[Congressional Record (Bound Edition), Volume 156 (2010), Part 4]
[Extensions of Remarks]
[Page 5385]
[From the U.S. Government Publishing Office, www.gpo.gov]




         THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010

                                 ______
                                 

                           HON. ALAN GRAYSON

                               of florida

                    in the house of representatives

                        Tuesday, April 13, 2010

  Mr. GRAYSON. Madam Speaker, the Patient Protection and Affordable 
Care Act of 2010 is a triumph for American consumers of health 
insurance and health care. When fully implemented, it will extend 
health care insurance to 32 million uninsured Americans, covering 95 
percent of American citizens and legal residents. It will extend 
premium affordability tax credits to 20 million Americans and help 4 
million small businesses provide health insurance for their workers. By 
the end of this year it will end some of the worst insurance company 
abuses such as post-claims underwriting or lifetime limits on coverage. 
When fully implemented it will ban even more, including health status 
underwriting and exclusions of pre-existing conditions. This 
legislation will ``bend the curve'' in the unsustainable growth in 
health care costs while improving the quality of American health care. 
It encourages wellness and prevention and will help Americans become 
among the best informed health insurance consumers in the world.
  Such sweeping legislation cannot explicitly address every issue that 
will arise under its provisions. In the near term, the legislation must 
be implemented through regulations promulgated by the federal executive 
agencies--in particular Health and Human Services, Labor, and 
Treasury--and by the states. Ultimately, the courts may need to 
interpret some of the provisions of the statute.
  It is important, therefore, to set down the intention of Congress as 
to the principles of construction that should be applied in 
implementing and interpreting the law. The first and foremost of these 
is captured in the title of the bill. This legislation should always be 
construed to protect patients and to make health insurance and health 
care more affordable for consumers. Whenever the bill is silent or 
ambiguous on a particular issue it should be construed by a federal or 
state agency or court to accomplish this goal.
  Many of the provisions of this bill, including the premium tax 
credits and cost-sharing assistance, the individual and employer 
responsibility provisions, and the Medicare and Medicaid reforms and 
expansions, must be implemented by the federal agencies. In drafting 
regulations, the agencies must first and foremost attend to the 
interests of patients, consumers, and beneficiaries. Many other 
provisions will ultimately be implemented by the states. The general 
interpretive principle of the insurance reform legislation in relation 
to the states is found in section 1321(d), which states ``Nothing in 
this title shall be construed to preempt any State law that does not 
prevent the application of the provisions of this title.'' In other 
words, state laws more protective of consumers are preserved; state 
laws less protective of consumers are preempted.
  Several issues raised by the legislation illustrate the application 
of these principles. First, nowhere does section 2719, which prescribes 
internal and external review procedures that insurance plans must 
follow when consumers appeal coverage determinations, explicitly state 
that all state and federal judicial remedies remain available if an 
appeal is denied both internally and externally. Every state, however, 
provides for judicial review of insurance claims denials in the 
nongroup market and 29 U.S.C. sec. 1132 offers judicial review of group 
health claims. These remedies are not expressly displaced by the law, 
and it is the intention of Congress that they continue to be available 
to aggrieved consumers.
  Second, grandfathering of insurance plans that pre-date the 
legislation is not forever. A principle announced repeatedly by the 
President throughout the debate was that ``if you like the insurance 
coverage you have, you can keep it.'' Congress never intended, however, 
that if you had insurance coverage you did not like, you would be stuck 
with it forever. Section 1251 of the PPACA, therefore, should not be 
interpreted to mean that an insured who is enrolled in a group health 
plan will never be extended the consumer protections found in the 
legislation. If coverage under the plan changes significantly, for 
example through increased cost-sharing for members, the plan's 
grandfathered status should be lost and the full protections of the 
legislation apply.
  Third, the ban on pre-existing condition exclusions for children 
under sec. 10103(e) does not merely mean that plans cannot exclude pre-
existing conditions from coverage, but also that they cannot exclude 
children with pre-existing conditions from coverage. The law must be 
interpreted broadly to achieve its purposes, not narrowly to encourage 
evasion.
  Fourth, the provisions of sec. 2714 of the Public Health Services Act 
added by sec. 1001 of the PPACA extending coverage to adult children up 
to age 26 should be interpreted to require the extension of family 
coverage to cover adult children, not to permit insurers to separately 
underwrite such children or to require them to pay the full cost of 
adult coverage.
  Fifth, the provisions of sec. 1332 of the PPACA allowing state 
waivers for innovation are intended to provide maximum flexibility for 
the Secretary of the Treasury and the Secretary of Health and Human 
Services so long as the state plan is at least as comprehensive and 
affordable, and so long as it covers at least as many people as the law 
would provide otherwise.
  Finally, the provisions of sec. 715 of ERISA added by 1562 of the 
PPACA should be understood to fully extend all of the protections of 
the PPACA that apply to group health plans to all employment-related 
health plans, including self-insured plans. The law should also be 
understood to intend that the full authority of the Departments of 
Labor and Treasury in regulating and enforcing the law against ERISA 
plans is available to enforce the terms of the PPACA.
  These are only a few examples of many issues that will no doubt arise 
in implementing and interpreting the law. The general principles that 
they illustrate, however, must be applied throughout by the federal 
agencies, by the states, and by the courts. This law is intended to 
protect patients and consumers, and whenever it is silent or unclear, 
it must be construed toward these ends.