[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                     PROPOSALS TO ACHIEVE UNIVERSAL 
                          HEALTHCARE COVERAGE

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           DECEMBER 10, 2019

                               __________

                           Serial No. 116-84


      Printed for the use of the Committee on Energy and Commerce
                   govinfo.gov/committee/house-energy
                        energycommerce.house.gov
                        
                             __________

                                
                    U.S. GOVERNMENT PUBLISHING OFFICE                    
44-546 PDF                  WASHINGTON : 2023                    
          
-----------------------------------------------------------------------------------     
                      
                    COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
                                 
BOBBY L. RUSH, Illinois              GREG WALDEN, Oregon
ANNA G. ESHOO, California              Ranking Member
ELIOT L. ENGEL, New York             FRED UPTON, Michigan
DIANA DeGETTE, Colorado              JOHN SHIMKUS, Illinois
MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California          CATHY McMORRIS RODGERS, Washington
KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland           PETE OLSON, Texas
JERRY McNERNEY, California           DAVID B. McKINLEY, West Virginia
PETER WELCH, Vermont                 ADAM KINZINGER, Illinois
BEN RAY LUJAN, New Mexico            H. MORGAN GRIFFITH, Virginia
PAUL TONKO, New York                 GUS M. BILIRAKIS, Florida
YVETTE D. CLARKE, New York, Vice     BILL JOHNSON, Ohio
    Chair                            BILLY LONG, Missouri
DAVID LOEBSACK, Iowa                 LARRY BUCSHON, Indiana
KURT SCHRADER, Oregon                BILL FLORES, Texas
JOSEPH P. KENNEDY III,               SUSAN W. BROOKS, Indiana
    Massachusetts                    MARKWAYNE MULLIN, Oklahoma
TONY CARDENAS, California            RICHARD HUDSON, North Carolina
RAUL RUIZ, California                TIM WALBERG, Michigan
SCOTT H. PETERS, California          EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             JEFF DUNCAN, South Carolina
MARC A. VEASEY, Texas                GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
A. DONALD McEACHIN, Virginia
LISA BLUNT ROCHESTER, Delaware
DARREN SOTO, Florida
TOM O'HALLERAN, Arizona
                                 ------                                

                           Professional Staff

                   JEFFREY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                MIKE BLOOMQUIST, Minority Staff Director
                         Subcommittee on Health

                       ANNA G. ESHOO, California
                                Chairwoman
ELIOT L. ENGEL, New York             MICHAEL C. BURGESS, Texas
G. K. BUTTERFIELD, North Carolina,     Ranking Member
    Vice Chair                       FRED UPTON, Michigan
DORIS O. MATSUI, California          JOHN SHIMKUS, Illinois
KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland           H. MORGAN GRIFFITH, Virginia
BEN RAY LUJAN, New Mexico            GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon                BILLY LONG, Missouri
JOSEPH P. KENNEDY III,               LARRY BUCSHON, Indiana
    Massachusetts                    SUSAN W. BROOKS, Indiana
TONY CARDENAS, California            MARKWAYNE MULLIN, Oklahoma
PETER WELCH, Vermont                 RICHARD HUDSON, North Carolina
RAUL RUIZ, California                EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire         GREG WALDEN, Oregon (ex officio)
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
LISA BLUNT ROCHESTER, Delaware
BOBBY L. RUSH, Illinois
FRANK PALLONE, Jr., New Jersey (ex 
    officio)
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................     1
    Prepared statement...........................................     2
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     3
    Prepared statement...........................................     5
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     6
    Prepared statement...........................................     8
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................     9
    Prepared statement...........................................    11

                               Witnesses

Hon. Rosa L. DeLauro, a Representative in Congress from the State 
  of Connecticut.................................................    12
    Prepared statement...........................................    15
Hon. Pramila Jayapal, a Representative in Congress from the State 
  of Washington..................................................    21
    Prepared statement...........................................    24
Hon. Brian Higgins, a Representative in Congress from the State 
  of New York....................................................    29
    Prepared statement...........................................    31
Hon. Antonio Delgado, a Representative in Congress from the State 
  of New York....................................................    33
    Prepared statement...........................................    35
Hon. Tom Malinowski, a Representative in Congress from the State 
  of New Jersey..................................................    37
    Prepared statement...........................................    39
Sara Rosenbaum, Harold and Jane Hirsch Professor, Health Law and 
  Policy, George Washington University Department of Health 
  Policy and Management..........................................    42
    Prepared statement...........................................    44
    Answers to submitted questions...............................   280
Peter Morley, Patient Advocate...................................    53
    Prepared statement...........................................    55
    Answers to submitted questions...............................   284
Jean Ross, R.N., President, National Nurses United...............    67
    Prepared statement \1\
    Answers to submitted questions...............................   293
Douglas Holtz-Eakin, Ph.D., President, American Action Forum.....    68
    Prepared statement...........................................    71
    Answers to submitted questions...............................   293


----------

\1\ Ms. Ross' prepared statement has been retained in committee files 
and also is available at https://docs.house.gov/meetings/IF/IF14/
20191210/110313/HHRG-116-IF14-Wstate-RossJ-20191210.pdf.
Scott W. Atlas, M.D., David and Joan Traitel Senior Fellow, 
  Hoover Institution, Stanford University........................    76
    Prepared statement \2\
    Answers to submitted questions \3\                              294

                           Submitted Material

H.R. 584, the Incentivizing Medicaid Expansion Act of 2019, 
  submitted by Ms. Eshoo\4\
H.R. 1277, the State Public Option Act, submitted by Ms. Eshoo\4\
H.R. 1346, the Medicare Buy-In and Health Care Stabilization Act 
  of 2019, submitted by Ms. Eshoo\4\
H.R. 1384, the Medicare for All Act of 2019, submitted by Ms. 
  Eshoo\4\
H.R. 2000, the Medicare-X Choice Act of 2019, submitted by Ms. 
  Eshoo\4\
H.R. 2085, the Consumer Health Options and Insurance Competition 
  Enhancement (CHOICE)Act, submitted by Ms. Eshoo\4\
H.R. 2452, the Medicare for America Act of 2019, submitted by Ms. 
  Eshoo\4\
H.R. 2463, the Choose Medicare Act, submitted by Ms. Eshoo\4\
H.R. 4527, the Expanding Health Care Options for Early Retirees 
  Act, submitted by Ms. Eshoo\4\
Statement of Randy Albelda, Professor of Economics, University of 
  Massachusetts Boston, et al., November 19, 2019, submitted by 
  Mr. Engel......................................................   115
Article of November 13, 2019, ``Health Reform's North Star: 10 
  Guidelines to Reach Universal Health Care Coverage,'' by 
  Jamilia Taylor and Jen Mishory, The Century Foundation, 
  submitted by Ms. Eshoo.........................................   124
Report of The Century Foundation, ``Road to Universal Coverage: 
  Addressing the Premium Affordability Gap,'' by Jen Mishory and 
  Katie Keith, September 18, 2019, submitted by Ms. Eshoo........   129
Letter of December 10, 2019, from Advocates for Youth, et al., to 
  House Committee on Energy and Commerce, submitted by Ms. Eshoo.   136
Letter of July 10, 2019, from A. Philip Randolph Institute, et 
  al., to Members of Congress, submitted by Ms. Eshoo............   139
Letter of December 9, 2019, from Patrick Yoes, National 
  President, National Fraternal Order of Police, to Ms. Eshoo and 
  Mr. Burgess, submitted by Ms. Eshoo............................   142
Letter of December 10, 2019, from Harold A. Schaitberger, General 
  President, International Association of Fire Fighters, to Rep. 
  Tom Malinowski, submitted by Ms. Eshoo.........................   144
Letter of December 10, 2019, from Mary R. Grealy, President, 
  Healthcare Leadership Council, to Mr. Pallone and Mr. Walden, 
  submitted by Ms. Eshoo.........................................   145
Letter of December 10, 2019, from Ingrida Lusis, Vice President, 
  Policy and Government Affairs, American Nurses Association, to 
  Ms. Eshoo and Mr. Burgess, submitted by Ms. Eshoo..............   148
Statement of Representative Cedric L. Richmond, December 10, 
  2019, submitted by Ms. Eshoo...................................   149
Statement of the Texas Hospital Association by John Hawkins, 
  Senior Vice President of Advocacy and Public Policy, December 
  9, 2019, submitted by Mr. Burgess..............................   151
Statement of the American Hospital Association, December 10, 
  2019, submitted by Mr. Burgess.................................   152
Letter of October 11, 2019, from Paul Hardin, President and Chief 
  Executive Officer, Texas Food and Fuel Association, to Mr. 
  Burgess, submitted by Mr. Burgess..............................   157
Letter of April 29, 2019, from Carol Tobias, President, National 
  Right to Life, to Representatives, submitted by Mr. Shimkus....   159
Letter of April 29, 2019, from Thomas McClusky, President, March 
  for Life Action, to Representatives, submitted by Mr. Shimkus..   162


----------

\2\ Dr. Atlas' prepared statement has been retained in committee files 
and also is available at https://docs.house.gov/meetings/IF/IF14/
20191210/110313/HHRG-116-IF14-Wstate-AtlasS-20191210.pdf.
\3\ Dr. Atlas did not answer submitted questions for the record by the 
time of printing.
\4\ The proposed legislation has been retained in committee files and 
also is available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=110313.
Letter of October 28, 2019, from Leanne Gassaway, Senior Vice 
  President, State Affairs and Policy, America's Health Insurance 
  Plans, to Executive Director Kim Bimestefer, Colorado 
  Department of Health Care Policy and Financing, and 
  Commissioner of Insurance Michael Conway, Colorado Division of 
  Insurance, submitted by Mr. Griffith...........................   164
Letter of March 7, 2019, from America's Health Insurance Plans to 
  Senate Chairman Matt Lesser and House Chairman Sean Scanlon, 
  Connecticut Insurance and Real Estate Committee, submitted by 
  Mr. Griffith...................................................   171
Letter of May 1, 2019, from Leanne Gassaway, Senior Vice 
  President, State Affairs, America's Health Insurance Plans, to 
  Jay Inslee, Governor of Washington, submitted by Mr. Griffith..   175
Letter of March 13, 2019, from Stephanie Berry, Regional 
  Director, State Affairs, America's Health Insurance Plans, to 
  Representative Andrea Salinas, State of Oregon , submitted by 
  Mr. Griffith...................................................   177
Letter of January 30, 2019, from Stephanie Berry, Regional 
  Director, State Affairs, America's Health Insurance Plans, to 
  Representative Eileen Cody and Senator David Frockt, State of 
  Washington, submitted by Mr. Griffith..........................   181
Letter of September 26, 2018, from Sara Orrange, Regional 
  Director, State Affairs, America's Health Insurance Plans, to 
  Legislative Health & Human Services Committee, New Mexico State 
  Legislature, submitted by Mr. Griffith.........................   186
Summary, WA SB 5526: Cascade Care, America's Health Insurance 
  Plans, submitted by Mr. Griffith...............................   190
Statement of the Blue Cross Blue Shield Association, December 10, 
  2019, submitted by Mr. Griffith................................   192
Letter of March 18, 2019, from Neil L. Bradley, Executive Vice 
  President and Chief Policy Officer, Chamber of Commerce of the 
  United States of America, to Members of the House of 
  Representatives, submitted by Mr. Griffith.....................   198
Report, Partnership for America's Health Care Future, submitted 
  by Mr. Griffith................................................   199
Memo of May 20, 2019, from Lauren Crawford Shaver, Partnership 
  for America's Health Care Future, submitted by Mr. Griffith....   211
Letter of December 9, 2019, from Lauren Crawford Shaver, 
  Executive Director, Partnership for America's Health Care 
  Future, to Ms. Eshoo and Mr. Burgess, submitted by Mr. Griffith   215
Fact sheet, ``Explaining The Facts on Medicare For All,'' 
  Partnership for America's Health Care Future, submitted by Mr. 
  Griffith.......................................................   217
Statement, ``Medicare Buy-In, Public Option Proposals Would Harm 
  Our Health Care System,'' Partnership for America's Health Care 
  Future, submitted by Mr. Griffith..............................   221
Statement, ``Medicare For All Means Layoffs,'' Partnership for 
  America's Health Care Future, submitted by Mr. Griffith........   225
Statement, ``Medicare For All Was `Spectacular Failure' & 
  `Financial Train Wreck' In Vermont,'' Partnership for America's 
  Health Care Future, submitted by Mr. Griffith..................   229
Membership list, Partnership for America's Health Care Future, 
  submitted by Mr. Griffith......................................   232
Statement, ``Public Option `Could Be Plenty Disruptive,''' 
  Partnership for America's Health Care Future, submitted by Mr. 
  Griffith.......................................................   237
Statement, ``Public Option Limits Patient Choice,'' Partnership 
  for America's Health Care Future, submitted by Mr. Griffith....   240
Memo of July 30, 2019, ``Under Sanders's Medicare For All, 
  Americans Would Pay More To Wait Longer For Worse Care,'' 
  Partnership for America's Health Care Future, submitted by Mr. 
  Griffith.......................................................   242
Statement of the Partnership for Employer-Sponsored Coverage, 
  December 10, 2019, submitted by Mr. Griffith...................   246
Statement, ``The Medicare for All Act of 2019 Presents Grave 
  Life, Conscience Protection, and Religious Liberty Concerns,'' 
  The Ethics & Religious Liberty Commission of the Southern 
  Baptist Convention, submitted by Mr. Griffith..................   247
Letter of December 9, 2019, from Marjorie Dannenfelser, 
  President, Susan B. Anthony List, to Representatives, submitted 
  by Mr. Griffith................................................   248
Statement of the American Action Forum, ``Is a Medicare Buy-In 
  Plan Viable?,'' by Christopher Holt, November 15, 2019, 
  submitted by Mr. Griffith......................................   249
Report prepared for the American Hospital Association and the 
  Federation of American Hospitals, ``The Impact of Medicare-X 
  Choice on Coverage, Healthcare Use, and Hospitals,'' by KNG 
  Health Consulting LLC, March 12, 2019, submitted by Mr. 
  Griffith \5\
Report of the Committee for a Responsible Federal Budget, 
  ``Choices for Financing Medicare for All: A Preliminary 
  Analysis,'' October 28, 2019, submitted by Mr. Griffith........   251
Report of The Heritage Foundation, ``How `Medicare for All' Harms 
  Working Americans,'' by Edmund F. Haislmaier and Jamie Bryan 
  Hall, November 19, 2019, submitted by Mr. Griffith \6\
Report of the Mercatus Center at George Mason University, ``The 
  Costs of a National Single-Payer Healthcare System,'' by 
  Charles Blahous, July 2018, submitted by Mr. Griffith \7\
Memo from Lauren Crawford Shaver, Partnership for America's 
  Health Care Future, December 9, 2019, submitted by Mr. Griffith   261
Statement, ``New Poll: Vast Majority Satisfied With Current 
  Health Care Coverage,'' Partnership for America's Health Care 
  Future, submitted by Mr. Griffith..............................   263
Article, ``Pelosi: ObamaCare could `be path to Medicare for 
  All,''' by Rachel Frazin, The Hill, December 6, 2019, submitted 
  by Mr. Griffith................................................   265
Article, ``Biden and Buttigieg say you can keep your health-care 
  plan. They're lying--just like Obama,'' by Marc A. Thiessen, 
  The Washington Post, December 3, 2019, submitted by Mr. 
  Griffith.......................................................   266
Statement, ``By The Numbers: The Devastating Costs of the 
  Democrats' Proposed Government Takeover of Your Healthcare,'' 
  Blue Cross Blue Shield Association, submitted by Mr. Griffith..   268
Statement, ``The Medicare for All Act of 2019: HR 1384,'' 
  Congressional Pro-Life Caucus, submitted by Mr. Griffith.......   270
Statement, ``House Dem Campaign Chief On Medicare For All: `Hard 
  To Conceive How That Would Work' & Price Tag `A Little 
  Scary,''' Partnership for America's Health Care Future, 
  submitted by Mr. Griffith......................................   272
Mission statement, Partnership for America's Health Care Future, 
  submitted by Mr. Griffith......................................   273
Statement, ``CRFB: Medicare For All `Would Mean ... Tripling 
  Payroll Taxes Or More Than Doubling All Other Taxes,''' 
  Partnership for America's Health Care Future, submitted by Mr. 
  Griffith.......................................................   274
Statement, ``Exploring The Effects Of The Public Option On 
  America's Health Care System,'' Partnership for America's 
  Health Care Future, submitted by Mr. Griffith..................   275
Statement, ``Examining The Impact Of The Public Option On Rural 
  Health Care,'' Partnership for America's Health Care Future, 
  submitted by Mr. Griffith......................................   276
Statement, ``Assessing Medicare for America,'' Partnership for 
  America's Health Care Future, submitted by Mr. Griffith........   277
Statement, ``Understanding Medicare-X Choice,'' Partnership for 
  America's Health Care Future, submitted by Mr. Griffith........   278
Statement, Partnership for Employer-Sponsored Coverage, submitted 
  by Mr. Griffith................................................   279

----------

\5\ The report has been retained in committee files and also is 
available at https://docs.house.gov/meetings/IF/IF14/20191210/110313/
HHRG-116-IF14-20191210-SD013.pdf.
\6\ The report has been retained in committee files and also is 
available at https://docs.house.gov/meetings/IF/IF14/20191210/110313/
HHRG-116-IF14-20191210-SD014.pdf.
\7\ The report has been retained in committee files and also is 
available at https://docs.house.gov/meetings/IF/IF14/20191210/110313/
HHRG-116-IF14-20191210-SD015-U5.pdf.

 
           PROPOSALS TO ACHIEVE UNIVERSAL HEALTHCARE COVERAGE

                              ----------                              


                       TUESDAY, DECEMBER 10, 2019

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:31 a.m., in 
room 2322, Rayburn House Office Building, Hon. Anna G. Eshoo 
(chairwoman of the subcommittee) presiding.
    Members present: Representatives Eshoo, Engel, Butterfield, 
Matsui, Castor, Sarbanes, Lujan, Schrader, Kennedy, Cardenas, 
Welch, Ruiz, Dingell, Kuster, Kelly, Barragan, Blunt Rochester, 
Pallone (ex officio), Burgess (subcommittee ranking member), 
Shimkus, Guthrie, Griffith, Bilirakis, Long, Brooks, Hudson, 
Carter, Gianforte, and Walden (ex officio).
    Staff present: Jeffrey C. Carroll, Staff Director; Tiffany 
Guarascio, Deputy Staff Director; Zach Kahan, Outreach and 
Member Service Coordinator; Saha Khaterzai, Professional Staff 
Member; Josh Krantz, Policy Analyst; Una Lee, Chief Health 
Counsel; Aisling McDonough, Policy Coordinator; Meghan Mullon, 
Staff Assistant; Kaitlyn Peel, Digital Director; Alivia 
Roberts, Press Assistant; Samantha Satchell, Professional Staff 
Member; Rebecca Tomilchik, Staff Assistant; Rick Van Buren, 
Health Counsel; C.J. Young, Press Secretary; Nolan Ahern, 
Minority Professional Staff Member, Health; Margaret Tucker 
Fogarty, Minority Legislative Clerk/Press Assistant; Theresa 
Gambo, Minority Financial and Office Administrator; Tyler 
Greenberg, Minority Staff Assistant; Peter Kielty, Minority 
General Counsel; Ryan Long, Minority Deputy Staff Director; 
Kate O'Connor, Minority Chief Counsel, Communications and 
Technology; J.P. Paluskiewicz, Minority Chief Counsel, Health; 
Kristin Seum, Minority Counsel, Health; and Kristen Shatynski, 
Minority Professional Staff Member, Health.
    Ms. Eshoo. Good morning, everyone. The Subcommittee on 
Health will now come to order. The Chair now recognizes herself 
for 5 minutes for an opening statement.

 OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    And welcome to our colleagues that are at the table and 
everyone that is here in the hearing room.
    Today's hearing features House colleagues who will present 
their legislative proposals to advance what I have always 
called the North Star of the Democratic Party, and that is to 
achieve universal healthcare for the American people. Five 
members are or will be at the witness table. Two 
representatives, Mr. Lujan and Ms. Schakowsky, will speak from 
the committee seats and two others, Representative Cedric 
Richmond and Representative Veasey, are submitting written 
statements.
    Every American should feel secure that, if they get sick or 
if they are hurt, they will receive the care they need without 
going bankrupt. That principle is why President Johnson signed 
Medicare and Medicaid into law, despite the protests at that 
time that it was ``socialized medicine'' and the ``Moscow party 
line.'' Today, Medicare covers 44 million Americans and 
Medicaid covers 75 million Americans.
    Our goal to achieve universal coverage motivated Congress 
to pass the Children's Health Insurance Program in 1997. It is 
why President Obama signed the Affordable Care Act into law in 
2010, which today provides health coverage to more than 20 
million Americans. But we know there is more work to be done to 
achieve universality. During our second panel today, we will 
hear the stories of fellow Americans who live in daily fear 
that they will lose their healthcare because of a decision by 
their employer, their insurer, or this President.
    My hope rises as I see the talented colleagues before us 
who will present their proposals and broaden our thinking. That 
is why I specifically asked each to be here today. My hope 
rises as I look out at doctors, nurses, and patients in the 
audience who have dedicated their lives to achieving quality 
healthcare for every American. Advent is a season of hope and 
an appropriate time for colleagues on both sides of the aisle 
to approach this hearing with open minds and hearts, knowing 
that the goal is to have healthcare for every American.
    Shortly before his death, Senator Ted Kennedy wrote a 
letter to President Obama about health reform and what he 
called ``that great unfinished business of our society.'' He 
wrote, ``What we face is, above all, a moral issue; that at 
stake are not just the details of policy, but fundamental 
principles of social justice and the character of our 
country.'' I think we all need to reflect on that moral issue 
today.
    [The prepared statement of Ms. Eshoo follows:]

                Prepared Statement of Hon. Anna G. Eshoo

    Today's hearing is historic and hopeful. It continues our 
near century-long work to achieve universal healthcare for the 
American people.
    Every American should feel secure that if they get sick or 
hurt, they will receive the care they need without going 
bankrupt.
    That principle is why President Johnson signed Medicare and 
Medicaid into law despite protests that it was ``socialized 
medicine'' and the ``Moscow party line.''
    Today, Medicare covers 44 million Americans and Medicaid 
covers 75 million Americans.
    Our goal to achieve universal coverage motivated Congress 
to pass the Children's Health Insurance Program in 1997.
    It's why President Obama signed the Affordable Care Act 
into law in 2010, which has provided health coverage to more 
than 20 million Americans.
    But there's more work to be done.
    During our second panel today we will hear stories from 
fellow Americans who live in daily fear that they'll lose their 
healthcare because of a decision by their employer, their 
insurer, or this President.
    It shouldn't be this way. The question is: How to fix it?
    Today, we'll hear nine plans to do just that.
    Those nine plans are why this hearing isn't only historic, 
but hopeful.
    I feel hope looking at my talented colleagues before me who 
will present their proposals.
    It's why I specifically asked you to be here today.
    I feel hope looking at the doctors, nurses, and patients in 
the audience who've dedicated their lives to achieving quality 
healthcare for every American.
    And I feel hope during this Advent season, that my 
colleagues on both sides of the aisle can approach this hearing 
with open minds and hearts knowing that the goal is to ensure 
universal healthcare, including for the most vulnerable among 
us.
    Shortly before his death, Senator Ted Kennedy wrote a 
letter to President Obama about health reform and what he 
called ``that great unfinished business of our society.''
    He wrote, ``What we face is above all a moral issue; that 
at stake are not just the details of policy, but fundamental 
principles of social justice and the character of our 
country.''
    Let us all reflect on that moral issue today.
    I yield the rest of my time to Representative Dingell.

    Ms. Eshoo. I now would like to yield the remainder of my 
time to Congresswoman Dingell.
    Is she here? Not here? Pardon me? She is on her way. Well, 
we are going to move on, because the Chair is now going to 
recognize Dr. Burgess, the ranking member of the subcommittee, 
for his 5 minutes for an opening statement.
    Mr. Burgess. Actually, before I start that, may I ask a 
unanimous consent request, unanimous consent to insert into the 
record the two letters that Mr. Walden and I sent asking for 
this hearing earlier in the year?
    Ms. Eshoo. So ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Burgess. And also, I am OK with you yielding your final 
minute and a half to Mrs. Dingell when she gets here.
    Ms. Eshoo. Thank you.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. So, thank you for leading the hearing. 
Certainly, Mr. Walden and I have requested this, and we 
requested it very early in the year and I appreciate that you 
took our request seriously.
    So, Chairman Pallone and Chairwoman Eshoo stated in 
noticing this hearing that universal healthcare coverage has 
long been the North Star of the Democratic Party. Every bill 
before us today is paving the road to the North Star, if that 
is even possible. The idea is we accomplish one-size-fits-all 
healthcare.
    Another Advent analogy: The Three Wise Men--not quite the 
same, but I am not sure they would appreciate your comparison, 
as this North Star journey would lead our healthcare system as 
we currently know it to disintegrate. If, in fact, we are 
listening to the great philosopher Joni Mitchell, then the 
Northern Star is not very reliable, as it is constantly in the 
dark.
    Medicare for All would eliminate private insurance, 
employer-sponsored health insurance, Medicaid, the Children's 
Health Insurance Program upon which many Americans depend. I am 
concerned about the consequences for existing Medicare 
beneficiaries. The policy would raid the Medicare Trust Fund, 
which is already slated to go bankrupt in 2026. This will not 
help. Our Nation's seniors have been paying into and depending 
upon the existence of Medicare for their healthcare needs in 
retirement for, literally, their entire lives.
    More than 70 percent of Americans are satisfied with their 
employer-sponsored insurance, which does provide robust 
protections. We should focus on strengthening the parts of our 
health insurance markets that are working. However, instead of 
building upon the success of our existing health insurance 
framework, a one-size-fits-all policy would tear it down.
    I also feel obligated to mention, having been in the 
healthcare provider business, the doctor business, coverage 
does not equal care. It never has and never will. Single-payer 
healthcare would be another failed attempt. As a one-size-fits-
all approach to healthcare, single-payer is in reality not one-
size-fits-all, it is one-size-fits-no one. Single-payer 
healthcare would cost over $33 trillion for the first 10 years. 
This high price tag would require new tax increases. In fact, 
it would double the currently projected Federal individual and 
corporate income tax collections in order to pay for it, 
according to the Mercatus Center.
    So each and every one of these bills before us today is 
about Medicare for All and the pathway to socialized medicine. 
We have all seen the reports of increased wait times for 
patients in countries like Canada of up to almost 9 weeks for a 
specialist consultation. Hospitals stand to lose billions under 
a Medicare for All plan. The New York Times reported rural 
hospitals saying that they would virtually close overnight, 
while others said that they would try to offset the steep cuts 
by laying off hundreds of thousands of workers and abandoning 
the lower-paying services such as mental health services.
    We simply cannot afford the financial or human suffering 
that would accompany such a misguided policy. It is clear that 
this takeover of even one sector of the healthcare industry we 
are going to be talking about later this week, prescription 
drugs in Speaker Pelosi's H.R. 3 bill--and it would reduce the 
number of new drugs coming to the market--the Congressional 
Budget Office estimated between 8 to 15 new drugs would fail to 
come to the market over the course of the next 10 years. The 
Council of Economic Advisors anticipated as many as a hundred 
drugs. It doesn't matter which figure you use, everyone is in 
agreement that it would reduce new drugs coming that we have 
all wanted through innovation.
    I support commonsense, market-driven improvements to our 
healthcare system. The goal should be to increase access to 
healthcare services and drive down the costs for our patients. 
These universal healthcare coverage bills are all going in the 
wrong direction. In fact, I introduced H.R. 1510, the Premium 
Relief Act of 2019, which does include reinsurance that is 
coupled with a structural reform of the Affordable Care Act. 
This would give States more choice on how to repair their 
markets that have been damaged by previous legislative 
attempts. Even better, this legislation is fully paid for by 
stopping bad actors from gaming the system.
    There are policies that we could work on to get Americans--
to reduce their cost and complexity of healthcare, but we have 
before us today nine bills that fail to have a single 
Republican cosponsor among them. I am glad we finally are 
having this hearing, Madam Chair. It has been a long time 
coming and certainly something we should have done as we 
started this year. But at the end of the day, I would really 
hope the Energy and Commerce Committee can open the blinds and 
reveal what the North Star really looks like, completely in the 
dark. I yield back.
    [The prepared statement of Mr. Burgess follows:]

             Prepared Statement of Hon. Michael C. Burgess

    Thank you, Madam Chair. Thank you for holding this hearing 
on various universal heath care coverage proposals, including 
Medicare for All. Ranking Member Walden and I requested a 
hearing on Medicare for All numerous times this year, and I 
appreciate that you took our request seriously enough to hold 
today's hearing. I would like to ask unanimous consent that our 
two letters be included in the record. Coverage does not equal 
care.
    Chairman Pallone and Chairwoman Eshoo stated in noticing 
this hearing that ``universal healthcare coverage has long been 
the North Star of the Democratic Party.'' Every bill before us 
today is paving that road to the North Star--to accomplishing 
one-size-fits-all healthcare coverage.
    I'm not sure the Three Wise Men would appreciate your 
comparison, as this North Star journey would lead our 
healthcare system as we currently know it to disintegrate into 
ashes. If we're listening to Joni Mitchell, then the Northern 
Star is not very reliable as it is constantly in the dark.
    Medicare for All would eliminate private insurance, 
employer-sponsored health insurance, Medicaid, and the 
Children's Health Insurance Plan, upon which many Americans 
depend. I am concerned about the consequences for existing 
Medicare beneficiaries, as this policy would raid the Medicare 
Trust Fund, which is already slated to go bankrupt in 2026. Our 
Nation's seniors have been depending on the existence of 
Medicare for their healthcare needs in retirement for their 
entire lives.
    More than 70 percent of Americans are satisfied with their 
employer-sponsored health insurance, which provides robust 
protections for all individuals. We should be focused on 
strengthening the parts of our health insurance markets that 
are working. However, instead of building upon the successes of 
our existing health insurance framework, a one-size-fits-all 
policy would tear it down.
    Single-payer healthcare would be another failed attempt at 
a one-size-fits-all approach to healthcare. Single-payer is not 
one-size-fits-all, it is really one-size-fits-no-one. Single-
payer healthcare would cost $32.6 trillion for the first 10 
years of full implementation. This high price tag would require 
new tax increases. In fact, doubling all currently projected 
Federal individual and corporate income tax collections would 
be insufficient to finance Medicare for All, according to the 
Mercatus Center.
    Let me be clear, each and every one of these bills before 
us today is about Medicare for All and the pathway to 
socialized medicine. We have seen reports of increased wait 
times for patients in countries like Canada of up to almost 9 
weeks for a specialist consultation. Hospitals stand to lose 
billions under a Medicare for All plan. The New York Times 
reported rural hospitals saying they would virtually close 
overnight, while others said they would try to offset the steep 
cuts by laying off hundreds of thousands of workers and 
abandoning lower-paying services like mental health. We simply 
cannot afford the financial or human suffering that would 
accompany such misguided policy. To further lay out that 
argument, I would like to request unanimous consent to insert 
statements from the Texas Hospital Association and American 
Hospital Association into the record.
    It is clear that a socialist takeover of even one sector of 
the healthcare industry--prescription drugs--in Speaker 
Pelosi's HR 3, there would be a reduced number of new drugs 
coming to market. The Congressional Budget Office estimated 
between 8-15 new drugs would fail to come to market over the 
course of 10 years.
    Whereas the Council of Economic Advisors anticipated as 
many as 100 drugs would not reach Americans. This is the effect 
of a socialist policy, the ramifications of which would be even 
greater under Medicare for All.
    Evidently, the House Democrats are looking to socialize all 
of medicine and our whole healthcare system.
    While I support commonsense, market-driven improvements to 
our healthcare system that would increase access to healthcare 
services and drive down costs for patients, these universal 
healthcare coverage bills are steps in the wrong direction.
    I introduced HR 1510, the Premium Relief Act of 2019, which 
includes reinsurance that is coupled with a structural reform 
of the Affordable Care Act. This would give states more choice 
on how to repair their markets that have been damaged by 
Obamacare.
    Even better, this legislation is fully paid for by stopping 
bad actors from gaming the system.
    There are many policies that we could work on that would 
get to providing more Americans healthcare coverage; however, 
nine bills that fail to have a single Republican cosponsor 
among them, is not the answer. I am glad we finally had a 
hearing on Medicare for All so the Energy and Commerce 
Committee can open the blinds and reveal what this ``North 
Star'' really looks like to the American people--completely in 
the dark. I yield back.

    Ms. Eshoo. The gentleman yields back. I now would like to 
yield the minute and a half that I want to yield to 
Congresswoman Dingell so that you can make use of the time that 
you asked for.
    Mrs. Dingell. Thank you.
    Today, we have the opportunity to discuss legislation that 
would, once and for all, address the cost and access issues 
that continue to deny millions of Americans the right to 
quality, affordable healthcare. Every member of this committee 
has heard from--and every Member of this Congress--has heard 
from constituents who are fearful and frustrated by our current 
health system. We have received letters and calls from 
individuals who face devastating financial hardship as a result 
of predatory health insurance companies enabled by the current 
system.
    And as I have always said, when I would take John to the 
doctor, it was like holding a town hall. Person after person 
would come up and share their stories that were just--they were 
people that were desperate and scared and needed help. We can 
and must do better. This is the promise of Medicare for All, a 
comprehensive system of coverage that empowers all Americans.
    The Medicare for All of 2019 would provide coverage for all 
Americans, improve traditional Medicare for seniors by offering 
additional benefits at lower cost, and utilizing administrative 
efficiencies and negotiations to bring down prices. This is a 
historic day. I thank you, Madam Chair, for scheduling this 
hearing. We have never had a Medicare for All hearing in this 
committee, and I look forward to discussing this legislation 
further with our distinguished experts today and to keep 
answering questions and giving people the facts as we go 
forward. Thank you, Madam Chair.
    Ms. Eshoo. The Chair now recognizes the chairman of the 
full committee, Mr. Pallone, for his 5 minutes for an opening 
statement.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Madam Chair.
    Since the passage of the Affordable Care Act, more than 20 
million Americans have gained the peace of mind that comes from 
knowing that they and their loved ones have health insurance. 
This landmark law resulted in the highest insured rate in our 
Nation's history. It also expanded consumer protections so 
that, no matter where you live or work in the U.S., your family 
would have access to affordable, comprehensive healthcare.
    The ACA ended decades of insurance companies price gouging 
older Americans, charging women more than men, and 
discriminating against people with preexisting conditions. It 
not only prevented health insurance companies from 
discriminating against people with preexisting conditions, it 
also required insurance companies to cover a set of essential 
health benefits like hospitalization, emergency services, 
maternity care, and substance use disorder services. It also 
eliminated annual and lifetime limits on coverage that for 
years had forced people with preexisting conditions into 
bankruptcy. Thanks to the ACA, young Americans can stay on 
their parents' plan until they turn 26.
    The law also expanded Medicaid, which made health insurance 
available to millions of low-income Americans, including many 
with serious and chronic preexisting conditions and unmet 
medical needs. Yet, millions more would be covered today if it 
were not for the continued resistance of Republican Governors 
to the law's Medicaid expansion and the repeated attempts by 
congressional Republicans and the Trump administration to 
undermine and dismantle the law.
    House Republicans voted 69 times to repeal the ACA. 
Luckily, they failed to do so, but they did repeal the law's 
individual mandate, increasing prices for everyone. Meanwhile, 
20 Republican attorneys general and Governors sued the Federal 
Government, challenging the constitutionality of the law. The 
Trump administration has taken the extraordinary position of 
refusing to defend the law in the courts. If the Republicans 
are successful in court, it would cause millions of people to 
lose their health insurance, eliminate protections for people 
with preexisting conditions, and immediately spike healthcare 
costs for all Americans.
    I firmly believe that today we would be very close to 
universal coverage had it not been for the sabotage and for the 
refusal of Republican Governors to expand Medicaid. I also 
believe that, had the final law included the public option as 
supported by the majority of this committee and the House at 
the time, that we would be even closer to universal coverage. 
Now, unfortunately, that is not the case, and millions of 
Americans remain uninsured, particularly in States that have 
refused to expand Medicaid.
    Also, among the uninsured are undocumented immigrants and 
their families. When we drafted the ACA, I worked to include 
the undocumented, but I couldn't get the votes, and I would 
like to know how the various bills before us today would 
address the undocumented. When people get sick, they get other 
people sick, so it makes no sense to exclude any group of 
people regardless of their legal status. And, under the Trump 
administration, the uninsured rate has gone up and American 
families have lost coverage, including hundreds of thousands of 
children. We need to enact policies that include all the 
uninsured, and that is why we are here today.
    The bills we are considering reflect Democrats' continued 
commitment to achieving universal coverage and making 
healthcare more affordable and accessible for all Americans. I 
believe that we must continue to build on the success of the 
ACA until healthcare is truly a right for all Americans, which 
it should be.
    [The prepared statement of Mr. Pallone follows:]

             Prepared Statement of Hon. Frank Pallone, Jr.

    Since the passage of the Affordable Care Act, more than 20 
million Americans have gained the peace of mind that comes from 
knowing that they and their loved ones have health insurance. 
This landmark law resulted in the highest insured rate in our 
Nation's history. It also expanded consumer protections so 
that, no matter where you live or work in the United States, 
your family would have access to affordable, comprehensive 
healthcare.
    The ACA ended decades of insurance companies price gouging 
older Americans, charging women more than men, and 
discriminating against people with preexisting conditions. It 
not only prevented health insurance companies from 
discriminating against people with preexisting conditions, it 
also required insurance companies to cover a set of essential 
health benefits, like hospitalization, emergency services, 
maternity care, and substance use disorder services. It also 
eliminated annual and lifetime limits on coverage that for 
years had forced people with preexisting conditions into 
bankruptcy.
    Thanks to the ACA, young Americans can stay on their 
parents' plans until they turn 26 years old.
    The law also expanded Medicaid, which made health insurance 
available to millions of low-income Americans, including many 
with serious and chronic preexisting conditions and unmet 
medical needs.
    Yet millions more would be covered today if it were not for 
the continued resistance of Republican Governors to the law's 
Medicaid expansion and the repeated attempts by congressional 
Republicans and the Trump administration to undermine and 
dismantle the law.
    House Republicans voted 69 times to repeal the ACA. 
Luckily, they failed to do so, but they did repeal the law's 
individual mandate, increasing prices for everyone.
    Meanwhile, 20 Republican attorneys general and Governors 
sued the Federal Government, challenging the constitutionality 
of the law. The Trump administration has taken the 
extraordinary position of refusing to defend the law in the 
courts. If the Republicans are successful in court, it would 
cause millions of people to lose their health insurance, 
eliminate protections for people with preexisting conditions, 
and immediately spike healthcare costs for all Americans.
    I firmly believe that today we would be very close to 
universal coverage had it not been for the sabotage and for the 
refusal of Republican Governors to expand Medicaid. I also 
believe that had the final law included the public option, as 
supported by the majority of this committee and the House at 
the time, that we would be even closer to universal coverage.
    Unfortunately, that's not the case and millions of 
Americans remain uninsured, particularly in States that have 
refused to expand Medicaid. Also, among the uninsured are 
undocumented immigrants and their families. When you have more 
uninsured people, costs go up for everyone. And, under the 
Trump administration, the uninsured rate has gone up and 
American families have lost coverage, including hundreds of 
thousands of children. We need to enact policies that include 
all the uninsured.
    And that's why we are here today. The bills we are 
considering reflect Democrats' continued commitment to 
achieving universal coverage and making healthcare more 
affordable and accessible for all Americans. I believe that we 
must continue to build on the success of the ACA until 
healthcare is truly a right for all Americans.
    I look forward to the discussion today and I yield back.

    Mr. Pallone. I look forward to the discussion and yield the 
balance of my time to the gentlewoman from Illinois, Ms. 
Schakowsky.
    Ms. Schakowsky. Thank you so much. Today really does mark a 
landmark day to discuss ways that the United States of America 
can join the rest of the industrialized world in saying that 
healthcare is a right and not a privilege for all of our 
people. You know, we spend more than any other country on 
healthcare right now, yet millions of people don't have access 
to care. We have the highest rates of infant--or maternal 
mortality, we have a shorter life span, and we can do better.
    So I have been a cosponsor and a supporter of single-payer 
healthcare since a lot of you in this room were even born, but 
I also want to say that I am a cosponsor of every single bill 
that is going to improve healthcare in this country because we 
have to move forward. I am a cosponsor of a bicameral public 
option bill ever since the Affordable Care Act didn't include 
it. I am a cosponsor--and you will hear from Representative 
DeLauro--on Medicare for America. I am a Medicare for All--I am 
a cosponsor of that and was there at its inception.
    So we don't know exactly what path we are going to take, 
but over the last 50 years we have seen some dramatic changes. 
We have seen Medicare and Medicaid get passed, we have seen the 
ACA, and these are examples of the dynamic changes that we can 
make and that we should be making. We need to work together. 
Americans are asking us, begging us to improve our healthcare 
system. They all want to be covered. We can do this, and we are 
going to hear about how we can do this today. I thank the 
panel, and I yield back.
    Ms. Eshoo. Does the gentleman yield back? Mr. Pallone?
    Mr. Pallone. I am sorry. Yes, I yield back, Madam Chair.
    Ms. Eshoo. What are you dreaming about there, over there?
    Mr. Pallone. Dreaming about a better world.
    Ms. Eshoo. Lovely.
    I now would like to recognize the ranking member of the 
full committee, my friend Mr. Walden, for his 5 minutes for an 
opening statement.

  OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Mr. Walden. Thank you. I want to join the chairman in 
dreaming about a better world. It is that spirit we should have 
here this holiday season.
    Ms. Eshoo. Well, I believe it is. I believe it is.
    Mr. Walden. Madam Chair, yes. Thanks for holding this 
hearing. I think it really is important to flesh out these 
issues and learn a lot about them.
    As you know, our committee has moved forward on maternal 
mortality legislation. Ms. Schakowsky referenced that as a huge 
issue, and it is, and I am glad we have moved forward on some 
of those specific issues. This is the committee that created 
Medicare Part D to help seniors get access to affordable 
prescription drugs that had never been a part of Medicare 
before. We did that. The House passed it. I helped write it and 
support it all along.
    This is the committee that led the effort in a bipartisan 
way on 21st Century Cures. I know there is an effort beginning 
to look at a Cures 2.0 so we can find these magic miracles that 
are saving people's lives and invest in American innovation and 
research. This is the committee that is on the cusp of 
reauthorizing fully funding our community health centers for 
the next 5 years. I am a big fan of our community health 
centers. When I chaired the committee, I helped lead the effort 
to fully fund them.
    And Chairman Pallone and I are working together on 
legislation to stop surprise billing so consumers aren't ripped 
off when they go to the emergency room. One in five are getting 
a surprise bill today. That is wrong. We are on the cusp of 
dealing with that. And we fully funded Children's Health 
Insurance Program in the last Congress, when I chaired the 
committee, for 10 years. It had never been fully funded for 
more than 5.
    So I think we all share a commitment to trying to find 
answers to the cost of healthcare, to access issues when it 
comes for healthcare. Some of us, however, think that Medicare 
for All is not the right approach; that it would actually take 
away the health insurance that 180 million Americans have 
today, many of whom have bargained for that health insurance as 
part of very aggressive union-employer bargaining agreements. 
They have traded away wages in order to have better healthcare 
or lower-cost deductibles and all. Medicare for All would strip 
that away from them, as it would take away Medicare Advantage 
Plans and put it all under one system. And I will just tell 
you, when Washington politicians promise you something for 
free, you better hold on to your wallets.
    As you know, 84 percent of Americans actually like the 
health insurance they have today. We all think it is probably 
too expensive. We all wish it were a little better. We can work 
to make changes to fix some of those issues, but a one-size-
fits-all system that rations care and restricts access and 
blows a hole in the budget is not where many of us are at.
    At the presidential debate in October, a top Democrat said, 
and I quote, ``If you eliminated the entire Pentagon, every 
single thing, it would pay for about a total of 4 months'' of 
this Medicare for All plan. These plans are so complex and 
confusing and costly that even the Congressional Budget Office 
could not figure out the price tag. However, two think tanks, 
one on the left and one on the right, came up with a range of 
between 28 trillion and 32 trillion dollars over the next 10 
years. Other versions we have heard about would cost upwards of 
$52 trillion.
    Even doubling the current--doubling the current--personal 
and corporate taxes would not cover the costs. Doubling. 
Doctors and hospitals could see payment cuts of 40 percent. 
Forty percent. How would they keep their doors open? What 
happens to our access to care? We can look north to Canada. The 
Fraser Institute did some research on this and found that a 
doctor's referral for specialty care, the medium wait time was 
20 weeks, double what it was 25 years ago. That is a 
government-run system.
    Canada is facing a shortage of medical providers, and in 
some provinces some hospitals have responded by actually 
closing their emergency rooms 2 days a week. In British 
Columbia, 300 patients died waiting for surgery between 2015 
and 2016 because of a lack of anesthesiologists. And, according 
to the British Columbia Anesthesiologists' Society, they say 
that is a huge problem.
    Canada has 16 CT scans for every million people. In 
America, we have 45 for every million people. That means that 
you can get access to care quicker here, get those scans. Delay 
and denial of care is how government-run healthcare systems 
control costs. You see what is going on in England right now 
with a young boy that was being treated, I think, in a hallway. 
They ration care. They delay care. If the government decides a 
treatment or drug you need is not cost effective, you are 
denied access. We had that debate in this committee. The data 
are clear about how long you wait to get access to miracle 
drugs in other countries. Upwards of 40 percent of the new 
drugs are not available. These are cancer drugs. These are new 
drugs on the market that would save lives, and do, in America.
    We have got to deal with the issue of costs, certainly, but 
there is a way to do that. And by the way, most of these 
government-run systems prevent you from going around the 
government-run system. Some people do flee a country, come to 
another one, mainly America, to get access to care when their 
own government system fails them. It is not just a theory. It 
is what happens in some of these countries.
    So I am not a fan of that complete government takeover. I 
am a fan of reform and of making sure we have the network in 
place. So, Madam Chair, thanks for having this hearing. I yield 
back.
    [The prepared statement of Mr. Walden follows:]

                 Prepared Statement of Hon. Greg Walden

    Today we're here to talk about the greatest government 
takeover of private business, and the greatest denial of 
individual choice, in modern history. Medicare for All would 
not only take away your health insurance, but also end Medicare 
as we know it. It would ban private insurance and rob consumers 
of any choice they have in making healthcare decisions that 
work for them.
    We hear all the time, ``don't worry, Medicare for All will 
give you free healthcare from Washington, D.C. that's better 
than what you get today.'' When Washington politicians promise 
you something for free, you better hold onto your wallet.
    Let's look at what Medicare for All would do. More than 180 
million Americans lose the health insurance plan they've chosen 
or bargained for. Even Medicare Advantage plans for seniors are 
wiped out.
    A recent poll found that 84% of Americans are satisfied 
with the healthcare plans they're on. These are union members 
and workers who have negotiated their healthcare benefits for 
decades--under the Democrats' plan, they would lose the 
coverage they've chosen for their families and are shoved into 
a one-size-fits-all system that rations care, restricts access 
and blows a hole in the budget.
    At the presidential debate in October, a top Democrat said, 
`If you eliminated the entire Pentagon, every single thing. it 
would pay for a total of four months.'
    These plans are so complex, confusing and costly that even 
the Congressional Budget Office could not figure out the price 
tag. However, independent studies from think tanks on the left 
and the right arrived at similar conclusions: Medicare for All 
would cost between $28 trillion and $32 trillion over 10 years. 
Other versions could cost up to $52 trillion. Leading Democrats 
are forced to admit this would require massive tax increases on 
working families and American companies.
    But even doubling current personal and corporate taxes 
would NOT cover the costs. DOUBLING--still not enough. Doctors 
and hospitals could see payment cuts of 40%! How would they 
keep their doors open? What would happen to our ability to 
access care?
    We can look north to Canada to see what Canadians deal with 
every day. The Fraser Institute found that after a doctor's 
referral for specialty care, the median wait time is 20 weeks, 
double what it was 25 years ago.
    Canada is facing a shortage of medical providers and in 
some provinces, some hospitals have responded by closing their 
emergency rooms on certain days of the week. In British 
Columbia, 300 patients died waiting for surgery between 2015 
and 2016 because of a lack of anesthesiologists, according to 
the British Columbia Anesthesiologists' Society. Canada has 16 
CT scanners for every million people. Here in the U.S. we have 
nearly three times as many CT scanners.
    Delay and denial of care is how government-run healthcare 
systems control costs. They ration care. If the government 
decides the treatment or drug you need are not ``cost 
effective,'' you are denied access. And the law prevents you 
from going around the government to get care.
    This is not just a theory, this is what happens in other 
countries with government-run healthcare administered by 
bureaucrats--care is rationed, access is restricted, and 
patients have worse outcomes. That's not what Republicans want 
for Americans.
    Mr. Chairman, I do want to thank you for having this 
hearing. The American people deserve to hear the facts about 
what a government takeover of their health insurance will mean 
for access to care in a timely manner. These plans ration care 
and deny life-saving treatments. Importing foreign healthcare 
systems to the U.S. runs counter to our shared goal of 
expanding access to the latest cures and improving access to 
lifesaving therapies.

    Ms. Eshoo. The gentleman yields back.
    The Chair wants to remind Members that, pursuant to 
committee rules, all Members' written opening statements shall 
be made part of the record, and certainly the written 
statements of the two Members that are part of the nine 
proposals that we are going to hear about today.
    So they don't really need any introduction, but I think 
that it is appropriate to still do so. It is an honor to 
welcome our colleagues here today for this hearing. Each of 
them is going to speak for 5 minutes to present their specific 
proposal. Each one differs, and I think that, as I said in my 
opening statement, that it is important for everyone to listen 
because we have varying sets of ideas, and I think that we need 
to have an open mind about them.
    So, beginning with Congresswoman Rosa DeLauro from my home 
State where I was born and raised, Connecticut, welcome to you; 
to Representative Jayapal from the State of Washington, welcome 
to you; to Representative Higgins from New York, thank you for 
making yourself available today; to Representative Delgado from 
the State of New York; and Representative Malinowski from New 
Jersey. Welcome to each one of you. Thank you for the work that 
you have put into the product that--the legislation that you 
are going to explain to us today.
    So we will start with Congresswoman DeLauro. You are 
recognized for 5 minutes to speak to your legislation, 1384, 
the Medicare for--no, 2452, I am sorry, the Medicare for 
America Act. You all know the light system, so I don't need to 
explain that to anyone.
    Welcome. Thank you, Rosa.

 STATEMENT OF HON. ROSA DeLAURO, A REPRESENTATIVE IN CONGRESS 
                 FROM THE STATE OF CONNECTICUT

    Ms. DeLauro. Thank you so much, Madam Chair. Congressman 
Pallone, Congresswoman Eshoo, Ranking Members Walden and 
Burgess, I am delighted to be here this morning. It is an honor 
for me join with the members of this committee and also to be 
with all of my colleagues here this morning on what is a 
critical, critical discussion on what are the pathways that we 
can move forward to universal care.
    I am here this morning to advocate for Medicare for 
America, which I first introduced with my dear friend and my 
colleague, Congresswoman Jan Schakowsky. We did this in 
December 2018, and we reintroduced it this May. Medicare for 
America achieves universal, affordable, high-quality health 
coverage by creating a program based on Medicare and Medicaid 
that covers all Americans through auto enrollment starting at 
birth while maintaining high-quality, affordable employer 
coverage.
    Medicare for America moves every individual currently 
enrolled on the individual exchanges and Medicare beneficiaries 
on to the program. Individuals and children enrolled in 
Medicaid and CHIP are transitioned on to Medicare for America, 
over time, to ensure that their care is not disrupted as we 
transform our healthcare system. We made this deliberate choice 
after working with members of the disabilities community who 
know all too well about disruptions in the face of budget cuts 
and other complications.
    For those with employer-sponsored coverage, two things can 
be true, and are true: employers have shifted many Americans to 
high-deductible plans with less generous coverage, and many are 
very satisfied, including those union members that negotiated 
very good coverage in lieu of wages in lean budget years. So 
Medicare for America allows high-quality, affordable, private 
employer-sponsored coverage to remain, or employers can enroll 
their employees in Medicare for America and continue to pay a 
contribution, or those employees who work for these employers 
that continue to offer private coverage can choose Medicare for 
America and their employer contributes toward the premium. This 
way, no one is locked into employer-sponsored coverage.
    Let me touch on something that I hear from most of my 
constituents and that is cost. For individuals, seniors, 
families living below 200 percent of the Federal poverty level, 
they will have no premiums and no cost sharing. There are never 
out-of-pocket costs for children under 21 and for maternity 
services, for preventive and chronic services, for long-term 
services and supports, and for prescription drugs. There are 
also zero deductibles. Zero. Annual out-of-pocket costs are no 
more than $3,500 for individuals, $5,000 for families on a 
sliding scale, and premiums are capped no more than 8 percent 
of income for enrollees and are determined on a sliding scale.
     And, additionally, on the topic of the cost of the 
program, our bill included pay-fors. I ask you to read it. I 
won't enumerate all of them, but the pay-fors are there.
     Let me discuss what is innovative about Medicare for 
America. Today, healthcare benefits are too dependent on your 
ZIP Code. Universal coverage must be universal, so Medicare for 
America is explicit in the benefits covered, especially with 
respect to long-term services and supports.
    We are in a crisis. Families spend themselves into poverty 
to get the care their aging loved ones need, hundreds of 
thousands of individuals with developmental and intellectual 
disabilities that wait years for services that may never come, 
so Medicare for America establishes the gold standard for long-
term services and support. We partnered with members of the 
disability community on the entire bill in order to ensure 
their needs. The resulting coverage: home health aides, 
personal attendant care services, hospice, care coordination, 
respite services, to name a few.
    We prioritized those supports and services for workforce 
development, raising the reimbursement rates for direct-care 
workers and ensuring a career pipeline, credentialing, and 
worker rights. Then, in the interim, the bill recognizes the 
central role that family caregivers play by compensating them 
for their work, because it is work. Beyond the LTSS workforce, 
Medicare for America preemptively raises reimbursement rates 
for primary care and mental and behavioral health and cognitive 
services.
    Far too many individuals face roadblocks because 
reimbursement rates are too low. Far too many providers are 
weighed down or scared off because of mounting debt and choose 
only private insurance. So Medicare for America establishes 
all-payer rate setting. Private insurance pays the Medicare for 
America rate. It all comes back to getting patients the care 
they need. That is why we ban private contracting. Current law 
allows providers to cover individuals and private coverage. 
They also talk about paying out-of-pocket for care even if 
their insurance covers the benefit. It is a two-tiered system 
that must not continue. Patients deserve to be treated fairly 
to get the care they need.
    We acknowledge the crippling of the student loan debts that 
many healthcare workers face that often leads to private 
contracting, so we say to providers: Pay our rates, see our 
patients, and we forgive 10 percent of your student loan. By 
making smart investments upfront, the American people save a 
great deal of money in the long run. At its core----
    Ms. Eshoo. Rosa.
    Ms. DeLauro. One second. At its core, Medicare for America 
is about ensuring that every American has healthcare, and as we 
debate into the future on universal healthcare coverage, my 
view: Medicare for America is the best way forward in providing 
historic change.
    Ms. Eshoo. Amen.
    Ms. DeLauro. Thank you. And thank you for inviting me.
    [The prepared statement of Ms. DeLauro follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, Congresswoman DeLauro. With all the 
energy she always brings to everything that she does, thank 
you.
    Next, we welcome and thank Congresswoman Jayapal. She is 
the sponsor of H.R. 1384, the Medicare for All Act. So you have 
your 5 minutes to present your proposal.
    Ms. Jayapal. Thank you.
    Ms. Eshoo. And thank you again for being here today. I know 
that you have Judiciary as well, so away we go.

STATEMENT OF HON. PRAMILA JAYAPAL, A REPRESENTATIVE IN CONGRESS 
                  FROM THE STATE OF WASHINGTON

    Ms. Jayapal. Thank you so much, Chairwoman Eshoo, Ranking 
Member Burgess, and Chairman Pallone and Ranking Member Walden, 
and distinguished members of the Subcommittee on Health. Thank 
you for holding this historic hearing. This is a great day.
    And let me start by saying that the Affordable Care Act was 
critically important in expanding healthcare for tens of 
millions of Americans across the country and providing 
insurance for those who had preexisting conditions, but equally 
important, the Affordable Care Act allowed Americans to dream 
of a future where everybody had the right to healthcare. And 
for us, we need to ensure that we don't stop with the 
Affordable Care Act and that we get to the place where we have 
universal care for all people in our country.
    And that is why I am so proud to have introduced, along 
with my esteemed colleague, Representative Debbie Dingell, H.R. 
1384, the Medicare for All Act of 2019. Our 119 cosponsors, 
over half of the Democratic Caucus, many of you on this 
committee, thank you for your input and your support as we 
developed this bill. This is now the fourth historic hearing we 
have had on Medicare for All in the House of Representatives, 
and that would not be possible without an enormous movement for 
Medicare for All.
    And I want to particularly recognize, quickly, a few 
groups: Physicians for a National Health Program; National 
Nurses United, who you will hear from today; Public Citizen; 
the labor coalition; the Disability Rights Coalition; and a 
racial justice coalition and a women's coalition that worked 
with us for over 6 months to develop this piece of legislation, 
I would submit, the most comprehensive and bold solution to fix 
our broken healthcare system. We simply wouldn't be here 
without their leadership.
    Our Nation's healthcare system is the most expensive in the 
world. Contemplate that. This year, we will spend almost $3.9 
trillion, or 18 percent of our GDP, on healthcare expenditures, 
and that is almost double what every other industrialized 
country in the world spends. Over the next decade, our current 
healthcare system will cost America about $55 trillion. What 
does that astronomical spending get us? The highest maternal 
and child mortality rates among our peer countries and the 
lowest life expectancy. It gets us 500,000 Americans who every 
year are forced into bankruptcy because of medical costs. It 
gets us 70 million people who still remain uninsured or 
underinsured, and that is just a bad deal.
    Why is America so far behind our peer countries? You might 
ask that. Because profit-making motives are baked into our 
system and our healthcare system incentivizes putting profits 
over patients. For-profit insurance companies with extremely 
high administrative waste stand between Americans and good 
quality, affordable healthcare. Every American knows someone, a 
loved one, a friend, a child, or a parent, who has suffered a 
healthcare crisis, and they know that the system we have 
doesn't work.
    So how do we respond to this? I think, if we really want to 
fix this, we have to do three things. First, any plan that 
proposes to fix our healthcare crisis has to cover everyone. 
Not just expand coverage for some, but cover everyone, 
guaranteed. Second, it has to provide comprehensive benefits 
and high-quality healthcare when you need it. And, finally, it 
has to take on the out-of-control costs, administrative waste, 
and for-profit motive of the current system and bring down 
costs for American families.
    Our bill, H.R. 1384, is a 125-plus-page bill, a 
comprehensive plan to lay out exactly how we get there, and it 
is the only plan that does all three of those things. Our bill 
improves the successful Medicare program that we have, but it 
expands it to cover everyone with a guaranteed government 
insurance plan, including comprehensive benefits, vision, 
hearing, dental, mental health, and of particular importance, 
long-term care for people with disabilities and older 
Americans.
    All of this with no copays, no private insurance premiums, 
and no deductibles. And because all doctors and hospitals will 
be in network, Medicare for All gives the American people more 
choice than ever before. No more worrying about a massive 
surprise bill that you might get. No more worrying about what 
happens if you have to quit your job because you are too sick 
to work. No more worrying if you want to go start a small 
business but you can't afford the cost of healthcare.
    H.R. 1384 also includes important cost-containment measures 
to ensure that we rein in health spending. It bolsters rural 
hospitals and safety-net hospitals with special provisions to 
help these hospitals stay open and thrive and have patients who 
are all insured. I want to be clear that every study, including 
the Koch Brothers' conservative study, says that we will save 
money with a Medicare for All plan.
    American families will pay 14 percent less than they 
currently pay in healthcare costs, and that is why over 250 
economists sent a letter to Congress saying that Medicare for 
All is the right plan for our economy. It is why former CMS 
Administrator under President Obama, Don Berwick, said that, 
after being the Director of Medicare for some, he now believes 
it is time for Medicare for All, and it is why 30 unions for 
the first time--don't listen to the arguments that unions don't 
want this. For the first time, 30 unions, including the major 
unions in our country, have supported this bill.
    Ms. Eshoo. Pramila?
    Ms. Jayapal. Now it is up to us.
    Ms. Eshoo. Pramila?
    Ms. Jayapal. And it is time for us----
    Ms. Eshoo. Wind up.
    Ms. Jayapal [continuing]. To pass Medicare for All.
    I am just listening to my mentor, Rosa DeLauro, who took a 
minute more--
    Mr. Shimkus. Regular order. Regular order.
    Ms. Eshoo. Yes. Yes.
    Ms. Jayapal [continuing]. To continue to say----
    Ms. Eshoo. Just wrap up.
    Ms. Jayapal [continuing]. That it is time for us to pass 
Medicare for All. Thank you, Madam Chair.
    [The prepared statement of Ms. Jayapal follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you. Thank you very much for being here 
today and testifying.
    We will now call on Congressman Brian Higgins. Welcome, 
Brian. It is wonderful to see you here, and you have 5 minutes 
to present your proposal.

 STATEMENT OF HON. BRIAN HIGGINS, A REPRESENTATIVE IN CONGRESS 
                   FROM THE STATE OF NEW YORK

    Mr. Higgins. Yes, thank you very much, Chairwoman Eshoo and 
Chairman Pallone and Ranking Member Burgess. I just want to say 
that I was a proud supporter of the Affordable Care Act, which 
will be 10 years old this March. But even the President, the 
Speaker, recognized that the passage of the Affordable Care Act 
represented a start, not a finish, and that it was highly 
imperfect in many ways, including the lack of a public option, 
to be a real countervailing force to private insurance, because 
I think by and large private insurance screws people. They jack 
up premiums. They jack up deductibles. They jack up copays. And 
then, when you go to use the insurance that you already paid 
too much for, there is very little underlying insurance.
    You know, before the Affordable Care Act, if you had a kid 
that was stuck with childhood cancer, an insurance company 
could deny you coverage because of a preexisting condition. You 
can't do that anymore. It is against the law. And the only 
Federal law that protects people with preexisting conditions is 
the Affordable Care Act. In 2010, Democrats lost control of the 
House because of healthcare; 2018, Republicans lost control of 
the House because of healthcare. We are even. Let's move 
forward.
    I want to talk about three things: complexity, cost, and 
leverage. The human body has 11 organ systems. There are 70,000 
ways that those organ systems can fail. There are 4,000 medical 
procedures. There are 6,200 FDA-approved prescription drugs. 
There are 206 bones in the human body. There are 30 trillion 
cells in 200 cell types. The human body and healthcare are 
fascinating but complicated.
    The United States Government pays $1.3 trillion for 
healthcare this year under Medicare, Medicaid, and the Veterans 
Administration, then another $360 billion in prescription 
drugs. That is a lot of money. The Federal Government pays 
about a third of the Nation's entire healthcare bill. But it is 
also a lot of leverage, and that is what I want to talk about 
today.
    All of these bills are outstanding. We need to make 
progress by using the best public option that already exists, 
and that is Medicare. Medicare has been around for 54 years. It 
is wildly popular with those who have it and those who provide 
services for those who have that as their health insurance. 
Ninety-six percent of Medicare beneficiaries have access to 
both a primary care doctor and a physician specialist, and all 
of the hospital institutions take Medicare as well.
    I have a bill that would allow people 50 to 65 to buy 
Medicare as a medical option. The Henry J. Kaiser Family 
Foundation that has done extraordinary work in this regard says 
that 77 percent of the American people support a Medicare buy-
in 50 to 65. Why that age demographic? Because this age 
demographic, 50 to 65, is to this century what the traditional 
Medicare population was to the previous century, and that is 
that private insurance had every opportunity to write policies 
for people that were older and sicker but chose not to do it. 
And a good and generous nation responded by establishing the 
Medicare program, and then all the privates wanted in on it 
when it was deemed to be profitable and successful under the 
Medicare Advantage program.
    This age demographic experiences very high preexisting 
conditions, about 50 percent. Their premiums are very high, 
their deductibles are very high, and their copays are very, 
very high. I will give you an example. A 60-year-old able to 
buy into Medicare at their own cost that will not adversely 
affect the Medicare Hospital Insurance Trust Fund, according to 
the Rand Corporation and the Henry J. Kaiser Family Foundation, 
would save 48 percent when compared to a Gold Plan on the 
individual market.
    Now Rand also said that 6 million Americans would take 
advantage of that plan. That is almost 14,000 people per 
congressional district. And I would remind you that that age 
demographic also votes, so it is good on the politics. It is 
good on the substance. I think we have an obligation to, much 
like we said 10 years ago, we need the next iteration, the next 
exciting iteration of Medicare expansion, and I believe that my 
bill should be in that conversation relative to that goal. 
Thank you very much.
    [The prepared statement of Mr. Higgins follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much. And thank you for being on 
time as well, on time with your conclusion using your 5 
minutes.
    It is a pleasure to welcome and thank Representative 
Delgado from New York to present his idea, his proposal, which 
is H.R. 2000, the Medicare-X Choice Act. So welcome and----

STATEMENT OF HON. ANTONIO DELGADO, A REPRESENTATIVE IN CONGRESS 
                   FROM THE STATE OF NEW YORK

    Mr. Delgado. Thank you. Thank you, Chairwoman Eshoo. Thank 
you, Ranking Member Burgess. Chairman Pallone. It is really 
nice to be with you all this afternoon, or this morning. I am 
pleased to see the committee considering my bill, the Medicare-
X Choice Act, and I am honored to have the opportunity to 
explain why it is a priority of mine.
    The title of today's hearing, ``Proposals to Achieve 
Universal Healthcare Coverage,'' an urgent need, indeed. We are 
the richest nation in the world and yet the only developed one 
without some form of universal coverage. If unable to qualify 
for Medicare, TRICARE, or Medicaid, Americans are left to fend 
with a system that is entirely beholden to the profit motives 
of the private insurance marketplace. As a result, millions of 
Americans are priced out of the market and left uninsured or 
have insurance but simply can't afford to take advantage of it. 
It is unacceptable.
    We have got to achieve universal healthcare coverage, and I 
believe we can get there with a public option. I promised my 
constituents I would pursue this path, and with that promise in 
mind, this spring introduced the Medicare-X Choice Act along 
with my colleagues including Representative Higgins and Larsen. 
Medicare-X establishes a public option, a government-run 
insurance plan available in the marketplace for anyone to buy 
if they are uninsured or unhappy with their current plan. The 
effect of a public competitor in the private insurance 
marketplace will undoubtedly bring down the skyrocketing costs 
of premiums and deductibles.
    The plan starts in rural areas, where coverage options can 
be scarce, and it automatically enrolls every child in the CHIP 
program. Critically, Americans who like their current plans, 
like many union members who have spent years bargaining for 
what they have now or seniors on Medicare Advantage, can keep 
them. This plan covers every American in just 3 years, but also 
attacks the underlying affordability crisis that plagues 
families across the country, an issue not discussed nearly 
enough.
    We start by, one, requiring Medicare to negotiate drug 
prices; two, increasing Federal support for those who need it 
by eliminating the subsidy cliff for Americans above the 400 
percent of the Federal poverty line and increase in the tax 
credit for those individuals below it; and three, authorizing 
30 billion over 3 years for a national reinsurance program. 
Under this bill, a family of four with an income of $101,000 
would see their premiums cut in half. We do all that without 
costing the Federal Government a dime.
    The Congressional Budget Office recently found that 
Medicare-X would actually add money to the Treasury over time. 
Medicare-X fulfills the promise of the Affordable Care Act that 
healthcare coverage will be simpler, more accessible, and more 
affordable when families can choose the plan that works best 
for them.
    Every time I have held a town hall--and I have held quite a 
few--I hear from folks about the cost of healthcare. Congress 
needs to get this done so families don't have to choose between 
paying medical bills or buying groceries. As this committee 
considers the healthcare legislative options, I hope you will 
find two main takeaways from my testimony today: more choice, 
lower costs. Two concepts I hope everyone on this panel can get 
behind.
    I thank the committee again for your time and the 
opportunity to share my priorities with all of you.
    [The prepared statement of Mr. Delgado follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. We thank the gentleman. It is a great source of 
pride to all of us that of the five that are speaking at the 
witness table this morning that Mr. Delgado and Malinowski are 
new Members of Congress. This is their first term. And you are 
a source of pride to us, and you more than hit the ground 
running with ideas. You are fresh off the campaign trail, and 
it is always refreshing to see what new people bring to the 
Congress, so thank you as a combination with the others.
    Mr. Delgado. Thank you.
    Ms. Eshoo. Now it is a pleasure to both welcome and 
recognize Mr. Malinowski for your 5 minutes to talk about your 
proposal, which is H.R. 4527, the Expanding Healthcare Options 
for Early Retirees Act.

STATEMENT OF HON. TOM MALINOWSKI, A REPRESENTATIVE IN CONGRESS 
                  FROM THE STATE OF NEW JERSEY

    Mr. Malinowski. Thank you so much for those kind words, 
Chairman Eshoo, Mr. Ranking Member Burgess. Thank you for the 
opportunity to testify today alongside my colleagues, each of 
whom have put together thoughtful proposals to get us closer to 
that North Star of universal coverage. And speaking of North 
Stars, Mr. Burgess, Joni Mitchell is Canadian, which means she 
comes from a country with lower healthcare costs and higher 
life expectancy. So I am hoping you might have her for the next 
panel to answer some of Mr. Walden's concerns. All right.
    Chairman Pallone, I also want to thank you for your 
leadership and your work with Mr. Walden, especially on the 
surprise-medical-billing issue. Let's please get that passed 
before we go home for the holidays. That would be a huge win, I 
think, for all of our constituents. I am here to talk about a 
bill that I also hope that we can find common ground on.
    My bill, the Expanding Healthcare Options for Early 
Retirees Act, would allow retired first responders--
firefighters, police officers, EMTs--to buy into Medicare 
beginning at age 50. Due in part to the physically demanding 
nature of their work, first responders often retire earlier 
than other workers and can experience gaps in coverage until 
they become eligible for Medicare. This legislation would close 
that gap. Coverage under this bill would be identical to the 
coverage provided under the existing Medicare program. Retirees 
would be eligible for tax credits, subsidies, and tax advantage 
contributions from their former employers or pension plan. 
Further, the bill specifically requires that it be implemented 
in a way that will not harm the existing Medicare program 
beneficiaries or trust fund.
    We are grateful to have the support of the International 
Association of Fire Fighters, the Fraternal Order of Police, 
the National Association of Police Organizations, the National 
Sheriffs' Association, the National Troopers Coalition, the 
International Union of Police Associations, the National 
Conference on Public Employee Retirement Systems, AFSCME, among 
other organizations. Many of their representatives are with us 
today.
    And since introducing the bill in September, my office has 
received dozens of phone calls and letters and messages from 
people all across the United States describing how it would 
help them or a family member. A person from Wilson County, 
Tennessee, wrote to us, ``This is a such a needed law. More and 
more agencies are washing their hands of insuring first 
responders when they retire. It is not a young person's job. 
And when we retire, we are damaged physically and emotionally 
and need the healthcare that eats up most of our pension.''
    A paramedic from Florida wrote, ``I am 53 and can retire in 
2 years. Healthcare has been my major concern after my 
retirement. I pray for all of you working on this proposed 
bill.''
    A paramedic firefighter from Oregon wrote, ``I was born to 
be a firefighter in the community I was born and raised in. You 
naturally never think about your body wearing out. I have had 
several Toradol and steroid shots in both my elbows, shoulders, 
and neck over my career so that I can be at work answering my 
community's calls. It would be so helpful being eligible for 
Medicare benefits when I retire.''
    A newspaper in Texas quoted the head of the Abilene Police 
Officers Association saying, ``The bill would allow us to 
retire at a good age and be able to afford healthcare. This 
affords us the opportunity to retire earlier, spend more time 
with our families, and enjoy life.''
    This is why we are here today examining how to improve our 
healthcare system so that every American can spend more time 
with our families and enjoy our lives so that we can choose a 
profession we love and to change it when we please without the 
crushing existential anxiety that comes from being uninsured or 
underinsured, without the fear that an accident or an illness 
could lead to bankruptcy.
    Now, I believe that everybody who wants Medicare--teachers, 
caregivers, coal miners, farmers, service workers, everyone--
should be able to live with the dignity and security that the 
program provides. But, as we debate how to free every American 
of the anxiety of dealing with the current healthcare system, 
let us at least do something to free the few, the dedicated and 
brave few, who risk their health and their lives to protect us.
    Thank you so very much, and I yield back.
    [The prepared statement of Mr. Malinowski follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. The gentleman yields back. And let me express on 
behalf of all of the members of the committee, both sides of 
the aisle, for not only accepting our invitation to be here 
today to describe your idea, your legislative proposal, but the 
clarity in which you have done so. We are legislators. We are 
lawmakers, and it is incumbent upon us to respect the thinking 
that goes into each person's proposal, and your thoughtfulness 
is on display this morning.
    I know that two of our colleagues have left, but my kudos 
to each of you, all five of you. So thank you for spending time 
with us here this morning, and now you can go on with the rest 
of your full schedule for the day, and the staff will prepare 
the table for the second panel of witnesses.
    And you can come--let's see. We need to change the name 
tags at the table so that they know where they are sitting. But 
can we do that with some sense of timeliness? Who is going to 
do that on the staff?
    All right, let's get to it. Maybe everyone can check their 
phones while we are waiting.
    Mr. Burgess. Are you expecting a call?
    Ms. Eshoo. No, I am not expecting a call, but people like 
to see what messages they have received.
    [Pause.]
    Ms. Eshoo. 0K. We are now going to hear from our second 
panel of witnesses on this all-important issue, and we welcome 
you. We thank you for making yourselves available to us today.
    First, Ms. Sara Rosenbaum. She is a health law and policy 
professor at the Milken Institute of Public Health at George 
Washington University. Welcome and thank you to you.
    Mr. Peter Morley, patient advocate, thank you to you, and 
welcome.
    Ms. Jean Ross, the president of the National Nurses United, 
welcome to you.
    Dr. Douglas Holtz-Eakin, president of the American Action 
Forum. It is nice to see you again, and thank you for being 
here today.
    Dr. Scott Atlas, a senior fellow at the Hoover Institution 
at Stanford University, which I have the privilege of 
representing, thank you, and it is wonderful to see you again.
    So I will now recognize Ms. Rosenbaum for your 5 minutes of 
testimony, and you can begin. I think you all know what the 
lighting system--green. When you see the yellow light speed up, 
because on the heels of the yellow light comes the red light. 
Welcome, and you may proceed.

STATEMENTS OF SARA ROSENBAUM, HAROLD AND JANE HIRSCH PROFESSOR, 
HEALTH LAW AND POLICY, GEORGE WASHINGTON UNIVERSITY DEPARTMENT 
    OF HEALTH POLICY AND MANAGEMENT; PETER MORLEY, PATIENT 
 ADVOCATE; JEAN ROSS, R.N., PRESIDENT, NATIONAL NURSES UNITED; 
 DOUGLAS HOLTZ-EAKIN, Ph.D., PRESIDENT, AMERICAN ACTION FORUM; 
AND SCOTT W. ATLAS, M.D., DAVID AND JOAN TRAITEL SENIOR FELLOW, 
            HOOVER INSTITUTION, STANFORD UNIVERSITY

                  STATEMENT OF SARA ROSENBAUM

    Ms. Rosenbaum. Thank you, Madam Chair and Ranking Member 
Burgess and members of the subcommittee for this opportunity.
    Over the past half century, Congress has pursued various 
solutions in its effort to insure all Americans, as the limits 
of what could be achieved through a voluntary employer 
insurance system became evident, especially for the elderly, 
the poor and low-income people, and people with disabilities. 
We have embraced over many years a range of solutions ranging 
from a single-payer solution in the case of Medicare to efforts 
to strengthen public and private insurance and expand our 
largest public health program, Medicaid. Much work remains to 
be done, and, of course, this work takes place against a 
backdrop of the highest-cost health system among wealthy 
nations.
    After years of progress, the number of uninsured is growing 
again, and millions more are underinsured because costs are too 
high and coverage is too limited. Using an incremental payer 
approach, the Affordable Care Act accomplished a great deal. 
Immediately before the law took effect, 44 million people were 
uninsured. By 2016, the number had dropped 26.7 million. 
Progress occurred at all income levels and in all States, but 
especially among lower-income people and, of course, in the 
ACA's Medicaid expansion States.
    Preventive coverage has improved markedly, and coverage has 
improved for children and adults with disabilities. People with 
serious health conditions have benefited from the law's 
essential health benefit rules that broadened coverage and 
limited out-of-pocket exposure while promoting actuarial value. 
Fifty-four million Americans have benefited from the protection 
against preexisting condition exclusions and discriminatory 
coverage practices. Medicare prescription drug coverage has 
improved, 2.3 million young adults have coverage through their 
parents' plans, and community health centers have doubled their 
capacity.
    But now the latest census data show that we are moving 
backwards. The percentage of uninsured Americans is growing, 
from 7.9 percent in 2017 to 8.5 percent in 2018. We are up to 
27.5 million uninsured children and adults. The Trump 
administration is championing a lawsuit that could disinsure 
over 20 million people overnight. Fourteen States remain 
without the Medicaid expansion, and over 2 million people are 
caught in this coverage gap, ineligible for Medicaid but too 
poor for tax subsidies.
    Other administration initiatives are aiming to push 
Medicaid enrollment still lower through block grants, work 
experiments, and other administration strategies. The 
administration has targeted the private insurance reforms under 
the ACA in order to erode access to higher-value policies in 
favor of what experts call ``junk insurance,'' while taking 
constant aim at the law's essential health benefit and 
affordability provisions.
    I think that we face two major challenges, one set in the 
near term and one set for longer-term discussion, and they are 
reflected in the amazing range of bills you have before you 
today and the deeper thinking that has gone on behind those 
bills. The first is to what I would call ``stanch the flow.'' 
We need steps to redouble the effort to incentivize the 
Medicaid expansion where it has not happened and people who 
depend on subsidized private insurance need more help. The ACA 
insurance market needs to be stabilized in order to promote 
affordable coverage. That is an immediate set of needs.
    In the longer term, you face bigger decisions, as you well 
know. What is the best mix of public and private insurance 
coverage? Do we preserve employer coverage? Do we maintain 
multiple programs or consolidate various public programs into 
one major alternative? If we move in this direction, should 
this program be open to employers and individuals, or just 
individuals? And should it remain--instead, should we retain 
multiple public programs with various targeting built in?
    How broad should public coverage be? Should it subsume 
long-term care? Should we use auto-enrollment to cut down on 
churn? What is the best approach to financing reform? And in 
order to achieve true health equity, do we need to think beyond 
coverage itself and also focus on community-level investments 
in order to ensure accessible healthcare and a broad continuum 
of health-promoting policies?
    Thank you very much for this opportunity.
    [The prepared statement of Ms. Rosenbaum follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you. It is so wonderful to have people 
widen the lens.
    Welcome again and thank you, Mr. Morley. You have 5 minutes 
to offer your testimony.

                   STATEMENT OF PETER MORLEY

    Mr. Morley. Sorry, OK. Sorry.
    Thank you, Chairwoman Eshoo, Ranking Member Burgess, and 
members of the subcommittee. I am honored to speak with you 
today on my 28th trip to DC since July 2017 to fight for 
healthcare.
    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 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 is 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 as well as 
millions of others. 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 
from us because an insurance company decides it is in their 
best interest not to cover something, or if Congress decides to 
repeal our insurance, or if the Trump administration sabotages 
and refuses to defend the Affordable Care Act.
    As someone who spends the majority of my waking hours in 
doctors' offices, the ACA has meant focusing on healing, not 
bankruptcy. I did not ask to be chronically ill. I used to be 
very private about my health, but once President Trump was 
elected and set 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. In the last 2\1/
2\ years, I have traveled to DC 27 times. I have collected the 
healthcare stories of thousands of people who shared their 
personal stories and concerns with me. I have held over 350 
meetings with Democratic and Republican Members of Congress 
alike. Many of you actually sit here in front of me today.
    My message is simple. If you think people don't get hurt 
when this administration doesn't defend the ACA, think again. 
We do. I do. Millions do. And if you think preexisting 
condition protections are not 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.
    This past July, I testified for the late Congressman Elijah 
Cummings. He thanked me for taking my pain, turning it into a 
passion to do my purpose. I will never forget those words. So, 
today, in the spirit of our beloved Congressman, I have an ask 
of this entire subcommittee. Please work together to make 
healthcare of all Americans your passion.
    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 DC. But I am here today to ask you to 
protect the ACA so we can enhance it and move towards universal 
health insurance for all Americans. Thank you for allowing me 
the opportunity to testify, and I am happy to answer your 
questions.
    [The prepared statement of Mr. Morley follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. What an honor to have you here. Thank you for 
your courage and your tenacity. It really is an honor to have 
you here, and we are going to do everything to help keep you 
healthy. And I will never forget your testimony and your words, 
just as you will never forget our late Elijah Cummings.
    And now it is a pleasure to recognize Ms. Jean Ross, the 
president of the National Nurses United, for your 5 minutes of 
testimony. Thank you again for being here and for what you will 
say, so you are recognized.

                     STATEMENT OF JEAN ROSS

    Ms. Ross. Good morning and thank you, Chairwoman Eshoo, 
Ranking Member Burgess, and members of the subcommittee for 
inviting me to testify today. My name is Jean Ross. I have been 
a registered nurse in Arizona for 45 years, and I am president 
of National Nurses United, the largest union representing 
bedside nurses in the United States, with over 150,000 members.
    In my testimony today, I want to illustrate two main 
points. First, our current patchwork system of public programs 
and private for-profit insurers is ineffective, inefficient, 
and financially unsustainable. Second, the only way we can 
guarantee every person living in this country receives the care 
they need is by adopting a single-payer Medicare for All 
system. Every day, nurses witness the failure of our current 
health system. I have watched as patients don't seek the care 
they need because they can't afford their copays or deductibles 
or don't have insurance. I have watched as insurers refused to 
cover the care that my patients need.
    Over many years, I cared for countless patients who showed 
up in the ER with severe illnesses only because they could not 
afford preventive care. One patient always stands out to me. He 
arrived in the ER in a hypertensive crisis. We treated him for 
an imminent stroke. I learned he was rationing his blood 
pressure medication. Instead of taking it every day as 
prescribed, he was taking it every 2 days. He knew he needed to 
take those pills daily, but he could not afford the medication 
even with his private insurance plan.
    As a nurse I have so many stories like this, but I am also 
a mother and a grandmother, and this broken system has affected 
my family too. My son, Tony, suffers from a leaky heart valve. 
For the past 15 years he has been consistently unable to afford 
the cardiology care he needs, so he just doesn't see his 
cardiologist. As a nurse, I know that this valve could lead to 
heart failure. As his mother, I live with the constant fear 
this could happen to my son because the health system I work in 
is failing him.
    My daughter is a single parent, and she struggled to pay 
the copays for my grandchildren's care. When my grandson, Evan, 
was an infant, my daughter called me because he was sick, she 
wanted my advice as a nurse. She didn't have the money to take 
him to the doctor. I told her I would pay the copay because I 
knew that Evan needed immediate attention, medical attention, 
now. Indeed, he was suffering from encephalitis, which is an 
inflammation of the brain, which can cause permanent brain 
damage and even death. I am so grateful that I had the economic 
resources to help, because if I hadn't, like so many other 
patients who don't have the means, Evan would have been in 
severe trouble.
    As a grandmother, I want to leave my grandchildren with a 
country where healthcare is a right, where they know when they 
or their children get sick, they will only have to worry about 
their health and not the cost. As a nurse for 45 years, I know 
these stories are not unique. Thirty million people have no 
health insurance, an additional forty-four million people are 
underinsured, yet the U.S. spends more money on healthcare per 
capita than any other nation in the world.
    But despite paying top dollar for our healthcare, we get 
poor results. Our country ranks poorly on many international 
health indicators, including average life expectancy, infant 
and maternal mortality, and death from preventable diseases. 
High cost and poor health outcomes persist because access to 
insurance is not the same as guaranteed healthcare for all.
    This brings me to my second point. Single-payer Medicare 
for All is the only way we can guarantee healthcare while also 
reducing the amount of money we spend on healthcare overall. 
Under Medicare for All, we will transform our profit-driven 
health system--insurance system--into a healthcare system, one 
that prioritizes patient care. Everyone will receive quality, 
comprehensive, therapeutic care without any financial barriers. 
With Medicare for All, doctors and nurses will be able to 
provide care based on our professional judgment without 
insurance company interference. We will have better patient 
outcomes, and we will save money too.
    As you consider different options to improve our health 
system, I encourage you to consider the following questions. 
Will this proposal guarantee safe, therapeutic healthcare to 
every person in the country regardless of their ability to pay? 
Will it allow people to get healthcare independent of where 
they work or if they have a job? Will it reduce administrative 
complexity and waste in the system and control costs?
    There is only one bill before the subcommittee today that 
will achieve all of these things, H.R. 1384, the Medicare for 
All Act of 2019, authored by Congresswomen Jayapal and Dingell. 
The primary responsibility of a registered nurse is to protect 
the health and well-being of her patients. In my professional 
judgment, the only way we can put our patients first, as we are 
ethically and morally bound to do, is through Medicare for All. 
I urge every Member of Congress to support H.R. 1384. Thank 
you. 1A\1\
---------------------------------------------------------------------------
    \1\ Ms. Ross' statement has been retained in committee files and 
also is available at https://docs.house.gov/meetings/IF/IF14/20191210/
110313/HHRG-116-IF14-Wstate-RossJ-20191210.pdf.
---------------------------------------------------------------------------
    Ms. Eshoo. Thank you, Ms. Ross.
    It is now a pleasure to recognize Dr. Holtz-Eakin, who is--
you are recognized for your 5 minutes of testimony, and thank 
you again for joining us today.

            STATEMENT OF DOUGLAS HOLTZ-EAKIN, Ph.D.

    Mr. Holtz-Eakin. Chairwoman Eshoo, Ranking Member Burgess, 
and members of the committee, thank you for the privilege of 
being here today to discuss these proposals for progress 
towards universal coverage, which is, indeed, a very important 
goal for the United States. The proposals fall into two broad 
categories, as you have heard. Some are like Medicare for All, 
sweeping single-payer reforms which would cover everybody in 
the United States, and then a series of more targeted reforms 
that take the character of Medicare buy-ins, Medicaid buy-ins, 
and then public options, and I want to discuss them in turn.
    The proposal for Medicare for All is a truly sweeping 
reform unlike any single-payer elsewhere on the globe. Other 
single-payers do not ban private insurance, indeed, often 
supplement it; do not eliminate a role for regions and States, 
but often rely on them to deliver their healthcare and their 
insurance. They don't eliminate copays and other incentives for 
individuals to utilize care effectively. And in one case, 
Britain, they actually own and operate the hospitals. In this 
case, that no such thing goes on.
    So this is not something where you can say we are going to 
get something that looks like something elsewhere in the world. 
This is like nothing else that has ever been proposed, and it 
has embodied in it, inevitably, some serious tradeoffs. Among 
them will be the tradeoff between covering folks in this manner 
and access to care and the quality of that care.
    In the data, it is quite clear that, as hospitals try to 
reach higher-quality goals, they can be more successful the 
larger the fraction of commercial payers they have in their 
patient base. That relationship between the rate of 
reimbursement and the quality of the care is quite strong and 
important in the research. These proposals would diminish the 
rate of reimbursement for hospitals and thus would inevitably 
degrade the quality of that care.
    In the extreme, one would worry that the reimbursements 
would be so low that hospitals could not actually be able to 
remain open and thus diminish access to care entirely, which is 
obviously counter to the basic intention, but it is something 
that needs to be dealt with in these proposals. The easiest way 
to deal with it, of course, is to reimburse at higher rates, 
but that is going to be extraordinarily expensive. As proposed, 
the Medicare for All is on the order of 30 trillion expense, or 
32, 35, get in that ballpark. To give you a flavor for what 
that means as a matter of public finances, if you were to 
finance that in the traditional fashion of Medicare with a 
payroll tax, you would need to have a 21-percentage point 
increase in the payroll tax, according to a Heritage Foundation 
study.
    And in doing that, the additional payroll taxes would 
outweigh the savings and health premiums for two-thirds of 
American households, so they would financially be worse off by 
the imposition of this proposal. And to what end? The goal, 
obviously, is universal coverage, but if you look at the 30 
million-odd uninsured individuals in America, half of them are 
already eligible for an important public program, the ACA, 
Medicaid, or CHIP. Others are turning down an offer for 
employer-sponsored insurance. They have been offered that.
    Indeed, if you can identify the group that, really, you 
might be able to get, it is about two and a half million 
individuals who are relatively low income and did not reside in 
a Medicaid expansion State. Is it worth overturning the 
enormous heterogeneity and rich complexity of the U.S. 
healthcare system for two and a half million individuals? There 
has got to be a better way to do that.
    Some of the other approaches are more targeted. So, for 
example, there is a Medicare buy-in proposal that you heard 
Congressman Higgins describe. We have taken a look at that at 
the American Action Forum, the think tank that I run, and in 
our estimate that bill would get about 293,000 Americans to buy 
a Medicare buy-in the first year. By the end of 10 years, it 
will be down to about 170, 187,000 individuals.
    To the extent that there are increases in coverage from 
that bill, it comes from adding additional funding to the 
existing ACA channels. But even with $180 billion in additional 
Federal money, total coverage only rises by about 500,000 
individuals. So we have these two approaches, a sweeping 
turnover of the American healthcare system to little gain, and 
some approaches that are targeted but probably not very 
effective.
    And so, I would encourage the committee to continue to 
search for ways to get to universal coverage, but these don't 
appear to be the way to go. I thank you and look for the chance 
to answer your questions.
    [The prepared statement of Mr. Holtz-Eakin follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you for your testimony.
    It is a pleasure to welcome Dr. Atlas, and you have 5 
minutes to present your testimony.

                 STATEMENT OF SCOTT ATLAS, M.D.

    Dr. Atlas. Thank you, Chairwoman.
    Ms. Eshoo. Thank you again for accepting our invitation to 
be here.
    Dr. Atlas. OK. Thank you, Chairwoman Eshoo, Ranking Member 
Burgess, and members of the committee for the opportunity to 
speak today. The overall goal of U.S. healthcare reform should 
be to broaden access for all Americans to high-quality medical 
care and not simply to label them as insured. The notion that 
single-payer healthcare represents a goal for health system 
reform is mainly driven by the attractiveness of a simple 
concept: the government explicitly ``guarantees'' medical care.
    In England, the NHS constitution explicitly states ``you 
have the right to receive NHS services free of charge,'' 
despite taxing citizens $160 billion per year. The opposition 
to single-payer care, though, should not focus only on massive 
new taxes that will be required, but instead on the well-
documented half century of its failure in the medical 
literature to provide timely, quality medical care. The truth 
is that single-payer systems--including in the U.K., Canada, 
Sweden, and other European and Nordic countries--impose 
shockingly long waiting times for doctor appointments, 
diagnostic procedures, drugs, and surgery that are virtually 
never found in the United States specifically as a means of 
rationing care.
    Indeed, the Supreme Court of Canada in the 2005 Chaoulli 
decision, famously stated ``access to a waiting list is not 
access to healthcare.'' Barua calculated that over a 16-year 
period, over 44,000 additional Canadian women died due to 
Canada's imposed wait times for medically necessary care. In 
England alone, a record 4.2 million patients are on NHS waiting 
lists, a hundred thousand of whom have been waiting for more 
than 6 months for treatment after receiving their diagnosis.
    The average Canadian woman--maybe not Joni Mitchell--waits 
5 months for her GP visit to her treatment by her gynecologist. 
In the U.K.'s single-payer system, more than 19 percent of 
those referred for ``urgent treatment for cancer'' wait more 
than 2 months for their first treatment. In Canada, almost 8 
months for brain surgery after seeing the doctor. These long 
waits are the defining feature of all single-payer systems, and 
they stand in stark contrast to U.S. healthcare.
    Waiting lists are not a feature in the United States, as 
stated by the OECD and verified by numerous studies. Even for 
low-priority checkups, U.S. wait times are far shorter than for 
seriously ill patients in countries with single-payer care. 
Single-payer systems also restrict the availability of new 
drugs, including cancer drugs, sometimes for years. Of the 
world's 54 new cancer drugs from 2013 to 2017, by 2018, 94 
percent were available for Americans, for Brits 70 percent, in 
Canada 53 percent, in France 43 percent, in Australia 28 
percent.
    These long waits have major consequences. In the medical 
literature--not anecdote--worse health outcomes than the U.S. 
system from cancer, heart disease, stroke, hypertension, 
diabetes. Why would Americans voluntarily move toward a system 
proven worse than current U.S. healthcare? Americans should 
also ask why the U.S. would move towards single-payer care when 
every other country with decades of that experience now use 
private care to solve their failures.
    Governments in Finland, Ireland, Italy, the U.K., The 
Netherlands, Norway, Spain, Sweden, Denmark--all with single-
payer care--spend taxpayer money now, sometimes even outside 
their own country, on private care to solve their 
unconscionable failures. Americans should also wonder why those 
with financial means spend even more money than their already 
high taxes for something that is ``guaranteed and free.'' Half 
of all Brits earning more than 50,000 pounds now buy or plan to 
buy private insurance. Here is the reality: Only the poor and 
lower middle class are stuck with nationalized single-payer 
healthcare because only they cannot afford to circumvent the 
system.
    Those who advocate a conversion to Medicare for All fail to 
acknowledge this widely published evidence in the world's top 
medical journals, and they fail to acknowledge that continued 
access to care is already at risk according to the Actuary of 
CMS who calculated that most hospitals, nursing facilities, and 
in-home healthcare providers already lose money per patient 
with Medicare. And they fail to acknowledge this, that about 70 
percent of seniors choose to rely on private insurance 
supplementing or replacing traditional Medicare coverage. Why 
would beneficiaries need that if pure government insurance was 
so satisfactory?
    What is wrong with offering government insurance as an 
option? Because government insurance expansions only erode or 
crowd out private insurance. The public option is not a 
moderate or compromised proposal. It is simply a more insidious 
pathway to single-payer healthcare where only the affluent 
could afford to circumvent that.
    Contrary to the false guarantees, the only valid guarantees 
from single-payer healthcare is worse healthcare for Americans 
and higher taxes. Rather than compelling Americans to accept an 
inferior government-run system that literally restricts medical 
care to regulate cost, why not focus on creating conditions 
long proven to bring down prices while simultaneously improving 
quality in every other good or service in the United States?
    Incentivizing empowered consumers to seek value for their 
money with cheaper, broadly available, higher-deductible care 
less burdened by regulations; markedly more valuable expanded 
health savings accounts; tax reforms to eliminate 
counterproductive incentives; and then coupling that with 
strategic increases by deregulation and breaking down anti-
consumer barriers to competition in the supply of doctors and 
hospitals.
    These reforms would permit all Americans, rich or poor, to 
access the same excellence of medical care that the affluent--
including some of the most strident advocates for single-payer 
care for the rest of us--all use for their own personal 
healthcare. Thank you. 1A\1\
---------------------------------------------------------------------------
    \1\ Dr. Atlas' prepared statement has been retained in committee 
files and also is available at https://docs.house.gov/meetings/IF/IF14/
20191210/110313/HHRG-116-IF14-Wstate-AtlasS-20191210.pdf.
---------------------------------------------------------------------------
    Ms. Eshoo. Thank you.
    Now we will--we have concluded the witnesses' opening 
statements, and we will move to Member questions, so I am going 
to recognize myself for 5 minutes for questions.
    Now we have, obviously, the whole span of what, thinking, 
on public and private health insurance and that has been 
expressed rather eloquently by each witness. I am taken with 
the following, and that is that the percentage of people that 
still are not insured in our country. I don't understand why 
people that are eligible are not enrolled. It is such a loss 
because they are subjected to all of the things that we know--
Mr. Morley, you spoke to them and that they are not enrolled, 
that is a whole other issue--but at 6.8 million people in our 
country.
    Now, in terms of the ACA, we have brought the percentage of 
uninsured down, so--but we need to always remember that there 
were 14 States where Governors denied their own constituents 
the coverage that they were entitled to where the Federal 
Government for 5 years was picking up the full tab.
    I would like to hear from each one of you--and I am sorry 
to say this, Dr. Atlas, but I think that you don't agree with 
anybody on the panel, but you can try to answer the question. 
You may have----
    Dr. Atlas. I will give it a shot.
    Ms. Eshoo [continuing]. Something that you like somewhere. 
But for each one of you, in terms of the thoughtful proposals 
that have been put forward by the nine Members of Congress, 
what do you think will best help to achieve universal 
healthcare in our country? So I will start with Ms. Rosenbaum.
    Ms. Rosenbaum. Thank you very much.
    Ms. Eshoo. And everyone be brief. You have 3 minutes to 
answer that, and that will be my only question. But I am 
curious to hear from each one of you what fits with your 
thinking.
    Ms. Rosenbaum. Thank you. So, if you look at the number of 
people in the United States who are not enrolled but who are 
eligible for something, the overwhelming majority will tell you 
that they can't afford it. And getting to affordable quality 
coverage, of course, is a very complicated thing to do. I think 
the reality for this country over the past half century has 
been an employer system that was limited in its reach to begin 
with. It worked very well and continues to work well for people 
who are in a position----
    Ms. Eshoo. But what do you think? I mean, my question is 
very specific.
    Ms. Rosenbaum. Right.
    Ms. Eshoo. Of the nine proposals, is there anything--given 
your background, research, all that you know--that you think 
would best help us achieve universal healthcare in the country?
    Ms. Rosenbaum. Yes. I think, because of the backdrop, there 
has got to be some combination, and it may change over time, of 
a strong public insurance option coupled with potentially 
private insurance option for people who have good comprehensive 
coverage.
    Whether you ever take the next step----
    Ms. Eshoo. Thank you. Thank you. But we need to get to the 
others, all right. And you are going to have the opportunity to 
tell me more with written questions that will be submitted to 
all the witnesses.
    Mr. Morley?
    Mr. Morley. Thank you for asking this question. I just have 
to say I have, you know, the majority of my advocacy has been 
defending the Affordable Care Act, so----
    Ms. Eshoo. Thank you for that.
    Mr. Morley. You are so welcome. But I have very limited 
opportunity to think proactively, but I take my cues from 
Congresswoman Schakowsky, all of them. I support all of them. 
Anything that is going to get us access, to increased access, I 
believe in all of them.
    Ms. Eshoo. You are so beautiful.
    Ms. Ross, we already know where you are, right? But if you 
want to restate it.
    Ms. Ross. I would like to start by saying that we have 
always been very appreciative of the ACA, very appreciative.
    Ms. Eshoo. Oh, and we appreciate what the United Nurses did 
in that effort, certainly.
    Ms. Ross. Because it moved us so much closer to making sure 
that everyone got care. Now we need to take the next step. It 
won't do it anymore, not as long as private insurers are 
involved.
    Ms. Eshoo. OK.
    Ms. Ross. We have to eliminate barriers to care and, 
really, Medicare for All is the only one that will do that.
    Ms. Eshoo. Thank you.
    Dr. Holtz-Eakin?
    Mr. Holtz-Eakin. Yes, I would say two things. First, I want 
to echo the importance of genuine delivery system reforms to 
make whatever gains in coverage you achieve sustainable, 
because they just won't stay unless we do that. It is why I am 
very worried with the Medicare for All. That is going backwards 
to fee-for-service medicine, which this committee with MACRA 
recognized was not the way to go.
    In terms of the low-hanging fruit, there is a report out 
today that there are 4.7 million people who could sign up for a 
zero-premium Bronze Plan today, so it can't be cost. There is 
something else going on. Cover those people.
    Ms. Eshoo. Thank you very much.
    Dr. Atlas. Yes, I mean the disconnect, in my view and with 
my proposal, is that the goal is not to label someone as 
insured. The goal should be to bring the cost of medical care 
down. And when you bring the cost of medical care down, 
insurance premiums come down because 80 percent of insurance 
premiums are due to cost of care, and all government outlays 
for programs for healthcare are much less, and by that way you 
broaden access to care.
    So the way to do that is to empower patients by putting 
them in the driver's seat in controlling the money, to getting 
rid of the regulation that has falsely stopped competition----
    Ms. Eshoo. Yes, I appreciate it, and it reflects your 
original testimony.
    And I should just announce that December 15th is the 
deadline for enrollment, so whomever is listening in--if it is 
C-SPAN and everyone else--we are talking about insurance, 
affordable coverage, everyone understand, December 15th.
    And now I would like to recognize--thank you, witnesses, 
for answering my question. Now it is a pleasure to recognize 
the ranking member, the gentleman from Texas, Mr. Burgess, for 
his 5 minutes of questions.
    Mr. Burgess. Thank you.
    And, Dr. Atlas, let me just give you a few minutes to wrap 
up what you were saying, or a few seconds to wrap up what you 
were saying.
    Dr. Atlas. Yes. Well, the basic plan should be to get 
people to be incentivized to save money on healthcare by higher 
deductibles, paying more directly, cheaper insurance, and 
therefore care about the cost of care to increase the supply of 
competitors for that money, and to get rid of the, really, 
incorrect incentives in the current tax code that make people, 
incentivize people to spend more on healthcare.
    That is the way everything in the United States gets 
reduced price with higher quality. That is exactly how it 
works, and it can work with healthcare, as we have evidence 
that it does.
    Mr. Burgess. Well, and I thank you for your observations. I 
thank you for your testimony. It was some of the most 
interesting I have read in a while.
    Dr. Holtz-Eakin, can you talk somewhat about the--well, I 
guess the phenomenon is cross-subsidization. Currently, the 
current Medicare system does not reimburse for the cost of the 
care so that cost, that delta, is covered by generally 
employer-sponsored insurance or individual insurance. Can you 
speak to that? What would happen in a world where there was no 
longer the ability for that cross-subsidization?
    Mr. Holtz-Eakin. I am deeply concerned about that in these 
proposals, (A) because there is evidence that many institutions 
have negative Medicare margins. They lose money seeing a 
Medicare beneficiary. Proposals that would move everyone to 
Medicare levels of reimbursement or something close to that run 
the risk of turning everyone into that position, and that risks 
cutting off access to care entirely, particularly if you have a 
single rural hospital. It can't pay the bills. That is a 
concern to me.
    The importance of that level of reimbursement for things is 
brought home by some of the work the administration did on 
international drug prices where the attention was that drugs 
are cheaper elsewhere. But what was not caught in that proposal 
was that, of the 27 most expensive drugs that Medicare patients 
in the United States get and use, only 11 were available in all 
of the other 16 countries that were studied.
    If you don't reimburse at adequate levels, people do not 
get access to modern care. That is what I am concerned about. 
Getting rid of the commercial subsidy runs that risk.
    Mr. Burgess. And, of course, as you know, I spent years of 
my life trying to get rid of a Medicare formula called the 
sustainable growth rate formula and----
    Mr. Holtz-Eakin. Congratulations.
    Mr. Burgess [continuing]. The effect of that, of course, 
was to limit the number of providers who would--I mean, one of 
the questions I got at town halls when I first became a Member 
of Congress was, How come you turn 65 and you have got to 
change your doctor? And the answer was because their doctor was 
no longer taking Medicare, was not a participating physician 
because of the ratcheting down of reimbursement rates that 
happened automatically every year, year in and year out.
    Dr. Atlas, if you could--and you didn't mention it in your 
oral testimony--but in your written testimony you talked a 
little bit about the difference in infant mortality rates--
United States, other parts of the world--and I think the 
statement that you have is about how in the United States the 
effort to save some of the most premature infants is different 
from other parts of the world.
    Some people would argue, well, maybe that is not a 
worthwhile activity. But I will just tell you, in 1976, I am in 
medical school and a neonatal intensive care unit was unheard 
of, and today every good-sized hospital has one, so our ability 
to take care of those infants has increased because of that. I 
just wonder if you had any thoughts on that.
    Dr. Atlas. Yes, I do. I think this is very important vis-a-
vis what has been said about both life expectancy and infant 
mortality. These statistics are very coarse and poorly 
calculated numbers, and I will give you the specific reason 
why. Infant mortality, for instance, is not a valid indicator 
at all because, when you look at the way it is calculated, the 
European countries--the United States counts every live birth 
as a live birth with one heart rate, one heartbeat, one 
respiration. That is WHO criteria. When you look at countries 
in Western Europe who are so-called pure nations, some of them 
don't count infants as having been born unless they are a 
certain gestational age or unless they survive 24 to 48 hours. 
They don't count the babies who died as having been born if 
they don't live that long.
    So you can imagine, in a fraction, if you change the 
denominator you have a totally invalid statistic. This is 
documented in the peer-reviewed medical literature. This is not 
my assertion.
    Same thing with life expectancy, although a little bit 
different. Most of the deaths in young people in the United 
States are not even due to illness. Immediate gunshot wound to 
the head in murder is not a reflection of healthcare quality, 
OK. And when you look at, for instance, lifestyle behavior is 
very different in the U.S. than other countries. Forty percent 
of the difference in life expectancy between the U.S. and other 
countries is due to one lifestyle behavior: obesity.
    If you standardize for these things, you see these 
statistics are not meaningful. That is why, to me, the best way 
to sort of compare health systems is to look at outcomes in 
diseases.
    Ms. Eshoo. It is hard for me to cut people off, but you 
are----
    Dr. Atlas. I am sorry there are too many facts, but----
    Mr. Burgess. A lot of facts.
    Ms. Eshoo. Yes.
    Mr. Burgess. But, just before I yield back, I would like to 
ask unanimous consent to add to the record a letter from the 
Texas Hospital Association and the American Hospital 
Association.
    Ms. Eshoo. So ordered, happy to place it in the record. 
Thank you. The gentleman yields back.
    Now it is a pleasure to recognize the chairman of the full 
committee, Mr. Pallone.
    Mr. Pallone. Thank you, Chairwoman. I should thank you for 
having this hearing. I was one of the drafters of the ACA and 
obviously very proud of that fact, and I do believe that the 
ACA could have and still can achieve almost universal coverage. 
I mean, the idea was that, you know, 65-some percent of the 
people get their insurance through the employer, and then we 
had this large group of people who buy insurance individually 
on the marketplace but can't afford it, so the idea was to try 
to make it affordable, and that is where the subsidies came in.
    And the mandate, you know, the idea of the mandate was 
that, you know, we will give them enough of a subsidy so they 
will buy insurance rather than paying a penalty to not buy it. 
But there were still two groups that were still out there even 
with that scenario, one where those who wouldn't be able to pay 
a premium--and that is why we wanted to expand Medicaid--and 
then the last group were the uninsured--I mean, I am sorry, not 
the uninsured, the undocumented, which as far as I am 
concerned, you know, we should have addressed and we had a 
debate, but we couldn't get the votes.
    So I wanted to ask Ms. Rosenbaum, you know, with regard to 
the Medicaid expansion, you know, it was not supposed to be 
optional under the ACA, but the Supreme Court holding in NFIB 
v. Sebelius said they had a choice whether to expand or not, 
and if all of the States were willing to put aside this 
partisanship and act in the best interest of their residents, I 
think we would be much closer to the goal of universal 
coverage.
    So let me quickly, because I want to get to the 
undocumented, can you tell us as of today how many States have 
expanded Medicaid?
     Ms. Rosenbaum. Everybody but 14. A couple are still on the 
verge of phasing in, but there are 14 left.
    Mr. Pallone. OK. And for those States that expanded 
Medicaid, you know, they got a pretty generous deal in terms of 
how much of that cost is paid for by the Federal Government, 
correct?
    Ms. Rosenbaum. Yes.
    Mr. Pallone. And Congressman Veasey's bill that we are 
considering today, the Incentivizing Medicaid Expansion Act, 
would make that offer even more generous, correct?
    Ms. Rosenbaum. Yes.
    Mr. Pallone. So, if all States were to expand Medicaid as 
originally intended by the ACA, how many people do you think 
would gain coverage that don't have it now?
    Ms. Rosenbaum. We are at about 15 million now. It is 
roughly another 2 million people, a little more than 2 million 
people.
    Mr. Pallone. OK. Now do you want to--and not open-ended, 
because I want to get to the undocumented--but would you give 
me any sense of why you think these States are still rejecting 
the Medicaid expansion? Is it strictly ideology? What is it, do 
you think?
    Ms. Rosenbaum. This has been looked at a lot. I would say 
it is a deep philosophical opposition to the expansion. Cost 
certainly doesn't explain it. The Federal financing doesn't 
explain it, even at the current rate. So I would say we are 
dealing with something deeper.
    Mr. Pallone. Ideological, all right.
    Now let me get to the undocumented. You know, we know that 
a large portion of this country's uninsured rate comes from 
undocumented individuals. What would you--like, if we covered 
all the undocumented, what, you know, what do you think 
percentage-wise that would mean?
    Ms. Rosenbaum. Well, I mean, that would be universal 
coverage, their proposals that are universal up to legally 
present immigrants and also that address the short-term, the 
people who have been here for less than 5 years.
    Mr. Pallone. Well, let me put it to you this way.
    Ms. Rosenbaum. But undocumented----
    Mr. Pallone. Let's assume that everybody who was----
    Ms. Rosenbaum. Yes.
    Mr. Pallone [continuing]. Legally here, documented, had 
insurance coverage. I think we--would it be accurate to say we 
would still maybe be only at 95 percent because there would be 
another 5 percent that are undocumented? I mean, I know that is 
a huge----
    Ms. Rosenbaum. Right. No, and it is not a good thing for 
any healthcare system to leave anybody out, in my opinion.
    Mr. Pallone. OK. But would you agree, you know, even if 
everyone was covered who is legal, you would probably still 
have another 5 percent of the total population that is not 
covered because they are undocumented.
    Ms. Rosenbaum. Yes. Yes.
    Mr. Pallone. OK. So, I mean, I agree with you. It doesn't 
make any sense. You get sick, you spread disease. I mean, what 
are we talking about here? It is, you know, you can't operate 
in isolation, so, I mean, those undocumented people obviously 
have healthcare needs. How do they get that care, and what cost 
does that add to our system? How is this--does this make any 
sense--I don't think so--to not cover the undocumented in terms 
of the cost to our system and how we operate?
    Ms. Rosenbaum. Those who are willing to come forward use 
isolated public health services. In extreme situations they 
would turn to an emergency department, but the care is uneven, 
too late, and too many people live in the shadows, really, 
without any healthcare at all. There are no waiting lists for 
people who are uninsured.
    Mr. Pallone. But also doesn't it just not make sense from a 
cost point of view, because if those people got preventive care 
and were able to see a doctor, they wouldn't end up in the 
hospital emergency room because they wouldn't get as sick. I 
mean, do you want to comment on that?
    Ms. Rosenbaum. Absolutely. And it is very difficult to 
begin to quantify these kinds of shifts, but very important to 
bring everybody in to deal with health problems before they 
become serious enough to be high cost.
    Mr. Pallone. All right, thank you so much. Thank you, Madam 
Chair.
    Ms. Eshoo. The gentleman yields back. It is a pleasure to 
recognize the gentleman from Illinois, Mr. Shimkus, for his 5 
minutes of questions.
    Mr. Shimkus. Thank you, Madam Chairman, and I appreciate 
the hearing and I appreciate the people in the healthcare 
sector because this compassionate, trying to do the right 
thing, even those who are trying to make sure we can pay for it 
adequately, we are on it for the right reasons.
    You know, I was here when we passed Medicare Part D. It was 
helpful. I was here when we did expansion of Medicare 
Advantage, very helpful. So--but numbers and budgets and 
dollars matter. So, Dr. Holtz-Eakin, what happens with the 
hospital insurance, HI Trust Fund in 2026?
    Mr. Holtz-Eakin. At that point it will be exhausted and----
    Mr. Shimkus. What does that mean, ``exhausted''?
    Mr. Holtz-Eakin. It means that the payments out to 
hospitals will have cumulatively exceeded the payroll taxes 
that go in, and at that point there will not be the legal 
authority to reimburse for care.
    Mr. Shimkus. Can you say that again?
    Mr. Holtz-Eakin. At that point it will be illegal for you 
to reimburse hospitals for their care to Medicare 
beneficiaries. They will have to do it, but----
    Mr. Shimkus. So how do--by adding more people to Medicare, 
how does it help solve this 2026 funding problem?
    Mr. Holtz-Eakin. It would not help solve. That would 
increase the outflow without raising the inflow.
    Mr. Shimkus. So it actually would create an insolvency much 
sooner.
    Mr. Holtz-Eakin. Yes.
    Mr. Shimkus. And, Dr. Atlas, you identify this in your 
testimony, kind of, on your Figure 3 here in your statement. 
And this is no different than our problems with Social 
Security: Workers today pay for Medicare for our retirees. That 
more people are retiring and living longer, it is financially 
unsustainable. Is that what you are trying to say here on this 
Figure 3?
    Dr. Atlas. Yes. What figure you are alluding to shows that 
the number of workers funding per Medicare beneficiary started 
out when the program started at 4.6, and now it is about 2-
point-something. And so, when you have not enough people 
working to fund the program at the same time as this explosion 
of an aging population and actually a positive of people living 
longer, living longer also means incurring more medical 
expenditures because older people have these----
    Mr. Shimkus. Well, let me reclaim my time, and I appreciate 
that. So I want our friends here to understand that there is a 
funding crisis. I have said it for 20 years. Someday, someone 
is going to believe us, that there is a funding problem on 
Social Security, there is funding problem with Medicare.
    And we are part of the problem on Medicare, because who in 
this room--who doesn't get visited by people saying the coding 
for fee-for-service is screwed up, pay us more, right? Who 
doesn't get visited by folks here in the audience who say we 
are not compensated enough, right? And that is going to 
continue.
    Let me ask a question to both of you, Dr. Holtz-Eakin and 
Dr. Atlas, what happens when a new product comes to market 
under Medicare for All?
    Mr. Holtz-Eakin. It is not clear.
    Mr. Shimkus. OK. And we are talking about this too. We have 
this big H.R. 3 drug debate about, well, maybe 10 new 
blockbuster drugs won't get to market, some estimates are a 
hundred. If you are the patient who is looking for that 
lifesaving new drug, you want to be able to get it. And it is, 
I think, the countries that we have talked about who have 
single-payer systems, their actuary--not actuary, but their 
listing--it takes a long time for new products to come on the 
market, is that correct?
    Mr. Holtz-Eakin. That is absolutely correct. In the U.S. of 
new brand-name drugs, new therapies becoming available, 95 
percent are available in 3 or 4 months. That number is about 
half that size elsewhere.
    Mr. Shimkus. Right. And Medicare Advantage under Medicare 
for All, what happens to that?
    Mr. Holtz-Eakin. It is gone.
    Mr. Shimkus. It is gone.
    Let me finish with this. I am from rural America. A lot of 
our hospitals are not-for-profit, faith-based institutions and 
who do their best to cover folks.
    Madam Chairman, I would like to submit two letters for the 
record from the National Right to Life Committee, April 29, 
2019, and the March for Life Action, and whenever you are 
willing to do that, and I know you may want to look at it.
    But I want to read a statement: ``There are certain key 
details of this legislation that would mean dramatic and 
radical departure from longstanding abortion-related policy. 
The legislation would require government funding of abortion 
without limitation and also likely would require unwilling 
hospitals and doctors to perform abortion procedures.''
    When you go into a government system and you don't have 
choice, you have to play by the rules.
    And, Madam Chairman, I would like to submit those two, and 
I yield back my time.
    Ms. Eshoo. I will review them and advise the gentleman as 
to whether they will be placed in the record.
    Mr. Shimkus. Thank you.
    Ms. Eshoo. OK, it is a pleasure to--the gentleman yields 
back. It is a pleasure to recognize our colleague, Mr. Engel 
from New York, for his 5 minutes of questions.
    Mr. Engel. Thank you, Madam Chair, and I have a lot to get 
in. I am going to see if I can do it all, but let me first say 
healthcare continues to eat a growing share of every American 
family's income. We know that from years of watching this and 
also from the testimony today.
    The trend is reflected by the healthcare sector consuming 
an increasing portion of our Nation's GDP. In 2016 it has 
accounted for 18 percent of our GDP, but in 2026 it will jump 
to 20 percent, and that trend is unaffordable and 
unsustainable. And every day, like my colleagues, I hear 
heartbreaking stories from my constituents about how families 
are having to choose between paying for lifesaving healthcare 
and other necessities such as groceries.
    So I am pleased to be an original cosponsor of the Medicare 
for All Act and a founding member of the Medicare for All 
Caucus. This legislation will improve and expand Medicare for 
all Americans and will provide new benefits, including dental, 
vision, and hearing, all without copays, premiums, and 
deductibles. As I have said many times before, healthcare is a 
human right, and I believe that H.R. 1384 will help every 
American access high-quality healthcare.
    Ms. Ross, let me ask you, could you please describe how 
Medicare for All will save money and put our Nation's 
healthcare expenditures on a sustainable financial footing?
    Ms. Ross. I think the biggest savings in Medicare for All 
will come from administrative costs, because right now there 
are so many different plans to administer. Nurses and doctors 
just want to care for their patients. That is their main goal, 
so without the interference of those insurance companies we can 
actually do that. So you have got the lowering of the 
administrative costs. You have got accurate budgeting which we 
have not had before that is actually sustainable.
    Mr. Engel. Thank you.
    Madam Chairwoman, I would like unanimous consent to submit 
into the record a letter in support of H.R. 1384 from 253 
leading economists discussing how this bill will reduce 
healthcare costs while guaranteeing every American access to 
comprehensive care.
    Ms. Eshoo. So ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Engel. Thank you. Let me also say again, Madam Chair, I 
want to thank you and Mr. Pallone for holding today's important 
hearing.
    The ACA, the Affordable Care Act, which I helped author, I 
was on this committee when we tried so hard, first to get 
everyone covered and then--for a public option--we didn't have 
the votes. But the ACA has enabled over 20 million Americans to 
become covered, including a hundred thousand of my 
constituents, and yet despite this remarkable progress, the 
Trump administration is taking actions to gut the ACA, 
including promoting junk plans and curtailing outreach 
programs. This committee has led the charge to reverse this 
sabotage through legislation such as the Strengthening 
Healthcare and Lowering Prescription Drug Costs Act, and I want 
to thank Chairwoman Eshoo for her hard work with that.
    With that said, we must continue to build on the ACA's 
success, and two of the bills before us today introduced by New 
York, my colleagues in New York, Brian Higgins and Antonio 
Delgado, would create public options to help improve access to 
coverage. Let me ask Ms. Rosenbaum, how would a public option 
as envisioned by the bill as drafted by Congressmen Higgins and 
Delgado help strengthen the ACA marketplaces?
    Ms. Rosenbaum. What they would do is introduce a 
competitive alternative to private plans for especially 
vulnerable older Americans, whose healthcare costs are quite 
expensive, relatively speaking. This would give them a more 
affordable way to buy care.
    Mr. Engel. Thank you.
    And, finally, Mr. Morley, I have a question for you because 
I want to thank you for coming from my hometown, New York City, 
to testify. One of the hallmark features of the ACA is that it 
prohibits health insurance companies from discriminating 
against Americans living with preexisting conditions such as 
diabetes. The Center for American Progress estimates that 
nearly 311,000 of my constituents below the age of 65 have a 
preexisting condition, and the Trump administration's efforts 
to weaken these protections through regulatory actions 
jeopardize the health coverage of my constituents.
    So I want to thank the leadership of Members like 
Congresswoman Kuster who authored the Protecting Americans with 
Preexisting Conditions Act. The House is fighting back against 
these policies. So, Mr. Morley, could you describe the impact 
that eliminating the ACA's protections for preexisting 
conditions would have on your ability to access healthcare 
services?
    Mr. Morley. It wouldn't just obviously be mine, it would be 
for 130 million Americans so I can't really speak for myself on 
that. I think the stress of all the sabotage that has been done 
by the Trump administration has been really overwhelming at 
times. I have lost a lot of sleep, as I am sure a lot of people 
have. That is the number one concern I hear from people.
    But limiting my access to care, insurance companies can go 
back to discriminating against me. And, as I stated in my oral 
testimony, you know, I have experienced that already, and it 
has cost me tens of thousands of dollars. And I had the ability 
to work at that point in my life, and I don't have the ability 
to work anymore, so there is no way that I could pay for that. 
I have monthly infusions. Each one of my infusions for my lupus 
costs $10,000, and there is no way I could pay for that.
    Mr. Engel. Thank you. Thank you, Madam Chair.
    Ms. Eshoo. The gentleman yields back.
    I just want to add something to what the gentleman from New 
York said relative to the ACA and the public option. The House 
passed that. It was the Senate that fell short on--we all feel 
strongly about it because we fought so hard and we achieved 
what we wanted to achieve in the House, but I think it is 
important to have that as part of the record.
    It is a pleasure to recognize the gentleman from Missouri, 
Mr. Long, for his 5 minutes of questions.
    Mr. Long. It is a pleasure to be recognized by my buddy, 
the Madam Chairwoman, and thank you. And thank you all for 
being here today on this extremely important topic. Every day 
we hear of someone. In fact, when I go home, I usually give 
them the health report, and it just seems like every day 
someone is coming down with a disease, someone we know, someone 
we are close to, near and dear to.
    My daughter--she is 30 now--25 years old she was diagnosed 
with Hodgkin's lymphoma. She went through all of the treatments 
and lost her hair, got her hair back, and is doing very good 
now. In fact, going to get married next October. And I am 
wearing today my St. Jude's Children's Research Center tie that 
I am very passionate about and have been for over, well, close 
to 40 years now, I guess, but over 30 years.
    When I was an auctioneer before this life, for 30 years I 
was on the National Auctioneers Board of Directors, and we 
picked one national charity to support, and that was St. Jude, 
so I always try and showcase my St. Jude tie at any 
opportunity.
    Sunday night, we were at the Kennedy Center Honors. Two of 
the honorees, one that founded Earth, Wind and Fire, suffered 
from Parkinson's disease before his demise, and Linda Ronstadt, 
who had to give up singing--one of the most beautiful voices 
ever--was honored Sunday, and she had to give it up due to 
Parkinson's disease. So, again, it is a very, very important 
topic, and thank you all for being here.
    Dr. Atlas: First name Charles, middle name Charles, any?
    Dr. Atlas. Not many people know who that was anymore, I 
don't think.
    Mr. Long. I am showing my age, but I have never met an 
Atlas that wasn't named Charles, so I am just----
    Dr. Atlas. OK.
    Mr. Long [continuing]. Curious, but inquiring minds want to 
know.
    But if you think back to 2013, with the rollout of 
healthcare.gov and all the issues that they had getting the 
website opening up, and I think six people actually were able 
to sign up that first day. It took months and months to get it 
where it was fully functional and more than $1\1/2\ billion 
over budget to get it up and going. In the end, healthcare.gov 
website finally launched about 3\1/2\ years after the passage 
of the Affordable Care Act.
    The Medicare for All bill is estimated to cost over $30 
trillion and would fully transition from our current healthcare 
system to a single-payer system in 2 years. So if the United 
States Government couldn't build a functioning website in 3\1/
2\ years and went massively over budget trying, how can we 
possibly expect the Government to successfully transition to a 
single-payer system in just 2 years and stay on budget? Any 
comment?
    Dr. Atlas. Yes. I don't think there is an answer to the 
question, except I would say to the point about why single-
payer, why Medicare for All will save money, it is because the 
same reason that every other single-payer system is less than 
the United States. They restrict the use of healthcare and they 
have worse results for that. So, if that is what people, voters 
are interested in doing, having worse healthcare and having 
more people die like Canada and England and everywhere else and 
no access to these drugs that we enjoy as Americans, you know, 
that would be a reform that would be appropriate.
    I think the best way to get access is to reduce the cost 
for everyone just like it is done--that is why the cellphone in 
your pocket, it is a supercomputer, doesn't cost $20,000, from 
competition and empowering consumers who care about the price 
of what they are actually directly buying.
    Mr. Long. OK. The Harvard School of Business determined 
that the lack of relevant experience, lack of leadership, and 
time constraints were the primary factors leading to 
healthcare.gov's initial failure. Do you believe the United 
States Government currently has the manpower, resources, 
management talent, and expertise to fundamentally take over our 
healthcare system?
    Dr. Atlas. Not in the Government, no. The private sector 
would.
    Mr. Long. OK. In your testimony, the opposition to single-
payer should not--you said the opposition to single-payer 
should not focus only on requirement for massive new taxes, but 
instead on the well-documented half century of its failure to 
provide timely, quality medical care. This failure is not just 
about low=priority checkups or routine appointments, it is 
about people that are seriously ill. You note that the U.K.'s 
NHS system has set a standard and declared it would be 
acceptable for 15 percent of cancer patients.
    And I have spoken of cancer patients, including my 
daughter, here this morning to wait 2 full months. And when I 
think of the day that I took her to the emergency room here in 
Washington and first was told her there was nothing wrong and 
go home, but they had an IV in her arm and she couldn't get 
dressed and go home. They decided to do an x ray and they came 
back and they said ``You have a large mass in your chest, and 
it is malignant.'' Waiting 2 full months for treatment would 
definitely have not been acceptable in her case, or it should 
not be in anyone's case, and one out of five patients has to 
wait over 2 months for their first treatment of cancer.
    And I am beyond my time by 20 seconds, and I yield back to 
my friend.
    Ms. Eshoo. The gentleman yields back. I am a kind 
chairwoman. I have a hard time cutting people off. It is only 
at the urging of others that I do this. So it is a----
    Mr. Long. That is an auctioneer's gavel. I can do that.
    Ms. Eshoo. Yes. He is a real live auctioneer. You can hear 
it in his voice, can't you?
    Now all the--let's see, we have all of our women to ask 
questions. The gentlewoman from California, Ms. Matsui, is 
recognized for 5 minutes for her questions.
    Ms. Matsui. Thank you very much. And I want to thank the 
witnesses for all being here today and thank Chairwoman Eshoo 
for having this hearing here today.
    You know, for the past decade, our healthcare system has 
been constantly under attack. Republicans in Congress and the 
statehouses across the country have made it their mission to 
repeal or systematically undermine the Affordable Care Act. The 
goal of universal coverage has long been, as we always say, a 
North Star for the Democratic Party. We believe everyone should 
have access to care, and I was disappointed when more 
progressive policies to expand coverage were ultimately left 
out of the Affordable Care Act.
    But that is why this moment presents a unique opportunity. 
The ACA improved the quality of basic care everyone receives. 
It unlocked access to care for Americans who have been 
historically shut out of or priced out of the system. It has 
expanded coverage to over 20 million Americans since it was 
signed into law. While acknowledging our successes, we must 
also recognize the need for improvement, the need to look up 
again at the North Star of universal coverage and ask ourselves 
what comes next.
    It is my hope that today we can have a productive 
conversation about how to obtain universal coverage, increase 
the role of Federal Government in lowering the cost of care, 
and maintain our role as the global leader in cutting-edge 
treatments and health technology. Our path forward will say a 
lot about who we are as a nation.
    Healthcare touches all of our lives in some way. That is 
why I am excited by the proposals before us today, all of which 
are united by the common goal of improving the access and 
affordability of healthcare. California is the first State in 
the Nation to improve coverage affordability for low- and 
middle-income consumers by expanding subsidies available 
through our ACA marketplace, Covered California. California has 
also reinstated the individual mandate tax penalty. As a result 
of both policies, plans sold through our health insurance 
marketplace saw A record-low statewide average rate change of 
less than 1 percent for 2020, bringing savings and stability to 
the entire individual market.
    Many of the bills we will discuss here today would enhance 
ACA premium tax credits and cost-sharing subsidies to 
marketplace enrollees. Ms. Rosenbaum, can you briefly explain 
how the ACA subsidy cliff works and what groups face the 
biggest affordability challenges as a result of this phenomena?
    Ms. Rosenbaum. Yes. There are two kinds of subsidies under 
the ACA: There is a premium subsidy, and then there is a cost 
sharing subsidy. The premium subsidy begins at the Federal 
poverty level and it ends at 400 percent of poverty, and it 
essentially works by keeping down your cost of coverage to a 
certain percentage of your income. Currently, the subsidy has 
sort of a steep cliff and ends completely at 400 percent of 
poverty.
    The cost-sharing assistance is similar in that it 
essentially discounts the cost of care at the point of service, 
but its cliff is steeper. It ends at 250 percent of poverty.
    Ms. Matsui. Right. So you would agree that improving 
subsidies is key to increasing coverage for both low- and 
middle-income individuals?
    Ms. Rosenbaum. Absolutely. It is the number-one reason why 
people----
    Ms. Matsui. So if we were to scale these solutions 
nationwide, how would you expect enhanced subsidies coupled 
with return of the individual mandate to impact overall 
uninsured rates and the stability individual marketplace?
    Ms. Rosenbaum. Estimates suggest that just those two 
changes alone, probably along with, of course, something for 
the Medicaid expansion States that have not expanded, would 
probably raise the insured levels by at least 10 million 
people, even more with autoenrollment.
    Ms. Matsui. Sure. Now, in the Medicaid expansion States, 
the ACA is working as we envisioned, filling historical 
coverage gaps tied to income level by expanding Medicaid 
eligibility and providing subsidies for purchasing coverage. In 
nonexpansion States, many adults whose incomes are above 
Medicaid eligibility but below the threshold for subsidies are 
trapped in a coverage gap.
    Ms. Rosenbaum, how many people nationwide would be eligible 
for Medicaid if their States expanded?
    Ms. Rosenbaum. It is slightly more than 2 million people.
    Ms. Matsui. So are larger populations of people caught in 
the coverage gap concentrated in certain States or parts of the 
country?
    Ms. Rosenbaum. Yes. They are disproportionately people of 
color. They are disproportionately residents of southern 
States.
    Ms. Matsui. Mr. Morley, I just want to make a comment. 
Thank you for your testimony. We really do understand what you 
have been going through, and we really want to work on behalf 
of you and many other patients such as yourself. And thank you 
for sharing your unique perspective with us. I am equally 
concerned about the actions taken by the administration to 
undermine Medicaid and the ACA protections and that have 
increasingly exposed, you know, consumers to coverage gaps. 
And, believe me, that is what we are trying to do today, to 
ensure that we level the playing field and understand how 
important it is. Thank you very much, appreciate it.
    Mr. Morley. Thank you very much for saying that. I 
appreciate that.
    Ms. Eshoo. The gentlewoman yields back. It is a pleasure to 
recognize the gentleman from Kentucky, Mr. Guthrie, for his 5 
minutes of questions.
     Mr. Guthrie. Thank you very much. Sorry. There is another 
hearing of this full committee, a subcommittee that was meeting 
earlier, and it was on foreign drug inspections, so I wasn't 
able to hear your stories, Mr. Morley. But God bless you and 
thanks for being here to share.
    What I kind of want to talk about with Dr. Atlas and Dr. 
Holtz-Eakin is, I think all of us here are wanting people to be 
covered with--the question is that we get to when you look at 
Medicare for All, how does it change the healthcare system we 
have today?
    We are currently in discussion this week about H.R. 3, 
which is setting a price for pharmaceuticals. We all want lower 
drug prices, and there is a bipartisan bill to do that, but now 
we are going to where we are setting drug prices to the point 
where CBO says we will get less, 8 to 15 less drugs over the 
next 10 years. And people on this committee in that hearing 
said, if we are going to lose miracle cures or--they didn't say 
that, I won't put the words--if we are going to lose some cures 
because we are going to have lower drug prices, that is a 
tradeoff we are willing to pay.
    I like to take people when they come to my district to 
Owensboro, a fantastic medical center; Bowling Green, two 
medical hospitals; Elizabethtown, a medical hospital; Danville, 
Ephraim McDowell, father of modern gynecology, hospital, and 
just say, if we were in a European state or Canada, a city this 
size would not have a hospital of this quality, in my opinion. 
I mean, and I tell them, take me to a city of less than a 
hundred thousand people that have world-class--we can do heart 
surgery. We do a lot of different things.
    So the concern as we go down this path is--and we have to--
it is not just a slogan that we can put on a bumper sticker or 
a T-shirt, it is, How is this going to affect the healthcare 
system that Americans have? We can cure sickle cell anemia. 
We--cystic fibrosis is going to be a disease that people can 
live with further. It is going to be a maintenance disease. 
Artificial pancreases, available now. Just the things that are 
coming out of this country, and we are subsidizing the rest of 
the world. And that is an issue that we try to address in H.R. 
19 on drugs, is that we have a U.S. trade negotiating or 
negotiate with other drugs.
    But just ramping down payments and giving, in order to get 
a hundred percent universal coverage in one plan, Medicare for 
All, at the expense of that which I don't see how you take that 
much money out of the system and not lose hospitals. For 
example, under the Affordable Care Act we did Medicaid 
expansion and within--and my State expanded, Kentucky--and with 
Medicaid expansion, it was paid for by decreasing the DSH 
payments, disproportionate share payments, because if everybody 
is covered, we are not going to have to have these subsidies.
    Well, I will tell you, every rural hospital in Kentucky 
today, an expanded State, would say if--and we are making it 
up, we are doing Medicaid expansion and DSH payments because it 
just doesn't work--they would all say they would close or have 
difficult--particularly the smaller ones. I won't say Owensboro 
or Bowling Green, but the smaller hospitals would close, they 
tell me, if we didn't make up the DSH payments when the policy 
was everybody be covered, but the problem is the payments are 
so low, even the people covered, the hospitals can't make it 
up.
    So, Dr. Atlas or Holtz-Eakin--or I will open it up to 
anybody--what do you see, if we go to a one-size reimbursement 
for Medicaid, Medicaid to all of our hospitals and our 
providers, what kind of healthcare system would you see? For 
instance, we know under H.R. 3 that 50 percent of the drugs 
that would be priced under H.R. 3 are not available in Canada. 
They are not. They are just not available. That is just a fact.
    And so, what would you see with our----
    Dr. Atlas. Well, I will answer about the drug pricing issue 
that hasn't been brought up. You look at what a single-payer 
system does with drug pricing, we can look at the NHS. They 
have a budget impact test of 2017. They set a number, and if 
the system is going to cost 20 million pounds or more for a 
drug, they are not going to have that drug available, and they 
are going to ``negotiate,'' and they give themselves 3 years.
    If your wife has breast cancer and wants one of these new 
drugs, she is going to sit there for 3 years while the 
government, the NHS, negotiates that price down. It has been 
calculated by the NHS itself and the Alzheimer's Foundation in 
the U.K. that a drug for Alzheimer's would have to cost less 
than $4 a month to be approved, because so many people need it. 
So if you look at this way, ironically, the more people that 
need the drug when you are capping the total expenditure--the 
more people that need the drug, the less likely it will be 
available. That is what the NHS Budget Impact Test does.
    You can't have the government, a third party--the 
government doesn't care if your wife doesn't get her drugs. She 
cares if she doesn't get them.
    Mr. Guthrie. Well, this is what I want to point out, is 
that we can't just sell that we are creating a whole new 
payment system and not affect the healthcare system we have. I 
think people are envisioning we are going to have exactly what 
we have and somebody else is paying for it, and that is not 
what will happen, in my opinion.
    Dr. Atlas. Well, we know that the CMS Actuary just now said 
it that their warning in 2018, hospitals and nursing facilities 
and in-home care are going out of business because they are 
losing money per patient. If you lose money per patient, you 
don't make up for that in volume, as the old joke goes.
    Mr. Guthrie. Dr. Holtz-Eakin--well, I am out of time.
    Mr. Holtz-Eakin. Yes, I mean, that restricts access to 
existing technologies. And in the data we see that increasing 
quality, which is the adoption of a medical innovation, is 
correlated with higher reimbursements, you put all that risk. 
And the international evidence shows it. Our domestic evidence 
shows it as well.
    Mr. Guthrie. Thank you very much. I yield back.
    Ms. Eshoo. The gentleman yields back.
    I have a factoid, and that is a lot of people have said 
things about the Affordable Care Act. All Members of Congress 
receive their healthcare through the Affordable Care Act. All 
staffers receive their healthcare through the Affordable Care 
Act. I think there is only one member who has not accepted it, 
and that is Dr. Burgess, but that was his choice. So I think 
that we have a lot of people invested in it and I just can't 
help but say, ``Thank God for Medicare and Medicaid.'' Where 
would people in this country be without that coverage?
    So it is a pleasure to recognize the gentlewoman from 
Florida, Ms. Castor, for her 5 minutes.
    Ms. Castor. Well, thank you, Chairwoman Eshoo. And let me 
thank you for this hearing, because it isn't it refreshing that 
we can focus on how we are going to lower the cost of 
healthcare in America, expand access, build upon Medicare and 
Medicaid and the Affordable Care Act, so thank you very much.
    Dr. Rosenbaum, in your testimony you cite the lasting and 
measurable achievements under the Affordable Care Act.
    And, Peter Morley, thank you for being here and speaking on 
behalf of millions of Americans with preexisting conditions.
    When you say the Affordable Care Act, here we are 10 years 
later, it is time to take stock. What stands out to you 
overall, Dr. Rosenbaum?
    Ms. Rosenbaum. I think the remarkable effect of the 
affordability provisions, the enormous impact of the market 
reforms for people like Peter Morley, and the vision of 
combining access to affordable coverage with, actually, 
improvements in communities to access to care.
    Ms. Castor. So the protection. No longer can an American be 
discriminated against for any preexisting condition. It has 
been very meaningful for young people to stay on their parents' 
policies until they are age 26.
    And to Mr. Shimkus, who was here: Remember, the Affordable 
Care Act extended the life of the Medicare Trust Fund, and it 
strengthened Medicare, and it helped to close the doughnut 
hole. Now, the Democrats this week are going to pass one of the 
missing links to allow Medicare to negotiate prices and drive 
down drug costs and then carry that over to private insurance, 
so that is going to be a great thing for families.
    You know, coming from the State of Florida, boy, there is 
some good news and there is some really difficult news. We have 
led in the marketplace every year. We have about 1.8 million 
Floridians who sign up for affordable coverage under 
healthcare.gov. At the same time, we have a little less than a 
million of our residents who are stuck in the coverage gap. 
That means they are too poor to access the tax credits. This is 
crazy, OK. Floridians--and this goes for Texans too--we want to 
bring our tax dollars home. And Leavitt Partners did a study--
recently it came out--$13.8 billion of your tax dollars, they 
want to give them back to the State of Florida so that about a 
million of our residents can get signed up for Medicaid health 
services.
    Chairwoman Eshoo, when you talk about this cohort of people 
who don't have health coverage, because of that Florida, the 
fact they haven't expanded Medicaid, 10 percent of all working 
adult or all uninsured adult population comes because of that 
coverage gap, so I appreciated Chairman Pallone and 
Congresswoman Matsui highlighting this.
    Dr. Rosenbaum, can we just--we can look at Mr. Veasey's 
legislation to increasing incentives, but I mean $13.8 billion, 
we would cover people, it would help our GDP, we would be able 
to hire, we would be healthier, infant--I mean across the 
board. What else can we do? We have to just go ahead and say we 
intended Medicaid to be expanded under the Affordable Care Act. 
Do we have to craft that again and pass it, and would it 
withstand scrutiny of the Supreme Court?
    Ms. Rosenbaum. Well, certainly, further incentivizing 
States to expand coverage is a good idea. Why a State would not 
expand coverage is a bit of a mystery, especially since the 
expansion would not only extend coverage to all the people who 
are left out, but would actually bring down the cost of 
premiums in the marketplace because, in States that start their 
marketplace coverage at 138 percent of poverty, the premiums 
tend to be lower, so it is good all around.
    Ms. Castor. Can we just pass the law? Go back and----
    Ms. Rosenbaum. Unfortunately, the Supreme--well, the 
Supreme Court has said that expansion on a mandatory basis is 
no longer constitutional, but certainly many people have 
thought--I am among them--that sweetening the pot is a very 
good thing to do in hopes that the expansion will happen.
    Ms. Castor. So, Peter Morley, thank you for providing a 
real-world example of how meaningful it is to have healthcare 
coverage. You know, we are in the holiday season now, and is 
there any better gift to a loved one than health insurance? And 
remind us what the deadline is.
    Mr. Morley. First of all, thank you for saying that. I 
spent 3 days in Congress last week, in the House and the 
Senate, making videos with people like Congresswoman Castor. 
The deadline, the Federal exchange deadline, is December 15th.
    Ms. Castor. Wow. That is Sunday, I think.
    Mr. Morley. It is Sunday. Go to healthcare.gov. That is the 
way that we keep enhancing the ACA. And just to add, when you 
talk about Medicaid expansion, a lot of people--I have heard 
for the majority of people in Texas and Florida--those are two 
major States that have not expanded Medicaid, and I am very 
sympathetic and compassionate to that, so thank you for 
mentioning that.
    Ms. Castor. Thank you.
    Ms. Eshoo. I made the announcement, December 15th, whomever 
is tuned in.
    It is a pleasure to recognize the gentlewoman from 
Delaware, Ms. Blunt Rochester, for her 5 minutes of questions.
    Ms. Blunt Rochester. Thank you, Madam Chairwoman. And I 
want to thank both panels for your testimony and the 
deliberations.
    As I was sitting here listening to the testimony, I thought 
of a quote from Martin Luther King that says of all the forms 
of inequity, injustice in healthcare is the most shocking and 
inhumane. A decade ago, this very subcommittee debated one of 
the country's most sweeping and comprehensive pieces of 
healthcare policy, the Affordable Care Act. Twenty million 
Americans gained health coverage through either the marketplace 
or Medicaid expansion, and for the first time, patients 
received critical protections from things like coverage denials 
because of a preexisting condition, like you shared, Mr. 
Morley, or lifetime limits on essential health benefits. 
Delaware alone saw the State's uninsured rate drop to 5 
percent.
    But an issue that it still plaguing our healthcare system 
is cost. I held town hall meetings, I met with families, I met 
with small businesses in my State, and three things kept coming 
up. For many, the out-of-pocket costs were unaffordable. For 
some there were gaps in coverage or they were underinsured. 
And, number three, health inequities and disparities still 
persist, which is why we are still talking about maternal 
mortality in this country.
    Since hearing those concerns, I have been working on a 
comprehensive strategy, the Cap Costs Now Act. I am going to 
say it again, the Cap Costs Now Act. My bill would cap out-of-
pocket costs, including premiums, deductibles, and copays, so 
no one is spending their whole paycheck for healthcare, no 
matter where they are getting their health insurance. The Cap 
Costs Now Act would allow us to achieve truly universal 
coverage by automatically covering everyone through an easy-to-
navigate system with new options for coverage such as a 
Medicare E program for those 50 to 64. Finally, the bill would 
align incentives in our healthcare system to better tackle 
health inequity and continue our nation's move towards value-
based care.
    Unaffordable, out-of-pocket healthcare costs aren't just an 
issue in my State. The Commonwealth Fund has found that about 
one in six Americans face healthcare costs they can't afford, 
even with health insurance. Deductibles alone have tripled in 
the last decade. More than 4 in 10 workers enrolled in a high-
deductible plan reported that they don't have enough savings to 
cover their deductible. In other words, in the words of one of 
our previous witnesses, if you can't afford it, you don't have 
it.
    So I would like to thank my colleagues for their 
leadership, who were on the first panel, and their work on the 
various pieces of legislation, and I would like to thank all of 
you who are on this panel. We all want our constituents to have 
quality healthcare, and we all want our constituents to be able 
to afford it. With my plan, we can move towards affordable, 
universal coverage without starting from scratch or removing 
the 180 million Americans in employer-sponsored insurance from 
their existing plans. We can immediately get to the work by 
building on the current foundation of our Nation's healthcare 
system to provide everyone with coverage that is affordable and 
universal.
    As I begin to roll out my healthcare proposal in the 
upcoming weeks, I want to encourage my colleagues to look out 
for it and to support the Cap Costs Now Act. Thank you, and I 
yield back.
    Ms. Eshoo. The gentlewoman yields back. A pleasure to 
recognize the gentleman from Georgia, Mr. Carter, for his 5 
minutes of questioning.
    Mr. Carter. Thank you, Madam Chair. And thank all of you 
for being here. I appreciate this very much, you taking time 
out. This is extremely important, extremely important to the 
future of our country, to the future of healthcare in our 
country in particular.
    I find it interesting that we are having this discussion 
during the same week that we are also going to be voting on 
Speaker Pelosi's bill, H.R. 3, that is going to essentially 
keep up to a hundred lifesaving drugs from coming to the market 
if it were to be enacted, and that comes from the Economic 
Development Commission, and that is what they have proposed. 
Even CBO tells us that we can expect anywhere from 8 to 15 
drugs not to come to market if this were to be passed.
    But, Dr. Atlas, I wanted to ask you, because I think your 
testimony really tells the full story. It has come up in our 
debates about the anticures bill, H.R. 3, as you mention in 
your testimony as well that other single-payer systems have far 
fewer choices in terms of medicines available to them. Is that 
correct?
    Dr. Atlas. That is absolutely true. And, since most new 
drugs are cancer drugs, people die because of that.
    Mr. Carter. You cited some figures. I listened attentively 
to your opening statement about other countries and comparing 
us to what is available here in America as opposed to what is 
available in those other countries. Do you have that by chance 
again?
    Dr. Atlas. Yes, I do, because I was speaking so quickly 
that probably no one remembers what I said.
    Mr. Carter. I would like to make sure they do remember what 
you said, because I certainly heard it.
    Dr. Atlas. The latest data on the 54 new cancer drugs 
launched from 2013 to '17 in the world, within the 2 years, the 
United States' patients had 94 percent available, Brits had 70 
percent, Canada's cancer patients had 53 percent of those 
drugs, France 43 percent, Australia 28 percent. It is proven in 
economics but not in--and in drugs in particular. when you cap 
prices, you are going to stop the production, the availability 
of good and the innovation of that good.
    The real solution to drug prices is to figure out why they 
are costing so much, because the cost of developing a drug has 
exploded over the past decade to $2\1/2\ billion in 15 years, 
and nobody is going to develop a drug if they are not going to 
get that money back. So we as a government, really, have added 
a lot of bureaucracy and a lot of hurdles and therefore cost to 
the development of new drugs, and that is where the attention 
should be focused.
    Mr. Carter. And, you know, for those of you who don't 
know--and I am sure members of the committee know--currently I 
am the only pharmacist serving in Congress. I spent my 
professional career dealing with this. I have seen nothing 
short of miracles.
    Ms. Eshoo. We are so glad that you said it.
    Mr. Burgess. Yes, who knew?
    Ms. Eshoo. Who knew? That is right.
    Mr. Carter. Excuse them.
    But anyway, I have seen nothing short of miracles through 
the way of research and development and what has come on the 
market. I give the example all the time of the drug Sovaldi. 
Now here is a drug that, when I first started practicing 
pharmacy in 1980, if you were diagnosed with hepatitis C, you 
were going to die. I mean, that is all there was to it. Now how 
phenomenal is it that we can cure that disease with a pill? 
That is simply phenomenal to me. Someone who was there at that 
time, who saw people who came in who were diagnosed with that 
disease and knew that they were diagnosed that they were going 
to be dying soon, but now we can treat them. That is 
phenomenal.
    Now, you know, the thing that concerns me so much is that 
both sides, both Democrats and Republicans, want the same 
thing. I get it. I understand that if a drug costs $85,000 and 
is not accessible to you, it does you no good whatsoever. I get 
the fact that we need to bring prescription drug prices down. 
But I also understand that there are other things that we can 
do aside from what is being posed in H.R. 3 that will lower 
drug prices without stifling innovation, and that is what I am 
trying to get to here.
    And let me ask you, Dr. Atlas, why would these countries 
restrict their patients' access to these medications? Is it 
simply just to manage the cost of government?
    Dr. Atlas. That is exactly--well, they are trying to 
minimize the cost that they are paying out for their healthcare 
system, and the way that they all do it is to restrict the use 
of care, the availability of technology, the availability of 
drugs, and their results of their survivals in these specific 
diseases are worse than ours.
    Mr. Carter. Exactly. And again, I don't fault my colleagues 
on the other side of the aisle. They want the same thing I 
want. We all want the same thing, to bring the prescription 
prices down, and we can do that. And I see the need for 
transparency so much, because I know what is going on here and 
I know that there are middlemen who are bringing no value 
whatsoever to the system but are taking profits out of the 
system.
    And thank you again, Dr. Atlas, for being here and for 
bringing up this important point. Thank all of you for being 
here. Thank you, Madam Chair, and I yield back.
    Ms. Eshoo. The gentleman yields back. It is a pleasure to 
recognize the gentleman from Massachusetts, Mr. Kennedy, for 
his 5 minutes of questions.
    Mr. Kennedy. Thank you, Madam Chair. I want to thank my 
colleagues for, I think, unanimously, as this one, all agreeing 
how important this hearing is. Grateful to be here for it. I 
want to thank our witnesses for your courage, for your 
testimony, for your service, and for your perspective. It is 
important that we get this right.
    Let's start by just walking through some of the comments 
that I think some of our colleagues have made and has been put 
forward in testimony, this question that some aspect of a more 
robust guarantee of access to coverage is somehow going to make 
sure that drugs are not available. Ms. Ross, are you familiar 
with the statistic that roughly 26 percent of patients in need 
of insulin ration their care?
    Ms. Ross. I am.
    Mr. Kennedy. And so does that seem like insulin is in fact 
readily available in the United States of America?
    Ms. Ross. It does not.
    Mr. Kennedy. When we talk about the fact that procedures 
might end up in expanded wait times, are you aware that for 
GoFundMe, that popular crowdsource fundraising website, that a 
third--a third--of the donations of a GoFundMe page are used 
for healthcare costs. Were you aware of that?
    Ms. Ross. I am aware of that.
    Mr. Kennedy. Are you aware that the founder of GoFundMe 
said that, quote--I will get this more or less right--that he 
did not, they did not intend to found a site that would be one 
of the most influential healthcare companies, but it turns out 
that they did, as a GoFundMe page?
    Ms. Ross. I did hear that, yes.
    Mr. Kennedy. And we talked about wait times and access to 
care. Are you aware, Ms. Ross, that 55 percent of the counties 
in our country do not have a single practicing psychiatrist, 
psychologist, or social worker?
    Ms. Ross. I am aware.
    Mr. Kennedy. Are you aware of the fact that about over 50 
percent of the adults in this country in need of mental 
behavioral illness will not get the access to care today?
    Ms. Ross. Yes.
    Mr. Kennedy. Are you aware of the fact that that is 
actually worse for kids?
    Ms. Ross. Absolutely.
    Mr. Kennedy. So I was at a regional hospital on my district 
a little while ago--keep in mind, in a State with 98 percent, 
98 percent of people covered with health insurance, 98--there 
was a little boy that was waiting that was being boarded. He 
had been waiting for over 150 hours and counting, waiting for a 
bed. That they couldn't get the stretchers down the hallways in 
the emergency room because there are so many patients suffering 
from mental illness waiting for a bed.
    That a mom had come in to my office, now a couple years 
ago, detailing her daughter's challenges with mental behavioral 
illness, and at one point their daughter was boarded on the 
neurology floor at an academic medical center in Boston for 19 
days as they called looking for a bed from Virginia to Maine. 
Nineteen days. Any guess as to how much it would cost to board 
a child at a neurology floor waiting for a bed in Boston?
    Ms. Ross. A lot.
    Mr. Kennedy. That sounds about right to me.
    Mr. Holtz-Eakin, I think, would agree with ``a lot'' 
figure. Fair enough?
    Mr. Holtz-Eakin. It is a good estimate.
    Mr. Kennedy. So I point these stories and these statistics 
out because I think the reality that I think many of us 
experience in our healthcare system today is that, when we talk 
about quality, when we talk about access, when we talk about 
what treatments are available, without question--without 
question--they are right. Without question from a perspective, 
Dr. Atlas, what you just said is correct.
    The challenge--where I would challenge you and challenge 
others on this is that the focus of that system ends up being 
on those who have access to it and not the drastic number of 
Americans that don't. And the fact that, even today in a place 
like Massachusetts that is so proud of the healthcare industry 
that we have invested in and that we have nurtured, that a 
story that ran in the Boston Globe about 8 months ago--no, 
about a year ago--about an African-American woman who slipped 
and fell in a minority part of Boston, broke her wrist, got in 
a cab and went to Boston Medical Center, the old city hospital. 
She broke her wrist out in front of or down the block from New 
England Baptist. It is where the Boston Celtics go to get an 
orthopedic surgery. She didn't even know that the hospital was 
there. And, even if she did, it wouldn't have mattered, because 
it is a private hospital and they don't take Medicaid.
    But when we have, when Medicaid--shifting gears--is the 
largest payer of mental behavioral services in this country, 
and the vast majority of providers won't take Medicaid because 
the reimbursement rates are so low, yes, if I can afford to pay 
out of pocket, I have access. But for so many others that 
don't, they don't. Mr. Morley would not be here but for the 
grace of God, of Affordable Care Act, and the fact that 
certainly--I mean, Mr. Morley, you have been eloquent about 
your story, but how many people in this country, how many 
people are even forced to have to tell your story?
    Mr. Morley. Honestly, I have lost track. I really--it is, I 
mean, I will never understand why all can't just work together 
to bring that access for everyone.
    Mr. Kennedy. And so, my time is up here. I will just say 
this. This is complex, and this is complicated, and there are 
tradeoffs. But the core question here is that, for a system 
that every single one of us will draw on, whether you are born 
into a system or whether you welcome a new child or watch a 
loved one pass through it, why would we not want to make sure 
that it is a system that is there for everyone else, the same 
system that we want for a loved one? And I yield back.
    Ms. Ross. Could I add one comment to that?
    Mr. Kennedy. That is up to the chair.
    Ms. Ross. Would I be allowed?
    Ms. Eshoo. Well, I think we need to move along because it 
is 24 minutes past--or yes, seconds past the gentleman's time. 
I now would like to recognize the gentleman from Virginia, Mr. 
Griffith, for his 5 minutes of questions.
    Mr. Griffith. Thank you, Madam Chair..
    Ms. Ross, we try to get along on this committee. If you 
have something short, say it.
    Ms. Ross. Thank you. It is very difficult for me to hear 
the comparisons to other countries' single-payers with the 
constant comment that people are dying and denied care. As long 
as the for-profit motive is present in this country, that is 
what is happening now. The only way for them to make their 
profit is to deny care.
    Mr. Griffith. Well, and I don't necessarily agree with you 
on that and would take exception, but we try to be courteous on 
this committee and try to work together.
    That being said, Dr. Atlas, today many rural hospitals are 
closing because they cannot afford to stay in business, leading 
to access problems for sick Americans. One of the major reasons 
for these closures is that Medicare--and Mr. Kennedy mentioned 
Medicaid--doesn't pay hospitals enough. According to MedPAC, 
hospitals are unable to make money caring for Medicare 
patients. If it wasn't for privately insured patients, even 
more hospitals in rural communities would close. Research by 
the consulting firm Navigant predicts that a Medicare public 
option plan would put up to 55 percent of rural hospitals at 
high risk for closure.
    Now I say this with the backdrop that my rural western 
Commonwealth of Virginia district has lost two hospitals in the 
last few years. We are trying to get one of them back. But many 
of the plans we are discussing today involve expanding 
Medicare. If more patients are covered by government 
healthcare, won't that lead to even more rural hospital 
closures and access problems?
    Dr. Atlas. Well, absolutely, of course. Like I said before, 
the CMS Actuary put out the statistic that--and in fact the 
statement that--we expect access to Medicare-participating 
physicians to become a significant issue, quote/unquote. And 
the reason is because Medicaid and Medicaid pay not just lower 
than private insurance, but below the costs of delivering the 
care. That is the point. And so it brings you back to what I 
believe is the whole solution that should be the focus, which 
is to reducing the cost of care without needing to limit or 
restrict the use of care. If you reduce the cost of care, 
everybody gets access, including those on government programs.
    Mr. Griffith. Yes, and I appreciate that. And I guess, you 
know, the question is begged, How can we guarantee access to 
care for patients in rural areas on a Medicare for All plan if 
there are no open hospitals in rural communities? And, for 
those who haven't heard me say this before, sometimes you can 
look at a map and Point A to Point B doesn't look like it is 
very far, but when you have a mountainous district like I do--
it may be Haysi to Dickenson--the mayor of Haysi plans on an 
hour if he is going to a meeting in Dickenson for travel time.
    And the same is true when we closed down the Scott County 
Hospital. That meant a minimum of 45 minutes to an hour for 
many of the people in Scott County to get to the nearest 
hospital just for basic stuff, not even counting something that 
might be more complex.
    But how can we guarantee that those folks are actually 
going to have care? It is not like getting in a cab and going 
to the next hospital down the road. There is no hospital down 
the road.
    Dr. Atlas. Well, that is--again, the solution is to 
introduce the forces that bring down the prices for every other 
good or service in the United States. That is how you ensure 
access. Not just based on price, but based on value or quality.
    Mr. Griffith. Dr. Holtz-Eakin, anything to add to that?
    Mr. Holtz-Eakin. Well, I think that is the essence of it. I 
don't think anyone is here to defend the status quo. The 
question is, How can you go forward and what set of reforms 
would deliver a downward pressure on delivering the cost of 
quality care?
    Mr. Griffith. I appreciate it. And with that, I yield back. 
Thank you.
    Ms. Eshoo. The gentleman yields back. Actually, you know, 
the GAO analyzed data and found that rural hospitals in States 
that had expanded Medicaid as of April 2018 were less likely to 
close compared with rural hospitals in States that had not 
expanded Medicaid. So we deal with a lot of complexities, but I 
think the facts need to be stated so that, you know, that we 
build on the foundation of facts. And it seems to me that we 
are in an era where that foundation continues to be eroded on a 
daily basis.
    It is a pleasure to recognize the gentleman from 
California, my friend Mr. Cardenas, for his 5 minutes of 
questions.
    Mr. Cardenas. Thank you, Madam Chair, and I appreciate the 
opportunity to have this hearing. And also, to the Ranking 
Member Burgess, thank you so much. And I want to say thank you 
for pointing out that statement that, when the politicians take 
the politics out of their decision making, more people have 
access to healthcare under the current system, which you just 
pointed, out with certain States not accepting that 
responsibility and opportunity. I appreciate the opportunity to 
hear from my colleagues and other experts such as yourselves--
thank you very much--on what it is most important of the issues 
facing our Nation. I am proud to serve on a committee that does 
not shy away from topics simply because they are difficult.
    And I myself know what it is to grow up in a family, a 
working family, where my parents faced the choice between going 
to the doctor or having enough food to feed their family, a 
choice that too many American families face today. To say that 
the establishment of federally qualified health centers changed 
our lives is an understatement. For the first time, we could 
get preventive care. We could go to the doctor when we first 
started feeling sick instead of when it was a dire emergency.
    The Affordable Care Act provided these same opportunities 
for more than 20 million Americans that before then did not 
truly have access to healthcare. Many of them live in the very 
district that I am proud to serve. Although I was not yet a 
member of this committee when the Affordable Care Act passed 
the House, I know many of my colleagues were. I think most of 
my Democratic colleagues are united in our firm belief that all 
Americans deserve access to quality health coverage. Together 
it is imperative that we continue that work, because while many 
Americans have benefited from these reforms, there are still 
too many without care. That is why it is so important that we 
are having this hearing today and discussing this very critical 
issue.
    Mr. Atlas, some of the comments that were made--and you, in 
fact, pointed out that some hospitals are closing. Hospitals 
closing, is that a new phenomenon in the United States, or have 
we had that happen over the past decades, hospitals closing 
and/or every American having access to healthcare? Are those 
two new phenomenons? Do all Americans have access to healthcare 
today?
    Dr. Atlas. Well, it is illegal to turn somebody away when 
they come to the hospital, so the answer----
    Mr. Cardenas. Yes, OK. You know, OK, I am sorry. Let me 
qualify my question a little bit better. How many Americans 
actually have healthcare coverage and direct access to 
preventive care today, a hundred percent or not?
    Dr. Atlas. Well, everyone with insurance has free 
preventive care.
    Mr. Cardenas. Does that cover a hundred percent of 
Americans?
    Dr. Atlas. No, not everybody opts for insurance.
    Mr. Cardenas. OK. OK, got it.
    Dr. Atlas. And if I could----
    Mr. Cardenas. Thank you, Mr. Atlas, reclaiming my time. I 
was trying to have a nice dialogue with you and a simple one, 
but you are complicating the answer.
    The bottom line is this: In the United States of America, 
we have--a hundred percent of Americans have never had truly 
access to healthcare. Just like I outlined in a period of time 
in my family's history when I was growing up, we truly didn't 
have access to healthcare, preventive care. Excuse me. Today, 
Americans don't--before the Affordable Care Act we never were 
at a hundred percent. During the Affordable Care Act, the new 
system, we are not at a hundred percent. Hospitals have closed 
and opened, et cetera, over the history of time in the United 
States of America.
    My point is this: What I don't appreciate is, when Members 
of Congress try to point out that today's system is the worst 
that it has been, and that is just not true. We have a system 
that needs improvement. That is true. We have a system that is 
trying to get more working families and every family and every 
child more access to healthcare, and to me that is what the 
core of this hearing is about today. How do we improve our 
system? How do we get to a better system where the percentages 
go up and the individuals and the families and the children 
truly have access to real healthcare, preventive care, et 
cetera? I hate to point out that an emergency room cannot turn 
somebody down, that is a conversation for another day. I hope 
we never have to narrow ourselves to that conversation.
    So the main thing that I think this hearing is about today 
is, How can we as elected Members of Congress in the House of 
Representatives--the people's house--how can we advance some 
legislation that will bring us to a better state, a better 
place where more Americans can appreciate the fact that they 
can live through a healthcare situation instead of die because 
of nonaccess to healthcare? That is at the core of what this 
hearing is about, and I really do appreciate all of you coming 
forward.
    Mr. Morley, thank you so much for your bravery of coming 
forth before all of us and letting us know that no one should 
suffer through what you have had to suffer through.
    Thank you very much, Madam Chair. I yield back.
    Ms. Eshoo. The gentleman yields back. The Chair now 
recognizes the gentleman from Florida, Mr. Bilirakis, for his 5 
minutes of questions.
    Mr. Bilirakis. Thank you, Madam Chair. I appreciate it so 
much.
    Dr. Holtz-Eakin, does Medicare for All repeal Obamacare? 
That is the first question.
    Mr. Holtz-Eakin. Yes.
    Mr. Bilirakis. OK. If so, why would Democrats now support 
to repeal Obamacare?
     Mr. Holtz-Eakin. You will have to ask them. I don't know.
    Mr. Bilirakis. OK. Could this be taken as an admission of 
Obamacare's failure to make healthcare more affordable and more 
accessible through increased government intervention and 
mandates?
    Mr. Holtz-Eakin. Again, I would direct you to the authors.
    Mr. Bilirakis. OK. Let me ask you this: Can it be 
guaranteed that taxes will not be raised on the middle class to 
pay for Medicare for All, or that individuals and families will 
not lose coverage under Medicare for All or that seniors' 
benefits will not be changed or reduced? Of course, your 
Medicare Advantage is very popular in my district. About 40 
percent of Medicare recipients are on Medicare Advantage, and 
we have got to protect Medicare Advantage and Medicare for 
seniors in general.
    So that is what my main concern is. Are seniors that are on 
Medicare now--traditional Medicare but also Medicare 
Advantage--could they be affected by this Medicare for All 
bill?
    Mr. Holtz-Eakin. The bill would eliminate Medicare, 
Medicare Advantage included, so that would be gone. So would 
Medicaid. It would eliminate private insurance, so those 
individuals would definitely be affected. The bill is silent on 
financing the costs, which are substantial. I personally 
believe having looked at a variety of these that it is 
implausible to imagine that that taxpayer cost could be picked 
up by a small subset of affluent Americans. It is simply too 
big of a number.
    Mr. Bilirakis. OK, so when you say that Medicare for All--
did you feel that the reimbursement would be cut for hospitals, 
doctors and nurses, et cetera, healthcare providers in general?
    Mr. Holtz-Eakin. Reimbursements would be cut to Medicare 
reimbursement rates and some variations slightly above that, 
which is well below the average of what they get now from 
commercial players, and this would produce financial stresses, 
and those would be solved by either diminishing access and 
quality or by raising other reimbursements and the taxes 
necessary to finance it.
    Mr. Bilirakis. OK, thank you.
    Dr. Atlas, does Medicare for All lead to government 
rationing? If so, why?
    Dr. Atlas. Well, the purpose of Medicare for All, as other 
single-payer systems, part of it is going to be controlling 
costs. And the way that controls costs is certainly not by 
letting people be price-sensitive. It eliminates concern for 
price. So yes, the only way to control costs in the single-
payer systems is to restrict care, and that means rationing of 
care. Yes.
    Mr. Bilirakis. OK.
    Dr. Atlas. That is proven all over the world.
    Mr. Bilirakis. Yes. Well, give me a specific country where 
that takes place, the rationing, please.
    Dr. Atlas. Well, the United Kingdom, Canada, every Western 
European--you know, Denmark, Netherlands, Italy, France, 
everywhere.
    Mr. Bilirakis. OK, thank you very much. I appreciate the 
answer. This is very dear to my heart. I am cochair of the Rare 
Disease Caucus. Increasing access to breakthrough cures and 
treatments, again, are one of my priorities, and I am sure the 
entire committee, both Democrats and Republicans, that is one 
of their priorities as well. How would Medicare for All impact 
patients with rare diseases, in your opinion, Dr. Atlas?
    Dr. Atlas. Well, I think that there is sort of an indirect, 
longer-term problem with single-payer systems, and that is they 
don't just control the costs by restricting access to things 
like new drugs. I mean, the drugs, new drugs, are the basis for 
the new survivals for these rare diseases, generally speaking, 
but they also are going to inhibit innovation because, if you 
are reducing the costs by restricting the use and restricting 
the upside of developing new technology and new drugs, the 
goods are not produced. That is just a fact.
    Mr. Bilirakis. OK, thank you very much.
    Madam Chair, if no one else wants my time, I will yield 
back. And I do appreciate you holding this hearing and then 
allowing us to ask the questions.
    Yes, I will be happy to yield, if you would like, please.
    Ms. Kelly. Thank you so much. I just wanted to----
    Ms. Eshoo. Put your microphone on, please.
    Ms. Kelly. I was looking right at you, Ms. Ross, so--and 
you were shaking your head. I just wanted to give you an 
opportunity to respond to my colleague's question or comments.
    Ms. Ross. Well, obviously we are not proponents of denying 
care to people. We are proponents of making sure that everybody 
gets them. There has been a lot of discussion about the rural 
hospitals, very near and dear to our hearts too. You are right. 
The main reason is the nonexpansion of Medicaid, but the other 
is the for-profit motives of private employers, hospital 
corporates that come in and they opt for a model that will 
serve them better, make them more money, so they close off 
services that people in those communities really need and they 
move them to other places so that our patients cannot get the 
care that they need that they once were able to. So Medicare 
for All actually has globalized budgets, and it has a budget 
for special projects which ensures that those rural hospitals 
and others will be built and opened.
    Ms. Eshoo. Does the gentleman yield back?
    Mr. Bilirakis. Yes.
    Ms. Eshoo. Thank you. The gentleman yields back. Pleasure 
to recognize, from California, Dr. Ruiz for his 5 minutes of 
questions.
    Mr. Ruiz. Thank you very much for having this hearing, this 
very, very important hearing, and I am so happy that we are now 
presenting a variety of different options that can move the 
healthcare system in America forward, because I truly believe--
and I know many of us in this room believe--that every American 
should get the care they need when they need it at an 
affordable low cost, and that should be our goal. Our goal in 
order to achieve that should be universal coverage. Everybody 
should have coverage. And that is how we should, (1), look at 
our efforts, and (2), making sure that out-of-pocket costs are 
low for people, for patients.
    Ms. Ross, you and I are made from the same fabric because 
we worked in the emergency departments, and so we know what it 
means to fight for people, for our patients, and put them at 
the very center of our universe. And, you know, we have made 
some progress. The ACA went a long way in moving us towards 
that goal. In fact, because of the ACA, over 20 million 
individuals are now insured.
    Let me just remind people that being uninsured is a health 
risk. Some may say how can that be? I tell you straight up it 
is a health risk, because if you don't have insurance you can't 
afford your medicine if you get sick, and you will get sicker. 
And you will present to the emergency department, if you make 
it, with ICU-type-level care and your ability to recuperate is 
even worse. So yes, being uninsured is a risk factor, health 
risk factor, and you can die for not being able to prevent 
certain illnesses.
    So this is of important urgency for all of us. We can see 
the benefits of Medicaid expansion when we look at expansion 
States versus nonexpansion States in terms of the providers and 
the hospitals. If you just expanded Medicaid in those States 
that could expand Medicaid but for political reasons chose not 
to, you would reduce the uninsured rate by 5 percent, just by 
that alone.
    So--but, unfortunately, the ACA has not been fully 
implemented. There has been a lot of changes since then to make 
it worse because the number-one singular goal of the--of, you 
know, the Republican Party since Obama passed this--was to 
destroy it, to sabotage it, to then say, ``See, it is not 
working,'' at the expense of the American people's health.
    And so, what are our next steps? You know, well, definitely 
we need to stabilize the market. We need to reduce overall 
healthcare costs. And then we have got to look at adding some 
provisions that would increase the ability for Americans to 
have coverage and therefore to eliminate the uninsured problem, 
health risks, of the American people here.
    So, Professor Rosenbaum, you know, there are a variety of 
Federal public option plans that we have looked at today to 
accomplish universal coverage. And I know the specifics of how 
we do that varies, but can you talk generally about the 
benefits of adding a public option to our current system? 
Specifically is there research to suggest that a public option 
will increase competition, lower costs?
    Ms. Rosenbaum. Yes. Thank you very much. I do believe that 
adding a strong public option both gives people access in 
communities that right now are poorly served by private 
insurance plans and by injecting additional competition into 
the system helps stabilize the cost of care and keep it under 
control.
    Mr. Ruiz. Well, you know, the thing we have to focus here 
is that we need a preferential option. We need not just any 
option, we need a preferential option. And when you look at 
health insurance, you want to make sure that it is expansive 
and protects you and will cover what you need to be covered. 
And let's--I am an emergency medicine doctor, so there is 
nobody who is immune to accidents. Nobody is immune to that 
unfortunate surprise diagnosis that you get that you never 
thought you would ever get, like cancers and whatnot.
    So we need to make sure that it is affordable and that it 
can cover as many ailments that we need to protect patients. In 
addition to that we must address a couple of other issues, and 
one is the provider shortage that we have in our country. We 
need to. We don't have enough nurses. We don't have enough 
doctors. And we need to also look at the delivery of our 
healthcare system and where we focus our resources for 
prevention and public health, not on expensive end-of-life kind 
of care, but the prevention and the public health at the 
beginning. Thank you.
    Ms. Eshoo. And the gentleman----
    Mr. Ruiz. Yields back.
    Ms. Eshoo [continuing]. Yields back. That is right. A 
pleasure to recognize the gentleman from North Carolina, Mr. 
Hudson, for his 5 minutes of questions.
    Mr. Hudson. Thank you, Madam Chair. I appreciate you 
holding this hearing today. I thank the witnesses for your time 
being with us today.
    While I support the broad goals of all the pieces of 
legislation we are considering today, which is to expand access 
to affordable health coverage, I have grave concerns with the 
impacts these bills would have on real people who need to 
access our healthcare system.
    And, Madam Chair, my friend from California just finished 
speaking, and he is and truly my friend, but I have to disagree 
with his characterization that Republicans want to destroy the 
healthcare system to score some political point. I think 
everyone in this room wants to make the system better, wants to 
make it more affordable, and I think the question is, How do we 
get there?
    First, broadly speaking, the population we are trying to 
help is roughly 28 million Americans who cannot afford 
insurance or who have decided not to purchase insurance. By 
comparison, 293 million Americans do have insurance, which is a 
little more than 9 out of every 10 people in this country are 
insured. Medicare is already going broke. The program currently 
covers roughly 44 million people in this country. Under 
Medicare for All, it would have to cover 327 million people. 
That is seven times the size it currently covers. To think that 
we could add seven times more people to the Medicare program 
without a cut in benefits defies common sense.
    Second, we would also be eliminating an entire segment of 
our economy and giving providers a massive pay cut. I shudder 
to think what would happen to access to care in rural areas in 
my district which are already hamstrung. For example, 
Montgomery County in my district, there is only one 
psychiatrist and only two part-time psychiatrists for the 
entire county, and further cuts in benefits or pay rates would 
exacerbate this problem.
    Dr. Atlas, you spoke at length in your testimony about the 
quality of care in this country compared to other countries, 
including wait times experienced by those patients. Have you 
ever studied the private systems that exist alongside the 
public system in those countries, such as in Canada or Great 
Britain, and if so, can you speak to who has access to these 
private systems?
    Dr. Atlas. Yes. There is an increasing trend in countries 
with single payers--specifically the U.K. is a florid example, 
but also all the other countries of Western Europe--that people 
with money opt out of the system--or not opt out, they pay 
their taxes, but they then supplement. There is a significant 
increase in buying private insurance, significant increase in 
paying out of pocket, and they all avoid using their single-
payer system of the people who are affluent enough to do it.
    And that was my point, that the only people stuck with the 
single-payer system are the very people that everybody in this 
room wants to help, the low-income people.
    Mr. Hudson. So in single-payer countries the average 
taxpayer has to wait while wealthy customers don't have to. 
They can see a doctor immediately.
    Dr. Atlas. Well, that is exactly right. There is a parallel 
system, basically, in the U.K. as there is here, really, with 
the Medicaid system, which everybody in this room probably 
knows has worse outcomes than comparable patients with private 
insurance. To celebrate an expansion of Medicaid when no one in 
Congress would want that coverage for their family I find a 
little bit unconscionable.
    Medicaid has worse outcomes from surgery, cancer, heart 
procedures, lung transplants than the same patients with 
private insurance, because of the restrictive access to 
technology and drugs that Medicaid covers. My plan is to make 
Medicaid money go for a bridge towards private insurance. We 
want everybody in the country to have excellence, to have 
access to the excellence of American healthcare, not a separate 
parallel pathway for poor people.
    Mr. Hudson. I agree. It doesn't sound fair to have one 
system for the wealthy and a different one for those who 
aren't. You also testified that the trend in single-payer 
countries is moving towards private options for health 
insurance to supplement or even completely circumvent the 
government-run system. Why do you think it is, and should it be 
instructive for us as we examine these extreme proposals 
looking forward?
    Dr. Atlas. What is the question? I didn't hear it.
    Mr. Hudson. Well, just to continue on the thought, you are 
saying that, for the folks who can afford it, private insurance 
options are supplementing or replacing it. And maybe you have 
answered it already, but why do you think this phenomenon is 
happening in these other countries, that the wealthy go to a 
separate system and everybody else is stuck in the government?
    Dr. Atlas. Because the single-payer coverage restricts 
care. And as we see in the United States, we can expand 
Medicaid all we want, but Medicaid is not accepted by more than 
half of doctors, including doctors who have signed contracts to 
accept Medicaid, according to HHS data. So you label someone as 
insured, but that is not the same as having access to care.
    Mr. Hudson. All right. Well, as my time is expired, Madam 
Chair, I will yield back and thank you.
    Ms. Eshoo. The gentleman yields back.
    I just want to add, Dr. Atlas, what you said about 
Medicaid, Mr. Morley would not be alive were it not for it.
    Now we would like to----
    Dr. Atlas. Yes. We are talking about data, not individuals.
    Ms. Eshoo. Well.
    Dr. Atlas. I am talking about the data in the medical 
literature.
    Ms. Eshoo. So that doesn't include Mr. Morley?
    Dr. Atlas. No, it does. I am thrilled he is here. I mean, 
it is fantastic.
    Ms. Eshoo. Yes, we all are. And we have many Mr. Morleys in 
our country.
    The Chair now would like to recognize the gentlewoman from 
California, Ms. Barragan, for her 5 minutes of questions.
    Ms. Barragan. I thank you.
    So there was a conversation about a system for the wealthy 
and a system for the poor. That, actually, very much describes 
what we have happening in this country. You have--it is even 
worse. You have people who don't have access to any care at 
all. And so, this is the problem, and this is why we need to 
figure out how to get to universal care, because access to 
healthcare is a human right. Everybody should have access to 
it.
    Now I represent a district that is a majority minority 
district. It is almost 90 percent Latino, African American, and 
it is very working class. One of my colleagues likes to hand 
out a list of where your congressional district lies by income. 
Mine is 358 out of 435. People are struggling, and people don't 
have access to healthcare. Now, the ACA was a step in the right 
direction. It did help increase access to healthcare, but there 
are still a lot of people who are left behind, still a lot of 
people who don't have that access. And some people who may have 
something, they get duped into buying some of these junk plans, 
and then they realize they really don't have coverage.
    And so, I want to thank the panelists for being here today 
and for this conversation. Ms. Ross, I want to thank you for 
your work. My sister is a nurse, and I know that you have been 
on the front lines of fighting for Medicare for All in making 
sure that everybody has access to healthcare. And I think the 
bottom line is we can probably all agree that everybody should 
have access to healthcare, and the disagreement happens to be 
on how we get there.
    And I mentioned to you the district, the makeup of my 
district. Can you explain what the benefit would be to 
communities of color if we had Medicare for All and how the 
bill would reduce minority health disparities?
    Ms. Ross. I think I would point to again what I talked 
about with how it is administered, the globalized budgets. 
There would be negotiations between the hospital and the 
regional directors, and you would look at what you would need 
for the following year, looking at what you needed for the year 
before, for one thing, and then you would project. So if you 
knew you had rural hospitals, communities that are underserved, 
and you needed more staff in those hospitals, maybe you needed 
to build a hospital, those are the kinds of things you would 
look at putting into the budget so that people who had 
previously been unserved and underserved would be able to get 
care.
    Ms. Barragan. Great. Thank you. Ms. Ross, in addition to 
being a registered nurse, you are also a national union leader. 
As the president of the largest union of registered nurses in 
the country, we often hear politicians telling us that Medicare 
for All would be bad for union members and that unions wouldn't 
support it. But your union does support Medicare for All, as do 
many national and local unions across the country. Ms. Ross, 
can you tell us, why do unions support this bill?
    Ms. Ross. Well, right now, there is at least 9.3 million 
unions that represent New Yorkers that do want Medicare for 
All. And I think, if you look back at our history, we are to 
the point now where we can't negotiate anymore for better wages 
and working conditions, pension benefits, because everything is 
taken up with bargaining for healthcare. If you look at most of 
the strikes across the country in the last several years, they 
have all been over healthcare benefits. So I think we see the 
handwriting on the wall. And also, I know union workers who 
might like to switch jobs, but they are afraid to because they 
have got their insurance tied to their employer.
    Ms. Barragan. Thank you.
    Mr. Morley, thank you for your advocacy. You are on the 
Hill all the time, and you are very active on social media and 
you are telling your story and telling people about how 
important it is for us to fight on healthcare, something that I 
am proud Democrats have been doing and have been working on a 
bipartisan basis to make sure we find solutions as best we can 
under current conditions.
    Mr. Morley, is there anything you want to share with us, 
any considerations you want to tell us about any of the bills 
before us today?
    Mr. Morley. I just want to say I really think it is so 
important for--I would love to see more of a bipartisan effort. 
There was no need to bring up anything about H.R. 3 today 
because this is not an H.R. 3 hearing, so that makes me kind of 
angry. So any and all bills that will get us towards coverage, 
increase our coverage towards all Americans, is what I am 
trying to achieve as a patient and for all the patients that 
have reached out to me through social media. That is all I have 
ever wanted. And to protect the protections for preexisting 
conditions that are already in place, the expanded Medicaid, 
the ways that the ACA has helped Medicare, that is all I have 
ever wanted, and I don't want to see those protections removed.
    Ms. Barragan. Great. Thank you all for your work. I yield 
back.
    Ms. Eshoo. The gentlewoman yields back. The Chair now 
recognizes the gentleman from Montana, Mr. Gianforte.
    Mr. Gianforte. Thank you, Madam Chair. This is a very 
important hearing for the future of our country. I appreciate 
the panelists being here.
    Medicare is critical to Montana seniors. We should work to 
protect these benefits that they have earned. I believe the 
Federal Government must honor the commitment it made to our 
seniors, but Medicare for All will destroy Medicare as we know 
it. To a casual observer, Medicare for All sounds appealing on 
its face, but it is really just a marketing gimmick. To dig 
deeper beyond the slick marketing efforts of a catchy name, 
Medicare for All is nothing more than a government-run, single-
payer healthcare system. It would end Medicare as we know it 
and leave our seniors in the cold. Medicare for All in practice 
is Medicare for none.
    Now, some of my Democrat colleagues will claim Medicare for 
All is a proposal out of a fringe, out-of-touch wing of the 
Democrat Party, but the truth is it has taken over the 
Democratic Party by storm. Many Democrats jockeying for the 
presidency in 2020 support Medicare for All, and half of the 
Democrats in the House have cosponsored Medicare for All. Let's 
be clear. Medicare for All would gut Medicare and the VA for 
our veterans and force 225,000 Montana seniors who rely on 
Medicare to the back of the line. Montana seniors have earned 
these benefits, and lawmakers shouldn't undermine Medicare and 
threaten healthcare coverage of Montana seniors.
    Medicare for All would devastate rural healthcare, we have 
heard that on the committee today, especially those in Montana. 
They already face overwhelming challenges. Since 2010, more 
than a hundred rural hospitals have closed their doors, and 
nearly 40 percent of all rural hospitals operate on a budget 
shortfall. Under Medicare for All, hospitals in Montana would 
take a 40 percent payment reduction. Hospitals in our rural 
areas would struggle further, and patients would lose access 
entirely to critical providers, like oncologists and heart 
surgeons. Medicare for All will lead to worse access to care in 
our rural communities.
    In addition to gutting Medicare and eliminating access to 
care in our rural communities, Medicare for All is a fiscally 
irresponsible budget buster. Elizabeth Warren, a frontrunner in 
the Democrat primary, has proposed Medicare for All that would 
cost $52 trillion. With a straight face, she campaigns that her 
plan will not raise taxes on the middle class. I don't believe 
that. It doesn't pass the reasonability test. Medicare for All 
would terrify Americans who rely on Medicare and who like their 
employer-sponsored plans. Under Medicare for All, private 
insurance would be banned.
    Folks, this is a government takeover of healthcare, plain 
and simple. We are not a socialist country. Medicare for All 
will gut Medicare and the VA as we know it and put Montana 
seniors at the back of the line. To force 225,000 Montanans who 
rely on Medicare to share their pool with everyone isn't fair 
to Medicare seniors, Montana seniors.
    In reality, Medicare for All is Medicare for none. Instead 
of a reckless government takeover of our healthcare system, we 
should take a bipartisan approach to fix our broken healthcare 
system. We should protect patients with preexisting conditions, 
increase transparency and choice, preserve rural access to 
care, and lower costs. Let's get to work on that and end this 
socialist charade.
    Now, Dr. Atlas, as I said earlier, it seems like our rural 
providers will struggle under a Medicare for All proposal. What 
do you believe will happen to rural hospitals and other 
providers under Medicare for All?
    Dr. Atlas. Well, under a single-payer system where private 
insurance is banned, we already know that Medicare pays less 
than the cost of delivering the care. These hospitals survive 
because of the extra reimbursement they get from the private 
insurers. So it is very naive to think that, oh, we are just 
going to wipe out private insurance and have the Medicare 
payments support all these hospitals. The hospitals will go out 
of business, just like the CMS Actuary said in 2018.
    Mr. Gianforte. OK. Dr. Atlas, would you agree that this 
legislation and bills like it would also require taxpayers to 
fund elective abortion with no limitation?
    Dr. Atlas. I don't know the answer to that.
    Mr. Gianforte. How would you rate--well, with that, Madam 
Chair, I am glad we are having this hearing today. It is very 
important for the American people that we preserve access to 
quality care and get costs down, and with that I yield back.
    Ms. Eshoo. The gentleman yields back. The gentleman from 
Maryland, Mr. Sarbanes, is recognized for 5 minutes.
    Mr. Sarbanes. Thank you, Madam Chair. I want to thank the 
panel.
    First of all, I want to push back pretty hard on the 
doomsday scenario that is being painted by some of our 
colleagues on the other side of the aisle, which to me amounts 
to fearmongering. There is a lot of distortions of what the 
cost of the Medicare for All proposal would be, these scenarios 
about what would happen to hospitals, rural hospitals. The fact 
of the matter is that, under the current Medicare and Medicaid 
programs there is a lot of investment, and that is what it is 
that goes into those kinds of hospitals and delivery systems. 
And so, if you had a Medicare for All system, I think you would 
continue to see that kind of investment. It is not like we 
would just walk away from these critical parts of our delivery 
system, so that has to be accounted for when we are having this 
discussion.
    The thing about the Medicare for All proposals--and there 
are many that have been presented, they all have different 
merits--to me it is the most honest in the sense that I think 
that is where we are going to land, ultimately. The fact of the 
matter is, Americans like Medicare, they like Medicaid, they 
like the veterans' healthcare system, they have basically 
already made a judgment that these systems that are delivered 
and led out of the public sector are ones that give them a 
sense of confidence about their healthcare, and so I think that 
it is just a matter of time before we get to a place where we 
have a Medicare for All system.
    As Representative Jayapal described it, it has got the 
three things you want. It has got universal coverage and access 
so everybody is covered. It has got a comprehensive set of 
benefits so people understand that when they need to see a 
doctor, they need to go to the hospital, they need to get care, 
that that is going to be available to them. And it eliminates 
the wasteful overhead and the predatory practices of the health 
insurance industry, which have inflicted a lot of suffering on 
people for decades now. So that is what Americans want. That is 
where we are going to be, ultimately.
    The discussion that we are having--we are seeing it play 
out even in the sort of the presidential sweepstakes--is how do 
you transition? How quickly do you get there? I think there is 
an appetite to get there as quickly as we can, and that is 
being discussed and it is part of what I think are very robust 
and meaningful and carefully executed analyses of the Medicare 
for All plan that have been put forward. So it doesn't help 
things to just engage in this kind of knee-jerk denigration of 
Medicare for All, pulling out of thin air some of these 
numbers, predictions, and fearmongering. That is not a 
constructive contribution to the discussion.
    Now, I wanted to ask Ms. Ross--the only thing, I only have 
a minute and a half left because I couldn't stop talking. But 
there is--Maryland just--there is just a report released by CMS 
about Maryland's all-payer model, which includes global 
budgeting, and it did show that, when you put global budgeting 
in place, in that instance you are reducing Medicare 
expenditures by 2.8 percent, hospital expenditures by 4.1 
percent, reducing admissions and avoidable hospitalizations, 
and I was just curious to get your perspective on kind of 
global budgeting.
    Obviously, many of the proposals included here, Medicare 
for All as well, incorporates, conceptually, this idea of more 
global budgeting. And so, if you could speak to how that would 
promote transparency, potentially lower costs, and benefit 
patients in underserved and vulnerable communities, if you 
think that kind of approach would achieve those things.
    Ms. Ross. I do, indeed. And I think we are lucky that we 
have the example of Maryland, because it has worked so well 
there. For those who might not know, Maryland started their 
what amounts to global budgeting in 2010, and they started with 
rural hospitals, and it was so successful then they put it in 
the rest of their hospitals, private and public. And what they 
found was--I have got some figures. Their global budget saved 
Medicare as a payer over 420 million in just 3 years. And, 
originally, their goal was to save 330 million over 5 years, so 
it was a whopping success. And, from a nurse's perspective, 
what it does for patients is wonderful, because it reduced 
infection rates, it improved care, it reduced readmission 
rates, and those are all things to look at.
    Ms. Eshoo. I need to interrupt. The gentleman's time has 
expired.
    Mr. Sarbanes. Thanks very much.
    Ms. Eshoo. And we have votes on the floor. I just want to 
inform Members that the Members that are not part of the 
subcommittee I don't think are going to have the opportunity. I 
would stay were it not for the fact that we have votes on the 
floor.
    So where is Mrs. Dingell? Is she here?
    All right, I am going to call on Ms. Kelly from the State 
of Illinois for her 5 minutes. And if Mrs. Dingell comes back, 
I will take her, but then we are going to have to close the 
hearing. So the gentlewoman from Illinois is recognized for her 
5 minutes.
    Ms. Kelly. Thank you all for your testimony today and your 
patience. One thing I have to say, you know, we worked hard 
on--I wasn't here, but my colleagues worked hard on the 
Affordable Care Act, and I don't think there is a Democrat that 
would say that was a perfect bill. But a lot of people that 
didn't have coverage received coverage, but as we know there is 
still about 27\1/2\ million people that don't have the 
coverage.
    But when I came here, instead of spending time and time and 
time trying to repeal the bill, we should have been working on 
how we could make it better, but all we faced was a wall, and I 
think we voted to repeal it 63-plus times. So, you know, let's 
be honest about, you know, what happened. And then there was 
the trifecta of Republican Senate, House, and the President, 
and we still didn't improve healthcare in this nation.
    I am the chair of the Congressional Black Caucus Health 
Braintrust, so I am very concerned about the disparities in 
health for minorities. We, when it comes to morbidity and 
mortality, I mean we lead the cause. I had a bill, the MOMMA's 
Act, that dealt with maternal mortality, and as some of you 
know black women die at 3 to 4 times the rate of white women. I 
had a bill that would take the Medicaid coverage to a year 
instead of 2 months, but I could not get one Republican on that 
bill even though we talk about, you know, we don't want two 
different healthcare systems for the poor and for the rich, but 
then when we have the opportunity we don't do it. Now we got a 
bill out, but we had to water it down.
    Now, Ms. Rosenbaum, you mentioned the need for coordination 
across healthcare, public health education, and job development 
service systems. Could you expand upon this and explain what 
are the ways to address disparities and improve community 
health aside from increasing access to care, which we all know 
is needed?
    Ms. Rosenbaum. Yes. I would like to actually begin by 
disagreeing with Dr. Atlas. I think the infant mortality 
problem in the United States is very real. It is not simply a 
matter of numbers and how we count, and it is made all the more 
real by the terrible disparities on the basis of race and 
income.
    I think it is very important to couple any health coverage 
reform legislation with provisions that do the kinds of things 
that the Braintrust has been such an advocate for, which is 
bulking up public health, bringing healthcare providers under 
sort of a broader public health umbrella, making sure that part 
of the healthcare experience is care management to be able to 
get better access to the kinds of services and interventions 
that we commonly call the social determinants at this point, 
making sure that when you walk in the door for healthcare you 
not only have good healthcare, but you have access to 
nutrition, to housing assistance, to the other things that make 
people healthy.
    The Affordable Care Act actually did a good job of starting 
that process of bridging between health and healthcare. The 
community health center expansion was, of course, incredibly 
important. The Public Health Trust Fund was important. And I 
think it is absolutely key that the Black Caucus continue as it 
was, it was the leader on those kinds of equity measures, that 
it continue to lead on these issues.
    Ms. Kelly. Thank you. And because of time, I yield back.
    Ms. Eshoo. The gentlewoman yields back. And do we have 
anyone else? Is--Mrs. Dingell leave?
    All right, I am going to place in the record the following 
documents: an article from the Century Foundation, ``Health 
Reform's North Star;'' report from the Century Foundation, 
``Road to Universal Coverage;'' coalition letter from Advocates 
for Youth, et al.; a letter from NAACP, et al., regarding 
Medicare for All; letter from the Fraternal Order of Police in 
support of H.R. 4527; letter from the International Association 
of Fire Fighters in support of H.R. 4527; letter from the 
Healthcare Leadership Council; statement from the American 
Nurses Association; and the statement from Representative 
Cedric Richmond; and a statement from BCBS of California; as 
well as the documents that Congressman Shimkus asked to be 
entered in the record. Hearing no objections, so ordered.\1\
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    \1\ The information has been retained in committee files and also 
is available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=110313.
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    Ms. Eshoo. We will recognize the gentleman from Virginia 
for his additions.
    Mr. Griffith. Thank you, Madam Chair. I ask unanimous 
consent to include the following into the record. I understand 
these documents have been shared previously with the majority. 
It would be statements from the American Hospital Association; 
America's Health Insurance Plans; Blue Cross Blue Shield 
Association; Chamber of Commerce; Partnership for America's 
Healthcare Future; Partnership for Employer-Sponsored Coverage; 
Texas Hospital Association; March for Life letter; National 
Right to Life; Ethics and Religious Liberty Commission; Susan 
B. Anthony List; American Action Forum; American Hospital 
Association; Committee for a Responsible Federal Budget; 
Heritage Foundation; Mercatus Center; Partnership for America's 
Healthcare Future; polling from Partnership for America's 
Healthcare Future; news articles and op-eds from the Hill, the 
Washington Post; one-pagers from Blue Cross Blue Shield 
Association; Congressional Pro-Life Caucus; Partnership for 
America's Healthcare Future; and Partnership for Employer-
Sponsored Coverage.
    Thank you, Madam Chair.
    Ms. Eshoo. So ordered.\2\
---------------------------------------------------------------------------
    \2\ The information has been retained in committee files. The 
American Hospital Association, Heritage Foundation, and Mercatus Center 
reports also are available at https://docs.house.gov/Committee/
Calendar/ByEvent.aspx?EventID=110313.
---------------------------------------------------------------------------
    Ms. Eshoo. All Members, pursuant to committee rules, have 
10 business days to submit additional questions for the record 
to be answered by the witnesses who have appeared today, and I 
ask each witness to respond as promptly as possible to any 
questions that are submitted to you.
    Before I gavel the adjournment of the subcommittee, I want 
to thank each one of you. You have taken a great deal of your 
time, put a great deal of effort into your written testimony. 
Each one of you has the passion that you have brought to the 
witness table. You have traveled to come to be with us. I thank 
each one of you.
    At the beginning of this year, as when my colleagues 
elected me the chairwoman, the question was asked, ``Will you 
have a hearing on Medicare for All?'' And I said that I would. 
No one had to twist my arm off for it. This subcommittee has 
been the most productive subcommittee of the Energy and 
Commerce Committee, so it may be December that we are having 
this hearing, but we have taken up major legislation all year 
long. And that was appropriate, and now this hearing.
    So I thank all the advocates that have traveled to be with 
us. Thank you for your passion, for your big dreams--keep it 
up. And with that, the subcommittee is adjourned.
    [Whereupon, at 1:57 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
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