly and disabled individuals. Nearly 1 in 5 Americans are 
     covered under Medicaid and rely on it to get health services 
     Under the AHCA, those Americans would lose access to vital 
     care that may mean the difference between life and death.
       Additionally, the AHCA would cap the amount of money states 
     receive in Medicaid funding from the federal government each 
     year, regardless of the cost of providing healthcare to those 
     who qualify. Medicaid is already a lean program especially 
     when measured on a per capita basis, and cuts from capping 
     federal funding will quickly force states to cut services, 
     limit enrollment, and decrease payments to hospitals and 
     other providers. Also, Medicaid is the largest payer for long 
     term care in the country. The program pays for more than 60 
     percent of all nursing home residents and for more than 3.2 
     million Americans with home- and community-based care, which 
     allows many older Americans and people with disabilities to 
     remain in their homes rather than move to a more expensive 
     institutional setting. States--which must balance budgets and 
     already face fiscal pressures--will not be able to make up 
     the lost federal dollars and will be forced to deny care. The 
     inevitable result will be that the AHCA will make it much 
     harder and more costly for older Americans, people with 
     disabilities, and their families to get services they need.
       In addition, the legislation will effectively end the 
     Medicaid expansion, which provides health coverage to 
     millions of people earning low to moderate incomes. While the 
     bill purports to allow states to maintain the expansion, 
     states will only receive an enhanced match, or additional 
     funding, for people who enroll before 2020 and maintain 
     continuous coverage. It is widely understood that there is 
     significant churn on and off the program in this coverage 
     category, and thus over time the reimbursement rates for 
     states will drop. The resulting large cost shift to states 
     may lead them to eliminate coverage for this group 
     altogether. In fact, seven states have triggers that would 
     end the Medicaid expansion in their state if federal 
     reimbursement decreases.
       Lastly, Medicaid provider rates are already extremely low 
     in most states. Cuts to Medicaid, capped funding, and 
     elimination of the Medicaid expansion would lead to further 
     reductions in rates for providers, leading to job and other 
     spending cuts in the health care industry that will have 
     ripple effects on the broader economy. We have serious 
     concerns that hospitals, especially those that serve 
     communities that may not have access to many providers, could 
     be forced to close or cut back services, further reducing 
     access to care in underserved areas.
       Those who purchase coverage in the individual market do not 
     fare much better under the proposed bill. The AHCA provides 
     tax credits ranging from $2,000 to $4,000 to individuals to 
     purchase private insurance--substantially lower than the 
     ACA's current levels for the majority of those who receive 
     them. Unlike the ACA, it is unclear that people with access 
     to employer insurance that is unaffordable or inadequate will 
     be eligible for credits, which would mean that they will be 
     left without access to coverage and care. The bill also 
     creates an age tax on older Americans by letting insurance 
     companies charge people over 60 as much as five times what 
     they charge others for the same coverage. CBO found that 
     under the initial bill introduced, premiums for those between 
     age 50 and 65 would sky-rocket. Moreover, it is unclear what 
     coverage will be available on the individual market or if the 
     current healthcare marketplaces will even still exist under 
     this scheme. Between premiums and out of pocket costs like 
     deductibles, especially for those most in need of care due to 
     pre-existing conditions, illness, or age, the result could be 
     higher costs for less coverage.
       A bad bill has managed to have been made even worse by the 
     ``MacArthur-Meadows Amendment.'' The amendment guts essential 
     protections for those with pre-existing conditions. It would 
     allow states to charge those with pre-existing conditions 
     higher premiums by allowing states to very easily waive 
     community rating requirements, which currently prohibits this 
     practice. Furthermore it would grant states, through a waiver 
     that is approved by default, the ability to opt out of 
     essential health benefit requirements, a core set of medical 
     services, like hospitalizations, mental health, maternity 
     care and prescription drug coverage, which all insurers are 
     required to cover under the ACA. If states waive 
     requirements, insurers could leave those who are sick or with 
     pre-existing conditions out to fend for themselves and face 
     exorbitant costs to get life-saving care they need. Experts 
     agree that the funding included in the ``Upton-Long 
     Amendment'' is completely inadequate to protect those with 
     pre-existing conditions. The Administration and Congressional 
     Leaders promised to the American people that those with pre-
     existing conditions would remain protected--this bill even 
     with added amendments defaults on that promise.
       Another failure of the AHCA is that it hurts women by 
     freezing funding to providers like Planned Parenthood, 
     risking the health and well-being of the 2.5 million people 
     who rely on the organization for basic care. One in five 
     women in the United States has visited Planned Parenthood 
     clinics and for many low-income women of color, including 
     many of our members, Planned Parenthood is their essential 
     health provider. For these individuals, healthcare is not an 
     ideological struggle or about the politics of one policy 
     versus another; it is a necessity that could mean the 
     difference between sickness and health.
       The real winners of the AHCA appear to be special interests 
     and the wealthy. The legislation repeals most if not all of 
     the ACA tax provisions for special interests like the 
     pharmaceutical and insurance industries, offsetting these 
     costs with the massive cuts to Medicaid described above. The 
     bill also maintains the so-called ``Cadillac tax,'' which 
     places a tax on workers who have robust health coverage, 
     merely delaying implementation to 2026. Implementation of the 
     tax will punish people who have decent insurance, and will 
     encourage employers to further shift health costs to workers. 
     Furthermore, the incentives for health savings accounts, 
     which encourage wealthier people to shelter pre-tax income, 
     are of little use to working households earning low-to 
     moderate incomes.
       The AHCA is not care, it is chaos. The legislation creates 
     an environment of uncertainty and unaffordability for 
     Americans and is a bad deal for working families. The bill 
     radically restructures Medicaid as we know it and cuts 
     funding for the program significantly, endangers women's 
     health, and further enriches corporations, special interests, 
     and the wealthiest Americans at the expense of working 
     families' access to healthcare and financial stability. The 
     American people will hold you accountable for how you proceed 
     in this moment. We therefore respectfully ask you vote no on 
     the American Health Care Act and the proposed amendments to 
     the legislation when it comes to a vote in the House of 
     Representatives. We will add this vote to our legislative 
     scorecard. If you need any additional information please 
     contact Ilene Stein, Assistant Legislative Director.
           Sincerely,
                                                   Mary Kay Henry,
                                          International President.

  Mr. JEFFRIES. Mr. Speaker, the House majority has once again made 
clear that, under Republican rule, the system is rigged. The fix is in. 
The deck is stacked against hardworking Americans, and exhibit A is 
your reckless Republican healthcare plan. Under TrumpCare, 24 million 
Americans will lose access to health insurance. Under TrumpCare, a 
draconian age tax will be imposed on people between 50 and 64. Under 
TrumpCare, costs will go up, premiums will go up, copays will go up, 
deductibles will go up. Under TrumpCare, tens of millions of Americans 
who are living with preexisting conditions will be screwed.
  House Republicans are out to destroy the American healthcare system 
as we know it, but you will be held accountable for the cruel and 
unusual punishment that you have decided to inflict on the American 
people.
  Vote ``no'' against this draconian piece of legislation.
  The SPEAKER pro tempore. The Chair would remind Members to direct 
their remarks to this Chair.
  Mrs. BLACK. Mr. Speaker, I reserve the balance of my time.

[[Page H4154]]

  

  Mr. SCOTT of Virginia. Mr. Speaker, I include in the Record an 
article in Consumer Reports dated May 2, 2017, entitled: ``How the 
Affordable Care Act Drove Down Personal Bankruptcy.''

       How the Affordable Care Act Drove Down Personal Bankruptcy


   Expanded health insurance helped cut the number of filings by half

                          (By Allen St. John)

       As legislators and the executive branch renew their efforts 
     to repeal and replace the Affordable Care Act this week, they 
     might want to keep in mind a little-known financial 
     consequence of the ACA: Since its adoption, far fewer 
     Americans have taken the extreme step of filing for personal 
     bankruptcy.
       Filings have dropped about 50 percent, from 1,536,799 in 
     2010 to 770,846 in 2016 (see chart, below). Those years also 
     represent the time frame when the ACA took effect. Although 
     courts never ask people to declare why they're filing, many 
     bankruptcy and legal experts agree that medical bills had 
     been a leading cause of personal bankruptcy before public 
     healthcare coverage expanded under the ACA. Unlike other 
     causes of debt, medical bills are often unexpected, 
     involuntary, and large.
       ``If you're uninsured or underinsured, you can run up a 
     huge debt in a short period of time,'' says Lois Lupica, a 
     bankruptcy expert and Maine Law Foundation Professor of Law 
     at the University of Maine School of Law.
       So did the rise of the ACA--which helped some 20 million 
     more Americans get health insurance--cause the decline in 
     bankruptcies?
       The many experts we interviewed also pointed to two other 
     contributing factors: an improving economy and changes to 
     bankruptcy laws in 2005 that made it more difficult and 
     costly to file. However, they almost all agreed that expanded 
     health coverage played a major role in the marked, recent 
     decline.
       Some of the most important financial protections of the ACA 
     apply to all consumers, whether they get their coverage 
     through ACA exchanges or the private insurance marketplace. 
     These provisions include mandated coverage for pre-existing 
     conditions and, on most covered benefits, an end to annual 
     and lifetime coverage caps. Aspects of the law, including 
     provisions for young people to be covered by a family policy 
     until age 26, went into effect in 2010 and 2011, before the 
     full rollout of the ACA in 2014.
       ``It's absolutely remarkable,'' says Jim Molleur, a Maine-
     based bankruptcy attorney with 20 years of experience. 
     ``We're not getting people with big medical bills, 
     chronically sick people who would hit those lifetime caps or 
     be denied because of pre-existing conditions. They seemed to 
     disappear almost overnight once ACA kicked in.''
       The first attempt to repeal and replace the ACA, in March, 
     failed to gain enough Congressional support and never came to 
     a vote.
       Then in April, details of a new replacement plan were 
     released. Although President Donald Trump has said that this 
     new version, like the first bill that was pulled from 
     consideration, will cover pre-existing conditions, the 
     revised law gives states broad latitude to allow insurance 
     companies to increase rates for consumers with an existing 
     illness.


                      A Rare and Costly Diagnosis

       Since the start of the year, more than 2,000 consumers have 
     answered an online questionnaire from Consumer Reports' 
     advocacy and mobilization team, sharing their experiences 
     with the ACA. Katie Weber of Seattle was one of them.
       In 2011, she had just landed her first job out of college, 
     as a teacher with AmeriCorps, she explains in a phone 
     interview. That's when the unusual numbness in her hand 
     began, which she--and her doctor--at first mistook for a 
     pinched nerve.
       Then came debilitating headaches and nausea and, 
     ultimately, a diagnosis of medulloblastoma, a fast-growing 
     cancerous brain tumor.
       The treatment for her tumor was straightforward: surgery, 
     radiation, then chemotherapy. Figuring out how to pay for it 
     was much less clear. She worried that the insurance she had 
     through AmeriCorps wouldn't cover enough of her bills.
       ``My dad said to me, `Your health is the most important 
     thing. If you have to declare bankruptcy at age 23, it's no 
     big deal,' '' Weber says.
       Because of the ACA, she says, it never came to that. After 
     her year with AmeriCorps, the new healthcare law enabled her 
     to get coverage under her parents' insurance plan.
       The ACA provisions required that the family's insurance 
     company cover her even though she had already been diagnosed 
     with cancer. That would not have been the case before the 
     ACA, which mandates the coverage of pre-existing conditions 
     for all consumers.
       Later, when she aged out of her parents' insurance, Weber 
     was able to enroll in Apple Health, Washington state's 
     version of Medicaid, a program that was expanded once the ACA 
     was passed. That coverage, she says, has been crucial to her 
     financial and medical well-being, especially once the cancer 
     returned last fall.
       Weber says she now spends more time discussing treatment 
     options and less time worrying how she'll pay for MRIs and 
     drugs. These are covered in full under her Apple Health 
     policy.
       ``Cancer is really expensive,'' she says. ``My insurance 
     saved my life.''


                            Numbers Plummet

       If you want further testimony about how much personal 
     bankruptcies have dropped over the past decade, talk to Susan 
     Grossberg, a Springfield, Mass., attorney.
       For more than 20 years she has helped consumers push the 
     financial reset button when debt triggered by divorce, 
     unemployment, or a costly illness or medical episode became 
     too much to handle. ``Medical debt can get really big really 
     quickly,'' Grossberg says. ``When you're in the emergency 
     room they're not checking your credit score while they're 
     caring for you.''
       With the advent of the ACA--and before that, expanded state 
     healthcare in Massachusetts--she says fewer clients with 
     large medical debts walked through her door.
       Grossberg adds that her bankruptcy business has slowed so 
     much that she has been forced to take on other kinds of legal 
     work--landlord-tenant and housing discrimination cases--to 
     cover her own bills.
       The American Bankruptcy Institute suggested that veteran 
     Chicago bankruptcy attorney and trustee David Leibowitz could 
     also help parse the reasons for the decadelong decline.
       First, he says, the Bankruptcy Abuse Prevention and 
     Consumer Protection Act of 2005 made it more difficult for 
     consumers to file for bankruptcy. The law required credit 
     counseling and income verification and forced many consumers 
     to seek protection under Chapter 13, which restructures, but 
     does not eliminate, most debt. The piles of paperwork also 
     meant most filers needed a lawyer, which made bankruptcy more 
     costly and therefore not an option for many poor consumers.
       Then there was the economy. After a slow and steady 
     recovery following the housing crisis of 2008, Leibowitz 
     explains that American consumers generally had fewer problems 
     with their mortgages, better employment prospects, and 
     greater access to credit, which made them less likely to 
     file.
       The final factor, according to Leibowitz, has been the ACA, 
     which afforded health coverage to many more consumers and 
     expanded protections for all.
       Of course, not everyone sees such a direct connection 
     between the decline in bankruptcies and the emergence of the 
     ACA.
       Thomas P. Miller, resident fellow at the American 
     Enterprise Institute and co-author of ``Why ObamaCare is 
     Wrong for America'' (HarperCollins, 2011), cautioned against 
     ``reaching broad conclusions'' because the subject is so 
     complex.
       ``Certainly there are fewer people declaring bankruptcy, 
     and certainly fewer are declaring bankruptcy because of 
     healthcare spending,'' he says. But his earlier research 
     suggested that some studies exaggerated the degree to which 
     high healthcare bills cause bankruptcies. ``They tended to 
     reflect other problems with credit card balances well beyond 
     healthcare,'' he says. ``It stems from multiple causes.''


                            Figuring Out Why

       Over the past decade, determining the cause-and-effect 
     relationship between medical debt and bankruptcy has become a 
     political football, particularly during the years the Obama 
     administration was trying to pass the ACA through Congress.
       The truth is that it's not that easy to determine how many 
     bankruptcies are caused by medical debt. Examining the 
     paperwork doesn't always offer insight because debtors often 
     juggle their indebtedness, for example, using a credit card 
     to pay an outstanding medical bill while leaving other debts 
     unpaid.
       But a 2014 study from Daniel Austin, a bankruptcy attorney 
     and, at the time, a professor at the Northeastern University 
     School of Law, offers some of the most in-depth research to 
     date.
       Austin and his team selected a nationwide group of 100 
     bankruptcy filers meant to represent a cross-section of the 
     U.S. population, studied their paperwork, then followed up 
     with a survey asking filers, basically, ``Why?''
       His team's research found that medical debt is the single 
     largest factor in personal bankruptcy. First, Austin analyzed 
     the paperwork of individual case files, which suggested that 
     medical bills were a factor in 18 percent of filings. But 
     when he directly asked the same filers, in a survey, the 
     number was even higher, with 25 percent citing medical bills 
     as a factor in their decision to file bankruptcy.
       In addition to the nationwide group, Austin isolated a 
     group of 100 bankruptcy filers from Massachusetts. 
     Why Massachusetts? Because its citizens, starting in 2006, 
     had been covered by a comprehensive state healthcare 
     program similar to the ACA known as Romneycare, after the 
     state's former governor, Mitt Romney.
       The differences between the two groups were striking. Even 
     though the Massachusetts filers owed substantially more in 
     unsecured debt (that is, debt not backed by a home, a car, or 
     another asset) than their counterparts in other states, they 
     reported less than half as much medical debt, which is also 
     unsecured.
       ``The average medical debt in Massachusetts in 2013 was 
     relatively low at just $3,041 (6 percent of total unsecured 
     debt) compared to $8,594 (20 percent of total unsecured debt) 
     nationwide,'' Austin writes in his 2014 study,

[[Page H4155]]

     portions of which were published in the Maine Law Review.
       ``Only about 9 percent of Massachusetts debtors felt their 
     bankruptcy filing was a result of medical bills,'' Austin 
     explains. ``This compares to 25 percent for debtors from 
     [other] jurisdictions.'' Austin's research found that 
     comprehensive medical coverage in Massachusetts had all but 
     eliminated medical bills as a cause for bankruptcy.
       ``Not only in absolute numbers--they had much smaller 
     medical debt--but psychologically, medical debt did not loom 
     nearly as large for people in Massachusetts as it did for 
     other people in other states.'' And in 2010, four years after 
     Romneycare began, the state had a bankruptcy rate that was 
     about 30 percent lower than that of other states.


                  In Search of Certainty, Consistency

       At its most basic level, health insurance allows consumers 
     to pay for the medical care they need. Each year, the Centers 
     for Disease Control and Prevention determines how well the 
     system is working by surveying Americans and asking a simple 
     but powerful question: Did you have problems paying medical 
     bills in the last 12 months?
       The percentage of those reporting problems has dropped from 
     21.3 percent of households when they first asked the question 
     in 2011 to 16.2 percent in 2016. That's almost 13 million 
     fewer Americans no longer facing collection notices from a 
     doctor or hospital.
       ``It's been happening across the board, by race, by age, by 
     insurance status, by gender,'' says Robin Cohen, the study's 
     lead author.
       But insurance is also about peace of mind. And judging from 
     the consumers who have shared their stories with Consumer 
     Reports, that certainty is in short supply as the fate of the 
     ACA is decided. People are wondering what comes next: Repeal? 
     Replace? Improve? Retain and neglect? No one really knows the 
     answer. Americans are concerned about how the future of 
     healthcare will affect them and their families.
       In CR's Consumer Voices survey in January 2017, 55 percent 
     of consumers said they lacked confidence that they or their 
     loved ones would be able to afford insurance to secure that 
     care.
       Don Shope of Ocean View, Del., said the availability of ACA 
     coverage gave him the confidence to leave a corporate job and 
     start his own consulting business. But now, with the ACA's 
     future in limbo, he and his wife are watching the action in 
     Washington and worrying that they might have to return to 
     jobs with benefits.
       ``I'm not a liberal or a conservative, a Democrat or a 
     Republican,'' Shope said in a phone interview. ``Our biggest 
     concern is that with repeal and replace we're going to be 
     left high and dry.''
       He also believes in expanded health coverage for all. ``If 
     any American is sick, we should be willing to take care of 
     them,'' Shope says. ``It's the right thing to do. Economics 
     and profit shouldn't be part of the healthcare equation.''


                     Hanging On Every Dip and Turn

       And then there's Kristin Couch, who has channeled the 
     uncertainty into her own brand of activism.
       ``I was kind of anxious,'' Couch says about the day in 
     March when Congress was set to vote on a less robust bill 
     that would replace the ACA.
       The 31-year-old public relations executive, of Gainesville, 
     Ga., has started to follow health-care politics in the 
     intense, almost obsessive way some people follow sports. The 
     morning after Election Day, she called the offices of her 
     local congressional representatives, urging them to preserve 
     the protections the ACA offers.
       Couch began caring about healthcare as a high school senior 
     when she was diagnosed with lupus and since then has become 
     something of a reluctant expert on how to manage not only her 
     treatment but also the insurance that pays for it.
       With friends and neighbors she talks about the law in 
     simple but personal terms. ``I tell people, `I have a pre-
     existing condition, and this has helped me,' '' she says of 
     the ACA. Couch follows the healthcare debate in Washington so 
     closely because she knows firsthand what happens when you 
     don't have adequate coverage.
       Couch remembers the time, before the ACA, when a new 
     immunosuppressive drug that wasn't covered by her policy 
     became available. ``It was expensive,'' she explained in an 
     interview, ``but it worked, and I knew I needed it. Every 
     month I'd just put it on a credit card. When your medication 
     is thousands of dollars a month, that's the start of being in 
     debt.'' She considered bankruptcy but ultimately worked her 
     way out from under the pile of medical bills.
       As a result of the ACA, her coverage shifted again when her 
     employer no longer offered a traditional plan and she had to 
     switch to one with a high $3,000 deductible. Initially she 
     was stunned by her out-of-pocket costs, but she quickly 
     realized that her total costs would be capped once she'd met 
     that threshold.
       ``It seemed scary and it seemed different,'' she explains. 
     ``But it actually saved me money.'' And now, she says, ``I 
     don't have to worry about how much a new drug costs.''
       So on the March day the House of Representatives was 
     supposed to vote on repealing the ACA, she worried that the 
     insurance she'd come to depend on was about to be yanked 
     away. Only after emerging from a client meeting did she learn 
     the vote had been canceled. ``I started crying I was so 
     happy,'' Couch recalls. ``It's like a weight has lifted.''
       But Couch's relief was short-lived. Now she's back to 
     paying close attention to the rhetoric and vote-counting 
     deals in Washington, awaiting another possible vote on the 
     newly revised plan. ``I'm still optimistic,'' she said this 
     week. ``I think enough people will stand up and fight for the 
     coverage.''

  Mr. SCOTT of Virginia. I yield 1 minute to the gentleman from New 
Jersey (Mr. Norcross).
  Mr. NORCROSS. Mr. Speaker, a month ago I was ready to speak right 
here on the floor when this bill was abruptly removed. Apparently, it 
wasn't bad enough that day, it wasn't harmful enough. But now it is 
back worse than ever. So bad, it might actually pass.
  I don't have a lot of time to explain, but let me tell you two groups 
that are really going to say thank you: it is the billionaires and it 
is the undertakers.
  This bill will make health care more unaffordable and cause 
preventable deaths. Meanwhile, it gives $600 billion--excuse me--$800 
billion to the wealthy, to the billionaires. TrumpCare brings us higher 
costs, less coverage, guts the benefits, has a crushing age tax, and 
steals from Medicare. In my district alone, 43,000 people will lose 
coverage. 9,000 of those are children. The elderly, Medicaid will be 
lost, close to 2,000.
  There is a reason they are trying to jam this down our throats. There 
is no CBO score because they don't want to hear a score.
  Mr. Speaker, let me make it plain. Let's put this bill in a coffin, 
not Americans. Let's kill and bury this bill.
  Mrs. BLACK. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from 
Louisiana (Mr. Scalise), our distinguished whip.
  Mr. SCALISE. Mr. Speaker, I thank the chairwoman of the Budget 
Committee for yielding.
  I was in strong support of this bill, Mr. Speaker, that finally 
provides relief to the American people across this country from the 
failures of ObamaCare.
  Just how bad is it failing?
  You don't have to look any further than what happened in Iowa 
yesterday, where literally they are going to have in 94 out of 99 
counties nobody to write insurance for people that are in the ObamaCare 
exchanges.
  So what do the people, Mr. Speaker, that are opposed to this bill say 
to those millions of people in Iowa who are about to have no place to 
go to get health care?
  What are the people that oppose this bill, Mr. Speaker, going to say 
to the millions of people with preexisting conditions across the 
country who are being faced with double-digit increases in their health 
insurance every year and, oh, by the way, premiums and deductibles as 
high as over $10,000, which are creaming those folks that are 
struggling under the weight of this bill?
  So what we are replacing it with, Mr. Speaker, are reforms that 
actually lower premiums, that actually put patients back in charge of 
their healthcare decisions so that elitists up here in Washington won't 
tell you what you have to buy. You actually get to make that choice 
yourself.

                              {time}  1300

  You get to focus on plans that are good for your family at lower 
costs so that you can be in charge. And, by the way, reforming the 
Medicaid system, one of the most broken forms of health care so that 
States actually have the ability to innovate and help low-income 
families.
  This bill is important, Mr. Speaker, to rescue the American people 
from a law that has failed dismally. Let's end the skyrocketing premium 
increases. Let's lower costs and put patients back in charge of their 
healthcare decisions.
  Mr. SCOTT of Virginia. Mr. Speaker, I remind my colleague that his 
vote for this bill can take away protections for over 800,000 people 
with preexisting conditions in Louisiana. For example, those with 
breast cancer could see their premiums go up by over $34,000.
  Mr. Speaker, I yield 1 minute to the gentlewoman from Delaware (Ms. 
Blunt Rochester).
  (Ms. BLUNT ROCHESTER asked and was given permission to revise and 
extend her remarks.)
  Ms. BLUNT ROCHESTER. Mr. Speaker, I include in the Record a letter 
from AARP which makes clear

[[Page H4156]]

health care will be sabotaged under this bill, and healthcare costs for 
older Americans will ``dramatically increase.''

     [From the House Democratic Leader's Press Office, May 3, 2017]

  AARP Press Release: New Changes to the AHCA Makes a Bad Bill Worse!

       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 preexisting 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 4o percent of 50- 
     to 64-year-olds (about 25 million people) who have a deniable 
     preexisting 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.

  Ms. BLUNT ROCHESTER. Mr. Speaker, I know in these polarized times we 
often forget our actual connections to each other, but we are all 
connected. A sick, uninsured employee affects the bottom line of a 
small business. Uncompensated care in the emergency room, we all pay 
the bill. When a child from an uninsured family goes to school with an 
undiagnosed virus, not only does it impact his or her ability to learn, 
it impacts other kids and puts them at risk. We are all connected.
  As Martin Luther King so powerfully said: ``We may have come over on 
different ships, but we are all in the same boat now.''
  Mr. Speaker, it is time we start rowing together. Unfortunately, this 
bill fails to recognize this. It still fails that we are connected, 
and, instead of bringing us together, this simply divides us by 
providing less coverage, imposing an age tax, forcing people to pay 
more, and stripping key protections.
  Mr. Speaker, I urge all my colleagues to vote ``no'' on H.R. 1628.
  Mrs. BLACK. Mr. Speaker, I continue to reserve the balance of my 
time.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the gentleman 
from Illinois (Mr. Krishnamoorthi).
  (Mr. KRISHNAMOORTHI asked and was given permission to revise and 
extend his remarks.)
  Mr. KRISHNAMOORTHI. I include in the Record a letter from the 
American Medical Association that states: ``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.''

[[Page H4157]]

  


          [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. KRISHNAMOORTHI. Mr. Speaker, the country will not remember what 
we say here today, but it will never forget what we do today, 
especially if we make the wrong choice and adopt this bill.
  The 159 million Americans whose employer-sponsored health care could 
be cut would never forget. Neither would the 24 million Americans who 
would lose their coverage or the 52 million people with preexisting 
conditions who would struggle to find health insurance again.
  If this bill passes, Mr. Speaker, no cancer survivor denied coverage 
will forget, no survivor of sexual assault charged more for her ordeal 
will forget, and no parent struggling to afford emergency surgery for a 
newborn child could ever forget. They would not have that choice.
  But today, we have one. We can choose to vote no and prevent millions 
of Americans from losing their health care. We can choose the right 
path rooted in morality, decency, and reason. I implore you, vote 
``no.''
  Mrs. BLACK. I continue to reserve the balance of my time.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the gentleman 
from New York (Mr. Espaillat).
  (Mr. ESPAILLAT asked and was given permission to revise and extend 
his remarks.)
  Mr. ESPAILLAT. Mr. Speaker, I include in the Record a letter from 
AFSCME which states this bill would cause millions to lose their health 
coverage and return to the days when even inadequate coverage was 
unaffordable.

                                                       AFSCME,

                                                      May 3, 2017.
     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. ESPAILLAT. Mr. Speaker, I strongly oppose this bill. We all 
should. Protecting ACA is the top issue for my constituents. 
Constituents like Leslie Gauthier who, without the protections of the 
ACA, would not have gotten the treatment for leukemia that she was 
diagnosed just at the age of 22.
  Leslie is now in remission thanks to ObamaCare. For Leslie, the ACA 
protections like essential health benefits were a matter of life and 
death. This Republican bill would destroy those patient protections.
  Under the ACA in my district: a 5-percent drop in uninsured rates; 
subsidies based on income and region and not on age; Medicaid Expansion 
covering of 156,000 people will be lost.
  The President promised not to cut Medicaid. This bill guts it by $880 
billion. This bill is a gut punch to America. Pregnant women seeking 
health care, kicked to the curb. Patients with preexisting conditions, 
kicked to the curb. Senior citizens who will have to pay more for less, 
kicked to curb. Over 24 million people, including 6.5 million Latinos, 
kicked to the curb.
  Mr. Speaker, we demand Republicans stop kicking to the curb 
Americans. Stop this bill.
  Mrs. BLACK. Mr. Speaker, I continue to reserve the balance of my 
time.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield to the gentlewoman from 
California (Ms. Lee) for the purpose of a unanimous consent request.
  (Ms. LEE asked and was given permission to revise and extend her 
remarks.)
  Ms. LEE. Mr. Speaker, I include in the Record the Service Employees 
International Union's letter voicing strong opposition to the deadly 
American Health Care Act for their 2 million Members.

[[Page H4158]]

                                                         SEIU,

                                                      May 2, 2017.
       Dear Representative: On behalf of the 2 million members of 
     the Service Employees International Union (SEIU), America's 
     largest healthcare union, I write to voice strong opposition 
     to the American Health Care Act (AHCA). New provisions in the 
     legislation manage to make a bad bill worse. Not only does 
     the bill cause millions to lose insurance coverage, face 
     higher costs, and end Medicaid as we know it, but now it also 
     strips essential protections for those with pre-existing 
     conditions. The AHCA will leave millions of men, women, and 
     children without access to high quality, affordable health 
     care. The AHCA legislation unequivocally jeopardizes working 
     families' safety, health, and financial security.
       The AHCA will leave millions of Americans without health 
     insurance and therefore without access to healthcare. The 
     last available estimate from the nonpartisan Congressional 
     Budget Office (CBO) estimated about 14 million fewer people 
     will have health insurance in 2018, and by 2026, 24 million 
     fewer people will have coverage compared to the current 
     baseline under the ACA. Unfortunately, we do not have more up 
     to date information. Despite the importance that healthcare 
     plays in the lives of working families, Congressional leaders 
     have indicated that they intend to hold a vote on the 
     legislation without knowing its impact.
       The AHCA also decimates the Medicaid program, rationing and 
     endangering healthcare for children, seniors, people with 
     disabilities, and their families as well as for those who 
     have gained coverage as a result of the Medicaid expansion. 
     According to CBO, the legislation will cut federal funding 
     for Medicaid by $880 billion over ten years. Americans know 
     that Medicaid is working and realize the key role that the 
     program plays in helping families afford care--including 
     nursing home care and home and community-based services for 
     elderly and disabled individuals. Nearly 1 in 5 Americans are 
     covered under Medicaid and rely on it to get health services. 
     Under the AHCA, those Americans would lose access to vital 
     care that may mean the difference between life and death.
       Additionally, the AHCA would cap the amount of money states 
     receive in Medicaid funding from the federal government each 
     year, regardless of the cost of providing healthcare to those 
     who qualify. Medicaid is already a lean program especially 
     when measured on a per capita basis, and cuts from capping 
     federal funding will quickly force states to cut services, 
     limit enrollment, and decrease payments to hospitals and 
     other providers. Also, Medicaid is the largest payer for long 
     term care in the country. The program pays for more than 60 
     percent of all nursing home residents and for more than 3.2 
     million Americans with home- and community-based care, which 
     allows many older Americans and people with disabilities to 
     remain in their homes rather than move to a more expensive 
     institutional setting. States--which must balance budgets and 
     already face fiscal pressures--will not be able to make up 
     the lost federal dollars and will be forced to deny care. The 
     inevitable result will be that the AHCA will make it much 
     harder and more costly for older Americans, people with 
     disabilities, and their families to get services they need.
       In addition, the legislation will effectively end the 
     Medicaid expansion, which provides health coverage to 
     millions of people earning low to moderate incomes. While the 
     bill purports to allow states to maintain the expansion, 
     states will only receive an enhanced match, or additional 
     funding, for people who enroll before 2020 and maintain 
     continuous coverage. It is widely understood that there is 
     significant churn on and off the program in this coverage 
     category, and thus over time the reimbursement rates for 
     states will drop. The resulting large cost shift to states 
     may lead them to eliminate coverage for this group 
     altogether. In fact, seven states have triggers that would 
     end the Medicaid expansion in their state if federal 
     reimbursement decreases.
       Lastly, Medicaid provider rates are already extremely low 
     in most states. Cuts to Medicaid, capped funding, and 
     elimination of the Medicaid expansion would lead to further 
     reductions in rates for providers, leading to job and other 
     spending cuts in the health care industry that will have 
     ripple effects on the broader economy. We have serious 
     concerns that hospitals, especially those that serve 
     communities that may not have access to many providers, could 
     be forced to close or cut back services, further reducing 
     access to care in underserved areas.
       Those who purchase coverage in the individual market do not 
     fare much better under the proposed bill. The AHCA provides 
     tax credits ranging from $2,000 to $4,000 to individuals to 
     purchase private insurance--substantially lower than the 
     ACA's current levels for the majority of those who receive 
     them. Unlike the ACA, it is unclear that people with access 
     to employer insurance that is unaffordable or inadequate will 
     be eligible for credits, which would mean that they will be 
     left without access to coverage and care. The bill also 
     creates an age tax on older Americans by letting insurance 
     companies charge people over 60 as much as five times what 
     they charge others for the same coverage. CBO found that 
     under the initial bill introduced, premiums for those between 
     age 50 and 65 would sky-rocket. Moreover, it is unclear what 
     coverage will be available on the individual market or if the 
     current healthcare marketplaces will even still exist under 
     this scheme. Between premiums and out of pocket costs like 
     deductibles, especially for those most in need of care due to 
     pre-existing conditions, illness, or age, the result could be 
     higher costs for less coverage.
       A bad bill has managed to have been made even worse by the 
     ``MacArthur-Meadows Amendment.'' The amendment guts essential 
     protections for those with pre-existing conditions. It would 
     allow states to charge those with pre-existing conditions 
     higher premiums by allowing states to very easily waive 
     community rating requirements, which currently prohibits this 
     practice. Furthermore it would grant states, through a waiver 
     that is approved by default, the ability to opt out of 
     essential health benefit requirements, a core set of medical 
     services, like hospitalizations, mental health, maternity 
     care and prescription drug coverage, which all insurers are 
     required to cover under the ACA. If states waive 
     requirements, insurers could leave those who are sick or with 
     pre-existing conditions out to fend for themselves and face 
     exorbitant costs to get life-saving care they need. Experts 
     agree that the funding included in the ``Upton-Long 
     Amendment'' is completely inadequate to protect those with 
     pre-existing conditions. The Administration and Congressional 
     Leaders promised to the American people that those with pre-
     existing conditions would remain protected--this bill even 
     with added amendments defaults on that promise.
       Another failure of the AHCA is that it hurts women by 
     freezing funding to providers like Planned Parenthood, 
     risking the health and well-being of the 2.5 million people 
     who rely on the organization for basic care. One in five 
     women in the United States has visited Planned Parenthood 
     clinics and for many low-income women of color, including 
     many of our members, Planned Parenthood is their essential 
     health provider. For these individuals, healthcare is not an 
     ideological struggle or about the politics of one policy 
     versus another; it is a necessity that could mean the 
     difference between sickness and health.
       The real winners of the AHCA appear to be special interests 
     and the wealthy. The legislation repeals most if not all of 
     the ACA tax provisions for special interests like the 
     pharmaceutical and insurance industries, offsetting these 
     costs with the massive cuts to Medicaid described above. The 
     bill also maintains the so-called ``Cadillac tax,'' which 
     places a tax on workers who have robust health coverage, 
     merely delaying implementation to 2026. Implementation of the 
     tax will punish people who have decent insurance, and will 
     encourage employers to further shift health costs to workers. 
     Furthermore, the incentives for health savings accounts, 
     which encourage wealthier people to shelter pre-tax income, 
     are of little use to working households earning low-to 
     moderate incomes.
       The AHCA is not care, it is chaos. The legislation creates 
     an environment of uncertainty and unaffordability for 
     Americans and is a bad deal for working families. The bill 
     radically restructures Medicaid as we know it and cuts 
     funding for the program significantly, endangers women's 
     health, and further enriches corporations, special interests, 
     and the wealthiest Americans at the expense of working 
     families' access to healthcare and financial stability. The 
     American people will hold you accountable for how you proceed 
     in this moment. We therefore respectfully ask you vote no on 
     the American Health Care Act and the proposed amendments to 
     the legislation when it comes to a vote in the House of 
     Representatives. We will add this vote to our legislative 
     scorecard. If you need any additional information please 
     contact Ilene Stein, Assistant Legislative Director.
           Sincerely,
                                                   Mary Kay Henry,
                                          International President.

  Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the 
gentlewoman from California (Ms. Maxine Waters).
  (Ms. MAXINE WATERS of California asked and was given permission to 
revise and extend her remarks.)
  Ms. MAXINE WATERS of California. Mr. Speaker, I will include in the 
Record a letter from the Association of American Medical Colleges which 
states: ``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 
reduce access to vital care.''
  Mr. Speaker, I rise to caution those Republicans who have allowed 
themselves to be persuaded by this President into supporting this 
terrible bill which would leave millions of Americans without health 
care and raise the cost of care for millions more. You are going to pay 
a terrible price for not protecting your constituents.
  TrumpCare will cause 24 million Americans to lose their health 
coverage and slash Medicaid by $880 billion; for older Americans, 
premiums, deductibles, and copayments will skyrocket. Those between the 
ages of 50 and 64 will be forced to pay premiums five times higher than 
what others pay for the same coverage.

[[Page H4159]]

  This crushing age tax will fall on some of the most vulnerable 
members of our society, elderly people on fixed incomes who often have 
serious health issues.
  Meanwhile, hidden in this bill is an outrageous tax break for 
billionaires. TrumpCare gives $600 billion in tax cuts to large 
corporations and wealthy people, including $2.8 billion to the 400 
richest families in America. The MacArthur amendment made this bill 
even worse by jettisoning protections for people with preexisting 
conditions.
  Mrs. BLACK. Mr. Speaker, I continue to reserve the balance of my 
time.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the gentleman 
from Michigan (Mr. Conyers).
  Mr. CONYERS. Mr. Speaker, I have been here for five decades, and I 
can't recall a time when we have debated something so obviously harmful 
to seniors and working people in this country. This bill strips health 
care from 24 million people. It requires seniors to pay sometimes 100 
percent or more of their income in premiums.
  This legislation drastically and dramatically cuts Medicaid, directly 
contradicting President Trump's claim not to.
  In Michigan, half of all children rely on Medicaid. In my district 
alone, 56,000 people will lose coverage, including 16,000 children and 
3,200 seniors.
  Let's be clear. If we pass this bill, people will die. Health care is 
a right and not a privilege.
  Mrs. BLACK. Mr. Speaker, I continue to reserve the balance of my 
time.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the gentleman 
from Minnesota (Mr. Walz), the highest ranking enlisted soldier ever 
elected to Congress.
  (Mr. WALZ asked and was given permission to revise and extend his 
remarks.)
  Mr. WALZ. Mr. Speaker, I include in the Record a letter from the 
Paralyzed Veterans of America urging rejection of the latest version of 
the American Health Care Act.

                                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 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. WALZ. Mr. Speaker, there are many reasons that people may come to 
the conclusion this is not the piece of legislation for them. I would 
argue most egregious amongst this is the manner in which it was done. 
There was clearly an error made on the 7 million veterans you heard 
about. I do not question a single Member's commitment in here to caring 
for veterans. You did not do it on purpose. You did it because you had 
to, to meet the arcane rules of the Senate, so you stripped it out, and 
you will, by all intents and purposes, fix it in the Senate.
  For you, I would say good luck with that. But for the Members who are 
sitting here: Why would we not debate this? Why would we not fix it? 
Why would we not go through regular order so all of us would ensure 
there is not a loophole that would deny coverage to 7 million veterans. 
This is too important to rush. It is too important to make errors like 
this. It is darn sure too important to count on the Senate to fix it. 
And it was our responsibility.
  So here we sat with 30 seconds among 15 of us to make points that are 
important to the American public.
  Mr. Speaker, I urge my colleagues: reject this. Come back and do it 
right, and provide the health care our veterans deserve.
  The SPEAKER pro tempore. Members are again reminded to address their 
remarks to the Chair.
  Mrs. BLACK. Mr. Speaker, I continue to reserve the balance of my 
time.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the 
gentlewoman from Hawaii (Ms. Hanabusa).
  (Ms. HANABUSA asked and was given permission to revise and extend her 
remarks.)
  Ms. HANABUSA. Mr. Speaker, I include in the Record a letter from Save 
Medicaid in Schools, a coalition of dozens of organizations. This 
letter states that this bill jeopardizes health care for the Nation's 
most vulnerable children: students with disabilities and students in 
poverty.
                                                      May 2, 2017.
     Re The American Health Care Act Vote

     Hon. Mitch McConnell,
     Majority Leader, U.S. Senate,
     Washington, DC.
     Hon. Paul Ryan,
     Speaker, House of Representatives,
     Washington, DC.
     Hon. Chuck Schumer,
     Minority Leader, U.S. Senate,
     Washington, DC.
     Hon. Nancy Pelosi,
     Minority Leader, House of Representatives, Washington, DC.
       Dear Majority Leader McConnell, Speaker Ryan, Minority 
     Leader Schumer, and Minority Leader Pelosi: The undersigned 
     member organizations of the Save Medicaid in the Schools 
     Coalition are concerned that the American Health Care Act 
     (AHCA) jeopardizes healthcare for the nation's most 
     vulnerable children: students with disabilities and students 
     in poverty. Specifically, the AHCA reneges on Medicaid's 50+ 
     year commitment to provide America's children with access to 
     vital healthcare services that ensure they have adequate 
     educational opportunities and can contribute to society by 
     imposing a per-capita cap and shifting current and future 
     costs to taxpayers in every state and Congressional district. 
     While children currently comprise almost half of all Medicaid 
     beneficiaries, less than one in five dollars is spent by 
     Medicaid on children. Accordingly, a per-capita cap, even one 
     that is based on different groups of beneficiaries, will 
     disproportionally harm children's access to care, including 
     services received at school. Considering these unintended 
     consequences, we urge a `no'' vote on The American Health 
     Care Act (AHCA).

[[Page H4160]]

       Medicaid is a cost-effective and efficient provider of 
     essential health care services for children. School-based 
     Medicaid programs serve as a lifeline to children who can't 
     access critical health care and health services outside of 
     their school. Under this bill, the bulk of the mandated costs 
     of providing health care coverage would be shifted to the 
     States even though health needs and costs of care for 
     children will remain the same or increase. Most analyses of 
     the AHCA project that the Medicaid funding shortfall in 
     support of these mandated services will increase, placing 
     states at greater risk year after year. The federal 
     disinvestment in Medicaid imposed by the AHCA will force 
     States and local communities to increase taxes and reduce or 
     eliminate various programs and services, including other non-
     Medicaid services. The unintended consequences of the AHCA 
     will force states to cut eligibility, services, and benefits 
     for children.
       The projected loss of $880 billion in federal Medicaid 
     dollars will compel States to ration health care for 
     children. Under the per-capita caps included in the AHCA, 
     health care will be rationed and schools will be forced to 
     compete with other critical health care providers--hospitals, 
     physicians, and clinics--that serve Medicaid-eligible 
     children. School-based health services are mandated on the 
     States and those mandates do not cease simply because 
     Medicaid funds are capped by the AHCA. As with many other 
     unfunded mandates, capping Medicaid merely shifts the 
     financial burden of providing services to the States.


 Medicaid Enables Schools to Provide Critical Health Care for Students

       A school's primary responsibility is to provide students 
     with a high-quality education. However, children cannot learn 
     to their fullest potential with unmet health needs. As such, 
     school district personnel regularly provide critical health 
     services to ensure that all children are ready to learn and 
     able to thrive alongside their peers. Schools deliver health 
     services effectively and efficiently since school is where 
     children spend most of their days. Increasing access to 
     health care services through Medicaid improves health care 
     and educational outcomes for students. Providing health and 
     wellness services for students in poverty and services that 
     benefit students with disabilities ultimately enables more 
     children to become employable and attend higher-education.
       Since 1988, Medicaid has permitted payment to schools for 
     certain medically-necessary services provided to children 
     under the Individuals with Disabilities Education Act (IDEA) 
     through an individualized education program (IEP) or 
     individualized family service program (IFSP). Schools are 
     thus eligible to be reimbursed for direct medical services to 
     Medicaid-eligible students with an IEP or IFSP. In addition, 
     districts can receive Medicaid reimbursements for providing 
     Early Periodic Screening Diagnostic and Treatment Benefits 
     (EPSDT), which provide Medicaid-eligible children under age 
     21 with a broad array of diagnosis and treatment services. 
     The goal of EPSDT is to assure that health problems are 
     diagnosed and treated as early as possible before the 
     problems become complex and treatment is more expensive.
       School districts use their Medicaid reimbursement funds in 
     a variety of ways to help support the learning and 
     development of the children they serve. In a 2017 survey of 
     school districts, district officials reported that two-thirds 
     of Medicaid dollars are used to support the work of health 
     professionals and other specialized instructional support 
     personnel (e.g., speech-language pathologists, audiologists, 
     occupational therapists, school psychologists, school social 
     workers, and school nurses) who provide comprehensive health 
     and mental health services to students. Districts also use 
     these funds to expand the availability of a wide range of 
     health and mental health services available to students in 
     poverty, who are more likely to lack consistent access to 
     healthcare professionals. Further, some districts depend on 
     Medicaid reimbursements to purchase and update specialized 
     equipment (e.g., walkers, wheelchairs, exercise equipment, 
     special playground equipment, and equipment to assist with 
     hearing and seeing) as well as assistive technology for 
     students with disabilities to help them learn alongside their 
     peers.
       School districts would stand to lose much of their funding 
     for Medicaid under the AHCA. Schools currently receive 
     roughly $4 billion in Medicaid reimbursements each year. Yet 
     under this proposal, states would no longer have to consider 
     schools as eligible Medicaid providers, which would mean that 
     districts would have the same obligation to provide services 
     for students with disabilities under IDEA, but no Medicaid 
     dollars to provide medically-necessary services. Schools 
     would be unable to provide EPSDT to students, which would 
     mean screenings and treatment that take place in school 
     settings would have to be moved to physician offices or 
     hospital emergency rooms, where some families may not 
     visit regularly or where costs are much higher.
       In addition, basic health screenings for vision, hearing, 
     and mental health problems for students would no longer be 
     possible, making these problems more difficult to address and 
     expensive to treat. Moving health screenings out of schools 
     also reduces access to early identification and treatment, 
     which also leads to more costly treatment down the road. 
     Efforts by schools to enroll eligible students in Medicaid, 
     as required, would also decline.


   The Consequences of Medicaid Per Capita Caps Will Potentially Be 
                        Devastating for Children

       Significant reductions to Medicaid spending could have 
     devastating effects on our nation's children, especially 
     those with disabilities. Due to the underfunding of IDEA, 
     districts rely on Medicaid reimbursements to ensure students 
     with disabilities have access to the supports and services 
     they need to access a Free and Appropriate Public Education 
     (FAPE) and Early Intervention services. Potential 
     consequences of this critical loss of funds include:
       Fewer health services: Providing comprehensive physical and 
     mental health services in schools improves accessibility for 
     many children and youth, particularly in high-needs and hard-
     to-serve areas, such as rural and urban communities. In a 
     2017 survey of school district leaders, half of them 
     indicated they recently took steps to increase Medicaid 
     enrollment in their districts. Reduced funding for Medicaid 
     would result in decreased access to critical health care for 
     many children.
       Cuts to general education: Cuts in Medicaid funding would 
     require districts to divert funds from other educational 
     programs to provide the services as mandated under IDEA. 
     These funding reductions could result in an elimination of 
     program cuts of equivalent cost in ``non-mandated'' areas of 
     regular education.
       Higher taxes: Many districts rely on Medicaid 
     reimbursements to cover personnel costs for their special 
     education programs. A loss in Medicaid dollars could lead to 
     deficits in districts that require increases in property 
     taxes or new levies to cover the costs of the special 
     education programs.
       Job loss: Districts use Medicaid reimbursement to support 
     the salaries and benefits of the staff performing eligible 
     services. Sixty-eight percent of districts use Medicaid 
     funding to pay for direct salaries for health professionals 
     who provide services for students. Cuts to Medicaid funding 
     would impact districts' ability to maintain employment for 
     school nurses, physical and occupational therapists, speech-
     language pathologists, school social workers, school 
     psychologists, and many other critical school personnel who 
     ensure students with disabilities and those with a variety of 
     educational needs are able to learn.
       Fewer critical supplies: Districts use Medicaid 
     reimbursement for critical supplies such as wheelchairs, 
     therapeutic bicycles, hydraulic changing tables, walkers, 
     weighted vests, lifts, and student-specific items that are 
     necessary for each child to access curriculum as closely as 
     possible to their non-disabled peers. Replacing this 
     equipment would be difficult if not impossible without 
     Medicaid reimbursements.
       Fewer mental health supports: Seven out of ten students 
     receiving mental health services receive these services at 
     school. Cuts to Medicaid would further marginalize these 
     critical services and leave students without access to care.
       Noncompliance with IDEA: Given the failure to commit 
     federal resources to fully fund IDEA, Medicaid reimbursements 
     serve as a critical funding stream to help schools provide 
     the specialized instructional supports that students with 
     disabilities need to be educated alongside their peers.
       We urge you to carefully consider the important benefits 
     that Medicaid provides to our nation's most vulnerable 
     children. Schools are often the hub of the community, and 
     converting Medicaid's financing structure to per-capita caps 
     threatens to significantly reduce access to comprehensive 
     health and mental and behavioral health care for children 
     with disabilities and those living in poverty. We look 
     forward to working with you to avert the harmful and 
     unnecessary impacts the AHCA would impose on Medicaid, which 
     has proven to benefit children in a highly effective and 
     cost-effective manner.
       If you have questions about the letter or wish to meet to 
     discuss this issue further, please do not hesitate to reach 
     out to the coalition co-chairs: John Hill, Sasha Pudelski and 
     Kelly Vaillancourt Strobach.
           Sincerely,
       AASA, The School Superintendents Association, Accelify, 
     American Civil Liberties Union, American Dance Therapy 
     Association, American Federation of Teachers, American 
     Foundation for the Blind, American Occupational Therapy 
     Association, American Psychological Association, Association 
     of Assistive Technology Act Programs, Association of 
     Educational Service Agencies, Association of School Business 
     Officials International (ASBO), Association of University 
     Centers on Disabilities, Autistic Self Advocacy Network, 
     Center for American Progress, Center for Public 
     Representation, Clearinghouse on Women's Issues, Colorado 
     School Medicaid Consortium, Conference of Educational 
     Administrators of Schools and Programs for the Deaf, Council 
     for Exceptional Children, Council of Administrators of 
     Special Education, Council of Parent Attorneys and Advocates, 
     Disability Rights Education & Defense Fund.
       Division for Early Childhood of the Council for Exceptional 
     Children (DEC), Health and Education Alliance of Louisiana, 
     Healthy Schools Campaign, Healthmaster Holdings LLC, Higher 
     Education Consortium for Special Education, Judge David L. 
     Bazelon Center for Mental Health Law, LEAnet, a national 
     coalition of local education agencies,

[[Page H4161]]

     Learning Disabilities Association of America, Lutheran 
     Services in America Disability Network, Michigan Association 
     of Intermediate School Administrators, Michigan Association 
     of School Administrators, National Association of Pediatric 
     Nurse Practitioners, National Association of School Nurses, 
     National Association of School Psychologists, National 
     Association of Social Workers, National Association of State 
     Directors of Special Education (NASDSE), National Association 
     of State Head Injury Administrators.
       National Black Justice Coalition, National Black Justice 
     Coalition, National Center for Learning Disabilities, 
     National Association of Councils on Developmental 
     Disabilities, National Disability Rights Network, National 
     Down Syndrome Congress, National Education Association, 
     National Health Law Program, National Respite Coalition, 
     National Rural Education Advocacy Collaborative, National 
     Rural Education Association, National School Boards 
     Association, Paradigm Healthcare Services, School Social Work 
     Association of America, School-Based Health Alliance, Share 
     Our Strength, Society for Public Health Education, Teacher 
     Education Division of the Council for Exceptional Children, 
     The Arc of the United States, United Way Worldwide.

  Ms. HANABUSA. Mr. Speaker, I rise in strong opposition to the 
TrumpCare Act. I am fortunate to have been born and raised in Hawaii 
where we are taught to never forget our seniors, our kupuna.
  AARP, with a national membership of 38 million and over 150,000 in 
Hawaii, remains steadfastly opposed to TrumpCare. The amendment 
proposed today makes the bill worse. And for our kupuna in Hawaii and 
nationally, they will have no relief from the age tax.
  This chart shows how much more at age 64 a person will pay in 
premiums, almost $6,800 in Hawaii where we have one of the best health 
cares. A 55-year-old will see a premium increase of almost $3,600 a 
year. Why? What did the seniors do that TrumpCare wants to penalize 
them and pay such a premium when they are moving towards retirement? 
TrumpCare is out to get those 50 to 64 with this terrible age tax.
  Vote against H.R. 1628. These numbers will not be different in your 
districts.
  Mrs. BLACK. I continue to reserve the balance of my time.
  Mr. SCOTT of Virginia. Mr. Speaker, could you advise us how much time 
is remaining on both sides?
  The SPEAKER pro tempore. The gentleman from Virginia has 5\1/2\ 
minutes remaining, and the gentlewoman from Tennessee has 2\1/2\ 
minutes remaining.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the 
gentlewoman from Illinois (Mrs. Bustos).
  (Mrs. BUSTOS asked and was given permission to revise and extend her 
remarks.)

                              {time}  1315

  Mrs. BUSTOS. Mr. Speaker, I include in the Record letters from the 
United Steelworkers, the AFL-CIO, and the International Brotherhood of 
Teamsters in relation to this bill.


                                          United Steelworkers,

                                                      May 3, 2017.
     House of Representatives,
     Washington, DC.
       Dear Representative: On behalf of the members of the United 
     Steelworkers union (USW), I continue to urge you to oppose 
     the American Health Care Act (AHCA), despite proposed 
     amendments. This legislation will adversely affect every 
     American's health insurance benefits including workplace 
     plans, Medicare, Medicaid, and the individual market.
       This harmful and partisan legislation will cause tens of 
     millions to lose insurance coverage over the next decade. 
     Deductibles and premiums are expected to rise. In short, 
     rather than reducing costs of health care, this bill will 
     simply shift costs to working Americans and their families 
     while cutting taxes for the wealthy and corporations.
       The MacArthur Amendment allows states to opt out of certain 
     protections under the Affordable Care Act such as the 
     requirements that insurers provide plans with a minimum 
     package of services and don't discriminate against people 
     with pre-existing conditions. The amendment also lets states 
     allow insurance companies to charge older people up to five 
     times what they charge younger people. This amendment will 
     allow for an uneven patchwork of insurance coverage across 
     the country and will make insurance cost prohibitive for many 
     working and retired Americans. Although lawmakers are working 
     to address the treatment of individuals with pre-existing 
     conditions, none of the proposals have adequately addressed 
     the costs associated with removal of the Affordable Care 
     Act's protections for those individuals.
       Overall, the AHCA is a transfer of wealth from working 
     Americans to the very wealthy and to corporations including 
     the pharmaceutical industry, insurance companies, and medical 
     device manufacturers. It removes taxes on the very wealthy 
     and on corporations, giving the wealthiest 400 household an 
     average tax cut of about $7 million each. Meanwhile, the bill 
     retains the ``Cadillac Tax'' which puts the burden of the 
     cost of this legislation squarely on the backs of middle 
     class working families.
       Most of our members are covered under employer-negotiated 
     insurance plans. However, the AHCA removes the employer-
     mandate included in the Affordable Care Act. This 
     dramatically changes the incentive and landscape for 
     employer-sponsored insurance, which threatens the system that 
     provides insurance for millions of hard-working Americans. 
     CBO estimated that 7 million people will lost their workplace 
     coverage as a result of this bill.
       The AHCA also undoes protections and assistance for older 
     Americans and our members who are retirees with dramatically 
     increased out-of-pocket costs to Americans who are older but 
     not yet eligible for Medicare. For those who will or 
     currently rely on Medicare this bill reduces the solvency of 
     the program by three years by repealing taxes on the wealthy 
     and on corporations.
       Additionally, this bill makes perilous cuts to Medicaid 
     which provides health care to low-income Americans who have 
     been laid off, work at low-paying jobs, are disabled, or are 
     elderly. This will strain already limited state budgets, 
     restrict the needy Americans who are eligible for assistance, 
     and eliminate needed services.
       Our members who work in the health care industry may also 
     be affected by job losses and strained budgets caused by the 
     passage of this bill. Providers (our employers) may be 
     subjected to lower reimbursement rates from state Medicaid 
     programs as a result of the federal cuts. Also, the costs of 
     uncompensated care will rise as millions of Americans lose 
     health insurance but still need health care treatment for 
     illnesses and injuries. Once again, hard-working middle class 
     health care workers will have to bear the costs of this 
     harmful legislation.
       The amendments to the bill do not change the fundamental 
     flaws in the legislation enough to make it worthy of your 
     support. Harmful tax cuts are retained, and the bill would 
     not do anything to reduce costs or to prevent Americans from 
     losing health insurance--in fact, this bill would make those 
     problems worse.
       The American Health Care Act is a harmful piece of 
     legislation that does not solve the problems in our current 
     health insurance system. Despite amendments, the costs of 
     this bill would still be borne by working families, making 
     health care less affordable and less accessible. The United 
     Steelworkers strongly opposes the AHCA and we urge you to 
     vote against it.
           Sincerely,
                                                    Leo W. Gerard,
     International President.
                                  ____



                                                      AFL-CFO,

                                                      May 4, 2017.
     House of Representatives,
     Washington, DC.
       Dear Representative: On behalf of the 12.5 million working 
     people represented by the AFL-CFO, I urge you to oppose the 
     American Health Care Act (AHCA, H.R. 1628). In a stunning 
     fashion, this bill takes health coverage away from about 24 
     million people while providing massive tax cuts for the 
     wealthy and large corporations. No one in good conscience can 
     support this legislation.
       It is important to understand what is driving Republicans 
     to pursue a massive roll back in health coverage. While it is 
     packaged as health care reform, a straightforward look at 
     this legislation shows that it is fundamentally designed to 
     pare back public commitments to health coverage in order to 
     benefit the wealthy.
       House Speaker Paul Ryan publically boasted that the AHCA is 
     a ``trillion dollar tax cut'' that will benefit corporations 
     and pave the way for further tax ``reform.'' He made clear 
     that repealing the Affordable Care Act (ACA) taxes is a major 
     aim of the bill. The tax cuts, however, largely go to higher 
     earners and corporations. The one ACA tax left intact is the 
     only one that predominantly impacts working people--the so-
     called ``Cadillac'' tax on workplace health benefits.
       There are terrible human costs to this upward 
     redistribution of wealth. Millions of individuals will again 
     face the dilemma of choosing between getting life-saving 
     medical treatment and meeting their families' basic financial 
     needs.
       The AHCA replaces ACA subsidies that support a minimum 
     level of coverage with tax credits so small that at least 3 
     million people will be unable to afford coverage in the 
     individual market, according to the Congressional Budget 
     Office (CBO). Millions more will find that they can only 
     afford skimpy coverage that will leave them exposed to 
     substantial costs should they face major sickness, 
     undoubtedly increasing the number of medical bankruptcies. 
     The bill allows insurers to require that seniors in the 
     individual market pay five times as much in premiums as 
     younger adults, imposing an ``age tax.''
       The bill also decimates Medicaid, ending the program as we 
     know it--placing seniors, people with disabilities, and 
     children in jeopardy of losing access to care. The AHCA 
     slashes the program by $839 billion dollars over ten years, 
     and CBO estimates that these cuts will result in 14 million 
     people losing their coverage. In using the program as a

[[Page H4162]]

     piggy bank, without efforts to improve the services it 
     provides, the AHCA manages to shift resources away from many 
     of the nation's most vulnerable people as part of its 
     redistribution project.
       Medicare is not spared either. The bill pulls approximately 
     $77 billion from the Medicare Hospital Insurance Trust Fund 
     to provide a tax cut to the wealthy, shortening the lifespan 
     of the fund. An additional $28 billion is extracted from 
     Medicare's trust fund for outpatient medical services, to 
     provide a tax break for pharmaceutical companies.
       Employer-based health insurance, the nation's major source 
     of coverage, also gets hit. The AHCA preserves the so-called 
     ``Cadillac'' tax on workplace health coverage that will 
     impact more than 42 percent of large employer plans when it 
     goes into effect. Economists predict the tax will cause 
     employers to hollow-out the coverage provided in their plans, 
     exposing workers to higher out-of-pocket costs, such as 
     deductibles and copays. In some cases, employers are expected 
     to drop coverage altogether. The bill also eliminates the 
     penalty that employers face when they do not comply with the 
     ACA's employer shared responsibility requirements. 030 
     estimates that seven million people will lose employer-based 
     coverage under the AHCA.
       These sacrifices in health coverage finance stunning tax 
     cuts for the very wealthy and corporations. The legislation 
     provides the 400 highest-income households with an average 
     annual tax cut of $7 million each. Large corporations see 
     impressive windfalls. The AHCA gives insurance companies 
     alone $145 billion in tax relief, while medical device makers 
     get $20 billion, and pharmaceutical companies benefit by 
     paying less into Medicare.
       The reasons for opposing this legislation, which sacrifices 
     health coverage for millions to support tax cuts for the few, 
     are clear. We hope you stand with working people when you 
     make your choice.
           Sincerely,

                                               William Samuel,

                                                         Director,
     Government Affairs Department.
                                  ____

                                         International Brotherhood


                                                 of Teamsters,

                                                      May 4, 2017.
     House of Representatives,
     Washington, DC.
       Dear Representative: On behalf of the 1.4 million members 
     of the International Brotherhood of Teamsters and their 
     families, I urge you to vote no on the American Health Care 
     Act (AHCA) today. The Teamsters have long opposed proposals 
     to tax worker health benefits and this legislation retains 
     the 40 percent excise tax on high quality health care plans 
     which would ultimately reduce the health benefits that hard 
     working Americans receive and increase their out of pocket 
     costs. The amendments added to the bill do nothing to allay 
     Teamster concerns nor address the fundamental flaws of the 
     underlying bill. The amendments make the bill worse than 
     before by opening the door to the erosion or elimination of 
     minimum coverage and pre-existing condition protections and 
     by allowing insurers to charge older adults much higher 
     premiums. It does not change the fact that the millions of 
     American families will lose health insurance.
       Congress should be looking for ways to strengthen the 
     middle class instead of promoting policies that will 
     ultimately take money from their hard earned paychecks and 
     reduce, and make more costly, the health care benefits they 
     receive.
       The American Health Care Act remains fatally flawed 
     Accordingly, I call on you to oppose and vote no on the 
     American Health Care Act when it comes to the floor today.
           Sincerely,
                                                   James P. Hoffa,
                                                General President.

  Mrs. BUSTOS. Mr. Speaker, this is not how Washington is supposed to 
work. We are supposed to improve the lives of hardworking people. 
Instead, this reckless and dangerous TrumpCare bill would undermine 
both the health and the economic security of millions of Americans, 
people like Emily Carlson.
  Emily is a small-business owner and mother of two from rural 
Abingdon, Illinois. She lives with MS, a lifelong and very expensive 
preexisting condition. Before healthcare reform, Emily and her husband, 
Kevin, a farmer, often had to sit around the table at night, go over 
their bills, and decide between sickness or debt from one month to the 
next. If this bill passes, that is a choice they are going to have to 
face once again.
  For families like the Carlsons, TrumpCare means higher costs, fewer 
choices, and worse coverage.
  TrumpCare is a bad deal for Americans, but it is devastating for 
rural Americans. Right now, there are nearly 700 rural hospitals at 
risk of closure. This bill will pull the plug on far too many of them, 
killing thousands of jobs and ripping the economic heart out of small 
towns across our Nation.
  It is time to put hardworking families first. Do the right thing, and 
vote against this bill.
  Mrs. BLACK. Mr. Speaker, I reserve the balance of my time.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the 
gentlewoman from New Hampshire (Ms. Shea-Porter).
  (Ms. SHEA-PORTER asked and was given permission to revise and extend 
her remarks.)
  Ms. SHEA-PORTER. Mr. Speaker, I include in the Record a letter from 
the American Cancer Society, which states cancer patients and survivors 
need affordable, accessible insurance coverage with no preexisting 
condition exclusions or annual and lifetime caps and that high-risk 
pools have failed to meet these basic needs.

                                           American Cancer Society


                                        Cancer Action Network,

                                      Washington, DC, May 3, 2017.
     Hon. Paul Ryan,
     Speaker of the House, 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 pre-existing 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.

  Ms. SHEA-PORTER. Mr. Speaker, I oppose this cruel bill on behalf of 
my constituents, especially those it would hurt the most: people with 
preexisting conditions, older Americans, veterans, and lower income 
people.
  If this bill passes, we will go back to the days when people with 
preexisting conditions could be denied coverage or charged more, when 
insurers could decide whether or not to cover basic care like 
hospitalization, and when sick babies might hit their insurer's 
lifetime coverage limit before they could even walk.
  Under this bill, older Americans will pay more. In fact, Americans 
aged 50 to 64 would pay premiums five times higher than others. 
Veterans will lose access to tax credits that make private coverage 
affordable, and lower income people will be hurt.
  Taking away Medicaid expansion would put affordable coverage out of 
reach for millions and set us back in the fight against the heroin, 
fentanyl, and opioid crisis.
  Instead of this cruel bill, let's come together to improve health 
care, not take health insurance away from millions just to give tax 
credits to the wealthiest. We are better than that.

[[Page H4163]]

  

  Mrs. BLACK. Mr. Speaker, I yield 30 seconds to myself.
  The American Health Care Act has gone through many fits and starts 
over the last few months. This bill begins to fulfill our promise to 
the American people by reducing costs for American families. It 
eliminates ObamaCare's burdens on small businesses and families and 
protects those with preexisting conditions. We must continue to work to 
build on this.
  I yield 1 minute to the gentleman from California (Mr. McCarthy), our 
majority leader.
  Mr. McCARTHY. Mr. Speaker, I thank the gentlewoman from Tennessee for 
yielding, but, more importantly, I thank Congresswoman Diane Black for 
more than four decades as a nurse, for caring for the sick, for her 
passion for the unborn, and for her work on this legislation.
  Now, Mr. Speaker, Americans are a practical people. We know that we 
can have fair health care that helps those who need it without trapping 
everyone in a government-run system dreamed up by Washington's central 
planners.
  Now, contrary to our freedom, ObamaCare forced the American people to 
purchase insurance. Contrary to our well-being, ObamaCare imposed taxes 
we cannot bear. Contrary to what is responsible and right, ObamaCare 
made Medicaid unsustainable for the people most in need. And contrary 
to common sense, ObamaCare regulations continued to drive up the cost 
of insurance beyond what people can afford.
  You want to know how ObamaCare is working? Just read this week's 
papers. Now, let me take you all the way back to yesterday. This is the 
headline: ``Medica, the last insurer selling individual health policies 
in most of Iowa, likely to exit.''
  Now, 94 of the 99 counties will have no insurer in Iowa. Ninety-four 
of the 94 counties in Iowa will have no insurer.
  Here is another headline from yesterday: ``Aetna will exit ObamaCare 
markets in Virginia in 2018.''
  Humana left the ObamaCare exchanges. Blue Cross left Nebraska. United 
Healthcare left all but a handful of markets this year.
  Mr. Speaker, we have roughly 3,000 counties in all of America. One-
third, 1,022, only have one provider. Soon, more counties will have 
none.
  So do you know what doesn't cover preexisting conditions? A 
healthcare system that doesn't have coverage. No options means no 
coverage. That is the road ObamaCare is leading us down, and doing 
nothing leaves too many Americans out in the cold.
  Now, Mr. Speaker, we will not stand for that. We tried the ObamaCare 
way. It is failing remarkably, and the American people are demanding a 
change.
  Now we have a chance to do something great. We could have care 
without control, stability without centralization, and support without 
mandates. We have a chance to listen to the American people and repeal 
and replace ObamaCare.
  The American Health Care Act will repeal the individual and employer 
mandates. It will repeal ObamaCare taxes. It will repeal ObamaCare 
rules. It will repeal ObamaCare subsidies. And it will do what is right 
by stopping taxpayer funding for abortion providers and by refocusing 
Medicaid on those who most need it. We replace all of that with a 
system that protects those with preexisting conditions.
  Mr. Speaker, I heard a lot about this bill, and this bill is not 
2,000 pages. It is less than 130. But, Mr. Speaker, I have heard things 
on this floor that are not true.
  So let me state it one more time. We will replace all that with a 
system that protects those with preexisting conditions and then reduces 
premiums through the tried-and-true process of fair competition.
  As the price of insurance decreases, we give those who still can't 
quite afford it a step up through tax credits and expanded health 
savings accounts. This is fundamental and structural reform.
  Now, Mr. Speaker, since I have had the honor to stand on this floor 
and serve in this House, this body has done many good things. We have 
stood time and again for what was best for our country, struggling 
against other branches for so long. Many times that required us to dig 
in our heels and stop something terrible. It is good to stop bad things 
from happening, but it is great to make good things happen. Finally, 
after years of waiting, we have the chance to do something good today.
  This bill is not perfect. No bill could be. The question is not: Why 
can't it be made perfect? The question is: Do we retreat or do we act? 
Do we take this great leap to repeal and replace ObamaCare, extend a 
hand to our fellow citizens most in need and break free from Washington 
control, or do we continue to wait for a day that is already here in 
the hope of a better day that may never come?
  We were not sent here to wait. We are called to action. This is our 
opportunity. Mr. Speaker, I do not want to read another day of 
headlines of more people going without insurance, without insurance 
without preexisting conditions, without coverage.
  Today we will do something good. That is why today we will act.
  Mr. SCOTT of Virginia. Mr. Speaker, I remind my colleague that his 
vote for this bill could take away protections for preexisting 
conditions from almost 6 million people in California who would have 
access to coverage. Those with diabetes could see their premiums go up 
by $5,000 a year.
  Mr. Speaker, I yield to the gentleman from Florida (Mr. Crist) for 
the purpose of a unanimous consent request.
  (Mr. CRIST asked and was given permission to revise and extend his 
remarks.)
  Mr. CRIST. Mr. Speaker, this is a terrible bill. This bill will cut 
24 million Americans out of health insurance. This bill will gut 
Planned Parenthood in the first year, affecting women across the 
country. And it will cut $850 billion out of Medicaid hurting the poor 
and the disabled in our country. It is unconscionable.
  The SPEAKER pro tempore. Is the gentleman from Virginia yielding for 
the purpose of debate?
  Mr. SCOTT of Virginia. No. Just for the purpose of a unanimous 
consent request.
  The SPEAKER pro tempore. The gentleman is engaging in debate. The 
time of the gentleman will be deducted.
  Mr. SCOTT of Virginia. Would the Speaker advise how much time is 
remaining?
  The SPEAKER pro tempore. The gentleman has 3\1/4\ minutes remaining.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield to the gentleman from New 
York (Mr. Engel) for the purpose of a unanimous consent request.
  (Mr. ENGEL asked and was given permission to revise and extend his 
remarks.)
  Mr. ENGEL. Mr. Speaker, I rise in strong opposition to this bill, and 
I include in the Record a statement of the American Hospital 
Association against the bill.
  I just want to say this bill can have a very simple slogan: American 
people are going to pay more and get less. That is what this bill does.

               Statement on the American Health Care Act

  (By Rick Pollack, President and CEO, American Hospital Association, 
                            April 27, 2017)

       The latest version of the AHCA continues to put health 
     coverage in jeopardy for many Americans. Our top concern is 
     what this change could mean for older and sicker patients, 
     including those with preexisting conditions, such as cancer 
     patients and those with chronic conditions. For these 
     reasons, along with our previously stated concerns about the 
     AHCA, we cannot support the bill. However, we urge Congress 
     to continue to work with stakeholders on a solution that 
     provides meaningful coverage.
       The amendment proposed this week would dramatically worsen 
     the bill. The changes included put consumer protections at 
     greater risk by allowing states to waive the essential health 
     benefit standards, which could leave patients without access 
     to critical health services and increase out-of-pocket 
     spending. This could allow plans to set premium prices based 
     on individual risk for some consumers, which could 
     significantly raise costs for those with pre-existing 
     conditions.
       Additionally, the Congressional Budget Office has not yet 
     scored the amendment. However, CBO previously projected that 
     the AHCA would result in 24 million fewer people covered in 
     2026. It is unlikely this amendment would improve these 
     coverage estimates.
       As the backbone of America's health safety-net, hospitals 
     and health systems must protect access to care for those who 
     need it and ensure that the most vulnerable patients are not 
     left behind. The AHCA continues to fall far short of that 
     goal.

  Mr. SCOTT of Virginia. Mr. Speaker, I yield to the gentleman from 
Georgia (Mr. David Scott) for the purpose of a unanimous consent 
request.

[[Page H4164]]

  

  Mr. DAVID SCOTT of Georgia. Mr. Speaker, I ask unanimous consent to 
make one point: It is most shameful to take $882 billion out of 
Medicaid to help the poor--
  The SPEAKER pro tempore. The gentleman is not making a unanimous 
consent request.
  Mr. DAVID SCOTT of Georgia.--and give it to the wealthy. That is the 
wrong thing to do.
  The SPEAKER pro tempore. The gentleman is not recognized.
  Mr. SCOTT of Virginia. Mr. Speaker, would the Speaker advise again 
how much time is remaining?
  The SPEAKER pro tempore. The gentleman has 3\1/4\ minutes remaining.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield 2\1/4\ minutes to the 
gentleman from South Carolina (Mr. Clyburn).
  Mr. CLYBURN. Mr. Speaker, I rise in strong opposition to the 
Republican's pay-more-for-less healthcare plan.
  I often repeat the 1966 observation of Martin Luther King, Jr., that, 
of all the inequalities that exist, the injustice in health care is the 
most egregious and inhumane.
  On the day it was passed, I observed that the Affordable Care Act is 
the Civil Rights Act of the 21st century. Repealing the Affordable Care 
Act would be inhumane and put egregious forms of discrimination back 
into our healthcare delivery system.
  My Republican colleagues and President Trump have promised more 
coverage and less cost for everyone. However, this plan would allow all 
States to eliminate essential health benefits, such as maternity and 
newborn coverage, prescription drugs, hospitalization, emergency 
coverage, and mental health services. It would also allow States to tax 
older Americans five times more than younger Americans.
  Republicans are reneging on their promise to protect Americans with 
preexisting conditions. Without essential health benefits standards, 
protections for those with preexisting conditions will exist in name 
only.
  Repeal of the essential health benefits would drive a race to the 
bottom, with insurers dropping coverage for everything from 
chemotherapy to high-cost drugs.
  It would precipitate a proliferation of junk policies that have 
historically plagued unsuspecting low-income communities for years. 
People with preexisting conditions who need these and other costly 
services would not be able to find the coverage they need at any price, 
much less an affordable one. We took a giant step away from this with 
the ACA, but this Republican bill takes us back to that era where 
people with preexisting conditions are left in the cold.
  Adding money to a State slush fund is not a solution. Repealing the 
ACA would, once again, institutionalize inhumanity and egregiousness.

                              {time}  1330

  Mrs. BLACK. Mr. Speaker, I am prepared to close, and I reserve the 
balance of my time.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield the balance of my time to 
the gentlewoman from California (Ms. Pelosi), the Democratic leader, 
for our closing statement.
  Ms. PELOSI. Mr. Speaker, I thank the gentleman for yielding. I thank 
him, Congressman Scott, I thank Frank Pallone, John Yarmuth, Ritchie 
Neal, our ranking members, who have done such excellent work on this 
debate on the values of our country.
  Mr. Speaker, our colleague, Mr. Clyburn, began his remarks quoting 
Reverend Dr. Martin Luther King, and I want to join him. I think those 
words bear repeating. Over 50 years ago, Dr. King said: ``Of all of the 
forms of inequality, injustice in health care is the most shocking and 
the most inhumane because it often results in physical death.''
  We come to the floor with the moral force of Dr. Martin Luther King's 
words in our hearts: Affordable health care is a civil right, a 
fundamental right for every person in our country, not just the 
privileged few.
  And so, in the spirit of Mr. Clyburn and Dr. King, let us be 
prayerful about how we go forward on this very personal issue about the 
well-being of every person in our country.
  Speaker Ryan once called this bill an act of mercy. There is no mercy 
here. Indeed, inequality and inhumanity is exactly what TrumpCare has 
in store for the American people. But when he said it is an act of 
mercy, here is what others said.
  From the beginning, TrumpCare was a moral monstrosity that will 
devastate seniors, children, and hardworking Americans. That was from 
me. But don't take it from me.
  Sister Simone Campbell said: This is not the faithful way forward and 
must be rejected.
  The Catholic Health Association wrote: We strongly encourage the full 
House to reject this replacement bill.
  And the United Methodist Church, opposing TrumpCare, this is what 
they said: People will die because of efforts like this to roll back 
health care.
  Lutheran Services in America said: TrumpCare will jeopardize the 
health care and long-term services and supports of millions of 
Americans.
  The Episcopal Church said: TrumpCare falls woefully short of our 
spiritual calling to care for the least of these, as well as the noble 
values upon which our great Nation was founded.
  And all that was said before the Republicans decided to destroy the 
protections of Americans with preexisting conditions.
  I grant our Republican friends their position. I respect them and 
their constituents who sent them here. But I reject the wrong 
priorities in TrumpCare--tax cuts for the rich at the expense of the 
health insurance for tens of millions of working families across 
America.
  TrumpCare very clearly spotlights the differences in priorities 
between Democrats and Republicans in Congress. It has stepped forward 
in the longstanding Republican belief that Medicare should wither on 
the vine, that Medicaid should be shrunken, and that Social Security 
should be privatized.
  If you believe in the health and well-being of the American people, 
you must reject this bill before us now. It is what TrumpCare--here is 
what it means to the American people. You know, much has been said 
about policy here today and over time. Much has been said about 
politics, what are the politics of this.
  What is really important is what this means to the American people. 
And they know they are listening. They know what it means to them.
  It means, TrumpCare does, it forces families to pay higher premiums 
and deductibles, increasing out-of-pocket costs. Higher costs.
  Less coverage. TrumpCare will take away health care from more than 24 
million hardworking Americans.
  A crushing age tax. TrumpCare forces Americans aged 50 to 64 to pay 
premiums five times higher than what others pay for health coverage, no 
matter how healthy they are.
  It steals from Medicare. TrumpCare shortens the life of the Medicare 
trust fund and ransacks funds that seniors depend on to get long-term 
care they need. That is why it is consistent with their wither on the 
vine for Medicare philosophy.
  And then, if that were not bad enough, and they couldn't pass their 
bill because it was that bad, they moved further away from the American 
people by gutting key protections. TrumpCare eviscerates essential 
health benefits such as maternity care, prescription drugs, emergency 
coverage, prenatal care, and guts protections for Americans with 
preexisting medical conditions.
  As bad as TrumpCare was the first time around, you know, it was dead. 
It died. It died right here on the floor. Now it has come back to life 
like a zombie, even more scary than before, and it is even worse.
  If Republicans had their way, Americans with preexisting conditions 
will be pushed off their insurance and segregated into high-risk pools, 
where they will face soaring costs, worse coverage, and restricted 
care.
  TrumpCare means huge premium increases. It is a frightening future 
for families who need affordable, dependable care the most.
  Now, on the floor, the Republicans have recklessly, and some would 
say fraudulently, claimed that TrumpCare covers Americans with 
preexisting conditions. It does not.
  As Robert Graboyes at the conservative Mercatus Center said about the 
Upton amendment: ``. . . the $8 billion amount is a pittance. Spread 
over 5 years, it is a fifth of a pittance.''
  As Karen Pollitz from the Kaiser Family Foundation said, the Upton

[[Page H4165]]

amendment will cover the costs for only 1 percent of the individual 
market. Others have given it up to 5 percent; 1 to 5 percent. Does that 
mean covering? No.
  Forcing a vote without a CBO score shows that the Republicans are 
afraid of the facts. They are afraid of learning the full consequences 
of their plan to push Americans with preexisting conditions into the 
cold or, as my colleague from New York said, off the sidewalk.

  If Republicans thought they were really protecting people, they 
wouldn't be afraid of the facts. But they are also afraid of the truth, 
and the truth that would come forth if we knew the facts. And they are 
afraid that the American people would find out that this is not a 
healthcare bill, this is a tax bill disguised as a health bill.
  This is a bill that is one of the biggest transfers of wealth from 
the middle class to the richest people and corporations in America. 
This is a tax bill not a healthcare bill. That is why they have to do 
it now so they can get on with their tax bill.
  But the suffering TrumpCare will inflict on the sick is all too 
clear. That is why this disastrous bill has been condemned by the 
American Medical Association, the American Cancer Society, the American 
Diabetes Association, the American Heart Association, the American Lung 
Association, the American Society of Clinical Oncology, the Cystic 
Fibrosis Foundation, AIDS United, the Children's Hospital Association, 
AARP, the March of Dimes. The list goes on and on--the American Cancer 
Society.
  Instead of reading all of these pages, I include them for the Record.

       Trumpcare--pulled from the House Floor by Speaker Paul Ryan 
     on March 24--already meant higher health costs, more than 24 
     million Americans losing their health coverage, gutting key 
     protections, a crushing Age Tax, and stealing from Medicare.
       Amazingly, Republicans have managed to make Trumpcare even 
     worse. The MacArthur Amendment would completely gut the 
     protections for people with pre-existing conditions by 
     allowing states to waive essential health benefits and 
     community rating rules, which prevent insurers from charging 
     people with pre-existing conditions more. This will make it 
     all but impossible for millions of Americans fighting illness 
     to afford the coverage they desperately need.
       As seen below, over the last few days, the number of health 
     care, consumer, seniors, children, disability and other 
     groups that are speaking out against Trumpcare continues to 
     grow.
       A Coalition of Patient Advocacy Groups, Including American 
     Cancer Society, American Heart Association, American Lung 
     Association, American Diabetes Association, and March of 
     Dimes: ``In March, our patient advocacy organizations 
     collectively urged Congress to ensure that any changes made 
     to the Patient Protection and Affordable Care Act (ACA) 
     provide affordable, accessible and adequate coverage and do 
     not result in a loss of coverage for any Americans. The AHCA 
     would do the opposite, causing at least 24 million Americans 
     to lose health insurance, according to the non-partisan 
     Congressional Budget Office. . . . We are alarmed by recent 
     harmful changes to AHCA . . . These changes include allowing 
     states to waive the requirement for essential health benefits 
     . . . Another change allows states to waive protections 
     against health status rating. Weakening these rules would 
     enable insurers to charge higher prices to people with pre-
     existing conditions, possibly making insurance unaffordable 
     for those who need it most. . . . The individuals and 
     families we represent cannot go back to a time when people 
     with pre-existing conditions could be denied coverage or 
     forced to choose between purchasing basic necessities and 
     affording their health care coverage. Given these factors, we 
     oppose the latest draft of the AHCA. We urge Members of 
     Congress to reject this legislation.'' [5/1/17]
       American Academy of Pediatrics, American College of 
     Physicians, American Congress of Obstetricians and 
     Gynecologists, National Association of Nurse Practitioners in 
     Women's Health, National Partnership for Women & Families: 
     ``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. . . . 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; [and] to waive community rating rules. . . . 
     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. . . .  Women and families must 
     not be made to suffer, lose access to care and coverage, and 
     pay higher healthcare costs. . . . The AHCA and the MacArthur 
     Amendment turn the clock back on women's health and should 
     not move forward.'' [5/1/17]
       Association of American Medical Colleges: ``This week, the 
     House could vote on a new version of the American Health Care 
     Act that includes the MacArthur amendment. . . . The 
     [MacArthur] 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 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.'' [5/2/17]
       Children's Hospital Association: ``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 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. CHA urgently asks 
     members of Congress to vote against the AHCA.'' [4/27/17]
       Children's Leadership Council: ``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 ACHA'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 states, 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. . . . This legislation is a dangerous 
     step backward.'' [5/1/17]
       Consortium for Citizens with Disabilities: ``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 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 would also allow states to 
     seek waivers from the Affordable Care Act's requirement to 
     provide essential health benefits, including services for 
     people with disabilities . . . We urge you to oppose the bill 
     should it come to a vote.'' [4/28/17]
       National Education Association: ``Apparently, snatching 
     health care coverage from children and families was not 
     enough for House Republican leaders and the Trump 
     administration. To make a terrible bill even worse, a new 
     amendment to the American Health Care Act (AHCA) would allow 
     states to jettison existing essential health benefit 
     requirements and permit insurance companies to charge people 
     with pre-existing conditions more than they charge healthy 
     people. . . . If the AHCA and new amendment are enacted, 
     millions of kids and families would effectively lose the 
     health care coverage they need. The new amendment also 
     threatens to make insurance for people with pre-existing 
     conditions prohibitively expensive.'' [4/27/17]
       American Society of Clinical Oncology: ``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. . . . 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. . . . The AHCA as 
     currently constructed will create or worsen barriers to care. 
     It will add costs to the system, decrease access to 
     appropriate treatment and increase existing disparities of 
     care. We are especially concerned with provisions allowing 
     state waivers that could erode important protections for 
     people with cancer, including pre-existing condition 
     safeguards, coverage of essential services, and access to 
     affordable health insurance. . . . ASCO strongly opposes 
     passage of the AHCA in its current form.'' [4/27/17]
       American Thoracic Society: ``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). . . . The ATS opposes any

[[Page H4166]]

     legislation that does not ensure affordable health insurance 
     coverage for Americans currently insured under 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 preexisting 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.'' [4/27/17]
       Lutheran Services in America: ``Lutheran Services in 
     America continues to oppose the drastic and unnecessary 
     restructure of the Medicaid guarantee to a per capita cap 
     system as proposed in the American Health Care Act (AHCA). 
     Furthermore, we oppose the bill's new provisions that 
     eliminate protections for people with pre-existing conditions 
     as these provisions would be devastating to people with 
     chronic diseases and disabilities. . . . In addition, the 
     modified bill maintains the AHCA's drastic cuts and 
     fundamental restructuring of the Medicaid program, shifting 
     significant risks and costs to states, and to the people who 
     need and provide Medicaid services. . . . Lutheran Services 
     in America respectfully urges members of Congress to reject 
     this or any legislation that would erode Medicaid, increase 
     the number of uninsured and/or decrease protections for 
     preexisting conditions.'' [4/28/17]
       Planned Parenthood Federation of America: ``The latest 
     Republican proposal to repeal the Affordable Care Act is the 
     worst legislation for women's health in a lifetime. It 
     eliminates the community rating provision, allowing insurers 
     to charge people with pre-existing conditions an exorbitant 
     amount for coverage. Despite the fact that the proposal 
     claims to maintain the current prohibition on gender rating, 
     it still allows insurers to once again discriminate against 
     women and charge more for being a woman. Eliminating the 
     community rating provision disproportionately affects women, 
     since insurers can claim having given birth, having had a C-
     section, or having been a survivor of domestic violence is a 
     so-called pre-existing condition. For example, a woman who 
     had breast cancer could be charged more than $28,000 per year 
     for coverage and a woman who was previously pregnant could be 
     charged more than $17,000 per year for . . . They took a bad 
     bill that would result in 24 million people losing their 
     insurance and higher premiums and actually made it worse. [4/
     27/17]
       Federal AIDS Policy Partnership: ``The undersigned 77 
     organizations are writing to strongly urge you to oppose the 
     amended American Health Care Act (AHCA) on behalf of the 24 
     million or more Americans estimated to lose coverage, 
     including tens of thousands of people with HIV. . . . 
     Healthcare coverage can be a life or death issue for people 
     living with HIV, and in the three years that the Patient 
     Protection and Affordable Care Act (ACA) coverage has been 
     available it has made a critical difference. . . . We cannot 
     afford to go back to the pre-ACA sick care system that 
     focused on treating disability and disease rather than 
     preventing it. Please support access to healthcare coverage 
     for the more than 52 million Americans living with pre-
     existing conditions, including 1.1 million living with HIV. 
     We hope we can count on you to oppose the amended American 
     Health Care Act.'' [5/1/17]
       AIDS United: ``AIDS United seeks a health care system that 
     will eventually enable the end of HIV in the United States. 
     AHCA makes major changes to the U.S. health care system that 
     would, if passed, worsen the provision of HIV prevention 
     services for people at risk for HIV and the treatment and 
     care for people living with HIV. . . . AIDS United is 
     especially concerned that the [MacArthur] amendment, far from 
     improving the situation, will make it easier for insurance 
     companies to raise rates on people living with HIV, people 
     with other chronic conditions and the elderly. . . . AIDS 
     United notes that thanks to Congress's strong response over 
     many years, the U.S. has made substantial progress in 
     responding to the HIV epidemic. However, doing so requires a 
     strong health care system that can ensure that people living 
     with HIV are able to access care and treatment . . . H.R. 
     1628 will reverse some of the gains that we have made in 
     ensuring coverage for both prevention and treatment. AIDS 
     United urges you to decide to vote no and publicly state 
     your position prior to any vote.'' [4/28/17]
       American College of Nurse-Midwives: ``On behalf of the 
     American College of Nurse-Midwives, . . . we strongly urge 
     the House of Representatives to vote NO on the revised 
     American Health Care Act (ACHA). The legislation, in its 
     current form, would further impeded access to healthcare and 
     coverage for millions of women and newborns. Midwives stand 
     for improving access to quality care and coverage for women 
     and newborns . . . including, but not limited to, coverage 
     and access to a full range of preventative, reproductive and 
     sexual health services under state Medicaid programs and 
     coverage and access to essential health benefits (EHBs), 
     including maternity and newborn care. The newly-revised AHCA 
     language will end this guarantee and radically turn back the 
     clock on the progress made in women's health. Specifically, 
     the ``MacArthur Amendment'' would enable states to apply for 
     the ability to waive EHBs, including those for maternity and 
     newborn care, to waive community rating rules, and to shift 
     patient with preexisting conditions or illnesses into high-
     risk pools. These provisions, if adopted, could have dire 
     consequences for women's health and health coverage.'' [4/27/
     17]
       AARP: ``This harmful legislation still puts an Age Tax on 
     older Americans and puts vulnerable populations at risk 
     through a series of backdoor deals that attempt to shift 
     responsibility to states. Older Americans need affordable 
     health care services and prescriptions. This legislation 
     still goes in the opposite direction, increasing insurance 
     premiums for older Americans and not doing anything to lower 
     drug costs. AARP continues to oppose legislation that would 
     impose an Age Tax, eliminate protections for pre-existing 
     conditions, weaken Medicare, erode seniors' ability to live 
     independently because of billions of dollars in Medicaid 
     cuts, and give sweetheart deals to drug and insurance 
     companies while doing nothing to lower the cost of health 
     care or prescription drugs. We intend to let all 38 million 
     of our members know exactly how their Representative votes on 
     this bill in newsletters, in our publications, on social 
     media and in other formats.'' [4/26/17]
       American Medical Association: ``After reviewing the 
     MacArthur Amendment to H.R. 1628, the American Health Care 
     Act (AHCA), the American Medical Association (AMA) remains 
     opposed to passage of this legislation. As we have previously 
     stated, we are deeply concerned that the AHCA would result in 
     millions of Americans losing their current health insurance 
     coverage. Nothing in the MacArthur amendment remedies the 
     shortcomings of the underlying bill. The MacArthur Amendment 
     would allow states to apply for waivers for critical consumer 
     protections provided in the Affordable Care Act (ACA), 
     including . . . . the requirements that health insurers must 
     cover certain essential health benefits, and the ban on 
     health status underwriting. The current ban on health status 
     underwriting protects individuals from being discriminated 
     against by virtue of their medical conditions. Prior to the 
     passage of the ACA, such individuals were routinely denied 
     coverage and/or priced out of affordable coverage. We are 
     particularly concerned about allowing states to waive this 
     requirement because it will likely lead to patients losing 
     their coverage.'' [4/27/17]
       American College of Physicians: ``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.'' [4/24/17]
       American Hospital Association: ``The latest version of the 
     AHCA continues to put health coverage in jeopardy for many 
     Americans. Our top concern is what this change could mean for 
     older and sicker patients, including those with pre-existing 
     conditions, such as cancer patients and those with chronic 
     conditions. For these reasons, along with our previously 
     stated concerns about the AHCA, we cannot support the bill. . 
     . . The amendment proposed this week would dramatically 
     worsen the bill. The changes included put consumer 
     protections at greater risk by allowing states to waive the 
     essential health benefit standards, which could leave 
     patients without access to critical health services and 
     increase out-of-pocket spending. This could allow plans to 
     set premium prices based on individual risk for some 
     consumers, which could significantly raise costs for those 
     with pre-existing conditions.'' [4/27/17]
       America's Essential Hospitals: ``This latest version of the 
     AHCA is not an improvement. It's simply bad policy that will 
     cut a lifeline of health care for millions of Americans. The 
     legislation also would leave unchanged more than $800 billion 
     in Medicaid cuts over the next decade, breaking the nation's 
     safety net and saddling state, local governments, and 
     taxpayers with new costs for indigent care. The nation has 
     spoken on the AHCA: only 17 percent of the public support it 
     and their elected representatives have rejected it once 
     already.'' [4/26/17]
       Catholic Health Association: ``It is critically important 
     to look at this bill for what it is. It is not in any way a 
     health care bill. Rather, it is legislation whose aim is to 
     take significant funding allocated by Congress for health 
     care for very low income people and use that money for tax 
     cuts for some of our wealthiest citizens. This is contrary to 
     the spirit of who we are as a nation, a giant step backward 
     that should be resisted.'' [4/27/17]
       U.S. Conference of Catholic Bishops: ``It is deeply 
     disappointing to many Americans that, in modifying the 
     American Health Care Act to again attempt a vote, proponents 
     of the bill left in place its serious flaws, including 
     unacceptable modifications to Medicaid that will endanger 
     coverage and affordability for millions of people, according 
     to reports,'' said Bishop Dewane. ``Sadly, some of the 
     recently proposed amendments--especially those designed to 
     give states flexibility--lack apparent safeguards to ensure 
     quality of care. These additions could severely impact many 
     people with pre-existing

[[Page H4167]]

     conditions while risking for others the loss of access to 
     various essential coverages.'' [4/27/17]
       American Nurses Association: ``The new bill is an even 
     further departure from our principles; endangers consumer 
     protections put into place by the ACA. [4/26/17]
       American Cancer Society Cancer Action Network: ``The 
     American Cancer Society Cancer Action Network (ACS CAN) is 
     deeply concerned about a proposed amendment to the American 
     Health Care Act (AHCA) that would create an option for states 
     to obtain waivers from the Essential Health Benefits (EHB) 
     and the community rating rule. These two rules work together 
     to guarantee access to comprehensive and affordable insurance 
     that covers cancer prevention and treatment for patients and 
     survivors with pre-existing conditions. . . . In short, the 
     proposal could lead to bare bones coverage plans that push 
     significant costs onto patients who access care.'' [4/20/17]
       American Lung Association: ``The American Lung Association 
     requests that Representatives oppose the American Health Care 
     Act (AHCA) with the new amendment by Rep. MacArthur. The 
     American Lung Association opposes the MacArthur amendment 
     because would allow states to opt-out of the Essential Health 
     Benefits (EHB)--resulting in millions of Americans having 
     inadequate care. . . . All Americans--regardless of the state 
     in which they live--need adequate coverage for the range of 
     essential health services and treatments including life-
     saving cancer screening.'' [4/26/17]
       March of Dimes: ``Women and children need quality, 
     affordable insurance coverage to be born healthy and lead 
     healthy, productive lives. Unfortunately, in its current 
     form, the MacArthur amendment to American Health Care Act 
     will deny millions of pregnant women, babies, and their 
     families the affordable coverage and quality services they 
     need. . . . The MacArthur amendment will offer states and 
     health plans numerous opportunities to charge people with 
     pre-existing conditions higher rates, design plans that 
     explicitly exclude the services they are most likely to need, 
     and erect barriers to care.'' [4/26/17]
       Families USA: ``America's families must be heard. By now, 
     it should be clear to House Republicans and the Trump 
     Administration from all the town halls, letters, phone calls 
     and tweets that this is not what people want. They do not 
     want to return to the dark days when insurers were free to 
     charge the sick and old more for coverage and offered 
     policies that covered very little, often leaving people to 
     cope with staggering medical bills. It's time for President 
     Trump and the GOP to drop this harmful effort to undermine 
     the nation's health care system. It's time to move on.'' [4/
     26/17]
       American Psychological Association: ``We are writing on 
     behalf of the American Psychological Association and the 
     American Psychological Association Practice Organization to 
     express our opposition to the American Health Care Act, as 
     recently revised and proposed for floor consideration. Our 
     organizations comprise nearly 115,700 members and affiliates, 
     who are clinicians, researchers, educators, consultants, and 
     students.'' [4/26/17]
       Arc of the United States: ``The Arc of the United States 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. The new amendments make the AHCA even more 
     harmful to people with disabilities.'' [4/26/17]
       Chronic Illness and Disability Partnership: ``On behalf of 
     the Chronic Illness and Disability Partnership as well as 
     allied organizations, we are writing to strongly urge you to 
     oppose the American Health Care Act (AHCA), with or without 
     the amendment to allow states to waive community rating and 
     Essential Health Benefits protections (the MacArthur 
     Amendment). If enacted, the amended bill will only increase 
     the 24 million Americans estimated to lose coverage under the 
     AHCA, including millions of individuals living with chronic 
     conditions and disabilities. The MacArthur Amendment seeks to 
     deliver cheaper insurance to healthy Americans by 
     undercutting crucial Essential Health Benefits requirements 
     and excluding the most vulnerable Americans from the private 
     insurance market by allowing states to remove crucial 
     consumer protections.'' [4/27/17]
       Democratic Governors Association: ``This new proposal is 
     nothing more than the reheated leftovers of the failed 
     Trumpcare bill. Just like last month's bill, this one would 
     slash Medicaid funding, throw millions out of health coverage 
     and leave states holding the bag. The only fresh idea in this 
     proposal is a new way to raise insurance rates on sick 
     people. States are happy to work with the federal government 
     on strengthening health care, but we never asked for the 
     flexibility to jack up premiums on people with pre-existing 
     conditions. Congress should again reject this disastrous 
     proposal that would wreck state budgets and cut millions off 
     of health coverage.'' [4/27/17]
       National Nurse United: ``The original version of the 
     American Health Care Act posed a mortal threat to the health 
     and well-being of our patients, and to the health security of 
     our country. The new version, which incorporates changes 
     negotiated between the House Freedom Caucus and Congressman 
     Tom MacArthur, will be even worse for our patients. This new 
     version has not yet received a score from the Congressional 
     Budget Office, and it should not be considered by the House 
     until a CBO score has been made public.'' [4/26/17]
       Leadership Council of Aging Organizations: ``While LCAO is 
     made up of organizations that often have different 
     perspectives on public policies, as a coalition LCAO strongly 
     opposes the American Health Care Act (AHCA) of 2017, which 
     would cause at least 24 million Americans to lose their 
     health care insurance. We strongly oppose the Medicaid cuts 
     and caps that remain the core of the American Health Care 
     Act. Over six million older adults rely on Medicaid. Among 
     the non-Medicare population, Americans aged 50-64 are the 
     most likely to face health challenges and have pre-existing 
     conditions. The AHCA will expose these older Americans to 
     significantly higher premiums and health care costs, if they 
     can afford to purchase coverage at all. We are also deeply 
     disappointed that there is a push to vote on the bill without 
     a revised estimate from the Congressional Budget Office on 
     how it will impact Americans. We fear and expect that the 
     proposed changes will increase the number of uninsured beyond 
     the current estimate of 24 million. For these reasons, as 
     well as other harms that would result for older Americans and 
     their families, LCAO opposes AHCA and urges members to vote 
     against it.''
       Common Sense Kids Action: ``On behalf of the millions of 
     American kids and families who rely on comprehensive, 
     dependable health insurance to stay healthy and to get 
     medical treatment when they need it, we are writing to 
     respectfully express our strong opposition to your bill, H.R. 
     1628, the American Health Care Act (AHCA). Thanks to current 
     law, including the Affordable Care Act, Medicaid, and the 
     Children's Health Insurance Program (CHIP), 95% of young 
     children in the U.S. today have health insurance. That's a 
     remarkable achievement. However, the AHCA will result in 24 
     million fewer Americans having coverage, including millions 
     of children. Even with changes recently suggested to your 
     bill, America's kids will be best served by strengthening the 
     Affordable Care Act and preserving Medicaid and CHIP, not by 
     repealing the Affordable Care Act and block granting or 
     establishing a per capita cap on Medicaid. We urge you to 
     keep our children's future foremost in your thinking, 
     withdraw your bill, and work on a bipartisan basis to support 
     measures that protect and strengthen children's health 
     care.''
       American Hospital Association: ``The latest version of the 
     AHCA continues to put health coverage in jeopardy for many 
     Americans. Our top concern is what this change could mean for 
     older and sicker patients, including those with pre-existing 
     conditions, such as cancer patients and those with chronic 
     conditions. For these reasons, along with our previously 
     stated concerns about the AHCA, we cannot support the bill. 
     The amendment proposed this week would dramatically worsen 
     the bill. The changes included put consumer protections at 
     greater risk by allowing states to waive the essential health 
     benefit standards, which could leave patients without access 
     to critical health services and increase out-of-pocket 
     spending. Additionally, the Congressional Budget Office has 
     not yet scored the amendment. However, CBO previously 
     projected that the AHCA would result in 24 million fewer 
     people covered in 2026. As the backbone of America's health 
     safety-net, hospitals and health systems must protect access 
     to care for those who need it and ensure that the most 
     vulnerable patients are not left behind. The AHCA continues 
     to fall far short of that goal.''

  Ms. PELOSI. Mr. Speaker, under TrumpCare, families, seniors, 
vulnerable children, Americans with disabilities, people struggling to 
overcome addiction, and the sick will lose their health care. Rural 
hospitals will be closed. Nearly 2 million jobs will be destroyed 
across America. Seven million veterans will lose access to tax credits 
for health care.
  And all of this, to give a massive tax cut to the richest in America. 
TrumpCare is a billionaire's tax cut, again, disguised as a healthcare 
bill. It is Robin Hood in reverse, one of the largest, again, transfers 
of wealth from working families to the rich in our country.
  Today, we honor the visions of our Founders, we can, who risked 
everything. They risked everything, their lives, their liberty, their 
sacred honor, to advance the right to life, liberty, and the pursuit of 
happiness; the life, a healthier life, the freedom to pursue your 
happiness, the freedom from being job-locked or policy-locked because 
of what the Republicans want to do today.
  Today, we fight to preserve affordable health care as the right of 
every American, again, not the privileged few.
  Today, we fight for children like Zoe Madison Lihn. Zoe was born with 
a congenital heart defect in May of 2010. She faced her first of three 
heart surgeries at 15 hours old. By 6 months old, Zoe was halfway to 
her lifetime limit her insurer had placed on her. She

[[Page H4168]]

faced a grim future, not only using up her lifetime limit by preschool 
but by carrying a preexisting condition that will require attention and 
care for the rest of her life.
  Under the Affordable Care Act, Zoe is protected, but TrumpCare puts 
her future in danger.
  I wish that our Members who vote for this bill, I hope you make time 
to sit down with the parents of a newborn with a heart condition, or a 
young woman who just learned she had breast cancer, the family of loved 
ones struggling with a disease or a chronic condition, any of the tens 
of millions of Americans who are rightfully terrified of what TrumpCare 
will mean in their lives.
  Mr. Speaker, we have, with this bill, a right, a wonderful 
opportunity. This is one of the best civics lessons we can engage in. 
Because of what happened following the election, the American people 
are engaged. They are paying attention. I am not saying in a political 
way, I am saying in a personal way.
  A former Speaker said: All politics is local. In the case of health 
care, all politics is personal when it comes to health care. And so, 
this civics lesson will teach the American people a number of things.
  As special as we think we are when we come to the floor here, most 
Americans don't know who their Member of Congress is. But they will 
now, when they find out that you voted to take away their health care. 
They will know when you put an age tax on them, or undermine Medicare 
and Medicaid and the rest.
  Oh, yeah, they are paying attention because it is really personal 
with them and their families. So I think we have to get ready for that.
  I have Members, I have colleagues who have the mantle of being a 
moderate. You vote for this bill, you have walked the plank from 
moderate to radical. And you are walking the plank for what? A bill 
that will not be accepted by the United States Senate. Why are you 
doing this?
  Do you believe in what is in this bill?
  Some of you have said: Well, they will fix it in the Senate. But you 
have every provision of this bill tattooed on your forehead. You will 
glow in the dark on this one. You will glow in the dark. So don't walk 
the plank, especially unnecessarily.
  Our responsibility to the sick and the hurt is Biblical. It is 
fundamental to who we are.
  As Pope Francis said: ``Health is not a consumer good but a universal 
right, so access to health services cannot be a privilege.''
  Today, let us declare, once again, that affordable health care must 
be the right of every American, not the privileged few.
  So I ask you, my colleagues, does TrumpCare lower health costs?
  Does TrumpCare provide better health care?
  Does TrumpCare protect seniors and families?
  Is TrumpCare good for our veterans?
  Is there any caring in TrumpCare at all?
  For the sake of our values, to honor our responsibilities to our 
Founders, life, liberty, and the pursuit of happiness, to our veterans 
who protect us, and to our children whose aspirations are our guide, I 
urge my colleagues to vote ``no'' on this disastrous TrumpCare bill.
  The SPEAKER pro tempore. Members are reminded to address their 
remarks to the Chair.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield back the balance of my 
time.
  Mrs. BLACK. Mr. Speaker, it really is my privilege now to yield 1 
minute to the distinguished gentleman from Wisconsin (Mr. Ryan), the 
Speaker of the House.
  Mr. RYAN of Wisconsin. First off, there are a few people I would like 
to thank. I would like to thank the committee chairs. I would like to 
thank Chairman Walden, Chairman Brady, Chairman Black, Chairman 
Sessions.
  I want to thank the members of those committees: Energy and Commerce, 
Ways and Means, Budget, and Rules.
  I want to thank all the Members who made constructive contributions 
throughout this entire deliberative, bottom-up organic process.
  I want to thank the President of the United States for his steadfast 
leadership.

                              {time}  1345

  Mr. Speaker, in his address in this Chamber, he called on Congress to 
act; and today we take the next step to repeal and replace ObamaCare.
  I want to thank Vice President Pence, Secretary Price, Director 
Mulvaney, and all of their teams.
  Mr. Speaker, there is a fundamental and urgent choice at the heart of 
this debate. We can continue with the status quo under ObamaCare, and 
we know what this looks like. It means even higher premiums, even fewer 
choices, even more insurance companies pulling out, even more 
uncertainty, and even more chaos.
  Look at what has happened in Iowa this week. As is the case in so 
many areas in this country, Iowa is down to one insurer. That, of 
course, is not a choice. But now that one insurer is saying that it 
will have to pull out of 94 of the 99 counties in Iowa. This is 
happening right now. So tens of thousands of Iowans will go from having 
one option to no options. That is not a choice. This is a crisis, and 
it is happening right now.
  What protection is ObamaCare if there is no healthcare plan to 
purchase in your State?
  This is the direction ObamaCare is rapidly heading. So we can 
continue with this status quo or we can put this collapsing law behind 
us and end this failed experiment. Let's make it easier for people to 
afford their health insurance. Let's give people more choices and more 
control over their care. Let's make insurance companies come in and 
compete for your business. Let's return power from Washington to the 
States. Let's help give people peace of mind. Let's put the patient, 
not bureaucrats, at the center of this system. This bill does all of 
those things. This bill delivers the promises that we have made to the 
American people.
  A lot of us have been waiting 7 years to cast this vote. Many of us 
are here because we pledged to cast this very vote to repeal and 
replace ObamaCare, to rescue people from this collapsing law.
  Are we going to meet this test? Are we going to be men and women of 
our word? Are we going to keep the promises that we made? Or are we 
going to falter?
  No. After all of this--after seeing what is happening in Iowa and 
around the country, after seeing this law collapsing while we witness 
it across the country and knowing all this turmoil that is coming, we 
will not falter. We will replace; and today is the day that we are 
going to do this.
  Today this House has the opportunity to do more than just fulfill a 
promise. We have the opportunity to raise our gaze and set a bold 
course for our country. We have the opportunity to show that we have 
got the resolve to tackle the big challenges in this country before 
they tackle us; to stop the drift of arrogant, Big Government policies 
in our lives, and to begin a new era of reform based on liberty and 
self-determination, giving people choices and letting them control 
their own destinies.
  That is the day that is before us right here. So let us pass this 
bill to take the next step to put ObamaCare behind us; let us pass this 
bill to build a better healthcare system for American families; and let 
us pass this bill to leave this country better than we found it because 
that is why we are here.
  That is what is at stake today. That is why I am going to be so proud 
to cast my vote for this legislation, and I urge all of my colleagues 
to do the same.
  Mrs. BLACK. Mr. Speaker, I yield back the balance of my time.
  

  Mrs. BEATTY. Mr. Speaker, I rise today in strong opposition to the 
Republicans' latest version of Trumpcare.
  Trumpcare will cover fewer people, provide weaker protections, and 
result in higher costs.
  Trumpcare will eviscerate essential health benefits and protections 
for pre-existing conditions and make it all but impossible for millions 
of Americans fighting illness to afford the health coverage they 
desperately need.
  Trumpcare will mean higher costs for less coverage.
  It will result in 24 million hard-working Americans losing health 
coverage.
  It will destroy protections for Americans with pre-existing 
conditions and gut Essential Health Benefits, such as maternity, 
prescription drug coverage, and emergency coverage.

[[Page H4169]]

  Trumpcare will create a crushing age tax--it will force Americans 
aged 50-64 to pay premiums five times higher than what others pay for 
health coverage, no matter how healthy they are.
  Mr. Speaker, healthcare should be a right for all, not just the 
privileged few. I will vote against Trumpcare and urge all my 
colleagues to vote no.
  Ms. LEE. Mr. Speaker, I rise once again in strong opposition to H.R. 
1628, which is a bill to take away health care from 24 million 
Americans.
  Whether you believe it or not, health care is a basic right.
  This shameful bill steals from the most vulnerable among us, 
including seniors, veterans, people living with HIV, children, and the 
disabled. And this new bill is even more dangerous and destructive than 
when they brought it to the Floor last time.
  It would, yes, rip away health care from 24 million people. It would 
reduce benefits, make families pay more for less, and transfer $600 
billion in tax cuts to the very wealthy.
  This is outrageous.
  Access to women's health is denied by defunding Planned Parenthood. 
Medicaid, as we know it, will end. Healthcare costs for working 
families and seniors will skyrocket.
  It allows states to eliminate essential health benefits like 
maternity care, cancer screenings, and emergency care.
  Mr. Speaker, this is not a health bill at all. This is a massive tax 
giveaway to the wealthy.
  Let me tell you, as a woman of faith, I am appalled and I am saddened 
by the hypocrisy displayed in this bill by people who say they are 
religious.
  I want to remind you--in the Scriptures, the Book of Mark, chapter 
12:31, we are reminded to love your neighbor as yourself.
  I hope Republicans remember to love their neighbor as themselves 
today and vote ``no'' on this mean-spirited, evil and morally bankrupt 
bill.
  This is a matter of life and death, and the American people deserve 
better.
  Mr. DANNY K. DAVIS of Illinois. Mr. Speaker, first of all, the 
Affordable Healthcare Act is the best thing that has happened to 
healthcare in the U.S. since the mid 1960's when Congress passed 
Medicare and Medicaid. More than twenty million people in our country 
have health insurance coverage now who never had it before.
  In Illinois, 36 percent of children receive coverage through Medicaid 
with approximately 3.1 million people covered overall.
  There are 649,000 Illinoisans enrolled under the Affordable Care Act, 
this bill AHCA would repeal and replace the ACA.
  Implementation of the AHCA will lead to a loss of coverage for 24 
million people nationwide.
  Overall 44,296 Illinoisans covered under the ACA and 252,612 covered 
under Medicaid expansion will be in danger of curtailed coverage.
  Healthcare professionals and activists have worked hard over the past 
fifty years to improve healthcare access and delivery and it would be a 
shame to have us go backwards.
  Passage of the AHCA would probably cause real estate taxes in Cook 
County to go up in order to keep Stroger Hospital and its other health 
services adequately funded to meet the health needs of the medically 
indigent in Cook County.
  Practically every professional healthcare group in America is opposed 
to the AHCA.
  It will spell disaster for residents of Illinois.
  Mr. NADLER. Mr. Speaker, the Republicans have rushed this bill to the 
floor before they even had a chance to print the text, let alone get a 
CBO score. They are pushing this bill through without any analysis so 
that the American people won't know how terrible this bill really is--
how many millions of people will lose their health insurance, how much 
premiums will skyrocket for those with pre-existing conditions, how 
little money they will actually save. And all to score empty political 
points or to impress Donald Trump, a man who has demonstrated again and 
again that he does not know or care what is in this bill, and just 
wants to ``win.''
  This bill is the same terrible legislation the Republicans failed to 
pass in March, but with amendments to make it even more cruel to the 
American people. The bill will kick 24 million people off their health 
insurance and eliminate employer-provided coverage for seven million 
people. The bill creates an ``age tax'' that would allow insurers to 
charge older Americans five times as much as a younger person for the 
same plan. The bill raises premiums 30 percent for people who allow 
their insurance to lapse for any reason. The bill cuts $880 billion out 
of Medicad and forces states to ration care to the millions of families 
and children who rely on it, in clear violation of Donald Trump's 
campaign pledge. The bill gives the wealthiest Americans a trillion 
dollar tax cut and cuts taxes on drug companies and health insurance 
companies that pay their CEOs more than $500,000.
  But that bill wasn't terrible enough to get the votes of the right 
wing of the Republicans in the House, so the Republicans made it even 
crueler. The amendments the Republicans will add today allow states to 
waive the essential health benefits requirements for insurance plans, 
meaning you could lose coverage for services as basic as hospital 
stays, prescription drugs, or doctor visits. States will also be able 
to waive the guarantee against discrimination against people with pre-
existing conditions. Of course, the Republicans are saying that 
insurance companies cannot deny people coverage, but insurers will be 
able to charge people whatever they want. The Center for American 
Progress estimates that premiums could increase by over $36,000 per 
year for people diagnosed with breast cancer. Pregnancy will result in 
a $17,000 increase in premiums. Asthma, a $4,000 increase. The high 
risk pools Republicans are touting will do nothing to protect people by 
sequestering the sickest Americans in pools and then drastically 
underfunding them. The Republicans are hiding from these numbers behind 
the so-called Upton Amendment, which provides a paltry $8 billion to 
cover some extra costs for those with pre-existing conditions. But even 
the conservative Mercatus Foundation found that to be less than a 
pittance compared with the skyrocketing costs for those who need it.
  Every day, we are finding new egregious consequences of this 
legislation. Last night, the New York Times reported that passing this 
bill will cut special education programs to over 2500 students with 
disabilities. Yesterday, the Center for Budget and Policy Priorities 
reported that the tax credits Republicans are proposing in this bill 
will be totally unusable in states like California and New York because 
of state laws that require coverage of abortion. Reports have come out 
that sexual assault and domestic violence would, once again, be 
considered a pre-existing condition, making insurance unaffordable for 
survivors. The Wall Street Journal reported that the bill could allow 
employers to reinstate lifetime caps and eliminate out-of-pocket caps 
for their employees' insurance plans, leaving the 159 million Americans 
who get insurance through their employer with no insurance coverage 
when they need it most. That's right--if you think that because you 
don't buy insurance on the exchange and therefore don't have to worry 
about this bill, you're wrong. I have no doubt that in the time it 
takes to read this statement another round of articles and reports will 
come out finding even more abhorrent consequences of this contemptible 
piece of legislation.
  So I ask my Republican colleagues--who are you passing this bill for? 
Are you so out of touch with the lives of real Americans that you no 
longer understand what it means to struggle to pay your medical bills? 
Have you traveled so far from the values you claim to uphold that you 
are willing to force parents to watch their children die of curable 
diseases because they have reached the lifetime cap on covered costs 
that your bill reinstates, and they can no longer afford to pay for 
treatment? Are you willing to gamble away their lives and the lives of 
their children just to say you passed a bill to repeal the Affordable 
Care Act?
  Shame on any member who votes for this cowardly, cruel bill and tries 
to sell this bill to their constituents as a win for the American 
people. Shame on this House for even considering a bill that could 
leave the most vulnerable in our country--children born with 
disabilities, women fleeing domestic violence, older Americans too sick 
to buy insurance but too young to enroll in Medicare--at the mercy of 
insurance companies and fate. Shame on you for playing political games 
with people's lives.
  Ms. EDDIE BERNICE JOHNSON of Texas. Mr. Speaker, I rise in opposition 
to the American Care Act. After seven years, the Republicans have 
released a plan that works to kick people off health insurance very 
quickly, increases out-of-pocket costs, and punishes older and sicker 
Americans. This is not the package that I envisioned.
  Some of the key features of the Affordable Care Act that millions of 
people relied on would be gone under this proposal. Under the 
Affordable Care Act, states could expand Medicaid, but this proposal 
would freeze enrollment to expanded Medicaid at January 1, 2020. On 
that date, enrollees who drop off of Medicaid due to income changes 
would not be able to return to Medicaid coverage if they dropped on for 
one full month. The proposal also changes Medicaid funding to a per 
capita cap system which will lead to deep cuts to Medicaid in my home 
state of Texas. This punishes low-income Americans who would otherwise 
have no access to health insurance.
  This piece of legislation forces Americans to pay more and get less. 
The average subsidy under the American Health Care Act will likely be 
about 60 percent of the average subsidy under current law. Deductibles 
and out-of-pocket spending in the individual market will have to 
increase due to the elimination of requirements that insurance plans 
cover a certain value. Americans will pay more for their

[[Page H4170]]

premiums, more for their care, more on out-of-pocket expenses and 
deductibles; all the while giving tax breaks to the wealthy and the 
tanning industry.
  One amendment to this bill would repeal the Essential Health 
Benefits, the ten coverage rules set up by the Affordable Care Act. The 
Affordable Care Act required insurers to cover ten ``Essential Health 
Benefits'' from maternity care, mental health, and prescription drugs, 
to hospitalization and outpatient care. If this is repealed, 
comprehensive health insurance will become virtually unavailable in the 
individual market. This means that individuals with pre-existing 
conditions would not be protected. Younger and healthier people 
benefit, older and sicker people suffer.
  Another amendment would allow states to waive out of the Affordable 
Care Act's ban on pre-existing conditions. However, Members of Congress 
and their staff would be protected from this provision and would be 
guaranteed coverage of pre-existing conditions.
  Mr. Speaker, the public has spoken about this so-called 
``replacement'' bill. People will live or die as a result of this 
legislation. The Republican leadership has rushed this bill to the 
floor without any consideration and I urge you all to consider its 
harmful effects. Your constituents are asking you to work with us to 
repair the Affordable Care Act. Work with us.
  Ms. ESHOO. Mr. Speaker, include in for the Record a letter from 
common sense kids action:

                                     Common sense kids action,

                                                   April 25, 2017.
     Re H.R. 1628--OPPOSE

     Hon. Diane Black,
     Chairwoman, House Budget Committee, House of Representatives, 
         Washington, DC.
       Dear Representative Black: On behalf of the millions of 
     American kids and families who rely on comprehensive, 
     dependable health insurance to stay healthy and to get 
     medical treatment when they need it, we are writing to 
     respectfully express our strong opposition to your bill, H.R. 
     1628, the American Health Care Act (AHCA). We have added this 
     bill to our Common Sense Legislative Ratings Tool as an 
     ``Against Kids'' bill and will communicate our position to 
     our parent and teacher members.
       Common Sense is the nation's leading independent nonprofit 
     organization dedicated to helping kids thrive in a rapidly 
     changing world. We empower parents, teachers, and 
     policymakers by providing unbiased information, trusted 
     advice, and innovative tools to help them harness the power 
     of media and technology as a positive force in all kids' 
     lives. The policy arm, Common Sense Kids Action, is building 
     a movement of parents, teachers, business leaders, and others 
     dedicated to making kids our nation's top priority by 
     supporting policies at the state and federal level that 
     contribute to the building blocks of opportunity for kids. 
     Access to affordable and quality medical care for kids is 
     certainly one of those key building blocks.
       Thanks to current law, including the Affordable Care Act, 
     Medicaid, and the Children's Health Insurance Program (CHIP), 
     95% of young children in the U.S. today have health 
     insurance. That's a remarkable achievement. With health 
     insurance, parents are more likely to seek medical care for 
     themselves and for their children, helping to prevent 
     illnesses from developing and shortening their duration when 
     they occur. However, the AHCA will result in 24 million fewer 
     Americans having coverage, including millions of children. 
     This jeopardizes the health and well-being of America's kids 
     and will alarm any parent who understands the importance of 
     health insurance for their children and family. The 
     Affordable Care Act certainly needs to be fixed, but if 
     Congress has the goal of making sure that all families and 
     businesses have access to affordable and comprehensive health 
     insurance, it could improve the law for everyone without 
     forcing millions of kids and their parents to lose access to 
     critical medical care.
       As Congress continues to grapple with this issue, health 
     insurance programs, we think these facts about children's 
     health insurance from the Congressional Budget Office and the 
     Georgetown University Center for Children and Families are 
     important to keep in mind:
       Ninety-five percent of children age 0-5 are insured today.
       Forty-five million of those children access health care 
     through two programs: about 37 million through Medicaid (a 
     federal-state program) and 8 million through CHIP, the 
     Children's Health Insurance Program.
       Children are the single-largest group of persons covered 
     under Medicaid.
       Under the Affordable Care Act, as you know, many states 
     expanded Medicaid with help from the federal government, 
     increasing coverage for kids and families, including coverage 
     for mental health care.
       Changes being considered, including under the AHCA, would 
     cut funding to Medicaid by as much as $880 billion over the 
     next 10 years.
       The AHCA, when compared with current law, would result in 
     24 million fewer Americans with health insurance by the year 
     2026.
       Even with changes recently suggested to your bill, 
     America's kids will be best served by strengthening the 
     Affordable Care Act and preserving Medicaid and CHIP, not by 
     repealing the Affordable Care Act and block granting or 
     establishing a per capita cap on Medicaid. We urge you to 
     keep our children's future foremost in your thinking, 
     withdraw your bill, and work on a bipartisan basis to support 
     measures that protect and strengthen children's health care. 
     Thank you for your consideration of our views and we would be 
     happy to talk with you at any time about this and other 
     issues that matter to America's children and families.
           Sincerely,
                                                      Danny Weiss,
                                   Vice President, Federal Policy.

  The SPEAKER pro tempore. All time for debate has expired.
  Pursuant to House Resolution 228, the previous question is ordered on 
the bill, as amended.
  The question is on the engrossment and third reading of the bill.
  The bill was ordered to be engrossed and read a third time, and was 
read the third time.
  The SPEAKER pro tempore. The question is on the passage of the bill.
  The question was taken; and the Speaker pro tempore announced that 
the ayes appeared to have it.


                             Recorded Vote

  Mr. SCOTT of Virginia. Mr. Speaker, I demand a recorded vote.
  A recorded vote was ordered.
  The SPEAKER pro tempore. Pursuant to clause 8 of rule XX, further 
proceedings on this question will be postponed.

                          ____________________