Congressional Record, Volume 169 Issue 108 (Wednesday, June 21, 2023)

[Congressional Record Volume 169, Number 108 (Wednesday, June 21, 2023)]
[House]
[Pages H3022-H3036]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

CUSTOM HEALTH OPTION AND INDIVIDUAL CARE EXPENSE ARRANGEMENT ACT

General Leave

Mr. SMITH of Missouri. Madam Speaker, I ask unanimous consent that
all Members have 5 legislative days to revise and extend their remarks
and submit extraneous material on H.R. 3799.
The SPEAKER pro tempore (Ms. Hageman). Is there objection to the
request of the gentleman from Missouri?
There was no objection.
The SPEAKER pro tempore. Pursuant to House Resolution 524 and rule
XVIII, the Chair declares the House in the Committee of the Whole House
on the state of the Union for the consideration of the bill, H.R. 3799.
The Chair appoints the gentleman from Arkansas (Mr. Crawford) to
preside over the Committee of the Whole.

{time} 1524

In the Committee of the Whole

Accordingly, the House resolved itself into the Committee of the
Whole House on the state of the Union for the consideration of the bill
(H.R. 3799) to amend the Internal Revenue Code of 1986 to provide for
health reimbursement arrangements integrated with individual health
insurance coverage, with Mr. Crawford in the chair.
The Clerk read the title of the bill.
The CHAIR. Pursuant to the rule, the bill is considered read the
first time.
General debate shall be confined to the bill and shall not exceed 80
minutes equally divided among and controlled by the chair and ranking
minority member of the Committee on Education and the Workforce, or
their respective designees, and the chair and ranking minority member
of the Committee on Ways and Means, or their respective designees.
The gentlewoman from North Carolina (Ms. Foxx), the gentleman from
Virginia (Mr. Scott), the gentleman from Missouri (Mr. Smith), and the
gentleman from Texas (Mr. Doggett) each will control 20 minutes.
The Chair recognizes the gentleman from Missouri (Mr. Smith).
Mr. SMITH of Missouri. Mr. Chair, I yield myself such time as I may
consume.
Mr. Chair, we are here today considering this legislation because we
have listened to the American people and are taking action on their
behalf.
The Ways and Means Committee has traveled over 5,000 miles to hear
directly from working Americans about the impact today's economy has
had on them and their communities. Whether it be in a lumber mill in
West Virginia or a cattle ranch in Oklahoma, workers, families,
farmers, and small businesses have told us the same thing: They need
relief from the Biden economy.
The legislation before us today will help make life a little bit
easier on small businesses. It allows them to provide more options to
their employees when it comes to health insurance benefits.
The CHOICE Arrangement Act gives small businesses more flexibility to
provide health insurance benefits to current and future workers.
Introduced by Representative Hern, this legislation codifies a Trump
administration rule allowing small businesses to reimburse employees
for buying their own health insurance on the individual market.
Washington should not stand in the way of workers getting the
healthcare coverage that is best for them and their families. Just as
important, workers should be able to take their insurance plan with
them if they leave their current job. This bill gives small businesses
the opportunity, if they so choose, to shed the administrative burden
of managing traditional insurance coverage. At the same time, it gives
workers more options for their own healthcare and makes the coverage
portable.
Also included in the underlying bill is a provision from
Representative Tenney that ensures small businesses are made aware of
the flexible, tax-advantaged insurance coverage options available to
them and their employees. We have heard that 70 percent of small
businesses are not aware of the various health insurance options out
there, such as CHOICE arrangements, qualified small employer health
reimbursement arrangements, or the small business healthcare tax
credit. This bill would make sure small businesses are notified about
the availability and tax benefits of these options so businesses can
make more informed decisions about how to support their employees'
healthcare choices.
This legislation also includes important provisions to increase
access to stop-loss insurance and expand association health plans,
which will create more choices for American small businesses to offer
health benefits to their workers at lower costs.
Mom-and-pop stores did not set out to be paper pushers and benefit
managers, and we should not force them into that role. I urge my
colleagues to support this bill to help small businesses support
their workforce and let them focus on what they do best: serving their
customers and employees.

Mr. Chair, I reserve the balance of my time.
Mr. DOGGETT. Mr. Chair, I yield myself such time as I may consume.
Millions of Americans are finding the security and the peace of mind
that comes from having access to a family physician through the
Affordable Care Act. If the gentleman has been listening to the
American people, he has turned a tin ear to the 16 million Americans
that have now enrolled in the marketplaces under the Affordable Care
Act.
Republicans, unwilling to accept the success of what they demeaned as
ObamaCare, Republicans who failed more than 60 times in this House to
repeal ObamaCare, who failed three times in the Supreme Court to
undermine ObamaCare, have now embarked on a new strategy, which is to
circumvent and undermine the invaluable protections of the Affordable
Care Act.

{time} 1530

With this bill, Republicans are demanding that every individual who
gets stuck in one of these newfangled plans that they have is denied
protection from having their insurer exclude preexisting conditions, no
assurance of coverage for essential medical care, and no assurance of
affordability.
I offered an amendment to correct one part of this defective bill to
give Americans statutory protection, so they are not back in the old
pre-Affordable Care Act period of losing coverage when they needed it
most because they had something the insurance company defined as a
preexisting condition, but that was rejected.
At the time, they claimed that was their intent, but when you look at
the specific statutory language, there is no doubt that the protection
for preexisting conditions and essential conditions is excluded from
their legislation.
These so-called Individual Coverage Health Reimbursement
Arrangements, ICHRAs, are about as convoluted as the name suggests.
They are as my grandson, Canyon, would say, they are icky.
Handing people a voucher and telling them to go shop for coverage
follows the same ill-conceived Republican approach to sabotage
Medicare, which they continue to promote in their latest budget.
Instead of giving Medicare beneficiaries guaranteed coverage, they
would give seniors a voucher with declining value and tell them to go
find coverage.
Instead of the guaranteed, comprehensive coverage workers now
receive, this bill would force so many people to find healthcare in a
sea of junk, exposing them to misleading marketing and aggressive
brokers. An estimated 2 million workers would be immediately impacted
by this sorry bill, and with another provision that is in the bill that
directs the Treasury Department to go out and promote access to junk
plans, we could expect these numbers of impacted workers to increase.
Inevitably, the result is bare-bones, junk insurance that misleads on
coverage, has high out-of-pocket costs, and abandons those with
preexisting conditions. The policy's fine print takes away all the bold
promises of the marketing. Those who need coverage the most will be
unable to afford it or receive minimal junk coverage.
In a Nation that is as rich as America, going broke shouldn't be a
side effect of trying to get healthcare, but exposing more people to
financial ruin is exactly what this kind of legislative approach will
achieve.
This misguided scheme suffers, I think, from a form of preexisting
condition itself. It is called amnesia, because they forget the
conditions that

[[Page H3023]]

existed for so many Americans in this country before the Affordable
Care Act became law. Situations like those who contacted me from Texas:
Someone who had been a victim of domestic violence declared to have a
preexisting condition; an infant born with some preexisting condition
denied the coverage that they need; any number of excuses when coverage
was needed the most because of preexisting conditions.
That is why I thought it was so important to amend this legislation,
and the refusal of my Republican colleagues to clarify that now sends
forward loud and clear that that is their objective.
There is even more ick to the ICHRA bill that is being introduced,
and that is the opportunity that is created for class discrimination.
This bill legalizes that discrimination. My amendment would have
prevented that also.
Employees that are out there on the assembly line; those who are in
the chicken processing plant, or the meat-packer, or out in the
cornfields; they are in the dirtiest, most difficult, and usually the
lowest-paid jobs. They can be treated one way under this bill, while
the executives sitting off in the office tower are treated another and
getting an entirely different kind of coverage because of the way they
have written their bill.
Lower-wage workers who would be eligible, in fact, for a better
policy under the Affordable Care Act with a no-premium or low-premium
policy, would instead be required to search for a policy with more
holes than safety net.
Finally, we discover something on which Republicans are pro-choice. I
didn't think they were pro-choice on anything, but the genuine choice
they provide is to the employer, not to the employee, a choice to
divide employees into the haves and the have-nots; providing employer
coverage to some and leaving others to fend for themselves.
Predictably, that burden will fall on the low-wage workers and the
sick employees that employers don't want to cover. One survey already
of employers found that 60 percent of large firms intended to offer
ICHRA to only low-wage workers. That is icky.
To prohibit discrimination by employers and junk plans alike, the
amendment I offered would have offered protection. This bill, as it
stands, does not. It should be rejected.
Mr. Chairman, I reserve the balance of my time.
Mr. SMITH of Missouri. Mr. Chair, all CHOICE Arrangement Act plans
must cover preexisting conditions, cap out-of-pocket expenses, and
cover key health benefits.
CHOICE arrangements do not allow employers to discriminate against
any group of employees. They require equal contributions to all
employees with the same employment status, and only adjust contribution
amount for age and family size, to make the record straight.
I yield 3 minutes to the gentleman from Oklahoma (Mr. Hern), the
sponsor of this legislation.
Mr. HERN. Mr. Chairman, as a small business owner and job creator for
over the past 35 years, I offered healthcare plans to my employees and
worked with them to find the best coverage for their families. I have
seen firsthand the impact of increasing healthcare, and I have also
done the burdensome paperwork to manage the plans on the back end.
I came to Congress 4 years ago, and the reason I came was because of
the burden that this Congress over the years has put on job creators
across America.
The small business healthcare package being debated today helps
simplify healthcare and empower people in one of their most personal
decisions, their healthcare.
I find it ironic that the gentleman across the aisle identifies the
ACA requirements as junk because the CHOICE Arrangement Act follows the
ACA guidelines. It encourages people to go out and shop. It follows the
rules on preexisting conditions.
But what we really know, what they don't like about this is it
doesn't go in the direction they want to go, which is to federalize all
healthcare. That has been the mission since day one, for the government
to run your healthcare. That just simply won't work.
I am proud that this package includes my bill, the CHOICE Arrangement
Act, which allows employees to use money from their employer to buy the
healthcare plan that works best for them.
Four years ago, the Trump administration finalized a rule to create
CHOICE accounts, allowing businesses to reimburse their employees for
the cost of the health insurance plan of their choosing. CHOICE
accounts put individuals--individuals, not the Federal Government--in
the driver's seat when it comes to picking their healthcare plan and
lets their employer financially support their decision.
This bill would codify that rule into law, benefiting everyone and,
overall, increasing the amount of people who have health insurance. You
would think that would be a good thing, but apparently not with my
Democratic colleagues.
Every patient's health needs are unique, and every person's situation
is different. This is why it is so important to expand and protect the
different options available to employers to provide health benefits in
different ways.
I am happy to see Congress address the burdens small businesses face
when providing healthcare benefits to their employees. This bill
fulfills part of a promise that the Republican Party has made to
America, to bring back true choice to American healthcare by enabling
small businesses to provide the best care for their employees.
As the chairman said, time and time again, in hearings that we have
been at across America talking to people that are experiencing the
burdens that come out of this Congress, it is amazing to me that the
Democrats who are businesspeople that are on the committee, when
talking without their talking points identify--
The CHAIR. The time of the gentleman has expired.
Mr. SMITH of Missouri. Mr. Chair, I yield an additional 1 minute to
the gentleman from Oklahoma.
Mr. HERN.--businesses as people who apparently abuse their employees
and the employees continue to come to work. That is the irony of this.
They have no idea what they are talking about.
The reality is there are other job openings for everybody to go to,
and yet, people continue to work. The only way you are prosperous in
America and run a great business is if you take care of your people.
That is it. That is all you have. That is what differentiates you in
the world of a free market. I would hope that my Democratic colleagues
would recognize that and give a little credit to the people who are out
there putting their money and their risk on the line.
In addition to my bill, this small business package includes
legislation from my colleagues Bob Good, Claudia Tenney and Tim
Walberg that will provide small businesses access to the association
health plans to build their negotiating power, stop-loss insurance to
protect from catastrophic losses, and reporting from Treasury to update
small business owners on new healthcare plans.
Small businesses make up the foundation of the American economy and
have true incentives, moral and financial, to pay to keep Americans
healthy. We should enable them to do so. I urge my colleagues to vote
``yes'' on this bill.
Mr. DOGGETT. Mr. Chairman, I yield myself such time as I may consume.
The gentleman has repeated his stated intent to provide the
protection that his bill denies, and I would refer him, again, to page
3, line 2 of this bill as it was presented in committee, and the
failure to refer to section 2791(b)(5) of the Public Health Service Act
means that that protection will not be there. It could easily have been
added if that were the true intent. It is omitted.
Same page, line 12, the failure to include guarantees against
nondiscrimination is not there.
He is concerned about federalizing healthcare. Well, all that I want
to do is set a minimum Federal standard that no person in this country
will be denied because of a preexisting condition the healthcare that
they deserve. That is what the Affordable Care Act was designed to
achieve, not only for those in the marketplace, but beyond.
Secondly, I want to ensure that different classes of employees are
not treated differently. Let me just describe a little more of what is
involved there.
Just as they would allow insurers to discriminate against a newborn
with a

[[Page H3024]]

heart murmur and call that a preexisting condition, their bill would
permit an employer to discriminate against their own employees.
Just to give you a practical example. We have a lot of chicken
processing plants down in northeast Texas. If there is a facility out
there where the chicken pluckers are chasing the chickens, removing the
feathers that are flying, those tough, dirty, hot jobs processing them
may be managed by a group in some high-rise in Dallas or Tyler.
Well, this bill, as it is written, will allow those executives to get
their group health insurance policy with all the protections against
preexisting conditions and being able to see, perhaps, a concierge
service for their healthcare. But the folks that are down there chasing
the chickens and plucking the chickens, they get an ICHRA. All they get
is ick. That is wrong.
Mr. Chairman, I reserve the balance of my time.
Mr. SMITH of Missouri. Mr. Chairman, the CHOICE Arrangement Act will
expand coverage for more types of workers by allowing employers to
offer a CHOICE Arrangement to different groups of employees who may not
have been offered health insurance previously, such as part-time or
seasonal workers.
Under this policy, nearly 1 million workers will have health
insurance coverage for the very first time.
Mr. Chair, I yield 2 minutes to the gentlewoman from New York (Ms.
Tenney), who is an author of a piece of this legislation.
Ms. TENNEY. Mr. Chair, I rise today in support of the CHOICE
Arrangement Act and my Small Business Flexibility Act, which is
included in the underlying bill as the chairman just recognized.
Over the past 10 years, health insurance premiums have gone up 130
percent, and deductibles have increased by 125 percent, and that is on
average. It is even greater in some areas, especially for small
business owners.
This lack of affordability has led to the percentage of small
businesses providing health insurance decreasing from almost 45 percent
to 31 percent today. In addition, 75 percent of businesses with fewer
than 200 employees now only offer one healthcare choice. That is no
choice.
Small business operators want to provide for their employees. They
want to offer competitive benefits that promote choice in the
marketplace while prioritizing excellent care, quality, and
affordability. The problem is these costs are simply prohibitive.
We should not accept this as the status quo, and, thankfully, there
are commonsense solutions that can help small businesses lower cost and
increase choice for their employees.
Recent surveys have found that 70 percent of small businesses are not
even aware of the flexible opportunities to help them provide
affordable health insurance as a benefit to their employees, such as
the Small Business Healthcare Tax Credit, CHOICE Arrangement Act, and
Qualified Small Employer Health Reimbursement Arrangements.
My Small Business Flexibility Act will close this awareness gap by
requiring the Treasury Department to notify and educate small
businesses on the flexible coverage options.
Small employers want to provide these benefits to their employees
for, among so many other reasons, long-term retention to allow them to
ensure that they have high quality of life, and each of them has access
to healthcare.
It is time that we increased awareness of these programs and address
any obstacles to their successful and effective implementation.
Therefore, I urge my colleagues to support the CHOICE Arrangement Act
and the Small Business Flexibility Act.

{time} 1545

Mr. DOGGETT. Mr. Chairman, I continue to reserve the balance of my
time.
Mr. SMITH of Missouri. Mr. Chairman, I yield 2 minutes to the
gentleman from Pennsylvania (Mr. Smucker).
Mr. SMUCKER. Mr. Chairman, I rise in support of H.R. 3799.
The comments by Mr. Doggett and others would make you think it is an
entirely different bill. There is nothing in this bill that would
change coverage for preexisting conditions. I don't know what he is
talking about with icky because more people will have healthcare
available to them as a result of this bill.
Mr. Chairman, I serve on two committees that have crafted pieces of
this legislation, the Ways and Means Committee and the Education and
the Workforce Committee. I think that all of us--and I think this is
probably shared on both sides of the aisle--want all Americans to have
access to the healthcare and to the insurance that they choose for
themselves. As I said, I think we share that.
Certainly, as a small business owner myself, I can relate to
businessowners who want to ensure that their employees, their team
members have access to the healthcare. They want them to be healthy;
they want them to go home from work healthy; and they are very
interested in ensuring that their employees have affordable coverage.
This committee focused on expanding the CHOICE arrangements, which is
a system that will provide numerous benefits for employees and small
businesses because it lets job creators offer their workers cash to
purchase individual health plans, which will help by ensuring that if
workers move from one job to another, they can take their health plan
with them. They are more portable, so that is a great change that will
help a lot of individuals.
On the Education and the Workforce Committee, we wrote legislation
that expands association health plans, or AHPs, which enable employers
and the self-employed to band together. I have heard from a lot of
self-employed individuals in my community who are having trouble
accessing health insurance that they prefer. This would allow them to
band together across State lines to purchase health coverage for
themselves and, in the case of small businesses, for their workers.
The CHAIR. The time of the gentleman has expired.
Mr. SMITH of Missouri. Mr. Chair, I yield an additional 1 minute to
the gentleman from Pennsylvania.
Mr. SMUCKER. Mr. Chair, there is one other thing in this bill which I
think is very positive. We took action to preserve self-insurance. This
is a system in which large and small employers pay for healthcare
services directly instead of purchasing plans with a large insurer,
which leads to savings and leads to collaboration between employers and
workers at their company to ensure better wellness approach to keep
employees healthy and not be required to access healthcare costs. It
helps the workers, and it saves costs across the board. Self-insurance
is another part of this bill that we preserve, which I think is very
great.
The bottom line is that American workers and businesses need
affordable and flexible healthcare options. This package of bills
achieves those goals, and I urge my colleagues to support this
legislation.
Mr. DOGGETT. Mr. Chairman, I yield myself such time as I may consume.
Let me respond to the gentleman from Pennsylvania. He says there is
nothing in this bill about preexisting conditions and discrimination,
and he is absolutely right. That is the whole failing of this bill. It
does not include the protections that are necessary to ensure that no
American is discriminated against on the basis of preexisting
conditions and that no employer can discriminate among groups of its
employees.
He also says this is going to open more opportunities for more people
to get health coverage. I would point out that studies have shown that
95 percent of the people who are in these icky plans now once had good
group health coverage. My concern is that we will see even more people
lose their good group health coverage and be put into an icky plan.
As for the Small Business Flexibility Act, I am for the Treasury and
others educating all employers and employees about their rights and
opportunities, but I think this part of the overall package is very
slanted. Treasury needs to be out there educating employers, some of
whom may not know themselves the limitations that these junk plans have
and how much they will disserve their employees. We need education of
employees on how to understand whether their employer's offer of
coverage meets the minimum standard and is truly affordable for the

[[Page H3025]]

purposes of being able to otherwise enroll in subsidized marketplace
coverage. I think there are limitations on that portion of the bill as
well and that it, therefore, should be rejected.
Mr. Chairman, I reserve the balance of my time.
Mr. SMITH of Missouri. Mr. Chairman, when Democrats expanded
ObamaCare subsidies in the Inflation Reduction Act, those billions of
dollars flow directly to large health insurers. CHOICE arrangements,
however, allows small businesses--small businesses--to reimburse their
own employees directly for them to shop and purchase their own health
insurance. This is how Washington should be empowering small
businesses, not bailing out large health insurers.
Mr. Chairman, I yield 1 minute to the gentlewoman from Oregon (Mrs.
Chavez-DeRemer).
Mrs. CHAVEZ-DeREMER. Mr. Chairman, I rise in support of the CHOICE
Arrangement Act.
Small business owners are being hamstrung by soaring healthcare
costs. I know firsthand because I am a small business owner, but you
don't have to take my word for it. The data speaks for itself.
In Deschutes County in my district, the average small business
premium for a family has increased by 111 percent from 2014 to 2022.
It is past time to provide small business owners with more options so
workers can access cheaper coverage. We can accomplish this by
expanding association health plans and providing more flexibility to
ensure employees can get the coverage that fits their needs best.
Mr. Chairman, I am proud to support small businesses, which create
jobs, foster innovation, and keep our economy running strong.
Let's get this done to ensure these employers can keep their doors
open.
Mr. DOGGETT. Mr. Chairman, I yield myself such time as I may consume.
The chairman of our committee says that there were great gifts to
insurance companies. What the Build Back Better bill did was to give
individuals additional tax credits. Some Republicans call those tax
cuts, but they were credits given to people to be able to afford
insurance. As a result of that improvement, many more Americans got the
insurance that they need.
Mr. Chairman, I reserve the balance of my time.
Mr. SMITH of Missouri. Mr. Chairman, I remind the body that Build
Back Better was never signed into law because neither the Democrats in
the Senate nor the White House would even support it.
Mr. Chairman, I yield 1 minute to the gentleman from Pennsylvania
(Mr. Meuser).
Mr. MEUSER. Mr. Chairman, I thank the chairman of Ways and Means, my
good friend from Missouri, very much for having this important debate
for the CHOICE Arrangement Act.
Mr. Chairman, this bill does nothing more than expand the association
health plans. Businesses want to have current coverage that exists
today. They can keep it. President Trump years back enacted an
expansion of association health plans which greatly benefited the
farmers in my district and the small businesses in my district to find
plans that suited them.
They used the power of their numbers to reduce costs 29 percent. We
have better coverage, preferable to the entities, at lower costs. If
they like their current coverage, they can keep it. It sounds way too
logical, apparently, for this body. There is no logical reason to
oppose H.R. 3799 other than for special interests or political
motivation.
Mr. DOGGETT. Mr. Chairman, I yield myself such time as I may consume.
I say to the chairman, he is absolutely correct. I referred to the
Build Back Better instead of the American Rescue Plan. It is easy to
get confused about them. The American Rescue Plan was, of course,
signed into law and has helped so many Americans. However, we always
know that whatever the name, Republicans are against all of them, as
they were, and voted unanimously against all of the opportunity that
they created for millions more Americans to get and keep health
insurance and provide themselves security.
Mr. Chairman, I reserve the balance of my time.
Mr. SMITH of Missouri. Mr. Chairman, if the gentleman from Texas has
no further speakers, I am prepared to close. I reserve the balance of
my time.
Mr. DOGGETT. Mr. Chairman, I yield myself the balance of my time to
close.
I focused on one part of this entire package of bills, but together
it is truly a thinly veiled attempt to circumvent the Affordable Care
Act. Being unable to repeal it, having nothing but nothing care to
replace it with is really kind of a death by a thousand cuts, making
healthcare less accessible and affordable for so many at-risk workers.
The bills in this package include a codification of the Trump-era
rule that allows employers to offer these ICHRA plans to their
employees instead of employer-sponsored health plans.
Under this plan, employers may offer a voucher and force their
employee to shop for their own coverage.
Under this bill, employers are permitted to pick and choose among
their employees and discriminate against some with their vouchers.
This bill also includes an expansion of the association health plans,
which my colleague from Virginia will discuss at greater length. That
has been a standard tenet of Republicans' assault on the Affordable
Care Act. It is a provision that would allow self-employed individuals
and small businesses to circumvent the guarantees of the Affordable
Care Act and steer consumers into shoddy coverage that does not cover
the healthcare they most need when they need it, the essential health
benefits.
It also does not offer them protection against preexisting conditions
or age or the fact that before the Affordable Care Act was adopted,
women were discriminated against at a great rate and often denied the
coverage that they needed or it was priced so high they could not
afford it.
The bill would also preempt State regulation of association health
plans and disrupt risk pools as these plans do not have to follow
standard premium-setting rules and risk adjustment. This bill is
similar to the Trump administration rule that was struck down in 2019.
If you are beginning to recognize a pattern here, this is all Trump,
Trump, Trump because he is still the Pied Piper for the Republican
Conference, as we just saw in this disgraceful presentation about our
honorable colleague Adam Schiff.
This package also contains a provision to encourage employers to
offer self-funded plans, which are not required to comply with ACA
protections, again, on preexisting conditions, on essential health
benefits, and more. Most employers do not want to take on the risk of
offering a self-funded plan. However, by expanding stop-loss coverage,
which sets a catastrophic amount the employer will be responsible for,
and then covers any other costs that may come up from covering their
employees, self-funded plans will be more attractive.
This legislation prevents Federal and State governments from
regulating stop-loss coverage and risks more employers opting for self-
funded plans that do not protect healthcare consumers.
Finally, without providing any additional resources, this legislative
package tells the Treasury Department to educate employers about how
great these new icky plans are and their health reimbursement accounts,
which would bar workers from more affordable coverage under the
marketplace already available.
At the heart of this effort is just the perpetual push by House
Republicans to weaken the protections of the Affordable Care Act, which
have prevented financial ruin for so many people and assured access to
healthcare for so many people.
Under the provisions of this bill, employers can form association
health plans to skirt some of the requirements of the ACA like the
essential health benefits. State and Federal regulators will be
hamstrung in their ability to protect small businesses and workers in
self-funded plans.
Utilizing these icky ICHRA plans, employers can also push those with
preexisting conditions, women, and older workers into the individual
market with vouchers while keeping their younger and healthier
employees on employee-sponsored insurance. Therefore, the sick get
treated differently.

[[Page H3026]]

Those who have disabilities, who have had long-term chronic conditions,
could be treated very differently and put at great risk.
I think for all these reasons that this legislation should be soundly
rejected. This is an opportunity to defend all that the Affordable Care
Act has meant to Americans and offer that opportunity to more people
rather than deception that is the hallmark of this bill and following
the Trump approach that junk insurance is what would be most available
to Americans.
Mr. Chairman, I yield back the balance of my time.

{time} 1600

Mr. SMITH of Missouri. Mr. Chair, I yield myself the balance of my
time.
Congress has an opportunity to help small businesses by making it
easier for those who choose to provide health insurance for their
employees.
This bill is the best of both worlds for small businesses and
workers. It relieves many small businesses of the burden of
administering a complex health insurance plan by allowing them to
instead offer meaningful financial support to employees so that they
can buy their own insurance. It takes some of the guessing game out of
offering coverage by making sure small businesses are informed of the
various options they have. It gives workers the freedom to choose the
best possible coverage for themselves and their families.
By passing this legislation, we will allow small businesses to get
back to the basics, helping their customers, taking care of their
employees, and serving their communities.
I want to address the misleading claims we have heard from our
Democrat colleagues. At our markup, one of my Democrat colleagues
called the health plan options under this bill junk plans. That is
unequivocally false. These funds can only be used to purchase plans
that cover preexisting conditions. Regardless of what you hear on the
other side, this covers plans with preexisting conditions. It covers
plans that cap out-of-pocket expenses and guarantees coverage during
open enrollment.
They also claim that we are opening a backdoor for businesses to
discriminate in the health benefits offered to their employees. CHOICE
arrangements provide the opposite of discrimination. They provide equal
contributions to all employees with the same employment status, only
adjusting for age and family size.
In fact, many businesses today don't offer health benefits to any of
their part-time employees. Through CHOICE arrangements, these employees
may be seeing their first offer of meaningful health benefits.
Today, we are taking another step forward to cut the bureaucratic red
tape holding back small businesses. We should make it easier, not
harder, to give America's workers, families, farmers, and small
businesses access to flexible healthcare options.
Madam Chair, I urge my colleagues to support this legislation, and I
yield back the balance of my time.
The Acting CHAIR (Mrs. Wagner). The Chair now recognizes the
Committee on Education and the Workforce. The gentlewoman from North
Carolina (Ms. Foxx) and the gentleman from Virginia (Mr. Scott) each
will control 20 minutes.
The Chair recognizes the gentlewoman from North Carolina.
Ms. FOXX. Madam Chair, I yield myself such time as I may consume.
Madam Chair, I rise today to support the House Republican package to
alleviate rising healthcare costs for small businesses. I am proud that
the Committee on Education and the Workforce has taken a leading role
in this effort.
Healthcare cost is the number one issue facing small businesses
today. In fact, according to the NFIB, it has been their top issue for
over 30 straight years. Through the dot-com bubble, the Great
Recession, the COVID-19 pandemic, and record inflation, small
businesses have consistently identified healthcare costs as their
greatest concern.
House Republicans recognize that these small businesses are the
engines of the American economy, and this package is the first step
toward much-needed relief.
I will take a moment to discuss the two pieces of this package from
the jurisdiction of the Education and the Workforce Committee. First,
this package incorporates Representative Good's Self-Insurance
Protection Act. We passed the Self-Insurance Protection Act through
committee because small businesses are being squeezed. There is no
other way to put it.
On the one hand, premiums are skyrocketing, and it is costing small
businesses a fortune to cover their employees. Single-coverage premiums
cost about $8,000 per year now, and they are drastically outpacing
inflation. The bottom-up inflationary pressures have inevitably forced
small businesses out of the insurance marketplace, and more and more
are deciding to self-insure. Experts predicted this when the ACA
passed, and it has held true.
On the other hand, the government is coming from the top down and
telling small businesses they cannot access stop-loss insurance. Stop-
loss insurance is a financial tool that self-insured businesses
typically buy to protect themselves from catastrophic costs, but the
government overreaches, overregulates, and denies many small businesses
this critical tool.
For example, in New York, insurers are expressly prohibited from
selling stop-loss insurance to employers with fewer than 100 employees.
The New York State Association of Health Underwriters wrote regarding
the law: ``Some groups have already lost their employer-provided health
coverage altogether and have had to go into the New York health
insurance marketplace exchange to obtain coverage, only to find that
their new coverage has higher copays, larger deductibles, greater total
out-of-pocket annual limits, narrower in-plan healthcare provider
networks, and fewer out-of-network medical specialists.''
Like in a pincer maneuver, the government is coming from both sides
and trapping small businesses in the middle with no options.
The Self-Insurance Protection Act is the solution. It provides a
lifeline to small businesses and hardworking Americans who are being
squeezed by the soaring cost of traditional health insurance. It would
stop Federal and State overregulation of stop-loss insurance, allowing
self-insured small businesses a way out of the government's two-sided
trap.
Next, this package also incorporates Representative Walberg's
Association Health Plans Act, which is perhaps the single best cost-
saving tool at our disposal. The Association Health Plans Act would
offer immediate relief for everyday workers, taxpayers, and job
creators. I know this because it has been tested.

In 2019, before the courts stopped President Trump's association
health plan, AHP rule, America got a chance to see and feel the impact
of deregulation. AHPs produced savings of up to 29 percent on average.
At the upper limit, groups saved 50 percent with their newly formed
AHPs.
AHPs achieve these savings by allowing small businesses to band
together to increase their bargaining power when purchasing health
insurance. Currently, many regulations restrict small businesses and
individuals from doing so.
Enabling small economic actors to pool resources is critical to their
competitiveness in the market. In healthcare, big companies enjoy large
economies of scale, and only more so with each passing year.
Countless studies and evidence point toward this worrisome trend of
market consolidation. Three pharmacy benefit managers own 80 percent of
the market. Physician practices and hospitals are merging at a rapid
pace. Thankfully, hospital mergers have slowed during and after the
pandemic, but it is not enough. This bill helps mom-and-pop shops and
self-employed workers fight back.
I should also clarify that this bill does not turn healthcare into
the Wild West, like some Members claim. Important regulatory guidelines
exist to make sure enrollees would not be defrauded under AHPs.
For example, every AHP must have a board consisting of at least 75
percent employer membership. This ensures that AHPs are maintained in
good faith.
They are also required to abide by existing consumer protections,
such as prohibitions against discriminating

[[Page H3027]]

based on an individual's health status and prohibitions against using
preexisting conditions to deny coverage, increase premiums, or impose
waiting periods.
The benefits of the Association Health Plans Act can be summed up in
the words of Trump's DOL: ``AHPs are about more choice, more access,
and more coverage.'' I agree.
Let's help small businesses get the relief they need and working
Americans the coverage they deserve.
Madam Chair, I urge passage of this healthcare package, and I reserve
the balance of my time.
Mr. SCOTT of Virginia. Madam Chair, I yield myself such time as I may
consume.
Madam Chair, the proposals in H.R. 3799 are yet another recycled,
futile attempt to sabotage the Affordable Care Act and actually make it
harder for workers and families to find affordable, high-quality health
insurance.
This legislative package includes two bills that were marked up by
the Committee on Education and the Workforce.
The first is the Association Health Plans Act. This act undermines a
core promise of the ACA, access to affordable healthcare for all. This
faulty legislation may provide lower costs for some enrollees, but it
would do so by skimping on benefits and increasing costs for everybody
else.
Specifically, the bill would allow association health plans to
cherry-pick low-risk, young individuals for a pool separate from the
ACA marketplace. You may hear my colleagues on the other side of the
aisle tout the bill's nominal protections against discrimination based
on preexisting conditions, but they omit the details regarding the
other large loopholes that leave consumers vulnerable in this bill,
such as charging higher risk groups more so that the plan will not be
attractive to them and charging low-risk groups less so that they will
be the ones that come in.
In fact, this legislation explicitly authorizes AHPs to set premiums
based on the ``specific risk profile'' of employer members, enabling
them to charge higher premiums to groups based on their age, gender,
and other factors. AHPs could also exclude certain categories of
coverage, such as maternity care, mental health, or substance abuse
disorder, to dissuade certain groups or individuals from enrolling.
Under the bill, association health plans could also evade essential
health benefits and other consumer protections under State and Federal
law.
It is a bad idea because of simple arithmetic. If healthy, low-risk
individuals can leave the Affordable Care Act marketplace risk pool and
join a separate association and pay lower rates on average, those that
did not get into these plans will, on average, pay higher premiums.
Let's be clear. Only low-cost groups will be in these plans because
if you are a high-risk group, the cost will be too much and will not be
attractive. If they are high-risk groups with preexisting conditions,
older groups, and whatnot, they will not be able to form groups that
charge less than the ACA marketplace, and nobody will want to join.
Under the ACA, everybody pays an average. If you have a preexisting
condition or do not have a preexisting condition, everybody pays the
same, and everybody gets insurance at an affordable cost.
Everybody enjoys all the essential benefits under the ACA.
Association plans, for example, do not have to provide coverage for
essential benefits like maternity benefits. All the costs of maternity
care will be borne by fewer and fewer people.
The average cost of insurance for those not in the plans will slowly
grow as the number of association plans grows.

{time} 1615

Various versions of this legislation have been pushed by Republicans
for decades, but all iterations suffer from the same fundamental flaw,
they shift costs to the most vulnerable. That is why more than 30
leading consumer and patient groups have expressed serious concerns
with this harmful legislation.
The other bill marked up in the Education and the Workforce Committee
was the Self-Insurance Protection Act, legislation that further erodes
the ACA by exempting stop-loss insurance from key consumer protections.
The bill would prevent the Secretaries of Health and Human Services,
Labor, and the Treasury from regulating stop-loss insurance coverage.
Even more troubling, the bill makes it virtually impossible for States
to protect consumers from abusive practices by invalidating State laws
that regulate stop-loss.
Stop-loss insurance usually covers costs above a catastrophic level,
over a million dollars or something like that. They can be written to
cover everything over a thousand dollars when they become essentially
regular insurance except that they are not regulated. There are no
solvency regulations, no benefit regulations, no nothing.
We can all agree that small businesses and self-insured people
deserve access to affordable healthcare, and that is what you get under
the Affordable Care Act. We should also agree that people deserve basic
consumer protections to ensure that they have insurance with quality,
solvency, an agency to call if something goes wrong, and coverage for
essential benefits. That is why we passed the Affordable Care Act in
the first place. It is also why, when Democrats were in charge in the
last Congress, we passed the American Rescue Plan and the Inflation
Reduction Act to make coverage even more affordable.
The question before us is: Do we want to make sure that every
individual can continue to find affordable and quality healthcare
coverage, or do we want to pass H.R. 3799 and create roadblocks for
Americans seeking care?
Madam Chair, I would hope that we would oppose this bill, and I
reserve the balance of my time.
Ms. FOXX. Madam Chair, our colleagues are opposed to freedom in
choosing healthcare. They want everyone in government-controlled
healthcare and are quite willing to mislead the American people on what
these bills do.
Madam Chair, I yield 3 minutes to the gentleman from Michigan (Mr.
Walberg), a member of the Committee on Education and the Workforce.
Mr. WALBERG. Madam Chair, I rise in support of H.R. 3799, the CHOICE
Arrangement Act. I thank both the Ways and Means Committee and the
Committee on Education and the Workforce for their hard work in
bringing this important bill to the floor.
I must state that what I have heard over the last 20 minutes of
sitting here and listening to my colleagues, it would lead me to
believe that they think Republicans don't want good healthcare, that we
don't need good healthcare, that we don't use good healthcare, and that
we would support employers not giving us good healthcare or our
constituents good healthcare, and that we would expect that Republican
employers wouldn't feel the same impact of trying to compete with other
employers whose benefits their employees look for.
That is just not true. I don't think the American public believes
that. We have the same concerns. We want good healthcare. That is why
this bill has been put forward.
With the ACA, true, everybody had insurance, but not everybody had
healthcare when they tried to use it. The high cost of healthcare
remains a struggle for small businesses, many of whom are facing
lingering hardships from the pandemic as well as inflation.
In fact, a recent survey from the NFIB showed that while employers by
and large believe offering health benefits is important, 98 percent of
small businesses are concerned that healthcare costs will become
unsustainable within the next 5 to 10 years.
The CHOICE Arrangement Act provides innovative healthcare solutions
to bring down healthcare costs for small businesses.
I am proud that H.R. 3799 includes my legislation to expand
association health plans. AHPs are commonsense solutions that empower
small employers and their employees when making health coverage
decisions.
Right now, small businesses are often on an unequal playing field
with larger companies and unions. Because they have fewer employees,
small businesses have limited bargaining power when it comes to
negotiating for lower insurance costs for their workers and higher care
coverage.

[[Page H3028]]

By providing small businesses with greater bargaining power, the
Association Health Plans Act allows them to offer more quality options
for workers at a better price.
Madam Chair, the Association Health Plans Act will level the playing
field for small businesses and empower their employees to access
quality healthcare at a lower cost. It also represents an important
step toward purchasing health insurance across State lines.
Today's vote is an immediate first step to help job creators provide
affordable healthcare options to their employees and transition toward
a patient-centered healthcare system that works for Republicans and
Democrats.
Madam Chair, I encourage support of H.R. 3799.
Mr. SCOTT of Virginia. Madam Chair, I yield such time as he may
consume to the gentleman from Texas (Mr. Doggett), the ranking member
of the Health Subcommittee of the Ways and Means Committee.
Mr. DOGGETT. Madam Chair, I would say to the gentleman from Michigan,
I am sure there are many Republicans who want to assure good healthcare
to all people. The problem is with this specific bill.
The one-page amendment that I offered could have guaranteed these
ICHRA employees that they would face no discrimination among classes of
employees and no barrier of preexisting conditions.
That clarification would have solved this problem, and their failure
repeatedly to accept that one-page amendment, with no explanation other
than that they wanted to do the same thing, or that it was duplicative,
betrays the promise of this bill and suggests that discrimination and
denial of coverage based on preexisting conditions is what Americans in
these plans will face.
The chairman of the Ways and Means Committee, our colleague from
Missouri (Mr. Smith) closed by saying that his goal is to cut red tape.
Well, that is a goal that I think all of us can share, but I am afraid
that this bill, as written, will only throw more Americans into the red
and into medical debt, which is already high despite the protections
that we have provided to date.
There are so many families overwhelmed by medical debt, and some who
will be denied the opportunity to get the protection they need from
their healthcare providers because they simply cannot afford it.
Madam Chair, I would say at the appropriate time I will offer a
motion to recommit to this bill and send it back to committee. If the
House rules permit it, I would have offered this motion with an
appropriate amendment to the bill.
My amendment would ensure that this bill does not take effect unless
the Secretary of Health and Human Services certifies that this bill
will not result in anyone losing access to coverage of essential health
benefits or see their healthcare costs rise, the very objective that
the gentleman from Virginia has been discussing.
Madam Chair, I include in the Record the text of this amendment.
Mr. Doggett moves to recommit the bill H.R. 3799 to the Committee on
Ways and Means with instructions to report the same back to the House
forthwith, with the following amendment:
Add at the end the following new title:

TITLE VI--EFFECTIVE DATE

SEC. 601. EFFECTIVE DATE.

Notwithstanding any other provision of this Act, the
provisions of this Act and the amendments made by this Act
shall not apply unless the Secretary of Health and Human
Services submits to Congress a certification that such
provisions and amendments will not result in--
(1) individuals losing access to coverage of essential
health benefits (as defined for purposes of section 1302(b)
of the Patient Protection and Affordable Care Act (42 U.S.C.
18022(b))); or
(2) higher costs to individuals for coverage that includes
such benefits.

Mr. DOGGETT. Madam Chair, I hope my colleagues will join us in
supporting it, recommitting this, pursuing the objective of better
healthcare for all, and protecting all Americans from preexisting
condition barriers, and ensuring they are not the subject of
discrimination.
Ms. FOXX. Madam Chair, I yield 3 minutes to the gentleman from
Virginia (Mr. Good), who introduced this resolution, and is chair of
the Health, Employment, Labor, and Pensions Subcommittee.
Mr. GOOD of Virginia. Madam Chair, I rise in support of the CHOICE
Arrangement Act because it charts a course for Americans to take charge
of their healthcare.
This bill includes several important provisions, including one of my
bills, the Self-Insurance Protection Act. Self-insured healthcare plans
give employers more choices to build and tailor health plans that best
meet the needs of their employees.
Self-insured plans are popular. In fact, in 2022, 65 percent of
workers were enrolled in self-insured plans. Small and midsize
businesses are turning to self-insured plans because of the
flexibilities they provide in offering high-quality healthcare coverage
at an affordable cost to employees.
Stop-loss insurance is a critical component of an employer's ability
to successfully self-insure in a way that best suits their needs. Most
employers choose to purchase stop-loss insurance to manage financial
risk, shielding them from potentially catastrophic medical claims that
could sink their businesses.
Unfortunately, Washington bureaucrats have tried to regulate stop-
loss insurance into nonexistence. The Obama administration threatened
to regulate stop-loss as traditional health insurance, a move that
would make self-insurance inaccessible, and force individuals onto the
ObamaCare exchange and drive up costs.
My bill would make sure the Biden administration can't mandate the
decision of small business owners and weaponize regulations to prevent
access to stop-loss policies for small business owners.
Additionally, some State laws unfairly limit small businesses from
accessing the self-insured market solely based on the size of their
operations. My legislation would protect the ability for businesses to
self-insure and ensure that no government entity can prevent them from
making the best possible decision for their business and their
employees.
Another key provision of the CHOICE Arrangement Act would make
Association Health Plans more accessible for small businesses and self-
employed workers.
This policy is a big win for my home State of Virginia. Last year,
Virginia passed a law allowing realtors to form Association Health
Plans. Sadly, the Biden administration has threatened to block
implementation of the State law because it doesn't comply with
ObamaCare.
Voting for the legislation today would allow for the Virginia law to
flourish without Federal Government intervention. The Medicare for All
mentality thinks that businessowners aren't equipped to provide quality
health coverage for their employees. That simply is not the case.
A majority of Americans, 159 million, in fact, have health benefits
through their jobs, and they like their plans. Madam Chair, 78 percent
of employers decide to enroll in employer-sponsored insurance when
given the option.
The CHOICE Arrangement Act responds to the needs of the American
people, and I hope all of my colleagues can support this effort to
empower small business owners across America.
Mr. SCOTT of Virginia. Madam Chair, I would inquire as to how much
time is remaining.
The Acting CHAIR. The gentleman from Virginia has 11\1/2\ minutes
remaining, and the gentlewoman from North Carolina has 7\1/2\ minutes
remaining.
Mr. SCOTT of Virginia. Madam Chair, I yield myself such time as I may
consume.
Madam Chair, the gentleman from Michigan talked about the motive of
employers. I think the employers want to give good coverage. The
problem with this bill is it enables one company to find loopholes to
get a good deal for that company even if it results in higher costs for
everybody else. That is the problem with this legislation.
Madam Chair, I include in the Record a letter of opposition written
by the AFL-CIO.
Among other things, the letter states that this bill undermines
comprehensive coverage and subjects workers to financial risk.
AFL-CIO

Legislative Alert,

June 20, 2023.
Dear Representative: On behalf of the AFL-CIO, I urge you
to oppose the CHOICE Arrangement Act (H.R. 3799). This
package would make two substantial changes in

[[Page H3029]]

health coverage policy--both harmful to workers.
First, H.R. 3799 will loosen the definition of association
health plans (AHPs), opening the door for more employers to
establish plans that evade Affordable Care Act (ACA)
requirements to cover essential health benefits and
participate in market-wide risk pools. Despite what their
name suggests, association health plans are not a form of
niche coverage for professional associations. Under current
rules, AHPs may be established by multiple employers and draw
broadly from insurance markets to enroll self-employed
individuals. With the ability to set rates based on a limited
pool of enrollees, AHPs have been able to offer coverage with
lower premiums, but their track record is poor. Too often,
these plans misjudged the risks involved and have gone
insolvent, leaving enrollees in the lurch. In other cases,
enrollees have been defrauded by scammers who exploited the
AHP regulatory loopholes.
Second, under the guise of ``protecting'' stop-loss
insurance for self-funded group health plans, H.R. 3799 would
allow employer health plans to avoid the ACA requirement that
insured plans cover essential health benefits. The policy is
intended to allow plans that are unable to actually self-fund
with adequate reserves to instead purchase a high level of
stop-loss insurance. Lack of adequate reserves leave many of
these plans, and their enrollees, at risk since stop-loss
insurers often retain the right to drop the insurance if
medical costs for the group begin to climb. This is not a
stable form of coverage.
By allowing plans to offer coverage that does not comply
with ACA essential health benefits requirements, both of
these policies would allow plans to cherry pick healthier,
less-costly enrollees from the small group and individual
markets. This will increase premiums for good comprehensive
coverage because risks cannot be spread widely to reduce
costs for all.
We urge you to protect working people by opposing this
legislation that undermines comprehensive coverage and
subjects workers to financial risk.
Sincerely,
William Samuel,
Director, Government Affairs.
Mr. SCOTT of Virginia. Madam Chair, I include in the Record a broad
post written by the Center on Budget and Policy Priorities.
Among other things, the post states that the bill will undermine
consumer protections, segment insurance markets, and impose new burdens
on individuals to navigate an already complex system.

[From the Center on Budget and Policy Priorities, June 20, 2023]

Health Bills Headed for a Vote in the House Undermine Consumer
Protections and Market Rules

(By Sarah Lueck)

The House is moving toward a vote on legislation that would
weaken Affordable Care Act (ACA) consumer protections and
private market rules. Proponents of these changes claim they
will increase choices and reduce red tape for employers, but
a closer look shows the problems they would create. The
legislation would:
Expand association health plans (AHPs). The legislation
would allow AHPs, a type of health plan that trade
associations, professional groups, and other organizations
may offer their members, to cover self-employed individuals
and small businesses as if they were large employers. This
would exempt them from ACA standards that otherwise apply to
health plans in the individual and small group markets.
Similar to a Trump-era rule a court struck down in 2019, the
bill would segment insurance risk pools: some individuals who
are younger and healthier, or small businesses whose
employees have that profile, could get plans with lower
premiums because they would be priced separately from ACA-
compliant coverage and would not have to meet ACA standards,
such as a requirement to cover a set of essential health
benefits. As a result, other individuals and small businesses
remaining in ACA-regulated markets would see higher premiums.
Expand Individual Coverage Health Reimbursement
Arrangements (ICHRAs). The legislation would codify
provisions similar to a Trump-era rule currently in place
that allows employers to forgo offering a regular group
health insurance plan and instead offer an HRA (a tax-
favored, employer-funded account) that workers could use to
buy their own individual insurance coverage. Increasing such
arrangements could raise ACA marketplace premiums; they are
likely to attract sicker-than-average firms that can spend
less to fund an ICHRA than they must pay for a group health
plan. And firms may find strategies to shift sicker workers
to HRAs, even with guardrails in the legislation meant to
prevent this.
Plus, these arrangements require employees to do
considerable work compared with signing up for an employer
plan--they must apply for and select a plan, set up premium
payments, and understand what expenses the ICHRA covers.
Also, workers offered an ICHRA could be confused about
whether the offer renders them ineligible for a marketplace
premium tax credit--that is, whether it constitutes an
``affordable'' employer offer that precludes credit
eligibility. And while employers must give workers a notice
of HRA rules, they needn't personalize them to tell
individual workers whether their plan is affordable. These
complications for employees could drive down coverage.
Increase self-insured employer plans. Another provision
would encourage more small employers with healthier workers
to self-insure (meaning that the employer bears the financial
risk), rather than offering a fully insured health plan (for
which an insurer bears the risk). Specifically, the bill
would protect a complex self-insurance arrangement known as
level funding from tighter regulation. Similar to AHPs, this
scheme allows small firms with healthier workers to provide
plans that avoid ACA small-group market premium and benefit
standards without being a large employer or taking on the
risk of self-insurance. This provision would make level
funding an even more common way for smaller firms to avoid
having to offer plans that meet ACA market rules--this would
raise premiums for small businesses that remain in the fully
insured, small-group market if small firms with younger and
healthier workers move to self-insure.
House committees recently approved other health bills that
raise concerns. The Ways and Means Committee moved to expand
health savings accounts (HSAs), which overwhelmingly benefit
high income people and exacerbate racial and ethnic
inequities in coverage access and wealth accumulation. HSA
tax benefits currently are only available when someone has a
high-deductible health plan that meets certain federal rules.
But the committee approved a bill that would allow high-
deductible plans to cover telehealth services pre-deductible,
while still qualifying for HSA tax benefits. It is estimated
to cost $5 billion from 2025 through 2033.
Another bill, approved by the House Education and Workforce
Committee, would let employers offer workers stand-alone
telehealth-only plans and exempt the plans from providing ACA
consumer protections or meeting other federal laws that
otherwise apply to employer coverage. The bill would exempt
telehealth plans from, for example, covering mental health
care at parity with other care and providing preventive
services at no cost to enrollees. The plans could also impose
annual and lifetime limits on coverage and sharply limit the
types of conditions they would address.
Additional policy changes are needed to make health
coverage and care more affordable for many people, despite
the ACA's significant benefits for individuals and small
businesses. But the legislation heading to the House floor is
misguided. It would undermine consumer protections, segment
insurance markets, and impose new burdens on individuals to
navigate an already complex system.
Mr. SCOTT of Virginia. Madam Chair, I reserve the balance of my time.
Ms. FOXX. Madam Chair, I yield 3 minutes to the gentleman from
Georgia (Mr. Allen), a member of the Committee on Education and the
Workforce.
Mr. ALLEN. Madam Chair, I rise today to urge a vote in support of the
CHOICE Arrangement Act to enhance the flexibility and affordability of
healthcare options for small businesses. Competition is the only way to
drive down costs.

{time} 1630

Democratic policies like ObamaCare have led to consolidation in the
marketplace, skyrocketing premiums, and a broken individual health
market that costs taxpayers more than $1 trillion a year while covering
only 4.6 percent of the population. Make no mistake, Madam Chair, the
Federal Government owns healthcare, and there is no private system to
compete with it.
As a small business owner, I was fortunate to be able to offer my
employees private health insurance without having to send them to the
ACA exchange, and I understand how much employers want to be able to
offer their employees quality healthcare coverage at a low cost. I
guarantee you, Madam Chair, that the business community will figure out
healthcare and how to lower costs.
Unfortunately, many small businesses lack the economies of scale
needed to negotiate lower prices with insurance companies. This
commonsense package aims to reduce administrative burdens and empower
small employers to be able to provide healthcare coverage to their
employees by removing barriers and implementing innovative solutions
like association health plans.
Small businesses and private employers can band together in
association health plans to be in a better bargaining position to
reduce healthcare costs for their employees. As an original cosponsor
of the Association Health Plans Act, I am pleased it was included in
the package we have before us today.
This legislation will also expand association health plans by
allowing self-

[[Page H3030]]

employed individuals to participate in an ERISA-covered health plan.
I was proud to work with Congressman Hern on the Healthy Future Task
Force Affordability Subcommittee last Congress, and the legislation we
are debating today is a culmination of our hard work. We were able to
produce solutions to provide high quality, affordable, and personalized
healthcare for workers and their families, as well as innovative
policies so more small businesses can offer healthcare benefits.
I am proud to have worked on the solutions included in the CHOICE
Arrangement Act which will give small businesses the freedom to focus
on serving their customers and employees.
Madam Chair, I urge my colleagues to support this bill.
Mr. SCOTT of Virginia. Madam Chair, I am prepared to close, and I
yield myself the balance of my time.
Madam Chair, I regret that my Republican colleagues continue to
relitigate the Affordable Care Act. However, what we have seen is not
new. It is what we have seen time and time again over the last 13
years. They continue using every tool they can to undermine the ACA and
limit access to quality healthcare, weaken consumer protections, and
increase average costs.
The provisions of this package do nothing to lower overall healthcare
costs for workers and their families. In fact, for most consumers, the
result of this legislation is that while some may save a little bit,
most consumers will end up paying more.
Madam Chair, I strongly urge my colleagues to oppose the bill, and I
yield back the balance of my time.
Ms. FOXX. Madam Chair, I yield myself the balance of my time.
Madam Chair, my colleagues have explained that many things that our
colleagues across the aisle have said about these bills are not
accurate.
I am not going to say it again, but I think it is important that we
say that these bills are going to do good things for the American
people. It is going to provide choice and it is going to provide lower
costs.
I am certain of two things: one, healthcare costs present a
significant burden on small businesses; and, two, inaction is not going
to cut it.
This comprehensive small business healthcare package is a proven
first step on free market principles and reducing government
interference. By empowering small businesses with choice in
competition, we can lower healthcare costs and increase access to high-
quality care.
I hope the other side of the aisle gives this legislation the serious
consideration it deserves. I often hear complaints that Republicans
don't have a plan to fix healthcare costs. Here it is.
Let's reduce healthcare costs together and pass this package.
Madam Chair, I yield back the balance of my time.
The Acting CHAIR. All time for general debate has expired.
Pursuant to the rule, the bill shall be considered for amendment
under the 5-minute rule.
In lieu of the amendment in the nature of a substitute recommended by
the Committee on Ways and Means, printed in the bill, an amendment in
the nature of a substitute consisting of the text of Rules Committee
Print 118-9, modified by the amendment printed in part C of House
Report 118-115, shall be considered as adopted. The bill, as amended,
shall be considered as the original bill for the purpose of further
amendment under the 5-minute rule and shall be considered as read.
The text of the bill, as amended, is as follows:

H.R. 3799

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

TITLE I--ASSOCIATION HEALTH PLANS ACT

SEC. 101. SHORT TITLE.

This title may be cited as the ``Association Health Plans
Act''.

SEC. 102. TREATMENT OF GROUP OR ASSOCIATION OF EMPLOYERS.

(a) In General.--Section 3(5) of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1002(5)) is amended--
(1) by striking ``The term'' and inserting ``(A) The
term''; and
(2) by adding at the end the following:
``(B) For purposes of subparagraph (A), a group or
association of employers shall be treated as an `employer',
regardless of whether the employers composing such group or
association are in the same industry, trade, or profession,
if such group or association--
``(i)(I) has established and maintains an employee welfare
benefit plan that is a group health plan (as defined in
section 733(a)(1));
``(II) provides coverage under such plan to at least 51
employees after all of the employees employed by all of the
employer members of such group or association have been
aggregated and counted together as described in subparagraph
(D);
``(III) has been actively in existence for at least 2 years
prior to establishing and maintaining an employer welfare
benefit plan that is a group health plan (as defined in
section 733(a)(1));
``(IV) has been formed and maintained in good faith for
purposes other than providing medical care (as defined in
section 733(a)(2)) through the purchase of insurance or
otherwise;
``(V) does not condition membership in the group or
association on any health status-related factor (as described
in section 702(a)(1)) relating to any individual;
``(VI) makes coverage under such plan available to all
employer members of such group or association regardless of
any health status-related factor (as described in section
702(a)(1)) relating to such employer members;
``(VII) does not provide coverage under such plan to any
individual other than an employee of an employer member of
such group or association;
``(VIII) has established a governing board with by-laws or
other similar indications of formality to manage and operate
such plan in both form and substance, of which at least 75
percent of the board members shall be made up of employer
members of such group or association participating in the
plan that are duly elected by each participating employer
member casting 1 vote during a scheduled election;
``(IX) is not a health insurance issuer (as defined in
section 733(b)(2)), and is not owned or controlled by such a
health insurance issuer or by a subsidiary or affiliate of
such a health insurance issuer, other than to the extent such
a health insurance issuer--
``(aa) may participate in the group or association as a
member; and
``(bb) may provide services such as assistance with plan
development, marketing, and administrative services to such
group or association;
``(ii) meets any set of criteria to qualify for such
treatment in an advisory opinion issued by the Secretary
prior to the date of enactment of the Association Health
Plans Act; or
``(iii) meets any other set of criteria to qualify for such
treatment that the Secretary by regulation may provide.
``(C)(i) For purposes of subparagraph (B), a self-employed
individual shall be treated as--
``(I) an employer who may become a member of a group or
association of employers;
``(II) an employee who may participate in an employee
welfare benefit plan established and maintained by such group
or association; and
``(III) a participant of such plan subject to the
eligibility determination and monitoring requirements set
forth in clause (iii).
``(ii) For purposes of this subparagraph, the term `self-
employed individual' means an individual who--
``(I) does not have any common law employees;
``(II) has an ownership right in a trade or business,
regardless of whether such trade or business is incorporated
or unincorporated;
``(III) earns wages (as defined in section 3121(a) of the
Internal Revenue Code of 1986) or self-employment income (as
defined in section 1402(b) of such Code) from such trade or
business; and
``(IV) works at least 10 hours per week or 40 hours per
month providing personal services to such trade or business.
``(iii) The board of a group or association of employers
shall--
``(I) initially determine whether an individual meets the
requirements under clause (ii) to be considered a self-
employed individual for the purposes of being treated as an--
``(aa) employer member of such group or association (in
accordance with clause (i)(I)); and
``(bb) employee who may participate in the employee welfare
benefit plan established and maintained by such group or
association (in accordance with clause (i)(II));
``(II) through reasonable monitoring procedures,
periodically determine whether the individual continues to
meet such requirements; and
``(III) if the board determines that an individual no
longer meets such requirements, not make such plan coverage
available to such individual (or dependents thereof) for any
plan year following the plan year during which the board
makes such determination. If, subsequent to a determination
that an individual no longer meets such requirements, such
individual furnishes evidence of satisfying such
requirements, such individual (and dependents thereof) shall
be eligible to receive plan coverage.
``(D) For purposes of subparagraph (B), all of the
employees (including self-employed individuals) employed by
all of the employer members (including self-employed
individuals) of a group or association of employers shall
be--
``(i) treated as employed by a single employer; and
``(ii) aggregated and counted together for purposes of any
regulation of an employee welfare benefit plan established
and maintained by such group or association.''.
(b) Determination of Employer or Joint Employer Status.--
The provision of employee welfare benefit plan coverage by a
group or association of employers shall not be construed as
evidence for establishing an employer or joint employer
relationship under any Federal or State law.

[[Page H3031]]

SEC. 103. RULES APPLICABLE TO GROUP HEALTH PLANS ESTABLISHED
AND MAINTAINED BY A GROUP OR ASSOCIATION OF
EMPLOYERS.

Part 7 of subtitle B of title I of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1181, et seq.) is
amended by adding at the end the following:

``SEC. 736. RULES APPLICABLE TO GROUP HEALTH PLANS
ESTABLISHED AND MAINTAINED BY A GROUP OR
ASSOCIATION OF EMPLOYERS.

``(a) Premium Rates for a Group or Association of
Employers.--
``(1)(A) In the case of a group health plan established and
maintained by a group or association of employers described
in section 3(5)(B), such plan may--
``(i) establish base premium rates formed on an actuarially
sound, modified community rating methodology that considers
the pooling of all plan participant claims; and
``(ii) utilize the specific risk profile of each employer
member of such group or association to determine contribution
rates for each such employer member's share of a premium by
actuarially adjusting above or below the established base
premium rates.
``(B) For purposes of paragraph (1), the term `employer
member' means--
``(i) an employer who is a member of such group or
association of employers and employs at least 1 common law
employee; or
``(ii) a group made up solely of self-employed individuals,
within which all of the self-employed individual members of
such group or association are aggregated together as a single
employer member group, provided the group includes at least
20 self-employed individual members.
``(2) In the event a group or association is made up solely
of self-employed individuals (and no employers with at least
1 common law employee are members of such group or
association), the group health plan established by such group
or association shall--
``(A) treat all self-employed individuals who are members
of such group or association as a single risk pool;
``(B) pool all plan participant claims; and
``(C) charge each plan participant the same premium rate.
``(b) Discrimination and Pre-existing Condition
Protections.--A group health plan established and maintained
by a group or association of employers described in section
3(5)(B) shall be prohibited from--
``(1) establishing any rule for eligibility (including
continued eligibility) of any individual (including an
employee of an employer member or a self-employed individual,
or a dependent of such employee or self-employed individual)
to enroll for benefits under the terms of the plan that
discriminates based on any health status-related factor that
relates to such individual (consistent with the rules under
section 702(a)(1));
``(2) requiring an individual (including an employee of an
employer member or a self-employed individual, or a dependent
of such employee or self-employed individual), as a condition
of enrollment or continued enrollment under the plan, to pay
a premium or contribution that is greater than the premium or
contribution for a similarly situated individual enrolled in
the plan based on any health status-related factor that
relates to such individual (consistent with the rules under
section 702(b)(1)); and
``(3) denying coverage under such plan on the basis of a
pre-existing condition (consistent with the rules under
section 2704 of the Public Health Service Act).''.

SEC. 104. RULE OF CONSTRUCTION.

Nothing in this title shall be construed to exempt a group
health plan which is an employee welfare benefit plan offered
through a group or association of employers from the
requirements of part 7 of subtitle B of title I of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
1181 et. seq.), including the provisions of part A of title
XXVII of the Public Health Service Act as incorporated by
reference into this Act through section 715.

TITLE II--CHOICE ARRANGEMENT ACT

SEC. 201. SHORT TITLE.

This title may be cited as the ``Custom Health Option and
Individual Care Expense Arrangement Act'' or the ``CHOICE
Arrangement Act''.

SEC. 202. TREATMENT OF HEALTH REIMBURSEMENT ARRANGEMENTS
INTEGRATED WITH INDIVIDUAL MARKET COVERAGE.

(a) In General.--Section 9815(b) of the Internal Revenue
Code of 1986 is amended--
(1) by striking ``Exception.--Notwithstanding subsection
(a)'' and inserting the following: ``Exceptions.--
``(1) Self-insured group health plans.--Notwithstanding
subsection (a)'', and
(2) by adding at the end the following new paragraph:
``(2) Custom health option and individual care expense
arrangements.--
``(A) In general.--For purposes of this subchapter, a
custom health option and individual care expense arrangement
shall be treated as meeting the requirements of sections 2711
and 2713 of title XXVII of the Public Health Service Act.
``(B) Custom health option and individual care expense
arrangements defined.--For purposes of this section, the term
`custom health option and individual care expense
arrangement' means a health reimbursement arrangement--
``(i) which is an employer-provided group health plan
funded solely by employer contributions to provide payments
or reimbursements for medical care subject to a maximum fixed
dollar amount for a period,
``(ii) under which such payments or reimbursements may only
be made for medical care provided during periods during which
the individual is covered--

``(I) under individual health insurance coverage (other
than coverage that consists solely of excepted benefits), or
``(II) under part A and B of title XVIII of the Social
Security Act or part C of such title,

``(iii) which meets the nondiscrimination requirements of
subparagraph (C),
``(iv) which meets the substantiation requirements of
subparagraph (D), and
``(v) which meets the notice requirements of subparagraph
(E).
``(C) Nondiscrimination.--
``(i) In general.--An arrangement meets the requirements of
this subparagraph if an employer offering such arrangement to
an employee within a specified class of employee--

``(I) offers such arrangement to all employees within such
specified class on the same terms, and
``(II) does not offer any other group health plan to any
employees within such specified class.

``(ii) Specified class of employee.--For purposes of this
subparagraph, any of the following may be designated as a
specified class of employee:

``(I) Full-time employees.
``(II) Part-time employees.
``(III) Salaried employees.
``(IV) Non-salaried employees.
``(V) Employees whose primary site of employment is in the
same rating area.
``(VI) Employees who are included in a unit of employees
covered under a collective bargaining agreement to which the
employer is subject (determined under rules similar to the
rules of section 105(h)).
``(VII) Employees who have not met a group health plan, or
health insurance issuer offering group health insurance
coverage, waiting period requirement that satisfies the of
section 2708 of the Public Health Service Act.
``(VIII) Seasonal employees.
``(IX) Employees who are nonresident aliens and who receive
no earned income (within the meaning of section 911(d)(2))
from the employer which constitutes income from sources
within the United States (within the meaning of section
861(a)(3)).
``(X) Such other classes of employees as the Secretary may
designate.

An employer may designate (in such manner as is prescribed by
the Secretary) two or more of the classes described in the
preceding subclauses as the specified class of employees to
which the arrangement is offered for purposes of applying
this subparagraph.
``(iii) Special rule for new hires.--An employer may
designate prospectively so much of a specified class of
employees as are hired after a date set by the employer. Such
subclass of employees shall be treated as the specified class
for purposes of applying clause (i).
``(iv) Rules for determining type of employee.--For
purposes for clause (ii), any determination of full-time,
part-time, or seasonal employment status shall be made under
rules similar to the rules of section 105(h) or 4980H,
whichever the employer elects for the plan year. Such
election shall apply with respect to all employees of the
employer for the plan year.
``(v) Permitted variation.--For purposes of clause (i)(I),
an arrangement shall not fail to be treated as provided on
the same terms within a specified class merely because the
maximum dollar amount of payments and reimbursements which
may be made under the terms of the arrangement for the year
with respect to each employee within such class--

``(I) increases as additional dependents of the employee
are covered under the arrangement, and
``(II) increases with respect to a participant as the age
of the participant increases, but not in excess of an amount
equal to 300 percent the lowest maximum dollar amount with
respect to such a participant determined without regard to
age.

``(D) Substantiation requirements.--An arrangement meets
the requirements of this subparagraph if the arrangement has
reasonable procedures to substantiate--
``(i) that the participant is, or will be, enrolled in
coverage described in subparagraph (B)(ii) as of the
beginning of the plan year of the arrangement (or as of the
beginning of coverage under the arrangement in the case of an
employee who first becomes eligible to participate in the
arrangement after the date notice is given with respect to
the plan under subparagraph (E) (determined without regard to
clause (iii) thereof), and
``(ii) any requests made for payment or reimbursement of
medical care under the arrangement and that the participant
remains so enrolled.
``(E) Notice.--
``(i) In general.--Except as provided in clause (iii), an
arrangement meets the requirements of this subparagraph if,
under the arrangement, each employee eligible to participate
is, not later than 90 days before the beginning of the plan
year, given written notice of the employee's rights and
obligations under the arrangement which--

``(I) is sufficiently accurate and comprehensive to
appraise the employee of such rights and obligations, and
``(II) is written in a manner calculated to be understood
by the average employee eligible to participate.

``(ii) Notice requirements.--Such notice shall include such
information as the Secretary may by regulation prescribe.
``(iii) Notice deadline for certain employees.--In the case
of an employee--

``(I) who first becomes eligible to participate in the
arrangement after the date notice is given

[[Page H3032]]

with respect to the plan under clause (i) (determined without
regard to this clause), or
``(II) whose employer is first established fewer than 120
days before the beginning of the first plan year of the
arrangement,

the requirements of this subparagraph shall be treated as met
if the notice required under clause (i) is provided not later
than the date the arrangement may take effect with respect to
such employee.''.
(b) No Inference.--To the extent not inconsistent with the
amendments made by this section--
(1) no inference shall be made from such amendments with
respect to the rules prescribed in the Federal Register on
June 20, 2019, (84 Fed. Reg. 28888) relating to health
reimbursement arrangements and other account-based group
health plans, and
(2) any reference to custom health option and individual
care expense arrangements shall for purposes of such rules be
treated as including a reference to individual coverage
health reimbursement arrangements.
(c) Effective Date.--The amendments made by this section
shall apply to plan years beginning after December 31, 2023.

TITLE III--SELF-INSURANCE PROTECTION ACT

SEC. 301. SHORT TITLE.

This title may be cited as the ``Self-Insurance Protection
Act''.

SEC. 302. FINDINGS.

Congress finds the following:
(1) Small and large employers offer health benefit plan
coverage to employees in self-funded arrangements using
company assets or a fund, or by paying premiums to purchase
fully-insured coverage from a health insurance company.
(2) Employers that self-fund health benefit plans will
often purchase stop-loss insurance as a financial risk
management tool to protect against excess or unexpected
catastrophic health plan claims losses that arise above
projected costs paid out of company assets.
(3) Stop-loss coverage insures the employer sponsoring the
health benefit plan against unforeseen health plan claims,
does not insure the employee health benefit plan itself, and
does not pay health care providers for medical services
provided to the employees.
(4) Employer-sponsored health benefit plans are regulated
under the Employee Retirement Income Security Act of 1974,
however, States regulate the availability and the coverage
terms of stop-loss insurance coverage that employers purchase
to protect company assets and to protect a fund against
excess or unexpected claims losses.
(5) Both large and small employers that choose to self-fund
must also be able to protect company assets or a fund against
excess or unexpected claims losses and States must reasonably
regulate stop-loss insurance to assure its availability to
both large and small employers.

SEC. 303. CERTAIN MEDICAL STOP-LOSS INSURANCE OBTAINED BY
CERTAIN PLAN SPONSORS OF GROUP HEALTH PLANS NOT
INCLUDED UNDER THE DEFINITION OF HEALTH
INSURANCE COVERAGE.

Section 733(b)(1) of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1191b(b)(1)) is amended by
adding at the end the following sentence: ``Such term shall
not include a stop-loss policy obtained by a self-insured
group health plan or a plan sponsor of a group health plan
that self-insures the health risks of its plan participants
to reimburse the plan or sponsor for losses that the plan or
sponsor incurs in providing health or medical benefits to
such plan participants in excess of a predetermined level set
forth in the stop-loss policy obtained by such plan or
sponsor.''.

SEC. 304. EFFECT ON OTHER LAWS.

Section 514(b) of the Employee Retirement Income Security
Act of 1974 (29 U.S.C. 1144(b)) is amended by adding at the
end the following:
``(10) The provisions of this title (including part 7
relating to group health plans) shall preempt State laws
insofar as they may now or hereafter prevent an employee
benefit plan that is a group health plan from insuring
against the risk of excess or unexpected health plan claims
losses.''.

TITLE IV--SMALL BUSINESS FLEXIBILITY ACT

SEC. 401. SHORT TITLE.

This title may be cited as the ``Small Business Flexibility
Act''.

SEC. 402. NOTIFICATION OF FLEXIBLE HEALTH INSURANCE BENEFITS.

(a) In General.--Subchapter C of chapter 100 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new section:

``SEC. 9835. NOTIFICATION OF FLEXIBLE HEALTH INSURANCE
BENEFITS.

``(a) In General.--Not later than 1 year after the date of
enactment of this section, the Secretary shall notify
employers of the availability of tax-advantaged flexible
health insurance benefits, with an initial focus on small
businesses.
``(b) Definitions.--In this section:
``(1) Employer.--The term `employer' has the meaning given
such term in section 3(5) of the Employee Retirement Income
Security Act (29 U.S.C. 1002(5)).
``(2) Flexible health insurance benefits.--The term
`flexible health insurance benefits' means--
``(A) an individual contribution health reimbursement
arrangement (as described in the rule entitled `Health
Reimbursement Arrangements and Other Account-Based Group
Health Plans' (84 Fed. Reg. 28888 (June 20, 2019));
``(B) a qualified small employer health reimbursement
arrangement (as defined in section 9831(d)(2)); and
``(C) the small employer health insurance credit determined
under section 45R.''.
(b) Clerical Amendment.--The table of sections for
subchapter C of chapter 100 of such Code is amended by adding
at the end the following new item:

``Sec. 9835. Notification of flexible health insurance benefits.''.

TITLE V--RESCISSIONS

SEC. 501. PREVENTION AND PUBLIC HEALTH FUND.

Section 4002(b)(7) of the Patient Protection and Affordable
Care Act (42 U.S.C. 300u-11(b)(7)) is amended by striking
``for each of fiscal years 2024 and 2025, $1,300,000,000''
and inserting ``for fiscal year 2024, $1,055,000,000, and for
fiscal year 2025, $1,300,000,000''.

The Acting CHAIR. No further amendment to the bill, as amended, shall
be in order except those printed in part D of House Report 118-115.
Each such further amendment may be offered only in the order printed in
the report, by the Member designated in the report, shall be considered
as read, shall be debatable for the time specified in the report
equally divided and controlled by the proponent and an opponent, shall
not be subject to amendment, and shall not be subject to a demand for
division of the question.

Amendment No. 1 Offered by Mrs. Hayes

The Acting CHAIR. It is now in order to consider amendment No. 1
printed in part D of House Report 118-115.
Mrs. HAYES. Madam Chair, I have an amendment at the desk.
The Acting CHAIR. The Clerk will designate the amendment.
The text of the amendment is as follows:

Page 23, after line 13, insert:

TITLE V--EFFECTIVE DATE

SEC. 501. EFFECTIVE DATE.

This Act shall not take effect unless the Secretary of
Labor certifies that the amendments made by this Act would
not result in higher premium rates for older workers.

The Acting CHAIR. Pursuant to House Resolution 524, the gentlewoman
from Connecticut (Mrs. Hayes) and a Member opposed each will control 5
minutes.
The Chair recognizes the gentlewoman from Connecticut.
Mrs. HAYES. Madam Chair, I yield myself such time as I may consume.
Madam Chair, I rise in support of my amendment to the CHOICE
Arrangement Act.
This bill, as written, makes healthcare less accessible and
affordable for our most at-risk workers. My amendment prevents older
workers from obscene healthcare premiums and discrimination.
As of January 2023, a record 16.3 million people, including older
Americans, were insured under the Affordable Care Act.
According to the Center on Budget and Policy Priorities, under the
Affordable Care Act, older adults' uninsured rate has dropped by one-
third, a factor that is a key indicator their health and wellness has
improved. Further, they are now protected from coverage exclusions and
cost increases due to preexisting conditions.
In 2019, people aged 55 to 64 had the lowest uninsured rate among
nonelderly adults, but instead of working to build upon this success,
my colleagues are bolstering individual coverage health reimbursement
arrangements and association health plans which have a long, well-
documented history of cutting costs for themselves by cherry-picking
the cheapest people to cover, leaving the more expensive and vulnerable
ones behind. This raises costs for those not chosen and causes premiums
to go up for the rest of the insurance market.
Republicans have been pushing these efforts for decades, and experts
have consistently found it to be harmful. In its final rule adopted in
2018 by the Trump administration, the Department of Labor acknowledged
as much, noting the ``AHPs could use their regulatory flexibility to
design more tailored, less comprehensive health coverage . . . Which
will necessarily lead to some favorable risk selection toward AHPs and
adverse selection against individuals and small group markets.''
They predicted this would raise premiums for consumers who are left
behind in the small group and individual markets.
For decades, independent experts at the American Academy of Actuaries
and the Congressional Budget Office have repeatedly found premiums for
older workers would be higher as a result of the association health
plan legislation.
The bill has only superficial protections from discrimination based
on

[[Page H3033]]

health status and is entirely silent on discrimination and pricing
against older individuals. In fact, by explicitly allowing associations
to base premiums on the risk factor on each employee within the group,
it invites them to discriminate against other characteristics.
My amendment requires the Department of Labor to certify that the
bill would not raise premiums for older Americans before taking effect.
I ask my colleagues to support my amendment to protect older
Americans and implore that we work together to address the real
healthcare problems in our Nation and move toward a more equitable
healthcare system for older workers.
Madam Chair, I reserve the balance of my time.
Ms. FOXX. Madam Chair, I rise in opposition to the amendment.
The Acting CHAIR. The gentlewoman from North Carolina is recognized
for 5 minutes.
Ms. FOXX. Madam Chair, I yield myself such time as I may consume.
Madam Chair, I am pleased my Democratic colleagues are finally
expressing some concern for rising healthcare costs, particularly the
burden those costs can impose on our Nation's seniors.
I remind my Democrat colleagues that Medicare is expected to become
insolvent in 8 years. Increasing access to AHPs may be a lifesaving
option for these seniors if Congress does not address Medicare's
insolvency issues.
Unfortunately, for seniors, premiums of older Americans have risen
drastically thanks to ObamaCare. In fact, health plans in New York just
requested rate bumps of up to 40 percent.
The percentage of healthcare costs paid by a health insurance plan is
known as the actuarial value, AV. On average, the AV of an individual
employer-sponsored plan is 83 percent. When compared to the 70 percent
AV of a silver plan and even the 80 percent AV of a gold plan on the
Affordable Care Act exchanges, employer-sponsored plans provide
affordable and more comprehensive coverage than ACA plans.
Employer-sponsored plans also have lower average deductibles: $1,763
for an individual employer-sponsored insurance plan compared with
$5,155 for an individual ACA exchange silver plan.
I will repeat that: $1,763 on an employer-sponsored plan, for an
individual employer-sponsored insurance plan, compared with $5,155 for
an individual ACA exchange silver plan.
Individual employer-sponsored plans have lower average out-of-pocket
costs than ACA exchange plans.
Madam Chair, $4,355 is the average maximum for an individual-
sponsored insurance plan compared with an average maximum of $8,519 for
an individual marketplace silver/ACA plan.
Clearly, our government-run and government-subsidized healthcare
programs are facing incredible fiscal challenges. I urge my colleagues
to be more concerned with the older adults enrolled in those programs
than those enrolled in large group employer plans.
This amendment is an insincere attempt to delay implementation of
commonsense policy that will increase health coverage options for all
Americans. Instead, AHPs and the coverage options provided under this
bill give older Americans more affordable coverage options.
Madam Chair, for these reasons, I urge my colleagues to vote ``no''
on the amendment and ``yes'' on the underlying bill, and I reserve the
balance of my time.

Mrs. HAYES. Madam Chair, I yield 2 minutes to the gentleman from
Virginia (Mr. Scott), who is the distinguished ranking member of the
Committee on Education and the Workforce.
Mr. SCOTT of Virginia. Madam Chair, I thank the gentlewoman for
yielding.
Madam Chair, I rise in support of this amendment. Association health
plans have a long, well-documented history of cutting costs for
themselves by cherry-picking the cheapest people to cover and leaving
the more expensive behind. This raises costs for everybody else and
causes premiums to go up in the rest of the market. Republicans have
been pushing this idea for decades, and experts have consistently found
it to be harmful.
The Affordable Care Act made a number of reforms to commercial
insurance markets, including a requirement that plans in the individual
and small group markets cover essential health benefits such as
maternity care and prescription drugs. The ACA also prevented these
plans from charging higher rates based on health status and limited the
premium amount that older people could be charged compared to younger
people. This was a vital protection that ensured that an age tax would
not make coverage unaffordable for older individuals.

{time} 1645

This legislation has no protection without this amendment. The bill
is entirely silent on discriminatory pricing against older people. In
fact, by explicitly allowing associations to base premiums on risk
factors of each employer within the group, it actually invites them to
charge older Americans much more.
This amendment would ensure that older workers are protected by
providing in this bill that it would not take effect until the
Secretary of Labor certifies that it would not have the impact of
raising premiums for older workers.
I thank the gentlewoman from Connecticut for her leadership on the
Education and the Workforce Committee.
Madam Chair, I urge my colleagues to support the amendment.
Ms. FOXX. Madam Chair, I believe I have the right to close, so I
reserve the balance of my time.
Mrs. HAYES. Madam Chair, I urge my colleagues to support this
commonsense amendment to protect older Americans with preexisting
conditions.
The ACA expanded Medicaid for low-income Americans and protected
coverage for people with preexisting conditions. We want to make sure
we continue that tradition and make sure that the CHOICE Arrangement
Act will not go into effect until the Secretary of Labor certifies that
this bill will not result in higher premiums for older Americans and
seniors. It is critical that we protect this access.
Madam Chair, I yield back the balance of my time.
Ms. FOXX. Madam Chair, again, our colleagues continue to try to
mislead the American people about what this bill does. These plans
cannot cherry-pick, cannot exclude, and must cover preexisting
conditions.
The opposition to this bill from our colleagues across the aisle,
unfortunately, is to freedom of choice. The title of this bill is the
CHOICE Arrangement Act, freedom of choice, which would allow people to
stay out of the non-affordable care act, known as ObamaCare, but still
have affordable health insurance.
This bill is about choice, freedom, and good healthcare coverage, and
we should approve the bill without this amendment.
Madam Chair, I ask my colleagues to vote ``no'' on the amendment, and
I yield back the balance of my time.
The Acting CHAIR. The question is on the amendment offered by the
gentlewoman from Connecticut (Mrs. Hayes).
The question was taken; and the Acting Chair announced that the noes
appeared to have it.
Mrs. HAYES. Madam Chair, I demand a recorded vote.
The Acting CHAIR. Pursuant to clause 6 of rule XVIII, further
proceedings on the amendment offered by the gentlewoman from
Connecticut will be postponed.

Amendment No. 2 Offered by Mr. Molinaro

The Acting CHAIR. It is now in order to consider amendment No. 2
printed in part D of House Report 118-115.
Mr. MOLINARO. Madam Chair, I have an amendment at the desk.
The Acting CHAIR. The Clerk will designate the amendment.
The text of the amendment is as follows:

Page 22, line 17, insert ``, particularly in rural areas
(as defined in section 1393(a)(2))'' after ``businesses''.
The Acting CHAIR. Pursuant to House Resolution 524, the gentleman
from New York (Mr. Molinaro) and a Member opposed each will control 5
minutes.
The Chair recognizes the gentleman from New York.
Mr. MOLINARO. Madam Chair, I yield myself such time as I may consume.
Madam Chair, I appreciate the opportunity this afternoon to speak on
my

[[Page H3034]]

amendment to the underlying bill, which, as we know, does help to
unlock the growth and prosperity of our Nation's small businesses and
their employees.
My amendment is simple and straightforward. It will ensure that small
businesses and employers, particularly those in rural communities
across the country, are made aware of tax-advantaged flexible health
insurance benefits. Employers, especially in the rural areas like the
ones I represent in upstate New York, should have the tools to provide
their employees with various options to lower their healthcare costs
and to access quality care.
As a member of the House Committee on Small Business, I know the
unique challenges businesses in rural communities and those
businessowners and employees face every day. With a comprehensive focus
on rural areas, we can help ensure that all businesses, regardless of
their ZIP Code, have equal opportunity to provide affordable, high-
quality healthcare benefits.
Madam Chair, I appreciate the opportunity to speak to this amendment.
I urge its consideration, and I reserve the balance of my time.
Mr. DOGGETT. Madam Chair, I rise in opposition to the amendment.
The Acting CHAIR. The gentleman from Texas is recognized for 5
minutes.
Mr. DOGGETT. Madam Chair, I yield myself such time as I may consume.
This amendment has a rather nominal effect in not improving what is a
very bad and deceptive bill.
It is appealing to talk about rural areas. I am concerned about those
rural areas, about the chicken pluckers, about the meatpackers, about
the field workers, and the way they will be discriminated against under
this bill.
I will elaborate on that. While this is mainly a Republican caucus
that follows the seditious pied piper who was our President, in this
case, even under the Trump administration, when they considered this
kind of proposal, the Treasury Department, the Labor Department, and
the Health and Human Services Department came together and recognized
the danger of discriminating against different classes of employees.
Ultimately, unfortunately, the Trump administration did not provide
the protection against discrimination, so that people who are working
in rural areas under this bill may be discriminated against by their
employer as a result of this legislation.
It is the failure to have clear language in this bill to prevent such
discrimination against rural workers, in favor of those who are in the
office towers managing everything, that is at the heart of our
opposition, as well as the refusal to provide protection and guarantees
against people being denied as a result of their preexisting
conditions.
Rural Americans are more likely to die from heart disease, cancer,
stroke, unintentional injury, and respiratory disease. Yet, we would
take our sickest workers, our most vulnerable low-income workers, and
deny them a comprehensive employer plan with many protections and allow
them to be the subject of discrimination.
There has already been too much discrimination against rural areas
and rural workers. We ought to prevent it, not make it worse.
There are no guarantees that these people can find any coverage with
their ICHRA plan, let alone affordable and quality coverage.
I think rural Americans deserve far better than this amendment to try
to put a patch on a very sorry bill that undermines the protections of
the Affordable Care Act that has offered great benefit to so many
Americans, and I urge everyone to vote ``no.''
Madam Chair, I reserve the balance of my time.
Mr. MOLINARO. Madam Chair, I yield 30 seconds to the gentlewoman from
North Carolina (Ms. Foxx).
Ms. FOXX. Madam Chair, I appreciate Mr. Molinaro's amendment. I
support it, and I appreciate his working to make a good bill better.
Mr. MOLINARO. Madam Chair, this amendment, as a reminder to my
colleagues across the aisle, is simply meant to broaden access and
educate small business owners all across this country as to the
benefits that are available to them to access affordable, quality
healthcare.
Madam Chair, I yield back the balance of my time.
Mr. DOGGETT. Madam Chair, I yield myself the balance of my time.
Madam Chair, I would say that the only education that would be really
helpful on this bill would be to educate both employers and employees
about all the shortcomings of this bill.
Educating employers that they ought not to be discriminating against
classes of workers and treating the rural, hardworking employees there
at lower wages differently where they get an ICHRA policy that denies
them preexisting conditions, that denies them the essential benefits
under the Affordable Care Act, while the folks in the city in
management get treated differently--they get a concierge kind of
treatment that is not available to the rural workers. Just educating
about this bill, which allows that discrimination, would not accomplish
much of anything.
I think what we are going to see with this kind of legislation is
more and more workers in rural areas, as well as urban areas, who face
discrimination and who face great medical debt because these plans are
so weak. They are junk insurance that will deny the benefits that most
people need.
Educating about them, if truthful education, if not the kind of
deception that is buried in this bill, educating about them will only
tell people the limitations and the shortcomings. Otherwise, it will be
a kind of education that covers up, as this bill does, the great harm
that is being done in denying folks access to a family physician with
the protection that is there.
Remember that in moving to these ICHRA plans, we already know that 95
percent of those that are in ICHRA plans today, that have this icky
kind of coverage, are people who once had good group health insurance
that I would like to see available to more Americans.
Again, I urge my colleagues to definitely vote ``no'' on this
amendment and vote ``no'' on this sorry bill and support our motion to
recommit.
Madam Chair, I yield back the balance of my time.
The Acting CHAIR. The question is on the amendment offered by the
gentleman from New York (Mr. Molinaro).
The question was taken; and the Acting Chair announced that the ayes
appeared to have it.
Mr. DOGGETT. Madam Chair, I demand a recorded vote.
The Acting CHAIR. Pursuant to clause 6 of rule XVIII, further
proceedings on the amendment offered by the gentleman from New York
will be postponed.

Amendment No. 3 Offered by Mr. Roy

The Acting CHAIR. It is now in order to consider amendment No. 3
printed in part D of House Report 118-115.
Mr. ROY. Madam Chair, I have an amendment at the desk.
The Acting CHAIR. The Clerk will designate the amendment.
The text of the amendment is as follows:

Page 23, after line 13, insert the following:

TITLE V--SENSE OF CONGRESS THAT AMERICANS SHALL HAVE HEALTHCARE FREEDOM

SEC. 501. SENSE OF CONGRESS THAT HEALTHCARE FREEDOM IS THE
FUTURE.

It is the sense of Congress that--
(1) the future of healthcare lies in healthcare freedom,
not in socialized medicine;
(2) Congress should take steps to address the broken
healthcare system by restoring free market practices to lower
costs;
(3) coverage is not care, and expanding direct access to
healthcare should be prioritized over expanding access to
coverage; and
(4) patients and doctors, not government bureaucrats or
insurance bureaucrats, should make healthcare decisions.

The Acting CHAIR. Pursuant to House Resolution 524, the gentleman
from Texas (Mr. Roy) and a Member opposed each will control 5 minutes.
The Chair recognizes the gentleman from Texas.
Mr. ROY. Madam Chair, I notice that my friend and colleague from
Texas talks about the current system discriminating. Well, the current
system discriminates against small businesses and people who can't
afford the massive cost of insurance or care. That is the truth.
My colleague refers to an icky kind of coverage. The fact of the
matter is

[[Page H3035]]

that we have a large segment of the American people who are trapped in
so-called coverage, but they are not able to get care.
That is why we are here. We are trying to increase options for the
American people.
My only concern about what we are doing with this legislation, which
I wholeheartedly support, and trying to encourage small businesses and
give them options to be able to provide better options for their
employees, is I don't believe that, in America, you should only be able
to get insurance through government or your employer.
We should be freeing up the system. We should be embracing healthcare
freedom. We should be creating an environment where the American people
control their healthcare rather than employers and government. That is
the truth.
I offered an amendment to simply spell that out in the form of a
sense of Congress, a sense of Congress that the future of healthcare
lies in healthcare freedom, not in socialized medicine; that Congress
should take steps to address the broken healthcare system by restoring
free market practices to lower costs; that coverage is not care and
expanding direct access to healthcare should be prioritized over
expanding access to coverage; and that patients and doctors, not
government bureaucrats or insurance bureaucrats, should make healthcare
decisions.
Why do I think that? Well, the deals that are struck with the
government by big corporations are the problem. For example, most
recently, ObamaCare guaranteed their actual growth and profit. For
example, Anthem had a 344 percent increase in government revenue from
2010 to 2020. UnitedHealthcare had a 198 percent increase. Cigna,
Anthem, UnitedHealthcare, and Humana have seen an average increase of
562 percent in their stock prices from January 2011 to January 2021.
Here is the kicker. In 2018, for at least three of these companies,
the majority of their revenue came from the government:
UnitedHealthcare, 53.4 percent; Anthem, 58.7 percent; and Humana, a
whopping 86.9 percent.
It is that corporate cronyism that is reducing options. They are
making it more difficult for the American people.
The fact is, for Americans who are trapped in coverage through
ObamaCare--for example, when I came to Congress as a Member of
Congress, I was put on ObamaCare, not some gold-plated plan that flies
around on the internet that we supposedly have, but on ObamaCare. The
place I went to cure the cancer that I had a decade ago, MD Anderson, I
wouldn't be allowed to use. What kind of coverage is that?
That is what we are telling the American people. That is the best we
can do in the freest, greatest country in the history of the world. Bow
down to the altar of government and corporate America to be able to
figure out how you should get care.
Madam Chair, I reserve the balance of my time.
Mr. DOGGETT. Madam Chair, I rise in opposition to the amendment.
The ACTING Chair. The gentleman from Texas is recognized for 5
minutes.
Mr. DOGGETT. Madam Chair, I yield myself such time as I may consume.
Madam Chair, I don't believe that we have noted yet in the course of
this debate the great irony, the fact that this is called the CHOICE
Arrangement Act, that we have some pro-choice Republicans here who want
to give employers the choice and allow them to discriminate against
different classes of their own employees. All of this is happening the
same horrible anniversary week of the Supreme Court's wrongful decision
to overturn decades of reliance upon Roe v. Wade and to eliminate the
right to an abortion with an effect on women's healthcare that is so
far-reaching that it is affecting our colleges of medicine across the
country and delivery of healthcare to women who may never have been
involved in the slightest way with an abortion.

{time} 1700

They called this healthcare freedom today. I call it the repression
and the interference with the basic healthcare rights of women.
By the terms of their own amendment, patients and doctors should make
healthcare decisions, not government bureaucrats or insurance
companies. The CHOICE Arrangement Act comes at the same time that they
interfere with what happens in our bedrooms and our doctors' offices
and, most recently, even in our kitchens.
They would sentence patients under this basic legislation with
preexisting conditions to a future of very few choices and no freedom.
With no choices for adequate and affordable healthcare, this
legislation guarantees one kind of prescription and one kind of
prescription only, and that is a prescription for personal bankruptcy
and unlimited medical debt from policies that do not provide essential
healthcare benefits.
It is really a shame that, in a country as wealthy as ours, we still
have millions of citizens who go without health coverage. Over 30
million Americans, in fact, lack coverage, and many in our home State
of Texas lack coverage because of the fact that our State legislature
and Governor were never willing to provide the guarantee we anticipated
with the Affordable Care Act of Medicaid expansion as most States have
done.
Patients do not have a choice, do not have freedom when they suffer a
heart attack or are diagnosed with a dreaded disease or a broken arm,
and they lack insurance coverage that provides them the benefits that
they need.
Under this amendment, which is a sense of Congress resolution that
really doesn't accomplish much of anything, this bill is not improved.
Americans would have so much skin in the game they would get burned
just as the Republican dirty fossil fuel plan would burn up our planet.
It is not just the Affordable Care Act that is being targeted today.
There is reference to socialized medicine of the kind that Newt
Gingrich once attacked in this body when he suggested Medicare should
``wither on the vine.''
Contrary to Republican attacks, we have heard about public insurance
programs. Seniors on Medicare value their Medicare as do the 16 million
people who signed up for the Affordable Care Act this year.
Madam Chair, I reserve the balance of my time.
Mr. ROY. Madam Chair, do you know who should decide what an essential
health benefit is? The consumer, the American, not a government
bureaucrat or a corporate bureaucrat. I will stand up for the 5,000
babies that have been born in Texas greater than last year's number of
babies in the wake of the Dobbs decision.
Let me just say this. According to the CBO, Federal subsidies for
health insurance coverage for Americans under the age of 65 will hit $1
trillion this year. The average American family spends more than
$22,000 a year on premiums for themselves through their employees.
Again, coverage is not care.
There are other healthcare models that work. The Wall Street Journal
showed what cutting out the middleman in healthcare can do for costs:
$150 a month to cover a family of five on a direct primary care model.
A DPC practice in my district charges only $50 to $80 for an X-ray
compared to the national average of $125. MRIs are $300 to $450
compared to the national average of $1,325.
It is not just primary care. For example, at the Surgery Center of
Oklahoma, a direct care model, a knee replacement costs $18,000
compared to the average cost of $50,000 in the United States.
Healthcare sharing ministries are driving down costs for the American
people, giving them coverage and giving them options.
The fact is we should imagine an America where, through a health
savings account, your employer can give you real dollars, rather than a
faceless insurance company, to pursue real care of your choice, so for
a flat monthly fee, you and your children have unlimited access to the
physician of your choice. You could still get insurance for the big
stuff, walking into a doctor's office and knowing how much things are
going to cost.
Right now, the American people do not have options. I support this
bill, but this amendment is important because we need a trajectory
change in this country in favor of healthcare freedom, in favor of
personalized care, in favor of patients and doctors over bureaucrats
and corporations that are getting rich because the government is
subsidizing their corporate cronyism.

[[Page H3036]]

Madam Chair, I yield back the balance of my time.
Mr. DOGGETT. Madam Chair, this is the freedom resolution on the week
that we have the anniversary of the anti-choice Dobbs decision as part
of the CHOICE Arrangement Act.
Well, I am reminded of the lyrics of a famous Janis Joplin song:
``Freedom is just another word for nothing left to lose.'' No choice is
left. No freedom is left. This is our future under Republican plans--so
much to lose, nothing left tomorrow.
We need to protect more Americans from the dangers of health debt and
bankruptcy. We need to ensure broader coverage. There is a huge
coverage gap that is leaving perhaps as many as 2 million Texans
without coverage because of the failures and ideological objections of
our State Republican government.
Those Americans deserve the same protection that 16 million Americans
got when they signed up for the Affordable Care Act this year. They
have access to a family physician that is so very important. They have
access to the essential benefits of the Affordable Care Act, getting
access to the kind of care that they need to ensure their family is
secure.
I believe that there are many improvements that are necessary in the
Affordable Care Act. We were limited in being able to make those
improvements when all we had for more than a decade were 60-plus
Republican attempts to repeal the Affordable Care Act.

Let us reject this bill and this amendment.
Madam Chair, I yield back the balance of my time.
The Acting CHAIR. The question is on the amendment offered by the
gentleman from Texas (Mr. Roy).
The question was taken; and the Acting Chair announced that the ayes
appeared to have it.
Mr. DOGGETT. Madam Chair, I demand a recorded vote.
The Acting CHAIR. Pursuant to clause 6 of rule XVIII, further
proceedings on the amendment offered by the gentleman from Texas will
be postponed.
Ms. FOXX. Madam Chair, I move that the Committee do now rise.
The motion was agreed to.
Accordingly, the Committee rose; and the Speaker pro tempore (Mr.
Self) having assumed the chair, Mrs. Wagner, Acting Chair of the
Committee of the Whole House on the state of the Union, reported that
that Committee, having had under consideration the bill (H.R. 3799) to
amend the Internal Revenue Code of 1986 to provide for health
reimbursement arrangements integrated with individual health insurance
coverage, had come to no resolution thereon.

____________________