[Congressional Record (Bound Edition), Volume 163 (2017), Part 4]
[House]
[Pages 4760-4778]
[From the U.S. Government Publishing Office, www.gpo.gov]




 PROVIDING FOR CONSIDERATION OF H.R. 1628, AMERICAN HEALTH CARE ACT OF 
                                  2017

  Mr. SESSIONS. Mr. Speaker, by direction of the Committee on Rules, I 
call up House Resolution 228 and ask for its immediate consideration.
  The Clerk read the resolution, as follows:

                              H. Res. 228

       Resolved, That upon adoption of this resolution it shall be 
     in order to consider in the House the bill (H.R. 1628) to 
     provide for reconciliation pursuant to title II of the 
     concurrent resolution on the budget for fiscal year 2017. All 
     points of order against consideration of the bill are waived. 
     The amendments specified in section 2 of this resolution 
     shall be considered as adopted. The bill, as amended, shall 
     be considered as read. All points of order against provisions 
     in the bill, as amended, are waived. The previous question 
     shall be considered as ordered on the bill, as amended, and 
     on any further amendment thereto, to final passage without 
     intervening motion except: (1) four hours of debate equally 
     divided and controlled by the chair and ranking minority 
     member of the Committee on the Budget or their respective 
     designees; and (2) one motion to recommit with or without 
     instructions.
       Sec. 2.  The amendments referred to in the first section of 
     this resolution are as follows:
        (a) The amendment printed in part A of the report of the 
     Committee on Rules accompanying this resolution modified by 
     the amendment printed in part B of that report.
       (b) The amendment printed in part C of the report of the 
     Committee on Rules accompanying this resolution modified by 
     the amendments printed in part D and part E of that report.

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


                             General Leave

  Mr. SESSIONS. Mr. Speaker, I ask unanimous consent that all Members 
may have 5 legislative days to revise and extend their remarks.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Texas?
  There was no objection.

                              {time}  0915

  Mr. SESSIONS. Mr. Speaker, I rise in support of this rule and the 
underlying legislation.
  This rule is a fair rule that adequately provides both sides of the 
aisle with ample time to debate the merits of the underlying 
legislation. In fact, the Rules Committee thought it was so important 
that ample time be provided to this debate, that we are provided 4 
hours of general debate on the underlying bill.
  Mr. Speaker, in honor of our former President, Ronald Reagan, I wear

[[Page 4761]]

brown today. The former President, when he was President, believed that 
wearing brown was good luck to him and good luck for the things which 
he was undertaking. So, in honor of Ronald Reagan, I, too, wear my 
brown jacket today.
  Mr. Speaker, it has become abundantly clear that ObamaCare has failed 
the American people. Our Nation's healthcare system today is broken and 
only getting worse under the current law, known as the Affordable Care 
Act, or ObamaCare.
  Simply put, ObamaCare is collapsing, and it is collapsing fast. 
Options and choices are disappearing for consumers, and an 
anticompetitive marketplace has been created that firmly harms 
patients.
  How bad is it? Nearly one-third of all U.S. counties currently have 
only one insurer offering plans on their State's exchanges. That is a 
government-created monopoly, Mr. Speaker, and that kills the free 
market, meaning no choices for the American people and higher costs are 
what the American consumer and the healthcare market are finding.
  And it is only continuing to get worse. As more and more insurers 
leave the marketplace, prices will continue to rise, forcing healthy 
individuals to make economic decisions not to purchase health care, 
creating a self-defeating spiral of rising costs and less options. That 
is why we must act, and act today, which is what we are doing.
  It is no wonder that in such a government-controlled system that 
premiums have increased by an average of 25 percent on the ObamaCare 
exchanges this year alone. And it is no wonder that some 19.2 million 
taxpayers chose to outright pay the individual mandate penalty or 
claimed an exemption. What this means is that ObamaCare is not a good 
option to these 19.2 million people.
  Mr. Speaker, the American people, I believe, sent us to Washington, 
D.C., to fix this issue. They are telling us directly: this must be 
fixed now. And people certainly outside of Washington resent the 
Federal Government telling them how to purchase health care and what 
that healthcare marketplace would look like. But we really do not have 
to tolerate this. We do not have to agree that we will accept the 
status quo.
  Mr. Speaker, I believe the American people are smart. I believe the 
American people want independence, they love freedom, and they want to 
know that they can make their own choices, because they believe they 
make better choices than a one-size-fits-all plan out of Washington, 
D.C.
  What brings us here today, however, most assuredly, is a broken 
system. So, Republicans offer today H.R. 1628, the American Health Care 
Act of 2017, which will eliminate Washington's one-size-fits-all 
healthcare policy for the American people. It dismantles the disastrous 
ObamaCare taxes that are strangling the working middle class and 
diminishing America's economic prowess. We will end this with the 
opportunity to vote today to change the status quo.
  It eliminates the onerous employer and individual mandates. It 
prohibits health insurers from denying coverage and helps young adults 
access health care by getting back into the marketplace while 
stabilizing and restoring the free market opportunities for all 
Americans.
  Mr. Speaker, the American people are counting on Washington getting 
it right this time. What does getting it right mean? Getting it right 
means giving them the opportunity to exit a bad system and to have a 
better chance at a new system.
  This rule provides House Republicans with the opportunity to restore 
exactly that--a better healthcare plan to provide the middle class and 
low-income families who have been left behind on either side of the 
aisle, and it gives them an opportunity to have tax advantages in the 
employer marketplace.
  Mr. Speaker, today, we will be dissecting this into three separate 
areas. We will have Members of the Republican majority here to explain 
that and the bill.
  Mr. Speaker, I reserve the balance of my time.
  Mr. McGOVERN. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, I want to thank the gentleman from Texas (Mr. Sessions), 
my friend, for yielding me the customary 30 minutes.
  Mr. Speaker, the majority is rushing to congratulate itself for 
finally having a bill to repeal the Affordable Care Act. For 7 years, 
Republicans had nothing to actually replace the law with, but that 
didn't stop them from making one empty political promise after another.
  And after all that, what do we have in front of us today? This bill 
will take away health care from 24 million hardworking Americans. It 
forces families to pay higher premiums and deductibles, increasing out-
of-pocket costs. It is a crushing age tax, forcing Americans age 50 to 
64 to pay premiums five times higher than what others pay for health 
coverage, no matter how healthy they are. Not to mention the $880 
billion cut to Medicaid or the fact that it steals from Medicare, 
shortening the life of the Medicare trust fund by 3 years and 
ransacking funds that seniors depend on to get the long-term care they 
need.
  I don't see anything there to be excited about. But then again, I 
come from the old-fashioned school of thought that we should actually 
take care of our fellow citizens as they grow older, rather than 
tossing them off the ship without a life preserver.
  It is no wonder that after developing such an ill-conceived and far-
reaching bill on the fly, the majority has had to try and jam this 
legislation through our Chamber.
  First, they rushed this bill through the committee process without 
holding a single hearing, and without the benefit of a nonpartisan 
Congressional Budget Office score outlining its costs and impacts.
  Then the majority came out of a back room somewhere and filed four 
managers' amendments in the dark of night to try to appease the 
conservative and moderate holdouts, including the infamous Buffalo 
bribe. The Republican leadership has been trying to strong-arm their 
conference into voting for this bill all week, and nobody knows how 
today's vote will go. The only thing we do know is that this is a 
terrible bill that is only getting worse, not better.
  This thing has been a mess from beginning to end. Now, I know our 
President prides himself on his negotiating skills, but this seems more 
like the art of no deal to me, no matter what the final vote tally 
looks like.
  That brings us to this early morning, when we met at 7 a.m. in the 
Rules Committee to report out this rule, which rewrites the bill to 
make it far worse.
  Last night, we were presented with a provision, concocted in some 
back room, that boggles the mind with its cynicism. So what is this 
mysterious grand bargain that will appease the Republican Conference 
and finally buy Speaker Ryan enough votes to pass this disaster of a 
bill? Well, Mr. Speaker, it is so cartoonishly malicious that I can 
picture someone twirling their mustache as they drafted it in their 
secret Capitol lair last night.
  Republicans are killing the requirements that insurance plans cover 
essential health benefits--essential health benefits. Now, perhaps you 
are wondering: What are these so-called essential benefits? Well, I 
will give you a partial list: emergency room trips, maternity care, 
mental health care and substance abuse treatment, and prescription 
drugs. These are the types of exotic, extravagant benefits that 
Republicans apparently don't think are important for working Americans 
to be able to afford.
  It would be literally unbelievable if we weren't here considering it 
right now, Mr. Speaker. Now, I have been awake since before dawn--
thanks to our Rules Committee meeting--so I know that this isn't a 
nightmare. We are actually voting on a bill with a backroom deal, made 
in the dark of night, that would take away any guarantee that plans 
would cover these basic essential benefits.
  And, of course, we have no idea what the costs will be or how many 
people it will affect. We can't know those things

[[Page 4762]]

until we get an analysis from the nonpartisan Congressional Budget 
Office, which, obviously, we will not have before we vote on this 
reckless legislation.
  And that is the real problem. Because every time you come out of a 
back room, this bill gets worse. For the sake of our country, maybe we 
should consider putting locks on the back rooms you huddle in.
  President Trump keeps talking about crowd size. My colleagues across 
the aisle keep talking about page size. This morning, in the Rules 
Committee, Republicans kept saying that the fifth manager's amendment 
is only 4 pages long. How bad could it be?
  Well, they need to stop worrying about size and pay more attention to 
how this bill will affect regular, working Americans. These 4 pages are 
the worse 4 pages on this planet because of the terrible consequences 
it will have on real people. It will be devastating for millions and 
millions of Americans.
  So, Mr. Speaker, instead of rushing this horrendous bill, patched 
together with backroom deals, to the floor and voting on it just hours 
after seeing the final product, we should be working together in a 
bipartisan way to improve people's lives, and certainly not putting 
them at risk. My colleagues seem too concerned about winning at any 
cost to stop and think about the consequences for millions upon 
millions of Americans. This is a lousy bill.
  Mr. Speaker, I reserve the balance of my time.
  Mr. SESSIONS. Mr. Speaker, I yield 10 minutes to the gentleman from 
Lewisville, Texas (Mr. Burgess), a distinguished member of the Rules 
Committee, a gentleman who sits on both the Energy and Commerce and the 
Rules Committee. He is quite literally the most knowledgeable person on 
health care in the United States Congress.
  Mr. BURGESS. Mr. Speaker, I thank the gentleman for yielding.
  Mr. Speaker, we all know why we are here--the problems that exist 
within the Affordable Care Act. It is simply not working for the 
American people--limited choice, costs going up, and millions without 
access to care. Unfortunately, these are not just talking points, but 
real issues affecting real Americans.
  The Affordable Care Act has damaged the individual market. It has 
driven insurers away from offering coverage. Now, we are seeing one-
third of all United States counties with only one insurer. And among 
the plans that have chosen to remain in the markets, there have been 
widespread, double-digit premium increases.
  The individual markets are a death spiral and are failing to live up 
to the promises made 7 years ago--that Americans would be able to 
receive affordable health care. As we knew then, and we know now, this 
was an empty promise that has left an estimated 19.2 million Americans 
without coverage. What is worse, these individuals are forced to pay 
the individual mandate penalty or seek a hardship exemption because of 
the costs to purchase and use health insurance.
  Nine months ago, Mr. Speaker, we began our Better Way plan to save 
the Nation's healthcare system and to bring relief to the American 
people. This plan, which served as the blueprint for the American 
Health Care Act, laid out the policies to stabilize the collapsing 
insurance markets and to repeal the more burdensome Affordable Care Act 
taxes and mandates that have hindered innovation and limited access to 
care. So let's take a look at what the American Health Care Act does.
  First and foremost, it provides immediate relief to the State 
insurance markets. As Republicans, we know that one-size-fits-all works 
for no one and certainly did not work for the individual markets. The 
States should have the flexibility to support their insurance markets 
and ensure that plans can continue to provide options for coverage.
  To do this, we relaxed two of the egregious market regulations that 
were imposed under the Affordable Care Act: the mandate that premiums 
cannot vary for younger and older Americans by more than a 3-to-1 
ratio, and the mandate creating fixed actuarial values for plans.
  The mandate limiting a plan's ability to set premiums by age has 
driven up the cost for coverage for younger and healthier Americans and 
has pushed away those seeking coverage by the millions. Of the 19.2 
million Americans who have sidestepped the individual mandate, it 
estimated that as many as 45 percent of these individuals are under the 
age of 35. Without these younger Americans seeking coverage, the 
markets have further plunged into death spirals, as insurers hike up 
premiums year after year.
  To change this, we are relaxing the ratio to 5-to-1. It will lower 
premium costs and provide necessary opportunities to stabilize the 
markets.
  Additionally, we are repealing the actuarial values mandate to 
provide insurers with additional flexibility to offer more coverage 
options.

                              {time}  0930

  To further supplement these efforts, we are establishing the Patient 
and State Stability Fund. This fund provides States with $100 billion 
over 10 years to promote innovative solutions to lower cost and 
increase access to health care for unique patient populations in each 
State. The goal is simple: to provide States with maximum flexibility 
as to how they address the cost of care for their citizens.
  The Congressional Budget Office estimated that a combination of the 
Stability Fund and other proposed changes to the market would reduce 
premiums by 10 percent by calendar year 2026. We all want patients to 
have access to high-quality, affordably priced coverage. The Patient 
and State Stability Fund can help to lower costs.
  In Medicaid, in addition to supporting the insurance market, the 
American Health Care Act provides needed reforms to the Medicaid 
program. Without changes, the Medicaid expansion alone is expected to 
cost $1 trillion over the next decade. Medicaid desperately needs 
reform so that States can continue to provide coverage to children, 
people with disabilities, and other vulnerable groups.
  To address these concerns, the American Health Care Act first phases 
out the Medicaid expansion, the expansion that has crippled State 
budgets and limited States' ability to ensure that resources will 
continue to be available for those vulnerable populations.
  Additionally, our bill helps further bend the Medicaid cost curve by 
shifting programs toward per capita allotments. The per capita 
allotments, an idea that originated during the Clinton administration, 
will set limits on the annual cost for growth for per capita 
expenditures for which the States will receive matching funds from the 
Federal Government.
  The American Health Care Act increases the amount of flexibility that 
States have in managing their Medicaid programs. The bill scales back 
the Affordable Care Act mandates that have limited a State's ability to 
tailor their plans to the needs of their beneficiaries. States can and 
should be trusted to manage the needs of their beneficiaries, and this 
bill allows States to do that.
  Additionally, the bill before us today furthers the goal of providing 
the States with greater flexibility in managing their Medicaid programs 
by providing States with the option to implement two additional 
opportunities: work requirement and block grants for Medicaid.
  This time around we chose to engage our State counterparts in the 
discussion and listen--listen--to their input as we designed this bill. 
At the top of their list were the desire to see the work requirement 
built in and the opportunity to work with Medicaid as a block grant.
  We don't tell them what to do. They are given the permission to do 
what they feel is best for their citizens. Republicans trust the States 
and trust the Governors and the elected leaders in those States.
  Finally, the American Health Care Act provides additional resources 
to bolster State safety net providers. The bill provides increases in 
the community health center funding, offers enhanced funding to support 
safety net

[[Page 4763]]

providers in States that did not expand Medicaid, and ends the cuts to 
the disproportionate share hospital payments.
  We are committed, Mr. Speaker, to ensuring that our local providers 
can continue to deliver lifesaving care. The American Health Care Act 
turns this commitment into action. For millions of Americans in rural 
and medically underserved areas, these actions will provide needed 
relief that was undercut by the Affordable Care Act.
  Let me just say, Mr. Speaker, it has been an interesting process. We 
had a 27\1/2\-hour markup in the Energy and Commerce Committee. We have 
had over 15 or 16 hours in the Rules Committee. This bill has been 
almost talked to death. I want to just acknowledge that I appreciate 
the input of the administration. I appreciate the fact that the 
directive to us last night was to put our pencils down and turn our 
papers in. It is time, Mr. Speaker.
  This is a good bill. The rule deserves our support. The underlying 
bill deserves our support.
  Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the 
AARP; a letter from the National Rural Health Association; a letter 
from the American Society of Addiction Medicine; and a letter from the 
American Medical Association--all strongly opposed to the Republican 
bill.

                                                         AARP,

                                                    March 7, 2017.
     Hon. Greg Walden,
     Chairman, Committee on Energy and Commerce, House of 
         Representatives, Washington, DC.
     Hon. Kevin Brady,
     Chairman, Committee on Ways and Means, House of 
         Representatives, Washington, DC.
     Hon. Frank Pallone,
     Ranking Member, Committee on Energy and Commerce, House of 
         Representatives, Washington, DC.
     Hon. Richard Neal,
     Ranking Member, Committee on Ways and Means, House of 
         Representatives, Washington, DC.
       Dear Chairmen and Ranking Members: AARP, with its nearly 38 
     million members in all 50 States and the District of 
     Columbia, Puerto Rico, and U.S. Virgin Islands, is a 
     nonpartisan, nonprofit, nationwide organization that helps 
     people turn their goals and dreams into real possibilities, 
     strengthens communities and fights for the issues that matter 
     most to consumers and families such as healthcare, employment 
     and income security, retirement planning, affordable 
     utilities and protection from financial abuse.
       We write today to express our opposition to the American 
     Health Care Act. This bill would weaken Medicare's fiscal 
     sustainability, dramatically increase health care costs for 
     Americans aged 50-64, and put at risk the health care of 
     millions of children and adults with disabilities, and poor 
     seniors who depend on the Medicaid program for long-term 
     services and supports and other benefits.


                                Medicare

       Our members and older Americans believe that Medicare must 
     be protected and strengthened for today's seniors and future 
     generations. We strongly oppose any changes to current law 
     that could result in cuts to benefits, increased costs, or 
     reduced coverage for older Americans. According to the 2016 
     Medicare Trustees report, the Medicare Part A Trust Fund is 
     solvent until 2028 (11 years longer than pre-Affordable Care 
     Act (ACA)), due in large part to changes made in the ACA. We 
     have serious concerns that the American Health Care Act 
     repeals provisions in current law that have strengthened 
     Medicare's fiscal outlook, specifically, the repeal of the 
     additional 0.9 percent payroll tax on higher-income workers. 
     Repealing this provision could hasten the insolvency of 
     Medicare by up to 4 years and diminish Medicare's ability to 
     pay for services in the future.


                           Prescription Drugs

       Older Americans use prescription drugs more than any other 
     segment of the U.S. population, typically on a chronic basis. 
     We are pleased that the bill does not repeal the Medicare 
     Part D coverage gap (``donut hole'') protections created 
     under the ACA. Since the enactment of the law, more than 11.8 
     million Medicare beneficiaries have saved over $26.8 billion 
     on prescription drugs. We do have strong concerns that the 
     American Health Care Act repeals the fee on manufacturers and 
     importers of branded prescription drugs, which currently is 
     projected to add $25 billion to the Part B trust fund between 
     2017 and 2026. AARP believes Congress must do more to reduce 
     the burden of high prescription drug costs on consumers and 
     taxpayers and is willing to work with you on bipartisan 
     solutions.


                  Individual Private Insurance Market

       About 6.1 million older Americans age 50-64 currently 
     purchase insurance in the non-group market, and nearly 3.2 
     million are currently eligible to receive subsidies for 
     health insurance coverage through either the federal health 
     benefits exchange or a state-based exchange (exchange). We 
     have seen a significant reduction in the number of uninsured 
     since passage of the ACA, with the number of 50-64 year old 
     Americans who are uninsured dropping by half.
       Affordability of both premiums and cost-sharing is critical 
     to older Americans and their ability to obtain and access 
     health care. A typical senior seeking coverage through an 
     exchange has a median annual income of under $25,000 and 
     already pays significant out-of-pocket costs for health care. 
     We have serious concerns that the bill under consideration 
     will dramatically increase health care costs for 50-64 year 
     olds who purchase health care through an exchange due both to 
     the changes in age rating from 3:1 (already a compromise that 
     requires uninsured older Americans to pay three times more 
     than younger individuals) to 5:1 and reductions in current 
     subsidies for older Americans.
       Age rating plus premium increases equal an unaffordable age 
     tax. Our previous estimates on the age-rating change showed 
     that premiums for current coverage could increase by up to 
     $3,200 for a 64-year-old, while reducing premiums by only 
     about $700 for a younger enrollee. Significant premium 
     increases for older consumers will make insurance less 
     affordable, will not address their expressed concern of 
     rising premiums, and will only encourage a small increase in 
     enrollment numbers for younger persons. In addition, the bill 
     proposes to change current subsidies based on income and 
     premium levels to a flatter tax credit. The change in 
     structure will dramatically increase premiums for older 
     consumers. We estimate that the bill's changes to current 
     law's tax credits could increase premium costs for a 55-year-
     old earning $25,000 by more than $2,300 a year. For a 64-
     year-old earning $25,000 that increase rises to more than 
     $4,400 a year, and more than $5,800 for a 64-year-old earning 
     $15,000. When we examined the impact of both the tax credit 
     changes and 5:1 age rating, our estimates find that, taken 
     together, premiums for older adults could increase by as much 
     as $3,600 for a 55-year-old earning $25,000 a year, $7,000 
     for a 64-year-old earning $25,000 a year and up to $8,400 for 
     a 64-year-old earning $15,000 a year. In addition to these 
     skyrocketing premiums, out-of-pocket costs could 
     significantly increase under the bill with the elimination of 
     cost sharing assistance in current law. The cost sharing 
     assistance has provided relief on out-of-pocket costs (like 
     deductibles and certain benefits) for low-income individuals 
     who are some of the most financially vulnerable marketplace 
     participants.


              Medicaid and Long-Term Services and Supports

       AARP opposes the provisions of the American Health Care Act 
     that create a per capita cap financing structure in the 
     Medicaid program. We are concerned that these provisions 
     could endanger the health, safety, and care of millions of 
     individuals who depend on the essential services provided 
     through Medicaid. Medicaid is a vital safety net and 
     intergenerational lifeline for millions of individuals, 
     including over 17.4 million low-income seniors and children 
     and adults with disabilities who rely on the program for 
     critical health care and long-term services and supports 
     (LTSS, i.e., assistance with daily activities such as eating, 
     bathing, dressing, managing medications, and transportation).
       Of these 17.4 million individuals: 6.9 million are ages 65 
     and older (which equals more than 1 in every 7 elderly 
     Medicare beneficiaries); 10.5 million are children and adults 
     living with disabilities; and about 10.8 million are so poor 
     or have a disability that they qualify for both Medicare and 
     Medicaid (dual eligibles). Dual eligibles account for almost 
     33 percent of Medicaid spending. While they comprise a 
     relatively small percentage of enrollees, they account for a 
     disproportionate share of total Medicare and Medicaid 
     spending.
       Individuals with disabilities of all ages and older adults 
     rely on critical Medicaid services, including home and 
     community based services (HCBS) for assistance with daily 
     activities such as eating, bathing, dressing, and home 
     modifications; nursing home care; and other benefits such as 
     hearing aids and eyeglasses. People with disabilities of all 
     ages also rely on Medicaid for access to comprehensive acute 
     health care services. For working adults, Medicaid can help 
     them continue to work; for children, it allows them to stay 
     with their families and receive the help they need at home or 
     in their community. Individuals may have low incomes, face 
     high medical costs, or already spent through their resources 
     paying out-of-pocket for LTSS, and need these critical 
     services. For these individuals, Medicaid is a program of 
     last resort.
       In providing a fixed amount of federal funding per person, 
     this approach to financing would likely result in 
     overwhelming cost shifts to states, state taxpayers, and 
     families unable to shoulder the costs of care without 
     sufficient federal support. This would result in cuts to 
     program eligibility, services, or both--ultimately harming 
     some of our nation's most vulnerable citizens. In terms of 
     seniors, we have serious concerns about setting caps at a 
     time when per-beneficiary spending for poor seniors is likely 
     to increase in future years. By 2026, when

[[Page 4764]]

     Boomers start to turn age 80 and older, they will likely need 
     much higher levels of service--including HCBS and nursing 
     home--moving them into the highest cost group of all seniors. 
     As this group continues to age, their level of need will 
     increase as well as their overall costs. We are also 
     concerned that caps will not accurately reflect the cost of 
     care for individuals in each state, including for children 
     and adults with disabilities and seniors, especially those 
     living with the most severe disabling conditions.
       AARP is also opposed to the repeal of the six percent 
     enhanced federal Medicaid match for states that take up the 
     Community First Choice (CFC) Option. CFC provides states with 
     a financial incentive to offer HCBS to help older adults and 
     people with disabilities live in their homes and communities 
     where they want to be. About 90 percent of older adults want 
     to remain in their own homes and communities for as long as 
     possible. HCBS are also cost effective. On average, in 
     Medicaid, the cost of HCBS per person is one-third the cost 
     of institutional care. Taking away the enhanced match could 
     disrupt services for older adults and people with 
     disabilities in the states that are already providing 
     services under CFC.
       AARP has concerns with the removal of the state option in 
     Medicaid to increase the home equity limit above the federal 
     minimum. This takes away flexibility for states to adjust a 
     Medicaid eligibility criterion based on the specific 
     circumstances of each state and its residents beyond a 
     federal minimum standard.
       Although we cannot support the American Health Care Act, we 
     are pleased that the bill does not repeal some of the 
     critical consumer protections included in the Affordable Care 
     Act, such as guaranteed issue, prohibitions on preexisting 
     condition exclusions, bans on annual and lifetime coverage 
     limits and allowing families to keep children on their 
     policies until the age of 26. Also, AARP does support 
     restoring the 7.5 percent threshold for the medical expense 
     deduction which will directly help older Americans struggling 
     to pay for health care, particularly the high cost of nursing 
     homes and other long-term services and supports.
       We look forward to working with you to ensure that we 
     maintain a strong health care system that ensures robust 
     insurance market protections, controls costs, improves 
     quality, and provides affordable coverage to all Americans.
           Sincerely,

                                              Joyce A. Rogers,

                                            Senior Vice President,
     Government Affairs.
                                  ____


                Vote NO to the American Health Care Act

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

                                               American Society of


                                           Addiction Medicine,

                                     Rockville, MD, March 8, 2017.
     Hon. Kevin Brady,
     Chairman, Committee on Ways and Means, House of 
         Representatives, Washington, DC.
     Hon. Richard Neal,
     Ranking Member, Committee on Ways and Means, House of 
         Representatives, Washington, DC.
     Hon. Greg Walden,
     Chairman, Committee on Energy and Commerce, House of 
         Representatives, Washington, DC.
     Hon. Frank Pallone,
     Ranking Member, Committee on Energy and Commerce, House of 
         Representatives, Washington, DC.
       Dear Chairman Brady, Chairman Walden, Ranking Member Neal 
     and Ranking Member Pallone: On behalf of the American Society 
     of Addiction Medicine (ASAM), the nation's oldest and largest 
     medical specialty society representing more than 4,300 
     physicians and allied health professionals who

[[Page 4765]]

     specialize in the treatment of addiction, I am writing to 
     share our views on the American Health Care Act (AHCA) that 
     is being considered by the Ways and Means and Energy and 
     Commerce committees.
       ASAM is very concerned that the AHCA's proposed changes to 
     our health care system will result in reductions in health 
     care coverage, particularly for vulnerable populations 
     including those suffering from the chronic disease of 
     addiction, and we cannot support the bill in its current 
     form.
       More than 20 million Americans currently have health care 
     coverage due to the Affordable Care Act (ACA), including 
     millions of Americans with addiction. This coverage is a 
     critical lifeline for persons with addiction, many of whom 
     were unable to access effective treatment before the ACA's 
     expansion of Medicaid eligibility to low-income adults, and 
     its requirement that Medicaid expansion plans and plans sold 
     in the individual and small group market provide essential 
     health benefits (EHB) including addiction treatment services 
     at parity with medical and surgical services.
       We are concerned that rolling back the Medicaid expansion, 
     sunsetting the EHB requirements for Medicaid expansion plans, 
     and capping federal support for Medicaid beneficiaries will 
     reduce coverage for and access to addiction treatment 
     services, changes that will be particularly painful in the 
     midst of the ongoing opioid epidemic. Moreover, while the 
     AHCA retains the EHB requirements for private plans, it 
     repeals the ACA's actuarial value requirements for those 
     plans. We are concerned that this could result in insurers 
     offering addiction treatment benefits in name only due to 
     higher costs and/or less robust benefits.
       The Medicaid expansion in particular has led to significant 
     increases in coverage and treatment access for persons with 
     addiction. In states that expanded Medicaid, the share of 
     people with addiction or mental illness who were hospitalized 
     but uninsured fell from about 20 percent in 2013 to 5 percent 
     by mid-2015 and Medicaid expansion has been associated with 
     an 18.3 percent reduction in unmet need for addiction 
     treatment services among low-income adults. Rolling back the 
     Medicaid expansion and fundamentally changing Medicaid's 
     financing structure to cap spending on health care services 
     will certainly reduce access to evidence-based addiction 
     treatment and reverse much or all progress made on the opioid 
     crisis last year.
       To be sure, ASAM supports flexibility in the Medicaid 
     program and has supported several states' applications for 
     1115 waivers to transform their addiction treatment systems 
     to offer all levels of care described by The ASAM Criteria; 
     Treatment Criteria for Addictive, Substance-Related, and Co-
     Occurring Conditions. However, ASAM has seen for decades how 
     states underfund addiction treatment services and waste 
     federal dollars on inefficient and ineffective care when they 
     are left to decide how to manage their federal Medicaid 
     dollars without mandates for parity and accountability to 
     cover appropriate care. Based on this experience, we 
     commended the Congress for requiring accountability for the 
     $1 billion in funding sent to the states to combat the opioid 
     epidemic authorized by 21st Century Cures. This funding is an 
     additional lifeline to suffering communities, but it will 
     come to an end while patients will continue to need treatment 
     for the chronic disease of addiction. When it does, the 
     Medicaid program must continue to fund appropriate addiction 
     treatment at parity with medical and surgical services.
       ASAM has long advocated for broad access to high-quality, 
     evidence-based, individualized and compassionate treatment 
     services for persons suffering from the chronic disease of 
     addiction. The critical need for access to this type of care 
     has been heightened and highlighted by our nation's ongoing 
     epidemic of opioid addiction and related overdose deaths. The 
     ACA's Medicaid expansion, EHB requirements for addiction 
     treatment coverage, and extension of parity protections to 
     the individual and small group market have surely reduced the 
     burden of this epidemic and saved lives. As you consider this 
     legislation, we hope that parity protections will continue to 
     apply individual, small and large group plans as well as 
     Medicaid plans through the transition. Finally, throughout 
     this process, we implore you to keep in mind how your 
     decisions will affect the millions of Americans suffering 
     from addiction who may lose their health care coverage 
     entirely or see reductions in benefits that impede access to 
     needed treatment.
           Sincerely,
     R. Jeffrey Goldsmith, MD, DLFAPA, DFASAM,
       President, American Society of Addiction Medicine.
                                  ____



                                 American Medical Association,

                                      Chicago, IL, March 22, 2017.
     Hon. Paul Ryan,
     Speaker, House of Representatives,
     Washington, DC.
     Hon. Nancy Pelosi,
     Democratic Leader, House of Representatives,
     Washington, DC.
       Dear Speaker Ryan and Leader Pelosi: Due to projections 
     that enactment of the American Health Care Act (AHCA) will 
     result in millions of Americans losing health insurance 
     coverage, the American Medical Association (AMA) must express 
     our opposition to the proposal currently before the House of 
     Representatives. The need to stabilize the individual 
     insurance market and make other improvements in the 
     Affordable Care Act is well understood. However, as 
     physicians, we also know that individuals who lack health 
     insurance coverage live sicker and die younger than those 
     with adequate coverage. We encourage all members of Congress 
     to engage in an inclusive and thorough dialogue on 
     appropriate remedies. We cannot, however, support legislation 
     that would leave health insurance coverage further out of 
     reach for millions of Americans.
       Earlier this year, we shared with Congress key health 
     reform objectives that we believe are critical to improving 
     the health of the nation. Among these objectives are ensuring 
     that those currently covered do not lose their coverage, 
     maintaining market reforms, stabilizing and strengthening the 
     individual insurance market, ensuring that low and moderate-
     income patients are able to secure affordable and adequate 
     coverage, and ensuring that Medicaid and other critical 
     safety net programs are maintained and adequately funded. 
     While we appreciate that the bill's authors have made efforts 
     to maintain some market reforms and that regulatory efforts 
     are underway to strengthen the individual insurance market, 
     as a whole the legislation falls short of the principles we 
     previously outlined.
       Health insurance coverage is critically important. Without 
     it, millions of American families could be just one serious 
     illness or accident away from losing their home, business, or 
     life savings. The AMA has long supported the availability of 
     advanceable and refundable tax credits, inversely related to 
     income, as a means to assist individuals and families to 
     purchase health insurance. The credits proposed under the 
     AHCA are significantly less generous for those with the 
     greatest need than provided under current law. The reduced 
     purchasing power with the AHCA tax credits will put insurance 
     coverage out of reach for millions of Americans.
       We also remain deeply concerned with the reduction of 
     federal support for the Medicaid program and the resulting 
     significant loss of coverage. Medicaid expansion has provided 
     access to critical services, including mental health and 
     substance abuse treatment, for millions. Not only will the 
     AHCA force many states to roll back coverage to these 
     millions of previously ineligible individuals, but the 
     significant reduction in federal support for the program will 
     inevitably have serious implications for all Medicaid 
     beneficiaries, including the elderly, disabled, children, and 
     pregnant women, as well.
       We also continue to be concerned about provisions that 
     eliminate important investments in public health, and those 
     that inappropriately insert the federal government into 
     personal decisions about where Americans are allowed to 
     access covered health care services.
       We continue to stand ready to work with Congress on 
     proposals that will increase the number of Americans with 
     quality, affordable health insurance coverage but for the 
     reasons cited above, urge members to oppose the American 
     Health Care Act.
           Sincerely,
                                              James L. Madara, MD.

  Mr. McGOVERN. Mr. Speaker, I just want to say to my colleague from 
Texas, he said this bill was talked to death. It was talked to death by 
politicians. There were no hearings on this bill, so no experts came to 
testify, and none of these people who are now writing to us in 
opposition had the opportunity to be able to come before us and tell us 
how awful this bill is.
  Mr. Speaker, I yield 3 minutes to the gentleman from Florida (Mr. 
Hastings), a distinguished member of the Rules Committee.
  Mr. HASTINGS. Mr. Speaker, today is a sad day for this institution.
  Why are we here? Well, after 13 hours at the Rules Committee on 
Wednesday, did we report to the floor the Republicans' replacement to 
the Affordable Care Act? No.
  And why not? Because the legislation was not extreme enough. It 
didn't hurt enough people. It didn't make enough people uninsured. It 
didn't give a large enough tax break to the wealthiest among us.
  That 13-hour exercise yielded nothing except to reveal the callous 
depths of the Republican Party's attempt to deprive health care from 24 
million people.
  So after my friends on the other side of the aisle added yet another 
manager's amendment, bringing the total to five, and after stripping 
away essential health benefits, we are here this morning to push this 
extreme, dangerous, and callous bill under martial law.
  But why are we really here? Is this bill actually about improving 
health

[[Page 4766]]

care in this country? By my estimation, and by the analysis of 
virtually every healthcare group--Mr. McGovern has introduced some of 
them: hospitals, medical organizations, and the nonpartisan 
Congressional Budget Office--the answer is a flat-out, resounding no.
  Premiums are going to rise. Millions upon millions of people will 
lose health coverage. Essential benefits will be stripped away, and 400 
of the wealthiest Americans will get a substantial tax cut, while 
Medicaid is being cut by $880 billion.
  Mr. Speaker, during that 13-hour marathon meeting that yielded 
nothing but a rule allowing Republicans to continue to ram this measure 
through Congress, I quoted from Scripture, from the King James Bible, 
Matthew 25:45. It says:

       Then shall He answer them, saying, Verily, I say unto you, 
     inasmuch as you did it not to one of the least of these, you 
     did it not to me.

  My friends on the other side of the aisle often cite Scripture in 
their legislative motivations. I ask them now: How does cutting the 
benefits from the least among us, while showering more wealth upon the 
wealthiest among us, square with these teachings?
  In addition, Mr. Speaker, I noted to them that we hear from them all 
the time about liberty. So I noted that, in the Preamble to the 
Constitution, the document that guides our great Nation and that we all 
swear an oath to uphold, that we are entrusted to also, and I quote 
from the Preamble, ``promote the general welfare.'' I also note for you 
that this charge is placed before the first mention of the word 
``liberty.''
  Does stripping away of essential health benefits, which include 
maternity and newborn care, pediatric services, and emergency services, 
promote the general welfare?
  Does cutting $880 billion from Medicaid promote the general welfare?
  Does ensuring that, by 2026, 56 million people under the age of 64 
will be left without coverage promote general welfare?
  Finally, Mr. Speaker, in the debate at committee on this shameful 
bill, I answered the Republican charge that this bill was about freedom 
when I quoted a verse from Janis Joplin's ``Me and Bobby McGee.'' What 
she was saying is: ``Freedom's just another word for nothin' left to 
lose.''
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. McGOVERN. Mr. Speaker, I yield an additional 30 seconds to the 
gentleman from Florida.
  Mr. HASTINGS. Mr. Speaker, if this extreme bill becomes law, a bill 
which has been rushed through Congress, amended without care, brought 
before us without hearings, without a CBO score, without thoughtful 
consideration, without a Democratic amendment being approved, and 
without a clue, I fear--indeed, I know--that the American people will 
find themselves with nothing left to lose when it comes to their and 
their family's health care, which is the most perverse and wretched 
kind of freedom as you may have ever seen.
  Mr. SESSIONS. Mr. Speaker, I yield myself such time as I may consume, 
and I thank the gentleman from Florida very much. In fact, the 
gentleman is correct. We had an opportunity to quote the Bible, Janis 
Joplin, and ZZ Top when we were doing our hearings. We had so much time 
with each other, and I enjoyed the hours and hours that we had to 
debate these essential items.
  But the other side of the story is essential health benefits are not 
being done away with. They are being transferred entirely to States. 
States have asked for the ability to manage their own money, and manage 
their own people's benefits of what would be required in the States. So 
in no way should a person take away, well, we just did away with it. In 
fact, we transferred the authority and the responsibility of essential 
health benefits to the States because Governors have been asking for 
this.
  Mr. Speaker, I want to take just a moment to explain what I believe 
is at the heart of the legislation and really, in reality, the key to 
fixing health care. It is the second part of this.
  We heard the gentleman from Lewisville, Texas, Dr. Burgess, speak 
about the Energy and Commerce portions. I now would like to take a 
minute to talk about the portions that come directly out of the Ways 
and Means Committee.
  The gentleman, Mr. Brady, from The Woodlands, Texas, today, spoke 
about many of these; but at the heart of it, 170 million Americans 
currently receive their health care through an employee-employer tax 
advantage or tax benefits, an untaxed benefit whereby people who have 
an employer who can provide their health care, it is not taxed--
pretaxed to the employee, allowing them to have a good healthcare 
system. Well, all the while, millions of Americans pay higher premiums 
out of their pockets in the individual market. Those are people that do 
not have an employer who is able to help them. So that is not fair. 
That does not help these people.
  What we are doing here is putting together an addition of, really, a 
great Republican idea; and it takes the important step to provide the 
same tax-free benefits for those employer-sponsored plans that we will 
give to regular employees, and it is called a tax credit. This tax 
credit is going to work because it allows every single American that 
does not receive the tax benefit at work to get it for themselves.
  Who is this? Well, quite honestly, it is small-business owners; it is 
low-income workers; it is entrepreneurs. It includes, really, a lot of 
real estate agents and people that work for a small business, maybe 
heating and air-conditioning systems like we have all across this 
country. It will give their families an opportunity.
  How much money? Well, we will provide them between $2,000 and $14,000 
a year for their families to be able to have these opportunities to 
purchase a nongovernment healthcare plan, meaning that, as they would 
go to the marketplace, we are going to help these people through a tax 
credit available January 1, providing them with an opportunity to 
purchase health care on a benefit basis.
  Why is this important? It saves money because what it does, it 
creates two things: a family then has an insurance plan, including a 
healthcare component that goes to the hospitalization; and secondly, it 
gives them an opportunity to have their own doctor or healthcare plan 
that they choose. This is important because many of these people end up 
in the hospital in the most expensive kind of way we can provide health 
care: at the emergency room.
  So this gives these families parity in the marketplace. We believe 
that that is important and is another part of this Republican 
healthcare plan.
  Mr. Speaker, I reserve the balance of my time.
  Mr. McGOVERN. Mr. Speaker, I hear my friend talking about what came 
out of the Ways and Means Committee. I will tell you what came out of 
Ways and Means Committee: a $1 trillion tax cut for the wealthy.
  Mr. Speaker, I yield 2 minutes to the gentleman from Colorado (Mr. 
Polis), a distinguished member of the Rules Committee.
  Mr. POLIS. Mr. Speaker, look, first of all, this rather outrageous 
Republican healthcare bill still will cost 24 million Americans their 
healthcare insurance; and if you are lucky enough not to be one of 
those 24 million Americans, the nonpartisan Congressional Budget 
Office, the head of which was appointed by a Republican, says it will 
also increase the cost by 15 or 20 percent for those who are lucky 
enough to keep their insurance.
  In addition to that, it has a crushing age tax that forces people 
aged 50 to 64 to pay premiums five times higher than what other 
Americans pay for health care.
  As if that age tax wasn't enough, in this new amendment, which most 
of us only saw for the first time at 6:30 this morning, they increased 
the Medicare tax for another 5 years by 1 percent, so Americans will 
have to pay even more in taxes.
  The last manager's amendment, which we just got the information on, 
actually would increase the deficit by over $150 billion more than 
their original bill, somehow without covering even one additional 
American.

[[Page 4767]]



                              {time}  0945

  So what is going on here?
  They are creating a bill that has more taxes with this manager's 
amendment, creating a bill that costs the American people more and 
reduces the deficit more, and then pawns off the hard decisions to the 
States, without giving them enough to maintain the essential benefits 
that Americans rely on, like prescription drugs, rehabilitative care, 
and mental health services.
  They are not giving the States enough money to maintain those. And 
then they are saying: But you, States, be the bad guys and you guys 
make the cut so we in Washington can pat ourselves on the back and look 
good, even while we increase the deficit by more than $150 billion more 
than the original healthcare bill that was introduced last week and 
even though we maintain the age tax that forces people between the age 
of 50 and 64 to pay up to five times more than other Americans.
  This is simply the wrong way to go. Sometimes you need to reboot, 
restart, get together, look at real ideas that Democrats and 
Republicans have put on the table to reduce costs and expand coverage. 
That is what this discussion should be about. Yet, to do that, we need 
to defeat this rule now and go back to the starting point.
  Mr. SESSIONS. Mr. Speaker, I yield 2 minutes to the gentleman from 
Alabama (Mr. Byrne), a distinguished member of the Rules Committee.
  Mr. BYRNE. Mr. Speaker, 7 years ago yesterday, the Affordable Care 
Act, or ObamaCare, became law. Since then, this law has resulted in 
canceled plans, higher premiums, fewer choices, increased deductibles, 
and less freedom for the American people.
  Don't just take my word for it. Former Democratic President Bill 
Clinton said this about ObamaCare:
  `` . . . the people who are out there busting it, sometimes 60 hours 
a week, wind up with their premiums doubled and their coverage cut in 
half, and it's the craziest thing in the world.''
  I tend to agree with President Clinton on this. ObamaCare is crazy. 
But for far too many Americans, it is the crazy reality they face every 
day.
  So today is about a rescue mission. Today is about bringing relief to 
the families who are struggling under this failed law. Today it is 
about passing the American Health Care Act.
  ObamaCare is on a collision course with disaster. If Congress were to 
sit back and do nothing, ObamaCare would implode. This would leave 
millions of Americans with no insurance and the overall insurance 
market in a dangerous condition for the rest of us. So Congress must 
act.
  That is where the American Health Care Act comes into play. This bill 
repeals ObamaCare along with its costly taxes and burdensome mandates. 
By doing this, we can lower premiums for hardworking Americans.
  Most importantly, this bill gives Americans the freedoms, choices, 
and control they desperately want and deserve.
  So, Mr. Speaker, the vote today is for the family in Monroeville who 
can't afford their premiums. The vote is for the small-business owner 
in Daphne who had his plan canceled. The vote is for the mother in 
Mobile whose deductible is too high. The vote is for the people in 
southwest Alabama and across all of America who are struggling under 
ObamaCare.
  This is our chance. This is the bill. We have got to get this done.
  Mr. McGOVERN. Mr. Speaker, I would respond to the gentleman from 
Alabama with the words of another Alabama Member, Congressman Mo 
Brooks, who this morning said:

       This is one of the worst bills I've seen in my 30 years in 
     Congress.

  Mr. Speaker, I yield 1 minute to the gentleman from Michigan (Mr. 
Kildee).
  Mr. KILDEE. Mr. Speaker, today is the day. In hearing my friends on 
the other side of the aisle describe their efforts to improve health 
care, I just wonder if we have the right bill on the floor. Because 
looking at all the external analysis--the CBO, which I know you want to 
discount, but there are many other organizations--what do they say 
about this legislation?
  It is a terrible bill. It increases costs that Americans will bear. 
Despite the fact that we hear about decreasing premiums, all the 
reports say that this will increase premiums and increase out-of-pocket 
costs that Americans will have to put out in order to protect 
themselves from disease.
  It will provide less coverage. Twenty-four million Americans will 
lose coverage. But even for those who might be able to have health 
insurance without essential benefits assured, that will just be a 
health insurance card, but not access to an emergency room, not access 
to maternal care, not access to prescription drugs, not access to 
hospitalization. Basically you will be able to get diagnosed, but you 
won't get health care.
  This is a terrible bill. We ought to reject it today.
  Mr. SESSIONS. Mr. Speaker, I yield 5 minutes to the gentleman from 
Georgia (Mr. Woodall), who will be describing the third piece of this, 
and that is the putting together of the piece from the Budget 
Committee.
  Mr. WOODALL. Mr. Speaker, I appreciate all the hard work the Rules 
Committee chairman has done in this bill. Mr. Speaker, I have the great 
pleasure of serving on the Rules Committee, but I am the designee to 
the Budget Committee.
  This whole process that we are going through is a Budget Committee 
process. It is called reconciliation. And as folks have talked about 
it, they have talked about what the Ways and Means Committee has done 
and what the Energy and Commerce Committee did. But then those two 
bills come together in the Budget Committee, and we move the process 
forward.
  I can't help but notice my colleagues' frustration with the 
amendments that have been made to this bill along the way. Generally, 
we celebrate amendments that are made along the way because they 
improve the work product. We do them together.
  I point here, Mr. Speaker, to a tweet that the President sent out the 
day the healthcare bill was introduced. The President said:
  ``Our wonderful new HealthCare Bill is now out for review and 
negotiation.''
  And that was true. It was out for review so everyone could read it, 
and it was out for negotiation so that everyone could improve it.
  We did that in the Budget Committee. We had four motions to instruct 
that passed in the Budget Committee to provide Medicaid flexibility, to 
make sure the tax credits were targeted to the right populations, to 
ensure that able-bodied, working Americans had those incentives to both 
get health care and be able to go back to work.
  Now, every committee didn't have that experience. As my colleagues 
have asked for a bipartisan process, you will remember that the Energy 
and Commerce Committee spent 10 hours debating the title of the bill. 
They spent 10 hours debating Democratic amendments to change the title 
of the bill. Folks, we have opportunity after opportunity to make 
things better, but it is incumbent upon us to choose that opportunity 
to make things better.
  So often we get wrapped around the partisan action. Folks let that 
opportunity slip away. I am glad that we didn't do that.
  Mr. Speaker, when I talk about what we did in the Budget Committee to 
make it better, I am talking about focusing on the real problems. There 
is not a member in this body that doesn't understand that what is 
contributing to the ObamaCare death spiral is that young people are not 
enrolling. Young people are not enrolling.
  More Americans rejected ObamaCare and filed for an exemption or 
agreed to pay the penalty than enrolled in ObamaCare. I don't care how 
big your heart was when you passed the bill, you have to concede that 
wasn't what you intended. And we can do better.
  My friends are talking about the essential health benefits plan 
today. Young people are particularly sensitive to that. They are price 
sensitive in that way. We are talking in the Budget Committee about how 
to preserve that flexibility for States to design plans that are right 
for them.
  How many times today have we heard folks say that prices are going to

[[Page 4768]]

increase for Americans between the age of 54 and 64?
  I have heard it at least a dozen times. At the same time, my friends 
are demanding that every healthcare plan in the State of Georgia cover 
maternity benefits for those women between the age of 54 and 64. At the 
same time, my friends are demanding that every plan in Georgia cover 
pediatric benefits for those empty nesters between 54 and 64. That 
doesn't make sense. It doesn't make sense. We in Georgia know it 
doesn't make sense, and we can do better.
  Mr. Speaker, 45 percent of the almost 20 million people who rejected 
the Affordable Care Act and agreed to pay the fine or file an exemption 
instead were under the age of 35. There is not a serious thinker in 
this room who believes we can solve the insurance crisis in this 
country without getting these folks back into the marketplace. And that 
is what we did in the Budget Committee. That is what we have done 
throughout this entire amendment process, and that is what the 
amendments we considered in the Rules Committee this morning did as 
well.
  Mr. Speaker, since the passage of the Affordable Care Act, many 
States have had to pass a lot of legislation in order to conform their 
plans to new one-size-fits-all Federal mandates. But that is not the 
story. The story is that, at the same time, States were passing their 
own benefit mandates to serve their constituency better.
  Mr. Speaker, Chairman Session's State of Texas passed a mandate that 
orally administered anticancer medication be covered. The gentleman 
from Texas has seen those groups in his office. He has seen those 
families struggling. And what Texas said is: To respond to our people, 
we are going to require every plan sold in the State of Texas cover 
these issues.
  In my home State, Mr. Speaker, we created a commission to look at 
annually how to add more benefits, change those benefits, make sure we 
are being responsive to folks in the best way that we can.
  The gentleman from Colorado, his State did the very same thing. They 
required coverage for acupuncture services. They required the selling 
of child-only plans. They required coverage for fetal alcohol syndrome. 
We do these things collaboratively, and we do these things together.
  Mr. Speaker, I urge passage of the rule and passage of the underlying 
legislation.
  Mr. McGOVERN. Mr. Speaker, I notice the gentleman from Georgia relied 
on a tweet from Donald Trump for his facts in explaining the bill. I 
might suggest a more scholarly source, maybe, like, beginning with the 
Congressional Budget Office, which says that 24 million people will 
lose their health coverage as a result of the bill.
  I will also point to the Quinnipiac poll that says only 17 percent of 
the American people approve of what my Republicans friends are doing. 
Seventeen percent is lower than Trump's rating. That is quite an 
accomplishment.
  Mr. Speaker, I yield 1 minute to the gentlewoman from California 
(Mrs. Davis).
  Mrs. DAVIS of California. Mr. Speaker, it has been hard keeping up 
with all the changes over the last 24 hours. This process has been far 
from transparent.
  The CBO released a revised score last night that said that the 
changes made to appease the Freedom Caucus will cost about $200 billion 
more without doing or adding anything to increase coverage.
  So how is that possible?
  The latest edition to this healthcare disaster, the elimination of 
minimum essential benefits, is something that I want to focus on very 
briefly.
  This change hits women especially hard. Insurance companies will no 
longer have to cover maternity care, provide direct access to an OB/
GYN, or cover preventative services like cancer screening or birth 
control.
  Mr. Speaker, do we call this a mommy tax? Is this a mommy tax to 
finance a millionaire tax cut?
  I don't know.
  Earlier this week, I gave my colleagues the opportunity to 
demonstrate their commitment to women's health in a related bill, and, 
Mr. Speaker, they didn't even allow a vote. I hear my colleagues 
claiming that these changes are about choice. Forcing women to pay more 
for the care they need is a choice I think we could do without.
  Mr. Speaker, I urge opposition to this healthcare disaster.
  Mr. SESSIONS. Mr. Speaker, I yield 2 minutes to the gentleman from 
Oklahoma (Mr. Cole), the vice chairman of the Rules Committee.
  Mr. COLE. Mr. Speaker, I thank the gentleman from Texas for his 
remarkable leadership in this important debate.
  Seven years ago, I was on this floor and I heard that, if you liked 
your plan, you could keep it. I heard, if you liked your doctor, you 
could keep that doctor. And I heard that healthcare costs were going to 
drop by $2,500 per family. None of it was true.
  I sit here now and look at my State, and I know what is happening 
next year. The rates on the ObamaCare exchanges are going up by 69 
percent. We are down to a single provider. That is what 7 years ago 
brought us.
  Today we have a chance to do something different, and everybody from 
my State will do something different. They will vote for a plan that 
actually does what it says it is going to do. Number one, they will be 
able to actually have plans that are designed by Oklahomans, not by 
bureaucrats in Washington, D.C. They will be able to have a tax credit, 
if they are not already insured under Medicaid or Medicare or from 
their employer. They will be able to have an individual tax credit to 
purchase a plan that they design, that they like. They will be free of 
the mandates of ObamaCare, free to make their own decisions, free of 
the mandates that require them to buy insurance products that they 
simply don't need.
  I have got a lot of people in my district that are in their fifties 
and sixties. Some of them might like to have children again, but they 
are not likely to have children again, and they mostly don't want 
maternity care.
  So it is a pretty simple choice for us. It is a choice to be free and 
make our own decisions. It is a choice to design our own plans. It is a 
choice to have Federal assistance where we need it, but to be used 
under our direction. It is an easy choice.
  I urge the passage of this rule, and I urge the passage of the 
underlying legislation.

                              {time}  1000

  Mr. McGOVERN. Mr. Speaker, I include in the Record a statement from 
NETWORK, the lobby for Catholic Social Justice; a letter from the 
National Alliance on Mental Illness; a letter from the Mental Health 
Liaison Group; and an article in the New York Times entitled ``Late GOP 
Proposal Could Mean Plans That Cover Aromatherapy but Not 
Chemotherapy.''

       Dear Representative: NETWORK Lobby for Catholic Social 
     Justice urges you to vote NO on the American Health Care Act 
     (AHCA). This legislation fails to protect access to quality, 
     affordable healthcare for vulnerable communities. It would 
     widen the gaps in our society by making massive cuts to 
     Medicaid, giving large tax breaks to the very wealthiest 
     families and corporations, and threatening the health 
     security of American families.
       Our faith teaches that access to healthcare is an essential 
     human right that is necessary to protect the life and dignity 
     of every person. The bill would drastically increase the 
     number of people without health insurance--and I know that 
     behind those numbers are millions of stories of families 
     facing medical bankruptcy, forgoing treatment, and losing 
     loved ones who could have been saved by preventative care.
       The AHCA cuts Medicaid spending--an essential source of 
     care for millions of children, seniors, people with 
     disabilities, and people experiencing poverty in our nation--
     and a per-capita cap would force states to ration care. The 
     legislation would also increase costs for older and sicker 
     patients and burden low- and moderate-income families with 
     much higher premiums by cutting $312 billion of financial 
     assistance for people purchasing health insurance on the 
     individual market. This is far from the Gospel mandate to 
     care for our most vulnerable sisters and brothers.
       For any replacement to the ACA to be sufficient, it must 
     meet these 10 conditions--a Ten Commandments of Healthcare if 
     you will--and the AHCA breaks nine of 10 commandments:

[[Page 4769]]


       1. Thou shalt provide affordable insurance and the same 
     benefits to all currently covered under the Affordable Care 
     Act. AHCA fails.
       2. Thou shalt continue to allow children under the age of 
     26 to be covered by their parents' insurance.
       3. Thou shalt ensure that insurance premiums and cost 
     sharing are truly affordable to all. AHCA fails.
       4. Thou shalt expand Medicaid to better serve vulnerable 
     people in our nation. AHCA fails.
       5. Thou shalt not undercut the structure or undermine the 
     purpose of Medicaid, Children's Health Insurance Program 
     (CHIP), and Medicare funding. AHCA fails.
       6. Thou shalt create effective mechanisms of accountability 
     for insurance companies and not allow them to have annual or 
     lifetime caps on expenditures. AHCA partial fail.
       7. Thou shalt not allow insurance companies to discriminate 
     against those with pre-existing conditions. AHCA partial 
     fail.
       8. Thou shalt not allow insurance companies to discriminate 
     against women, the elderly, and people in poverty. AHCA 
     fails.
       9. Thou shalt provide adequate assistance for people 
     enrolling and using their health coverage. AHCA fails.
       10. Thou shalt continue to ensure reasonable revenue is in 
     the federal budget to pay for life-sustaining healthcare for 
     all. AHCA fails.
       At its heart, this bill has lost sight of community and the 
     common good. Its biggest problem is that it lacks the 
     awareness that it is community which makes healthcare 
     effective. Healthcare is not just about the individual--it is 
     a communal good. The hyper individualism evident in the AHCA 
     is sucking the life out of our nation. Just focusing on one's 
     individual self is contrary to our Catholic faith and 
     contrary to our Constitution. We will track the vote and 
     score it in our 2017 voting record.
       This dangerous legislation is not the faithful way forward 
     and must be rejected. Stand by Gospel principles and vote NO 
     on the AHCA.
           Sincerely,

                                     Sr. Simone Campbell, SSS,

                                 Executive Director, NETWORK Lobby
     for Catholic Social Justice.
                                  ____

                                              National Alliance on


                                               Mental Illness,

                                     Arlington, VA, March 8, 2017.
     Re The American Health Care Act.

     Hon. Greg Walden,
     Chairman, House Energy and Commerce Committee, House of 
         Representatives, Washington, DC.
     Hon. Frank Pallone,
     Ranking Member, House Energy and Commerce Committee, House of 
         Representatives, Washington, DC.
       Dear Chairman Walden and Ranking Member Pallone: NAMI is 
     the nation's largest grassroots mental health organization 
     dedicated to building better lives for the millions of 
     Americans affected by mental illness. On behalf of our 
     nonprofit, nonpartisan organization, I am writing to express 
     our views on the American Health Care Act (AHCA), which seeks 
     to repeal and replace the Affordable Care Act (ACA).
       The mental health crisis in our nation is well documented. 
     Half of all Americans with mental illness go without 
     treatment. Last year, Congress passed significant bipartisan 
     legislation to address the crisis in our nation's mental 
     health system. However, addressing the mental health needs in 
     our country relies on a foundation of affordable, quality 
     health coverage with fair and equal coverage of mental health 
     and substance use conditions. Thus, the importance of 
     Medicaid and insurance safeguards for individuals living with 
     mental illness cannot be overstated. Unfortunately, the 
     proposed reforms in the AHCA threaten to undermine the 
     historic progress being made to improve mental health and 
     substance use care.


          Restructuring Medicaid Threatens Mental Health Care

       Medicaid is the single largest payer of mental health and 
     substance use services in the United States. Medicaid is also 
     the largest funding source for the country's public mental 
     health system. One in five of Medicaid's nearly 70 million 
     beneficiaries have a mental health or substance use disorder 
     diagnosis.
       NAMI is deeply concerned with proposed provisions to 
     convert Medicaid financing into a per capita cap model. This 
     would limit federal funding to a lump sum for all enrollees 
     and, instead of providing more flexibility, would shift 
     financial risk for health care costs--including unexpected 
     costs, such as promising new innovations in treatment--to 
     states. Current estimates are that the per capita cap 
     provisions would shift an alarming $370 billion in Medicaid 
     costs to states over the next ten years. In the face of 
     budget shortfalls, states will be forced to cut people from 
     coverage, reduce health benefits and access to care, and/or 
     reduce already low provider payments, escalating our nation's 
     healthcare workforce crisis.
       The AHCA would set per capita caps for Medicaid at current 
     funding levels, adjusted for medical inflation. Funding for 
     mental health and substance use services is already 
     inadequate in Medicaid programs and, under this model, could 
     not be improved without cutting other health care. Further, 
     the deep reductions in federal Medicaid funding would mean 
     that people with mental illness will face even more desperate 
     circumstances when trying to access critical mental health 
     care.


             Freezing Medicaid Expansion Puts Lives at Risk

       Nearly 1 out of 3 people covered by Medicaid expansion 
     lives with a mental health or substance use condition. 
     Medicaid expansion has proven to be a lifeline that helps 
     people with mental illness who typically fall through the 
     cracks. Medicaid expansion provides coverage to people with 
     mental health conditions who are too sick to navigate the 
     traditional Medicaid application process, who are just stable 
     enough not to qualify for disability (often because they are 
     coming out of a psychiatric hospital), or who have first 
     symptoms of a serious mental illness.
       NAMI strongly urges the Committee to take further steps to 
     preserve enrollment in Medicaid expansion, rather than the 
     proposed end to new enrollment in 2020. Expanded eligibility 
     has brought mental health treatment and the hope of recovery 
     to millions affected by mental illness. It is helping keep 
     people healthier and productive in their communities. 
     Congress should not abandon this important means of improving 
     coverage for and access to critical mental health treatment.
       NAMI also urges the Committee to reject provisions in the 
     AHCA that would lock enrollees out of Medicaid expansion 
     should they experience a lapse of coverage of more than one 
     month. This is a high price to pay for forgetting to pay a 
     premium while in the hospital or experiencing severe symptoms 
     of mental illness. Denying coverage only serves to further 
     de-stabilize lives with costly consequences for individuals, 
     families and communities.
       Finally, NAMI is very concerned that the AHCA removes the 
     requirement for Medicaid expansion plans to cover essential 
     health benefits, including mental health and substance use 
     treatment. Congress' significant commitment to mental health 
     and substance use services in recent legislation should not 
     be jeopardized by making these vital services optional in 
     Medicaid. Our country can ill afford to weaken coverage at a 
     time when the need for mental health and substance use 
     treatment is so high.


             Continuing Insurance Subsidies and Protections

       To help Americans afford quality health insurance, NAMI 
     strongly urges the Committee to continue current levels of 
     federal support, tied to income, to purchase health care 
     coverage. Without assistance tied to income, more people with 
     mental illness will be unable to afford coverage for mental 
     health care. This threatens their overall health, resulting 
     in more costly and difficult-to-treat conditions and denying 
     people the chance to reach and maintain recovery and a stable 
     life in the community.
       NAMI appreciates that the Committee included essential 
     insurance safeguards in the AHCA. These safeguards include 
     protecting Americans from losing or being denied coverage 
     because of pre-existing health conditions. This also includes 
     continuing to allow young adults to remain on their parent's 
     health insurance plans to age 26 and banning annual and 
     lifetime caps for insurance coverage.
       Cutting corners in health coverage will keep people from 
     getting the treatment they need and will push people with 
     mental illness into costly emergency rooms, hospitals and 
     jails. Making the investment early in affordable, quality 
     mental health care promotes recovery and reduces the high 
     long-term financial burden to taxpayers in avoidable 
     disability, criminal justice involvement and hospital care.
       NAMI urges the Committee to maintain coverage and services 
     for people with mental illness by preserving financial help 
     based on income, removing the proposed per capita cap 
     financing model for Medicaid and protecting expanded Medicaid 
     eligibility. We appreciate the challenges in reforming 
     America's health coverage and look forward to working with 
     you to improve mental health coverage and care for children 
     and adults throughout our nation.
           Sincerely,
                                             Mary Giliberti, J.D.,
     Chief Executive Officer, NAMI.
                                  ____



                                  Mental Health Liaison Group,

                                                   March 17, 2017.
     Hon. Paul Ryan,
     Speaker, House of Representatives,
     Washington, DC.
     Hon. Nancy Pelosi,
     House Minority Leader,
     House of Representatives, Washington, DC.
       Dear Speaker Ryan and Democratic Leader Pelosi: The Mental 
     Health Liaison Group (MHLG) wishes to express our serious 
     concerns about the provisions of the American Health Care Act 
     (AHCA) that would restructure the Medicaid program and end 
     the Medicaid expansion, as well as provisions of that 
     legislation that would significantly reduce the Federal 
     premium assistance that

[[Page 4770]]

     enrollees receive from the Federal government to maintain 
     continuous insurance coverage, and impose a significant 
     penalty for not maintaining continuous coverage. We are also 
     very concerned that the legislation would eliminate required 
     coverage for prevention and treatment of mental illness and 
     substance use disorders under state Medicaid managed care and 
     alternative benefit programs, as Medicaid is the major source 
     of Federal funding in every state for mental health and 
     substance use services.
       The MHLG is a coalition of dozens of national organizations 
     representing consumers, family members, mental health and 
     substance use treatment providers, state behavioral health 
     agencies, advocates, payers, and other stakeholders committed 
     to strengthening Americans' access to mental health and 
     substance use services and programs.
       The elimination of Medicaid expansion under the AHCA would 
     leave without coverage the 1.3 million childless, non-
     pregnant adults with serious mental illness who were able, 
     for the first time, to gain coverage under Medicaid 
     expansion. It would also leave uncovered the 2.8 million 
     childless, non-pregnant adults with substance use disorders 
     who also gained coverage under expansion for the first time. 
     These are populations that Congress promised and worked to 
     serve with the passage of 21st Century Cures and the 
     Comprehensive Addiction and Recovery Act (CARA) of 2016, 
     respectively. And it is important to remember that untreated 
     mental health and substance use disorders intensify and serve 
     to increase the number of co-morbid medical conditions in 
     those populations, thereby multiplying total Medicaid program 
     costs.
       Medicaid is the single largest payer for behavioral health 
     services in the United States, accounting for about 26 
     percent of behavioral health spending, and is the largest 
     source of funding for the country's public mental health 
     system. The Congressional Budget Office estimates the 
     Medicaid provisions of the AHCA would reduce Medicaid funding 
     over 10 years by $880 billion, or about 25 percent. With an 
     estimated 14 million people--one in five of Medicaid's 70 
     million enrollees--living with mental illness or substance 
     use disorders and depending heavily on Medicaid services, 
     allowing states to determine whether those services should be 
     covered could very well leave many low-income Americans 
     without access to medically necessary prevention and 
     treatment services.
       Medicaid covers a broad range of behavioral health services 
     at low or no cost, including but not limited to psychiatric 
     hospital care, case management, day treatment, evaluation and 
     testing, psychosocial rehabilitation, medication management, 
     as well as individual, group and family therapy. In three 
     dozen states, Medicaid covers essential peer support services 
     to help sustain recovery. Additionally, because people with 
     behavioral health disorders experience a higher rate of 
     chronic physical conditions than the general population, 
     Medicaid's coverage of primary care is critical to help this 
     population receive needed treatment for both their behavioral 
     health and physical health conditions.
       In states that have expanded Medicaid and which have been 
     particularly hard hit by the opioid crisis, such as Kentucky, 
     Maine, Pennsylvania, Ohio, and West Virginia, Medicaid pays 
     between 35 to 50 percent of medication-assisted treatment for 
     substance use disorders. CARA and 21st Century Cures were to 
     increase payment for those services, but the elimination of 
     mandated coverage under Medicaid would likely result in state 
     cost shifting, so that CARA moneys (should they be 
     appropriated) and moneys provided under 21st Century Cures 
     for prescription opioid addiction prevention and treatment 
     services would supplant, rather than supplement, the existing 
     Medicaid coverage of services in the states.
       Similarly, converting Medicaid into a per capita cap block 
     grant program or a simple block grant program will shift 
     significant costs to states over time. Ultimately, states 
     will be forced to reduce their Medicaid rolls, benefits, and 
     already low payment rates to an already scarce workforce of 
     behavioral health providers. Mental health and substance use 
     disorder treatments and programs will be at high risk 
     because, even though they are cost-effective, they are 
     intensive and expensive. Furthermore, the elimination of the 
     ACA's required Medicaid managed care coverage of mental 
     health and substance use disorder services and the long-term 
     reduction of real funding dollars will leave states and 
     managed care plans no alternative but to reduce or eliminate 
     services in order to balance state Medicaid budgets and 
     operate within managed care organizations' capitated rates.
       In addition, these cuts will hit children with serious 
     emotional disorders, as well as adults with mental illness. 
     Fifty percent of Medicaid beneficiaries are children. 
     Seventy-five percent of mental conditions emerge by late 
     adolescence. The loss of Medicaid-covered mental and 
     substance use disorder services for adults would result in 
     more family disruption and out-of-home placements for 
     children, significant trauma which has its own long-term 
     health effects, and a further burden on a child welfare 
     system that is struggling to meet the current demand for 
     foster home capacity. In addition, we estimate $4 to $5 
     billion in Medicaid assistance will be lost by schools for 
     specialized instructional support services, including mental 
     and behavioral health services.
       More directly, the rollback of the maximum eligibility 
     level for children ages 6 to 19 from 133 percent of the 
     Federal Poverty Level to 100 percent FPL will undoubtedly 
     have the result of reducing access to mental health and 
     substance use disorder services, and critical Early and 
     Periodic Screening, Diagnostic, and Treatment (EPSDT) 
     services, for those older children. This is a particularly 
     problematic change since 5 percent (1.2 million) of 
     adolescents between the ages of 12 and 17 had substance use 
     disorders in 2015 and EPSDT screening is the most effective 
     early identifier for emergent mental health issues.


               ahca changes to private insurance coverage

       If Medicaid is not to provide the avenue for recovery for 
     individuals with mental illness or substance use disorders, 
     then the private insurance market may have to serve as an 
     alternative, but the $2,000 to $4,000 refundable tax credits 
     provided under the AHCA to subsidize insurance premiums 
     constitute a significant reduction in the advance premium tax 
     credits paid under the ACA, which averaged 72 percent of 
     gross premiums. Further, the 30 percent premium surcharge 
     required under AHCA to be imposed for a failure to maintain 
     continuous coverage will likely hit hardest the lowest-income 
     enrollees who will be struggling to maintain premium payments 
     for coverage. It will be particularly destructive for those 
     enrollees whose serious mental illness or substance use 
     disorders may render them cognitively impaired and thus 
     unable to maintain premium payment schedules until they 
     recover, when the sizeable surcharge will leave them unable 
     to pick up coverage. For the foregoing reasons, these 
     provisions of the AHCA leave us very concerned for the 
     continued well-being of the individuals with serious mental 
     illness and substance use disorders we have been better able 
     to serve since the implementation of the ACA's expanded 
     coverage.
       We urge you to continue to protect these vulnerable 
     Americans' access to and coverage of vital mental health and 
     substance use disorder care and services, and to not reverse 
     the recent progress made with the enactment of key mental 
     health and substance use disorder prevention and treatment 
     reforms under the 21st Century Cures Act and CARA.
           Sincerely,
       American Art Therapy Association, American Association of 
     Child & Adolescent Psychiatry, American Association for 
     Marriage and Family Therapy, American Association for 
     Geriatric Psychiatry, American Association on Health and 
     Disability, American Dance Therapy Association, American 
     Foundation for Suicide Prevention, American Nurses 
     Association, American Psychiatric Association, American 
     Psychoanalytic Association (APsaA), American Psychological 
     Association, American Society of Addiction Medicine, Anxiety 
     and Depression Association of America, Association for 
     Ambulatory Behavioral Healthcare, Association for Behavioral 
     Health and Wellness, Bazelon Center for Mental Health Law, 
     Campaign for Trauma-Informed Policy and Practice, Children 
     and Adults with Attention-Deficit Hyperactivity Disorder 
     (CHADD), Clinical Social Work Association, Clinical Social 
     Work Guild 49-OPEIU.
       Depression and Bi-Polar Support Alliance, Eating Disorders 
     Coalition, EMDR International Association, Global Alliance 
     for Behavioral Health and Social Justice, International 
     Certification & Reciprocity Consortium (IC&RC), The Jewish 
     Federations of North America, Mental Health America, National 
     Association for Children's Behavioral Health, The National 
     Association of County Behavioral Health and Developmental 
     Disability Directors (NACBHDD), The National Association for 
     Rural Mental Health (NARMH), National Association of Social 
     Workers, National Association of State Mental Health Program 
     Directors (NASMHPD), National Alliance on the Mental Illness 
     (NAMI), National Council for Behavioral Health, National 
     Disability Rights Network, National Federation of Families 
     for Children's Mental Health, National Health Care for the 
     Homeless Council, National Register of Health Service 
     Psychologists, No Health Without Mental Health (NHMH), School 
     Social Work Association of America, Trinity Health of 
     Livonia, Michigan, Young Invincibles.
                                  ____


                [From the New York Times, Mar. 23, 2017]

 Late G.O.P. Proposal Could Mean Plans That Cover Aromatherapy But Not 
                              Chemotherapy

                        (By Margot Sanger-Katz)

       Most Republicans in Congress prefer the type of health 
     insurance market in which everyone could ``choose the plan 
     that's right for them.''
       Why should a 60-year-old man have to buy a plan that 
     includes maternity benefits he'll never use? (This is an 
     example that comes up a lot.) In contrast, the Affordable 
     Care Act includes a list of benefits that have to be in every 
     plan, a reality that makes insurance comprehensive, but often 
     costly.

[[Page 4771]]

       Now, a group of conservative House members is trying to cut 
     a deal to get those benefit requirements eliminated as part 
     of the bill to repeal and replace the Affordable Care Act 
     moving through Congress. (The vote in the House is expected 
     later today.)
       At first glance, this may sound like a wonderful policy. 
     Why should that 60-year-old man have to pay for maternity 
     benefits he will never use? If 60-year-old men don't need to 
     pay for benefits they won't use, the price of insurance will 
     come down, and more people will be able to afford that 
     coverage, the thinking goes. And people who want fancy 
     coverage with extra benefits can just pay a little more for 
     the plan that's right for them.
       But there are two main problems with stripping away minimum 
     benefit rules. One is that the meaning of ``health 
     insurance'' can start to become a little murky. The second is 
     that, in a world in which no one has to offer maternity 
     coverage, no insurance company wants to be the only one that 
     offers it.
       Here is the list of Essential Health Benefits that are 
     required under the Affordable Care Act:
       Ambulatory patient services (doctor's visits)
       Emergency services
       Hospitalization
       Maternity and newborn care
       Mental health and substance abuse disorder services, 
     including behavioral health treatment
       Prescription drugs
       Rehabilitative and habilitative services and devices
       Laboratory services
       Preventive and wellness services, and chronic disease 
     management
       Pediatric services, including oral and vision care
       The list reflects some lobbying of the members of Congress 
     who wrote it. You may notice that dental services are 
     required for children, but not adults, for example. But over 
     all, the list was developed to make insurance for people who 
     buy their own coverage look, roughly, like the kind of 
     coverage people get through their employer. A plan without 
     prescription drug coverage would probably be cheaper than one 
     that covers it, but most people wouldn't think of that plan 
     as very good insurance for people who have health care needs.
       Under the Republican plan, the government would give people 
     who buy their own insurance money to help them pay for it. A 
     20-year-old who doesn't get coverage from work or the 
     government, for example, would get $2,000. If the essential 
     health benefits go away, insurance companies would be allowed 
     to sell health plans that don't cover, say, hospital care. 
     Federal money would help buy these plans.
       But history illustrates a potential problem.
       In the 1990s, Congress created a tax credit that helped 
     low-income people buy insurance for their children. Quickly, 
     it became clear that unscrupulous entrepreneurs were creating 
     cheap products that weren't very useful, and marketing them 
     to people eligible for the credit. Congress quickly repealed 
     the provision after investigations from the Government 
     Accountability Office and the Ways and Means Committee 
     uncovered fraud.
       Mark Pauly, a professor of health care management at the 
     Wharton School of the University of Pennsylvania, who tends 
     to favor market solutions in health care, said that while the 
     Obamacare rules are ``paternalistic,'' it would be 
     problematic to offer subsidies without standards. ``If 
     they're going to offer a tax credit for people who are buying 
     insurance, well, what is insurance?'' he said, noting that 
     you might end up with the government paying for plans that 
     covered aromatherapy but not hospital care. ``You have to 
     specify what's included.''
       A proliferation of $1,995 plans that covered mostly 
     aromatherapy could end up costing the federal government a 
     lot more money than the current G.O.P. plan, since far more 
     people would take advantage of tax credits to buy cheap 
     products, even if they weren't very valuable.
       There's another reason, besides avoiding fraud, that health 
     economists say benefit rules are important. Obamacare 
     requires insurers to offer health insurance to people who 
     have pre-existing illnesses at the same price as they sell 
     them to healthy people, and the Republican bill would keep 
     this rule. But if an insurance company designs a plan that 
     attracts a lot of sick people, it will be very expensive to 
     cover them, and the insurance company will either lose money 
     or end up charging extremely high prices that would drive 
     away any healthy customers.
       Sherry Glied, the dean of the Robert F. Wagner Graduate 
     School of Public Service at New York University, who helped 
     work on the essential health benefits in the Obama 
     administration, raised the example of mental health benefits. 
     Parents of adolescents with schizophrenia will be sure to buy 
     insurance that covers only mental health services. Other 
     parents won't care about that benefit.
       The result: Any company offering such benefits will end up 
     with a lot of customers requiring expensive hospitalizations, 
     while its competitors that drop them will get healthier 
     customers who are cheaper to insure. If mental health 
     services are optional, no insurance company will want to 
     offer them, lest all the families with sick children buy 
     their product and put them out of business.
       And then healthy people who develop mental illness, or drug 
     addiction, will also learn that their illness isn't covered. 
     The result could be a sort of market failure: ``If you don't 
     require that these benefits are required, they often just get 
     knocked out of the market altogether,'' she said.
       Before Obamacare passed, there were few federal standards 
     for health insurance bought by individuals, and it was not 
     uncommon to find plans that didn't include prescription drug 
     coverage, mental health services or maternity care. But plans 
     tended to cover most of the other benefits. That was in a 
     world where health insurers could discriminate against sick 
     people. In that era, insurers in most states could simply 
     tell the mother of a mentally ill child that she couldn't buy 
     insurance. That made it less risky for insurers to offer 
     mental health benefits to everyone else.
       David Cutler, a professor at Harvard who helped advise the 
     Obama administration on the Affordable Care Act, said he 
     thinks the kind of insurance products that would be offered 
     under the proposed mix of policies could become much more 
     bare-bones than plans before Obamacare. He envisioned an 
     environment in which a typical plan might cover only 
     emergency care and basic preventive services, with everything 
     else as an add-on product, costing almost exactly as much as 
     it would cost to pay for a service out-of-pocket.
       ``Think of this as the if-you-have-rheumatoid-arthritis-
     you-should-pay-$30,000 provision,'' he said. Such a system 
     would mean that Americans with costly problems--cancer, 
     opioid addiction, H.I.V.--would end up paying a substantially 
     higher share of their medical bills, while healthy people 
     would pay lower prices for insurance that wouldn't cover as 
     many treatments.
       There is most likely a middle way. Republican lawmakers 
     might be comfortable with a system that shifts more of the 
     costs of care onto people who are sick, if it makes the 
     average insurance plan less costly for the healthy. But 
     making those choices would mean engaging in very real trade-
     offs, less simple than their talking point.

  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from 
Indiana (Mr. Visclosky).
  Mr. VISCLOSKY. Mr. Speaker, I rise in opposition to the rule and the 
underlying legislation.
  I believe that the purpose of any healthcare legislation should be to 
improve the well-being of our Nation's citizens and to allow for access 
to quality and affordable health care for all. I think, particularly, 
the gentlemen from Massachusetts and Florida ably describe why today's 
legislation fails those tests. I would add that it will also jeopardize 
the healthcare coverage of over 429,000 Hoosiers currently enrolled in 
Indiana's expansion of Medicaid, the Healthy Indiana Plan.
  Further, I believe it is disingenuous that, if this bill is 
successful, the House will have pushed numerous adverse consequences 
until after the next congressional election.
  Congress should work to improve the Affordable Care Act. Congress 
should work to ensure affordable pharmaceutical products. Congress 
should act for the health concerns still facing ordinary Americans. But 
today's legislation does no such thing.
  I find it unacceptable, and I urge my colleagues to oppose the 
legislation.
  Mr. Speaker, I rise in strong opposition to the American Health Care 
Act.
  I believe that the purpose of any health care legislation should be 
to improve the health and well-being of our nation's citizens, and to 
allow for access to quality and affordable health care for all.
  That is why in the 111th Congress I was proud to support the 
Affordable Care Act. As a result of this landmark legislation, 19 
million people in the United States now have health insurance coverage 
who did not before, and over nine-in-ten individuals in my home state 
of Indiana now have health insurance.
  Regretfully, according to the nonpartisan Congressional Budget 
Office, the legislation we are considering today will leave 
approximately 14 million more Americans without health care insurance 
by 2018, and this number will continue to rise to an estimated 24 
million by 2026.
  I am especially concerned that the American Health Care Act will 
jeopardize the health care coverage of the over 429,000 Hoosiers 
currently enrolled in Indiana's expansion of Medicaid, also known as 
the Healthy Indiana Plan.

[[Page 4772]]

  Further, I believe it is especially disingenuous that if this bill 
passes today, this institution will have pushed the financial cuts to 
programs like the Healthy Indiana Plan conveniently until after the 
next congressional election.
  The Act before us also would negatively impact the health of millions 
of women and men who receive the medical services provided by Planned 
Parenthood. Additionally, it would not improve the well-being of our 
nation's elderly by allowing providers to charge older enrollees up to 
five times as much as younger individuals.
  Finally, I would note with great concern that a provision was just 
added to the American Health Care Act today that would remove the 
requirement that insurers cover life-saving, essential health benefits, 
including maternal and pediatric services, rehabilitative therapy, and 
mental health and substance abuse treatment.
  Congress should work to improve the Affordable Care Act and address 
important health concerns facing ordinary Americans, such as the rising 
cost of prescription drugs. But today's bill does no such thing.
  It is unacceptable and I urge my colleagues to oppose this 
legislation.
  Mr. SESSIONS. Mr. Speaker, I reserve the balance of my time.
  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentlewoman from 
California (Ms. Matsui).
  Ms. MATSUI. Mr. Speaker, I thank the gentleman for yielding.
  Mr. Speaker, we have heard a lot of rhetoric about how this bill 
would supposedly fix our healthcare system. President Trump said that 
his plan would provide insurance for everybody. That is not the bill 
before us today.
  The last-minute backroom changes have only made a bad bill worse. 
Republicans stuck in a provision to strip away essential health 
benefits for American families.
  The list of services in jeopardy is long, devastating, and cruel, 
services like emergency services, hospitalization, prescription drugs, 
preventive care, and many other guarantees.
  These are basic health services that every person in the country 
deserves, like my constituent Elizabeth, whose daughter is guaranteed 
pediatric care to treat her type 1 diabetes because of these essential 
benefits. Without coverage, out-of-pocket costs would add up to more 
than her entire year's salary.
  I can't stand here and allow my Republican colleagues to say they are 
saving people from ObamaCare while they are stripping away essential 
care for families like Elizabeth's. I urge my colleagues to oppose this 
bill.
  Mr. SESSIONS. Mr. Speaker, I continue to reserve the balance of my 
time.
  Mr. McGOVERN. Mr. Speaker, I just want to take a second to summarize 
this rule because people have been asking about it.
  It is a closed rule. The only amendments allowed are amendments 
offered by people who wrote the bill. Those amendments are fixes to 
fixes to fixes to fixes in their bill and, in the words of Trump, sad.
  I would just say, you know, usually when you have a lousy process you 
have a lousy bill, and that is why only 17 percent of the American 
people support what my Republican friends are doing.
  I yield 1 minute to the gentleman from Texas (Mr. Castro).
  Mr. CASTRO of Texas. Mr. Speaker, I come from the State, Texas, that 
has the highest percentage of people who have absolutely no healthcare 
coverage, who use the emergency room as their health provider, and who 
also have serious health challenges.
  For Texans, if this bill passes, it means that the following things 
will no longer be in their insurance policy or they will be charged 
jacked-up fees for them: outpatient care; emergency room trips; in-
hospital care; pregnancy, maternity, and newborn care; mental health 
and substance abuse disorder services; prescription drugs; 
rehabilitative services and habilitative services; lab tests; 
preventative services; and pediatric services.
  It should also be noted that, with this bill, about 660,000 Texans 
would lose their healthcare coverage.
  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from 
Colorado (Mr. Perlmutter).
  Mr. PERLMUTTER. Mr. Speaker, I thank the gentleman from Massachusetts 
for yielding me time.
  Mr. Speaker, this is a bad joke on America. Here we are, the choice 
act:
  The choice is get sick or go broke.
  The choice is more coverage for average Americans or more tax cuts 
for the rich, higher costs for families.
  Twenty-four million people, at least, lose their coverage under the 
choice act, or TrumpCare.
  That is a bad joke. That is a bad choice.
  Here is something: discrimination against older Americans. They have 
five times the cost of younger Americans under TrumpCare, under their 
choice act.
  This hurts Medicare.
  There are no savings in this bill--that was what the whole thing was 
all about--but instead, we get less coverage for average Americans. We 
get many people cut off their coverage, but we get big tax cuts for the 
rich.
  This is a bad joke. This bill should be defeated. This rule should be 
defeated.
  Mr. McGOVERN. Mr. Speaker, I would like to inquire of the gentleman 
from Texas, if I can.
  I know he has a few more speakers than he did yesterday, but we have 
a ton over here, and if there is additional time that he could share 
with us, we would appreciate it.
  Mr. SESSIONS. Mr. Speaker, we are going to keep moving on. We were 
allocated the same amount of time. I guess the answer would be no.
  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentlewoman from 
Illinois (Ms. Kelly).
  Ms. KELLY of Illinois. Mr. Speaker: ``Of all the forms of inequality, 
injustice in healthcare is the most shocking and inhumane.''
  Dr. King spoke these words because the health of our fellow Americans 
is a moral imperative. What we have before us today is a morally 
corrupt bill: morally corrupt because it claws away health insurance 
from 24 million Americans, morally corrupt because it leaves nearly 1 
million of my fellow Illinoisans without health insurance, morally 
corrupt because 240,000 Illinois kids will no longer have the safety 
and security of their current coverage.
  When you cast your vote today, know that you own its aftermath here, 
forward. Will you cast your vote for party or will you cast your vote 
to do what is best in the lives of the people you represent?
  Think of the last senior whose hand you shook at a townhall. Think of 
the last child you hugged at a school visit. Does this bill do right by 
them? Will they be better off?
  If you have any doubt, vote ``no.'' Vote ``no,'' and kill this bad 
bill.
  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from 
North Carolina (Mr. Price).
  Mr. PRICE of North Carolina. Mr. Speaker, I rise today in strong 
opposition to this misguided and shortsighted pay-more-for-less bill, 
also known as TrumpCare.
  In all my time in Congress, I have never seen such blatant disregard 
for the interests of the American people.
  Twenty-four million hardworking Americans will lose their coverage.
  TrumpCare will raise premiums, while reducing critical premium 
subsidies that millions depend on. Meanwhile, deductibles and out-of-
pocket expenses will go up.
  Particularly hurt will be the Americans aged 50 to 64 who will have 
to pay five times more than others for health coverage, no matter how 
healthy they may be themselves.
  TrumpCare then goes on to ransack the Medicaid funds that older 
Americans rely on for long-term care, and it shortens the life of the 
Medicare trust fund by 3 years.
  North Carolina consumers in the insurance marketplace, many of them 
insured for the first time, would face the second highest healthcare 
cost increases in the entire country, an average of over $7,500. Again: 
mainly older, poorer North Carolinians. For example, a 64-year-old 
resident making $22,000 a year would see a premium spike of over 
$14,000. That is over half of his income.
  After years of trying to destroy the ACA, is this the best that 
Speaker Ryan and President Trump can come up with? Defeat this bill.
  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from 
Rhode Island (Mr. Langevin).

[[Page 4773]]


  Mr. LANGEVIN. Mr. Speaker, I rise in strong opposition to the 
Republican effort to gut the Affordable Care Act, an effort that will 
result in millions of people across the country and tens of thousands 
of my constituents in Rhode Island to lose their health coverage, and 
it will ultimately result in costs rising.
  Before the ACA was passed, the House held 79 hearings over the course 
of a year. Today's Republican plan was pushed through three committees 
without a single hearing and with substantial changes being made behind 
closed doors in the dead of night.
  Mr. Speaker, I am a veteran of many healthcare debates, and I can 
tell you this is not how sound policy is made, especially policy that 
will have real consequences for hardworking Americans.
  Since the passage of the ACA, I have had faith that Republicans and 
Democrats could come together to strengthen the law and further improve 
healthcare for all Americans. There is still that opportunity to come 
together, Mr. Speaker, but the rule, along with the underlying bill, 
has shaken that faith.
  Supporting the rule means putting ideology above the well-being of 
the American people. This does not have to be a zero-sum game. I know 
that we can come together.
  Let's defeat this rule and the bill. Come together in a bipartisan 
way to fix the problems of the ACA.
  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentlewoman from 
Hawaii (Ms. Gabbard).
  Ms. GABBARD. Mr. Speaker, people in my home State of Hawaii and all 
across the country are in desperate need of serious healthcare reform 
to bring down costs and increase access to quality care.
  The legislation before us, though, is not the answer. It perpetuates 
the problems. It is a handout to insurance and pharmaceutical companies 
that literally pulls the rug out from those who are most needy and most 
vulnerable in our communities.
  While corporations rake in over $600 billion in tax breaks, many low-
income Americans will see their coverage drop completely.
  Medicaid, a program that one in five Americans depend on for basic 
care, would be slashed by hundreds of billions of dollars, shifting 
costs to already-strained State and local governments.
  Our kupuna, our seniors, could see their premiums increase up to five 
times more than young, healthy people under these new age rating rules 
in this bill.
  Simply put, we need a healthcare system that puts people before 
profits. I urge my colleagues strongly to vote ``no'' against this 
legislation.
  Mr. McGOVERN. Mr. Speaker, I include in the Record the CBO score for 
the underlying bill and the first four manager's amendments. We just 
got it last night, and it is already out-of-date given the fifth 
manager's amendment that was just submitted late last night.

                                                    U.S. Congress,


                                  Congressional Budget Office,

                                   Washington, DC, March 23, 2017.
     Hon. Paul Ryan,
     Speaker of the House, House of Representatives, Washington, 
         DC.
       Dear Mr. Speaker: At your request, the Congressional Budget 
     Office and the staff of the Joint Committee on Taxation (JCT) 
     have prepared an estimate of the direct spending and revenue 
     effects of H.R. 1628, the American Health Care Act, as posted 
     on the website of the House Committee on Rules on March 22, 
     2017, incorporating manager's amendments 4, 5, 24, and 25.
       As a result of those amendments, this estimate shows 
     smaller savings over the next 10 years than the estimate that 
     CBO issued on March 13 for the reconciliation recommendations 
     of the House Committee on Ways and Means and the House 
     Committee on Energy and Commerce. The estimated effects on 
     health insurance coverage and on premiums for health 
     insurance are similar to those estimated for the committees' 
     recommendations.


                     Effects on the Federal Budget

       CBO and JCT estimate that enacting H.R. 1628, with the 
     proposed amendments, would reduce federal deficits by $150 
     billion over the 2017-2026 period; that reduction is the net 
     result of a $1,150 billion reduction in direct spending, 
     partly offset by a reduction of $999 billion in revenues (see 
     Tables 1 and 2). The provisions dealing with health insurance 
     coverage would reduce deficits, on net, by $883 billion (see 
     Table 3); the noncoverage provisions would increase deficits 
     by $733 billion, mostly by reducing revenues.
       Pay-as-you-go procedures apply because enacting the 
     legislation would affect direct spending and revenues. CBO 
     and JCT estimate that enacting the legislation would not 
     increase net direct spending or on-budget deficits in any of 
     the four consecutive 10-year periods beginning in 2027.


                  Effects on Health Insurance Coverage

       CBO and JCT estimate that, in 2018, 14 million more people 
     would be uninsured under the legislation than under current 
     law. The increase in the number of uninsured people relative 
     to the number under current law would reach 21 million in 
     2020 and 24 million in 2026 (see Table 4). In 2026, an 
     estimated 52 million people under age 65 would be uninsured, 
     compared with 28 million who would lack insurance that year 
     under current law.


                          Effects on Premiums

       H.R. 1628, with the proposed amendments, would tend to 
     increase average premiums in the nongroup market before 2020 
     and lower average premiums thereafter, relative to 
     projections under current law. In 2018 and 2019, according to 
     CBO and JCT's estimates, average premiums for single 
     policyholders in the nongroup market would be 15 percent to 
     20 percent higher under the legislation than under current 
     law. By 2026, average premiums for single policyholders in 
     the nongroup market would be roughly 10 percent lower than 
     under current law.


                 Uncertainty Surrounding the Estimates

       The ways in which federal agencies, states, insurers, 
     employers, individuals, doctors, hospitals, and other 
     affected parties would respond to the changes made by the 
     legislation are all difficult to predict, so the estimates in 
     this report are uncertain. But CBO and JCT have endeavored to 
     develop estimates that are in the middle of the distribution 
     of potential outcomes.


                 Comparison With the Previous Estimate

       On March, 13, 2017, CBO and JCT estimated that enacting the 
     reconciliation recommendations of the House Committee on Ways 
     and Means and the House Committee on Energy and Commerce 
     (which were combined into H.R. 1628) would yield a net 
     reduction in federal deficits of $337 billion over the 2017-
     2026 period. CBO estimates that enacting H.R. 1628, with the 
     proposed amendments, would save $186 billion less over that 
     period. That reduction in savings stems primarily from 
     changes to H.R. 1628 that modify provisions affecting the 
     Internal Revenue Code and the Medicaid program.
       Over the 2017-2026 period, modifications to provisions 
     affecting the Internal Revenue Code that are not directly 
     related to the law's insurance coverage provisions would 
     reduce JCT's estimate of revenues by $137 billion. Reducing 
     the threshold for determining the medical care deduction on 
     individuals' income tax returns from 7.5 percent of income to 
     5.8 percent would reduce revenues by about $90 billion. Other 
     changes include adjusting the effective dates and making 
     other modifications to the provisions that repeal or delay 
     many of the changes in the Affordable Care Act, which would 
     reduce revenues by $48 billion.
       A number of changes to the Medicaid program would reduce 
     CBO's estimate of savings by $41 billion over the 2017-2026 
     period. The reduction would result from revising the formula 
     for calculating the per capita allotments in Medicaid to 
     allow for faster growth of the per capita cost of aged, 
     blind, and disabled enrollees. The effects of changing that 
     formula would be offset somewhat by the effects of three 
     other provisions that would increase savings: reducing the 
     per capita allotment in Medicaid for the state of New York in 
     proportion to any financing the state receives from county 
     governments; providing states the option to make eligibility 
     for Medicaid conditional on satisfying work requirements for 
     enrollees who are not single parents of children under age 6 
     or who are not pregnant or disabled; and allowing states to 
     receive a block grant for Medicaid coverage of children and 
     some adults instead of funding based on a per capita cap.
       Other smaller changes resulting from the manager's 
     amendments would reduce savings by an estimated $8 billion 
     over the period.
       Compared with the previous version of the legislation, H.R. 
     1628, with the proposed amendments, would have similar 
     effects on health insurance coverage: Estimates differ by no 
     more than half a million people in any category in any year 
     over the next decade. (Some differences may appear larger 
     because of rounding.) For example, the decline in Medicaid 
     coverage after 2020 would be smaller than in the previous 
     estimate, mainly because of states' responses to the faster 
     growth in the per capita allotments for aged, blind, and 
     disabled enrollees--but other changes in Medicaid would 
     offset some of those effects.
       The legislation's impact on health insurance premiums would 
     be approximately the same as estimated for the previous 
     version.
       If you wish further details on this estimate, we will be 
     pleased to provide them.
           Sincerely,
                                                       Keith Hall,
                                                         Director.

  Mr. McGOVERN. This analysis confirms that the Republicans will give a

[[Page 4774]]

trillion-dollar tax break to the wealthiest people in this country, and 
they will kick 24 million Americans off their health insurance.
  I will say that is why we are packed with speakers on this side, and 
there is probably only a couple of people on the gentleman's side, 
because we are standing with the American people who are outraged by 
this bill.
  Mr. Speaker, I yield 1 minute to the gentleman from Rhode Island (Mr. 
Cicilline).
  Mr. CICILLINE. Mr. Speaker, last night we watched the President and 
the House Republicans scramble to achieve political points at the 
expense of the American people, working through the night. Imagine if 
they worked this hard on a jobs bills or a bill that raised family 
incomes or a bill to rebuild our infrastructure. But instead they are 
trying to pass a tax cut for the rich disguised as a healthcare bill, a 
bill that will require us to provide big, gigantic tax cuts.
  To do that, they impose higher costs on families, higher premiums, 
higher deductibles. They strip 24 million hardworking Americans from 
health care, including 60,000 Rhode Islanders. They impose a crushing 
age tax. They steal from Medicare, and they will destroy nearly 2 
million jobs, all so they can give the wealthiest Americans and the 
most powerful special interests a big, huge tax cut.
  Shame on President Trump. Shame on the Republicans.
  This is wrong for our country. We can do better than this. We need to 
protect access to health care, not rob millions of Americans from 
health care.
  Mr. McGOVERN. Mr. Speaker, I yield 2 minutes to the gentlewoman from 
Connecticut (Ms. DeLauro).
  Ms. DeLAURO. Mr. Speaker, the healthcare proposal proposed by 
President Trump and Speaker Ryan raises premiums and deductibles. It 
imposes an age tax on older Americans, making their health care 
unaffordable. It throws millions--24 million--Americans off of their 
insurance. It shifts the cost of health care to the States, and it 
covers less and less people.

                              {time}  1015

  It raises people's fears and insecurities about what this will do if 
they get sick. It ends maternity care. It is quite outrageous when it 
tells you that you can't go for emergency services any longer. It would 
allow insurance companies to, once again, reimpose lifetime limits and 
annual caps. It allows insurance companies to charge women 48 percent 
more for the same insurance that any man would pay for.
  So why would you be for this? Why? Who benefits? Who benefits?
  We are going to provide 400 of the richest families in this Nation 
with a $7 million tax cut every year. Those are not my words. Take a 
look at what Families USA says. Take a look at what the Center on 
Budget and Policy Priorities says about that.
  Working people and older Americans are going to pay for a tax cut for 
the richest people in this Nation. Older Americans are going to be hit 
the hardest. Not only are they going to get an age tax, but they are 
going to shift $170 billion out of the Medicare trust fund--a lifeline 
for older Americans.
  Do you know what? It makes me believe that this is the case: What 
does the GOP stand for? Get Old People.
  That is what this bill does. That is what people are going to vote 
``yes'' for today. Let me just say this: We have an obligation. We have 
an obligation to the people of this country to vote ``no'' today on 
this misrepresented bill.
  Mr. SESSIONS. Mr. Speaker, I yield 1 minute to the gentlewoman from 
Wyoming (Ms. Cheney), who is the favorite daughter of Wyoming and 
serves on the Rules Committee.
  Ms. CHENEY. Mr. Speaker, there are a lot of charges and allegations 
being made about what this bill would do, and the reality, Mr. Speaker, 
is we are living today in the world that they have created on the other 
side of this aisle. We are living today in a world with skyrocketing 
costs, plummeting choices, and broken promises across the board.
  When you talk about the situation with respect to women in 
particular, when you talk about what is going to happen with maternity 
care and with child care, Mr. Speaker, there is a fundamental 
difference between what they believe on that side of the aisle and what 
we believe over here.
  What we believe over here is that every American--every individual, 
and in that, we Republicans include women--we think women ought to have 
the right to make their own choices and their own decisions about care. 
We know that the kinds of insurance--the so-called insurance--that has 
been provided under ObamaCare means that women have been denied access 
to things like maternity care. When you can only get a policy with a 
$6,000 deductible, that is not care and that is not insurance.
  This bill today is fundamental to being able to keep our promises to 
the American people, to being able to ensure that we have returned 
authority, we have returned power, and, yes, resources into the hands 
of individuals so people in Wyoming--in my home State--and all across 
this country can make their own healthcare decisions and no longer be 
forced to purchase things they don't want, don't need, and can't use to 
get coverage.
  Mr. McGOVERN. Mr. Speaker, I yield 30 seconds to the gentlewoman from 
New Hampshire (Ms. Kuster).
  Ms. KUSTER of New Hampshire. Mr. Speaker, all due respect to my 
colleague from Wyoming, it is not liberty for a woman to be forced to 
go to work within weeks of having a child. That is what this bill would 
do.
  Mr. Speaker, it is not liberty for people over 50 years old to be 
required to pay increased fees and increased expenses simply to go to 
the hospital, and it is not liberty to have their essential health 
benefits stripped away. They might not even be able to go to a 
hospital. It is not liberty for 7 million veterans to have a vets tax, 
to have their benefits stripped away from an amendment that was 
introduced in the middle of the night. That is not liberty. Vote ``no'' 
on this bill.
  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from 
Virginia (Mr. Connolly).
  Mr. CONNOLLY. Mr. Speaker, I thank my friend from Massachusetts for 
yielding me this time.
  The Hippocratic Oath says ``primum non nocere''; ``first, do no 
harm.''
  This bill violates the Hippocratic Oath in all respects. Twenty-four 
million people losing their health care, our friend from Wyoming thinks 
that is a choice?
  A string of benefits required to be covered by insurance companies to 
protect consumers, to protect our loved ones when they get ill, 
vitiated. Maybe that is popular in some parts of this country, but I 
don't know where they are. This bill will unravel health care for all 
Americans. It is the wrong path to take, and I urge defeat of this 
legislation in its entirety.


                         Parliamentary Inquiry

  Ms. KAPTUR. Mr. Speaker, I have a parliamentary inquiry.
  The SPEAKER pro tempore. The gentlewoman will state her parliamentary 
inquiry.
  Ms. KAPTUR. Mr. Speaker, I want to ask why the Democratic microphone 
is turned off. This happened to me the other day when the Republican 
microphone was on over there.
  The last two speakers we have not been able to hear as well as we 
heard Ms. Cheney, and I want to know why that is.
  I hope somebody hears my plea and that the Parliamentarian will take 
care of this problem. This debate is too important to have our 
microphones at a lower scale.
  The SPEAKER pro tempore. The Chair has heard the complaint and will 
look into it.
  The Chair advises that he has had no problem hearing from each of the 
speakers that have gone to the well or from the leadership tables 
today.
  The gentleman from Texas has 3\1/2\ minutes remaining and the 
gentleman from Massachusetts has 3\1/2\ minutes remaining in this 
debate on the rule.
  Mr. SESSIONS. Mr. Speaker, I reserve the balance of my time.
  Mr. McGOVERN. Mr. Speaker, I yield 30 seconds to the gentleman from 
Florida (Mr. Crist).

[[Page 4775]]


  Mr. CRIST. Mr. Speaker, this bill we are talking about takes about 
$880 billion out of Medicaid. Medicaid is for the poor, and Medicaid is 
for the disabled. We are in Lent. It is supposed to be the holiest 
time. I want to read to you from Matthew 25, verse 45: Whatever you do 
to the least of my brothers, you do unto Me.
  Think about that before you vote for this bill. Please vote against 
it. God bless.
  Mr. SESSIONS. Mr. Speaker, I yield 1 minute to the distinguished 
gentleman from Pasco, Washington (Mr. Newhouse), who is a member of the 
Rules Committee.
  Mr. NEWHOUSE. Mr. Speaker, I thank the gentleman for yielding.
  Mr. Speaker, under the ACA, 5 to 6 million Americans were kicked off 
their healthcare plans, including 300,000 of my fellow Washingtonians 
who lost coverage despite repeated promises they could keep their 
plans. A majority of Americans have faced skyrocketing costs, reduced 
access to quality care, and fewer choices for their families. I believe 
we can and we must do better.
  Under this bill, Americans will have health care that fits individual 
and family needs instead of federally mandated, one-size-fits-all 
coverage that is simply unaffordable for far too many people. This bill 
strengthens and guarantees access for the most vulnerable in our 
communities.
  The ACA has failed. I made a promise to the thousands of my 
constituents who have told me of the devastation this law has wreaked 
on their lives that I would not forget them. Americans in every 
election since 2010 have said loud and clear the same thing, and it is 
time that we listened.
  Mr. Speaker, the American Health Care Act is the first major step in 
keeping that promise, and I think that we need to take it.
  Mr. McGOVERN. Mr. Speaker, I yield 30 seconds to the gentleman from 
California (Mr. Panetta).
  Mr. PANETTA. Mr. Speaker, I rise today in opposition of what has 
become basically the complete repeal of the ACA. Don't get me wrong. I 
have talked to small-business owners, and I have talked to patients who 
have talked about the expenses of the ACA. But I have also heard from 
people in my district on the central coast of California how much it 
has benefited them, including 65,000 people who now have coverage under 
Medicaid and 25,000 people who have gained it through the marketplace.
  If the AHCA becomes law, we are not making it cheaper, and we are not 
making it more accessible. Instead, all that is happening is that they 
are fulfilling a campaign promise.
  Mr. Speaker, we must make sure that the ACA is here. We cannot take 
it away. We must make sure that we provide care, we provide coverage, 
and we provide the covenant that we promised our constituents.
  Mr. SESSIONS. Mr. Speaker, I reserve the balance of my time, and I am 
prepared to close.
  Mr. McGOVERN. Mr. Speaker, I yield myself the balance of my time.
  Mr. Speaker, I include in the Record a letter from 87 patient and 
provider organizations, including the Cystic Fibrosis Foundation, which 
is strongly opposed to this bill.

                                                   March 20, 2017.
     Hon. Mitch McConnell,
     Senate Majority Leader,
     Washington, DC.
     Hon. Paul Ryan,
     Speaker of the House,
     Washington, DC.
       Dear Leader McConnell and Speaker Ryan: The undersigned 
     organizations write to express grave concern about proposals 
     put forth in the American Health Care Act (AHCA) to alter the 
     fundamental structure and purpose of Medicaid, a vital source 
     of health care for patients with ongoing health needs.
       We feel compelled to speak out against proposals to phase 
     out Medicaid expansion and implement per capita caps, which 
     threaten the ability of Medicaid to provide critical health 
     care services to many of our most vulnerable citizens. These 
     proposals aim to achieve cost savings of approximately $880 
     billion, according to the Congressional Budget Office, at the 
     expense of tens of millions of patients who rely on Medicaid 
     for life-sustaining care. While we appreciate the 
     opportunities we have had to work with your staff, we cannot 
     support the Medicaid provisions in this bill and cannot 
     accept policies that prioritize cutting costs by limiting 
     patients' access to care.


                   Medicaid is Critical for Patients

       Medicaid is a crucial source of coverage for patients with 
     serious and chronic health care needs. Pregnant women depend 
     on Medicaid, which covers roughly 50 percent of all births 
     including many high-risk pregnancies. Medicaid covers cancer 
     patients: nearly one-third of pediatric cancer patients were 
     enrolled in Medicaid in 2013 and approximately 1.52 million 
     adults with a history of cancer were covered by Medicaid in 
     2015. Over fifty percent of children and one-third of adults 
     living with cystic fibrosis rely on Medicaid to get the 
     treatments and therapies they need to preserve their health. 
     Nearly half of children with asthma are covered by Medicaid 
     or CHIP and adults with diabetes are disproportionally 
     covered by Medicaid as well. The patients we represent are 
     eligible for Medicaid through various pathways, including 
     through income-related and disability criteria.


                         Reject Per Capita Caps

       The proposal to convert federal financing of Medicaid to a 
     per capita cap system is deeply troubling. This policy is 
     designed to reduce federal funding for Medicaid, forcing 
     states to either make up the difference with their own funds 
     or cut their programs by reducing the number of people they 
     serve and the health benefits they provide.
       For patients with ongoing health care needs, this means 
     that Medicaid may no longer cover the care and treatments 
     they need, including breakthrough therapies and technology. 
     In order to save money, the per capita caps are set to grow 
     more slowly than expected Medicaid costs under current law. 
     As the gap between the capped allotment and actual costs 
     increases over time, states will be forced to constrain 
     eligibility, reduce benefits, lower provider payments, or 
     increase cost-sharing. Moreover, by capping the federal 
     government's contribution to Medicaid in this manner, states 
     will be less able to cover the cost of new treatments. This 
     could be devastating for people with serious diseases, for 
     whom groundbreaking treatments represent a new lease on life. 
     For people with cystic fibrosis, cancer, and other diseases, 
     new therapies can be game changers that improve quality of 
     life and increase life expectancy. In fact, we have already 
     seen Medicaid programs respond to current budget constraints 
     by using clinically inappropriate criteria to restrict access 
     to therapies old and new. A per capita cap will only 
     exacerbate the downward pressure on Medicaid budgets and will 
     further reduce access to these therapies for patients.
       Pairing financing reforms with increased flexibility, as 
     has often been proposed, would further undermine Medicaid's 
     role as a safety net for patients. Without current guardrails 
     provided by federal requirements--coupled with reduced 
     federal funding--states will have the authority to reduce 
     benefits and eligibility as they see fit and to impose other 
     restrictions, such as waiting periods and enrollment caps. 
     These policies have serious implications for patients--for a 
     person with cancer, enrollment freezes and waiting lists 
     could mean a later-stage diagnosis when treatment costs are 
     higher and survival is less likely. For a person with 
     diabetes, this would risk the ability to adequately manage 
     the disease. Many of our patients rely on costly services 
     that will be quickly targeted for cuts if states are given 
     such flexibility, so it is imperative that current federal 
     safeguards remain in place.


                      Maintain Medicaid Expansion

       While the AHCA has been described as preserving Medicaid 
     expansion for those already enrolled in coverage, we are 
     concerned that estimates show that eliminating the enhanced 
     match for any enrollee with even a small gap in coverage 
     would actually result in millions of people losing coverage. 
     By eliminating the enhanced federal match for any enrollee 
     with a gap in coverage, eventually states will be on the hook 
     for billions of dollars to continue covering this 
     population--an insurmountable financial hurdle. Additionally, 
     seven states have laws that would effectively end Medicaid 
     expansion immediately or soon thereafter when the expansion 
     match rate is eliminated. Nearly half of adults covered by 
     the Medicaid expansion are permanently disabled, have serious 
     physical or mental conditions--such as cancer, stroke, heart 
     disease, arthritis, pregnancy, or diabetes--or are in fair or 
     poor health. Repealing Medicaid expansion will leave these 
     patients without coverage they depend upon to maintain their 
     health.
       The proposed financing reforms are a fundamental shift away 
     from Medicaid's role as a safety-net for some of the most 
     vulnerable members of our society. Repealing Medicaid 
     expansion would leave millions without the health care they 
     rely on. Our organizations represent and provide care for 
     millions of Americans living with ongoing health care needs 
     who rely on Medicaid and we cannot support policies that pose 
     such a grave risk to patients.
       We hope that we can continue our dialogue as you move 
     forward in this process to arrive at solutions that provide 
     all Americans with high-quality, affordable care regardless 
     of an

[[Page 4776]]

     individual's income, employment status, health status, or 
     geographic location.
           Sincerely,
       ADAP Advocacy Association; AIDS Action Baltimore; The AIDS 
     Institute; Alpha-1 Foundation; Alport Syndrome Foundation; 
     ALS Association; American Academy of Pediatrics; American 
     Behcet's Disease Association; American Congress of 
     Obstetricians and Gynecologists; American Diabetes 
     Association; American Lung Association; American Parkinson 
     Disease Association; American Society of Hematology; American 
     Thoracic Society; Amyloidosis Support Groups Inc.; ARPKD/CHF 
     Alliance; Arthritis Foundation; Batten Disease Support & 
     Research Association; Bladder Cancer Advocacy Network.
       Bridge the Gap--SYNGAP Education and Research Foundation; 
     Bronx Lebanon Hospital Center Department of Family Medicine; 
     CADASIL Together We Have Hope Non-Profit; Cancer Support 
     Community; Child Neurology Foundation; Children's Cause for 
     Cancer Advocacy; Children's Dental Health Project; Chronic 
     Illness and Disability Partnership; Community Access National 
     Network; Congenital Adrenal Hyperplasia Research Education & 
     Support Foundation, Inc.; COPD Foundation; Cure HHT; 
     Cutaneous Lymphoma Foundation; Cystic Fibrosis Foundation; 
     Cystinosis Research Network; debra of America; Endocrine 
     Society; Fibrous Dysplasia Foundation; First Focus Campaign 
     for Children.
       FORCE: Facing Our Risk of Cancer Empowered; Foundation for 
     Prader-Willi Research; Friedreich's Ataxia Research Alliance 
     (FARA); Genetic Alliance; Hannah's Hope Fund; Hide & Seek 
     Foundation for Lysosomal Disease Research; Hispanic Health 
     Network; Hope for Hypothalamic Hamartomas; Huntington's 
     Disease Society of America; Immune Deficiency Foundation; The 
     International Pemphigus and Pemphigoid Foundation; Kids v 
     Cancer; Latino Commission on AIDS; LFS Association (Li-
     Fraumeni Syndrome Association); Liver Health Connection; 
     March of Dimes; Medicare Rights Center; MLD Foundation.
       Moebius Syndrome Foundation; Muscular Dystrophy Association 
     (MDA); NASTAD (National Alliance of State & Territorial AIDS 
     Directors); National Alliance on Mental Illness; National 
     Coalition for Cancer Survivorship; National Health Law 
     Program; National Hemophilia Foundation; National Multiple 
     Sclerosis Society; National Organization for Rare Disorders; 
     National Patient Advocate Foundation; National Tay-Sachs & 
     Allied Diseases Association (NTSAD); National Urea Cycle 
     Disorders Foundation; National Viral Hepatitis Roundtable; 
     NBIA Disorders Association; Needle Exchange Emergency 
     Distribution (NEED); Parent Project Muscular Dystrophy 
     (PPMD); Parkinson Alliance; The PCD (Primary Ciliary 
     Dyskinesia) Foundation; Polycystic Kidney Disease Foundation; 
     Pulmonary Fibrosis Foundation.
       PXE International; Rett Syndrome Research Trust; 
     Scleroderma Foundation; The Sudden Arrhythmia Death Syndromes 
     Foundation; T1D Exchange; Trisomy 18 Foundation; Tuberous 
     Sclerosis Alliance; United Way Worldwide; VHL Alliance; 
     Wilson Disease Association; Wishes for Elliott: Advancing 
     SCN8A Research.

  Mr. McGOVERN. Mr. Speaker, I would say to my colleagues that this is 
a sad day for this institution. This process has been awful. But this 
is even a sadder day for the American people.
  I remind my colleagues that we are supposed to care about one 
another, especially the most vulnerable in our society. In this era of 
Trump, Washington has become a mean place. It is a place where it has 
become unfashionable to worry about the poor, about older Americans, 
and about those who struggle.
  There is absolutely no justification for giving huge tax breaks to 
billionaires--$1 trillion in tax breaks to millionaires and 
billionaires, and at the same time throwing 24 million people off of 
health care and denying millions more essential healthcare protections.
  Twenty-four million people--my Republican colleagues have lost their 
human ability to feel what that means. That is the entire population of 
Australia.
  Mr. Speaker, I have a great deal of respect for my colleagues, but 
when I look at this bill and I read this bill, I have to wonder: What 
are you thinking? How could you do this?
  I have come to the conclusion there are only two reasons--there are 
only two ways you can vote for this bill. One is you don't know what is 
in the bill; or two is you have to have a heart of stone, because this 
bill is shameful. It is going to hurt people. It is going to hurt your 
constituents.
  Withdraw this bill or vote ``no'' on this bill, but this bill cannot 
become law. The health care and healthcare protections for the American 
people are too important.
  Mr. Speaker, I urge all my colleagues--both Democrats and 
Republicans--reject this. Vote ``no.''
  Mr. Speaker, I yield back the balance of my time.
  Mr. SESSIONS. Mr. Speaker, I yield myself the balance of my time.
  Mr. Speaker, I want to begin by thanking our colleagues, the 
gentleman from Massachusetts leading the Rules Committee, and his 
ranking members as they came from each of the committees, some 50 
hours' worth of hearings and markups, including some 16 hours in the 
Rules Committee to not only talk about and vet, but to understand more 
clearly what we would be voting on.
  Mr. Speaker, today is a bill that is a compromise bill, no doubt 
about it. I had my own plan and I had my own ideas. I took 2 years to 
get involved in this process. It is difficult to write a healthcare 
bill. But it didn't have to be my bill; it had to be a bill that we 
could all work together on.
  President Trump has been a part of that. President Trump took time 
out of his schedule to do this. It is important to the American people. 
President Trump, more than any single Member of Congress, gave the 
message to the American people about what was necessary and what he 
would do. He is going to live up to that, and we should, too.
  Mr. Speaker, the bottom line to this whole thing is we are going to 
present a Republican plan, and we are going to stand behind what we 
sell. It is better for the American people. But make no mistake about 
it: we are transferring power, authority, and responsibility not just 
to States, but also to the American people. It will be up to them to 
make determinations about their own health care because, for the first 
time, we will allow some 50 million Americans to have a tax equity, an 
opportunity to use tax credits that will be available to families 
anywhere from $2,000 for an individual to $14,000 for a family.

                              {time}  1030

  This will empower people who have not found a fair shot at the tax 
advantages it will give them: small-business owners; the American 
people; the average worker in this country, including those who work 
two or three different jobs; as well as those who are uninsured. We 
believe it is a better shot, an opportunity. We are willing to put our 
name on it and behind it.
  For these reasons, Mr. Speaker, I urge us to move forward. There will 
be 4 hours of debate that remain in this opportunity. For that reason, 
I urge my colleagues to support this rule and the underlying bill.
  Ms. JACKSON LEE. Mr. Speaker, I rise in opposition to the rule 
governing House consideration of H.R. 1628, the ``American Health Care 
Act of 2017,'' better known as ``Trumpcare.''
  I oppose the rule, and the underlying legislation, for the following 
reasons:
  1. The rule under consideration is brought pursuant to ``martial 
law'' rule passed yesterday which suspends the normal House procedure 
and allows for same day consideration, debate, and vote of legislation 
that will adversely affect the lives of everyone in America except for 
the top 1 percent;
  2. The underlying bill is less than 2 weeks old and has not had a 
single hearing in any of the Committees of jurisdiction; and
  3. The underlying bill does not reflect the input of nearly half the 
Members of this body because the legislation was drafted in secret, 
marked up in a single overnight session, and brought to the floor 
without incorporating a single amendment or idea proposed by the 
minority.
  Mr. Speaker, none of us here has had a meaningful opportunity to 
review the bill, ``Trumpcare 2.0'' we are being asked to vote on.
  This bill has undergone significant revision from the one marked up 
just last week by the Budget Committee of which I am a member.
  Trumpcare 2.0 no doubt contains many sweeteners and olive branches 
granted by the Administration and House Republican leaders in backroom 
deals in a last ditch effort to secure the necessary votes of 
Republican members to take away health care from 24 million Americans, 
many of whom are among the most vulnerable persons in society.
  None of these changes to the bill before us has been scored by the 
Congressional Budget Office so we do not know exactly how many more 
millions of Americans will be hurt.

[[Page 4777]]

  But what is unlikely to change is that 14 million Americans will lose 
Medicaid coverage and more than 52 million persons will be uninsured by 
2026 under this Republican plan.
  In addition to terminating the ACA Medicaid expansion, the 
``Trumpcare'' converts Medicaid to a per-capita cap that is not 
guaranteed to keep pace with health costs starting in 2020.
  The combined effect of these policies is to slash $880 billion in 
federal Medicaid funding over the next decade.
  In short, Trumpcare represents a clear and present danger to the 
financial and health security of American families, and to the very 
stability of our nation's health care system overall.
  We should follow regular order in the consideration of all 
legislation, but especially in a matter with great importance to the 
American people that could impact nearly 300 million people.
  For these reasons, I believe the House should reject this rule and 
the underlying bill.
  Instead of trying to enact the largest transfer of wealth from the 
bottom 99 percent to the top 1 percent in history, House Republicans 
should work with Democrats to strengthen the Affordable Care Act which 
has and continues to make life-affirming differences for the better in 
the lives of more than 300 million Americans.
  Mr. SESSIONS. Mr. Speaker, I yield back the balance of my time, and I 
move the previous question on the resolution.
  The SPEAKER pro tempore. The question is on ordering the previous 
question.
  The question was taken; and the Speaker pro tempore announced that 
the ayes appeared to have it.
  Mr. SESSIONS. Mr. Speaker, on that I demand the yeas and nays.
  The yeas and nays were ordered.
  The SPEAKER pro tempore. Pursuant to clause 8 and clause 9 of rule 
XX, this 15-minute vote on ordering the previous question will be 
followed by 5-minute votes on:
  Adopting the resolution, if ordered;
  Suspending the rules and passing H.R. 1365; and,
  Agreeing to the Speaker's approval of the Journal, if ordered.
  The vote was taken by electronic device, and there were--yeas 236, 
nays 186, not voting 7, as follows:

                             [Roll No. 191]

                               YEAS--236

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

                               NAYS--186

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

                             NOT VOTING--7

     Higgins (NY)
     Johnson (GA)
     Lieu, Ted
     Payne
     Rush
     Takano
     Tsongas

                              {time}  1054

  Messrs. O'HALLERAN, SCHNEIDER, and Mrs. TORRES changed their vote 
from ``yea'' to ``nay.''
  So the previous question was ordered.
  The result of the vote was announced as above recorded.
  The SPEAKER pro tempore. The question is on the resolution.
  The question was taken; and the Speaker pro tempore announced that 
the ayes appeared to have it.


                             Recorded Vote

  Mr. McGOVERN. Mr. Speaker, I demand a recorded vote.
  A recorded vote was ordered.
  The SPEAKER pro tempore. This is a 5-minute vote.
  The vote was taken by electronic device, and there were--ayes 230, 
noes 194, not voting 5, as follows:

                             [Roll No. 192]

                               AYES--230

     Abraham
     Aderholt
     Allen
     Amodei
     Arrington
     Babin
     Bacon
     Banks (IN)
     Barletta
     Barr
     Barton
     Bergman
     Biggs
     Bilirakis
     Bishop (MI)
     Bishop (UT)
     Black
     Blackburn
     Blum
     Bost
     Brady (TX)
     Brat
     Bridenstine
     Brooks (IN)
     Buchanan
     Buck
     Bucshon
     Budd
     Burgess
     Byrne
     Calvert
     Carter (GA)
     Carter (TX)
     Chabot
     Chaffetz
     Cheney
     Coffman
     Cole
     Collins (GA)
     Collins (NY)
     Comer
     Comstock
     Conaway
     Cook
     Costello (PA)
     Cramer
     Crawford
     Culberson
     Curbelo (FL)
     Davidson
     Davis, Rodney
     Denham
     Dent
     DeSantis
     DesJarlais
     Diaz-Balart
     Donovan
     Duffy
     Duncan (SC)
     Duncan (TN)
     Dunn
     Emmer
     Farenthold
     Faso
     Ferguson
     Fitzpatrick
     Fleischmann
     Flores
     Fortenberry
     Foxx
     Franks (AZ)
     Frelinghuysen
     Gaetz
     Gallagher
     Garrett
     Gibbs
     Goodlatte
     Gowdy

[[Page 4778]]


     Granger
     Graves (GA)
     Graves (LA)
     Graves (MO)
     Griffith
     Grothman
     Guthrie
     Harper
     Harris
     Hartzler
     Hensarling
     Herrera Beutler
     Hice, Jody B.
     Higgins (LA)
     Hill
     Holding
     Hollingsworth
     Hudson
     Huizenga
     Hultgren
     Hunter
     Hurd
     Issa
     Jenkins (KS)
     Jenkins (WV)
     Johnson (LA)
     Johnson (OH)
     Johnson, Sam
     Jordan
     Joyce (OH)
     Katko
     Kelly (MS)
     Kelly (PA)
     King (IA)
     King (NY)
     Kinzinger
     Knight
     Kustoff (TN)
     Labrador
     LaHood
     LaMalfa
     Lamborn
     Lance
     Latta
     Lewis (MN)
     LoBiondo
     Long
     Loudermilk
     Love
     Lucas
     Luetkemeyer
     MacArthur
     Marchant
     Marino
     Marshall
     Mast
     McCarthy
     McCaul
     McClintock
     McHenry
     McKinley
     McMorris Rodgers
     McSally
     Meadows
     Meehan
     Messer
     Mitchell
     Moolenaar
     Mooney (WV)
     Mullin
     Murphy (PA)
     Newhouse
     Noem
     Nunes
     Olson
     Palazzo
     Palmer
     Paulsen
     Pearce
     Perry
     Pittenger
     Poe (TX)
     Poliquin
     Posey
     Ratcliffe
     Reed
     Reichert
     Renacci
     Rice (SC)
     Roby
     Roe (TN)
     Rogers (AL)
     Rogers (KY)
     Rohrabacher
     Rokita
     Rooney, Francis
     Rooney, Thomas J.
     Ros-Lehtinen
     Roskam
     Ross
     Rothfus
     Rouzer
     Royce (CA)
     Russell
     Rutherford
     Sanford
     Scalise
     Schweikert
     Scott, Austin
     Sensenbrenner
     Sessions
     Shimkus
     Shuster
     Simpson
     Smith (MO)
     Smith (NE)
     Smith (NJ)
     Smith (TX)
     Smucker
     Stefanik
     Stewart
     Stivers
     Taylor
     Tenney
     Thompson (PA)
     Thornberry
     Tiberi
     Tipton
     Trott
     Turner
     Upton
     Valadao
     Wagner
     Walberg
     Walden
     Walker
     Walorski
     Walters, Mimi
     Weber (TX)
     Webster (FL)
     Wenstrup
     Westerman
     Williams
     Wilson (SC)
     Wittman
     Womack
     Woodall
     Yoder
     Yoho
     Young (AK)
     Young (IA)
     Zeldin

                               NOES--194

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

                             NOT VOTING--5

     Lieu, Ted
     Payne
     Rush
     Takano
     Tsongas


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore (during the vote). There are 2 minutes 
remaining.

                              {time}  1102

  So the resolution was agreed to.
  The result of the vote was announced as above recorded.
  A motion to reconsider was laid on the table.

                          ____________________