[House Hearing, 116 Congress] [From the U.S. Government Publishing Office] THE TRUMP ADMINISTRATION'S ATTACK ON THE ACA: REVERSAL IN COURT CASE THREATENS HEALTH CARE FOR MILLIONS OF AMERICANS ======================================================================= HEARING BEFORE THE COMMITTEE ON OVERSIGHT AND REFORM HOUSE OF REPRESENTATIVES ONE HUNDRED SIXTEENTH CONGRESS FIRST SESSION __________ JULY 10, 2019 __________ Serial No. 116-43 __________ Printed for the use of the Committee on Oversight and Reform [GRAPHIC NOT AVAILABLE IN TIFF FORMAT] Available on: http://www.govinfo.gov http://www.oversight.house.gov http://www.docs.house.gov ___________ U.S. GOVERNMENT PUBLISHING OFFICE 37-313 PDF WASHINGTON : 2019 COMMITTEE ON OVERSIGHT AND REFORM ELIJAH E. CUMMINGS, Maryland, Chairman Carolyn B. Maloney, New York Jim Jordan, Ohio, Ranking Minority Eleanor Holmes Norton, District of Member Columbia Paul A. Gosar, Arizona Wm. Lacy Clay, Missouri Virginia Foxx, North Carolina Stephen F. Lynch, Massachusetts Thomas Massie, Kentucky Jim Cooper, Tennessee Mark Meadows, North Carolina Gerald E. Connolly, Virginia Jody B. Hice, Georgia Raja Krishnamoorthi, Illinois Glenn Grothman, Wisconsin Jamie Raskin, Maryland James Comer, Kentucky Harley Rouda, California Michael Cloud, Texas Katie Hill, California Bob Gibbs, Ohio Debbie Wasserman Schultz, Florida Ralph Norman, South Carolina John P. Sarbanes, Maryland Clay Higgins, Louisiana Peter Welch, Vermont Chip Roy, Texas Jackie Speier, California Carol D. Miller, West Virginia Robin L. Kelly, Illinois Mark E. Green, Tennessee Mark DeSaulnier, California Kelly Armstrong, North Dakota Brenda L. Lawrence, Michigan W. Gregory Steube, Florida Stacey E. Plaskett, Virgin Islands Fred Keller, Pennsylvania Ro Khanna, California Jimmy Gomez, California Alexandria Ocasio-Cortez, New York Ayanna Pressley, Massachusetts Rashida Tlaib, Michigan David Rapallo, Staff Director Ali Golden, Chief Health Counsel Laura Rush, Clerk Christopher Hixon, Minority Chief of Staff Contact Number: 202-225-5051 C O N T E N T S ---------- Page Hearing held on July 10, 2019.................................... 1 Witnesses Ms. Abbe Gluck, Professor of Law; Director, Solomon Center for Health Law and Policy, Yale University Law School Oral Statement............................................... 6 Mr. Frederick Isasi, Executive Director, Families, U.S.A Oral Statement............................................... 8 Mr. David Balat, Director, Right on Healthcare Initiative, Texas Public Policy Foundation Oral Statement............................................... 9 Mr. Paul Gibbs, Patient/Consumer, West Valley, UT Oral Statement............................................... 11 Ms. Casey Dye, Patient/Consumer, Monroeville, PA Oral Statement............................................... 13 Ms. Stephanie Burton, Patient/Consumer, Kansas City, MO Oral Statement............................................... 15 Mr. Peter Morley, Patient/Consumer, New York, NY Oral Statement............................................... 16 Written opening statements and witnesses' written statements are available on the U.S. House of Representatives Repository at: https://docs.house.gov. Index of Documents ---------- The documents listed below are available at: https:// docs.house.gov. * Penn Ins Commissioner Jessica Altman Letter, re: Texasv. United States; submitted by Chairman Cummings. * Little Lobbyists Statement for the Record; submitted by Chairman Cummings. * National Partnership for Women and Families Statement for the Record; submitted by Chairman Cummings. * Edward Corcoran Testimony - Advocate; submitted by Chairman Cummings. * National Women's Law Center Statement for the Record on ACA; Submitted by Chairman Cummings. * 17 Organizations' Letter of Support for the ACA; submitted by Rep. Wasserman Schultz. * STAT article; submitted by Rep. Wasserman Schultz. * March of Dimes Statement for the Record; submitted by Rep. Lawrence. * Questions for the Record to Frederick Isasi, Families USA; submitted by Chairman Cummings. * Questions for the Record to Abbe Gluck, Yale; submitted by Chairman Cummings. * Questions for the Record Response by Frederick Isasi, Families USA. * Questions for the Record Response by Abbe Gluck, Yale. THE TRUMP ADMINISTRATION'S ATTACK ON THE ACA: REVERSAL IN COURT CASE THREATENS HEALTH CARE FOR MILLIONS OF AMERICANS Wednesday, July 10, 2019 House of Representatives Committee on Oversight and Reform Washington, D.C. The committee met, pursuant to notice, at 10:04 a.m., in room 2154, Rayburn Office Building, Hon. Elijah Cummings (chairman of the committee) presiding. Present: Representatives Cummings, Maloney, Norton, Clay, Connolly, Krishnamoorthi, Raskin, Rouda, Hill, Wasserman Schultz, Sarbanes, Welch, Speier, Kelly, DeSaulnier, Lawrence, Plaskett, Khanna, Gomez, Ocasio-Cortez, Pressley, Tlaib, Jordan, Amash, Gosar, Massie, Meadows, Hice, Grothman, Comer, Cloud, Gibbs, Norman, Higgins, Roy, Miller, Green, Armstrong, and Steube. Chairman Cummings. The committee will come to order. Without objection, the chair is authorized to declare a recess of the committee at any time. This full committee hearing is convened regarding the Administration's attack on the ACA. I now recognize myself for five minutes to give an opening statement. We are here today because on March 25, 2019, the Trump Administration filed a two-sentence letter with the United States Court of Appeals for the Fifth Circuit reversing its own previous position in the case of Texas v. United States, and asserting for the first time that it would not defend any portion of the Affordable Care Act in court. If the Trump Administration's position prevails and the entire ACA is struck down, there will be catastrophic implications for millions of Americans and the entire United States' healthcare system. I have often said that voting for the Affordable Care Act was the most important vote of my career, and let me tell you why. When Congress passed the ACA in 2010, we enshrined into the law that all Americans have the right to accessible, affordable health insurance coverage. The ACA established new protections to end legalized discrimination against approximately 130 million people in the United States with preexisting conditions. The ACA authorized states to expand their Medicaid programs, and approximately 17 million Americans gained coverage as a result. The ACA created online marketplaces for consumers to purchase insurance with financial assistance through premium tax credits and cost-sharing reduction payments, and today nearly 9 million individuals receive financial assistance to obtain coverage through the individual market. The ACA improved the quality of coverage for millions more by requiring the plans cover a set of essential health benefits, provide coverage for preventive services, such as immunizations and screen tests, and allow young adults to stay on their parents' plans until they turn 26. If the Trump Administration is successful, all of these Federal protections would disappear. People with preexisting conditions, like diabetes, cancer, HIV, asthma, substance use disorder, or even pregnancy, could be denied healthcare coverage or charged more. Babies born with health conditions could be uninsurable for their entire lives. Insurance companies in the individual and small-group markets would not have to cover essential services, such as preventative care, hospitalizations, emergency services, maternity care, and prescription drugs. However, since President Trump took office in January 2017, neither the Administration nor congressional Republicans have offered a plan to replace the ACA that would prevent coverage losses or the elimination of consumer protections. House Republicans have voted 69 times to repeal the ACA. Their last proposal, which failed to pass the Senate in 2017, would have increased the number of uninsured by 21 million people. There is something wrong with that picture. During the 2016 campaign, President Trump promised repeatedly that he would come up with a plan to replace the ACA, but never did. He never did. Now that he is running for President again, the promises have now returned, and you will be hearing them shortly if you have not already heard them. In April he promised to release, and I quote, ``a really great'' plan after the 2020 election. Unfortunately, nobody has seen it. Ironically, if the Trump Administration is successful in striking the entire ACA, it would directly undermine many of their own policy goals, including tackling the opioid epidemic, lowering prescription drugs prices, and ending the HIV epidemic. We wanted to hear from the Administration about why they suddenly reversed their position in litigation. We wanted to know what the Administration's plan is for millions of people if they went to court and invalidate the entire ACA. We invited the acting director of the Office of Management and Budget, Russell Vought, to testify at today's hearing, but he declined. Apparently he did not want to answer these crucial questions that affect so many millions of Americans with something that is very personal, and that is their health. I have often said to my proteges, the one thing that we must always ask ourselves every day, I think, and that is what is the enemy of my destiny. What is the enemy of my destiny? What will stop me from reaching where God meant for me to go? There is one common denominator that I have noticed that applies to all of us: health. Health and enjoying a life where you can truly pursue happiness. So although the Trump Administration refuses to answer these basic and critical questions, we are very fortunate to have a panel of legal and policy experts and patient witnesses who can tell us exactly what it will mean if the Trump Administration is successful in eliminating the Affordable Care Act. I ask our entire committee not to be blinded by what we see. Don't be blinded. The experts are here. They will let you know. They are the witnesses. They are on the front line. They deal with these matters every day. And then there are others who have gone through and continue to go through difficult circumstances. I can relate. Now that I am on a walker, I have learned what it is to be disabled, and it is a tremendous task in most instances just to get dressed. I got it, and I often say to our witnesses who have come to share with us your personal stories, thank you. Thank you for taking your pain and turning it into a passion to do your purpose. Pain, passion, purpose. So they have traveled from across the country, from Utah, Missouri, Pennsylvania, and New York, to share their stories with us. They are here to tell us what life was like for them and their loved ones before the ACA was passed. So I thank you again. With that, I yield now to the very distinguished gentleman from Ohio, the ranking member of our committee, Mr. Jordan. Mr. Jordan. Thank you, Mr. Chairman. I, too, want to thank our witnesses for making the trek here and being willing to share their story. I was hoping today that we could have a discussion about real solutions that will make the lives of everyday Americans better, talk about the cost of healthcare, access to healthcare coverage, preexisting conditions. There is no one on this committee who would support denying coverage to Americans with preexisting conditions. I was hoping we could focus on those issues, but unfortunately like so many other hearings in this committee, we are not. Rather than working toward bipartisan solutions, this committee is once again looking to score political points by attacking anything the Trump Administration does to improve the healthcare for American people. Next door in the Judiciary Committee, we have reported out multiple bills that would have had meaningful impact on the cost of prescription drugs. The Judiciary Committee spent months working on ideas to cut down on red tape and make improvements to how affordable generic drugs come to market. Those bills were bipartisan, and I was pleased to vote for them. In fact, many of them passed the Judiciary Committee unanimously. We could be talking about bipartisan substantive issues here today. Instead we are going to talk about why the Democrats are upset at the Administration, who thinks Americans deserve something better than the failed ideas of Obamacare. Under Obamacare, make no mistake, Americans saw their premiums skyrocket and their healthcare choices reduced. The majority's title for today's hearing is ``Trump's Efforts to Undermine the ACA.'' Undermine the ACA? Think about what we were told when this bill passed now, what, nine years ago? I call them the nine lies of Obamacare. Think about this. Remember this one? ``If you like your doctor, you can keep your doctor.'' Do you all remember that one? How about this one, ``If you like your plan, you can keep your plan?'' We were told by the President of the United States premiums were going to go down. We then got more specifics: premiums will go down on average $1,500. He said deductibles would decline. Five false statements right there. Oh, remember this one? This was on in the fall of 2013. Remember this one? They told us the website was going to work. They told us the website was secure. Your information would be secure there. They told us that these co-ops were wonderful, end-all, be-all creations. Twenty-three were created. Guess how many are still in existence? Four. The other 19 went bankrupt. Oh, and you know the 9th lie? First they told us it is not a tax, then they went to court and said it is a tax, and now they are saying, no, it is not really a tax at all because you can't tax them now because the individual mandate is gone and there is no penalty. Nine different lies we were told about Obamacare, and the hearing is titled ``How Trump's Efforts to Undermine.'' How can you undermine something that has already failed? I don't expect my Democrat colleagues to acknowledge it, but the Trump Administration has worked to increase competition, transparency, and quality of care in our healthcare markets. Increased competition, transparency, and quality of care are all goals we all should share. I don't know that there is anything the Trump Administration could do, though, that would satisfy my colleagues on the other side of the aisle. The timing of this hearing is also particularly troubling. Just yesterday the Fifth Circuit began oral arguments in a case that could invalidate Obamacare due to recent changes to the law. The Administration chose not to defend Obamacare in this appeal. That decision is entirely consistent with similar actions taken by other Administrations in the past for other laws, but here we are. Democrats sought to have the director of OMB here this morning to testify about how the Trump Administration made this decision. We could have had a witness from HHS. We could have a witness from DOJ. No, they wanted someone from OMB. Make no mistake. This isn't about serious congressional oversight. This hearing is about trying to manufacture a controversy based on anonymous sources and news reports. This hearing is just another attack on President Trump, and it is disappointing. We could have had a productive discussion today about real healthcare policy, and hopefully we can still some of that. I hope we can. I know that is what our side is going to try to do. We could have had a real discussion about how to make healthcare more competitive, more transparent, more cost effective, and with better quality of care. I hope at some point this committee will stop its relentless political attacks on the Administration and actually focus on something that makes a real difference in the lives of our constituents. Again, I want to thank our witnesses for coming here and telling your story, but I think the country deserves something better than the lies we were told. Anyone remember the name Jonathan Gruber? Remember that name? The New York Times called him the architect--the architect--of the Affordable Care Act. He is the guy who was caught on tape just a few years later. Remember him calling us all stupid, calling Americans stupid for buying the lies that the Obama Administration told us when they passed this thing? Again, they are not my words. It is Jonathan Gruber, the architect of Obamacare, but somehow the majority says that this is a hearing on efforts to undermine a law that was passed with so many false statements about it. Mr. Chairman, I yield back. Chairman Cummings. Thank you very much. Let me be clear to the witnesses. We want constructive solutions, believe me. Life is short. I do not waste people's time, and I damn sure don't waste mine. Now I would ask that our witnesses stand in a minute, but let me introduce them first. Abbe Gluck is professor of law, director of the Solomon Center for Health Law and Policy, Yale University Law School. Thank you. Frederick Isasi is executive director of Families USA. David Balat is director of Right On Healthcare Initiative, Texas Public Policy Foundation. Paul Gibbs is one of our patient consumers from West Valley, Utah. Welcome. Casey Dye is another patient/consumer from Monroeville, Pennsylvania. Stephanie Burton is another one of our patient/consumers from Kansas City, Missouri. And I will yield to the gentlelady from New York to introduce one of our constituents. Mrs. Maloney. Thank you so much, Mr. Chairman. It is my honor and pleasure to introduce my good friend and constituent, Peter Morley. Peter is an outstanding patient advocate, the most effective I have ever met in my entire life. He is a two- time cancer survivor living with lupus. Peter is an extraordinary advocate for the millions of Americans who can't come to Congress to advocate for themselves, but are living with preexisting conditions, whose lives depend on consistent and sufficient healthcare coverage that is guaranteed to them under the Affordable Care Act. I first met Peter two years ago on Twitter when he reached out to me to ask what he could do to save healthcare. He depended on it. Many of his friends depended on it. What can I do? I never dreamed how far he could go. He is a true example of how one person can make a difference. Peter, I said, become an advocate. He started in the city of New York going to forums, press conferences, meetings, and then expanded it to coming to Congress over 21 times, including today, testifying before Congress. He has held over 150 meetings with Members of Congress and Senators on both sides of the aisle, and he is incredibly effective. He is a voice for the many people that need to know what is happening on social media. He has a huge following, and he uses this platform to lift up the struggles, hopes, and dreams of so many people who are struggling with healthcare issues. His goal is to save the Affordable Care Act. Thank you so much for all your dedication Peter. Thank you. Chairman Cummings. Now I want to recognize Mr. Roy for an introduction. Mr. Roy. I thank the chairman. I just really quickly want to welcome David Balat, who is here. He is recently a constituent in Texas-21. He works at the Texas Public Policy Foundation, which is also in the 21st Congressional District in Texas, in Austin, Texas. David has for a long time been actively involved in the healthcare industry, and health administration, and in other areas of health. He is a great expert on health. Glad to have you here, and thank you for representing the great state of Texas and Texas-21. Thanks, David. Chairman Cummings. Thank you very much. Now those of you who can stand, stand please, to take the oath. Do you swear or affirm that the testimony you are about to give is the truth, the whole truth, and nothing but the truth, so help you God? [A chorus of ayes.] Chairman Cummings. Let the record show that the witnesses answered in the affirmative. Thank you. You may be seated. I just want to let you know that the microphones are very sensitive. Speak directly into them. Make sure they are on when you speak. There is nothing like testimony that we can't hear. And without objection, your written statement will be made part of the official record. With that, Professor Gluck, you are now recognized to give an oral presentation of your testimony. I want to remind the witnesses that we all have your official statements. We want to try to limit this to five minutes. I know. I know. I know. I know, it is hard, but you see all these people here? All of them want to ask you all questions. So I just want you to give a statement kind of summarizing. Stay within that five minutes, and there will be a light that will come on and let you know that you need to end, okay? All right. Professor Gluck. STATEMENT OF ABBE GLUCK, DIRECTOR, SOLOMON CENTER FOR HEALTH LAW AND POLICY, YALE UNIVERSITY LAW SCHOOL Ms. Gluck. Chairman Cummings, Ranking Member Jordan, members of the committee, good morning. Chairman Cummings. Good morning. Ms. Gluck. I appreciate the opportunity to testify here today. Texas v. Azar is unlike any other major case involving the Affordable Care Act. This is the first major challenge where there has been a consensus among legal experts, including prominent ACA opponents, that the lower court decision was dangerously wrong. The stakes are enormous. Twenty million people will lose their healthcare immediately. Millions more will be adversely affected. The ACA reaches every aspect of the healthcare system, not just people with preexisting conditions. Ten million get healthcare through an exchange, 17 million through the Medicaid expansion. Seniors on Medicare get billions of dollars in benefits. Also losing would be anyone who wants a vaccine. Preventative care, substance use treatment, and much more, all gone. It is critical to appreciate the overreach of the Texas decision that the entire ACA has to go and the Administration's decision to support it, despite the opposing legal consensus. For example, I filed a brief in this case with Jonathan Adler, the most influential critic of the ACA during the last major Supreme Court case. Another brief was filed by two Republican attorneys general. Many other prominent conservatives, including Judge Michael McConnell, Michael Cannon of Cato, and the Wall Street Journal filed briefs or wrote to oppose the case. That is because this case is about more than just Obamacare. It is about the violation of a century's-old legal principle that safeguards congressional lawmaking power. The principle is called severability, and unlike the legal questions at issue in the other cases, severability is settled, nonpolitical law. All nine justices apply the exact same test. The doctrine addresses what a court would do if it finds one part of a statute invalid. Does it strike down the entire statute, or just the offending provision? The Texas case, as you know, involves the 2017 tax law in which Congress made one change to the ACA. It reduced to zero the penalty for failing to obtain insurance. The plaintiffs argue that the coverage provision is unconstitutional, but that's not what's causing the crisis. That provision is not being enforced. What's causing the crisis is they're also arguing the entire ACA has to go down with it. That conclusion is at odds with unbroken Supreme Court precedent on severability. There are two parts to the test. First, we presume that we save, not destroy. Chief Justice Roberts and Justice Kavanaugh both recently wrote that courts must sever to the narrowest extent possible. Second, legislative intent. As Justice Alito recently wrote, ``Unless it is evident that Congress would not have enacted the rest, the remainder of the law remains standing.'' Sometimes the test can be difficult. It's hard to know what Congress would've wanted, but this case is not difficult, and that's what makes it different. The courts do not have to, and are absolutely not permitted to, guess whether Congress would've wanted the ACA to stand because here Congress itself, not a court, eliminated the penalty and left the rest of the statute standing. By leaving the ACA intact, Congress made as clear as possible in the text its determination that the ACA should continue. It doesn't matter that some Members of Congress wished to repeal the law. To implement the preferences of those who lost the vote would be for the Court to accomplish what Congress could not over two years of trying to repeal. That's what the Texas court did. To excerpt from the two Republican attorneys general, ``Congress' 2017 amendment establishes the law is capable of functioning without the mandate and that Congress preferred a law to no law at all.'' Moreover, to get the results it wished, the Texas court had to ignore the intention of the 2017 Congress and focus instead on the 2010 Congress. But the 2010 Congress, I must emphasize, is irrelevant. Later Congresses are allowed to amend statues passed by earlier Congresses, and courts are not allowed to give one Congress more power than the next. The legitimacy of Congress' 2017 judgment is not undermined by the fact that an earlier Congress might've said something different. I've already alluded to the enormity of the consequences. In addition to the 20 million who would lose coverage, we would again be charged based on health risk, and caps would be imposed. Kids couldn't stay on parents' plans until 26. Women could be charged more than men again. No more subsidies to make insurance affordable. We would lose basic services many of us now take for granted that were not provided before: maternity care, prescription drug coverage, preventative screenings, and the ACA's major drug benefits for seniors. The Administration itself can't even accomplish its own initiatives, whether ending the HIV crisis or the opioid crisis, without the ACA's reforms. Mr. Chairman, it is not every day that vigorous legal adversaries take a joint position. This case is about much more than the ACA or even about dire consequences. It is about separation of powers, congressional power, and the limits on judges. I thank you, and I look forward to your questions. Chairman Cummings. Thank you. Mr. Isasi? STATEMENT OF FREDERICK ISASI, EXECUTIVE DIRECTOR, FAMILIES USA Mr. Isasi. Chairman Cummings, Ranking Member Jordan, and members of the committee, thank you for the opportunity to testify today. I'm Frederick Isasi, the executive director of Families USA. For nearly 40 years, we have served as one of the leading national voices for healthcare consumers, both in D.C. and on the state level. Our mission is to allow every individual to live their greatest potential by ensuring that the best health and healthcare are equally accessible and affordable to all. Our work represents the needs and interests of families. We are extremely proud of our bipartisan work just this year to address surprise medical bills, prescription drug costs, and improve pricing transparency. With bipartisanship possible, it saddens me greatly to be here today to discuss the impact of this lawsuit. As you've heard, and it bears repeating, if the ACA is struck down, 20 million people in America will lose health insurance coverage, period. That includes more than 300,000 people in your home state of Maryland, Chairman Cummings, and more than 700,000 people in the home state of Congressman Jordan. Beyond that, vital consumer protections will be stripped from people with preexisting conditions, women, older adults. For those of us who receive our health insurance from employers, hundreds of millions of Americans, we could be subject again to annual or lifetime limits in our health insurance policies, meaning we could lose access to coverage when we are the sickest and need it most. Further, since the ACA, we've cut the national uninsurance rate for adults and children by almost half, including gains for families in rural America, for veterans, for older people pre-Medicare, and many, many others. And the ACA included a host of other improvements beyond private coverage reforms. As we've heard, the ACA lowered seniors' cost in Medicare. It increased the solvency of the Medicare Trust Fund. The ACA even created a pathway for affordable biologic drugs to treat devastating illnesses like breast cancer, leukemia, and diabetes. As you've heard, many will try and shift the focus of today's discussion from the vast improvements created through the ACA to focus instead on the impact of the ACA on health insurance premiums. We at Families USA share the public's deep concern about premium costs, and we are working to make healthcare much more affordable. However, the data are very clear: it is wrong to say that the ACA is the cause of high insurance premiums. First, despite all the rhetoric, according to the President's own actuaries, premiums in the employer market have grown more slowly since the ACA took effect in 2014. And in the individual marketplace, most families in the marketplace are paying less for their coverage. For others in the marketplace, we know costs have increased, but--and this is important--this is largely because the ACA forbids insurers from discriminating against people with preexisting conditions. Many more people, both kids and adults, with complex healthcare needs can get access to affordable insurance because of the ACA, and their costs are shared among all of us. Despite the truth that the ACA has lowered premium costs for most, we can all agree--we all agree--that health insurance premiums were rising too fast before the ACA, and premiums are still rising too fast. Health insurance premiums primarily reflect the cost of the care paid for by the insurance; for example, the cost of prescription drugs, hospitals, physicians. As we all know, the underlying costs of healthcare have been increasing far in excess of our paychecks for decades, most recently because healthcare prices are skyrocketing. No one in this chamber or watching from home doubts this. As a Nation, we have got to get a handle on healthcare costs, but to blame the ACA for out-of-control healthcare costs is like a drowning man blaming a life preserver for getting him wet. And, Members of the Committee, the public does not want the ACA to be overturned. For well over a year, a majority of Americans support the law, and when polling on individual coverage elements of the ACA, the public support was overwhelming, both among Democrats and Republicans. Finally, let's not forget how we got here. Republican leaders in Congress and President Trump failed to repeal the ACA, so they passed a law that zeroed out the individual mandate. Partisan attorneys general filed suit to say that without the mandate, the entire law should fail. As we've heard, both conservative and progressive legal scholars believe the litigation is groundless, and many also believe that the President has failed in his constitutional duties by choosing not to defend the healthcare law. As a result, our basic healthcare hangs in the balance, and this is why one of the broadest groups of healthcare stakeholders in our Nation's history supports the ACA, from the American Medical Association, AARP, the American Hospital Association, the American Cancer Society, and the American Heart Association. At Families USA, we hope this troubling hour will pass, that the bedrock protections of the ACA will remain, and that tens of millions of families across the country can breathe a sigh of relief. They will know that because of the ACA, if they or their children get sick or they need to get healthcare, they won't lose their home or all the other things they've worked for simply to get care. Thank you again for the opportunity to testify, and I look forward to taking questions. Chairman Cummings. Thank you very much. Mr. Balat? STATEMENT OF DAVID BALAT, DIRECTOR, RIGHT ON HEALTHCARE INITIATIVE, TEXAS PUBLIC POLICY FOUNDATION Mr. Balat. Thank you, Chairman Cummings, Ranking Member Jordan, and all the distinguished members of this important committee for having me here today. My name is David Balat. I'm the director of the Right on Healthcare initiative of the Texas Public Policy Foundation. I would also like to thank the others that have come here to testify this morning. I firmly believe we all want the same things. We want affordability. We want accessibly in healthcare. We simply have different ideas of how to get there. For those patients that are here today who may have benefited from the ACA, thank you for your bravery in telling your story because I know the difficulty you face in dealing with this broken system. Healthcare is an American issue, not a political one. It's personal, not partisan. My experience as a healthcare as a healthcare executive, hospital administrator, and patient advocate precedes my work in health policy. My journey coming from the healthcare industry into the realm of policy came about because lawmakers have consistently conflated and confused health insurance with healthcare. I'm here to confirm to this body that coverage is not care. As a hospital administrator, I've seen people use the emergency department for basic primary care because even though they may be insured, they're unable to afford their deductibles, which have inflated 200 to 400 percent in the last decade. The ACA sought to reduce emergency department services, but the unintended consequence has been the opposite, particularly in states that have expanded Medicaid. Outside the emergency departments, access to care has been an issue as well under our current system. It was no better prior to the introduction of the ACA, but the problems have certainly been exacerbated since its passage. The number of providers which accept the plans is minimal and shrinking, leaving patients waiting for appointments to see their primary care physician. When they do get to see their doctor, they may be referred to a specialist, which, again, can prove difficulty, especially in finding one in their region. The administrative burden created by the ACA has limited choice for those who are most vulnerable. In fact, a study in February of this year titled, ``The Effect of Health Insurance on Mortality: Power Analysis and What Can We Learn from the Affordable Care Act Coverage Expansion?,'' it demonstrated that there was no reduction in mortality for those that participated in the ACA, effectively demonstrating that the enrollment in the ACA had the same impact as having other forms of coverage or no coverage at all. Even those patients on the ACA exchange whose premiums are fully subsidized are left with a sizable deductible and co-insurance obligation. These large financial obligations left to the patient often leave them in the position of not being able to afford going to the doctor, and often waiting until they have to go the emergency room, which further drives up the cost of care. Let me be clear. Insurance coverage under the ACA that has driven up the cost of care, it has hurt patients with preexisting conditions, not helped them. As an adviser, I've been called to help families and patients navigate the complexity of hospital care or simply how to read and understand their explanation of benefits. There's always a common thread in their frustration: they don't get to decide, they pay more, and they get less. Needless to say, we have a corrupt system full of perverse incentives in virtually every segment of the industry. Rather than the patient being in charge of very personal decisions, government regulations have empowered insurance companies to be in charge. The patient and doctor are the main ones who care about patient health, and yet they have limited decision power. The decisions are being made instead by government administrators, the insurance companies, and a number of other middlemen. We have a lack of affordability and inefficiency because there are entirely too many middlemen who have come between the doctor and patient in that relationship. The Medicare bureaucracy sets prices for services, and then the insurance companies enforce those fixed prices on everyone else, even in the private market. We need a system in which everyone has a choice and the government role is limited to a safety net. The current system is failing because it is unaffordable and unreliable. Americans understand that the problem is the high cost of healthcare, and what they want is to be empowered to make decisions for themselves and their families, and to have a sense of peace of mind. This doesn't come from government mandates. This is evident when people are involved and participating in their care management with their doctor. We hear about the number of uninsured in this country, but not all of them are without care. I am among that statistic of the uninsured, but I would assert I get better healthcare as a patient because, to repeat my point, coverage is not care. I use direct primary care and medical cost sharing for my catastrophic coverage for both myself and my family. These models, in addition to the many others that have been promoted by the Trump Administration, do not have exclusions for preexisting conditions, and are demonstrating a higher degree of accessibility and affordability. The high cost of care in the country increased significantly during the time of the ACA. The high cost of care is the single-biggest reason why healthcare has become less accessible. The high cost of care is what American people care about. The high cost of care is the direct result of the Federal Government attempting to fix healthcare and failing. Choice and competition, not a one-size-fits-all plan, is what we need for something as local and personal as healthcare. We need a landscape of choices that are as diverse and as personal all of us. Thank you very much, and I look forward to your questions. Chairman Cummings. Thank you. As we now move to Mr. Gibbs, let me say to our patient witnesses. Again, I want to thank you for being here. I think your testimony is so important. So often here on Capitol Hill, we look at statistics, and we read about people having problems, but there is nothing like having people who go through it every second of their lives. So, Mr. Gibbs, I thank you. STATEMENT OF PAUL GIBBS, PATIENT/CONSUMER, WEST VALLEY, UTAH Mr. Gibbs. Thank you, Mr. Chairman. Thank you, members of the committee, for giving me the opportunity to speak today. Today I've heard this law referred to as, as it commonly is, by the names either the ``Affordable Care Act'' or ``Obamacare.'' For me, it's important to call this law by its full name--the Patient Protection and Affordable Care Act--because the patient protections of the ACA have been a gift from God for people like me and families like mine. My healthcare story begins in 1974 when my twin brother and I were born with serious medical conditions. He had a condition called Hirschsprung disease in his intestines, which caused him to need 17 surgeries by the time he was five years old. I had nine surgeries on my kidneys for a condition called bilateral vesicoureteral reflux, which meant that urine was going back up the urethra into my kidneys instead of down where it belongs. Now the costs of that were severe. My parents never got out from under the financial burden of those healthcare costs for my brother and me. Within the past 10 years, they've passed away with virtually nothing material to their names, but with a great legacy of caring for their family as much as anyone ever could. It was in November 2008 that my doctor told me in a routine visit--I thought a routine visit--that I was in end-stage kidney failure and needed a transplant as soon as possible. I was working. I was going to school. I was doing my best to be a contributing member of society, but I had no insurance coverage. Now coverage may not be care, but when you need a $79,000 surgery, there is no care without coverage. I'm a member of the Church of Jesus Christ of Latter-Day Saints, a church that's very well known for its generosity in taking care of its members, but my church couldn't pay for a $79,000 surgery, and I needed two surgeries. My kidneys were in bad enough shape that they were considered an infection risk for the new kidney, so they had to be removed first 10 years ago this week. I've heard opponents of the ACA say people don't die in America for lack of healthcare because they can go to the emergency room. You can't get a kidney transplant at the ER. Now I was fortunate. I fit the fairly narrow qualifications for Medicaid before the ACA expansion, and I also fit qualifications for Medicare coverage. Those allowed me to have that life-saving surgery 10 years ago this August, but the expenses didn't end there. Every day I have to take immunosuppressant medication to keep my own body from rejecting the kidney, and I also have to take other medications, which deal with the side effects caused by that immunosuppressant medication. Also, because my doctors later discovered that a chronic distended bladder may have caused my kidneys to decline to begin with, I have to use these catheters five or six times every day just to be able to empty my bladder. Without the ACA, it would be an expensive prospect for me to be able to urinate. All of these expenses together add up to almost as much per month as my mortgage payments. Now I hear talk of protecting preexisting conditions in other plans, that everybody wants to protect preexisting conditions. Well, the previous plans that have been put forth include things like pushing people like me into expensive and unreliable high-risk pools. Those are not protections for preexisting conditions. Potential lockouts for not having continuous coverage are not protections for preexisting conditions. I hear talk of relentless attacks on the Administration and the ACA. People like me feel relentlessly attacked by this Administration and by the members of committees like this one who keep attacking the ACA. My son Peter, five months old this week, was born with a kidney condition similar to mine. He, like Chairman Cummings talked about, is one of those babies who could be shut out for life. He had a kidney surgery two weeks ago, and without the ACA, he wouldn't have the protections to ensure that he could receive the followup care he may need his entire life, just for being born with a bad kidney. He's one of two sons I have who had the chance to be born because of the wisdom of the Patient Protection and Affordable Care Act, which gave me this coverage. In conclusion, I want to say that we are guaranteed in the Declaration of Independence the inalienable rights of life, liberty, and the pursuit of happiness. ``Life'' comes first because without life, all other rights are meaningless. Being subject to insurance companies being able to deny us coverage or make it prohibitively expensive because we're sick is not liberty. And without those protections, without access to healthcare, there can be no pursuit of happiness. My sons deserved the right to be born, they deserve the right to stay alive, and they deserve to have a father who has access to the care he needs to stay alive for them. Thank you very much. Chairman Cummings. Thank you very much, and congratulations. Mr. Gibbs. Thank you. Chairman Cummings. Ms. Dye. STATEMENT OF CASEY DYE, PATIENT/CONSUMER, MONROEVILLE, PENNSYLVANIA Ms. Dye. Thank you, Chairman Cummings, and the committee for letting me talk today. Over the past nine years, my family has faced a lot of challenges, but I hope you hear my story and recognize that I'm not some unique one-in-a-million story. The challenges my family have faced are like so many families who work hard, play by the rules, faced as they go through life. As parents, we want to make sure we can do the most essential thing for our kids and keep them safe and healthy. We also want to know as they go through their own journeys they will also overcome challenges and continue to pursue their dreams. In August 2010, my husband lost his job. We couldn't afford COBRA. Between August and November of that year, he and I went uninsured. Our one-year-old daughter, Chessie, got coverage through CHIP. In 2016, my husband lost a second manufacturing job, and thanks to the ACA, we did not have to worry about going uninsured again. My employer's health plan would cost $1,175 a month, and that's just for the two of us. We pay $60 a month for our son, Max, who's on CHIP, and our daughter, Chessie, is covered under the PH-95 Medicaid loophole for her disability. After my husband lost his job in 2016, we wanted to move closer to family in your state, Mr. Jordan, of Ohio, in Florida, and Arizona. Guess what, Mr. Jordan? Your state told me my daughter wouldn't get the services she needed, so, therefore, we have to stay in Pennsylvania. We also had to tailor our life around the needs of Chessie. For example, my husband is now going back to college to switch careers in the healthcare field, which doesn't require us moving from state to state to find a job. Thanks to the ACA, in 2018, I was able to get a mammogram. It showed I had three lumps in my left breast. Biopsies were done, and thankfully they were all benign. But what if I was uninsured and the results turned out differently? This could have been financially disastrous for my family. Before the followup this year in May, I actually looked at my husband, and I was kind of joking and being serious. ``I should just have the doctor remove both of my breasts'' because if I get cancer, I might actually be uninsured. This is my reality, and this is the reality of millions of families in America. And the fact is, I don't trust the Republican Party to say that you care about me and my family and the rest of the families in America to cover preexisting conditions, to cover those with disabilities. I also had decided to get a pelvic exam two years in a row, and when the doctor asked why I scheduled it this way because now you can go between three to five years, I told her the truth: I'm worried I'm not going to have coverage next year. So she looked at me and she said she was glad that I actually made that choice to come in. I am actually an LPN who works in pediatric home care, so a lot of the kids I take care of, they're on Medicaid. So not only is my job, but the lives of my patients are at risk if you guys make cuts to these vital programs. Our daughter, Chessie, who is right here in the white with the little pink headphones---- Chairman Cummings. Where is she? Oh, okay. All right. She seems to be listening to your testimony. Ms. Dye. I'm not as important as---- [Laughter.] Ms. Dye. Since she's been 19 months old, she has been in therapies. That's for OT for speech, and she also learned sign language so she could communicate with us, speech we use in everyday life from watching TV, listening to music, reading books, talking to our friends, socializing, and work. At the age of three, Chessie was seen by three doctors. Two diagnosed her with developmental language disorder, DLD, a condition where children have problems understanding or using spoken language. She will have this in adulthood. The other doctor diagnosed her on autism spectrum, but all doctors agree that she needs intense speech therapy. In school, she receives speech three times a week and OT one time a week. She also gets speech and OT once a week outpatient. She has a mobile therapist that comes to our house two hours per week. A mobile therapist helps Chessie to appropriately express her thoughts, her feelings, and work on coping skills, practicing social skills and all. Chessie gets six therapies week, not including a mobile therapist. If Chessie loses her Medicaid coverage and we had to pay, it would cost us $1,920 a month just to keep her at her current level of therapy. Because my husband is in school and we are on one income, we could never afford that. The hard work of her therapists in Chessie's life has improved her life skills tremendously. Today she talks a lot, and she talks to friends on her own. She has made significant academic progress. Last year she was a C student. This year at the age of 10, she got all A's and one B. In math and reading, she is two years behind, and she's in a support room. Just to make it clear to kind of break it down to visually, imagine a tripod and Chessie is on top of that tripod. The three legs represent, one is her parents, two is her therapists, and a third one is her teacher and her aides. If you guys cut Medicaid, you're going to knock down that tripod, and you're going to take away and knock down all the progress that she has made. The only chance of her being a productive member of our society and being able to get a job and hopefully just make minimum wage is these crucial programs that you guys have in place right now. So I just want you to realize what you guys are doing and not just think of my family and my daughter, but the millions of families around the United States that you guys are going to affect. Thank you. Chairman Cummings. Thank you very much. Ms. Burton. STATEMENT OF STEPHANIE BURTON, PATIENT/CONSUMER, KANSAS CITY, MISSOURI Ms. Burton. Chairman Cummings, Ranking Member Jordan, and the distinguished members of the committee, good morning. Chairman Cummings. Good morning. Ms. Burton. My name is Stephanie Burton, and I live in Kansas City, Missouri. In August 2008, I left my job as a probation officer to attend law school. I could not afford health coverage, so I was uninsured throughout school. Upon graduating in December 2010, like many of my classmates, I was unable to find work and was forced to hang my own shingle immediately after passing the Bar. Starting my own legal practice meant I still had no healthcare. As a single mother of four young children, that was devastating. My diabetes went untreated for five years. When my health got so bad that I could not tough it out, I was forced to seek medical care in the emergency room only. As a mother, I felt that I had let my children down. I had done everything that seemed right by furthering my education, yet I still couldn't even afford a routine doctor's visit. Something was terribly wrong with this picture. The Affordable Care Act changed all of that. On January 1st of 2014, I enrolled in a health insurance plan I purchased through the marketplace for less than $100 a month thanks to a subsidy. I no longer had to decide between paying my mortgage and going to the doctor. I've been able to manage my diabetes and get the medications I need to stay healthy for my kids and my clients. It's a huge load off of my mind. I've been covered through the marketplace since the beginning of the first open enrollment period, and I found the coverage affordable and easy to use. When taking a flight, the attendant always says if you're traveling with small children, in the event of an emergency, first place the oxygen mask over yourself and then over the small child. Now to every parent this sounds counterintuitive because we consistently put our children first. However, if we do not take care of ourselves and our health first, we will not be around to care for our children. The Affordable Care Act was like that oxygen mask. It allows me to have healthcare to keep myself healthy so I can continue to work and provide for my children. Until March 7 of this year, I was self-employed without the option of employer-provided health insurance. Upon accepting this new position eight years after having to hang my own shingle, I'm now offered health insurance through my employer. Though that benefit option is great, I can still say the policy that I have through the marketplace is better. I have had the same team of doctors since I enrolled in 2014. Although the need isn't as urgent for me today as it was eight years ago, I can honestly say that the Affordable Care Act saved my life. The last five years of coverage have kept me the healthiest I have been in the 11 years since I started law school. One of the requirements of my current employment was to undergo a health physical. I have no doubt that I would not have been healthy enough in 2014 to accept the position I have now. Maintaining preventative healthcare through routine visits, thanks to my ACA coverage, has allowed me to continue to treat my diabetes without fear of being turned away. Access to healthcare should be a fundamental human right to all people. There should not be Hobbesian choices when it comes to healthcare or housing. During this Administration, I frequently wonder what would happen if I lost my coverage and what would it mean for my children. In the event that I had to return to private practice, would I be able to afford my insurance without my subsidy? Would I be lucky enough to last without the treatment that I receive? This is not a partisan issue. This is what happens to families without health coverage issue. It's a why are we turning back the hands of time issue. It is a why should a single mother of four children be forced to choose between housing and healthcare issue. We create another undue burden on society if we can't keep parents healthy enough to raise their children issue. So I ask you and I urge you all, both sides, don't take away coverage from 20 million people. Don't return to the crisis, the health crisis, that we endured before the ACA. Thank you. Chairman Cummings. Thank you very much. Mr. Morley? STATEMENT OF PETER MORLEY, PATIENT/CONSUMER, NEW YORK, NEW YORK Mr. Morley. Thank you, Chairman Cummings, Ranking Member Jordan, and members of the committee. I am honored to speak with you today. My name is Peter Morley. In 1997, I had an injury during a lapse of insurance coverage. All treatment and medication costs were paid out of my own pocket. When I later needed surgery, my insurance company considered my injury to be a preexisting condition, and all my claims were denied. It was a financial burden totaling in tens of thousands of dollars. In 2007, I was permanently disabled from an accident. I was spared the costly medical bills of four spinal surgeries because I had continuous health coverage. In 2011, I survived kidney cancer and fought my way into remission after losing part of my right kidney. In 2013, I was diagnosed with lupus, which causes me severe fatigue, and most days it's a struggle to get out of bed. I now manage over 10 preexisting conditions, take 38 different medications, and receive 12 biologic infusions to slow the progression of my disease. I live on the brink of financial ruin and only live modestly thanks to insurance and the fact that I can't be discriminated against because of a preexisting condition. Preexisting conditions are a way of life for me as well as millions of others. Thanks to advances in science and medicine, most people like me with chronic diseases can live happy and productive lives, but only if we are provided access to health insurance that can't be taken away because an insurance company decides it's in their best interest not to cover something, or if Congress decides to repeal our healthcare, or the single- greatest threat we face to our health today: the Trump Administration's refusal to defend the Affordable Care Act. As someone who spends the majority of my waking hours in doctor's offices, the ACA has meant focusing on healing, not bankruptcy. I used to be very private about my health, but once President Trump was elected and set out to repeal the ACA, I could no longer be silent. In December 2016, I decided to foster awareness for lupus and advocate for healthcare. My Congresswoman, Carolyn Maloney, has taken up my cause and those of people like me. The Trump Administration's reckless support for the Texas v. Azar lawsuit to tear down the entire ACA, terminating it, as the President has said, is a grave form of subversion. In the last two years, I have traveled to D.C. 20 times to advocate for thousands of people who shared their healthcare stories with me. I have met with Democratic and Republican Members of Congress alike. My message is simple. If you think people don't get hurt when the Administration doesn't defend the ACA, think again. We do. I do. Millions do. If you think preexisting conditions aren't important, remember someone you love could have an accident, be diagnosed with cancer or lupus at any time, and that will change how you think about this. I know firsthand your healthcare can change in an instant. And if you think the ACA isn't perfect, your job as our representatives isn't to tear it down. It's to make it better. I appreciate the committee holding this hearing today. If the Trump Administration can choose not to defend the ACA, citizens like me understand that future administrations can do that with any law. I put my health at great risk to travel here and share these stories. I never know if this is the last time I am healthy enough to come to D.C. I would be remiss if I did not mention my friend and advocate of medically fragile children, Natalie Weaver, whose own daughter, Sophia Weaver, passed away in May. Sophia suffered from Rett syndrome and many other preexisting conditions and endured 30 surgeries in her short 10 years of life. Natalie spent precious time away from her daughter for the betterment of healthcare access for all children. She will never get that time back. These are the sacrifices that we make as advocates. That is why I am here today to ask you to protect the Affordable Care Act and to hold the Trump Administration accountable for not defending health insurance for all Americans. Thank you for allowing me the opportunity to testify, and I'm happy to answer your questions. Chairman Cummings. Thank you very much. Pain, passion, purpose. I will now yield to the distinguished lady from New York, Ms. Maloney. Mrs. Maloney. Thank you. Thank you, Mr. Chairman, for calling this very meaningful hearing. I am so proud that one of my constituents, Peter Morley, was invited to testify. He is the most effective patient advocate I have ever met, and he has been a fierce defender of the Affordable Care Act. Peter, thousands of patients and their families have reached out to you to share their stories and asked you to bring those stories to Congress. Can you share what some of these stories are like, and is there anyone that stands out to you? Mr. Morley. Absolutely. There are many that actually stand out to me. The most--the hardest stories for me to listen to are the people who could have been saved had the ACA been enacted, and also the patients who would have, like some of these people, these patients have testified here today, they would have been diagnosed sooner, their conditions would have been more under control, and, in some cases, healed. I hear from patients who--excuse me, rather, caregivers who are--they have medically fragile children and they get their health insurance because of Medicaid Expansion. I hear from people in states such as Texas, Florida, North Carolina, and Tennessee who don't have that same luxury because their states have not expanded Medicaid and they are denied that type of coverage, had they lived in a separate state, and they cannot afford to move to another state to receive that type of coverage. Those are the stories that keep me up at night, and of course, since I have lupus, anyone who reaches out to me who suffers from lupus and tells me, ``Thank you, Peter, for going to D.C. I don't know where you get the energy to do it,'' and truthfully, I don't know either. I am grateful to be here. It is that energy, as these patients have testified. It takes a lot of guts and a lot of courage to come here and to share something so vulnerable and so personal. Mrs. Maloney. I know. I know you suffer from chronic diseases and I know personally, from our exchanges, that it is very painful for you physically to come here. Why do you make these trips? Mr. Morley. Because, honestly, Congresswoman, I never expect to sit, whether it is a Democratic or Republican legislator, I never expect to change anyone's mind. But what I have learned from coming down here is it brings me hope, hope that there is a chance for change, hope that one person will listen, because it really only takes one person, and the hope that the people who follow me on social media, they receive and they say to me, you know, ``Peter, thank you. Thank you. I can feel that something positive may come out of all this sabotage that we have witnessed.'' Mrs. Maloney. Peter, the Trump Administration's recent attack on the Affordable Care Act in the form of the Texas v. United States court case really threatens health care for millions of Americans. What would it mean for your friends, the patients and families that you have spoken to, if protections for people with pre-existing conditions are eliminated? Mr. Morley. In some cases it might limit their access to medications and to life-saving infusions and to cancer treatments, and it could--I mean, it very well would mean death. Mrs. Maloney. What about if Medicaid was eliminated? What would that mean? Mr. Morley. Medical Expansion? Mrs. Maloney. Yes. Mr. Morley. Yes. Mrs. Maloney. What would happen to these families? Mr. Morley. A lot of them would lose coverage and access. Mrs. Maloney. And what would it mean to the parents of medically fragile children who have reached out to you, if the entire Affordable Care Act--what would happen to them if the Affordable Care Act was eliminated? Mr. Morley. I honestly don't know but I do know that they experience, just even if that didn't happen, they experience an incredible deal of stress. And this, even having to focus on that has caused them an undue stress, and it is already stress, as we all know, when we have a chronic illness, so it is stress upon stress. Mrs. Maloney. My time is expired. I am proud to be in this fight with you and I so proud of you. Mr. Morley. I am proud of you. Chairman Cummings. I yield now to Mr. Hice. Mr. Hice. Thank you, Mr. Chairman. Yes, I think there are two basic reasons why we are having this hearing today. No. 1 has just come up. It is an opportunity to trash the President, to impugn the President for not defending Obamacare, and I get where our witnesses are coming from, from that perspective. But that is the purpose-- one of the purposes of this hearing. But the reality is Obamacare is failing, and the President is not defending a failing policy, a bad policy, and he is right not to defend that. I mean, just look at the numbers, and it is very clear. Obamacare does not work. It has not worked and it is not going to work. We were told that there would be some 25 million people enrolled in Obamacare by now. It just has not happened. The truth, what has happened, insurance premiums have skyrocketed--skyrocketed--under Obamacare. Deductibles have soared. Coverage networks and access to providers have shrunk, in some cases been eliminated. Insurance companies have fled the ACA marketplaces. Rural hospitals have suffered enormously. I have a number of them in my district, and they have suffered tremendously because of Obamacare. Many rural hospitals have actually closed their doors. And yes, there are people who have benefited. I am not going to deny that. Of course, our panel is full of them today, and I appreciate the testimony from our witnesses, our panelists today. But I can also tell you this: for every person who has benefited from Obamacare, we can find tons of folks who have been hurt from it. You know, I look at the panel today, Mr. Chairman, six out of the seven are Democratic witnesses. Where are the ones--in fact, I would like, Mr. Chairman, to have entered into the record a letter from a constituent back home, Ralph, from Greensboro, Georgia, who talks about how he has suffered. Chairman Cummings. Without objection, so ordered. Mr. Hice. Thank you. You know, and we are told that--you know, I will just reverse it somewhat, of what has been said already today. If you think that people don't get hurt by ACA, you need to think again. Ralph, for example, before Obamacare he paid $700 a month for insurance with a $3,500 deductible. Both of those--in fact, he now has a nearly $14,000 deductible and his monthly costs are about $1,200 a month. A couple of years ago his two children--he has four children--two of them were in an accident. He is still paying for $30,000-plus that had to come out of pocket. That is before taxes, before groceries, before mortgage, before college. So this thing absolutely goes both ways. The second reason we are here today is really to lay the platform for Medicare For All, and that is the attempt that the Democrats are putting forth. In spite of the failures of Obamacare, the Democratic Party is going to double down and push for Medicare For All at a cost of some $32 trillion. It would totally eliminate employer-sponsored medical coverage, Medicaid, Medicare--all of it, gone. Mr. Balat, let me just ask you, what can we expect from a government single-payer health system? Mr. Balat. You can certainly expect rationing of services. That is what we have seen in many other countries that have gone this way. Many politicians have said those are models that we want to look for, that we want to look toward, to emulate. But my experience in being with those countries and working with patients--I will give you a specific example, if I may. My wife and I were on medical missions in Costa Rica that has a single payer, and the wife of the pastor that we were with was diagnosed with cervical cancer. She was approved for surgery but she had to have an ultrasound first. She could not have that ultrasound for 12 months. She asked, ``Well, when will I be able to have the surgery?'' and they said, ``Probably another 12 months after that.'' She had access. She may never get to the point where she has that surgery. But rationalizing is an inevitability when you have a limited amount of resources, and those resources continue to decrease, the more burden we place on the medical professionals that are actually delivering the care. Chairman Cummings. The gentleman's time has expired. Dr. Gluck, would you like to respond to that? Hice said he wants to see both sides. He said it is both sides. What is the other side of this? I saw you shaking your head. Go ahead. Ms. Gluck. So, you know, what occurs to me---- Chairman Cummings. Your mic. Your mic. We really want to hear you. Ms. Gluck. Oh, sorry. You know, with respect to discussing the case that is the subject of this hearing, one of the things that I would emphasize is that the case in Texas is not on policy referendum. It is not a case about the benefits or not of the Affordable Care Act. It is a case about a settled legal principle. The Administration doesn't get to decide whether to defend a law based on whether it likes the policy and the law or not. That is your job, Congress' job, is to pass the policies. The Administration's decision not to defend is only defensible under very limited circumstance, unless there is a real unsettled legal question. As I said in my testimony, what is striking about this case is that there is a dramatic legal consensus across both sides of the aisle that the principle at issue here, the legal principle, severability, is settled, and that there is no place not to defend the law. I would also just note that, you know, we have heard a lot of statistics about the benefits of the Affordable Care Act, including dropping the insurance rate by some 46 percent, including getting women covered at record rates, and I also would point out that the Trump Administration itself is actually relying on the statute for a lot of its initiatives. I heard this morning that the Trump administration announced an Executive Order about kidney disease that depends on the Center for Medicaid Innovation. Well, that would be gone if the Affordable Care Act is eliminated. The HIV Initiative requires---- Mr. Hice. Point of order, Mr. Chairman. Ms. Gluck [continuing]. everything in the Affordable Care Act. Mr. Hice. Point of order. Whose time is this? Chairman Cummings. I am trying to help you, man. You asked a question and I---- Mr. Hice. Not to this---- Chairman Cummings [continuing]. basically, I--I asked her to finish answering the question. She was shaking her head and I allowed her to do that, because I know you want a fair hearing. I know you want to hear both sides of it. That is what you just said. It is my time. Mr. Hice. Mr. Chairman, six out of seven is not exactly giving a fair hearing. Chairman Cummings. Oh, come on, man. Mr. Hice. We want a fair hearing. Chairman Cummings. Yes, well, you are getting it. Are you finished? Ms. Gluck. Yes, I mean, that is the point. The opioid crisis as well. Virtually all of their own health care policies rely on the statute as well. So, I mean, I think that is important to recognize that when we are talking about the benefits and what the statute has to offer. Chairman Cummings. Thank you very much. Thank you for giving us both sides. Ms. Norton? Ms. Norton. Thank you very much, Mr. Chairman. It took a lot of chutzpah to hear my friend on the other side go down the list of the costs going up of health care, deductions going up, when that is a direct result of actions that the Republican Congress took when they controlled this House. They are complaining about actions that they took to diminish the Affordable Care Act. Well, one of those actions was to take away the mandate. The district I represent, the Nation's capital, the District of Columbia, has a rate of about 96 percent covered, which means that virtually everybody is covered. That is people going from one side or the other who may not be covered. That is because, as my Republican friends took actions, that is detailed by my colleague on the other side that undermined the Health Care Act, in my district they simply made up for them themselves, for example, as I indicated, by reinstating a DC mandate, and so almost everybody has health care. Ms. Burton, I was interested in your testimony because it looked to me as though you had done all that anybody could be expected to do. You finished law school, you could not find employment, and then you did what is really difficult for someone just out of law school--you opened your own practice. Your children were covered, you said, by Medicaid, but you could not get coverage in the individual market, I understand, because of a pre-existing condition. Is that true? Ms. Burton. That is correct. Ms. Norton. Any idea of what the purchase of health insurance would have been for you before the ACA? Ms. Burton. It was $895 a month, which was more than my mortgage. Ms. Norton. I was going to ask you, compared to what other expenses. You indicated your mortgage. So you chose to give up coverage for yourself in order to pay the rent and provide for your children. Did that take any toll on your health? Ms. Burton. Absolutely. As a single mother of four kids you do what you have to do to maintain. You do what you have to do for their interests, even if it means you sacrifice your own. I worked in private practice 80-100 hours a week. I took time away from my kids to make sure they had everything that they needed. I don't have any regrets about that. I would give anything to make sure that they are okay. But I am all they have, and so if I am gone there is not somebody else willing to step up and take over that burden. Ms. Norton. Well, then came the Affordable Care Act---- Ms. Burton. Yes, ma'am. Ms. Norton [continuing]. with the Marketplace. What kind of coverage were you able to get, and how much did that plan cost? Ms. Burton. My plan with my subsidy cost $62 a month, and it was---- Ms. Norton. Compared to--now remind us, compared to---- Ms. Burton [continuing]. the $895 that I would have had to pay for an HMO coverage. The plan that I got through the marketplace was a PPO coverage. I was able to choose a doctor. I have got a great doctor and a great team of doctors. Because I have so many conditions--I have narcolepsy, I have asthma, I have diabetes, I have sleep apnea, I have cataplexy--because of that I have a team of doctors. Ms. Norton. Now--but now you work for the District Attorney's Office. Now that is a government agency. Ms. Burton. Correct. Ms. Norton. And the government agency we work for, the U.S. Government, provides health care for everybody who is sitting on this podium, so you would have what we would have. So did you take your health care that was provided by the District Attorney's Office? Ms. Burton. My health care that I have through the DA's office is supplemental. It is not Federal so it doesn't cover the benefits that you guys might have. My policy, through the marketplace, is still better than the insurance my employer offers. Now I did take it for my children. Ms. Norton. So you had health insurance offered by your employer, you compared that to the ACA, and you decided to stick with the ACA coverage. Ms. Burton. That is correct. Chairman Cummings. The gentlelady's time has expired. Did you finish? Ms. Burton. Yes, sir. Chairman Cummings. Thank you very much. Mr. Comer? Mr. Comer. Thank you, Mr. Chairman. I would like to welcome--I am over here--I would like to welcome all the witnesses here today, and I just have three quick general questions I would like to ask the entire panel, just with a show of hands for the sake of time. Do you all support--or how many support eliminating employer-sponsored insurance? [No response.] Mr. Comer. Second question. How many on the panel support the current version of Medicare For All, which I believe, if my math is correct, 17 members of this committee on the other side of the aisle support? Does anyone support Medicare For All? [No response.] Mr. Comer. Last question. Do you support extending health care benefits to illegal immigrants? [Hands raised.] Mr. Comer. A couple. This is one of the areas that I find troubling, because I represent Kentucky. I represent a poor district. I represent a district that has a high percentage of people on Medicaid. Before the Affordable Health Care Act Kentucky had a high Medicaid population. After the Affordable Health Care Act, Kentucky expanded Medicaid, and what happened when they expanded Medicaid, a significant number of new people got on Medicaid. What that did was it cut the pie into very small pieces. In fact, 30 percent of Kentucky is on Medicaid now. There are so many people on Medicaid that the providers continue to get cut and people on Medicaid are finding a hard time finding a provider who will actually take them. So Medicaid has not been cut in Kentucky. The fact that so many people are on Medicaid, the services are automatically getting cut. Everybody can't be on Medicaid, and Medicaid in Kentucky is free health care, and that is a great deal for the people that have free health care. But somebody is paying for the free health care, and the people that are paying for the free health care are the people that are in the private market. They are very upset because the premiums continue to skyrocket. So we have a problem with the Affordable Health Care Act. Mr. Balat, the reason I asked the question about extending health care to illegal immigrants is because I watched the Democratic debate the other night, when there were 10 on the panel, and they were asked the question, how many support extending health care, free health care, to illegal immigrants. And if I remember correctly, all 10 raised their hands. That is potentially millions of new Americans on what I would presume would be Medicaid. What happens to the current health care system in America if my friends on the other side of the aisle and those running for President from the other party get their wish and extend free health care to millions and millions of illegal immigrants? Mr. Balat. Thank you for the question. I am a child of immigrants. It is important what we do in this country for the people that are here. We, as Americans, have always taken care of our communities, and that is our focus. That is who we take care of. What it would do to health care, what it would do to our communities, what it would do to the medical professional community is it would strain it even further. Let me tell you what happens in Medicaid today. It is very difficult to get in and see the doctor. The wait times are exceptionally long, as I said in my testimony. If they do get in to see their doctor, getting a specialist referral is very difficult, because even less specialists participation in Medicaid panels. Then, getting the medication that they may need. You know, I hear all the time that doctors do not like to take care of Medicaid patients. Nothing could be further from the truth. They got into that field to take care of patients. They don't like the administrative burden that is consistent with how we deal with Medicaid and the ACA exchange, and so on. It is going to stretch it out. We are going to see less people participating on those panels, and it will leave people without care, and we are going to see our ERs continue to be flooded and increase in population. Mr. Comer. Right. Well, I think that is an important part that needs to be mentioned in this hearing, is that everyone can't have free health care, and we have got a problem with the health care system in America. We had a problem before Obamacare, it got worse after Obamacare, and, you know, there is no way to fix the Obamacare situation, especially in Kentucky with the massive expansion of Medicaid. So hopefully we will have a discussion in the future in Congress about ways to make health care more affordable to the working people that are paying, while, at the same time, protecting people with pre-existing conditions, which is a priority for me, and I think every member of this Congress. Thank you, Mr. Chairman. I yield back. Chairman Cummings. Thank you very much. Mr. Raskin? Mr. Raskin. Thank you very much, Mr. Chairman. Professor Gluck, let me start with you, because you said something extraordinary, which is that your partner in filing an amicus brief against this attempt to destroy the Affordable Care Act and strip 20 million people of their health insurance, is a person who was opposed to the Affordable Care Act and was your nemesis, essentially, your counterpart on behalf of the Affordable Care Act back in the Burwell case. Is that right? Ms. Gluck. Yes, it is. It is extraordinary. Mr. Raskin. So you are talking about a distinguished lawyer who was opposed to the Affordable Care Act, and thought it was originally unconstitutional, but he thinks it would be absolutely absurd and outrageous to use the invalidation of one provision, which zeroed out the penalty for not purchasing insurance, to unravel the entire act. Is that right? Ms. Gluck. Correct. Mr. Raskin. And you cite a bunch of other conservative legal scholars who are on that side. Would you repeat some of the ones you mentioned? Ms. Gluck. Sure. So there is the Republican Attorneys General from Montana and Ohio, Judge Mike McConnell. Mr. Raskin. Judge McConnell? Ms. Gluck. Yes. Professor Sam Bray, Professor Kevin Walsh. Mr. Raskin. In what context is Judge McConnell taking a position against the Administration's point of view here? Ms. Gluck. Judge McConnell authored an amicus brief with two other noted conservative legal scholars arguing that there is no jurisdiction to decide the case, and filed the brief not on behalf of neither party but actually on behalf of the blue states. Mr. Raskin. Okay. I want you to underscore this point for our colleagues. Obviously, we have a difference about whether or not 20 million people should be stripped of their health insurance and about the general progress we have made under the Affordable Care Act. But let's just get to the point about legal severability. In 2017, there were efforts to repeal the whole Affordable Care Act. I remember that. I was in Congress then, and they had voted 69 different times to repeal the Affordable Care Act in its entirety. They weren't able to do it because there was a massive uprising around the country. I remember people went out all the town hall meetings and said, ``Don't do this,'' eloquent, riveting testimony, like the kind we have heard today from patients, ``Don't do this to our families,'' and they weren't able to get enough Republicans to do it, even though the Republicans controlled the majority. So instead, they passed this one provision zeroing out the penalty on the compulsory purchase of insurance policy. That was it. And at that point everybody agreed that the Affordable Care Act should be saved. Some people thought it was a great thing. Some people thought it was a terrible thing. But now the proposition being pushed by--I don't even want to say conservative Republicans, because a lot of conservative Republicans are on our side, but by an extreme faction. Apparently, within the Trump administration, there is a position that the invalidation of this one provision--or I don't know if it is the passage of this one provision--but undoes the entire act. So it undoes everything--the protection for 26-year-old, pre-existing condition coverage, all of the Medicaid provisions, all the provisions that expand people's access to prescription drug benefits, closing of the donut hole. Everything that is in there, they are saying is now toppled because this one provision is gone. Now what does that do to the power of Congress, when we thought we were passing one thing and now the courts say, well, because this one provision is out we are going to strike down a 2,000-page piece of legislation? Ms. Gluck. Yes, I think one of the reasons you see this unprecedented consensus--you are absolutely right, that this case goes to the power of Congress. To let the court do what it did here, the court is taking over congressional lawmaking power. The court is being activist. It is usurping congressional lawmaking power. Conservative legal scholars and liberal legal scholars alike value separation of powers. Mr. Raskin. I would not even want to win that way. In other words, if I thought that the Affordable Care Act was the creature of the devil himself, and I was not able to get it through Congress but we were just able to chip off a little piece of it, and then, later, some judges say, ``Hey, we are going to go ahead and destroy the entire act,'' I would not support that, because that is an absolute defeat of legislative power, isn't it? Ms. Gluck. Well, yes. That is what the Wall Street Journal editorial page said. It started saying nobody hates Obamacare more than we do, but this is a corruption of the rule of law. Mr. Raskin. What are some of the other things that would fall if the Administration now gets its position in destroying the ACA? Ms. Gluck. Well, I don't think it can be overstated the reach of the statute. I mean, we have got Medicare prescription drugs, we have got no discrimination based on health status, we have got the Indian Health Care program, we have got the FDA approvals for biosimilars. Mr. Raskin. But they would invite us to believe that we all knew that when that vote took place, that we were essentially going to undo if one phrase or one sentence dropped out of the legislation. Ms. Gluck. Courts are actually, respectfully, not allowed to do that. Courts are not allowed to presume that the legislature sowed the seeds of its own destruction into a statute. Courts have to interpret statutes deferring to the legislature. Mr. Raskin. Well, thank you for what you are doing and thank you for reaching across the aisle to bring conservative scholars in and to work with them on defending this critical principle of the severability of provisions that are struck down by a court. Ms. Gluck. Thank you. Mr. Raskin. I yield back, Mr. Chairman. Chairman Cummings. Mrs. Miller? Mrs. Miller. Thank you, Chairman Cummings, and Ranking Member Jordan. Before I begin I would like to read a portion of a testimonial from one of Mr. Hice's constituents from Madison, Georgia. She writes: ``I co-own a small business in Madison, Georgia. When Obamacare was first passed we were one of the businesses that lost our health care coverage. When finding new coverage, my insurance went from $385 a month to $643, due to the fact that I am a female, which is an increase of 67 percent. I am beyond childbearing ability but I still have to have maternity coverage.'' Mr. Chairman, I ask for the unanimous consent that the full statement be entered into the record. Chairman Cummings. Without objection. Mrs. Miller. Thank you, and thank you all for being here today. It has been over nine years since the ACA has been signed into law. We all know that when a law is enacted that often there are kinks or problems that need to be worked out and issues that need to be resolved, as we move forward. However, the Obamacare has had countless issues since its enactment and has harmed health care for citizens across the United States. Republicans have been saying, for years, that we need a fix for this program to decrease the premiums, stabilize the market, increase access to care, and to protect those with pre-existing conditions. Now my colleagues across the aisle have decided to abandon this program completely and chase after a single-payer system, which would further increase health care costs on taxpayers and inevitably decrease access to care for people who need it the most. In West Virginia, enrollments in our exchange has decreased. While many are now enrolled in employer insurance due to the booming economy, many have cited high deductibles as a reason for going uninsured. We need to solve this problem and a single-payer system is certainly not the solution. Mr. Balat, has the ACA lowered monthly premiums for Americans? Mr. Balat. No, they have not. Mrs. Miller. In fact, how much have premiums gone up for Americans, on average, since this law was enacted? Mr. Balat. It has been significant and it has been a range, depending on the part of the country that they are in. But it has been 200 to 400 percent in some cases. Mrs. Miller. That is terrible. How has the ACA kept deductibles the same, or lowered them, for our constituents? Mr. Balat. Outside of the exchange or within the exchange? Mrs. Miller. Within the exchange. Chairman Cummings. Will the lady suspend? Mr. Morley, are you okay? Whatever--listen to me. Your health is No. 1. Whatever you need, let us know. Mr. Morley. It went down wrong. Chairman Cummings. All right. Okay. Mr. Morley. Thank you. Mrs. Miller. Thank you, Mr. Chairman. Mr. Balat. The premiums within the exchange have been--they have gone up probably closer to 60, 70 percent. Outside, in the private market, they have gone up substantially more. Mrs. Miller. Thank you. It sounds like what the goals for the ACA intended to be have not really been enacted. How has the current Administration helped ensure Americans to have increased access to health care? Mr. Balat. Well, I think some of the examples have already been given. You know, people have talked about fixing the ACA, and I think some of the measures that have been mentioned are attempts at fixing it, such as the opioid, HIV, and kidney initiatives. It looks to be that the White House and the Administration are looking to improve upon the ACA's foundation. But they have done other things as well. The Executive Order that the President put out in 2017, that would expand the already existing short-term limited-duration plans, the insurance health plans, extending those for those that may be in transition longer than the amount of time that was initially prescribed, helping people who are losing jobs, having to move, that are going through a divorce. It is allowing them more time to go through that transition period. Association health plans was another solution that was put out there, and they experienced great success. Some reports were showing that there were double-digit savings, that people were able to pool together and buy employer-style health plans. So that was another good innovation. Then the HRAs, the health reimbursement arrangements that will become effective January 1, that will allow the individual market to come back, because that went away, effectively, when the ACA was first implemented. Employers will be able to dedicate defined amounts of funds that are part of their compensation plan for the employee to go out and be a consumer of what fits them and their family the best. Mrs. Miller. Thank you. Mr. Chairman, I will yield back the rest of my time to the gentleman from Texas. Chairman Cummings. You have five seconds. Mrs. Miller. Sorry. Mr. Roy. Mr. Balat, could you expand on your concerns, earlier you stated about the Medicare For All and expanding coverage in the extent that that would drive up costs of health care? Chairman Cummings. The time has expired but you may answer the question. Mr. Balat. The cost of health care continues to go up. The more that we have had the government involved in trying to fix this entity, this industry, the more we have had the cost go up. We see the same thing in higher education. The more Federal Government has gotten involved, the higher tuitions have become. We have seen lots of technology--televisions, iPhones--that are not heavily regulated, but those prices go down. Yet when the government is involved in an industry, those prices go up. What comes with those costs? The reason that they are there, all the regulations, the administrative burden, the shackles that we put on the people that are doing the work, that are on the front line, that are trying to help the patients. We are hurting ourselves by doing this. Chairman Cummings. Mr. Connolly? Mr. Connolly. I thank the chair, and, good Lord, Mr. Balat's comments, the role of the Federal Government, that would come as news to a lot of the universities and colleges, especially the for-profit colleges. Let's just get government right out of the way, stop regulating it, and prices will go down, and, of course, cheating will stop and people won't be embezzled or defrauded with phony credentials or the credits. That logic escapes me. Professor Gluck, have you looked at the economics of health care insurance premiums? Ms. Gluck. Yes, to the extent that a law professor can. I'm not an economist, but yes. Mr. Connolly. So Mr. Balat, to the horror of my colleague on the other side of the aisle, says ever since the Affordable Care Act premiums have just skyrocketed. Is there, in fact, a correlation, and yes, Mr. Isasi, you can answer as well. Is there a correlation between the adoption of the Affordable Care Act and these, I don't know, all of a sudden, inexplicable premium increases that apparently are unprecedented. We have never had them before, right? Premiums were not going up before the Affordable Care Act. Everything was stable and hunky-dory, and, you know, 35 million people didn't have health care coverage, but, you know, somebody has got to suffer. Professor Gluck? Ms. Gluck. So you are correct. The Affordable Care Act made insurance more affordable for millions of people, to the extent that we have had some premium instability. A lot of that is attributable to the actions of the Administration---- Mr. Connolly [continuing]. and the Republican Congress. Ms. Gluck [continuing]. and the Republican Congress itself. Mr. Connolly. Yes. This strikes me as really amazing. We do everything we can to sabotage the law, and then we are horror- struck there is gambling here at Rick's, that it has an impact on the cost of insurance, because the mechanisms that we put in place to try to keep those down and keep it affordable were destroyed in the eight years the Republicans controlled the Congress, even before Mr. Trump took office. Would that be a fair statement? Ms. Gluck. Yes, I think it is. Mr. Connolly. Mr. Isasi, you have been shaking your head. Yes, please comment. Mr. Isasi. Yes, I think it is really important that we deal with facts in this conversation. Mr. Connolly. Oh, no. No. Now you are talking crazy. [Laughter.] Mr. Connolly. You are in the U.S. Congress, but all right. Mr. Isasi. Okay. We actually know the answer to this question. We know what happened to premiums, premiums post-ACA, and the first thing to say is--and this has been studied. The Commonwealth Fund looked and actually surveyed the American public, and the percentage of people reporting they could not afford health insurance in the individual market actually was cut in half after the ACA. One of the essential parts of the ACA was support to make sure that coverage was affordable. Most people in the exchange are getting that. Most people are paying far less for their premiums now than they were before the ACA, period, and it is empirical and it is well documented. In addition, as you point out, there are a lot of dynamics at play, but the No. 1 reason that premiums are high in this country is not the Affordable Care Act. It is because the health care prices in this country are out of control. It is a totally distinct thing, and the American people know this. We know we are paying too much for prescription drugs. We know we are paying too much for hospital care. We know we are paying doctors too much. We know that. But to blame the ACA for that, as I said in my opening statement, is a drowning man blaming his life preserver because he is wet. It is preposterous. That is not the reason that we have high health insurance premiums in this country. Mr. Connolly. Can you and Professor Gluck just remind us of a couple of the successful efforts by my Republican friends during their majority tenure here in the House and in the Congress, where they succeeded, in fact, in gutting certain provisions of the Affordable Care Act that were, in fact, directly related to trying to keep pressure down on premium increases? Ms. Gluck. Sure. So as you know, Congress turned off three streams of very important stabilization payments for the insurance industry. There was then a lawsuit about the continuing ability of the Administration to pay cost-sharing reduction payments, which showed dramatic instability into the insurance market. There was then an attempt to reduce enrollment on the exchange, reduce money for navigators, which are critical bridges between individuals and enrollment, and recently there has been a vigorous attempt to split the insurance pool, divide the insurance markets, and make health care more unaffordable for those still in the ACA market. Mr. Connolly. Well, Lord Almighty. And here I was thinking just we are perverse and the Affordable Care Act just drove up prices mindlessly. But now you tell me there is actually, yes, there is a cause and effect, but it is not the Affordable Care Act. It is, in fact, the insidious, relentless drive to gut the Affordable Care Act, which they could not defeat legislatively, but they could it both administratively and through amendments to laws that made it much harder for the protections, the bumpers, that have protected us and buffered us from---- Mr. Isasi. That is exactly right. In fact, the largest percentage increase we saw was after the risk corridor payments were stopped. That is when that happened. Mr. Connolly. Well, my time is up, but thank you both for illuminating my understanding of what really happened. Chairman Cummings. Mr. Gibbs? Mr. Gibbs. Thank you, Chairman. I don't think anybody on this panel, or in this room, or the President of the United States does not support applying for pre-existing conditions, have that in the bill. I mean, it is a tragedy when somebody loses their coverage or health care and can't get it because of pre-existing conditions. Unfortunately, in the last Congress we had a bill that was passed out of the House that addressed that, that protected pre-existing conditions, and it was unfortunate that the other side of the aisle would not work with us to make that bill better. I think it is interesting, when I look at what is going on, when we talk about the costs. I had a neighbor come to me, a little over a year ago. My county was down to one insurer on the exchanges, and she was going to lose her health insurance because that was going away. And the other thing I hear a lot about is people talking about the deductibles are so high they can't afford them. One of the reasons I hear a lot of people are uninsured--and I believe there are still 30 million people in this country uninsured--is because the deductibles are so high and it is a problem. I do notice, too, that there have been comments earlier about how the Affordable Care Act has failed. Most of the people running for President on the other side of the aisle aren't running on Obamacare. They are running on Medicare For All, which I think would just be a real big disaster. I will give you an example. We had a good friend here, a few years ago, that on Friday at 4 in the afternoon had severe chest pains. At 11 that night she had a quadruple bypass. Mr. Balat, what would happen if that was in Canada or anywhere else? Would that person get that care that fast, in a system where we have Medicare For All or a single-payer system? Mr. Balat. In an emergency situation that would be different, and that would certainly be considered an emergent situation. But if it were a planned procedure, the wait times would be exceedingly longer than what we would have in this country. Mr. Gibbs. Okay. It just amazes me. I know we talk about research, and medical research has come a long way, improving life expectancies, people having a higher quality of life, and if we have a single-payer, government-run system, what happens to that research? What happens to the private sector being innovative? What do you see happening? Mr. Balat. I don't know that I could actually speak to that. The one thing that I do want to say is that even when we talk about all these other issues we keep going back to insurance, and we talk about insurance, and we don't talk about the patient. The real victim in this is the patient and the cost of care itself. The insurance has contributed to it. Of course, the premiums went up after the risk corridor payments were reduced, because those risk corridor payments were put in place to artificially decrease the premiums in the ACA so it looked like it made sense, which it did not. So let's look to see what is going to happen to the patients themselves. That is the real tragedy of what is going to be in the future and how we are going to decide that we are going to take care of our citizens in this country. Mr. Gibbs. Let me just interrupt you. President Trump did an Executive Order to let association plans come back into effect, because Obamacare did away with association plans. And one of my neighbors--that I actually, you know, helped her get insurance through the association plans. Can you tell us what is happening with association plans? Mr. Balat. They were growing at a good clip. They had a great deal of popularity and then there was a suit, and the Federal judge essentially said that the association health plans were an end run around the Affordable Care Act. They are still in operation. There was no injunction, much like what happened with the Federal suite in ACA v. Azar. They are still able to operate. However, the uncertainty has caused many people who want to create those kinds of plans to not proceed further because they don't know what is going to happen. Mr. Gibbs. But association plans do give individuals the ability to have options. Mr. Balat. Absolutely. Mr. Gibbs. And because of the exchanges, there is no competition there. It is just--you know, it is just a government-set---- Mr. Balat. And because it functions like an employer plan, there is no exclusion for pre-existing conditions. It is affordable because you have got a bigger base, and yes, so there are more options. They can choose among different types of solutions and not just traditional insurance. Mr. Gibbs. Yes, and we know that health savings accounts are big part to help that. I have a health savings account on a Federal plan and I think it is a big help. It gives me more options and a better ability to direct my own health care. I will yield--I have got 20 seconds left--to my friend from Texas. Mr. Roy. With all this time, what can I do? Mr. Balat, I guess I would ask one question, is, you know, describe a little bit what you say in terms of--what are some of the alternatives we could look at with respect to empowering patients instead of empowering insurance companies? For the life of me I am not understanding why we are seeming to be focused on insurance, and my colleagues on the other side of the aisle seem more concerned about insurance than care. Can you talk a little bit about care and patient access, the doctors? Chairman Cummings. The gentleman's time has expired. You may answer the question. Mr. Balat. Thank you, Chairman. Let me just give an example, the personal one that I currently use. I use something called Direct Primary Care. Insurance has--well, I will say this. I will say it this way. The reason health care has become more inefficient and more unaffordable is because there has been a wedge driven between that relationship between doctor and patient. Health care is a very personal situation--I think all of the witnesses here have talked about their team--and it should be looked upon that way. Direct Primary Care is a membership model type of plan. I pay on the order of $60 a month for unlimited 24/7 access to my primary care physician. No exclusions on pre-existing conditions. I can communicate with him via electronic means, text, secure video chat, and the like. Chairman Cummings. Thank you very much. Mr. Balat. Thank you, sir. Chairman Cummings. Mr. Rouda? Mr. Rouda. Thank you, Mr. Chairman. I do want to level-set some information here. There has been talk about government- backed, single-payer systems. We already have two government- backed, single-payer systems in the United States. It is called Veteran Affairs and Medicare. I am hoping that the members on the other side of the aisle are not suggesting that those should be eliminated because they are single-payer systems. I also want to point out the fact that there is approximately 40 industrialized developed countries in the world, and 39 of them have universal health care. Only one does not--the wealthiest, greatest country in the history of the world, the United States of America. And, Mr. Balat, I take exception with your testimony that when the government is involved in providing health care insurance it drives prices up. In fact, those 39 countries who have universal health care spend about half of what we spend on health care. In fact, we spend 18 1/2 percent of our GDP on health care. So we know that we have a very inefficient system. And while the ACA may not be perfect, it has certainly brought quality insurance to a lot of individuals who did not have it. Mr. Isasi--and I hope I am pronouncing that correctly--I did want to touch base with you on a couple of areas. With the litigation going on in Texas, and the potential that we are facing that the ACA could be eliminated as we know it, and the protections under it, and some of the other key areas, one of them is talking about the donut hole that a lot of seniors face in prescription prices. Can you talk a little bit about what the impact would be if the ACA was thrown out in totality as the impact on senior citizens and prescription prices in general? Mr. Isasi. You bet. So first of all, if the ACA was repealed by these judges, the first thing that would happen is the seniors' Medicare costs would go immediately up. Their premium costs would go up, their cost-sharing would go up, and the Medicare trust fund solvency would immediately be weakened. So it would have a very specific and negative effective on the Medicare program writ large. In addition, the entire pathway to provide low-cost, high- value biologics, things to treat leukemia, to treat lupus, to treat some of the most devastating illnesses in this country, would disappear, because that was also part of the law. So it would have a very, very negative effect. And I do want to say something, this discussion about association health plans and other forms of new kinds of insurance. Let's be really clear. What we are talking about there is hurting people with pre-existing conditions and hurting people, letting insurance companies play tricks again on consumers. The only reason association health plans are cheaper is because it excludes people and it allows insurance companies to play tricks. We know, and we have done a lot of work across the aisle, this Congress, on surprise medical bills. The American people are fed up with buying insurance and then not getting financial protections. What we are hearing today is a description of insurance products that would, for example, exclude hospital care, or exclude prescription drugs altogether. It is letting insurance companies play tricks on consumers again, and that is not a pathway to affordable access for the American people. It is a pathway for tricks and for hurting the financial stability of our Nation's families. Mr. Rouda. And when we heard a member on the other side say that everyone here would support the view that the President supports coverage for pre-existing conditions, let me point out I don't believe that. I believe actions are greater than words. If the ACA was struck down in its entirety, wouldn't millions, tens of millions of Americans--I believe even over 100 million Americans would lose pre-existing coverage? Mr. Isasi. That is exactly right, and we know it is almost--and, by the way, it is almost half of the people--I am sorry--over half of the people before the ACA who went to the individual market tried to get coverage but had pre-existing conditions and could not get coverage. And it is important. This question has actually been answered. Republican leaders passed legislation that was an alternative to the Affordable Care Act. The CBO told us that 6.3 million Americans with pre- existing conditions would end up paying much more for their health insurance coverage or not be covered. They answered this question and they hurt people with pre-existing conditions, and that is the truth. Mr. Rouda. Professor Gluck, it looks like you are chomping at the bit to say something as well, so can you weigh in on this as well? Ms. Gluck. I just was nodding in agreement because before the Affordable Care Act I think the number was some 52 million people were denied insurance because of pre-existing conditions. So that is a statistic you have right there that is readily accessible, and, furthermore, just to emphasize that re-enacting just pre-existing conditions alone would not really do nearly enough, or really anything, for people who have serious medical conditions. If you have coverage but that coverage is priced prohibitively, it does nothing. If you have coverage but that coverage does not include the benefit of the prescription drug you need to treat your disease, that does nothing. If you have coverage but you don't have subsidy to pay for the coverage or you don't have Medicare or Medicaid to pay for the coverage, the coverage does nothing. So I think the pre-existing conditions discussion is important, but it is just the tip of the iceberg. Mr. Rouda. Thank you for your testimony. Mr. Chairman, I yield back. Chairman Cummings. Thank you. Mr. Roy? Mr. Roy. Thank you, Mr. Chairman. A couple of quick questions for Professor Gluck. In respect to the litigation that is currently going on with Texas v. Azar, did the Supreme Court find the mandate unconstitutional originally--the mandate? Yes or no. Ms. Gluck. No. Mr. Roy. The mandate was not found unconstitutional. The mandate itself. Ms. Gluck. No. Respectfully, there is no such thing as the mandate itself. What the Supreme Court did was it found that the mandate was not--could not be construed constitutionally as a breach of the Congress' Commerce Clause power, but was constitutional as a tax. Mr. Roy. Right. That is the point. The mandate is unconstitutional, pure and simple. That is what the court said. The mandate is unconstitutional, and you did not have the power, under the Commerce Clause, that the only power that remained was the taxing power. Then what happened? The tax was zeroed out, which means what? The tax does not exist. Correct? There is no tax. Is there a tax today? Ms. Gluck. The tax is set at zero. Mr. Roy. There is no tax today. There is a mandate in the legislation. The mandate is unconstitutional. The Supreme Court said this body does not have the power, under the Commerce Clause, to have a mandate to make people, make Americans, go purchase a product, in commerce. The tax is now zero. The tax no longer exists. Therefore, where do we sit today? The very thing that saved the mandate, the tax, which is now zero, does not exist. This is the theory that underlies the district court's opinion, and this is why we are in front of this. This is not because it is a policy choice, as some of my colleagues on the other side of the aisle have suggested. This is because it is a question. It is a constitutional question. It is a question about the power of this body, and whether this body can mandate that individuals buy something in the marketplace. When it was determined to be a tax, the penalty, then you have a taxing power question. Now we don't have a taxing power question, and this is where we now stand today. Is it not true that with respect to severability, that four justices, in the opinion, did find it to be inseverable? Is it not true that the district court in this case found it to be inseverable? Ms. Gluck. I really appreciate that question for two reasons. First of all, the mandate--the enforceability of the appellancy coverage provision is really not the issue in the case. It is not being enforced. What is at issue in the case is the district court's application of the next question--what happens without that provision? Does the whole statute get struck down? But your second question is very important, about the previous Supreme Court opinions. Those opinions were indeed based on the court's perception of the 2010 Congress' view of that provision. What is at issue in this case is the 2017 Congress' amendment. To hold otherwise is to undervalue the power of the 2017 Congress, vis-`-vis the 2010 Congress. Mr. Roy. Well, reclaiming my time, four Supreme Court judges have addressed it and said it is inseverable. The district court in this case said it is inseverable. The Obama Administration argued, in its filings, that it is, quote, ``Inextricably intertwined and the entirety of the ACA itself has language dotted throughout the ACA saying that the mandate is essential to the ACA.'' In fact, in King v. Burwell, SCOTUS described the individual mandate as one of a three-legged stool without which the ACA should not stand. This is what is at the heart of the litigation in question. This is why it is before the fifth circuit. That is why the arguments were held yesterday. This is why yesterday there were great questions from the panels on the judge--the judges on the panel, sorry--asking the questions, and it is why, frankly, the Carter appointee did not ask a single question, because this is a very legitimate litigation, and we will see, then, what unfolds. With respect to my colleague from California making the comment about single payer, that we have Medicare and that we have VA, while I am interested that we have got bipartisan agreement in the Veterans' Affairs Committee, on which I am proud to serve, that we need to make some changes to the VA to make it better, and that one of those changes, to rely on market forces, to rely on Choice, to rely on the Mission Act, to have more market forces and choices for our veterans to go out in the marketplace and get access to care, that a single- payer solution isn't meeting the needs of our veterans who are serving this country with valor. And that when we talk about the wealthiest and greatest country in the history of the world, when we compare ourselves to other countries, we are the one outstanding that does not have single-payer health care, I would argue that there is a reason that we are the wealthiest and greatest country in the history of the world, is that we shun the very stateism that my colleagues on the other side of the aisle would dare to put on the backs of the American people. So they are forced to pay premiums they cannot afford, forced to give up the health care that they were not able to have before, or that they were able to have before, forced to be put into a system that is sub-par, forced to say that there is now coverage for 20 million people, when the vast majority of which is Medicaid coverage, which is driving out the very people that Medicaid was designed to take care of in the first place. This is what we are talking about here, a $32 trillion Medicare For All scheme, which will blow up Medicare, which will blow up the ability for us to have a health care system that is affordable for the vast majority of the American people. With that I will yield back the five-seconds I have left. Chairman Cummings. Thank you very much. Ms. Wasserman Schultz. Ms. Wasserman Schultz. Thank you, Mr. Chairman. I think it is important to note, for the record, that Mr. Roy just came out for privatizing the VA, which the overwhelming majority of our veterans absolutely oppose, and are quite happy with the health care they are receiving and want it to continue. That having been said, I would like to ask unanimous consent to enter this article from STAT magazine into the record---- Chairman Cummings. Without objection. Ms. Wasserman Schultz.--the headline of which says, ``Name the Much-Criticized Federal Program That Has Saved the U.S. $2.3 Trillion. Hint: It Starts With Affordable.'' ``One month after the ACA''--and this is from the article-- ``One month after the ACA had passed, the Office of the Actuary of the Department of Health and Human Services projected its financial impact in a report entitled, 'Estimated Financial Effects of the Patient Protection and Affordable Care Act as Amended.' The government's official record-keeper estimated that health care costs under the ACA would reach $4.14 trillion per year in 2017, and constitute 20.2 percent of the gross domestic product.'' ``Fast forward to December 2018, notably during the Trump administration, when that same office released the official tabulation of health care spending in 2017, the bottom line? Cumulatively, from 2010 to 2017, the ACA reduced health care spending a total of $2.3 trillion. In 2017 alone,'' the article continues, ``health expenditures were $650 billion lower than projected and kept health care spending under 18 percent of GDP. Basically a tad over where it was in 2010, when the ACA was passed. It did all of this while expanding health care coverage to more than 20 million previously uninsured Americans. Compared to the 2010 projections, the government's Medicare bill in 2017 was 10 percent, $70 billion less, and spending for Medicaid and the Children's Health Insurance Program was a whopping $250 billion below expectations, partially--but only partially due to the failure of some states to expand the program. ``The actuary had predicted, in 2010, that employer- sponsored insurance would cost $1.21 trillion in 2017, but it actually came in at $1.04 trillion, a difference of $107 billion for that year. Put another way, health care spending in 2017, was $2,000 less per person than it was projected to be, and for the 176 million Americans who have private employer- sponsored insurance, their lower premiums averaged just under $1,000 per person.'' I could go on but we have entered the article into the record. So, essentially, we need to be dealing with the facts. That is why we have these hearings, and the fact is that health care costs have actually been lowered, premiums, on average, have lowered for people, and we have added $20 million to the health care rolls. With that having been said, some of you may know that I am a breast cancer survivor. I talk about it very openly. It is something that I live with and live in fear--Ms. Dye, I understand all of your concern and the thought process you went through about potentially having a prophylactic mastectomy or any other prophylactic surgery. No matter how assured I was that I did as much as I could do to prevent that cancer from coming back, I think about it every single day, like every single cancer survivor I know. So taking care of your health and making sure that you have the ability to go to the doctor when you are sick, not worry about how you are going to pay for it, which is what the fear was for every single uninsured American, or underinsured American before the Affordable Care Act, is absolutely paramount and what this debate is all about. Mr. Chairman, I would like to ask unanimous consent to enter this letter from--we have a letter from 17 advocacy organizations, plus the American Cancer Society, into the record. Chairman Cummings. Without objection. Ms. Wasserman Schultz. As the letter notes, before the ACA, the patients represented by their organizations ``were often forced to delay or forego necessary healthcare,'' which is simply unacceptable. Yet, that is exactly the world the Trump Administration would like to take us back to. Mr. Isasi, is it true that before the ACA, more than 40 percent of people who applied for insurance were denied coverage? I also want to simultaneously ask with the remainder of time about the impact on seniors because nearly one-fifth of the residents in my district are seniors, and we haven't talked a lot about the coverage gap, known as the donut hole, that would be reestablished if we actually go back to the bad old days pre-ACA. So, Professor Gluck, if you could also tell us what would happen to this provision if the Administration succeeds in overturning the ACA. Then I am sure my time will run out after that, Mr. Chairman. Mr. Isasi. So to your first question about the impact of the ACA on people with preexisting conditions, your stats are exactly right. We had almost half of the people who were applying being denied coverage because they had a preexisting condition. And that means, and it is important to note this, you know. In this country, most of us get coverage through our employer-sponsored coverage. When we get sick, we lose that coverage, and then guess what? Without protections for pre-ex, we don't have anything, right? So this is not just about people right now on the individual with pre-ex. It is about every single person in this room and watching from their homes right now. Ms. Gluck. May I answer? Ms. Wasserman Schultz. If the chairman is okay. Chairman Cummings. Yes. Ms. Wasserman Schultz.--remaining time, but I have---- Chairman Cummings. Yes. Ms. Gluck. So, Congresswoman, you are exactly right that the Affordable Care Act's protections for Medicare have been wildly under-appreciated. Sixty million seniors got access to free preventative services under the Affordable Care Act without a co-pay. Five million benefited from that coverage gap. Before the Affordable Care Act, you only had prescription drug coverage up to a low number, around $2,000, and then there was a large gap until the coverage benefit kicked back in. We call that the donut hole. Seniors had to pay out of pocket. More than 5 million benefit from that. The Medicare provisions also have a drug negotiation component to it that wind up lowering costs by some $26 billion in drug costs over the life of the bill. I would say that all of that will be gone if this decision is upheld. Ms. Wasserman Schultz. Thank you, Mr. Chairman. I appreciate your indulgence, and I yield back. Chairman Cummings. Before we go to Mr. Norman, I try to make sure that I run a fair hearing. Mr. Roy I am going to recognize for a minute because you want to clarify something. Mr. Roy. Mr. Roy. Yes, I would just ask my colleagues, Ms. Wasserman Schultz, to maybe re-frame her comments that I was calling for the privatization of the VA when, in fact, what I said was that the VA needs improvement and that the VA is seeking improvement. The Veterans Affairs Committee is seeking approval on a bipartisan basis through choice and mission to improve it, allowing private sector options to supplement the veterans' healthcare. So I think you mischaracterized a little bit what I said, and I would just ask if she would be willing to acknowledge that that was not what I said. Chairman Cummings. I recognize the gentlelady. Ms. Wasserman Schultz. I appreciate the gentleman's request. If the gentleman is willing to say that he is opposed to privatizing healthcare at the VA and making sure that the VA can continue to provide the excellent healthcare services that it provides, that the overwhelming majority of veterans support continuing, then sure. Mr. Roy. Well, I am not going to get into a back and forth about characterizing it. Chairman Cummings. Yes, I am not going to let you. Mr. Roy. What I am willing---- Chairman Cummings. Hey, hey, hey. Whoa, whoa. Mr. Jordan. Mr. Chairman? Mr. Chairman? Ms. Wasserman Schultz. Then if you are not willing to acknowledge that, then I have characterized your position correctly. Mr. Roy. No, you mischaracterized my position, and you did so blatantly when what I said was we have bipartisan support for---- Ms. Wasserman Schultz. Well, Mr. Chairman---- Mr. Roy. No, reclaiming the time. Reclaiming the time the chairman gave me, we have a bipartisan agreement that choice and mission are improvements to the VA, that adding market forces is a good thing, bipartisan agreement on that. That is a mischaracterization of what you said characterizing that I said we should fully privatize the VA. We should inject market forces and provide more choice for veterans. That is what I am saying. Ms. Wasserman Schultz. Mr. Chairman, since the gentleman has now addressed me, and has taken his time back, and wants me to correct how I characterized his position, and he has refused to acknowledge that he opposes privatization. That is a simple statement. I didn't hear him say he opposes privatization of healthcare at the VA. Mr. Jordan. Mr. Chairman? Mr. Chairman? Can I be recognized? Ms. Wasserman Schultz. So if he's not willing to say that, the direction that the Republican Party has been taking us in with the VA, including the Trump Administration, you know, pushing in that direction for more private market forces for healthcare coverage at the VA. And by the way, I chair the Military Construction and Veterans Affairs Appropriations Subcommittee, so I am responsible for the budgeting for the entire VA along with my committee colleagues. So you won't say that on the record, so I will not re-characterize what I said you said. Mr. Roy. Well, I am not going to engage in an inquisition from the gentlelady---- Chairman Cummings. Excuse me. Ms. Wasserman Schultz. I wasn't trying to---- Mr. Roy. Yes, you are. [Gavel.] Mr. Roy. But you mischaracterized my statement---- Ms. Wasserman Schultz. No, I think you will not say---- Chairman Cummings. Hello. Hello. Mr. Roy. I have not suggested that. Chairman Cummings. Hello. Ms. Wasserman Schultz. Then why won't you say you oppose privatizing the VA? Mr. Roy. Will you say you oppose mission and choice? Ms. Wasserman Schultz. I did oppose mission and choice. Mr. Roy. There you go. Ms. Wasserman Schultz. Yes, I did. Chairman Cummings. Please. Mr. Jordan. Mr. Chairman? [Gavel.] Chairman Cummings. The committee is not in order. The ranking member. Mr. Jordan. We can read the transcript. The gentleman from Texas did not say he was in favor of privatizing. He didn't say anything about it. He just talked about choice. This characterization by the gentlelady from Florida was that he said he was for privatizing the VA. He did not say that. The transcript will be clear because we all heard it. That is all he is saying to clarify that simple fact. Chairman Cummings. All right. We will take a look at the transcript. Ms. Wasserman Schultz. He won't say, Mr. Chairman, that he opposes it. Chairman Cummings. Right now we are going to get ready go to Mr. Norman. I tried to work it out---- Mr. Norman. Thank you, Mr. Chairman. Chairman Cummings. It sounds like I couldn't do it, but I did the best I could with what I had. Mr. Norman. Mr. Norman. Thank you, Mr. Chairman. I sincerely want to thank all the panelists, particularly ones that have, I assume, preexisting conditions, for taking the time to come here. I will take issue with, you know, six of the seven, as Mr. Hice said, I think where really the intent was to trash this President and to advocate Medicare for All. Ms. Dye, I take issue with what you said about all Republicans being against, I assume, any type changes in the healthcare. I take issue, I think, Mr. Gibbs, you singled out Mr. Jordan's state as not covering your particular problem. But, okay, I don't know which one of you did. But this is not a partisan issue. This is something all of us want, Democrats and Republicans alike. But the fact is that I think where we have a different world view, all of you raised your hand, I think, for health coverage for every illegal in this country, every one of you, except Mr. Balat. Everybody else. Mr. Isasa, I think you mentioned---- Ms. Dye. Excuse me. I didn't raise my hand for anything because I was uncomfortable with the whole---- Mr. Norman. Okay. Let me rephrase it. The majority of you raised your hand--take Mr. Balat out of it--raised your hand for healthcare for everybody. I am sorry. We don't know how many illegals are here. Just as six of the seven are predisposed to an opinion, let me just say this. I could fill this room with everybody behind you with that single mom who takes issue with Obamacare. They can't afford the premium jump from $400 to, in many cases, $6,000. I could bring a gentleman in who happens to be 75 years old who doesn't want a mandated maternity healthcare, having to pay for it in his policy. So I wish we could have a more balanced panelist because our intent is to solve this problem. A single provider, as it does not work in the private sector, will not work and has not worked with Obamacare. Name me one, if each of you had a single provider for, let's say, drugstores, one drugstore to shop from. I am sorry, the prices you couldn't afford as we can't afford healthcare now. I am in the private sector. I am a businessman, and I will say that it has not worked for the majority of the businesses. Look at the physicians that are leaving. If they are making too much money, Mr. Isasi, look at them that are leaving. We are not going to be able to get the specialists now that each one of you have had if it keeps going like it is going. I yield the balance my time to Congressman Roy from Texas. Ms. Dye. Excuse me, Mr. Chairman. Can I please acknowledge Mr. Norman because he actually brought up my name in his questioning or his stance. Mr. Norman. I will reclaim my time. I will talk to you privately. I yielded my time to Mr. Roy. Mr. Morley. Mr. Chairman, can I also state that I was not in the room when you asked that question, so I want to have that go on record that I did not raise my hand. I have never mentioned that I am for Medicare for All. Mr. Gibbs. I would also like to make that statement. I came here for a hearing about the Affordable Care Act, and it seems that most of this has been about Medicare for All. I didn't raise my hand in support for Medicare for All. I am not talking about Medicare for All. Why do we keep coming back for Medicare for All? This is supposed to be a hearing about the Affordable Care Act. Mr. Norman. Mr. Chairman, I would like to yield my full time that I think it was over--it was right at two minutes--to go Congressman Roy. Chairman Cummings. Sure. Mr. Roy. Well, thank you, Mr. Chairman. Mr. Balat, let me ask you a question. Was it not true that in 2013, PolitiFact said the lie of the year was if you like your healthcare plan, you can keep your healthcare plan? Mr. Balat. Yes, that is correct. Mr. Roy. Millions of people were kicked off their plans because Obamacare requires small group plans to provide 10 essential benefits. And while 22.8 million people gained coverage from 2013 to 2015, 6 million lost the coverage they had before Obamacare, correct? Mr. Balat. That is correct. Mr. Roy. Two-point-four million transferred from employer coverage to uninsured; 600,000 transitioned from Medicaid to uninsured; 600,000 transitioned from non-group to uninsured. Of those who gained coverage, of the 20-odd million, was that about half-and-half Medicaid and through the ACA, through Obamacare? Mr. Balat. It was more on the Medicaid expansion. Mr. Roy. Right. The original purpose for Medicaid was for those who are the most vulnerable, and we are now crowding out people. In fact, in Illinois, for example, in 2016, a study showed that 762 people died while on a waiting list because they were trying to get care because Medicaid was getting crowded out by healthier individuals shoved onto the Medicaid rolls. Chairman Cummings. The gentleman's time has expired. You may answer the question, whoever it is directed to. Mr. Balat. I have not seen that particular study. Mr. Roy. Okay. Chairman Cummings. Thank you very much. Mr. Roy. Thank you, Mr. Balat. Chairman Cummings. As we go on to Mr. Sarbanes, let me say this. It seems that my Republican colleagues would love to distract us--Mr. Gibbs, you had asked the question--from the efforts to sabotage the ACA by focusing on Medicare for All. But today's hearing--you are right--is about protecting the law of the land and the threat this Administration is opposing to the healthcare for millions of Americans. That is what this is about. My colleague from Maryland, Mr. Sarbanes. Mr. Sarbanes. Thank you, Chairman Cummings. Thank you for inviting these witnesses, and I want to thank you, the witnesses, for coming. Professor Gluck, welcome. A few minutes ago, I think you were trying to point out to Mr. Roy that his discussion around some of the Justice's statements about severability was fighting the last war, the 2010 war, rather than the more current battle that is most relevant to the question of severability. So I appreciate you doing that, and Mr. Roy's decision voluntarily to go back and fight the last war, of course, is his to make. What is not fair is to force some of the witnesses, who represent millions of patients across the country, to go back and fight the last war, and that is what the Trump Administration and Republicans here in Congress are doing. I remember, Chairman Cummings, when you and others were part of and helped to lead hearings back in 2010 where we heard all of these stories, but we were hearing them from the perspective of people that were desperate to get coverage that they did not have. We made a promise that we would do everything we could to try to deliver that coverage to them, and we did that with the Affordable Care Act. Now they are back again telling the same stories from the standpoint of being terrified that they could lose the coverage that has been made available to them under the Affordable Care Act. I want to thank you for that testimony which is extremely powerful. I don't know why my Republican colleagues think that it is a strong position to argue for taking this fundamental coverage away from millions of Americans. I wish them the best with that line of argument going forward. I think it is clear from what the polls show that Americans don't want to throw away the ACA. We can debate what we do from here, but the great majority of Americans want to hold on to the coverage that they've been given. And by the way, there is no evidence whatsoever that there's any kind of cogent, coherent, meaningful replacement plan for the ACA, notwithstanding all the attempts, 69 and counting, on the part of the Republicans here in Congress to repeal the Affordable Care Act. Professor Gluck, in your testimony, you discuss the essential patient protections and health programs that would disappear if the ACA were to be struck down. Does this include guaranteed issue and preexisting condition protections? Ms. Gluck. Yes, it does. Mr. Sarbanes. What about the community rating protection that prohibits insurers from charging older adults significantly more than they charge younger enrollees? Would that go away? Ms. Gluck. Yes, it would. Mr. Sarbanes. What about premium tax credits and cost- sharing reduction payments that make coverage more affordable for middle-income families? Ms. Gluck. That would also be gone. Mr. Sarbanes. What about the ACA's Medicaid expansion? Ms. Gluck. Gone. Mr. Sarbanes. What about the Prevention And Public Health Fund? What would happen to funding for essential public health programs like those that support safe drinking water, children immunizations, and smoking cessation? Ms. Gluck. All those funds would be eliminated. Mr. Sarbanes. Now let me come back to a point I was emphasizing earlier. Has the Trump Administration or congressional Republicans put forward any meaningful replacement plan for the ACA that would provide the same coverage gains and consumer protections that we just went through over the last few seconds? Ms. Gluck. No, nothing has come even close. Mr. Sarbanes. Let me ask you this. Why are preexisting condition protections on their own, without the ACA's other provisions, not a sufficient replacement plan? I mean, Republicans, I give them some credit. They have figured out that nobody in America wants to lose the coverage now available for preexisting conditions, so they keep invoking that and saying, well, we will hold on to that even as we are we are jettisoning all the rest of the Affordable Care Act. But can you explain why it is important to have other provisions in place in order for that to be an effective protection? Ms. Gluck. You are absolutely right, Congressman. It is not enough just to have insurance, to just be entitled to get insurance. You have to be able to afford the insurance, and the insurance has to cover the things for which you are sick, right? So just having the ability to get insurance doesn't stop insurers from charging you more for that insurance if you are sick, from creating benefits that don't include, say, your HIV drugs. And it doesn't give you the kind of financial assistance to make that affordable like the subsidies or the Medicaid expansion. Mr. Sarbanes. Thank you, and I just want to close by again thanking our witnesses and thanking our chairman for bringing those witnesses for today. I yield back my time. Chairman Cummings. Thank you very much, Mr. Sarbanes. Mr. Grothman. Mr. Grothman. Mr. Balat, I would like to kind of get a handle here a little bit on current problems we are having. Could you in general describe what has happened in this country for people who are fending for their insurance on their own voice, both the cost of insurance and the size of the deductibles, over the last five or six years? Mr. Balat. I could share with you talking about in the private market, premiums have gone up for employer-based plans and individual plans when they are available. Those dollars---- Mr. Grothman. Dramatically? Mr. Balat. Pardon? Mr. Grothman. Dramatically? Mr. Balat. Oh, considerably, yes. Where they used to be $300, they are on the order of $1,500. For a family, they could be around $2,000 a month. Mr. Grothman. Devastating. How about deductibles? Mr. Balat. Deductibles, you know, when HSAs came into being, they were coupled with high-deductible health plans. And there was a reason why that dollar amount was at $3,500, because that was considered a high-deductible health plan. Deductibles today are, I think, on average $6,000, $7,000, but I heard one just recently of $14,000. Mr. Grothman. Devastating for people who are not eligible for Medicaid, correct? Mr. Balat. Oh, without question, and with the majority of people in this country that don't have $1,000 in their savings accounts, it is just an unreachable number. Mr. Grothman. All right. Unbelievable what people out there have to put up with. I have heard, you know, stories of healthcare problems that I wouldn't have believed 10 years ago were possible. It still kind of amazes me, and I wasn't around here when the Affordable Care Act was passed, or the unaffordable care act, or whatever they call it. But it amazes me how people get elected to Congress and think that they are so smart that they can take over such a big segment of the American economy and make it better. Let's look, though, at why those costs have gone up so dramatically. First of all, how many Americans are on the Affordable Care Act, despite all the hoopla over it? Do you know about? Mr. Balat. Just over 8 million. Mr. Grothman. Okay. I think it is 11 million, 8 million? Okay. Mr. Balat. On the exchange? It is between 8 and 9 million. Mr. Grothman. Eight and 9 million, so you are talking, what, under three percent of Americans are on it for all the hoopla. Where is the big increase in government involvement in healthcare since Obamacare kicked in? Mr. Balat. I would say it is the Medicaid expansion. Mr. Grothman. Medicaid expansion, okay, in other words. And in Medicaid, you are down in Texas, but how much is the reimbursement? How much does the government pay people to provide Medicaid compared to Medicare and compared to what the private sector has charged? Mr. Balat. Medicaid is typically your lowest reimbursement whether you are a physician or a facility. It is just below Medicare rates typically. Mr. Grothman. Okay. Mr. Balat. And Medicare is about 60 percent of what private reimbursement is. Mr. Grothman. Okay. So you are maybe saying half, about? Mr. Balat. Just north of half. Mr. Grothman. Okay. So, in other words, as we change the system to put more and more people on Medicaid, what we are doing is we are driving up the cost for people not on Medicaid. Is that true? Mr. Balat. Yes, absolutely. Mr. Grothman. Okay. And is the reason, therefore, the cost of people who aren't eligible for ACA, the reason they are being punished and just put in such an impossible position is because the huge number of people now who are expected to get their healthcare through Medicaid type plans, who before may have gotten healthcare in other ways? Is that what is going on? Mr. Balat. If I could ask you to restate the question, please. Mr. Grothman. Okay. Right now, the reason the cost is going up is because more people are getting healthcare through Medicaid, people who in the past would have got healthcare either through their employer or purchasing on their own. Is that accurate? Mr. Balat. It is. It is. You know, we---- Mr. Grothman. So, in other words, this dramatic rocket up in costs for people who aren't eligible for Medicaid didn't just happen. It was by design almost, or maybe people were just so stupid. I can't believe people would be so stupid, they didn't realize that that was what was going to happen, but that is what happened, right? I will give you one more question because we are running out of time. We now hear people talk about picking up healthcare for all the illegal immigrants flowing through the country. I would like you to describe who really is going to wind up picking up the tab for that one. Mr. Balat. The American taxpayer. Mr. Grothman. The taxpayer or anybody who's paying for insurance on their own? Mr. Balat. Well, whoever is paying into the system currently, and the taxpayer will be the ones that will be paying for everybody that is benefiting. You know, a word was used earlier. It was talking about being forced into a situation they don't want to be in, and that was being patients should be ACA be repealed. But we are being forced as citizens to participate in programs that we don't want. So that is an act of force currently with the ACA in place. Chairman Cummings. The gentleman's time has expired. Mr. Welch. Mr. Welch. Thank you, and I want to thank the witnesses. Welcome to Congress. The debate continues, but, you know, the heart of this is about patients who need healthcare. I want to go back to some of our patients and really thank you for coming. Mr. Gibbs, I will start with you. What would it mean to you and to your son when he grows up if the ACA's preexisting conditions protections are eliminated? Mr. Gibbs. Thank you. It would mean that if something went wrong and I lost my kidney or something went wrong and Peter's kidney declined, that he would have absolutely no guarantee of any right to healthcare, any guarantee that he would be able to receive treatment for that kidney problem that he was born with. It would mean that he was born with a sentence to lose a fundamental right, and I do believe that the access to healthcare is 100 percent a fundamental right. It is something we cannot exist without. I mentioned life, liberty, and the pursuit of happiness. Without healthcare, you don't have that access to life. Mr. Welch. Right, and it is not a choice that you made to have this condition or your son. Mr. Gibbs. No, it is absolutely not a choice. Mr. Welch. The luck of the draw. Mr. Gibbs. Yes. Mr. Welch. Yes. Ms. Burton, how about you? What would it mean to your family if the ACA preexisting condition protections are no longer law? Ms. Burton. It would mean that I wouldn't be able to afford coverage. I have an expense of having four children, and I simply could not afford to pay $895 a month for health insurance. Before I would do that, I would go without like I did previously. I have limited resources, and I use those resources to raise the four kids that I brought to this world so that they don't have to be a burden on the American people and society. I have done everything I can to be responsible. Mr. Welch. Thank you very much. Ms. Dye, how about you? Ms. Dye. Thank you for the question. Chessie is 10, and for her speech, her receptive and expressive, she's two to three years behind her peers. It is never going to go away. She is going to have this in adulthood. Her speech therapy, she needs it in order for her to be a productive member of society. It is almost like life support for her. And what a lot of people don't understand, and--well, they kind of left--but Republican colleagues, they want to talk about [is], like, employer insurance. Mr. Welch. Yes. Ms. Dye. Well, a lot of employer insurance does not cover speech at all, and the ones that do, you only get 10 sessions a year. So if you can please explain to me, she is two to three years behind, how is that 10 sessions a year going to help? Mr. Welch. Right. I don't think any of us can imagine, if we are fortunate enough that at the moment we don't have a preexisting condition. At some point a lot of us will, but if you have children and you are really worried about how they are going to be affected, it is really existential. All of us can identify with that. But I want to ask each of you just to think about just emotionally what is it like and how did you feel before you had that guarantee of protection, and you had a child who was sick, and you had no confidence you could get it. Did it feel like it was your fault that your child was sick? Ms. Dye. For me, I felt like it was my fault. What did I do? Was I not taking care of myself in pregnancy and everything like that. But I also felt like my country, the Congress, was saying that my daughter doesn't matter, that her life doesn't matter, her future. And that is hard for me to take, especially when they kept saying that we are the greatest country in the world, but yet the greatest country in a world is telling my 10-year-old daughter she doesn't matter. That is heartbreaking for me. Mr. Welch. Well, go ahead. I have got just a little time here. Mr. Gibbs. For me, when my son was born, the ACA was in place. Part of me felt like it was my fault because I had a kidney condition, and I felt guilty that he may have inherited it from me. But part of me also felt it wasn't my fault because when I chose to have that child, the Affordable Care Act was in place. I made a responsible choice to have a child who could be guaranteed the right to healthcare. An irresponsible choice is being made, but not by me. Mr. Welch. All right. Thank you. And I want to thank all of the witnesses, and Mr. Morley, too, for his advocacy. Mr. Chairman, what we here is there are life circumstances that none of us can control, and if you can't get a fair shot, that is about justice. That is not about personal responsibility. There are a lot of life choices we do make, and that is on us, but when it is circumstances beyond your control--you can't get healthcare because the law won't allow it--that is on us. Justice requires we protect those preexisting condition protections. Thank you. Chairman Cummings. And people get sick and people die. Mr. Green. Mr. Green. Mr. Chairman, Ranking Member, I think most everyone knows I am an ER physician, cancer survivor. I am the father of a cancer survivor I am also the founder and CEO of a healthcare company that, when I left, employed over 1,000 medical providers and saw 1.5 million patients or so a year. I love caring for people and I love being a doctor, so much so that I started free healthcare clinics in Clarksville, Tennessee and Memphis, Tennessee. I do care, and my opposition to the ACA is because I think the ACA is going to crash the very system that today's witnesses have praised. But first I want to tell everyone about a shift I had in the ER. My first patient was a gang member. He had been shot in the lower abdomen. The guy was punching at the staff and yelling at us all. Meanwhile, we are trying to save his life. After giving this guy a world-class care, I walked out thinking, man, at least with a government payer, I would get paid for the risks, you know, taking care of this patient. But near the end of my shift, I had a woman who had just a few days prior got her dose of chemo. She was febrile and what we call neutropenic fever as the chemo had lowered her immunity system to a point that small infections threatened her life. With her were two children and a worried husband. The woman was only 35 years old. She didn't have insurance. As we stabilized her, I realized that early detection had saved this young woman's life. In Europe, socialized medicine has delayed early detection as care is rationed, and that is why mortality rates for specific illnesses are far better in the United States than they are in Europe and Canada. That woman would not have received timely detection there, and her chances of survival would have been significantly less than a socialized system. I was working in an ER and met a patient who was a CEO of a major corporation in Canada. He had a laceration. He hopped on his personal jet, flew to Nashville, Tennessee, and came to my ER because he could have been seen faster flying to the U.S. than waiting on a government-run healthcare system in Canada. True story. In Canada, you can get an MRI for your dog that day because there's a free market in veterinarian care, but you can't get one for grandma's knee. You are going to wait six months. Socialized medicine does not work. It does not provide better care. Study after study has shown Medicaid patients have equal outcomes to patients without insurance at all. Those are the real numbers. The ACA is not socialized medicine. What it does is it takes money from taxpayers and increased rates for small businesses. Yes, it has raised rates. I was on the insurance committee of Tennessee State Senate. We had to improve those insurance increases hundreds of percent, and it takes those cost-shifted dollars and gives that money to patients who can't afford care and allows them to do what? Purchase health insurance and participate in the incredible care other Americans are getting either through their employer or out of their own pocket. But unfortunately, that is not going to last. You have given great testimony about how it works. It is not going to last. You see, either by intention or accident, the ACA creates pressures on the healthcare system that are crashing the very system that the witnesses today were praising. You like your ACA insurance-based care, and I appreciate you sharing it today, but the ACA is driving the cost shifting to a point that small businesses can't afford it, and more people are shifted to government systems. As this dynamic pushes people onto the government care-- Medicare, Medicaid, all of that--we move to more and more socialized medicine. And at some point, the shifts cause the system to crash. That means the insurance-based system that the ACA is providing you and that you have given great testimony on today is going to go away. It can't last. But maybe that is exactly what the leaders of the Democrat Party want. Medicare for All will be abysmal. It will be akin to the VA. I am a veteran, I know. Ask your veterans: $32.6 trillion over 10 years. If you tax 100 percent of income earners at the top levels, you only get $700 billion. Seven hundred billion versus $32.6 trillion. It doesn't add up. Yet the ACA is driving us toward that system, I repeat, either intentionally or accidentally. The government is not the answer. Government healthcare is rationed care, late detection, and, worse, mortality. We need solutions to healthcare. My plan, I have written, and it is a bill this year, to create a healthcare swipe card. Unlike what Mr. Sarbanes said, it would fix the problem and allow us to provide help to even more people. I encourage, particularly my freshman Democrats, to go look at my plan. I think the people that I have talked to love it, even Democrats. But the healthcare you are getting is insurance based. You love it. You want to see it continue. Help us get rid of the Affordable Care Act, which is driving us to a single payer. Thank you. Chairman Cummings. Although the gentleman's time has expired, Ms. Gluck, you seem like you were shaking your head. I thought you were going to shake it off. Ms. Gluck. Not unless you would like me to respond to something. Chairman Cummings. No, did anyone have a response? Mr. Isasi. Mr. Isasi. Yes, I think, again, it is important that we actually have information and facts in this conversation. What we know in this country, and now there are a few things, one, if you look at the information comparing the U.S. to other countries, our babies are dying at faster rates. Our moms are dying at faster rates. We have more preventable medical injuries occurring in United States than other countries. That is the truth. That is what the data show. Two, right now in this country, the reason that healthcare is so expensive, and the studies are super clear on this, is not because we have brought everyone in and then given them access to health insurance. It is because the health insurance sector is increasing prices at astronomical rates, and we know this. The American people know this. They see what is happening to their prescription drugs . They see what is happening when they get those hospitals bills. That is why the system currently is unsustainable. The notion that ensuring that everybody has a shot at getting healthcare when they need it is breaking the bank is preposterous. Chairman Cummings. Thank you. Mr. Green. Mr. Chairman, he brings up a point that kind of contradicts something, and if I could just clarify. I will take 30 seconds. Chairman Cummings. Thirty seconds. Mr. Green. Yes, sir. Chairman Cummings. Yes. Mr. Green. You have to make sure you compare apples to apples. When we compare life spans and things like that in our country versus others. I mean, they eat less fried chicken in Europe, okay? I mean, they smoke less than us. It is not just the healthcare system. It is the healthcare system plus lifestyle and all that. So while some of the stuff that was just mentioned about the cost of drugs and all that stuff. I get it. But you can't compare apples and oranges. You have to compare apples to apples. Thank you, Mr. Chairman. Mr. Isasi. Just responding to that point. Chairman Cummings. No. No. No. No. Mr. Isasi. Okay. Chairman Cummings. Mr. Kelly? I mean, and I am not trying to be rude. I am trying to move the hearing along, okay? Ms. Kelly. Thank you, Mr. Chair. I just get amazed every time I come back to this committee. I was not here when my colleagues voted for or against the Affordable Care Act, but I know that since I have been here, no Democrat thought that was a perfect bill, but I know since I have been here we have never been given the chance to work on the bill, especially when President Obama was the President. All we have had a chance to do is, you know, repeal, repeal, repeal, repeal. And I know that, you know, he wanted more things in the bill, but in trying to get one Republican to support the bill, you know, he made concessions, and then no one wound up voting for the bill, as you guys know. Then we spent, I think over, 63 times trying to repeal it. Also I am glad you mentioned about maternal mortality and infant mortality. It was safer to have a baby 25 years ago, and it is not just from people eating fried chicken. That is not the reason. I know you were going there, but so, you know, I just want to add that for the record. I wanted to ask you, Mr. Isasi, how do the uninsured rates in states that have expanded their Medicare programs compare to those that have not? Mr. Isasi. Well, and, you know, it is an important point to make that what we do know, we actually know, is earlier the witness next to me cited a study that said that that access to health insurance had no impact on mortality. That study actually says, in the published study it says, ``Our results should not be interpreted as evidence that health insurance has no effect on mortality.'' What we do know from the IOM, and it was published in the in the journals of medicine, is that when people have access to health insurance, when people have access to Medicaid, they live longer lives and they are healthier, and that is the truth. I will also say that we have heard a lot about this question of hospitals closing in districts and people losing access. Before working at Families USA as the executive director, I ran healthcare for the National Governors Association, and I worked with Governors, Republican and Democratic, across this country. The No. 1 way to make sure that a rural hospital doesn't close is to expand Medicaid. And the Congressman who was speaking about his concerns about his hospitals is in a state that did not expand Medicaid. Ms. Kelly. Exactly. And now has the public health improved in states that have expanded Medicaid? Mr. Isasi. Right. Well, what we know is that not only are people healthier, not only are people able to get the care they need, but we also see a larger movement from people from public insurance into employer-sponsored coverage as they get jobs. It is all connected. It is all interlinked. Ms. Kelly. Also I wanted to thank the witnesses for sharing your personal stories. I know it is not easy to do, and I really appreciate it. Also, I am married to a doctor. He is an anesthesiologist, and he supports the ACA. Mr. Isasi. Right, and I think it is important, as I said in my opening statement. It is supported by the American Medical Association. It is supported by the American Hospital Association, the Heart Association, the Cancer Society. So we have one doctor who says he doesn't like the ACA, but all the associations that represent providers are saying this is really important for the American people and for us. Ms. Kelly. Also, I mean, they are right in the fact that, yes, you can find someone that believes this and someone that believes. It is personal experiences, but we have to look holistically and overall that what is the greatest benefit. Professor Gluck, what would happen to Medicaid expansion if the Trump Administration's position prevails in court? Ms. Gluck. Well, it would end, and all those people who got insurance would be thrown off the rolls. Ms. Kelly. I am the chair of the congressional Black Caucus Health Brain Trust, and information we have been given, when you look at African-American men, the rate of prostate cancer has gone down significantly since many more have the ACA, and also breast cancer in women, in black women, has also gone down because of access and care because of the ACA. Ms. Gluck. Yes. I recently wrote an article about disparities in cancer care across races and geographic regions, and it has been found that the Affordable Care Act has done more to reduce disparities in cancer than anything else in recent memory. Part of that is because of the covered early screening and checkups. It is incredibly important for health justice in our society. Chairman Cummings. Would the gentlelady yield? Are you finished? Ms. Kelly. Yes. Chairman Cummings. Thank you. A little earlier, Mr. Hice from Georgia mentioned that some of his rural hospitals were closing, and I think Georgia is one of the states that didn't accept Medicaid under ACA. If they did, I think would be a little bit different, I think. Can you comment on that? And comment on uncompensated care. How has that been affected by the ACA. Mr. Isasi. Absolutely, and what we know, if you look at hospital closures in rural America across this country, almost all of them, and I mean almost all of them--I think it is north of 80 percent--are occurring in non-expansion states, states that choose not to expand Medicaid. They have that ability. They don't do it, and then the rural hospitals end up closing. I was part of a lot of negotiations with Governors trying to expand Medicaid. This was the No. 1 issue. It is the reason why hospitals show up and push for it because they know when you have a group of people and explore community who do not have health insurance, they cannot keep their doors open. Health insurance provides access, and it allows for the economics of that community to survive and that hospital to survive. Chairman Cummings. Okay. All right. Mr. Higgins. Mr. Higgins. Thank you, Mr. Chairman. I thank all our guests here today for your courage in being here, and your stories are touching. I'm going to tell a story, too. My wife has MS. It is a preexisting condition. I have four children, three living. I lost a daughter long ago to a condition that she was born with. I myself have many, many physical injuries from my years as a police officer, including a reconstructed eye socket. As a cop, cops earn in Louisiana $12, $13, $15, $16 an hour. As a captain, when I resigned my commission to run for office, I was earning $20 an hour. My wife was a receptionist in parish government. She earned $12 an hour. Health insurance for many years before the ACA was always the same, $300, $400, $500 a month. The ACA came along, insurance premiums went up to unaffordable, $800, $900, $1,000 a month. Deductibles were always $500, $600, $1,000 for a deductible. It went up to $2,000, $3,000, $4,000, $5,000. Having a healthcare card from the ACA does not mean having healthcare. One of my colleagues mentioned that we want to destroy the ACA. We were told you can keep your plan. You can keep your doctor. Your premiums will go down by $2,500. You will have more access to care. Those with preexisting conditions will be protected. If the ACA had manifested well and Americans had not suffered the incredible increases in premiums and deductibles, we wouldn't be having this conversation. President Obama's crown jewel would be safe. But the fact is we must represent the interests of the American citizens that we serve. In business before the ACA, it was common for three, four, five, or six insurance companies to compete for the group policy of that business, or companies, large and small. That is gone. You don't have a competitive market anymore. Those companies have to search and beg. It used to be the other way around. Insurance companies would come to American businesses, large and small, and seek that business for the coverage they were providing their employees. My coverage expense after the ACA went up every year. It was quickly over a $1,000 a month. Couldn't afford it, man. Do the math. As a cop earning $15, $16 an hour, the wife of a cop earning $12. Very quickly you had to make a decision: are you going to buy groceries or health insurance? What do you think we did? We bought groceries. That was never an issue before the ACA. The ACA expense was not a distraction, as my colleague said. It was a disaster. Having an ACA policy card is not having healthcare. An unaffordable policy for a regular working American at $1,000 a month just to have the privilege of paying cash for your healthcare all year because you have a $5,000, $6,000, $7,000, $14,000 deductible that you never hit, that is not healthcare that we need to provide to our Nation. That is not real. My wife and I had to buy a non-ACA policy. That was reality, man. We had to buy a non-ACA policy, and we were subject to punitive fines from our own government whom we served, and I am a veteran as well, because the fines were down the line, the seizure of our property from the IRS, of all places, because we have the audacity to buy a non-ACA policy. That seizure of our property was down the line, but groceries were not. I am not opposed to the ACA because it was President Obama's crown jewel. I am opposed to the ACA because it has been an abysmal failure and a massive seizure of American property and American freedoms. Mr. Balat, you mentioned, and I thank you all for being here. You have mentioned reasonable postures, and you, my fellow children of God, my fellow Americans, have shared meaningful stories that touched our hearts. Help us fix this thing, man. That is what we seek. Mr. Chairman, I yield. Chairman Cummings. Mr. Isasi, his time has expired, but you---- Mr. Isasi. Yes, just a brief statement, which is, you know, first of all, this is literally a mission of our organization. We want all Americans to have access to high-quality, affordable health insurance. We are with you 1,000 percent in that fight. An 18 percent increase in health insurance premiums, an 18 percent increase in one year, guess what year that was? That was 1987. A, let's see, 11 percent increase in health insurance, that was 2002, okay? What we know for sure is that after the ACA was enacted, the increase in premiums for employer-sponsored coverage where most Americans get coverage was lower. It was two - two percent. It was one percent. These are the CMS actuary's own facts and figures. That is what we are looking at right here. So there have been problems with health insurance premiums in this country for decades. We are with you. I think everybody on this panel is with you. We have to solve this problem. But to blame the Affordable Care Act because in 1987, 30 years before it was even conceived of, there was an 18 percent increase seems a little bit absurd. Voice. Mr. Chairman, could I---- Chairman Cummings. You are going to ask a question in a few minutes, so if you don't mind. Ms. Pressley. Ms. Pressley. Thank you, Mr. Chairman, for convening today's hearing and for shining a light on what a critical lifeline the ACA has been for millions of families. I want to especially thank all of you for bringing the expertise of your lived experiences here, and I know just your advocacy alone will save lives. Ultimately, the ACA was saved the last time, not simply for the conviction of lawmakers, but for the courage of everyday people, who quite literally put their lives on the line, their bodies on the ground, and stood in the gap. And I believe that the same will be true again. So thank you for your courage and for being here today. Certainly in my district, the Massachusetts 7th, my congressional district, almost half of the residents are living with one or more preexisting conditions. I am grateful for the leadership of our Massachusetts attorney general, Maura Healey, who is an activist leader and a dear friend, who has been leading the fight on the front lines helping to protect the ACA, and affirming that healthcare is a fundamental right for all of us. Mr. Morley, I am paraphrasing, but it was very poignant and resonant when you said that instead of fighting to stave off bankruptcy, because of the ACA, you got to focus on staying well and staying alive. The fact is that we find ourselves at a time when people have to ask questions such as do I feed my family or pay my rent, or do I go start a Go Fund Me campaign, or do I risk forgoing the life-saving medicine my child needs to stay alive. I want to focus a line of questions on the persistent inequities and disparities a rollback to the ACA would cause for the 67 million women and girls who live with a preexisting condition. This law has saved countless lives, and undermining it and attacking it puts the health and well-being of our Nation's families at risk. Professor Gluck, could you explain for the committee what health insurance coverage was like for women before the ACA? Ms. Gluck. Women have benefited enormously--thank you for the question--from the ACA's protections. According to Kaiser, the uninsured rate on women dropped from 19 percent to 11 under the law. Before the ACA, only 12 percent of individual plans covered maternity care, which is a shocking statistic. Women could be charged 50 percent more than men for insurance because of the health risk that they pose because of conditions like pregnancy. The ACA ended that discrimination in pricing based on gender. It also significantly helped women's health because it now covers, without a co-pay significant, preventative services that are very important to women, and I mean much more than contraception. I mean breast cancer screening, colon cancer screening, HIV, HPV, and much, much more than that. The Medicaid expansion, it also worth noting, helps women have healthier pregnancies and keeps women healthier before they are pregnant, which in turn results in healthier pregnancies. Ms. Pressley. That is right. So women were paying out of pocket. Ms. Gluck. Yes. Ms. Pressley. Okay. All right. So is there anything else you would like to elaborate on, Professor, so far as to how the ACA put a stop to those kinds of discriminatory practices? Ms. Gluck. Well, you know, with this case that is pending in Texas right now, all of those protections would be gone. We would once again not have basic coverages that most people take for granted, like maternity care coverage for a huge swathe of the population. Ms. Pressley. Ms. Burton, as a woman with a chronic illness, you spoke of the stress of having to deal with being uninsured for so long. Before the ACA, women could be denied coverage for things like pregnancy, breast cancer, or treatment for sexual or domestic violence. We are also in the midst of, as Representative Kelly alluded to and has been leading on, a national maternal mortality crisis. Women are no safer giving birth today than they were 30 years ago. How important was it to you and your family that you were able to have coverage for maternity care during that time? Ms. Burton. It was definitely very important for me. I have had four C-sections. I did not have natural birth with any of my children. My pregnancies were all very high risk. My youngest child I gave birth to the first semester of my second year of law school. One of the biggest complications was my uterus had completely attached to my abdomen, and my C-section was a lot more extensive than it had been for the previous three. And had I not had coverage during that time, I wouldn't have had the followup care that I needed. Case in point, in 2014, I suffered a miscarriage 10 weeks in, and I did not have insurance. I had my miscarriage in the emergency room, and I never got to followup to see why my baby died or what condition was in place at that time. Ms. Pressley. Thank you, Ms. Burton. And just really quickly, one in four residents of my district benefit from the ACA's requirement that allows them to remain on their parents' plan until the age of 26. Would anyone like to elaborate on why this is important? Chairman Cummings. The gentlelady's time has expired, but you may answer the question. Ms. Burton. It is important for me because I, as a mother of four children, my older two children are 19 and 18. They work jobs, but their jobs don't provide healthcare. So through the healthcare I have now through my employer, my kids are still covered. It is important that when we have kids, we expect them to continue their education and go to college, but we don't have a means for them to be insured during that time. And while we want to have these safety nets in place for them, we put impossible choices in their way. So by allowing that coverage until they are 26 years of age, that allows them to go through with the comfort and safety of pursuing an education without having to worry about if they get sick what is going to happen to them. Ms. Pressley. Thank you, Mr. Chairman. Thank you, Ms. Burton. Chairman Cummings. Thank you. Mr. Armstrong. Mr. Armstrong. So right now in North Dakota, we have the same number of people uninsured as we did 10 years ago or prior to the implementation of the Affordable Care Act. And we have passed Medicaid expansion at our state level. We have done all of those things. But considering that we are a lot of small businesses, a lot of small family farms, what we have done is shifted the burden up the economic food chain. If you are a small family farmer, you are not employed, so you can't get insurance through employment. You don't qualify for Medicaid, and you don't qualify for Medicaid expansion. So one of the major concerns with Obamacare, regardless of the outcome of any ongoing litigation, is the lack of insurance products to small business owners, sole proprietors, farmers, who have largely been priced out of the market. So I guess my first question would be to Mr. Balat. Can you elaborate on any proposals that actually could increase coverage in rural America? Mr. Balat. I had suggested earlier what is happening with rural America is many of the farm co-ops that exist have been taking advantage of the association health plans. I understand earlier that the witness to my right was saying that was an opportunity for insurance companies to play tricks. People are walking into these things with eyes wide open, and they are shopping responsibly and addressing their needs for themselves and for the groups that they represent. That has been a good solution, again, for those that are in transition. They are using short-term plans. But, more importantly--most importantly--is we are looking at addressing the HSAs and personal accounts that people can start to use their own money rather than having the government pay directly into the insurance companies' coffers, allow us to purchase our own insurance for ourselves, and that would be a big boon to the rural community. Also, I would also add the use of tele-medicine and the technical advances that we have had, that has really been a big help for very remote rural areas. Mr. Armstrong. Well, I think part of that is, I mean, outside of insurance or anything, it is how we deliver medical care. I mean, people drive 100 miles now, and as a state, we have done a great job over 50 years putting up picket fences for licensing and those types of issues. And now in the last several years, we have done a really or a pretty good job of reducing those picket fences, so things like tele-medicine and those options can actually be brought into rural America. But those are independent of Obamacare, any of those things. So I appreciate that. I would just also say we didn't have a lot of choice before. We have a state a 750,000 people. I mean, the markets adjust for that, but over 10 years, we have seen insurers flee our markets. I mean, to say that we have stabilized after 10 years like that is some kind of accomplishment is really not the point because it was unsustainable to go any farther than actually stabilize at some point in time. Mr. Balat. I think it is also important to say that I have been part of a healthcare industry for 20 years. What we are talking about is not going back to pre-ACA. It is not a binary choice. It is not ACA today or pre-ACA. Those aren't our two choices. What we can do is create an environment that is better that will help address the real problems that people have for themselves and for their children. Let's give people choice. And I just want to add one more thing. One other issue that nobody has brought up about the Affordable Care Act is that the Kaiser Family Foundation has said that 20 percent of all in- network claims in the ACA are denied by the insurance companies. That is not protecting people. Mr. Armstrong. I appreciate that, and I hope whatever we do moving forward gives states like North Dakota and our Governor and our insurance commissioner more ability to make decisions and the Federal Government less. With that, I would yield to my friend from Texas, Mr. Roy. Mr. Roy. I thank the gentleman for yielding. Mr. Balat, in 2009, a CBO-JCT report said by 2016, the new law would cause premiums to increase in the individual market by 10 to 13 percent. Does that sound right? Mr. Balat. I believe so. I don't recall. Mr. Roy. And the Obamacare regulations, though, in fact turned out to cause premiums to more than double from 2013 to 2017. And, in fact, in the first four years of the ACA, every age group and household type experienced an increase of between 56 and 63 percent. Does that meet with your understanding of what occurred? Mr. Balat. In the exchange, yes. Mr. Roy. And so in 2013 to 2017, premiums increased an average of 60 percent. Now go back. In the four years before the ACA, every age group and family type either experienced a premium decrease or an increase of 9.2 percent or less. The dollar amounts of the increase varied from, you know, $2,500 to a different dollar amount. But my point is if you look at this chart back here, the red lines are post-Obamacare. The blue lines are immediately preceding Obamacare. And here is the deal. We don't have witnesses here testifying for all the people who lost their insurance because of Obamacare. We don't have families here testifying who are paying the premiums reflected in those red bars. That is the reality. That is what we are dealing with throughout the country. We have 330 million Americans. We are talking about 20 million, 10 or 11 million of whom are covered by Medicaid expansion, 10 or 11 million of whom are covered through the ACA, and I am glad that everyone who has that coverage does. I am just trying to figure out how we can make sure all of America is not getting stuck with insurance or an inability to get the healthcare of their choosing because we have created a system that is too expensive. Chairman Cummings. The gentleman's time has expired. Mr. Roy. Mr. Balat, any comments on that? Thank you. Chairman Cummings. The gentleman's time has expired, but you may answer that question. Mr. Balat. In spite of what happens with the ACA, my role is to help with research and educating lawmakers to find as many choices and find as many options and find as many solutions that work well regardless of the geography here in the United States. In Texas alone, my home state, South Texas is so different from North Texas and West, and East, and Central. It is culturally, geographically very diverse. And going back to my hospital days, my primary service area was one to three miles. That was my community. It is absurd to think that we can manage healthcare insurance coverage and the healthcare for people states away. It must be done at the state and local level. Chairman Cummings. Thank you very much. Ms. Tlaib. Ms. Tlaib. Thank you, Mr. Chairman, and thank you all so much for being here. Ms. Burton, I was very touched by your statement. I wasn't here, but I was able to get a written statement. But something that you said at the end was beautiful, that this is not a partisan issue, that it is about what happens to families without healthcare coverage. Why should a single mother of four be forced to choose between housing and healthcare? It is a "we are better as a Nation if we keep our people healthy" issue, and I really appreciate you emphasizing that. While the Affordable Care Act has helped millions of Americans obtain healthcare coverage nationwide, areas, such as Wayne County in my home state of Michigan, have some of the biggest impacts. According to a report from Georgetown University's Center for Children and Families, states that have expanded Medicaid under ACA have seen sharp declines in the rates of uninsured populations. For example, the percentage of those without insurance in Michigan decreased from 12.9 percent in 2013 to 6.1 percent in 2017. Mr. Isasi, why has Medicaid expansion been so effective? Mr. Isasi. Thank you so much for that question. Well, you know, one of the things is that before the ACA was passed, there was a misperception in the American public and a lot of lawmakers that if you were poor enough, you got Medicaid, and that wasn't the case. What Medicaid expansion did is it said that there is a group of people for whom nothing exists. I will give you an example. In the morning, I walk my dog in Logan Circle, and there is a gentleman with severe mental illness there. He lives. He is homeless. Before Medicaid expansion, there was nothing there for him. He could get nothing. There was a whole group of Americans who had access to nothing, no insurance whatsoever. Medicaid expansion said if you are poor enough, if you are struggling enough in your life, we are going to give you access to health insurance, and that is why it is been such a successful and important part of the Affordable Care. Ms. Tlaib. The ACA's Medicaid expansion is one of the many reforms that would disappear if the Trump Administration prevails in court. Is that correct, Professor Gluck? Ms. Gluck. Yes, it is. Ms. Tlaib. Our communities stand to lose if the Trump Administration wins, including 87,000 people alone in my district, in the 13th congressional District. It is not just Medicaid coverage that will be lost. Currently 79 million Americans live in what we call primary care health professional shortage areas, meaning there is less than one physician for every 3,500 people. Michigan has the third highest number of shortage areas for primary care, and the Metro Detroit area has over 20. This equals that individuals already have to travel further to receive healthcare coverage, and in many communities where hospitals have closed in recent years, they have to travel even further to receive emergency medical services. Mr. Isasi, under the ACA, patients do not have to pay a co-pay if they go to an out-of-network emergency room, correct? And would that change go if the Trump Administration prevails in court? Mr. Isasi. Under the ACA, there are protections for out-of- network billings. They are incomplete, but they are there. Ms. Tlaib. If the Trump Administration succeeds in striking down the ACA, millions of Americans risk losing healthcare coverage, but this will not mean that the Americans will not stop needing emergency medical care. Instead hospitals will just be forced to provide more uncompensated care. Is that correct? Mr. Isasi. That is right. Ms. Tlaib. What is likely to happen, particularly to hospitals in shortage areas like Detroit, if the number of individuals requiring uncompensated care increases? Will this help or hurt their stability or ability to keep their doors open? Mr. Isasi. There is no question whatsoever in every state in the country, every hospital will show up and say without that coverage, we could risk closing our doors. Ms. Tlaib. And the ACA has also helped address provider shortages through something called the Community Health Center Fund. Professor Gluck or Mr. Isasi, can you explain what that fund does? Mr. Isasi. So could you ask the question again please? Ms. Tlaib. So the fund, it is called Community Health Center Fund. Is anybody on the panel familiar with that? Mr. Isasi. Yes. Ms. Tlaib. Yes. Can you explain that? Mr. Isasi. So it was a significant increase in the funding for what were called federally qualified health centers. All those community health centers operate in rural America, in inner cities. They are one of the most important source of primary care coverage in this country. Ms. Tlaib. Before my dad worked at Ford Motor Company and finally got access to healthcare, thanks to his union, I went to one of those clinics, a CHASS clinic, in Southwest Detroit. And I remember just going into it, and they poke you, you know, and do all those things. But it was required for us to be able to even get access to schools, right, to do the medical exams. I mean, think about those kinds of things. I really believe, you know, the Trump Administration's refusal to defend the ACA threatens to widen existing healthcare gaps and make it even harder for Americans to access care if they need it. On our road to Medicare for All--crossing my fingers--we must continue to work to close our healthcare gaps and expand vital care for all Americans, not dismantle it. I represent the third poorest congressional district in the country, and I can tell you at the frontline when I speak to so many of my residents, healthcare is always at the forefront of them choosing, like Ms. Burton talked about, between, you know, taking care of their children, groceries, and those everyday issues, to healthcare. So I thank you again for your panel. Thank you, Mr. Chairman. Chairman Cummings. Thank you. Mr. Jordan. Mr. Jordan. Thank you, Mr. Chairman. Mr. Isasi. Mr. Isasi. Isasi. Mr. Jordan. Isasi. It looks a lot like a former chairman's name that we had. Mr. Isasi. That is right. Mr. Jordan. So I think I have counted no less than four times you said, ``It is wrong to say that Obamacare is the cause of increased premiums.'' You have said that several times. But with all due respect, Mr. Isasi, I don't think that was the promise. The promise was Obamacare was going to lower premiums. When Democrats voted for this, when President Obama rolled it out, he didn't say pass the Affordable Care Act, pass Obamacare, and your premiums will go up, but don't worry, this bill won't be the cause. And I would dispute, even if we take your assessment as accurate, that it is not the cause. I think Mr. Roy just offered some numbers that show that it may, in fact, have been. Mr. Balat, in the past decade, what is the single biggest change to healthcare policy in this country? Mr. Balat. To healthcare policy? Mr. Jordan. Yes. Mr. Balat. That would be the ACA. Mr. Jordan. It would be Obamacare, right? Mr. Balat. Without question. Mr. Jordan. So let's go back to the basics. We have been through it a few times. But when Obamacare was passed, again, the single biggest change to healthcare policy in the last decade, projections were we were going to have 24 million people enrolled in it today. How many are enrolled in Obamacare today? Just in the exchange, not counting Medicaid expansion. Just Obamacare. Mr. Balat. Between 8 and 9 million. Mr. Jordan. So not even close, a third of what was projected. When Obamacare passed, again, the single biggest healthcare policy change in the last year, we were told that if you like your doctor, you keep your doctor. Has that materialized? Was that statement true, Mr. Balat? Mr. Balat. No, it is not true. Mr. Jordan. When Obamacare passed, again, the single biggest change in American healthcare in the last decade, we were told if you like your plan, you can keep your plan. Was that true? Mr. Balat. No, sir, it was not. Mr. Jordan. And, of course, as we started here, when Obamacare passed, we were told premiums were going to decline. Again, just nice and again for the record, did that happen, Mr. Balat? Mr. Balat. No, it did not. Mr. Jordan. For everyone, premiums in the exchange, out of the exchange, single, individual market, employer-sponsored plans, everybody's costs went up. Is that right? Mr. Balat. It did. The cost of the premiums went up. However, with the subsidy, it wasn't felt by those that were part of the exchange. Mr. Jordan. Do you think we were lied to when this bill passed back in 2010, Mr. Balat? Mr. Balat. Congressman, I don't want to speculate as to what the intent was. Mr. Jordan. Yes, you don't have to because the architect of it, Mr. Gruber, said this. Jonathan Gruber, MIT Professor, New York Times, said, the architect of Obamacare, going to the White House several times, meeting with all the key players who are putting this policy and this plan together said this. ``If any American really believes that Obamacare is going to control costs, I have got some real estate in Whitewater, Arkansas I would like to sell them.'' So the guy who put it all together told us it was going to drive up costs, and it certainly has. Have the co-ops worked that were part of Obamacare? Mr. Balat. The data shows that they have. Mr. Jordan. The ones that are still left have? Mr. Balat. Oh, wait, the co-ops. Mr. Jordan. The co-ops under Obamacare, the 23 co-ops that were created? Mr. Balat. Oh, no, I was referring to the others outside of the ACA. Mr. Jordan. Oh, exactly. The ones out in the private sector have. That is a lot different than the ones they set up. Twenty-three set up, only four are left. Nineteen bankrupt. Are there more healthcare choices today? Again, Obamacare, single biggest healthcare policy change in this country in the last decade. Are there more healthcare choices today than there were in 2010? Mr. Balat. There are not. Many of the carriers have left. Our individual market in Texas was---- Mr. Jordan. Provider networks are smaller, larger, narrower networks? Mr. Balat. Much smaller. Mr. Jordan. Networks are much smaller. Mr. Balat. Much smaller, which is contributing to the surprise billing issue. Mr. Jordan. Exactly. What happens when you only got one insurance provider in a market? What happens to costs then? Mr. Balat. Premiums go up. Mr. Jordan. Well, frankly, you can go outside of healthcare. If you got one supplier of a product in any market, typically you don't have the kind of price consumers would prefer, do you? No, you typically don't. The last thing maybe I'd ask you is this. You said in your opening statement, Mr. Balat, that the ACA hurts families with preexisting conditions, and that stuck out in my mind. I actually wrote it down several hours ago when we started this hearing. Can you elaborate on that? Mr. Balat. Well, it really is a function of cost. Let's talk about insurance. The reason preexisting conditions is even a thing is because insurance is coupled with employment. The fact that we don't have more portable personal insurance plans causes us to jump from place to place, and that creates that preexisting condition issue. Now, in healthcare, we just call them conditions. Preexisting conditions is an insurance term, but how it has affected families is as these premiums have increased, as these deductibles have increased to high levels, they are just priced out of the market. And if they have a plan that they have had, and in some cases I have talked to people, you know, I have had my insurance for to 15 years and I just can't afford it anymore. And now that they have to look for some other product or go to another solution, they have a preexisting condition. That wasn't an issue so long as they had their plan that they've had for 15 years. Mr. Jordan. Thank you. Chairman Cummings. Thank you very much. Ms. Hill. Ms. Hill. Thank you, Mr. Chairman, and thank you all for being here today. When I speak to people in my district, whether they are community health centers and clinics, physicians and nurses, hospital associations, or patient groups, I hear by and large that we must focus on increasing access to critical services, like treatment centers, not decreasing those services and incentives. The Affordable Care Act massively expanded mental health and substance use disorder benefits and Federal parity protections for 62 million Americans. And the arguments we heard yesterday from the Trump Administration pose an imminent threat to the well-being of America. I would like to first focus on how the ACA is helping to address the drug overdose epidemic, which claimed over 70,000 lives in 2017, with opioids accounting for nearly 48,000 of those deaths. In California, buprenorphine is growing in popularity due to regulatory changes, physician training, and other initiatives. The rate of Medi-Cal enrollees, California's Medicaid program, who received buprenorphine nearly quadrupled from the end of 2014 to the third quarter of 2018. The counties that make up my district are part of 40 California counties taking part in the Drug Medi-Cal ODS, organized delivery system, Pilot Program, and have joined California's effort to expand, improve, and reorganize treatment of SUDs in Medi-Cal under California's Medicaid Section 1115 waiver. In that vein, Mr. Isasi, what tools has the ACA provided to help us fight the opioid epidemic? Mr. Isasi. So this really cannot be stated strongly enough. The No. 1 tool in this country to combat the opioid epidemic is the Medicaid expansion, period. I have worked with Governors all over this country who are trying to stop this terrible plague in this country. Governor Beshear from Kentucky could speak so eloquently. Kentucky is one of the worst-hit states in this country, and it was the Medicaid expansion that helped him save lives. It provides the medication people need, and it provides the therapy that they need to be able to deal with the addiction. Ms. Hill. Anyone else want to add to that? Ms. Gluck. I would add to that. I think before the ACA, 45 percent of individual plans did not cover substance use disorder treatment. With respect to the opioid crisis, you need treatment both before and after, so you need insurance access. You need to have coverage to cover you for your pain treatment. That is not necessarily a pill, but let's say as a behavioral therapy treatment, and you need that insurance coverage on the back end if you are addicted. There is nothing more important to combatting the opioid crisis like getting more Americans covered. Ms. Hill. Absolutely, and this is something that we hear. We need additional attention to and additional resources for, not the opposite. So let's focus on Medicaid for a moment. The ACA's Medicaid expansion has reduced the unmet need for substance abuse treatment by, according to some estimates, as much as 18 percent. Professor Gluck, you noted in your written statement that Medicaid is the largest payer for addiction treatment in this country, and, in fact, you both have said that. And according to the Kaiser Family Foundation, Medicaid provides comprehensive coverage to nearly four in 10 non- elderly adults dealing with opioid addiction. So, Professor Gluck, if the ACA is overturned, what would happen to people who have gained access to treatment through the Medicaid expansion? Ms. Gluck. Well, they would lose it, and the crisis that we are dealing with now and trying to solve would get even worse. Ms. Hill. It is that simple. There is no plan to---- Ms. Gluck. I have not been made aware of a plan, and I would say that the Administration's own plans to combat the crisis depend on that insurance coverage being in place. Ms. Hill. Right. There are other aspects of the ACA that have facilitated expanded access to treatment. In your written statement, you mentioned the importance of providing tax subsidies to help people purchase insurance through the marketplace. The ACA also expanded parity for mental health and substance use disorder coverage, meaning insurance plans are now required to cover these services just as they cover medical and surgical benefits. How would eliminating these provisions undermine the gains we have seen in connecting people with substance use treatment? Ms. Gluck. Well, these people who now have access to mental health and substance use disorder treatment would lose it, and we would go back to a time in which they were out there by themselves, maybe relying on pills, and not getting the kind of healthy treatment that we need to combat the crisis. Ms. Hill. Do you believe that insurance companies without the ACA would cover these kinds of things, these kinds of services? Ms. Gluck. Federal law requires mental health parity, but we know that mental health parity provisions have not been adequately enforced. In fact, there are different ways to get this kind of treatment. So you don't want insurers just covering a cheap pill. You want insurers covering the panoply of services that get people off pills and get the kind of pain and mental health treatment that they need. They need deeper insurance coverage to accomplish that. Ms. Hill. Right. We have received a statement for the record from Pennsylvania Insurance commissioner, Jessica Altman, crediting the Affordable Care Act's protection for preexisting conditions and expanded coverage of mental health and substance use disorders for helping the state fight the opioid epidemic. She wrote that overturning the ACA would, and I quote, ``effectively undo a decade of progress made toward ensuring those with mental health and substance use disorders have access to crucial, effective, evidence-based treatment services.'' I would like to enter Commissioner Altman's Statement into the record. Chairman Cummings. Without objection. Ms. Hill. We are truly facing the worst public health crisis in a generation, and yet this Administration is doing everything in its power to take health insurance coverage away from those who need it most. If the President truly wants to tackle the opioid epidemic, it starts with protecting and expanding, rather than taking away, healthcare for the millions of Americans battling substance use disorders. With that, I yield back my time. Thank you. Chairman Cummings. Thank you very much. Mr. Cloud. Mr. Cloud. Thank you, Chairman, and thank you, witnesses, for being here today. I appreciate the time that you are taking to be here and to share your stories, especially the witnesses who are with their personal stories. Mr. Balat, you are a fellow Texan. I appreciate you being here from the great state of Texas. I wanted to ask you if this sounds familiar: ``My insurance went from $345 a month to $1,200 a month.'' ``My premium increased drastically.'' ``Premiums increased from $247 a month to $1,024 a month.'' ``The deductible went from $1,500 to $6,000.'' ``My $225 a month catastrophic plan was declared illegal and premiums doubled.'' ``My insurance tripled in cost.'' ``It costs more and has fewer benefits.'' ``Premiums increased.'' ``Deductible increased $1,500 more a month.'' ``I was forced to go on Obamacare and lost all my doctors.'' ``My healthcare went from $125 a month for vision and full medical to $375. I couldn't afford it.'' ``My dad had to get Obamacare, and they denied him the meds he needed, denied him the surgery he needed, and his meds became beyond expensive, and his premiums and deductibles are ridiculous. He is limited on doctors, too.'' ``I have been without insurance for seven years because it is cheaper to pay the fee than have the medical insurance.'' Do these stories sound familiar? Mr. Balat. I hear those stories all the time, and many from the patients that would come into my own facility. Mr. Cloud. One of the reasons these sound familiar is we asked how has Obamacare affected you, and this is the response we have gotten. And while I appreciate the testimonies of the witnesses who are here, and I don't discount them at all, it would've been nice if the committee would have allowed us more than one witness so that we could have a more well-rounded understanding of how this is affecting American people, because the point is that a one-size-fits-all approach doesn't work for the American people. One thing that hasn't happened over the last decade, everybody keeps talking about healthcare, but we haven't had a real discussion about healthcare. Obamacare, as it was dubbed, should have been more dubbed Obama coverage. All the testimony we are hearing is about how many people are covered when I think the real question should be how do we get better access to care. The goal for all of us, regardless of what side of the aisle you are on, is care for the American people, not more coverage. So I think it would help us all if we could work our policymaking toward that objective and do so in a way that brings into light a well-rounded understanding of how this is truly affecting the American people. Can you tell me, there has been some talk about, you know, socialized medicine, whether or not Obamacare is or isn't that. One of the major concerns when the ACA was being debated is to whether it would be a first step to socialized medicine, universal healthcare. Could you explain the similarities? Indeed, I believe my understanding is over half the Democratic committee members have endorsed Medicare for All. So putting these two together, is there a similarity? Is there not? Mr. Balat. Well, the similarity is government-sponsored healthcare versus individual choice. That is what the distinction is at its most purest level. What we want is to have people have the freedom to use their own money the way that they wish, and to have some kind of coverage that protects them in a catastrophic fashion. But we are not in a place where we have that kind of relationship with our medical professionals anymore because insurance has been what we have pushed into. And you are right. Coverage is not what healthcare is. And I would say those folks that you read their stories, the increases in those premiums, many of them, the ones that I have talked to, are still uninsured today. They had good insurance. They were able to take care of their chronic disease. They were able to buy their medications. They were able to go to see their doctor. Today, they are uninsured, and they are having a challenge getting other kind of coverage because of a now preexisting condition, directly because of the ACA making things more expensive. Mr. Cloud. Do you believe market forces can work to help provide more access to care? Mr. Balat. I have seen it happen, without question. Mr. Cloud. I yield my remaining time to the current sitting ranking member, my friend from Texas, Mr. Roy. Mr. Roy. I thank my friend from Texas. I would ask my other friend from Texas, Mr. Balat, just expanding a little bit on what Mr. Cloud was talking about. I believe that the number is somewhere in the vicinity of 17 of my colleagues on the other side in this committee have, in fact, supported Medicare for All. I would be happy to correct that number if it is not right, but I think that is right. That is a sizable number. Could you explain to me why if Obamacare is working so well, so many of my colleagues are racing to go change it and offer a new approach in the form of Medicare for All, particularly after we were promised the ACA wasn't a path to a universal coverage kind of position? Thank you. Chairman Cummings. Your time has expired. You may briefly answer the question. Mr. Balat. I don't know that I could explain for them. However, it does seem as if they are abdicating their support of the ACA by going to this plan. It is a show that the current plan does not currently meet the needs of the people of this country. Chairman Cummings. Ms. Lawrence. Mrs. Lawrence. Thank you, Mr. Chair. I want to start by saying this meeting is not about Medicare for All, and as hard as others have tried, we are not going to dilute this debate. I want to thank my chair for holding this hearing. The ACA has increased access to care for every stage of children's lives, beginning with improved access to maternity care for better health outcomes for children. As the co-chair of the congressional Caucus on Women Issues and the congressional Caucus on Foster Youth, I firmly believe that the well-being of our country's children is of great importance. Thanks to the ACA, the insurers are no longer able to deny coverage for maternity care and treat pregnancy as a preexisting condition. I would like to ask unanimous consent to enter into the record a letter from the March of Dimes highlighting how important the ACA is to the health of children and women. Chairman Cummings. Without objection, so ordered. Mrs. Lawrence. Thank you, Mr. Chair. The letter notes that before the ACA, women with high-risk pregnancies could be unable to afford medical help for the rest of the year, and babies born pre-term ``exhaust a lifetime cap before the first birthday.'' Mr. Isasa, how did the ACA preexisting conditions protections on annual or lifetime limits change the health outcomes of such individuals? Mr. Isasi. Absolutely. It is one of the most critical protections in the Affordable Care Act, and really importantly, this is not just for people buying coverage in the marketplace. This is for all of us. For most Americans who are getting coverage through their employers, the ACA banned the ability of those insurers, the ones that your employers are enrolling with, from limiting, putting lifetime or annual caps [on]. In particular for moms who are giving birth to babies with complex healthcare needs, they could exhaust their entire benefit for their lifetime in a matter of just a few months. Mrs. Lawrence. And just for the record, America and everyone listening, the United States of America is leading in maternal mortality. That is women dying in childbirth. The fact that we are having a discussion, and if you want to say it is insurance, you can't discuss insurance if you are not talking about healthcare and healthcare lives. So, Professor, if the Trump Administration prevails in court, what would happen to these requirements? Ms. Gluck. Well, all of those caps would be put back in place, meaning lifetime caps, annual caps, no caps on out-of- pocket maximums. You would also have a return to a time in which insurers could refuse to insure you for maternity care. Mrs. Lawrence. Before the ACA, only 13 percent of plans, when life was good before the ACA, covered maternity care, and women in 11 state capital cities couldn't purchase maternity coverage. Until something changes, the only way that we can continue as a human race is through birth and pregnancies, and it is an insult for us not to provide the care for women who are giving birth. Now Mr. Isasa, is that correct, that insurers are now required to cover preventive services, including maternal health visits, without cost savings? Is that correct? Mr. Isasi. That is exactly right. Mrs. Lawrence. Ms. Burton, you talked about being a mom, four beautiful children. Before ACA, you were uninsured for years, except for when you briefly qualified for Medicare during your pregnancy. How important was it for your health as a mother with a preexisting health condition and the health of your daughter to have insurance during that time? Ms. Burton. It was critical. As I mentioned previously, all of my children, all four of them, were born via Cesarean. So if I wouldn't have had the insurance to be able to cover that, I still wouldn't have come from under those bills. I have had very high-risk pregnancies that were very difficult, and it is utterly necessary that I am there to be able to take care of my children. It is not enough to just have them. I have got to raise them and take care of them. Mrs. Lawrence. Exactly. So my closing comment is that when we talk about ACA, we are talking about, for me, such a passion I have for children and women and pregnancy, that we not allow this shade of saying it is ineffective and it can't happen because of the women, protecting them. In this country to say that we are leading and women are dying in pregnancy, this is a way for us to address that and reverse those trends. I yield back. Thank you so much. Chairman Cummings. Thank you very much. Ms. Ocasio-Cortez. Ms. Ocasio-Cortez. Thank you, Mr. Chair. You know, there has been a lot of talk today about how improving healthcare opportunities for American families will lead to all sorts of dystopian outcomes, right? There is this idea that we are going to be rationing care. So I am curious for those of us here, to raise their hand if you have been uninsured in your life. [Hands raised.] Ms. Ocasio-Cortez. Keep your hand raised, and also raise your hand if you have been insured, but your deductible was exceedingly expensive. [Hands raised.] Ms. Ocasio-Cortez. So you rarely went to the doctor or got care that you needed. Thank you. I have been there, too. I was uninsured less than a year ago. I was uninsured seven months ago. So I want folks to raise their hand again, because I know what being uninsured is like. It is not just a financial issue. It is the stress and it is the anxiety when you wake up every morning and you don't know if you are going to slip on a curb, if you are going to find something on your body that you want to get checked out, if your knee starts to ache. Everything becomes a spiral of anxiety because you don't know how you are going to afford it. So when we talk about rationing care in a for-profit healthcare system with no guardrails, where it is the Wild West, where you are allowed to profiteer off of insulin, off of people's lives, how many of you in your time of being uninsured or having healthcare that was too expensive delayed getting a prescription or delayed going to the doctor? [Hands raised.] Ms. Ocasio-Cortez. So you rationed your own care. Is that correct, Ms. Burton? Ms. Burton. Yes, absolutely. Ms. Ocasio-Cortez. The cost of a for-profit insurance company forced you to ration your own care, correct? Ms. Burton. Absolutely. Ms. Ocasio-Cortez. I know exactly what that is like. I rationed my own healthcare for 10 years. I was on a self- imposed wait list for 10 years, not going to an orthopedist when my knee hurt, not going to seek mental healthcare or counseling when my father died, all of those things. You know, what you shared with us, what you had the courage to share with us, Ms. Burton, about your miscarriage, about the fact that you had a miscarriage in the middle of an emergency room, and you said you were uninsured in that time, right? Ms. Burton. That is correct. Ms. Ocasio-Cortez. You were uninsured, so you miscarried in an emergency room, and you never were able to get the followup care that you needed. You never knew what happened to your baby, correct? Ms. Burton. That is correct. Ms. Ocasio-Cortez. Because insurance was too expensive, correct? Ms. Burton. That is correct. Ms. Ocasio-Cortez. Because CEOs needed to offer a profit margin, correct? Ms. Burton. Correct. Ms. Ocasio-Cortez. This right here is a complete, complete condemnation of the for-profit healthcare insurance industry because while they are talking about how socialized medicine, how a public guarantee to the right to healthcare will force us to ration care, we are rationing our own care. We are not talking about months-long waiting lists under the system we have now. We are talking about years-long waiting lists for the system that we have now. I will move on quickly. A key part of the ACA, Mr. Isasi, is Medicaid expansion, correct? Mr. Isasi. Yes. Ms. Ocasio-Cortez. Medicaid expansion allows people of lower incomes to essentially get covered by Medicaid, correct? Mr. Isasi. The very most vulnerable people in this country. Ms. Ocasio-Cortez. And that is a core part of the Affordable Care Act. Mr. Isasi. Correct. Ms. Ocasio-Cortez. Now there are some states that have not opted into this expansion. Mr. Isasi. That is right. Ms. Ocasio-Cortez. I have looked in some of these states. The states that have chosen to not cover, to not expand care to our lower-income Americans, Americans that are most vulnerable include Alabama. Is that correct, Mr. Isasi? Mr. Isasi. That is correct. Ms. Ocasio-Cortez. Florida? Mr. Isasi. That is correct. Ms. Ocasio-Cortez. Kansas? Mr. Isasi. That is correct. Ms. Ocasio-Cortez. Mississippi? Mr. Isasi. That is correct. Ms. Ocasio-Cortez. Missouri? Mr. Isasi. Correct. Ms. Ocasio-Cortez. North Carolina? Mr. Isasi. Correct. Ms. Ocasio-Cortez. South Carolina? Mr. Isasi. Correct. Ms. Ocasio-Cortez. Oklahoma? Mr. Isasi. Correct. Ms. Ocasio-Cortez. South Dakota? Mr. Isasi. Correct. Ms. Ocasio-Cortez. Tennessee? Mr. Isasi. Correct. Ms. Ocasio-Cortez. Texas? Mr. Isasi. Correct. Ms. Ocasio-Cortez. Wisconsin? Mr. Isasi. Correct. Ms. Ocasio-Cortez. Wyoming. Mr. Isasi. Correct. Ms. Ocasio-Cortez. These are the states that have chosen not to cover the most vulnerable Americans, correct? Mr. Isasi. That is right. Ms. Ocasio-Cortez. And these are the states that are also, we are seeing a lot of their representation trying to combat the ACA when they are not even buying into it to protect their own, correct? Mr. Isasi. We are talking about 2.5 million people who don't have coverage because they have not expanded Medicaid. Ms. Ocasio-Cortez. Why do you think they are doing that? Mr. Isasi. Well, you know, I used to work with the Governors on this very question. And the truth to that answer is because it was tainted as Obamacare, and it was a completely political decision. Ms. Ocasio-Cortez. So people are not getting insurance in these states for political reasons. That is your testimony? Mr. Isasi. Absolutely. Ms. Ocasio-Cortez. Thank you very much. Chairman Cummings. Thank you. And, Ms. Ocasio-Cortez, people are dying and getting sick. I will now go to Mr. Gosar. Mr. Gosar. Thank you, Mr. Chairman. Mr. Balat, you are from Texas, right? Mr. Balat. I am. Mr. Gosar. Are you familiar with federally qualified health centers? Mr. Balat. I am. Mr. Gosar. Now let me review. My understanding is it is first-come, first-served. You are seen on any basis, and your requirement for payment is a sliding-fee scale. Is that true? Mr. Balat. That is correct. Mr. Gosar. So technically, there is coverage for these populations. Mr. Balat. Yes, sir. Mr. Gosar. Hmm, interesting. So let me ask you another thing. You know, I have heard a number of things today in regards to the ACA. Who are the three groups that actually benefited from the ACA? Let me explain: big hospitals, the insurance industry, and pharmaceuticals. In fact, if you invested prior to the ACA in all those, you are a very wealthy individual, because one of the things we have overlooked is the lack of competition. We incentivized the insurance industry to gobble each other up, so you have regional monopolies. Then we had no competition in regards to the hospitals. Then what we had is a blow out in the pharmaceutical industry, so there are some common denominators here. Now I also know that we had a conversation about the VA. Mr. Balat. Mm-hmm. Mr. Gosar. And I am very astute about that. I am from Arizona, so the veterans that were dying were in my state. I also represent and have represented over 85 percent of the geography of Arizona, so a lot of rural areas, okay? And it was the implementation of the Choice Program that has actually saved us. Mr. Balat. Yes. Mr. Gosar. So that it actually helps those members that are out in the rural areas to pick and choose those providers, so it makes a big difference. Can you elaborate a little bit more in regards to the Veterans Administration as a single payer type apparatus, and why it is insufficient for the veterans? Mr. Balat. I can. I also serve as the chairman of a veterans charity. We build specially adapted housing for disabled veterans, and I have quite a few connections to the veteran community. I don't hear a lot of positive things about the VA. Talk about rationing. Talk about long wait lines. There was a time when I have seen veterans in their homes that have said my PTSD is so bad, I can't even come out the front door. It took him five minutes just to talk to me, but the only reason he came out to talk to me was to say we need to fix the VA. So they are a wonderful example of what a single payer would look like. You have got limited choices. You have got long wait lines. The care in many cases is good, but getting to it is often difficult. And what does it matter if you have the access if you don't have it until after something catastrophic happens, or until you have been living with pain for months and months and sometimes years? So, yes, it is problematic. It is very similar to how some of these other industrialized countries operate, and that is not what I would want for the people of this Nation. Mr. Gosar. Yes, sir. Now in getting back to pursuing how do we take care of people, one of the biggest problems, and just for clarity here, by the way, I was a dentist in a previous life, so I know a little bit about the healthcare industry. I was no fan of what was prior to Obamacare, and I am no fan of Obamacare. Mr. Balat. Nor was I. Mr. Gosar. I think there is something else. But my point is something has gone awry here, and the problem is that there are no real gatekeepers. We put them out of business. That would be primary care physicians. Isn't that true? Mr. Balat. Oh, yes. Mr. Gosar. So to stay in practice, you basically have to sell your soul to a hospital in order to stay in general practice. Mr. Balat. That is the unfortunate case. More than 50 percent of all our primary care physicians are currently employed by hospital systems. Mr. Gosar. So now, I also heard today in the conversation that we are providing healthcare for all sorts of individuals coming here illegally. And at the same time what we are doing is we are actually stealing their well-educated people for medicine for their doctors, are we not? A lot of our physicians coming here are from overseas because nobody from the United States is really going into that discipline. Mr. Balat. It is becoming less and less, but we have also contributed to that problem as a government because even in this country, those that are coming out of medical school, we don't have the residency spots for them. Mr. Gosar. Yes, I want to yield the rest of my time to the gentleman from Texas. Chairman Cummings. He doesn't have any time. Mr. Gosar. Okay. Chairman Cummings. We are at the end of this hearing, but I have just a few questions. I have not asked questions. Before I conclude today's hearing, I would like to enter into the record six letters the committee has received in recent days, including submissions from the Little Lobbyists, the National Partnership for Women and Families, the National Women's Law Center, and the Veterans Health and Advocate Sergeant Edward Corcoran. All of these letters express concern about the grave impact that the Trump Administration's position in the Texas lawsuit could have on millions of Americans and the U.S. healthcare system. I ask unanimous consent. It is so ordered. Chairman Cummings. You know, as I sit here and I listen to all of this, I ask myself, Mr. Isasi, first of all, healthcare costs are going to go up no matter what. Am I right? Mr. Isasi. Absolutely. Chairman Cummings. I have for at least seven years been fighting with many of my colleagues to bring down the cost of prescription drugs. How much does that play in the cost of healthcare going up? Mr. Isasi. The cost that we see in premium increases are mostly because of the prices being paid for what the people get. So if prescription drugs go up in price, premiums go up. If hospital prices go up, premiums go up. That is what drives the vast majority of price increases in health insurance. Chairman Cummings. No doubt about it. Mr. Isasi. No doubt about it whatsoever. Chairman Cummings. Wow. So it is very difficult, as you probably know, to get the Congress to move in a direction of reducing the cost of drugs, prescription drugs. Matter of fact, my first and only meeting with the President was just about that subject. That was two years ago, and the price of prescription drugs has gone up, not come down. So, but, you know, the thing that I am sitting here thinking, I have listened to Mr. Balat. You will never convince me that the ACA is perfect, but nor can you convince me that it could not be fixed so that it is most effective and efficient and so that we are covering our people in this country. Would you agree with that? Mr. Isasi. A hundred percent. Chairman Cummings. We could do it. Mr. Isasi. Absolutely. We could make coverage more affordable. We could increase subsidies for people who are higher on the income scale who are suffering right now because there is not support for them. There are a lot of things we could do to really strengthen and make the ACA a much more effective program. No question. Chairman Cummings. There does seem to be a stream in some of the questioning that sort of blames the victim. I don't like that word, but the person who is going through some difficulty, as if to say, oh, it is your fault. Well, I can tell you I was fine. I could walk just like you could a-year-and-a-half ago. Now I can't walk without a walker. That was overnight, literally. And as I am sitting here and I am listening to our patient advocates, our patient folks, consumers, you know, I was thinking, I think, and, God forbid, if more people went through some of the stuff or had family members that went through what you have gone through, perhaps they would have a different perspective. There is nothing like suffering. There is nothing like being disabled. There is nothing like having your life change overnight. There is nothing like taking two hours to get dressed. Come on now. There is nothing like sharing your pain. The idea that you would come here, and the stories that you have told are so personal, but you are willing to share them with the world to make somebody else's life better. In some kind of way, there is something in here that I think we are missing, and I think President Obama said it best. He said we have in our country quite often an empathy deficit. An empathy deficit. So some kind of way, we got to get around to making sure that all people are taken care of. It almost feels like we are saying, well, I can't help you because I got to help this person. Well, I believe that we can help all of us if we have the will, and it can be an effective and efficient system, and one that will work for all Americans. Now we talk about the rising healthcare costs. We should be talking about ways to ensure that all Americans have access to affordable healthcare. But we need to remember how far we have come under the Affordable Care Act, especially in the individual market. Mr. Isasi, I would like to ask you about the individual market which you described in your written testimony as I quote, ``terrible,'' prior to the ACA, but now ``much, much better'' thanks to the Affordable Care Act. Before the ACA, you state that 60 percent of consumers in the individual market found it ``very difficult or impossible to find affordable insurance. Now the Affordable Care Act has cut that number down to 34 percent, and more consumers are finding the coverage they need, so more consumers are buying insurance.'' Sir, isn't it a measure of success that more people are able to afford the coverage they need under the Affordable Care Act? Mr. Isasi. Absolutely, and more people are spending their own money to buy health insurance under the ACA as well. Chairman Cummings. One of the things that has happened in my district and in our state of Maryland, when the Trump Administration pulled away the Navigator money, do you know who did the navigating? The Members of Congress. Do you know why? Because we didn't want people to have an opportunity that they did not know about. If you don't know about an opportunity, you might as well not have it. We spent hours upon hours trying to get the word out, the deadlines and all that kind of thing, so that people could be insured. Mr. Isasi. And, you know, Chairman, by the way, that is also one of the most effective ways to bring premiums down, to get everyone to participate. We have seen that in Massachusetts. We have seen that in California. Chairman Cummings. No doubt about it. Wow. So let me just say this. My Republican colleagues have claimed that the ACA has made insurance coverage unaffordable. As Mr. Isasi has pointed out, the opposite is true. Before today's hearing, the committee received a letter from the Pennsylvania Insurance Department commissioner, Jessica Altman. In this letter, Commissioner Altman describes how the Administration's position in the Texas lawsuit would create chaos in the market, resulting in higher premiums and out-of-pocket costs for consumers in Pennsylvania and across the country. I request that this be made a part of the record. Without objection, so ordered. Chairman Cummings. If my colleagues were serious about making coverage more affordable for the American people, they will condemn the Administration's actions. I am going to conclude the hearing, but I, again, want to thank you. I want to thank all of you for being here, and I especially want to thank our consumers. There is something about pain. There is something about it is a driving force. As I have said in other hearings, when bad things happen to you, do not ask the question of why did it happened to me, but why did it happen for me. And in this instance, why did it happen for the people of the United States? I want you to keep those words in mind, those three words: pain, passion, purpose. Do you have something to say, Mr. Roy? Mr. Roy. I thank the chairman. I just wanted to also thank the witnesses, all of you, for your time. It is has been a good length hearing, and thank you for taking the time. Those of you who have been battling illnesses, your testimony, I appreciate it. I am a cancer survivor. There are a lot of people on this committee who have been afflicted with illnesses and dealing with it. And the chairman is right, this is something about which we should be able to agree more. We do have different perspectives on how to address making sure that everybody can afford high-quality healthcare, but I appreciate all of you all coming here and testifying on behalf of the entire committee, and including those in the minority. Thanks to the chairman. Chairman Cummings. Thank you very much. [Whereupon, at 1:55 p.m., the committee was adjourned.] [all]