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


                      HEALTHCARE LIFELINE: THE AFFORDABLE CARE 
                           ACT AND THE COVID-19 PANDEMIC

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

                            VIRTUAL HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                     WEDNESDAY, SEPTEMBER 23, 2020

                               __________

                           Serial No. 116-126
                           
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                           


      Printed for the use of the Committee on Energy and Commerce

                   govinfo.gov/committee/house-energy
                        energycommerce.house.gov
                        
                               __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
56-465 PDF                  WASHINGTON : 2024                    
          
-----------------------------------------------------------------------------------                           

                    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...............................     2
    Prepared statement...........................................     3
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................     4
    Prepared statement...........................................     5
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     6
    Prepared statement...........................................     8
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, prepared statement.............................   122

                               Witnesses

Benjamin D. Sommers, M.D., Ph.D., Huntley Quelch Professor of 
  Health Care Economics, Professor of Health Policy and 
  Economics, Professor of Medicine, Harvard Medical School, and 
  Brigham and Women's Hospital...................................    10
    Prepared statement...........................................    12
Douglas Holtz-Eakin, President, American Action Forum............    21
    Prepared statement...........................................    23
    Answers to submitted questions \1\
Aviva Aron-Dine, Ph.D., Vice President For Health Policy Center 
  on Budget and Policy Priorities................................    32
    Prepared statement...........................................    34
Dean Cameron, Director, Idaho Department of Insurance............    46
    Prepared statement...........................................    48
Peter V. Lee, Executive Director, Covered California.............    50
    Prepared statement...........................................    52

                           Submitted Material

Letter of April 3, 2020, to Ms. Seema Verma, from Members of the 
  Energy and Commerce Committee, submitted by Ms. Eshoo..........   124
Letter to Ms. Eshoo, from Charles E. Allen, Executive Director, 
  American Federation of State, County and Municipal Employees 
  Council 57, submitted by Ms. Eshoo.............................   128
Statement of September 23, 2020, from Margaret A. Murray, Chief 
  Executive Officer, Association for Community Affiliated Plans, 
  submitted by Ms. Eshoo.........................................   130
Report of on August 24, 2020, by Seto J. Bagdoyan, Director of 
  Audits, and Howard Arp, Director of Investigations, Forensic 
  Audits and Investigative Service, GAO, submitted by Ms. Eshoo..   139
Letter of September 22, 2020, to Ms. Eshoo and Mr. Burgess, by 
  Andrew Lautz, Policy and Government Affairs Manager, the 
  National Taxpayers Union, submitted by Ms. Eshoo...............   168
Statement from Community Catalyst, submitted Ms. Eshoo...........   175

----------
\1\ Mr. Holtz-Eakin did not answer submitted questions for the 
  record by the time of publication.

 
HEALTH CARE LIFELINE: THE AFFORDABLE CARE ACT AND THE COVID-19 PANDEMIC

                              ----------                              


                     WEDNESDAY, SEPTEMBER 23, 2020

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:00 a.m., via 
Cisco Webex online video conferencing, 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), 
Upton, Shimkus, Guthrie, Griffith, Bilirakis, Long, Bucshon, 
Brooks, Mullin, Hudson, Carter, Gianforte, and Walden (ex 
officio).
    Also present: Representatives Schakowsky, O'Halleran, and 
Rodgers.
    Staff present: Jeffrey C. Carroll, Staff Director; Waverly 
Gordon, Deputy Chief Counsel; Perry Hamilton, Deputy Chief 
Clerk; Saha Khaterzai, Professional Staff Member; Una Lee, 
Chief Health Counsel; Aisling McDonough, Policy Coordinator; 
Meghan Mullon, Policy Analyst; Joe Orlando, Policy Analyst; 
Kaitlyn Peel, Digital Director; Tim Robinson, Chief Counsel; 
Chloe Rodriguez, Deputy Chief Clerk; Rick Van Buren, Health 
Counsel; Nolan Ahern, Minority Professional Staff, Health; Mike 
Bloomquist, Minority Staff Director; William Clutterbuck, 
Minority Staff Assistant; Peter Kielty, Minority General 
Counsel; Ryan Long, Minority Deputy Staff Director; Clare 
Paoletta, Minority Policy Analyst, Health; and Brannon Rains, 
Minority Policy Analyst.
    Ms. Eshoo. The Subcommittee on Health will now come to 
order.
    And due to COVID-19, today's hearing is being held, 
obviously, remotely. All Members and witnesses will be 
participating via video conferencing.
    As part of our hearing, the microphones will be set on mute 
to eliminate background noise. So members and witnesses, please 
unmute your microphone each time you wish to speak so that we 
don't have to go through, can you hear me, am I--I see lips 
moving but no sound.
    Documents for the record, will be sent to--or should be 
sent to Meghan Mullon at the email address we have provided to 
the staff, and all documents will be entered into the record at 
the conclusion of the hearing.
    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

    We begin our hearing today on a really very somber note. 
This week, our country passed the tragic milestone of losing 
200,000 of our fellow Americans to COVID. And last Friday, 
America lost its most consequential jurist of our time, Justice 
Ruth Bader Ginsburg, to pancreatic cancer. These painful losses 
are why we are having this hearing today.
    Millions of Americans are struggling. They are sick, many 
are hungry, so many are jobless. Yet on November 10, the Trump 
administration, along with Republican attorneys general, will 
argue before the Supreme Court that it should strike down the 
entirety of the Affordable Care Act. If successful--and they 
may be--21 million Americans will lose healthcare immediately.
    Protections for the 133 million Americans with preexisting 
conditions, such as asthma, diabetes, and the lasting health 
conditions caused by COVID, which has infected 7 million 
Americans to date, will be gone. Young adults will lose their 
ability to stay on their parents' health insurance until the 
age of 26. Approximately 109 Americans will face lifetime 
limits on their coverage, keeping them from being able to 
afford care for expensive illnesses like cancer, hemophilia, 
and mental health conditions.
    The title of today's hearing calls the Affordable Care Act 
a lifeline. This is the first recession where Americans who 
lose their job-based health coverage have the lifeline of 
affordable coverage because of the ACA. A recent study by the 
Kaiser Family Foundation found that for workers who filed 
unemployment claims during the pandemic, more than 20 million 
may be eligible for the ACA's Medicaid or marketplace coverage.
    Some States, including my home State of California, have 
embraced the Affordable Care Act's lifeline and offered special 
enrollment periods. As we will hear from Peter Lee, the CEO of 
Covered California, the State offered a special enrollment 
period during the pandemic. Between March 20 and August 31, 
nearly 290,000 Californians signed up for coverage through the 
enrollment period.
    I would like to enter into the record the letter I received 
from AFSCME Council 57 that said, quote: California's decision 
to have a special enrollment period for the ACA has been a game 
changer in the lives of those who have lost their healthcare 
coverage when they lost their jobs during the pandemic or have 
been impacted by the wildfires. Sadly, the Trump administration 
has not offered a special enrollment period, keeping Americans 
from the ACA's lifeline.
    The American Medical Association wrote in a friend-of-the-
court briefing that striking down the Affordable Care Act, 
quote, at a time when the system is struggling to respond to a 
pandemic, would be a self-inflicted wound that could take 
decades to heal, unquote.
    I ask my Republican colleagues to avoid these self-
inflicted wounds, end your decade-long fight to repeal and 
weaken the Affordable Care Act. Join us in passing the HEROES 
Act to shore up Medicaid coverage for nearly 73.5 million 
Americans across our country and help save the jobs and health 
coverage of firefighters, of police officers, teachers, 
hospital workers, and other essential workers across our 
country.
    I thank everyone, and I look forward to--we all look 
forward to welcoming and hearing from our witnesses.
    [The prepared statement of Mr. Eshoo follows:]

                Prepared Statement of Hon. Anna G. Eshoo

    We begin our hearing today on a somber note. Earlier this 
week our country passed the tragic milestone of losing 200,000 
of our fellow Americans to COVID-19, and last Friday, America 
lost the greatest jurist of our time, Justice Ruth Bader 
Ginsburg to pancreatic cancer.
    These painful losses are why we're having this hearing 
today. Millions of Americans are struggling, sick, hungry, and 
jobless, yet on November 10th the Trump Administration along 
with Republican Attorneys General will argue before the Supreme 
Court that it should strike down the entirety of the Affordable 
Care Act.
    If successful, and they may be, 21 million Americans will 
lose health coverage immediately.
    Protections for the 133 million Americans with preexisting 
health conditions such as asthma, diabetes, and the lasting 
health conditions caused by COVID-19 which has infected 7 
million Americans to date, will be gone.
    Two million young adults will lose their ability to stay on 
their parent's health insurance until the age of 
26.Approximately 109 million Americans will face lifetime 
limits on their coverage, keeping them from being able to 
afford care for expensive illnesses like cancer, hemophilia, 
and mental health conditions.
    The title of today's hearing calls the Affordable Care Act 
a ``lifeline.'' This is the first recession where Americans who 
lose their job-based health coverage have the lifeline of 
affordable coverage because of the ACA. A recent study by the 
Kaiser Family Foundation found that for the workers who filed 
unemployment claims during the pandemic, more than 20 million 
may be eligible for the ACA's Medicaid or Marketplace coverage.
    Some states, including my home state of California, have 
embraced the Affordable Care Act's lifeline and offered special 
enrollment periods. As we'll hear from Peter Lee, the CEO of 
Covered California, the state offered a special enrollment 
period during the pandemic. Between March 20th and August 31st 
nearly 290,000 Californians signed up for coverage through the 
enrollment period.
    I'd like to enter into the record a letter I received from 
AFSCME Council 57 that said, ``California's decision to have a 
special enrollment period for the ACA has been a game changer 
in the lives of those who have lost their healthcare coverage 
when they lost their jobs during the pandemic or have been 
impacted by the wild fires.''
    Sadly, the Trump Administration has not offered a special 
enrollment period, keeping Americans from the ACA's lifeline.
    The American Medical Association wrote in a Friend of the 
Court Briefing that striking down the Affordable Care Act. ``At 
a time when the system is struggling to respond to a pandemic. 
would be a self-inflicted wound that could take decades to 
heal.''
    I ask my Republican colleagues to avoid these self-
inflicted wounds. End your decade-long fight to repeal and 
weaken the Affordable Care Act. Join us in passing the Heroes 
Act to shore up Medicaid coverage for nearly 73.5 million 
Americans across the country and help save the jobs and health 
coverage of firefighters, police, teachers, hospital workers, 
and other essential workers across the county.
    Thank you and I look forward to hearing from our witnesses.

    Ms. Eshoo. The Chair now recognizes Dr. Burgess, the 
ranking member of the Subcommittee on Health, for 5 minutes for 
his opening statement. And please remember to unmute.
    Is Dr. Burgess with us?
    If not, then I will recognize the ranking member of the 
full committee, Mr. Walden.

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

    Mr. Walden. Well, thank you very much, Madam Chair. I 
assume you can hear me now. I will go ahead and start. I don't 
know where Dr. Burgess is, but I want to thank you for this 
hearing. It could give us a great opportunity to hear from the 
experts--and I hope wewill--on how COVID-19's pandemic has 
affected healthcare coverage in this country.
    And so we all need to have this discussion. We know 
Americans were promised, when the Affordable Care Act passed, a 
$2,500 reduction in our insurance premiums, and lo and behold, 
that obviously never happened; in fact, just the opposite.
    I remember all the stories when the ACA took over about 
people who were promised they could keep their health plan or 
their doctor, and neither of those things panned out well 
either. And meanwhile, we still have their--you know, a lot of 
folks who have no access to care, still in the 10 to 20 percent 
range in some places.
    But I think even as troubling, if not more so, is the 
issues that have arisen around the edges. Chairman Pallone and 
I have worked a lot on this issue of surprise medical billing, 
something President Trump has been out front and leading on for 
most of the time in office. And we are very close it Should 
become law, to stop this practice of surprise medical billing, 
where people think that--who have played by all the rules, 
think that they should be covered. And then as we heard in our 
hearings, turns out they get stuck with a bill for $50,000 
because somebody contracted out some facility within a hospital 
that their insurance said was covered, and they get stuck.
    I am really troubled that we have not provided for 
continuous and robust funding for our community centers. It is 
a travesty that this Congress has not done that. As you know, 
Chairman Pallone and I, with our bill on surprise medical 
billing, could have funded that. And yet for whatever set of 
reasons, that hasn't happened either. And so our community 
health centers are left wondering, in the lurch, how long will 
they have their funding, how can they do their hiring, and they 
are hanging out there.
    And so while we are having this hearing today and certainly 
will be informed thereby, I just sort of suspect that it will 
go down the lines of my friend's opening statement and perhaps 
trigger into some of the politics of healthcare as we are 45 
days out from the election or whatever it is. And so it is 
unfortunate. We have worked together on a lot of issues, and 
there is certainly a lot we could do going forward.
    It is unfortunate that we did not find common ground on the 
issues related to high cost of prescription drugs. But trading 
off innovation for--and cures, especially as we are seeing the 
fight on COVID, for the illusion that you are going to get 
cheaper prices just doesn't make sense.
    And here we are, having worked together on 21st Century 
Cures legislation in the past and investing in our National 
Institutes of Health record amounts, looking forward to the 
various companies that have spent night and day trying to come 
up with a vaccine as they move through their trials. We have 
never needed innovation more, not only in the vaccine world, 
but also in the world of therapies.
    And finally I would just say, we need to work together to 
modernize the Strategic National Stockpile. There have been a 
lot of lessons learned at every phase as we have dealt with 
this unprecedented pandemic, a pandemic that, by the way, has 
killed millions across the world, hundreds of thousands. And it 
is not just in the U.S.
    And so I think that Operation Warp Speed is something that 
we should be proud of, as the administration has moved at 
record pace to break down bureaucratic barriers while 
maintaining safety and efficacy of whatever pharmaceuticals 
become available, either treatments, which they are working on, 
therapies, as well as vaccines. These are twin needs for the 
American people and the healthcare of American people, and the 
administration has moved at record speed through this process 
to get these cures out to the public.
    So I would close with this: I know the issue of preexisting 
conditions is something that is being raised, but let's not 
forget for those Republicans in 1996, as part of ERISA, put 
preexisting condition protection into law. I have multiple 
times this Congress, from day one, literally said, if we are 
going to have this litigation in the courts, shouldn't we come 
together as a Congress and reaffirm the preexisting conditions 
for American people, and that effort has been shot down every 
time by my friends on the other side of the aisle.
    So there is a lot we can find common ground on, Americans 
expect us to do that, and I hope that after this hearing gets 
behind us, we could still work together this fall and get good 
things done.
    And I yield back.
    [The prepared statement of Mr. Walden follows:]

                 Prepared Statement of Hon. Greg Walden

    Thank you, Madame Chairwoman. And welcome to our witnesses, 
thank you forbeing here today to offer your expertise.
    Today's hearing could offer us a great opportunity to hear 
from experts about how the COVID-19 pandemic has affected 
healthcare coverage in this country. We could also discuss how, 
despite the Affordable Care Act still being the law of the 
land, the underlying costs ofhealthcare have continued to rise 
and are now being borne by patients who may have lost their 
employer-based care. Furthermore, we could also explore ways 
for the economy to safely reopen in coordination with public 
health efforts to ensure furloughed workers can come back to 
their jobs and regain the benefits they have bargained for and 
earned. I hope this hearing is an opportunity to discuss those 
worthy issues, which I believe should be of bipartisan 
interest.
    I can't help but feel, however, that today's hearing is 
somewhat political in nature. That this topic will be used as 
an excuse to admonish the Trump Administration and celebrate 
the Affordable Care Act, to relitigate partisan debates of the 
past.
    I want to be perfectly clear: Republicans support 
affordable healthcare for Americans. We also fully support 
protections for patients with pre-existing conditions. In fact, 
measures we've put on the House floor to affirm these 
protections have been denied four different times by Democrats. 
This issue is not up for debate. Holding a hearing that drudges 
up old arguments about the Affordable Care Act in an attempt to 
label Republicans as anti-patient is not only disingenuous, it 
is a waste of precious time.
    In addition to supporting pre-existing conditions 
protections, we also want to address the cost of healthcare, an 
underlying problem that I hear from my constituents about on a 
regular basis. Americas were promised their premiums would go 
down by $2500 a year if we passed the ACA but they did the 
opposite. Addressing the cost of care is why I have worked in a 
bipartisan fashion with Chairman Pallone and Senators Alexander 
and Murray on the Lower Healthcare Costs Act, a bill that would 
bring much-needed transparency into our healthcare system and 
end the nefarious practice of surprise billing. These are the 
kinds of policies we should be discussing today, policies that 
put patients back in control of their healthcare and put 
dollars back in their pockets.
    States, as the laboratories for democracy and public 
policy, are innovating to keep healthcare coverage accessible 
and affordable. My home state of Oregon, by working with both 
the Obama and Trump Administrations, has successfully applied 
for multiple waivers from CMS to invest in care and drive down 
the cost curve.
    I'm also thrilled to have Director Cameron here from my 
neighboring state of Idaho. Director Cameron: I look forward to 
hearing about your partnership with providers to keep costs 
down for patients, especially during the COVID-19 pandemic.
    As for the federal response to COVID-19, we have worked in 
a bipartisan fashion to provide trillions of dollars in relief 
to our communities. We have made testing and associated visits 
free to all patients regardless of their insurance status. We 
have poured funds into state Medicaid programs and set aside 
$175 billion for medical providers to bring accessible testing 
and treatment to patients across the country. We have greatly 
expanded coverage of telehealth services and given patients 
more flexibility in how they spend their hard-earned dollars on 
healthcare expenses during the pandemic.
    We do not believe, however, that the answer to every 
challenge is billions of dollars in increased federal spending. 
We have seen how one-size-fits-all approaches have affected the 
underlying cost of care, and we should be wary of the 
politicization of this crisis as a reason to massively expand 
federal programs. There are many types of coverage, including 
government programs, designed for times like this.
    Dr. Holtz-Eakin: I look forward to your testimony on how we 
can target our response to directly address the challenges 
created by the economic downturn associated with this pandemic.
    I want to close by urging my colleagues on both sides of 
the aisle to resist the temptation to engage in partisan 
politics; to be forward looking in our response to the COVID-19 
pandemic; and to constructively engage our witnesses to tackle 
the legitimate public policy issues that have arisen during 
this crisis. If we simply retreat into our corners and use this 
hearing as an excuse to throw rocks at the other side, the 
American people will not benefit. I yield back.

    Ms. Eshoo. Part 3 contained legislation. Cost of 
therapeutic drugs--Stockpile.
    The Chair now recognizes the chairman of the full 
committee, Mr. Pallone. There is some terrible background 
noise.
    Mr. Walden. Ma'am, I am having trouble hearing you. I would 
like to suspend this----
    Ms. Eshoo. Would everyone mute so that we don't have that? 
It is really--thank you. Oh, there it goes again.
    Frank, I think you are going to have to speak against this 
background noise.

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

    Mr. Pallone. Well, how is it now? Do you hear me well or 
not?
    Ms. Eshoo. I can hear you, yes.
    Mr. Pallone. All right, let me try to----
    Ms. Eshoo. It is still there. It is still there.
    Mr. Pallone. Thank you, Chairwoman Eshoo.
    The COVID-19 pandemic has caused an unprecedented health 
and economic crisis. As many as 200,000 Americans have lost 
their lives, more than 6 million have been infected with the 
disease, of course, tens of millions have lost their jobs. And 
millions of American families are justifiably anxious and 
concerned about both their health and their financial security.
    So as you know, the HEROES Act, which the House passed more 
than four months ago, would provide a lot of support and 
assistance to struggling families by expanding the healthcare 
safety net, increasing support to States to fund the Medicaid 
programs, and ensuring access to free treatment for COVID-19. 
But unfortunately, Senator McConnell and the Trump 
administration either do not understand the need for the 
Federal Government to take bold action, or worse, they prefer 
to willfully ignore and downplay the seriousness of the 
challenge before us.
    So let me be clear, further delay in passing the HEROES Act 
or coming up with some kind of a consensus bill will cost us 
countless lives, lasting damage to our economy, and 
immeasurable financial hardship to millions of American 
families. And unfortunately, the Trump administration is not 
interested in working with Congress to address this crisis.
    I know the President says he wants this or that, he wants a 
big bill, but hasn't really seriously sat down with the House 
leadership to come up with something that we can all agree on. 
Instead, the administration is actually seeking, in my opinion, 
to do further damage to our healthcare system and to the social 
safety net that millions of Americans have turned to during the 
crisis, and that is because the President continues to support 
this Republican lawsuit that is now before the Supreme Court to 
strike down the entire Affordable Care Act in the middle of 
this pandemic.
    And now, the President and Senate Republicans are trying to 
jam a Supreme Court nominee through the Senate, just a month 
before the Presidential election, and I believe a big part of 
that is an attempt to seal the fate of the ACA and ensure its 
demise, because the hearing before the Supreme Court begins in 
November.
    And I want to remind folks that what is at stake here, if 
the Trump administration succeeds and they do strike--and the 
Supreme Court does strike down the ACA. We would have 20 
million Americans who would lose their healthcare coverage, 
protections for more than 133 million people with preexisting 
conditions would be eliminated, and everyone who has been 
infected with COVID-19 now has a preexisting condition and, in 
my opinion, could qualify as a preexisting condition. Also, tax 
credits for affordable health coverage would be gone, and young 
adults would no longer be able to stay on their parents' 
insurance until they turn 26. And of course, there is a lot, 
much more that would be repealed with the ACA, like the Indian 
Healthcare Improvement Act, and the list goes on.
    But it doesn't have to be this way. Instead of attacking 
the ACA, the Trump administration could use it to help people 
in time of crisis. According to a Census Bureau survey, over 3 
millions Americans have lost employer-sponsored coverage 
between April and July of this year. Yet the administration has 
refused to establish a broad special enrollment period to allow 
uninsured Americans to sign up for coverage through the ACA 
marketplace. And the Trump administration also refuses to 
invest in outreach and enrollment efforts to make Americans 
aware of their coverage options, and instead has imposed 
arbitrary barriers seemingly intended to deter enrollment.
    In contrast, State-based marketplaces that have implemented 
broad emergency special enrollment periods have reported 
significant enrollment during the pandemic. People want to sign 
up.
    Now, the Trump administration also continues to undermine 
Medicaid, even though it has been a lifeline for millions 
during the pandemic. According to one estimate, since February, 
Medicaid enrollment has increased by 6 million people. It is 
never a good time to be without health insurance, and it is 
especially dangerous during a pandemic.
    A study by the University of Michigan found that even 
before the pandemic, Medicaid expansion had saved the lives of 
over 19,000 adults between the ages of 55 and 64. Medicaid is 
helping people keep healthcare coverage when they need it most.
    So today's hearing is an opportunity to better understand 
the ACA's impact on the status of health coverage amidst the 
COVID-19 and what needs to be done to expand and improve access 
to qualify--to quality affordable healthcare. And it is also an 
opportunity to reflect on what is at stake when the Supreme 
Court hears oral arguments in Texas v. California on November 
11.
    While the ACA has been a lifeline for millions during the 
pandemic, its future, once again, hangs in the balance of the 
Supreme Court, and I can't imagine, Madam Chair, that the 
stakes could be higher right now. So I look forward to the 
discussion. I think this hearing is very timely. And thank you 
again, Ms. Eshoo.
    [The prepared statement of Chairman Pallone follows:]

                   Prepared Statement of Mr. Pallone

    The COVID-19 pandemic has caused an unprecedented health 
and economic crisis--200,000 Americans have lost their lives, 
more than six million have been infected with the disease and 
tens of millions have lost their jobs. Millions of American 
families are justifiably anxious and concerned about both their 
health and their financial security.
    The Heroes Act, which the House passed more than four 
months ago, would provide more support and assistance to 
struggling families, by expanding the healthcare safety net, 
increasing support to states to fund their Medicaid programs, 
and ensuring access to free treatment for COVID-19. 
Unfortunately, Senator McConnell and the Trump Administration 
either do not understand the need for the Federal Government to 
take bold action, or worse, they prefer to willfully ignore and 
downplay the seriousness of the challenge we face. Let me be 
clear--further delay in passing the Heroes Act will cost us 
countless lives, lasting damage to our economy, and 
immeasurable financial hardship to millions of American 
families.
    Unfortunately, the Trump Administration is not interested 
in working with Congress to address this crisis. Instead, the 
Administration is actually seeking to do further damage to our 
healthcare system and to the social safety net that millions of 
Americans have turned to during this crisis.
    President Trump continues to support the Republican lawsuit 
that is now before the Supreme Court to strike down the entire 
Affordable Care Act (ACA) in the middle of a pandemic that has 
claimed the lives of more than 200,000 Americans. And now, the 
President and Senate Republicans are trying to jam a Supreme 
Court nominee through the Senate just a month before the 
Presidential election, in attempt to seal the fate of the ACA 
and ensure its demise.
    I want to remind folks what is at stake here if the Trump 
Administration succeeds:
     20 million Americans would lose their healthcare coverage;
     1Aprotections for the more than 133 million people with 
pre-existing conditions would be eliminated and everyone who 
has been infected with COVID-19 now has a pre-existing 
condition;
     1Atax credits for affordable health coverage would be 
gone;
     1A young adults would no longer be able to stay on their 
parent's insurance until they turn 26; and much, much more.
    It doesn't have to be this way. Instead of attacking the 
ACA, the Trump Administration could use it to help people in 
time of crisis. According to a Census Bureau survey, over three 
million Americans have lost employer-sponsored coverage between 
April and July of this year alone. Yet, the Administration has 
refused to establish a broad Special Enrollment Period to allow 
uninsured Americans to sign up for coverage through the ACA 
marketplaces.
    The Administration also refuses to invest in outreach and 
enrollment efforts to make Americans aware of their coverage 
options, and instead, has imposed arbitrary barriers seemingly 
intended to deter enrollment. In contrast, state-based 
marketplaces that have implemented broad emergency Special 
Enrollment Periods have reported significant enrollment during 
the pandemic. The Administration also continues to undermine 
Medicaid, even though it has been a lifeline for millions 
during the pandemic. According to one estimate, since February, 
Medicaid enrollment has increased by 6 million people 
nationwide. There's never a good time to be without health 
insurance, and it's especially dangerous during a pandemic. A 
study by the University of Michigan found that even before the 
pandemic, Medicaid expansion had saved the lives of over 19,000 
adults between the ages of 55 and 64. Medicaid is helping 
people keep healthcare coverage when they need it most.
    Today's hearing is an opportunity to better understand the 
ACA's impact on the status of health coverage amidst COVID-19, 
and what needs to be done to expand and improve access to 
quality, affordable healthcare. It is also an opportunity to 
reflect on what's at stake when the Supreme Court hears oral 
arguments in Texas v. California on November 11. While the ACA 
has been a lifeline for millions during the pandemic, its 
future once again hangs in the balance with the Supreme Court. 
The stakes could not be higher.
    I look forward to the discussion today and I yield back.

    Ms. Eshoo. The gentleman yields back.
    To Mr. Walden, do you want to--do you have an opening 
statement for Dr. Burgess? And if not, then we will proceed 
with introducing the witnesses.
    Mr. Walden. Unless anybody else on our side wants the time? 
If not, I think we are prepared to go on to the hearing, Madam 
Chair.
    Ms. Eshoo. OK. Thank you, Mr. Walden.
    The gentleman yields back.
    And the Chair will once again remind Members that pursuant 
to committee rules, all members' written opening statements 
will be made part of the record.
    I now would like to welcome and introduce our witnesses for 
today.
    The first, Dr. Benjamin Sommers, is the Huntley Quelch 
professor of health policy and economics at Harvard, its T.H. 
Chan School of Public Health. Welcome, and thank you, Dr. 
Sommers.
    Mr. Douglas Holtz-Eakin is the president of the American 
Action Forum. Thank you for once again coming to our committee 
and being a witness. We appreciate it. You are always welcome.
    Dr. Aviva Aron-Dine is the vice president for health policy 
at the Center on Budget and Policy Priorities. Welcome to you, 
and thank you.
    Mr. Dean Cameron is the director of the Idaho Department of 
Insurance. Welcome to you, and on behalf of the subcommittee, 
we thank you.
    And last but not least, Mr. Peter Lee, the executive 
director of Covered California. I have said it before, and I 
would like to say it again, that the Lee family in California 
are legendary. His grandfather founded the Palo Alto Medical 
Clinic. Everyone in that generation, from his grandfather and 
father and uncles and aunt, were all MDs.
    So, Dr. Sommers, you are recognized for 5 minutes. And you 
can unmute so we can hear you. Welcome again, and thank you.

STATEMENTS OF BENJAMIN D. SOMMERS, M.D., PH.D., HUNTLEY QUELCH 
PROFESSOR OF HEALTH CARE ECONOMICS, PROFESSOR OF HEALTH POLICY 
& ECONOMICS/PROFESSOR OF MEDICINE, HARVARD T.H. CHAN SCHOOL OF 
  PUBLIC HEALTH/BRIGHAM & WOMEN'S HOSPITAL; DR. DOUGLAS HOLTZ-
   EAKIN, PRESIDENT, AMERICAN ACTION FORUM; AVIVA ARON-DINE, 
 PH.D., VICE PRESIDENT FOR HEALTH POLICY CENTER ON BUDGET AND 
POLICY PRIORITIES; DEAN CAMERON, DIRECTOR, IDAHO DEPARTMENT OF 
     INSURANCE; AND PETER LEE, EXECUTIVE DIRECTOR, COVERED 
                           CALIFORNIA

         STATEMENT OF BENJAMIN D. SOMMERS, M.D., Ph.D.

    Dr. Sommers. Chairwoman Eshoo, Ranking Member Burgess, and 
other distinguished members, thank you for having me here today 
to discuss this important topic. I am a professor at the 
Harvard School of Public Health, a health economist, and a 
physician, and I would like to make three main points in my 
testimony today.
    The Affordable Care Act produced the largest drop in the 
uninsured rate in the U.S. since the creation of Medicare and 
Medicaid more than 50 years ago, with far-ranging benefits to 
public health. Twenty million people gained health insurance, 
and nearly a decade of research has shown that the law has 
produced significant benefits to families of improved 
affordability and financial security, improved access to 
primary care, prescription medications, and care for chronic 
conditions, and downstream improvements in health status across 
a range of conditions, including surgical diseases like 
appendicitis, heart disease, cancer, kidney disease, and 
overall survival. The research is now showing that the ACA has 
literally been a life-saver.
    The second point is that even with the Affordable Care Act, 
there are still nearly 30 million people in the United States 
without health insurance before the pandemic. And this number 
has been rising since 2016. This erosion of coverage has 
happened during a period of low unemployment, and though the 
ACA has narrowed disparities, coverage rates are still lowest 
among low-income families and communities of color.
    The recent growth in the uninsured rate has happened due to 
a combination of factors where the administration has taken 
policy steps to actively undercut the law. These policies 
include shortening open enrollment periods, cutting funding for 
advertising and outreach, repeated efforts to repeal the law, 
which surveys showed left up to a quarter of the public 
confused as to whether the law was still in effect, as well as 
defunding important aspects of the law, including cost-sharing 
reductions for low-income families.
    Finally, the administration has allowed, and in some cases 
encouraged, States to implement policies that make it harder 
for people to enroll and to maintain their health insurance. 
The reason this latter point matters is because the uninsured 
is not a stable population where everyone in it has been 
uninsured for years and years. Many people move in and out of 
coverage over time. This is often called churning, and this 
particularly happens when enrollment in public programs and 
staying in public programs is made difficult.
    One prominent recent example encouraged by the 
administration was work requirements in Medicaid. In research 
that we recently published, we found that work requirements in 
the State of Arkansas, the first State to implement them, led 
to 18,000 people being disenrolled from Medicaid, even though 
our study found that more than 95 percent of the target 
population should have been eligible for coverage but got 
caught up in red tape and complications with the new policy. 
Rather than helping people get enrolled, these policies are 
roadblocks.
    All told, roughly half of the 30 million uninsured 
Americans, before the pandemic, were already eligible for 
either Medicaid or marketplace subsidies. Doing better 
outreach, eliminating red tape, and helping people keep their 
coverage over time are key policies to reduce this number.
    The third point is that the COVID pandemic threatens to 
leave millions more without health insurance, but the ACA is a 
critical safety net for many who are losing their jobs. Prior 
to the Affordable Care Act, when U.S. workers lost their 
coverage through work, roughly one in four no longer had that 
insurance by the end of the year.
    But when we went back and analyzed this data after the 
implementation of the ACA, what we found was that job loss did 
not lead to a significant risk of being becoming uninsured. 
While people did lose their employer coverage, large increases 
in Medicaid and marketplace coverage more than offset that 
loss.
    And more broadly, our research shows that the Affordable 
Care Act produced its largest coverage gains among blue collar 
workers, those in agriculture, transportation, construction, 
and service jobs, many of whom are essential workers during the 
pandemic but are also at high risk for losing their jobs during 
the economic downturn.
    Finally, on a personal note, I am a primary care doctor, 
and I work in a community health center in Boston. I was there 
yesterday afternoon seeing patients. Many of my patients are 
essential workers, stocking grocery store shelves, cleaning 
subway stations, delivering packages, cooking at restaurants, 
and caring for sick patients in nursing homes and hospitals. 
The community I work in has been hit very hard by COVID.
    Even in the best of times, the difference between having 
health insurance and not having it can mean financial security 
or financial ruin. It can mean life or death. And in a 
pandemic, health insurance means being confident that you can 
get seen, get tested, and get treated if you get sick.
    To conclude, there is a simple question for the members of 
the committee here today to face. Do we make it easy or hard 
for people to get coverage and stay enrolled? During a 
pandemic, as a primary care doctor and as a public health 
professor, the community answer is incredibly clear. We have to 
be doing everything we can to get people access to health 
insurance and healthcare.
    I appreciate the opportunity to be here today and to 
participate in this critical conversation.
    [The prepared statement of Dr. Sommers follows:]

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much, Dr. Sommers, for your 
superb testimony.
    It is a pleasure now to recognize Douglas Holtz-Eakin. You 
are recognized for your 5 minutes. And please unmute.

              STATEMENT OF DR. DOUGLAS HOLTZ-EAKIN

    Dr. Holtz-Eakin. Well, thank you, Chairwoman Eshoo, Ranking 
Member Walden, members of the committee. It is a privilege to 
be here today. And I will make three brief points in these 
remarks, and then I look forward to answering your questions.
    The first is the obvious one, which is that the large-scale 
job losses in the second quarter of 2020 really raised the 
specter of sharp increases in the number of uninsured in the 
United States. We saw 22 million people lose their jobs in 
March and April, 20 million in April alone, ten times more than 
the previous 1-month job loss in U.S. history. And I was among 
those who was deeply concerned that there would be a sharp 
decline in employer-sponsored insurance, and as a result, the 
specter of large increases in the uninsured during the middle 
of a pandemic.
    Since then, we have had a number of studies which have 
tried to get a handle on just what the risks are on this front. 
The Kaiser Family Foundation estimated about up to 27 million 
Americans were at risk of losing their insurance, but pointed 
out that all but a few million of them would have some other 
option, a spouse's employer-sponsored insurance, Medicaid, 
Affordable Care Act, things like that.
    There was some work done by the Urban Institute that said 
about 10 million people might lose their insurance, but all but 
3 million of those would find coverage somewhere else. 
Similarly, we have seen estimates of about 5.5 million by 
Families USA and about 6 million from the Economic Policy 
Institute. So all of these suggest that, you know, you could 
have potentially a 25 percent increase in the uninsured, and 
that is a serious concern for this committee.
    The Census Bureau, as I noted in my written testimony, has 
undertaken a remarkable effort to keep track of the welfare of 
American families during the pandemic through a weekly 
Household Pulse Survey which they have constructed. This asks a 
wide range of questions about the economic and personal welfare 
of the families and includes questions about health insurance 
status.
    Remarkably, if you look at those data, which began on April 
23 and have been collected through August 31, they show that 
over that period, there has been a tiny increase in the rate of 
insurance in the United States. I think a correct reading of 
those data is that they bounce up and down on a weekly basis, 
but we have seen no significant change in the number of 
uninsured, the rate of uninsurance, in the United States.
    That is, I think, promising news, that the large-scale 
losses, which we feared early in the downturn, have not yet 
come to happen, but I don't think it is truly a cause for 
complacency. We need to keep an eye on the options that people 
will have if they do lose their employer-sponsored insurance. 
And certainly among those options, first and foremost, is the 
marketplaces of the Affordable Care Act, where it seems to me 
that the major question is the issue of special enrollment 
periods. If an individual loses their employer-sponsored 
insurance due to job loss, they are automatically eligible to 
enroll in the ACA marketplaces. The question is whether we want 
to have special enrollment periods to actively recruit those 
who were not insured prior to the pandemic and now want to take 
up the opportunity to get into the ACA.
    Similarly, we have options for Medicaid as coverage. In the 
Great Recession and as a precedent, the Congress undertook to 
subsidize COBRA coverage. Giving people help in their COBRA 
makes some good sense from the point of view of keeping them in 
their current insurance product, keeping them in their--as a 
result, their current care networks, not switching their 
physicians in the midst of a pandemic.
    The downside to that is, the takeup wasn't particularly 
good in our last experience with this, and so whether it would 
be an effective outreach or not, I think, is an open question.
    And then as a matter of completeness, the last option on 
the table would be the short-term, limited-duration insurance 
plans, which are a recent innovation. These may not be ideal 
for long-term insurance coverage but seem good as a stop-gap 
measure in the midst of the pandemic.
    So I am thrilled to have the chance to be here today. I am 
pleased that the committee is looking at this issue, and I look 
forward to answering your questions.
    [The prepared statement of Dr. Holtz-Eakin follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much for your testimony and for 
joining us once again. The gentleman yields back.
    Now it is a real pleasure to welcome Dr. Aviva Aron-Dine. 
You are now recognized for 5 minutes. And please unmute. Thank 
you again.

              STATEMENT OF AVIVA ARON-DINE, PH.D.

    Dr. Aron-Dine. Thank you, Madam Chair and members of the 
committee, for inviting me to testify today. I will talk about 
the role that Medicaid and the ACA are playing in the crisis, 
the need for action to further strengthen health coverage 
programs, and the catastrophic harm that would occur if the 
Supreme Court struck down the law.
    Medicaid has long played a key role in protecting coverage 
during recession. During the Great Recession, for example, 
increased Medicaid in CHIP enrollment fully offset the loss of 
private coverage for children, preventing any increase in the 
children's uninsured rate.
    But before the ACA, this safety net had a gaping hole. It 
left out many of the adults who were most vulnerable to 
recessions. With Medicaid expansion and the ACA marketplaces 
now filling that gap, we would expect coverage programs to be 
even more responsive to need than in the past. The data 
suggests that is exactly what is happening.
    Through July, Medicaid enrollment in States with available 
data was up about 8 percent and expansion enrollment was up 
about 13 percent. Extrapolated nationwide, that would mean 
Medicaid is covering about 6 million people who might otherwise 
have become uninsured, with about a quarter covered through 
expansion. Mid-year sign-ups for ACA coverage seem to be up 
too, especially in those States that created special enrollment 
opportunities that are easier to access than the standard SEP.
    Medicaid and the ACA are also aiding the response to the 
crisis in other ways. In States that expanded Medicaid, the 
program covers almost 40 percent of low-income essential 
workers, such as home health aides, and hospital, transit, and 
grocery store workers, and low-income people in those jobs are 
about half as likely to be uninsured in expansion compared to 
nonexpansion States.
    States are also using Medicaid authorities to respond to 
the pandemic, for instance, by increasing payments to nursing 
homes and other health providers, expanding access to home- and 
community-based services, and increasing the use of telehealth.
    Congressional action is needed to make sure that the safety 
net doesn't fray under strain. The growing need for Medicaid 
coverage and other demands on the program coincide with the 
historic State budget crisis. In past budget crises, States 
restricted Medicaid eligibility, made it harder for eligible 
people to get in-State covered, eliminated or cut important 
benefits, cut provider payments, and cut other non-Medicaid 
health programs, especially behavioral health. Cuts like those 
would be especially harmful right now.
    Congress, with bipartisan leadership from this committee, 
took a crucial first step back in March, temporarily raising 
the Medicaid match rate and pairing those funds with strong 
protections for beneficiaries coverage. But the growing number 
of States that are making or considering harmful cuts to 
Medicaid shows that additional Federal funding is needed.
    Congress should also strengthen the health safety net for 
this and future recessions by filling remaining gaps. That 
involves both reversing administration policies that have 
undermined coverage and taking affirmative steps to improve the 
ACA's premium tax credits, to make it easier for eligible 
people to get and keep their coverage, and to add to the 
incentives for States to expand Medicaid.
    Unfortunately, as we have already talked about this 
morning, there is also a very real danger that the ACA could 
disappear altogether due to the lawsuit. Before the pandemic, 
Urban Institute researchers estimated that would cause 20 
million people to lose coverage, which means that about 1 in 
every 14 nonelderly people in the country would lose their 
health insurance, and about 1 in 10 among Black and Hispanic 
people. And this year or next, those coverage losses would be 
significantly larger, because more Americans are turning to ACA 
programs due to the crisis, as all of today's witnesses 
discussed in our written testimony.
    Striking down the law would also end protections for people 
with preexisting conditions, from heart disease to cancer to 
diabetes, to the millions of Americans who just acquired a new 
preexisting condition, having had COVID-19. And striking down 
the ACA would weaken health insurance for those still covered, 
from the tens of millions of people with employer plans, whose 
plans imposed annual or lifetime limits before the ACA, to 
Medicare beneficiaries for whom striking down the law could 
raise prescription drug costs.
    It is worth noting that the lawsuit would, at the same 
time, cut taxes for the highest income, one in a thousand 
Americans, by an average of $198,000 per year, which would also 
reduce the revenue flowing to the Medicare Trust Fund and speed 
its insolvency.
    Before I close, I would like to just address the notion 
that there is some viable alternative to the ACA or a 
forthcoming plan that would avoid those harmful consequences. 
Examining the actual ACA replacement proposals put forward 
since 2010 show that they near, rather than avert, the harmful 
consequences of the lawsuit. That includes jeopardizing 
coverage for people with preexisting conditions.
    Thank you, and I look forward to answering your questions.
    [The prepared statement of Dr. Aron-Dine follows:]
   [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, Doctor. It is really a pleasure to 
have you with us.
    The Chair now recognizes Mr. Dean Cameron. You are 
recognized for 5 minutes. And please unmute.

                   STATEMENT OF DEAN CAMERON

    Mr. Cameron. Thank you, Madam Chair. It is a pleasure to be 
with you. And thank you for the opportunity to testify 
regarding Idaho's experience regarding health insurance, the 
ACA, and the COVID-19 pandemic.
    Idaho's perspective and experience may be unique from what 
you have previously heard. I hope it will be helpful as you 
consider broad public policies and the implications on unique 
demographics of each individual State.
    Idaho prides itself on being creative and collaborative in 
finding solutions. It is that collaboration and our regulatory 
approach which led to the creation of our State-based exchange, 
the only Republican State to establish a State-based exchange. 
It is that collaboration and regulatory approach--and by the 
way, that is one of the most successful exchanges in the 
Nation. It is that collaboration that has provided consumers 
with up to five competing carriers participating in the 
individual insurance market. And it is that collaboration which 
proved critical and improved outcomes during this pandemic.
    At the outset, the pandemic in Idaho's emergency 
declaration, the Department of Insurance began meeting 
virtually, weekly, with our carriers. We began collaborating on 
finding solutions to the barriers and dilemmas caused by the 
pandemic, which included everything from testing to treatment, 
to telemedicine, to provider support, to enrollment, to 
pharmaceutical guidelines.
    The results are rather remarkable. Without mandating, 
without requiring, without threatening, all five carriers 
waived copayments, deductibles, and coinsurance on testing, and 
physician visits associated. All five carriers waived 
copayments and deductibles and coinsurance on treatment related 
to COVID-19. All five carriers expanded their telehealth 
network dramatically, allowing easier access for telehealth 
visits, allowing nearly every provider to see their patients 
remotely, and paying those providers as if the patient were 
being seen in person.
    Our telehealth usage increased by 120-fold from February to 
April and 250-fold from April 2019 to April 2020. We went from 
233 telehealth visits in February to 28,503 telehealth visits 
in the month of April alone. This was especially helpful to our 
citizens who needed their mental health provider, where we went 
from 97 visits in February to 11,333.
    We allowed for early refill of prescriptions and the 
ability to obtain a 90-day supply without signature logs or in-
person visits.
    We waived eligibility requirements, allowing employees to 
maintain their coverage while working fewer hours, allowing 
coverage to be more quickly obtained upon return to work, or 
allowing furloughed employees to even stay on their group plan. 
We extended grace periods and reinstatement periods. All five 
of our carriers did this.
    All five of our carriers also provided millions of dollars 
in timely assistance to providers and consumers of the COVID-
19--as non-COVID-19 claims decreased. And I won't take the 
time, in the interest of time, to go into all of those.
    Several of our carriers recently provided millions of 
dollars in refunds and credits to consumers, some as much as 50 
percent in 1 month. The carriers also contributed greatly to 
our community efforts, participating in governor's task forces 
and et cetera.
    From my perspective, the carriers have collaborated really 
well and have really stepped up at a time when all of their 
employees were working remotely.
    There was a huge uncertainty, also, of the impacts of 
COVID-19. Since then, carriers have filed their individual 
market premium rate increases, and I am proud to report that 
the net increases is 1 percent. Three of our carriers actually 
requested a rate reduction, and two of our least expensive 
carriers had a slight increase.
    Lastly, just a note on Medicaid. We have seen a dramatic 
uptick in the number of folks applying for Medicaid during the 
pandemic and a number who qualified for Medicaid expansion. 
That continues to grow. Even with the expanded FMAP match, 
those numbers are concerning to our State budget at this time 
where our economy is good but precarious.
    Madam Chairman, and these collaboration efforts didn't 
happen by accident. They required communication, understanding, 
commitment to our State and our citizens, and I am honored to 
be part of that process. And thank you for allowing me to tell 
part of the story.
    [The prepared statement of Mr. Cameron follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Well, thank you very much for telling your 
story. It is a good story, and we thank you for being with us.
    Last but certainly not least, Peter Lee. It is wonderful to 
see you again. Thank you for always accepting our invitation to 
testify at our subcommittee. You are recognized for 5 minutes. 
And please unmute. We don't want to miss a word.

                     STATEMENT OF PETER LEE

    Mr. Lee. Good morning, Chairwoman Eshoo, and thank you for 
your remarks. I would hope that my uncle, Phil Lee, is watching 
you as we speak today. Also, thank you, Ranking Member Walden, 
distinguished members of the committee. I am Peter Lee. I am 
the executive director of Covered California, which is one of 
the Nation's 13 State-based marketplaces.
    My remarks, written testimony, and just-released report 
from Covered California, reflect our experience working for 
almost ten years to effectively implement the Affordable Care 
Act, and more recently, respond to the COVID-19 pandemic.
    The pandemic and the resulting economic recession have 
demonstrated that, if implemented well, the ACA is working as 
it was intended to do. California, like most States across the 
Nation, red and blue, through the Affordable Care Act, have 
expanded Medicaid, providing coverage to millions.
    Here in California, immediately after Governor Newsom 
declared a state of emergency, Covered California opened a 
COVID-19 special enrollment period and spent millions of 
dollars to make sure Californians who lost their jobs knew they 
could come to us. Results? Yes. We enrolled over twice as many 
people than the same period the year prior, with almost 290,000 
Californians gaining coverage through our COVID-19 special 
enrollment period.
    In stark contrast, we project that nearly 500,000 more 
Americans could have insurance coverage, had the 38 States 
served by the federally facilitated exchange, created a COVID 
special enrollment period and aggressively marketed to 
Americans to know they had options.
    These results are not accidental. They could have been 
predicted. Federal inaction left as many as a half million 
Americans without coverage during a pandemic. This failure to 
act is one of life and death. Early diagnosis and treatment are 
critical to getting good care in COVID-19 times.
    But the pandemic has also put a spotlight on the gaps and 
shortcomings of the ACA. The pandemic exposed the fragility of 
employer-sponsored insurance for many Americans and the 
weaknesses of high-deductible, lower-premium plans that many 
low-income people select in marketplaces.
    Now, we have seen, and we just heard from the gentleman 
from Idaho, that many State, Federal Government, and insurance 
companies have addressed the realities of COVID-19 by having no 
cost sharing for consumers for testing and treatment.
    It is clear that in a pandemic, the public benefits by 
having potentially infected individuals get tested and treated. 
It is less clear why the same logic does not apply to those 
infectious with other conditions, such as hepatitis, malaria, 
HIV/AIDS, or tuberculosis.
    These are common diseases that are not only extremely 
deadly and costly to our health system, but that 
disproportionately impact lower-income consumers, communities 
of color, and those who are underinsured in their employer-
sponsored insurance markets.
    During a pandemic, when coverage is of paramount 
importance, we saw millions suddenly without coverage because 
they lost their job. We saw millions more discover the 
inadequacy of their coverage, and perhaps most problematic, we 
saw many people actually drop coverage altogether.
    This is precisely the opposite of what should happen during 
a global pandemic and economic recession. It is in the public 
interest to have everyone have coverage so they can get help to 
stay healthy and get needed care, regardless of their health 
condition.
    There are ways to strengthen and improve the ACA to make 
health coverage more affordable and accessible to all 
Americans. These are gone into in more depth in my written 
testimony, but I would like to highlight five of them.
    First, you can do what States do: Step up, do more 
outreach. But I need to note, States cannot take the role of 
Federal action. California has taken bold steps to expand 
subsidies. They can't keep doing that. It requires Federal 
action.
    Federally, we should increase subsidies for low- and 
middle-income consumers, such as using gold plans as a 
benchmark and limiting premium costs to no more than eight 
percent of income for all, getting rid of the cliff that is 
hurting middle-income consumers. We should provide options for 
Americans who aren't happy with and have employer coverage that 
isn't adequate. We need to address underlying healthcare costs, 
such as high prescription drug costs.
    And finally, we need to, as a Nation, directly address 
healthcare disparities and inequities. The disproportionate 
impact of COVID-19 on Blacks, Latinos, Asian Pacific Islanders, 
isn't an exception. Sadly, it is the rule that we should be 
addressing.
    The ACA is the right law to build upon, and we risk 
catastrophe if we turn our backs and abandon millions of people 
it protects.
    I look forward to responding to the committee's questions. 
Thank you very much for holding this hearing today, Chairwoman 
Eshoo.
    [The prepared statement of Mr. Lee follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much, Mr. Lee. You are always 
welcome at our committee.
    And to all of the witnesses, thank you for your testimony.
    We will now move to member questions, and the Chair will 
recognize herself for 5 minutes of questions.
    I have a few rapid-fire questions to each witness to 
establish a baseline of fact, so please answer yes or no.
    Dr. Sommers said in his written testimony that, quote, "the 
ACA provides a highly effective safety net for workers who lose 
their jobs," unquote. Mr. Holtz-Eakin said in his written 
testimony that the ACA, quote, appears to be meeting the need, 
unquote, during the pandemic and recession.
    Dr. Aron-Dine, Mr. Lee, and Mr. Cameron, yes or no, do you 
agree with your fellow panelists that the Affordable Care Act 
is a critical part of our social safety net?
    Mr. Lee. Absolutely.
    Ms. Eshoo. Dr. Dine? Mr. Lee?
    Dr. Aron-Dine. Yes.
    Ms. Eshoo. Mr. Cameron?
    All yeses.
    President Trump was interviewed on July 19 on FOX News and 
promised, quote, a full and complete healthcare plan within 2 
weeks.
    Yes or no, are any of you aware of the details of any 
comprehensive care plan, healthcare plan from the Trump 
administration? Dr. Sommers?
    Dr. Sommers. No, I am not.
    Ms. Eshoo. Mr. Holtz-Eakin?
    Dr. Holtz-Eakin. No.
    Ms. Eshoo. Dr. Aron-Dine?
    Dr. Aron-Dine. No, except for the repeal policies they put 
forward in prior budgets and proposals.
    Ms. Eshoo. Yes. Well, that is a wrecking ball.
    Mr. Cameron?
    Mr. Cameron. I can't say that I am.
    Ms. Eshoo. Mr. Lee?
    Mr. Lee. No.
    Ms. Eshoo. Last week, President Trump said during an ABC 
News townhall, quote, we are going to be doing a healthcare 
plan very strongly and protect people with preexisting 
conditions.
    Yes or no, are you aware of the details of any Trump 
administration policy that protects people with preexisting 
conditions? Dr. Sommers?
    Dr. Sommers. No.
    Ms. Eshoo. Dr. Holtz-Eakin--Mr. Holtz-Eakin?
    Dr. Holtz-Eakin. No.
    Ms. Eshoo. Dr. Aron-Dine?
    Dr. Aron-Dine. No.
    Ms. Eshoo. Mr. Cameron?
    Mr. Cameron. Many State laws already protect preexisting 
conditions, including Idaho, who was well in front of the ACA.
    Ms. Eshoo. But are you aware of any details of the Trump 
administration policy to protect people with preexisting 
conditions, yes or no?
    Mr. Cameron. Madam Chairman, I have heard the Trump 
administration and others speak of their intent to protect 
preexisting conditions, and we stand with that as well.
    Ms. Eshoo. I don't know what you are standing with. Are you 
aware of the details? That is what I am asking. Yes or no?
    Mr. Cameron. Madam Chairman, have I seen an actual bill? 
No, I have not seen a bill. Have I heard them speak of----
    Ms. Eshoo. OK. Mr. Lee?
    Mr. Lee. No, I am not, but I would also, Madam Chair, 
welcome the chance to expand on that.
    Ms. Eshoo. All right. Well, let's see how much time I have 
left.
    Mr. Lee. Absolutely.
    Ms. Eshoo. Yesterday, Politico reported that President 
Trump is planning to sign an executive order on healthcare 
coverage later this week.
    Dr. Aron-Dine, you served as senior counselor at HHS and 
Acting Deputy Director of OMB. In your experience, how long 
does it take for the policy ideas espoused in an executive 
order to go through rulemaking so it can be implemented?
    Dr. Aron-Dine. New rulemaking is typically a lengthy 
process, and that is true even when the objectives and legal 
authorities are clear.
    Ms. Eshoo. And when you say they are extended or it takes a 
long period of time, give us an approximation of that.
    Dr. Aron-Dine. A rapid rulemaking process, really starting 
from scratch, could still be a year-long process.
    Ms. Eshoo. Oh. On April 3, I led a letter with every 
Democratic member of the Energy and Commerce Committee, to CMS 
Administrator Seema Verma, asking her to allow Americans to 
enroll in coverage through healthcare.gov during a special 
enrollment period. Six months later, there is still no 
response. No response.
    Mr. Lee, California provided a special enrollment period. 
You spoke to it in your both oral and written testimony. That 
enrollment period was March 20, in response to the COVID 
pandemic. What was the outcome of it?
    Mr. Lee. Yes. The results of that special enrollment period 
were a doubling of enrollment compared to the prior year, 
meaning we enrolled during that period almost 300,000 
Californians, which means about 150,000 more than would have 
but for that effort.
    And I do want to underscore, it is not just a special 
period, because many of those people would be eligible in a 
normal period. It is marketing, it is outreach, it is letting 
people know that our doors were wide open. Those were the 
factors that helped make sure we got so many Californians in 
the door.
    Ms. Eshoo. Thank you.
    I think that my time has expired. And I see that Dr. 
Burgess--am I right--Dr. Burgess has joined us. So I will call 
on Mr. Burgess and then--when the time is appropriate so that 
you can be recognized.
    Do I recognize him now?
    I will recognize Dr. Burgess now for his 5 minutes of 
questions.
    We missed you in the beginning, but we are glad to see that 
you have joined us. You can unmute.
    Where are you?
    I guess he is still not here. So I will recognize Mr. 
Walden, the ranking member of the full committee, for your 5 
minutes of questions.
    Mr. Walden. Thank you, Madam Chair. And thanks to all our 
witnesses for your testimony as we work together on these 
issues to make sure people have adequate access to affordable 
healthcare.
    And again, I would repeat that I think we still have a lot 
of work to do, especially in the area of surprise billing. And 
it is unfortunate that this has not gotten across the finish 
line yet, and hopefully we can get there so that people who are 
covered and play by all the rules don't end up getting a bill 
that they should never get. I mean, there is a big rip-off 
going on out there, and we need to address it thoughtfully, and 
I think we have bipartisan legislation that will do that.
    I would like to go to Mr. Cameron in Idaho. Do you all take 
advantage of the Children's Health Insurance Program?
    Mr. Cameron. Yes, we do, sir.
    Mr. Walden. And what percent of that program is funded by 
the Federal Government in Idaho? I know in Oregon it is about 
99 percent.
    Mr. Cameron. Yes. I believe it is close to 80 percent in 
Idaho.
    Mr. Walden. All right. Do you know off the top of your head 
how many kids and mothers are signed up on CHIP in Idaho?
    Mr. Cameron. You know, I had that data, and I don't have it 
at my fingertips, so I can get it for you, Congressman.
    Mr. Walden. As your neighbor just to the west, because I 
represent all of eastern Oregon, obviously we pay close 
attention on that side of the State to what you all are doing. 
And it has been interesting, States and laboratories. And I 
would like you to go through again, in terms of the--using sort 
of a free-enterprise model, it sounds like, in Idaho, the 
effects you have gotten by competition in your insurance 
market.
    Mr. Cameron. Thank you, Congressman. And I did find that 
number for you on CHIP. We are at 25,846 in 2019.
    Mr. Walden. Is that 25,000?
    Mr. Cameron. 25,000.
    Mr. Walden. Yes. I think in Oregon, we are over 122,000 
kids. And under Republican leadership, we passed a 10-year, 
fully funded extension of CHIP when I chaired the committee. 
That is double the length of any extension that the Children's 
Health Insurance Program.
    And I think on the issue of preexisting conditions, it was 
Republicans in 1996 who led the effort under ERISA. And it is 
my understanding, as you pointed out, your State has 
preexisting protections in place, irrespective of what the 
Supreme Court may do. I put forward legislation and multiple 
initiatives on the floor of the House this Congress to double-
down on that so that we can protect people regardless of what 
the Supreme Court decision is, people with preexisting 
conditions would be protected.
    But I want to get back to the marketplace in Idaho, what 
you have seen, what is working.
    Mr. Cameron. So our experience is contrary to what some 
others testified earlier. Our uninsured population actually 
went up with the passage of the ACA. In fact, it dramatically 
went up and then started to wane, and then as we got into the 
2013 and 2014 year, we started seeing significant numbers of 
individuals leave the marketplace. They were being forced out 
of coverage. We believe that is----
    Mr. Walden. Why?
    Mr. Cameron [continue]. Because prices were too high, and 
they could not qualify for subsidies. We are a rural State, and 
many of our folks could not qualify for the subsidies. And it 
is not just because they were eligible for Medicaid expansion, 
but it was because they are farmers and their incomes are 
unpredictable, or they are spouses to schoolteachers and they 
couldn't qualify for subsidy.
    So we have seen a dramatic exodus from our individual 
market. We have attempted to try and bring those individuals 
back, bring back the young and the healthy. Many of the 
provisions of the ACA, in fact, push the young and the healthy 
away, which drives prices up, which causes more people to 
leave.
    And it is a little ironic, because some of the numbers that 
are counted on the uninsured population also include faith-
based programs, which a large number of our citizenry has gone 
to, or short-term plans. We have created a new plan, call it 
enhanced short-term plan, that is more like an ACA plan and is 
tied to the same risk pool to try and address those issues.
    Mr. Walden. And what kind of premiums can you get to charge 
for that enhanced short-term duration plan?
    Mr. Cameron. So our premiums are about 50 percent lower 
than the ACA plans, but I want to emphasize that we aren't 
pulling people away from the ACA into those programs. They are 
part of the same risk pool. So when the carrier filed their 
rate increases with us this year, that was a net 1 percent, 
some of them a decrease, that included those numbers from their 
enhanced short-term plans as well.
    We have two carriers offering those plans. There has not 
been as great an uptick as we had hoped because of the 
pandemic, I believe, but I think it is a solution that is worth 
exploring.
    Mr. Walden. All right. Well, I thank you for your 
participation, and to all our witnesses today.
    My time is expired, and I yield back, Madam Chair.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the chairman of the full 
committee, Mr. Pallone, for his 5 minutes of questions.
    Mr. Pallonen. Thank you, Chairwoman Eshoo.
    I wanted to ask Dr. Aron-Dine about the ACA and the Supreme 
Court. You know, I know that the ACA has been a lifeline for 
millions during the pandemic, but its future hangs in the 
balance because of this Republican effort to repeal it, which 
is now before the Supreme Court hearing oral arguments November 
11. And, of course, I believe that is the reason why--or a 
major reason why the President and McConnell are trying to push 
a new nominee, to, you know, vote against the--it is a vote in 
favor of the ACA repeal.
    So, Dr. Aron-Dine, if the Supreme Court agrees with the 
Republican position that the ACA should be struck down in its 
entirety, how many individuals would lose coverage?
    Dr. Aron-Dine. Pre-pandemic estimates were that 20 million 
people would lose coverage, and that number would be larger 
today because millions of people are turning to Medicaid 
expansion or the marketplaces for coverage during the 
recession.
    Mr. Pallone. And then, Doctor, based on what you know about 
health insurance prior to the ACA, would people with 
preexisting conditions still be able to get affordable health 
coverage in the event of the Supreme Court repeal?
    Dr. Aron-Dine. Prior to the ACA, the individual market 
really didn't work for people with preexisting conditions or 
other serious health needs. They could be denied coverage, they 
could be charged higher premiums, plans could have major 
benefit gaps, or annual and lifetime limits.
    And I do just want to address this point that States could 
somehow protect their markets against those effects. To the 
extent States try to do that, they face a few big barriers. 
First, they don't have jurisdiction to reimpose protections in 
the self-insured, large-group market. Also, they generally 
don't have the moneys. They are not going to be able to replace 
the tax credits that actually make a market that helps people 
with--that works for people with preexisting conditions work 
for all. A State can't do that by itself without the Federal 
funding that would be eliminated.
    Mr. Pallone. Thank you.
    Now, according to the Mayo Clinic, COVID-19 condemn is a 
long brain and hard and possibly have long-term health 
consequences. Given that, again, if the Supreme Court throws 
out the ACA, is it likely that having COVID-19 would be 
considered a preexisting condition?
    Dr. Aron-Dine. My expectation is yes, and I think this goes 
for a larger problem with insurance markets that don't have any 
coverage standards, which is that there is a really strong 
economic logic behind a race to the bottom. So if you are an 
insurer who doesn't treat COVID as excludable preexisting 
condition, you would worry all your competitors are doing that 
and you are going to cover all of those people and have to pay 
their costs, so you end up excluding it, too. And that same 
logic applies wherever you don't have benefit standards.
    So whether it is excluding maternity or excluding high cost 
drugs, and on and on, you get this race to the bottom that 
leaves people without an option for comprehensive coverage.
    Mr. Pallone. Well, thank you.
    Once again, you know, I am very concerned that the Supreme 
Court holds the future of healthcare for millions of Americans 
in its hands, and the Republicans' and President's efforts to 
jam through a justice, you know, that would vote against the 
ACA jeopardizes its future even further.
    Let me go to Dr. Sommers. I have a little over a minute. 
Could you just tell me--I know a lot of people have lost their 
job based coverage during the pandemic. You can comment on that 
or tell us, where are people turning for healthcare coverage 
during this time? And if individuals are still uninsured, you 
know, what is the reason?
    Dr. Sommers. Well, one place that people turn is if they 
are fortunate enough to have another family member with 
employer coverage, and that does explain part of why many 
people losing coverage haven't become uninsured. For those 
without that good fortune, their situation is either that they 
are going to rely on Medicaid, which, of course, depends on the 
State that you live in and the eligibility criteria. And we 
know that 12 States have not yet expanded Medicaid. And then we 
also have the subsidized coverage in the marketplaces where you 
don't have to be qualifying based on full-time benefit eligible 
employment. If you have got part-time work, if your hours have 
gotten cut and you have got lower income, you might still 
qualify, and that could be an important source of coverage for 
people during the pandemic.
    Mr. Pallone. But, you know, my concern is--and I think it 
is indefensible that the Trump administration has refused to 
establish a broad open enrollment period or invest in outreach 
and enrollment efforts during this pandemic, or people don't 
necessarily know where to turn to, and it is sometimes 
difficult to enroll even when you have lost your job. I don't 
know if you want to comment on that as well.
    Dr. Sommers. Yes, that is absolutely critical. We know that 
just making people eligible isn't enough to get them covered. 
Surveys show that people are often confused about how to 
navigate the process. So aggressive outreach, funding, and 
support for community efforts to assist people in enrolling is 
critical and is something that both States and the Federal 
Government should be doing during the pandemic.
    Mr. Pallone. Thank you, Dr. Sommers.
    And turn it back to Chairwoman Eshoo.
    Ms. Eshoo. The gentleman yields back.
    Has Dr. Burgess joined us? Are you here? Dr. Burgess I 
don't see you.
    Not seeing Dr. Burgess or hearing his voice, the gentleman 
from Illinois, Mr. Shimkus, is recognized for his 5 minutes of 
questions.
    Mr. Shimkus. Thank you, Madam Chairman, and it is great to 
be with you, and it is a great hearing.
    I want to first make a statement on just vaccine 
development. I know it is not the focus of this hearing, but I 
want to stress that while we are all focused on the work being 
done by Operation Warp Speed in expediting the development of 
select vaccine candidates, we still need to embrace the all-
the-above strategy and continue to welcome the contributions of 
non Operation Warp Speed companies and products.
    Operation Warp Speed investment should be purely additive 
and shouldn't displace other promising solutions that could 
prove to be superior to what we thought was possible just six 
months ago.
    And I thank you for that.
    To the panelists, a real quick, easy question, should be an 
easy question, and I think it should be an easy yes or no. Is 
the Constitution of the United States the supreme law of the 
land?
    Dr. Sommers.
    Dr. Sommers. I am not a lawyer, but I believe, yes.
    Mr. Shimkus. Dr. Holtz-Eakin?
    Dr. Holtz-Eakin. Yes.
    Mr. Shimkus. Dr. Aron-Dine?
    Dr. Aron-Dine. I am also not a lawyer, but yes.
    Mr. Shimkus. You don't have to be. You could have taken 
civics as I used to teach it.
    Mr. Cameron?
    Mr. Cameron. Absolutely.
    Mr. Shimkus. And, Mr. Lee?
    Mr. Lee. Yep.
    Mr. Shimkus. So let's talk about this court case that is 
coming up. The question to the Court is whether this National 
Government can force an individual to buy a product of service 
from a private company. When this case was litigated before the 
Supreme Court, the only thing that allowed it to stand was the 
right to tax, which was not what was discussed when we had our 
hearings and we even had this debate on the floor.
    In fact, Republicans continuously said, You are standing on 
the principle that the government has the right to tax, but my 
colleagues on the left kept saying, No, no, no, we can force 
individual citizens to buy a product or service. And that is 
how the debate rolled out.
    Well, under H.R.1 that tax was removed. The simple solution 
for Democrats is to reimpose the tax, and then that way 
reestablish the Affordable Care Act. That is the solution, but 
they are unwilling to do that.
    So I would--I just want to pose that premise that to me the 
Constitution is the preeminent law of the land, and regardless 
of the good intentions of Federal legislation, that is the 
primary arbiter. And since I support jurists who are strict 
construction or originalists, that they don't interpret, based 
upon their experiences, how the founders would have written the 
Constitution, that regardless of what should happen, the 
Supreme Court's rule is, as they say, is this law 
constitutional or is it not? And that is the debate before, not 
whether we like it or we don't like it.
    It is did the Federal Government have the right to pass 
this law on the citizens of the United States? I believe it was 
an unconstitutional law because of forcing people to buy 
something that they should not be forced to buy if they don't 
want it, regardless of the good intentions.
    Now, in my final time--I can't see the clock, Madam 
Chairwoman, so if I need to gavel down, go ahead and do that. 
But in my district, like in Idaho, I hear the ACA is too 
expensive and it doesn't cover folks who need it. And we have 
seen what has happened. The co-ops proposed--there is only 
three of the 26 that are left. Short-term plans are maligned, 
and associated health plans are sabotaged.
    So if we can go to Dr. Holtz-Eakin and my colleague, my 
friend from Idaho, if they could talk about this premise, I 
would appreciate it.
    Dr. Holtz-Eakin. Well, I think, from the beginning of the 
debate over the ACA, one of my concerns has been that it was 
coverage heavy and delivery system reform light and, as a 
result, wasn't addressing the underlying costs of healthcare 
and so insurance costs would inevitably go up. It ran into 
problems on top of that, in terms of pricing, poor competition, 
often very thin at times. Some States threatened to have parts 
where only a single provider was there to offer insurance. And 
so for ten years we have seen this continual issue of the cost 
of health insurance under the ACA.
    Mr. Shimkus. Mr. Cameron?
    Mr. Cameron. Yes, I would add to it, we continue to see 
cost increases, although the last couple of years have not been 
as bad, and as those cost increases occur, and many of them 
occur because they are healthy--you know, I have got, like, the 
couple from Twin Falls, Idaho, 62 and 63 years of age, who 
can't afford $1,500 a month in coverage. They don't qualify for 
a subsidy, and so they end up opting out. And those are the 
individuals we need to be back in the pool, in the system in 
order to make the ACA or any plan affordable.
    Mr. Shimkus. Thank you very much.
    Madam Chairwoman, I yield back my time.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the gentleman from North 
Carolina, Mr. Butterfield.
    Mr. Butterfield. Thank you very much, Madam Chair, for 
convening this hearing today, and thank you for keeping our 
subcommittee engaged even though we are facing some 
unprecedented challenges, and thank you to all of our 
witnesses. Your testimony today is very valuable.
    Before I get into my questions, I just want to respond 
briefly to my friend from Illinois, Mr. Shimkus. The Supreme 
Court is indeed the law of the land. I served as a judge for 15 
years, and certainly I recognize that, and even several years 
on my State Supreme Court. But sometimes the Court is wrong. I 
refer you to the Dred Scott case of 1857, not to mention the 
fact that the public loses confidence in the judiciary when it 
is politicized. I am just saying.
    But let me just address my question to Ms. Aron-Dine, Dr. 
Aron-Dine. We know from experience that when the economy goes 
south and people lose their jobs, their income goes down. They 
turn to Medicaid for health insurance, and enrollment in 
Medicaid increases. And so Medicaid, like SNAP and unemployment 
insurance, is a counter cyclical program, meaning that when the 
economy goes down, enrollment in these programs actually go up. 
This isn't a bad thing. Medicaid is designed to be there for 
people when they actually need it.
    So, Doctor, economic downturns can strain State Medicaid 
budgets in two ways, increase enrollment and decrease State 
revenues. Can you briefly describe for me how that works and 
what it means for State budgets?
    Dr. Aron-Dine. That is exactly right. During a recession, 
States see large drops in their revenues, and then they also 
experience additional, those smaller budget strains from more 
people signing up for Medicaid and other programs.
    In this recession, States are also seeing additional 
strains from specific COVID-19 related costs that they are 
incurring to try to address this pandemic.
    Mr. Butterfield. Now, in years past during economic 
downturns, Congress has stepped in and provided additional 
financial help in the form of increased Federal funds known as 
FMAP. Is that correct?
    Dr. Aron-Dine. Correct.
    Mr. Butterfield. And let me ask you this, the Families 
First Coronavirus Response Act included in my bill that 
increased FMAP by 6.2 percentage points for the duration of the 
public health emergency, how does that compare, if you know, to 
the FMAP increase that Congress included in the Recovery Act 
during the Great Recession?
    Dr. Aron-Dine. So the Recovery Act increase went up and 
down based on State economic conditions, but at its peak it was 
about twice the size of the assistance that was provided in 
this recession.
    Mr. Butterfield. I represent the State of North Carolina, 
and my State, which, unfortunately, has not expanded Medicaid, 
over 2 million people, including many children and seniors, 
receive necessary care from Medicaid. If our States are forced 
to make budget cuts, what coverage, what coverage would be at 
risk?
    Dr. Aron-Dine. Based on what we have seen in past 
recessions, I would be particularly worried about two things.
    One is States cutting back on optional services which are, 
in fact, quite critical, like home- and community-based 
services for seniors and people with disabilities, as well as 
dental and vision coverage.
    I would also be very concerned about States seeking to 
introduce procedural hurdles that make it harder to get 
covered, and so cutting costs by reducing the number of 
eligible people who are actually able to get access to the 
program. As well as others.
    Mr. Butterfield. Would reimbursement rates be affected, in 
your opinion, to the providers?
    Dr. Aron-Dine. Absolutely. And that is something we are 
already seeing, even with the Families First FMAP and the 
protections that came with it is that a number of States are 
cutting provider rates, including for some providers that are 
particularly financially fragile right now.
    Mr. Butterfield. Well, we haven't passed--the Senate hasn't 
passed the Heroes Act, and you certainly know that the Heroes 
Act contained a 14-point FMAP increase, and I am just so 
disappointed that our Senate Republican colleagues have just 
been unwilling to move that legislation.
    Madam Chairman, I think I am going to stop there and yield 
back. Thank you.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize now the gentleman from 
Kentucky,Mr. Guthrie, for his 5 minutes of questions. And 
please unmute.
    Mr. Guthrie. Thank you, Madam Chair, I believe that I have 
unmuted. Thank you very much.
    Dr. Holtz-Eakin, you talked about this, I think, as your 
second point if I remember your three points. And like Idaho, 
you know, I have a district that has lost small businesses, 
farmers, people that are typically in the individual market, 
quite a bit of people in the individual market, and have seen a 
large increase in premiums. And so that is what we have to 
balance, how do we get coverage, how do we get items covered, 
and how do we decrease premiums?
    And one of the ways the architects of the Affordable Care 
Act--one was individual mandate, but the other one was 
enrollment periods. And so now we are talking about, I think, 
talking about a special enrollment period has been proposed. 
And my understanding is if you are working--tell me if I am 
correct, if you have a job and employer and you have employer-
sponsored health insurance and you lose your job, therefore, 
your health insurance, due to the crisis, then you can enroll 
in another program.
    I know we may have to do assistance, I understand that, 
that is expensive, and we have to look at that. But you would 
already have the right to enroll in another program if you lose 
your employee-sponsored health insurance under the current law? 
Is that correct.
    Dr. Holtz-Eakin. That is correct.
    Mr. Guthrie. So we have a special enrollment period. A 
special enrollment period would benefit those who made a choice 
not to purchase health insurance, either through their employer 
or individual market, therefore, made the choice not to pay 
premiums; but now that we have a pandemic and we open up the 
enrollment period, they can go into the marketplace even though 
they haven't paid premiums.
    So what would that do to the costs of health insurance for 
everybody else if people made a choice not to buy health 
insurance and now can buy it because there is a pandemic moving 
forward and they haven't been paying premiums the whole time.
    Dr. Holtz-Eakin. Certainly you run the risk of getting some 
very expensive people into the pool who are not priced by the 
insurers at the beginning of the plan year and running into 
financial difficulties for those insurers. That is not a 
hypothetical.
    We saw this repeatedly during the startup of the ACA when 
there were about 13 special provisions in which you could enter 
the marketplaces during the middle of a plan year and the 
insurers repeatedly complained about how it made it impossible 
for them to manage their offerings effectively, how they as a 
result had to have price increases to anticipate people jumping 
in, and often those individuals would then jump back out and 
get a chance to reenroll somewhere else in the next year.
    Mr. Guthrie. Well, that is not point. It is not what it 
does to insurers, but what insurers do to make up for that. 
What is the end result of that?
    Dr. Holtz-Eakin. It went up. They had to raise premiums to 
anticipate this phenomenon.
    Mr. Guthrie. So those in the marketplace pay more----
    Dr. Holtz-Eakin. Yes.
    Mr. Guthrie [continue]. If you have a special enrollment 
period? That is the concern I wanted to bring up.
    So the second thing on this economic--and as we have seen 
from Idaho and experience that I have is that that causes more 
people to fall out of health insurance. I know the person 
that--I took my car in to get a transmission fixed, and the 
guys said, Well, I am only here certain hours because in the 
morning and afternoon I drive a school bus because I am driving 
for--he goes, essentially I am driving a school bus for $1,600 
a month because that is why he is an individual small business, 
sole proprietor, transmission business.
    But in this economic downturn, we have had big effects. And 
so I want to talk about health insurance coverage and effects 
from this. How does this downturn differ from other, like the 
post financial crisis downturn? Are some of the job numbers 
that we have seen in recent weeks indicative of any of those 
differences? And as the economy starts to come back, does that 
affect what policies you recommend to address any remaining 
coverage issues?
    Dr. Holtz-Eakin. This downturn is unlike any previous 
downturn in the United States. It is characterized by a sharp 
decline in household spending, particularly spending by 
affluent households on those services which involve personal 
contact. And that began in mid-March, and it was so severe that 
in the space of 2 weeks it turned the first quarter growth rate 
into a negative number.
    It continued into the second quarter with these large job 
losses, ten times larger than anything we have seen in a single 
month in U.S. history.
    So the onset is different, it isn't that people didn't have 
income and it isn't that we had a financial disturbance, it was 
the virus, people hiding from the virus and not spending, and 
especially affluent individuals. So that is an important piece.
    For this hearing, one of the things that has happened is 
that the health sector has never before been involved in the 
business cycle, and the health sector is the business cycle. Of 
the 5 percentage point decline in the GDP in the first quarter, 
two full percentage points came from the diminished use of 
health services. People stopped going to doctors and hospitals 
and clinics.
    And what happens to the deliver system going forward I 
think is a very important question. We have seen a lot of 
consolidation in recent years. That is why prices are high. 
That is why insurance becomes expensive. And the ACA actually 
fostered some of that. Now we have got this enormous financial 
distress in the healthcare delivery system that is going to be 
important for an online. But if there is less competition as a 
result, we are going to have a big problem.
    Mr. Guthrie. OK. Thank you. And I see my time just expired. 
I appreciate your answers.
    And I yield back. Thank you.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the gentlewoman from 
California, my wonderful friend, Congresswoman Matsui, for your 
5 minutes.
    Ms. Matsui. Well, thank you, Madam Chair, for calling this 
really important hearing, and thank you for the witnesses for 
being here today, and I just have to have a special shout out 
to Peter Lee as a wonderful Californian who has done a 
wonderful job.
    Let me just say this. The arrival of COVID-19, as we know, 
has quickly turned life as we know it upside down, and 
overnight the pandemic created unprecedented challenges that 
necessitated rapid and extraordinary responses. California has 
been a leader in preserving and expanding access to care, and 
this pandemic response has been no exception. The ACA has been 
a lifeline for millions in California, and in our current 
crisis, the law has proven vital to ensuring that we can meet 
the increased need brought on by the recession.
    Mr. Lee, I want to follow up on the previous question 
regarding the special enrollment period for previously 
uninsured. How have you seen the special enrollment impact the 
risk pool and what effect do you expect on premiums?
    Mr. Lee. Great. Thank you very much, Congresswoman Matsui. 
It is great to see you. I wish I could see you in person.
    Covered California is more sensitive than anyone about the 
importance of the risk mix. California, by enrolling more 
Californians than virtually any other marketplace, has enrolled 
healthier Californians, which means on average our premiums are 
20 percent less than they would have been.
    We engaged our health plan before we opened up the doors 
wide, and we saw 80 percent of the people signing up during the 
special enrollment period were previously eligible, but more 
came in because we marketed. But 20 percent were not eligible 
previously, but they weren't people in ICUs because of COVID. 
They were people scared about getting COVID. They were people 
who were healthy who we want to get tested. We saw those people 
come in, and we then assessed the risk mix.
    So I totally agree with the broad theories that Doug Holtz-
Eakin noted in the early days of the ACA risk mix. We saw a 
healthier risk mix coming in during our special enrollment 
period. It is a win-win.
    You want people to not avoid healthcare during a pandemic, 
and we want to get more people enrolled, a healthier risk mix. 
It is going to lead to lower premiums as in 2021, our plans are 
priced to have a .6 percent premium increase. That is because 
they looked at risk mix; we looked at risk mix. It has been a 
win-win, Congresswoman.
    Ms. Matsui. OK. Thank you very much for that.
    House Democrats have passed legislation to protect 
consumers and help make healthcare more affordable. We pushed 
for provisions in the Heroes Act, as has been mentioned before, 
to establish an emergency special enrollment period and ensure 
access to free COVID-19 treatment. Unfortunately, the Senate 
Republicans have refused to take this up.
    Dr. Aron-Dine, the ACA brought the uninsured rate to 
historic lows. However, under the Trump administration, nearly 
3 million Americans have lost coverage. Can you discuss why the 
number of uninsured Americans began to climb? And also what 
policies should we be putting forward to make it easier for 
people to get a State covered in this and future crises?
    Dr. Aron-Dine. Thank you.
    A number of policies from the administration I think 
contributed to the rise in the uninsured rates that we saw 
prior to the pandemic during a strong economy, but let me 
single out two.
    One is the set of administration policies, but particularly 
the public charge rule, which have really created a climate of 
fear for people, for immigrants and their family members, who 
are eligible for public coverage programs but are worried about 
what might happen if they enroll. And what we saw in the latest 
census data is that the groups you would worry would be most 
affected by that, such as Hispanic people, children not born in 
the United States, were particularly likely to lose coverage.
    A second factor I would single out is the set of 
administration policies that have made it harder for people to 
get and stay enrolled in Medicaid. The worker climate policies 
that Dr. Sommers spoke to were fortunately thrown out in court 
for the most part, but other policies have also created 
procedural barriers. For example, the administration actually 
told Idaho that they had to stop doing something that made it 
easier for people to renew their Medicaid coverage and instead 
had to require more paperwork.
    And so going forward, I think some of the areas to think 
about to fill in the remaining coverage gaps include continuing 
to work on affordability policies, finding ways to make it 
easier for people to get and keep their coverage instead of 
harder, and creating more incentives for the remaining 12 
States to expand Medicaid which is just critical to filling 
that major gap.
    Ms. Matsui. All right. Thank you very much.
    And I know that my time is gone, so I yield back. Thank you 
very much.
    Ms. Eshoo. I am sorry. The gentlewoman yields back.
    Now it is a pleasure to recognize our colleague from 
Virginia, Mr. Griffith, for his 5 minutes of questions.
    Please unmute.
    Mr. Griffith. Thank you very much, Madam Chair. Can you 
hear me?
    Ms. Eshoo. Yes.
    Mr. Griffith. All right. Thank you.
    Look, you know, we have talked about the Supreme Court, and 
one of the things that I think hasn't been said is that if the 
Supreme Court were to rule the ACA unconstitutional, that 
doesn't mean that there is a vacuum that cannot be filled. 
Congress, as civics teacher Shimkus would tell us, Congress has 
an opportunity to step in and fill that and act as it sees 
appropriate, and if we are so concerned about the preexisting 
condition issue, how come we haven't we brought up a standalone 
bill like Greg Walden's H.R. 692 which would take care of that 
and make it clear to everybody? Republicans and Democrats both 
believe that preexisting conditions should be covered.
    And to Chairman Pallone's point, those who have had COVID 
may now have a preexisting condition, well, science is out on 
that. We are trying to figure that one out. And, in fact, I 
have joined an NIH study to see, having had COVID, to see what 
are the subsequent consequence of having had COVID and are 
their health conditions that may come from that 2 to 3 years 
down the road. So we will find that out, but we can fix that if 
we wanted to and we have failed to act.
    Now, let's go to the underlying ACA, and, you know, I have 
said this many times, but it is still true. More than a decade 
ago President Barack Obama visited Bristol, Virginia, in my 
district, and in front of a large crowd, he proclaimed the 
virtues of his healthcare plan, which is now the Obama Care or 
ACA.
    Under the reform I propose, if you would like, you can--if 
you like your doctor, you can keep your doctor. If you like 
your healthcare plan, you can keep your healthcare plan. He 
went on to say, Under the Obama plan, the government would work 
with insurance companies to lower premiums by an average of 
$2,500 per family annually for those who have insurance.
    Well, here is what actually happened. According to Virginia 
State Corporation Commissioner of Insurance, currently seven 
percent of Virginia's population is uninsured. Only one 
insurance company, only one, covers the 29 jurisdictions that I 
am proud to represent, only one. And in 2019, the weighted 
average insurance premiums for individuals in Virginia was 
$796.29 per month. That is up from an average of $322.41 in 
2014 and even more over 2010.
    My constituents feel the pain financially as well as 
physically. Congress continues to hear about problems with the 
ACA and what those problems are causing, even as the pandemic 
has caused more to need individual insurance claims. Since June 
of this year we have had--in my office, we have had at least 54 
separate complaints.
    Dr. Holtz-Eakin, is Virginia isolated in these experiences? 
Did the ACA fulfill its dream of allowing folks to keep their 
healthcare plans, keep their doctors, and lower their health 
insurance premiums?
    Dr. Holtz-Eakin. No. Your characterizations are shared by 
many other States.
    Mr. Griffith. I appreciate that.
    And also, Dr. Holtz-Eakin, in your testimony you discuss 
short-term limited duration plans as a potential stopgap 
measure for some people who have lost their employer-sponsored 
health insurance because of the downturn. You mentioned 
particular people had previously made too much money to qualify 
on certain exchanges when they went to enroll in their special 
enrollment period.
    Can you help me put into understandable terms, who would 
that be? How much money would someone like that had to have 
made and what their choices in how much they pay in the ACA 
exchanges versus a short-term plan?
    Dr. Holtz-Eakin. You get folks making, you know, $150,000 a 
couple and they get hit with the downturn and now what are they 
going to do. So this is a degree of flexibility that was not 
present in prior years, and it gives people an opportunity to, 
you know, have insurance during what they hope is a relatively 
short recession and recovery.
    And we have already seen job growth return to the United 
States. We saw that in May, June, July, August, and in the 
August report we saw private payrolls rising at a 20 percent 
annual rate. So there are reasons to be hopeful that this will 
turn out to be a very limited, very sharp downturn, and then a 
short-term plan is the way to ride that out and get back into 
your regular insurance after that.
    Mr. Griffith. Well, and I appreciate that, and the short-
term plans can be helpful for some people; but let me 
underscore once again that while there has been a lot of 
discussion about preexisting conditions, neither Republicans 
nor Democrats want to see people with preexisting conditions 
not covered.
    And obviously, you know, I have told you I had COVID. I am 
one of those people that may be affected if Chairman Pallone is 
correct, and if the science bears out that there are some 
additional repercussions from having had even a mild case of 
COVID, we will just have to see what happens in the science.
    But neither Democrats nor Republicans are planning to get 
rid of the protection that is afforded to people who have 
preexisting conditions. You would agree with that, wouldn't 
you, Doctor Holtz-Eakin?
    Dr. Holtz-Eakin. Yes, I would. Both sides have put together 
proposals to preserve that protection, so there is no evidence 
that anyone is against it.
    Mr. Griffith. I appreciate it.
    And I yield back.
    Ms. Eshoo. The gentleman yields back.
    I would just add to this discussion that, on the Republican 
side of the aisle, not one Member in the entire House of 
Representatives has spoken up and said that this case at the 
Supreme Court is going to wipe this out and that they are 
deeply concerned about it.
    So I just think it is important to place that on the 
record.
    I now am pleased to recognize the gentlewoman from Florida, 
Ms. Castor, for her 5 minutes of questions. And please unmute. 
Wonderful to see you.
    Ms. Castor. Thank you, Chairwoman Eshoo. This is very 
important hearing today on the Affordable Care Act and COVID-
19. Thank you to our witnesses who are here.
    And, Chairwoman Eshoo, you are right, some of this rhetoric 
does not match the reality. We know, it is crystal clear, that 
President Trump and Republicans are urging the United States 
Supreme Court to strike down the Affordable Care Act in its 
entirety.
    That includes protections for 130 million Americans with a 
preexisting health condition and it also means the coverage for 
1.9 million Floridians who purchase their affordable health 
insurance on the healthcare.gov marketplace. You heard that 
right, 1.9 million Floridians. That is more than the population 
of about a dozen States.
    So the stakes are high here, and it is truly unconscionable 
that this would be urged on at any time, but especially in the 
middle of a public health crisis that has tragically claimed 
the lives of 200,000 Americans. Trump and the GOP are 
attempting to rip coverage away in the courts after they failed 
to do so in Congress, try as hard as they might. What they are 
doing by bringing this case to the United States Supreme Court 
is cruel and it is wrong.
    And, in addition to actively putting the ACA's preexisting 
condition protections at risk, President Trump and his 
administration have also recklessly expanded junk health plans. 
And the result has been that many bad actors have fraudulently 
sold junk plans to consumers.
    These junk plans often do not offer comprehensive coverage, 
and they discriminate against people with preexisting 
conditions. In fact, this committee did an investigation and 
found that junk plans leave families on the hook for hundreds 
of thousands of dollars in medical bills, and they often deny 
claims for medical care that rightfully should be covered.
    In fact, the Federal Trade Commission has gone after some 
of these bad actors for their bait-and-switch tactics. There 
are a number of Federal lawsuits filed against them. But the 
Trump administration has allowed them to proliferate 
needlessly.
    The Affordable Care Act was successful in limiting these 
junk plans and ensuring that families can rely on the 
meaningful health insurance policy when they purchase one. They 
don't want to go back to the battle days when insurance 
companies could discriminate against them if they have asthma 
or cancer, now COVID-19.
    So I understand, Mr. Lee, that California has outlawed junk 
plans. Can you briefly explain why?
    Mr. Lee. I can. Thank you very much for the question.
    I think there is a lot of confusion when people talk about 
short-term plans or faith-based plans. They are cheaper, they 
are great option, they are short term. Let's be clear, it is 
not just fraud. This is what health insurance was ten years 
ago.
    These are plans that can, number one, exclude people based 
on their health status, so they winnow off people. But then 
there is no guarantee that coverage will be there when you are 
sick. It is Swiss cheese coverage. You don't know what is 
covered and what is not covered.
    And they will say, sorry, this short-term plan doesn't 
cover mental health. This one has a cap on hospital. They are a 
great deal, they are cheap if you predict the future; but if 
you could predict the future, you don't need insurance. You 
don't know if you are going to get cancer or end up in the ICU.
    And I would note that in California, we have 800,000 people 
with unsubsidized coverage because we, the State, have kept all 
of the costs down, and that has been a failure of many States 
that have priced middle class Americans out of coverage because 
they have allowed premiums to skyrocket by not marketing, not 
getting people in the door. Going back to short-term plans is a 
wrong solution. We have people come in and out of Covered 
California every month. That is a working solution because, 
when they are with us, if they get sick, they are covered.
    Ms. Castor. So, Dr. Aron-Dine, do junk plans pose a risk 
for families who contract COVID-19? What is going on here? What 
would you warn consumers about here?
    Dr. Aron-Dine. Yes, I do think they pose a risk to people 
who contract any serious illness. And I think there is a bit of 
a sort of myth out there that the people purchasing these plans 
are fully informed consumers making totally rational decisions 
to assume those risks.
    You could question whether anyone is able to make that kind 
of decision about those kinds of risks, but it is also clear 
that these plans are being marketed in misleading ways and that 
they engage, your committee reports finds, in a lot of what is 
called ex-post underwriting, which is fancy word for finding 
reasons to deny people's claims once they get sick.
    So that is not coverage that people are making an informed 
decision to buy. It is coverage that is really leaving them 
without protection.
    Ms. Castor. Thank you.
    And I yield back.
    Ms. Eshoo. I am sorry. The gentlewoman yields back.
    It is a pleasure to recognize the gentleman from Florida, 
Mr. Bilirakis, for his 5 minutes of questions.
    Mr. Bilirakis. Thank you so much, Madam Chair. I appreciate 
it very much. And thanks for holding this hearing, and I thank 
the witnesses for testifying as well.
    Like my colleagues on and off this committee and this 
administration, I, too, support protections for those with 
preexisting conditions and funding our community health 
centers. However, like many Americans, I remain concerned with 
the continued high cost of healthcare despite the ACA's 
passage.
    Dr. Holtz-Eakin, one of the major promises of the ACA was 
affordable insurance for every American. The law even went so 
far as to penalize those who didn't enroll. However, in the 
decade since its enactment, costs continue to rise. Why is 
that, in your opinion? Why is that?
    Dr. Holtz-Eakin. Well, I think one of the key features 
across the United States has been increased consolidation in 
providers, hospitals buying up doctor physician groups, and the 
like, which allow them to have more market power and higher 
prices for delivering the underlying services.
    And insurance, in the end, is a product that just shifts 
the bill from one individual to another. If the bill is too 
large, insurance is going to be very, very expensive. And so I 
think that has been a concern among health policy experts of 
all stripes, that lack of competition and how to address the 
increase in prices.
    Mr. Bilirakis. OK. Thank you.
    Director Cameron, the pandemic has further stressed the 
mental health of our communities. I think we can all agree on 
that. Recent data from my district indicates increased overdose 
rates, unfortunately, this year, with August being one of the 
deadliest marks on record.
    Congressman Soto and I introduced H.R. 5473, the Enhance 
Access to Support Essential Behavioral Health Services Act, 
which builds on landmark opioid legislation passed by this 
committee last Congress to expand reimbursement for behavioral 
and mental health services delivered through telehealth, 
regardless of whether someone has substance abuse disorder.
    Would you agree that preventive measures like the EASE 
Behavioral Health Services Act would be helpful in addressing 
our Nation's mental health crisis? And I believe that that was 
placed in Ann Wagner's bill. But we would love to get that 
through this committee but also on the floor of the House as 
soon possible.
    What is your opinion on that, on that particular bill, sir?
    Mr. Cameron. Thank you, Congressman. I have not seen the 
language, but I certainly believe that providing mental health 
services is paramount. We have been very successful in 
improving that through our telemedicine. In fact, that has been 
a real hallmark of what has happened this last year and, you 
know, certainly support any efforts in that direction.
    Mr. Bilirakis. Yes, people have to have access, no 
question.
    Again, Director Cameron, you mention in your testimony 
seeing an uptick in telehealth visits in Idaho. Pre-pandemic, 
some stakeholders cited a lack of clarity around Federal 
reimbursement for telehealth for substance abuse disorders 
under Medicaid.
    Do you agree with that sentiment? And would additional 
guidance from the appropriate agencies at HHS be helpful to 
ultimately ensure that those who needed treatment can have 
access to it?
    Mr. Cameron. Well, it certainly can't hurt. I think it is 
more complicated than that. I think people were not using 
telehealth services, A, because they weren't especially 
comfortable with it, and they got real comfortable real quick 
in the pandemic.
    I think providers weren't offering it because they weren't 
necessarily comfortable. They liked the old system of being 
able to see people face-to-face. And in many cases, that is 
ideal. But one of the things the pandemic has done is it has 
sort of blown the doors open and allowed consumers to be able 
to access and utilize it, and I think many are seeing they 
actually prefer it now.
    Mr. Bilirakis. Yes. That is what we are hearing, too, 
because they can actually do it in the privacy of their own 
home and it is so very convenient.
    Mr. Cameron. Yes.
    Mr. Bilirakis. One last question. I don't want to go over, 
Madam Chair.
    Dr. Holtz-Eakin, CMS released a report in August of 2019 on 
individual insurance market enrollment trends. Data shows that 
between 2016 and 2018, unsubsidized enrollment declined by 
approximately 40 percent. If the ACA has fulfilled its promise 
to provide affordable healthcare to all, why has this decline 
occurred? Is it an affordable issue?
    Again, thank you, Madam Chair, for allowing me to ask that 
question.
    If you could respond briefly, I would appreciate it. This 
is for Dr. Holtz-Eakin.
    Ms. Eshoo. Yes.
    Dr. Holtz-Eakin. I think it is an affordable issue, by and 
large, and I would be happy to elaborate in writing after the 
hearing.
    Mr. Bilirakis. Thank you very much.
    I yield back, Madam Chair.
    Ms. Eshoo. The gentleman yields back.
    And the gentleman from Maryland, Mr. Sarbanes, please 
unmute and you have your 5 minutes for questions.
    Mr. Sarbanes. Thank you, Madam Chair. Can you hear me?
    Ms. Eshoo. Very well.
    Mr. Sarbanes. Excellent. I appreciate the testimony today.
    Let's call a spade a spade when it comes to the Republican 
attacks on the ACA. This has been an obsession with the 
Republicans for more than ten years. The attack that is coming 
with the Supreme Court case in November and its effort to ram 
through the appointment of a new justice before the election is 
just the latest play out of that playbook that we have seen for 
years, which, in my view, is really just an effort to try to 
attack one of the legacy achievements of President Obama.
    But leaving that where it is for the moment, Dr. Lee--or, 
Mr. Lee, if you could describe, we have seen the Trump 
administration, obviously, engage in leadership malpractice 
when it comes to responding to the pandemic, and we could speak 
about the broad GOP reluctance to embrace the opportunities of 
the ACA over the last ten years.
    But if you are in the middle of a pandemic, you start to 
see huge job losses disruptive to people's coverage. It seems 
to me that if there is in your tool kit something that you can 
do using the ACA and using exchanges and you don't take 
advantage of that, that is leadership malpractice of the 
highest order.
    Describe the moment when you pulled your team together to 
demonstrate proficiency in leadership in this moment, when you 
saw what was happening and you saw the amount of people that 
were being thrown into this place of not having coverage, that 
morning, that meeting when you convened people and you said, 
Here are the tools we are going to use that are available to us 
through Covered California, because of the ACA, to make sure 
that we help people get through this crisis.
    What were the first two or three things you knew you had to 
do that unfortunately were not happening at the Federal level?
    Mr. Lee. Thank you very much for that question.
    Now, oddly, I think the first meeting we had was six years 
ago. It is not just about a pandemic. It is for the last five 
years saying we will do everything to make every Californian 
over there for them. And I think there has been a failure of 
action at the Federal level since March but also for about 
three years, cutting back on spending, not supporting 
navigators, promoting short-term plans which weaken the risk 
mix.
    But what we did this year, March 19 our Governor declared a 
state of emergency. March 20 we declared a special enrollment 
period. And we have spent $9 million in advertising, and every 
day since then, when a Californian got an unemployment check, 
they got a flier from Covered California, and our 500 
storefronts across California were open virtually taking 
enrollment by phone, and we promoted that. It is a matter of 
saying again, in America, there is half a million more 
Americans uninsured today because of Federal inaction. Those 
are people----
    Mr. Sarbanes. Can you imagine--thank you for that.
    Can you imagine if the President of the United States in 
the midst of this crisis had led with all of the efforts that 
you just described at the national level, had gotten on the 
phone with Governors across the country and States who had 
their own health exchanges and said this is what we are going 
to do as a team to respond to this crisis? But he didn't do it. 
And now he is trying to take down the ACA in the middle of this 
pandemic once again.
    Let me turn to Dr. Sommers because my head is exploding 
when I keep hearing my colleagues across the aisle talk 
reverentially about their desire to protect people with 
preexisting conditions, but you can't just pull that out of 
thin air. I mean, there are actuarial dynamics to this, the way 
insurance pools function, and all the rest of it, that can 
allow you to do that effectively, i.e., through the mechanism 
that we have set up through the ACA or to just try and pull it 
out of thin air, which is what I think their approach is going 
to be.
    Can you just talk to why, if you really want to do that 
effectively, cover people with preexisting conditions, you need 
to do it inside of a structure, an insurance structure and a 
coverage structure that actually makes sense and is 
sustainable?
    Dr. Sommers. Yes. So States before the Affordable Care Act 
did try this, and what they found was that if they made rules 
that said you have to take all comers, but they didn't have the 
infrastructure of the ACA, they didn't have the tax credits and 
the subsidies, basically what happened was only sick people 
signed up, premiums went through the roof, and the markets 
collapsed. You need to hold infrastructure of the ACA. You 
can't just put out that edict that says cover everybody.
    Mr. Sarbanes. Thank you.
    I yield back.
    Ms. Eshoo. The gentleman yields back.
    Pleasure to recognize the gentleman from Missouri, Mr. 
Long, for his 5 minutes of questions. And please unmute.
    Mr. Long. Thank you, Madam Chair, and thank you all for 
being here today.
    Dr. Holtz-Eakin, much has been made of how the affordable 
healthcare is under the--excuse me. I am going to start again.
    Much has been made of how affordable healthcare is under 
the current system, but can you talk about any trends you have 
seen that relate to the actual cost of care, not what the 
patients pay at the counter in the form of co-pay or 
coinsurance, but the underlying costs of care?
    Dr. Holtz-Eakin. I think we saw in the 2 or 3 years in the 
aftermath of the Affordable Care Act a noticeable diminishment 
in the pace of so-called excess cost growth, the rate at which 
healthcare costs go up faster than incomes in the United 
States.
    But more recently we have seen that go back to something 
closer to the bad old days, and acceleration in those costs. A 
lot is made of prescription drugs and particularly retail 
prescription drugs, but they are a small fraction of the 
healthcare bill. The vast majority of the costs are hospitals 
and doctors and other providers, and it is there that the 
attention needs to be focused if we want to slow the pace of 
the healthcare billing in the United States.
    Mr. Long. OK. Thank you.
    And, Director Cameron, I understand that in Idaho you offer 
a specific type of short-term plan that might be useful during 
the time period when folks may have a few months' gap between 
their loss of a job-based coverage and the next open enrollment 
plan. Can you talk about these plans and what kind of feedback 
you have gotten on them?
    Mr. Cameron. Certainly. Thank you, Congressman.
    So these plans should not be confused with traditional 
short-term plans. They are what we call as enhanced short-term 
plans. They are designed to be renewable. They have all of the 
same essential health benefits or requirements or coverages. 
They are not what one Congressman has called as junk insurance. 
They have the same.
    They have the same preexisting predictions or very similar 
preexisting condition protections to an ACA plan, but they are 
available and allow enrollment year around or at open 
enrollment if a person chooses to.
    They have provided an answer for us because we keep them in 
the same risk pool. So they are tied--their rates are tied to 
that of the ACA plans, and it helps attract and bring back 
those young and healthy individuals and families that need 
coverage, like the family in Oakley, Idaho, who are--the wife 
is a breast cancer survivor who knows the importance of 
coverage but can't afford $2,100 a month. They are cattlemen. 
Their prices change every day, and they don't qualify for a 
subsidy.
    So for them they are being forced out of ACA coverage out 
of no desire of their own but simply because of price. This has 
provided an alternative for them that, in essence, helps all of 
those that are enrolled by keeping it in the same risk pool.
    Mr. Long. OK. I might add that my sister has been a 
resident of Ketchum, Idaho, for 40-some years now, so I don't 
think we are getting her back to Missouri.
    And do you regulate these products to ensure that they are 
marketed fairly and honestly to consumers?
    Mr. Cameron. Absolutely. We very strongly regulate them. We 
make sure--and, by the way, I need to tell you, when I talked 
earlier about the traditional plans waiving co-payments and 
deductibles and co-sharing for COVID, so did these enhanced 
plans. They did the same things, and we regulate to make sure 
that their advertisements are not misleading, that they fulfill 
the conditions of their policies, and we go after those that do 
so inappropriately.
    Mr. Long. So instead of issuing broad mandates and 
restricting plan design, is it safe to say you have opened up 
the markets, collaborated with your health plans, and increased 
competition to make more choices available to your citizens?
    Mr. Cameron. Absolutely. Our goal is to have more people 
insured. The original goal of the ACA was to insure more 
people, and then some of the provisions actually started 
limiting who could actually obtain coverage. So our goal is to 
have more people insured. We have collaborated with our 
carriers. We will now have three carriers offering these type 
of plans this coming year.
    Mr. Long. During the pandemic you had plans set up and 
volunteered to offer credits back to consumers, make advance 
payments to providers to help get them through the downturn?
    Mr. Cameron. Yes, yes, sir.
    Mr. Long. And what effect have these policies had on 
premiums for your citizens?
    Mr. Cameron. Well, in many cases they have actually lowered 
the price from where they were previously. One of our carriers 
lowered the price by 50 percent on dental premiums, others 
lowered it by 15 percent over this next year.
    What has happened is that we don't have as many people 
taking advantage of, you know, treatment that wasn't as 
necessary, and so the amount of claims being spent has 
dramatically decreased, and so they have been refunding that 
money back.
    Mr. Long. OK. Madam Chair, I don't have any time to yield 
back, but if I did, I sure would.
    Ms. Eshoo. The gentleman yields back.
    I would just like to say to the witness from Idaho, it 
would be, I think, instructive for you to read the June 25 
report that the Energy and Commerce Committee all put together 
that found short-term plans denied and rescinded coverage for 
millions of people. And after reading that, I would look 
forward to your kind of written response to it. But I do think 
that it would be instructive. It was highly instructive to me.
    Now it is a pleasure for me to recognize the gentleman from 
New Mexico, Mr. Lujan, for his 5 minutes of questions.
    Mr. Lujan. Thank you, Madam Chair.
    Before I begin my remarks, Madam Chair, I do have a 
unanimous consent request.
    Ms. Eshoo. Would you please state it.
    Mr. Lujan. That is to submit a GAO report, the Government 
Accountability Office, August 24, 2020, ``Private Health 
Coverage Results of COVID Testing for Selected Offerings.''
    Ms. Eshoo. The unanimous consent request is approved. It is 
already a part of the record, and at the end of the hearing, I 
will name everything that has been placed in the record.
    [The information appears at the conclusion of the hearing.]
    Mr. Lujan. Thank you, Madam Chair. I am not sure if my 
clock can be reset. But nonetheless, Madam Chair, the reason 
that that report is so very much is when you go into the 
summary findings of that report, what the GAO found is when 
they were out there looking at folks that were selling what my 
colleagues on the other side of the aisle are calling short-
term plans, that I have heard everyone else call a junk plan, 
they found that there were deceptive marketing practices 
similar to the findings from the Energy and Commerce Committee.
    And what is clearly listed here is that those short-term 
plans, the plans that I refer to as junk plans, they do not 
cover people with preexisting conditions. People need to stop 
lying to innocent folks that are out there and convincing them 
that these plans are going to cover their cancer, their 
diabetes, or if they get in an accident.
    Many of these plans don't even cover prescription drug 
costs. They don't cover ambulatory care. Enough. Let's just be 
honest. If you want to sell people these short-term plans, 
let's be honest with the American people as to what they are 
buying so that way people are not left without. That is all we 
are saying here.
    Truth and transparency. Why is it that the Trump 
administration eliminated the requirement on those junk plans 
to list exactly why they were so bad? I have screenshots from 
superintendent sites across America before President Obama's 
administration--or sorry, before President Trump's 
administration changed that rule and after, and you see that 
its name has changed. But that is a conversation for another 
day, Madam Chair.
    At this very moment, the Trump administration and 
Republican Governors and Attorney Generals are leading efforts 
with the U.S. Supreme Court in a case where they are seeking to 
strike down the entire Affordable Care Act.
    They aren't asking the U.S. Supreme Court to keep the parts 
they claim they like, such as protections for people with 
preexisting conditions. They are asking the Supreme Court to 
strike down the whole law during the public crisis that has 
taken the lives of more than 200,000 Americans.
    If the ACA is struck down, protections for people with 
preexisting conditions would be gone. That now includes the 
nearly 7 million Americans who have been infected with COVID-19 
who could be denied coverage for the rest of their lives. More 
than 20 million people would lose their healthcare coverage, 
including 226,000 New Mexicans, more than doubling the number 
of people in our State who are uninsured.
    The 9 million people who receive subsidies to make their 
premiums more affordable would be on their own. In the middle 
of a State budget crisis, States like New Mexico would be left 
to shoulder the full cost of keeping people covered through 
Medicaid.
    Now, remember that bill that Republicans tried passing in 
2017? That actually eliminated every dollar with the Federal 
Government's investments in Medicaid. Private insurance plans 
wouldn't have to cover preventative care, maternity care, 
mental and behavioral health, and other essential services.
    Young adults could no longer stay on their plans until the 
age of 26. And insurance companies could go back to charging 
more just because you are a woman, you have a health issue, or 
because of your age.
    My Republican colleagues have no plan to cover the 
preexisting conditions or to protect the American people. Their 
last proposal from a few years ago allowed insurance companies 
to charge ridiculous prices for people with preexisting 
conditions. They slapped an age tax on older Americans and 
enforced States to ration care by drastically cutting Medicaid.
    President Trump has not put forth a plan at all, although 
he has promised it for four years every two weeks. But what we 
have seen from him already is deeply troubling.
    The Trump administration has promoted those junk plans that 
we were just talking about, which looked cheaper until you get 
sick and realize the plan doesn't cover basics like emergency 
room visits or prescription drugs.
    Now, Madam Chair, I have a couple of questions.
    Dr. Aron-Dine, or Dr. Sommers, in both of your testimonies 
you talked about how Trump administration policies have chipped 
away at coverage gains achieved during the first few years of 
ACA implementation.
    Would either of you like to comment on short-term limited 
duration junk plans or other Trump administration efforts to 
sabotage not just the number of people covered but the quality 
of coverage?
    Dr. Sommers. Sure, I am happy to answer that.
    I think there are a couple of issues that I analyzed. The 
first is that people have to know about the coverage and be 
able to navigate the system to get there. And if you make the 
period that they can sign up shorter and spend less money on 
outreach and less money on assisting people on those 
applications, they don't get them covered. These are my 
patients. They struggle with the complexities of our healthcare 
system. If you make it harder for them to shine up, a lot of 
them won't.
    The other thing I will just say is that this is not a story 
where some States really suffered under the ACA. We have heard 
numbers that maybe Idaho, or Virginia, other places have 
suffered. Well, the numbers in Idaho, 100,000 more people were 
covered in 2016 compared to 2013; in Virginia, 300,000; in 
Florida, 1.6 million. Every single State in the U.S. 
experienced substantial increases in coverage under the ACA 
Act.
    Mr. Lujan. And, Dr. Aron-Dine, what would striking down the 
ACA mean for Medicaid and State budgets?
    Dr. Aron-Dine. As a starting point, it would eliminate 
Medicaid expansion, which covers 12 million people not eligible 
under pre ACA law. It is incredibly implausible that States 
could continue to cover those people who rely on that coverage. 
It would also undermine Medicaid in a host of other ways.
    Mr. Lujan. Thank you.
    Madam Chair, I yield back.
    Ms. Eshoo. The gentleman yields back.
    And now I would like to recognize the gentleman from 
Indiana, Dr. Bucshon, for your 5 minutes of questions. And 
please unmute.
    Mr. Bucshon. Thank you, Madam Chairwoman, and thanks for 
holding this very important hearing.
    First I would just like to say, you know, Republicans want 
people with preexisting conditions to have health coverage.
    I think really what we are talking about is people that are 
high-cost individuals that otherwise couldn't afford coverage 
before the mandate was put in place. But one of the biggest 
flaws of the Affordable Care Act is the way to solve this issue 
was done in a way that has resulted in dramatically increased 
costs for everyone.
    Republicans have a healthcare plan that will cover people 
with high-cost medical care, preexisting conditions but will 
allow others to get more affordable health coverage by putting 
those high-cost individuals in a separate insurance pool.
    Anyone that understands insurance knows if you put high-
cost individuals in the same pool as everybody else, 
everybody's cost goes up.
    As a provider, I had patients with preexisting conditions, 
high-cost health problems, and that couldn't get insurance, and 
that is just wrong. We want to solve that in a different way. 
So it is really not a good narrative--it is a false narrative 
that we don't.
    Dr. Holtz-Eakin, in the GAO report that was just discussed, 
were there any of the short-term limited duration plans found 
guilty of false marketing?
    Dr. Holtz-Eakin. I am not instantly familiar with that, but 
I would be happy to get back to you after reading it.
    Mr. Bucshon. That would be great. And also, I have seen 
some comments that, in the press, people saying the Republicans 
are undermining the Affordable Care Act, a lot of it tied to 
the repeal of the individual mandate. But I would like to ask 
you whether you agree with that sentiment or whether you agree 
with the recent story from The New York Times that ran the 
headline--and this is the actual headline--Republicans Killed 
the ObamaCare Mandate. New Data Shows It Really--It Didn't 
Really Matter.
    Dr. Holtz-Eakin. So this has been a long debate among 
researchers as to just how much the mandate was effective in 
getting people into the ACA insurance, and I think the 
Congressional Budget Office, in particular, has rethought the 
effectiveness of the mandate. It really wasn't as effective as 
people had thought.
    Instead, they pointed at some things that have been 
mentioned in this hearing, which is marketing, navigators, the 
kind of outreach that recruited people and got them into the 
ACA. That was a bigger part of the story than the mandate.
    Mr. Bucshon. Yes. I mean, I think--thank you for that 
answer. I think the issue was, from my perspective, is that the 
Federal Government was mandating the American people purchase a 
product, which, in this case, was health insurance. And as you 
pointed out, the American people don't necessarily follow 
Federal mandates because, you know, we believe in individual 
freedom and individual choice.
    As a followup, I have seen also a lot about how the 
administration has depressed enrollment in the ACA exchanges, 
but what about the health reimbursement accounts rule that the 
administration finalized last year that would let employees use 
their healthcare benefits to purchase coverage on the exchange. 
Wouldn't that actually increase the number of people who might 
join the exchanges in the coming open enrollment period.
    Dr. Holtz-Eakin. Certainly when the administration put out 
that rule, they had estimates of large-scale takeup, a very 
large-scale takeup, of those HRA provisions. They haven't been 
in place long enough for us to see if that comes to fruition, 
but it is a big change in the opportunities that people face.
    Mr. Bucshon. Thank you for that answer. So I think, you 
know, this has been a good hearing. I have one more question. I 
think I have about a minute left.
    Dr. Cameron, as a provider and member of the House Doctors 
Caucus, I was encouraged to hear about your work with health 
plans in Idaho to extend various forms of financial assistance 
to providers who are suffering during the pandemic. Can you 
expand on the specifics of what plans did and what the effect 
had on access to healthcare in Idaho?
    Mr. Cameron. Certainly. Can you hear me? Thank you.
    Mr. Bucshon. I can.
    Mr. Cameron. So--and I will just target or just list a few 
of the things that they did without naming specific companies. 
Again, we have five carriers, unlike many States who are down 
to one. We had targeted loan programs. Obviously, all of the 
carriers were processing their claims quicker and suspending 
prior authorization restrictions. $1.4 million was given by one 
company in cash advances to select provider groups. Three of 
our carriers banded together and gave another $5.5 million to 
providers in a specific hospital system, and another carrier 
offered $10 million in interest-free loans or cash advances to 
providers in order to assist them in getting through this 
pandemic.
    Mr. Bucshon. Thank you very much. I would just like to say 
finally that, you know, as a provider, I want everyone that has 
high-cost health problems, so-called preexisting conditions, to 
have affordable health coverage. I just believe that it needs 
to be done in a different way, because the way that it has been 
done in the ACA has increased the costs for everyone in the 
system. We can do it in a better way.
    With that, I yield back.
    Ms. Eshoo. Dr. Bucshon yields back. We thank him.
    And it is a pleasure to recognize the gentleman from 
Oregon. Mr. Schrader, you have 5 minutes for questioning. And 
please unmute.
    Mr. Schrader. Thank you very much.
    Ms. Eshoo. Is Mr. Schrader there?
    Mr. Schrader. Yes. Thank you very much, Madam Chair. I 
appreciate the opportunity here, and I appreciate the 
panelists.
    I would agree with my good friend and colleague from 
Indiana that, you know, the individual mandate has not been as 
important as we had originally anticipated, but as our good 
friend and colleague from California has pointed out, Mr. Lee, 
that, you know, the outreach is, and, you know, that is 
important. That has been curtailed, unfortunately, under the 
current administration, and caused some problems over the last 
couple years.
    Hopefully, one of the few good things comes out of this 
pandemic is the fact that people are now realizing that 
healthcare is an opportunity and they have access. It has been 
pretty amazing to me that we have not had a huge uptick in 
uninsured people as originally expected.
    Mr. Holtz-Eakin, you testified that there are basically 
three elements that have contributed to that, you know, some 
special enrollment periods, and ability to utilize the ACA, 
some of these short-term plans, and COBRA coverage. Do you have 
any feel for which of those has contributed more or less or 
what the rough percentages are that each of those options 
contributed to keeping people insured?
    Dr. Holtz-Eakin. Yes, I don't have any firm data on that. 
It is quite frustrating trying to sort it out. My instincts are 
that COBRA has been the least important and that we have seen 
people go Medicaid, ACA, and then perhaps some short-term 
plans.
    Mr. Schrader. OK. You know, a testament to, I think, 
American healthcare system. It is not a one-size-fits-all. We 
have many options for folks that are out there depending on 
your personal circumstances and your personal inclinations 
about how you want to get healthcare.
    I have a bill, actually, with a colleague, Rodney Davis 
from Illinois, that talks about COBRA coverage and making it, 
hopefully, a better option. I would hope the committee and 
Congress would consider this as one of the things in the mix by 
making sure that, you know, it pays at least what, you know, 
the premium for that employee that would have been covered 
under that employer-sponsored healthcare program, to make it--
at least during the pandemic here, make it so that there would 
be an option.
    Do you think, Mr. Holtz-Eakin, that that would be an 
incentive for COBRA to be a more effective help to keeping 
people insured?
    Dr. Holtz-Eakin. Well, as I said in my opening remarks, one 
of the advantages to COBRA is it avoids the churn that was 
mentioned by Dr. Sommers. And churn comes with the downside 
that you are often changing provider networks and your care 
gets disrupted, and that is the last thing you want in the 
middle of a pandemic. So getting people to stay on their 
insurance, using COBRA augmentation, is a way to avoid that 
entirely.
    And, you know, one of the difficulties for everyone, the 
experience to the American worker and for policymakers, is that 
we just cannot get a good, firm handle on how many of the job 
losses will turn out to be temporary. Of the 20 million we got 
in April, 18 million were reported as temporary layoffs. Some 
of those are going to turn into permanent job losses, and so, 
you know, which vehicle you want to use. If you are permanently 
going to lose that job, you might think very differently than 
if you are just temporarily laid off. It has been a real 
struggle thus far.
    Mr. Schrader. Thank you. Thank you for that.
    Mr. Sommers and Ms. Aron-Dine, a question on what is the--
do you have any feel for what this issue, economic makeup, is 
of those people that are using these special enrollment periods 
to sign up for healthcare? Is it reflective of the population 
writ large or is there some difference there?
    Dr. Aron-Dine. Certainly, in general, use of the 
marketplace is as concentrated among moderate-income people. 
And job losses have also been really concentrated among low-
wage workers, which is a consideration in thinking about COBRA. 
A big problem is a lot of the people losing their jobs may not 
have a COBRA option, particularly lower-income workers, 
particularly workers of color, who are especially vulnerable to 
becoming uninsured.
    Dr. Sommers. And I would just add briefly that, in 
addition, when workers might have had a plan that worked well 
for them when they had a higher income, if they become 
uninsured and lose their income, those copays from their 
employer coverage may no longer be adequate for them, and 
Medicaid may provide much better protection for them in terms 
of being able to get the care they need.
    Mr. Schrader. So it sounds like we need an all-of-the-above 
option like we have got currently in this country with the ACA 
and COBRA coverage and what all, you know, even the short-term 
plans for a very short period of time. But as pointed out by a 
lot of my colleagues, they do not offer a long-term option in 
terms of complete benefit protection, and we got to keep that 
in mind as we go forward.
    And I yield back, Madam Chair. Thank you.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize really just a superb member 
of our subcommittee. We are just going to miss her, miss her, 
miss her, the gentlewoman from Indiana, Mrs. Brooks. You have 5 
minutes, and I hope you are unmuted.
    Mrs. Brooks. I am, Madam Chairwoman, and thank you so very, 
very much. In fact, I would like to take this opportunity to 
thank you, to thank the ranking member, and my colleagues. 
First, I want to thank the witnesses for being here. And while 
this is an incredibly partisan hearing, so many of, in my six 
years of being on this subcommittee, I just want to remind the 
committee, we have accomplished incredible things. And there is 
still a lot more of incredible work to do on behalf of the 
American people.
    And the Energy and Commerce Committee, and particularly the 
Health Subcommittee, has an incredible track record. And I know 
we are working on this incredibly difficult issue of the ACA or 
better ways to provide healthcare for all Americans, and 
affordable healthcare, but I just want to thank you because I 
have been able to be a part of--this is my last hearing, in all 
likelihood--been able to be a part of the 21st Century Cures, 
able to be a part of CARES Act, able to be a part of PAHPA. I 
could go on and on with all the acronyms, which most Americans 
don't know much about, but you all know, as members of the 
committee, the important work we have done on opioids, mental 
health, healthcare affordability. There is so much--and 
preparing and responding for this pandemic.
    But there is a lot more work to do, and I just want to 
encourage all of you. I want to thank the staffs also. We have 
incredible staff. I have worked with really great staff on both 
sides of the aisle, and just want to thank them for their 
commitment in helping us find even better ways to work 
together.
    I am on the Select Committee on the Modernization of 
Congress, and we are going to be rolling out our 
recommendations, as we have been, and I just want you all to 
know that this completely bipartisan committee has more 
recommendations, which I hope that the body takes up, because 
we all have to do better to find the common ground. And I 
actually believe we have a lot more common ground and we can 
find more common ground if we just continue to really work 
together, talk together, find--it is difficult, I understand, 
in COVID and with us working remotely, but, you know, whether 
it is picking up the phone--I love that Kurt just mentioned 
that he is working with Rodney Davis on something, who is not 
even on the committee.
    We have got to find ways to keep working on all of these 
really incredibly important issues that this committee works 
on. So I want to encourage you all. I have great hope, and we 
have got to get through this for our citizens and our 
constituents.
    When it comes to COVID, obviously, healthcare has never 
been more important, and we are right in the middle of it. But 
the innovation that has come from our incredible health 
companies in this country, we have got to continue to support.
    I am really proud of the fact that we have been able to do 
a lot without expanding Affordable Care Act. Insurance 
companies have committed to providing COVID tests to patients 
free of charge. We are bringing our supply chains back. That is 
critically important.
    I am concerned that COVID, all these patients that have had 
it, all these citizens, will have a preexisting condition, and 
we have to, and must, and we are committed on both sides of the 
aisle, to covering preexisting conditions for all Americans. 
And now we have, you know, millions of people who have tested 
positive for COVID, and we have got to make sure we get this 
right.
    I just, in my brief time I have left, telehealth is one of 
those amazing things that we have talked about but now we are 
doing. Mr. Cameron, can you please share with us the dramatic 
increase in telehealth visits your State has seen? What are 
areas where it has been incredibly successful? Where are areas 
where maybe we shouldn't be focused on telehealth? I know it is 
great for mental health, but I talked to some dermatologists 
this week where it is really tough, in dermatology, for 
instance, for telehealth to be incredibly helpful. So can you 
talk to us in my brief time I have left.
    But I do want to thank the committee before Mr. Cameron 
answers. I have great hopes for you all, and I have loved 
working with all of you.
    Mr. Cameron?
    Mr. Cameron. Thank you, Congresswoman, and thank you for 
your service, and thank you for your comments. Telehealth has 
been in an infancy here in Idaho and not really a lot of 
takeup, mostly, I think, because a lot of providers and, as I 
said earlier, some consumers did not want to take it.
    I, myself, see a dermatologist, and I am--it is an 
interesting story that you shared. I actually, while in the 
State capitol building, did a dermatologist visit with my 
phone, to go over some of my issues and show some of my 
concerns. So it can be done, but there still has to be some 
hands-on followup.
    There are some health conditions, without getting into 
provider codes, where it doesn't fit really well, and so those 
need to be talked about. But we need to provide the services 
and the tools and the technology so that it can happen. I think 
consumers, as was said earlier, now actually prefer telehealth 
to other forms of coverage. They would rather have a telehealth 
visit than go to the emergency room, unless it is really 
dramatic,
    Mrs. Brooks. Well, thank you.
    And to my committee members, we have to continue to support 
and expand telehealth and help--I know everyone wants to help 
all Americans with their healthcare needs, especially right 
now.
    Thank you, Madam Chairwoman, and I yield back.
    Ms. Eshoo. Thank you for yielding back. And when you speak, 
you make all of us fall in love with you all over again, which 
then leads to how much we are going to miss you.
    And speaking of missing people, it is an honor to recognize 
the gentleman from Massachusetts, a really extraordinary and 
thoughtful member of the subcommittee, such value added, not 
only at our committee, but the entire Congress, the gentleman 
from Massachusetts, Mr. Kennedy.
    Mr. Kennedy. Madam Chair, thank you.
    Ms. Eshoo.
    Mr. Kennedy. Thank you. Grateful to you and to all the 
members of the committee, where I will follow Mrs. Brooks' 
example here briefly. This is, in all likelihood, my last 
committee hearing as well. It has been an extraordinary honor 
and pleasure and privilege for me to join all of you on the 
best committee in Congress, to work with all of you on both 
sides of the aisle to try to advance the interest of the 
American public.
    And to the incredible staff and committee staff here, a 
huge hats off to you, again, both sides of the aisle, for your 
work and collaboration and the effort that we have made 
together. It has been an enormous privilege for me, and I wish 
you all well going forward.
    And a number of big issues on the agenda to tackle, 
including the one, obviously, before us today, and I want to 
thank all the panelists for being here, for your work, and for 
appearing once again before the committee.
    Beyond the horrific loss of life caused by this pandemic 
and the administration's failed response, the economic 
consequence of job losses, business closures, imminent 
evictions, will last for generations.
    The national unemployment rate has more than doubled since 
February. In States like Massachusetts, it still remains 
stubbornly high. Losing your job can mean much more than the 
loss of income. It can also mean the loss of health insurance. 
And this is very much a life-or-death situation for the 
millions of people with chronic health conditions, for parents 
of children with complex medical conditions that require 
constant monitoring and treatment. Fortunately, for millions, 
Medicaid provides them with continuous quality health insurance 
so that they don't have to worry about getting the care that 
they or their children need.
    So, Dr. Aron-Dine, I want to start with you. What can you 
tell us about Medicaid enrollment since the beginning of the 
pandemic?
    Dr. Aron-Dine. It has risen, just as you would expect. What 
happens is Medicaid is supposed to be there for people as they 
lose their jobs or see reductions in income. Medicaid 
enrollment is up eight percent, generally, and up more in 
Medicaid expansion which targets some of the most vulnerable 
people.
    Mr. Kennedy. In other parlance, it is countercyclical, 
right? When you have an economic downturn, Medicaid enrollment 
increases, right?
    Dr. Aron-Dine. Exactly. Which helps people and also helps 
the economy.
    Mr. Kennedy. Right. Thank you. So I understand that many 
experts predict that Medicaid enrollment will continue to 
climb, and I would love to get your thoughts as to why that 
might be.
    Dr. Aron-Dine. I think that is likely. Even in a, quote/
unquote, normal recession, Medicaid enrollment often lags a 
little bit because signing up is not the first thing people do. 
And in this recession, as others have talked about, people 
haven't been seeking medical care because of the pandemic if 
they--healthy people haven't been seeking medical care, and 
that is often a mechanism by which people get enrolled and 
covered, is they go to a CHC and they find out that they are 
not doing that, they may not have gotten signed up yet.
    Mr. Kennedy. And, Doctor, you touched on this already a 
little bit, but just to flesh this out for us a bit more, how 
does Medicaid expansion specifically help States to respond to 
the current unprecedented health and economic crisis?
    Dr. Aron-Dine. Sure. And we have talked about how it is 
there for the people who are newly losing their health 
insurance, but I think it is equally important that millions 
more people, 12 million more people, are covered through 
Medicaid going into the pandemic than would have been without 
expansion.
    And there is, at this point, just a lot of research showing 
that it is improving their health, improving their financial 
security, reducing evictions, and actually saving lives. And, 
in fact, has been especially important to people with 
preexisting conditions for whom it has enabled them to get 
regular treatment for chronic conditions for the first time.
    Mr. Kennedy. We had a Medicaid director, I believe from 
North Carolina, testify before the committee now several months 
ago, back when we could do in-person hearings, and he actually 
testified, if I remember correctly, that they had determined 
that the ACA had saved literally hundreds of lives in North 
Carolina through Medicaid expansion.
    And given that, I think a lot of us obviously are 
incredibly concerned that, once again, the Affordable Care Act 
is before the Supreme Court, and the Trump administration is 
urging the justices to throw out every aspect of the law. So 
despite what some have argued today, that is literally the 
legal brief that has been filed by the Trump administration.
    So, Doctor, I am not asking you to read too far into the 
tea leaves here, but if the Supreme Court agrees that the ACA 
is unconstitutional, what happens to the 13 million Americans 
currently receiving health insurance through Medicaid 
expansion?
    Dr. Aron-Dine. Medicaid expansion would be eliminated, and 
I think it is likely that the large majority of those people 
would become uninsured and lose that access to care and 
financial security.
    Mr. Kennedy. And what happens, then, in the midst of--for 
those folks when, if that does take place, in the midst of a 
flu season, an unknown yet impact of another COVID-19 winter, 
and the economic prospects of recovery?
    Dr. Aron-Dine. I think the pandemic has reminded all of us 
that it is very important for people to have health insurance, 
for their own sakes, but also as a matter of public health.
    Mr. Kennedy. Yes. Doctor, thank you.
    COVID-19 has brought about unprecedented challenges to our 
healthcare system and our economy, and it is clear from the 
witnesses' responses that Medicaid has played a vital role in 
responding to this crisis and ensuring that adults and children 
continue to have access to the care that they need. However, 
for millions of Americans, that safety and security hangs in 
the balance if the Supreme Court sides with Republican 
attorneys general and takes healthcare insurance away from 20 
million people in our country.
    Doctor, thank you very much.
    And, Madam Chair, I yield back.
    Ms. Eshoo. The gentleman yields back.
    I now would like to recognize the gentleman from Georgia, 
Mr. Carter, for your 5 minutes of questions. Please unmute.
    Mr. Carter there? Paging Mr. Carter?
    Mr. Carter. I am here. I didn't know I was next. I 
apologize.
    Ms. Eshoo. That is all right. You are recognized for 5 
minutes.
    Mr. Carter. Well, thank you. And thank all of you for 
joining us here today. I appreciate everyone who has been on 
the panel. And I certainly would be remiss if I did not also 
offer my congratulations to Representative Kennedy and 
Representative Brooks and all the other members of this great 
subcommittee and this great committee who are going to be 
leaving us. We are going to be losing some valuable members 
with great institutional knowledge, and we certainly will miss 
all of them.
    Madam Chair, I want to begin by addressing the situation 
that continues to be a problem, and that is, my colleagues 
across the aisle seeming to want to communicate--or seem to 
want to put a message out there that Republicans are not 
wanting to protect preexisting conditions. Nothing could be 
further from the truth, and I think you all realize that. That 
is something that we have worked on and we continue to work on. 
In fact, if we look at the present Congress that we are in, the 
116th Congress, one of the first floor votes that we tried to 
have was to try and protect those with preexisting conditions.
    So I want to reiterate what has been said by a number of my 
Republican colleagues on the subcommittee here today, and that 
is that we are in favor of preexisting conditions. We continue 
to be, we have been, and we will always be. We understand, 
particularly in the trying times that we are in now, with the 
problems that we are having with the pandemic, we understand 
how important covering preexisting conditions are.
    Dr. Holtz-Eakin, in your testimony, you mentioned that 
through June, there were 6.2 million workers who lost their 
employer-sponsored insurance due to job loss from the pandemic. 
And President Trump has worked to make short-term, limited-
duration plans available to beneficiaries for up to 36 months, 
providing certainty and continuity for patients. Previously, 
the previous administration had made them available for only 
three months. How can short-term, limited-duration insurance 
plans fill the employer-sponsored insurance gap, and is there 
any indication that they have?
    Dr. Holtz-Eakin. So as I mentioned earlier, we don't have 
great data on what is happening on the ground right now, so I 
can't answer with any sort of definitiveness how many people 
are taking up short-term plans versus other options. But it is 
another option on the table. It is an option that was not 
available previously. It might hit a price point that is better 
than a price point on the ACA marketplace, and, you know, that 
would be a very valuable option in this situation.
    Mr. Carter. And wouldn't you believe that it would offer 
patients more flexibility and affordability in coverage?
    Dr. Holtz-Eakin. Certainly there is a greater variety of 
plan designs out there. That is one of the advantages. The 
concern that you have heard voiced is that people won't 
understand the plan design they are buying, but certainly there 
ought to be a way to do good consumer education, get them in a 
plan that is good for them.
    Mr. Carter. Well, I believe this subcommittee, this 
committee in general, has addressed that before. In fact, I 
know that I had advocated for us to publicize these plans more 
so that people would be educated as to the availability of 
these plans and how they could help them. But unfortunately, 
the other side of the aisle, again, are opposed to these plans, 
and did not want to offer education to our citizens as to the 
availability of these plans.
    Let me ask you also, Dr. Eakin, given that premiums have 
more than doubled during the time that the Affordable Care Act 
was signed into law, what are your recommendations for how we 
can reduce the cost of health insurance and allow people to 
shop for coverage that might best fit their needs?
    Dr. Holtz-Eakin. There are really two broad strategies. The 
first strategy is to provide greater competition in the 
insurance markets, lower the barriers to entry, allow more 
products and variety, and allow people to choose among them, 
and thus get a plan that fits their economic situation.
    The second strategy is to deal with the underlying costs 
and value proposition in the delivery system, and certainly 
there is a lot that Congress can do in that area through the 
big payment silos that are in Medicare and Medicaid, which 
really drive the delivery system in the United States.
    And something can be done at the local level. You know, 
State scope of practice, State certificate of need, all sorts 
of limitations on competition need to be addressed.
    I think the telehealth example is the best example of how 
the overregulated U.S. healthcare system couldn't respond 
flexibly to the pandemic, and it was only the emergency waiver 
of a lot of regulations that allowed telehealth to prosper. 
That should be made permanent. I mean, that is going to require 
legislation. That is a great opportunity going forward, and I 
would encourage the committee to look at that.
    Mr. Carter. So you would agree, just as the free market has 
worked in our society, that the free market can work in 
healthcare, to lower healthcare costs?
    Dr. Holtz-Eakin. Certainly if you have high prices, you 
have a supply problem, and you have got to look at the 
conditions that are limiting supply.
    Mr. Carter. Well, thank you very much.
    And thank you, Madam Chair, and I yield back.
    Ms. Eshoo. I thank the gentleman from Georgia. He yields 
back.
    Now it is a pleasure to recognize the gentleman from 
California, Mr. Cardenas, for your 5 minutes of questions. 
Please unmute.
    Mr. Cardenas. OK. I should be unmuted. Can you hear me?
    Ms. Eshoo. Yes, very well. Thank you.
    Mr. Cardenas. OK, thank you so much. Thank you, Madam 
Chair, and I appreciate the opportunity for us to have this 
important hearing. I want to thank all of our folks who are 
here to give us their opinion and expertise to be before our 
committee.
    I also want to say, thanks to the ACA, approximately 20 
million Americans have gained coverage through the law's 
various coverage protections. Nine million low- and moderate-
income Americans received health insurance subsidies to make 
their healthcare more affordable. 130 million Americans are 
allowed to receive coverage, without being discriminated 
against by the insurance companies and made sure that, by law, 
the Affordable Care Act law, they have the right to coverage, 
even though they have a preexisting condition, and they cannot 
be charged a penny more than anybody else who is getting the 
same coverage.
    In an unprecedented and nakedly political decision, the 
Trump administration declined to defend the Affordable Care 
Act, otherwise known as the ACA, in this Republican lawsuit 
that is seeking to declare the entire law invalid. The Trump 
administration is continuing with this extraordinary decision 
in the middle of a pandemic that has claimed the lives of now 
over 200,000 Americans. If the lower court's ruling is upheld, 
millions of Americans would lose their healthcare overnight in 
the middle of a global pandemic.
    I would like to ask some questions first to Dr. Aron-Dine. 
Dr. Aron-Dine, how many Americans would lose coverage if the 
decision were upheld shortly?
    Dr. Aron-Dine. Prior to the crisis, the estimate was 20 
million, and that number would be larger today with more people 
turning to these programs for coverage.
    Mr. Cardenas. Thank you. Could you discuss the impact of 
the court's decisions on Medicaid expansion?
    Dr. Aron-Dine. Medicaid expansion would be eliminated, 
meaning that the 12 million people who are newly eligible 
because of the ACA's Medicaid expansion could lose their 
coverage, would likely become uninsured. It wouldn't be there 
for people newly losing their jobs and their coverage in this 
recession to turn to, and State eligibility would presumably 
revert to the pre-ACA levels where few parents and almost no 
adults without children were able to get coverage.
    Mr. Cardenas. So I think you just described that the 
Affordable Care Act law, once it became implemented, and still 
to this day, millions of Americans are actually being able to 
see doctors, getting healthcare basically, that before were 
either struggling or not receiving healthcare?
    Dr. Aron-Dine. That is exactly right, and we have direct 
evidence of that, including from some of Dr. Sommers' research, 
that people are getting prescriptions filled, they are getting 
treatment for chronic conditions, and that the ACA's Medicaid 
expansion, as well as the marketplace coverage, has been 
literally lifesaving.
    Mr. Cardenas. And this also would be affecting working 
families with moderate and low income?
    Dr. Aron-Dine. Absolutely. Particularly if you look at 
coverage for the people who we now refer to as essential 
workers, many of them get their coverage through Medicaid, 
especially in expansion States, and that would be wiped out.
    Mr. Cardenas. So one thing I would like to clarify, did the 
Affordable Care Act only increase the availability for 
healthcare for unemployed, people who are not working, or did 
it, in fact, increase by millions, or not, being able to have 
access to healthcare for working families?
    Dr. Aron-Dine. I am not sure I understood your question, 
but----
    Mr. Cardenas. Let me clarify what I mean, Doctor. A low-
income family is probably a family that they have low income. 
They are actually working, but they are, say, at minimum wage 
or what have you, so therefore, providing healthcare for them 
and their children, for example, is very difficult because they 
otherwise can't afford it. And the Affordable Care Act has 
implemented an opportunity for them to actually get healthcare, 
even though they are low income, whereas before, they could not 
go out to the market and get it because they just couldn't 
afford it.
    Dr. Sommers. If I can jump in briefly?
    Mr. Cardenas. Please.
    Dr. Sommers. As described in my testimony, we actually have 
looked at this issue of working families, and the ACA's biggest 
coverage gains are in blue collar families. These are people in 
construction and mining and agriculture, concerned with jobs 
where they don't get coverage through work. So you are exactly 
right, Representative, this is a key feature that the ACA has 
helped working families substantially.
    Mr. Cardenas. Yes. Thank you so much. I am sorry my 
question wasn't that clear, but I appreciate your clarity in 
the answer.
    And then also, isn't it through the ACA now young adults 
can actually stay on their parents' coverage up through the age 
of 26, whereas before, that was not a typical coverage from the 
insurance industry?
    Dr. Aron-Dine. That is correct. That is a nationwide 
protection put in place by the ACA, and it is one of the 
reasons that young adults would see especially large coverage 
losses if the law were struck down.
    Mr. Cardenas. Yes, thank you. My time is limited, and even 
though the clock stopped, what I am going to do is I am just 
going to close by saying that I would like to thank you, 
Doctor, and also everybody testifying today, and just remind 
everybody that the truth is that the Republican lawsuit would 
have disastrous consequences on our Nation's most vulnerable 
Americans.
    Yes, Madam Chair?
    Ms. Eshoo. Thank you. The gentleman yields back.
    I understand that Dr. Burgess has joined us. Are you 
actually there?
    Mr. Burgess. Yes, I am, and unmuted.
    Ms. Eshoo. The Chair recognizes the ranking member of the 
subcommittee, Dr. Burgess, for his 5 minutes of questions. Glad 
you could join us.
    Mr. Burgess. I thank the Chair. I thank the committee's 
understanding of the morning where there was a lot of 
multitasking going on, where our time in town may be limited. 
There is a lot going on, as I am sure everyone is experiencing.
    I would ask, Madam Chair, that my entire opening statement 
be made as part of the record.
    Ms. Eshoo. So ordered.
    [The prepared statement of Mr. Burgess follows:]
    [The information appears at the conclusion of the hearing.]
    Mr. Burgess. And, Dr. Holtz-Eakin, welcome to our 
subcommittee. Thank you so much for participating with us 
today. I would just note, you know, on the issue of employer-
sponsored insurance--I think you talked about this in your 
testimony--well, employer-sponsored insurance, right, pre-
pandemic levels, have actually increased significantly in the 
year since President Trump had taken office. I think it was in 
excess of three million more people had the availability of 
employer-sponsored insurance.
    So of those employer-sponsored plans, now that we are in a 
situation where people are losing employment, what is the 
options that are available for someone who has lost coverage on 
an employer-sponsored insurance? They can sometimes get 
coverage on another family member's ESI plan. Is that not 
correct?
    Dr. Holtz-Eakin. That is correct. Their spouse could be 
covered, and they could acquire coverage that way.
    Mr. Burgess. So I guess, then, the question comes up, how 
does our existing safety net system work as intended to catch 
people that got hurt during the pandemic?
    Dr. Holtz-Eakin. The safety net really consists of the 
COBRA options that people have, the ACA, a place where they 
can, if they have lost employer insurance, they can go and 
enroll in a plan, and the Medicaid program. To date, I think 
that safety net has held up pretty well. As I noted in my 
written remarks, the Census Household Pulse Survey shows no 
strong trend in any direction on coverage, and that is not 
attributable to any single program but to the question of all 
of them.
    Mr. Burgess. OK. Well, then particularly appropriate to 
this subcommittee and this committee, are there any 
flexibilities that Congress has not provided to States and 
their insurance plans that would improve the uptake of other 
options?
    Dr. Holtz-Eakin. I think that something that would be 
really valuable for the committee to look at is to look at the 
waivers that have been provided by the administration on 
regulations that are due to the emergency--the declaration of 
the emergency. They have authority to waive an enormous number 
of things. Like I mentioned with the telehealth, you know, you 
can use a commercial device, use FaceTime, a waiver of 
protection against minor HIPAA violations for anything 
disclosed over that, that would allow people to actually stay 
in their homes instead of going someplace to do telehealth, 
which doesn't really make a lot of sense.
    And all that will go away when we, thankfully, get past the 
pandemic, but there is a lot of it that I think ought to be in 
law, and Congress should look at in providing flexibility. You 
know, we really learned that the U.S. healthcare system 
couldn't do two things at one time. It couldn't treat COVID-19 
and continue to provide ordinary care, and that, I think, was 
quite revealing by the sort of overregulated lack of 
flexibility.
    Mr. Burgess. Yes. I would certainly echo the overregulated 
lack of flexibility. Much of the curtailment of practice was 
actually a result of governmental direction where--tried to 
preserve capacity in an emergency room or ICU setting, 
hospitals were and medical practices and clinics were required 
to reduce their workload of elective procedures, which 
subsequently killed their cash flow and made it very difficult 
for them to recover.
    Dean Cameron, let me just ask you a question about 
populations of people are different and, arguably, Idaho and 
New York are significantly different. So the flexibility for 
States to develop plans that actually fit a State's 
population's needs is important. So could you perhaps provide 
us a little further detail about how Idaho insurance companies 
waived some of their eligibility requirements to make it easier 
for beneficiaries to maintain their access to high-quality 
care?
    Mr. Cameron. Yes, absolutely, and thank you for the 
question. As I mentioned in my remarks, we started meeting with 
our carriers and trying to talk about how we help citizens, how 
we keep them from being forced out of coverage, how they can 
access the special enrollment periods, how we can make that 
transition even easier.
    And we pointed to and found a number of provisions in State 
law, and even in some rules, that didn't seem to make sense at 
the time. For example, we had employers say to us, well, I have 
laid off my folks, but now I want to hire them back, but I 
don't want to go through a new eligibility period. Wouldn't 
make sense to do that.
    So we essentially issued bulletins, working with our 
carriers, saying, we are not going to do that. We issued 
bulletins allowing carriers to keep people that are furloughed 
on their plans even longer. Now, State law said that you had to 
be employed at least 20 hours a week in order to qualify for 
small-group coverage. We waived that.
    There were a number of provisions that way, that in sitting 
down and collaborating with our carriers, decided in this 
pandemic, that wasn't appropriate. We want people to have 
coverage, and we did everything we could to help them keep 
coverage.
    Mr. Burgess. Thank you for that. I see my time is expired. 
I have a couple of additional questions. Madam Chair, I will 
submit those for the record. I yield back.
    Ms. Eshoo. The gentleman yields back. I am so glad that you 
were able to make it, Dr. Burgess.
    It is a pleasure to recognize the gentlewoman from 
Michigan, Mrs. Dingell, for your 5 minutes of questions. And 
make sure you unmute.
    Mrs. Dingell. Thank you, Madam Chair, I did. And thank you, 
Ranking Member Burgess, both of you, for convening this 
hearing, because it is really important what is happening with 
COVID and the positive effects ACA has had and what is 
happening to people.
    And I too want to tell my colleagues how much I am going to 
miss Susan Brooks and Joe Kennedy. They are two people who 
deeply care about healthcare in this country, and we will miss 
them deeply.
    I want to touch upon a topic that we haven't really talked 
about as much as I think we need to be, which is the impact 
that COVID-19 has had on long-term care in this country and how 
it has exposed a number of issues in the way that we deliver 
it. Millions of aging and disabled people in this country rely 
on what is a total patchwork system of care to provide them 
with services and the supports that they need in their daily 
lives, and until you are in the system, you do not understand 
how broken it is.
    During the pandemic, we have all seen the tragic reports of 
how COVID-19 spreads in group settings like nursing homes. 
Compounding the tragedy is the fact that many people in nursing 
homes want to live at home with their friends and their family, 
but they are unable to because of the level of care that they 
need. And they are totally isolated, which is making it even 
worse as if they do become sick or what has happened to them in 
these last six months.
    Medicaid actually pays for things like home health aides, 
direct service providers, to help with activities of daily 
living, even modifications to make the person's home more 
accessible.
    So I would like to ask Dr. Aron-Dine some questions. Dr. 
Aron-Dine, there has been a concerted effort for over a decade, 
to rebalance long-term services and supports in Medicaid. Can 
you briefly explain what that means and why it matters so much?
    Dr. Aron-Dine. Sure. Rebalancing refers to a rebalancing 
between institutional long-term care, for instance, in a 
nursing home, versus home- and community-based services, such 
as home health aides or personal care provided to help a person 
live at home. Institutional care has always been part of 
Medicaid. The availability of home- and community-based 
services has been really expanded over time, including through 
the Affordable Care Act.
    It is very important for the reasons you note, that many 
people would prefer to receive care in their homes. It would be 
better for their health. It is also often more cost effective 
for a given person to receive care at home versus in an 
institutional setting.
    Mrs. Dingell. So--thank you for that. I understand that not 
everyone who wants to receive home and health community-based 
services, or HCBS as we call it, are able to receive them right 
away. What are some of the barriers currently for people who 
want to receive care in the community?
    Dr. Aron-Dine. One of the biggest barriers to receiving 
these services through Medicaid is State finances. I alluded to 
so-called optional services in Medicaid which makes them sound 
like frills, but actually optional services are really crucial 
things like home- and community-based services which States are 
allowed to limit because they are not mandatory. And there is a 
really big risk that during this recession, as in the past, 
that States are in a big budget crunch, this is one of the 
places they might look to cut, which can make the problem of 
HCBS waiting lists worse.
    Mrs. Dingell. Well, let me ask you two other questions. It 
is not funded enough even before COVID, is it? And is there an 
institutional bias against home-based care?
    Dr. Aron-Dine. I would agree, certainly even before COVID, 
you had this challenge, and it is a place where the Medicaid 
program has made progress over time through continued 
expansions, including the ACA's, and more is needed.
    Mrs. Dingell. So given these barriers and the threat that 
COVID poses to people in group settings, it is now more 
important than ever that we make it easier for people to 
receive care in the community. I was glad to see that the 
HEROES Act contained a policy that I, quite frankly, did work 
on to increase Federal funding for State Medicaid programs to 
spend on HCBS. And I have been working on it with my good 
friend, Mr. Guthrie, and we are trying to get more of this.
    But, Dr. Aron-Dine, the HEROES Act would provide State 
Medicaid programs with a ten percentage point increase for 
their HCBS programs. How would this help States to provide 
services to the people who need this type of care?
    Dr. Aron-Dine. I think both the targeted HCBS increase in 
HEROES and the general FMAP increase in HEROES, the 14 
percentage point bump, could be readily critical in helping to 
fill these holes in State budgets, discouraging them from 
cutting Medicaid, and making it possible for them to make some 
investments, particularly directly responsive to the pandemic.
    Mrs. Dingell. Madam Chair, I am out of time, so I may ask 
more questions for the record, and I yield back zero time.
    Ms. Eshoo. The gentlewoman has completed her questions. I 
love the red in the background, Debbie. It really jazzes up our 
hearing. We need that. It is wonderful. And I like ``Women Can 
Do It.'' We know that we can and we do.
    At this time, I would like to recognize the gentleman from 
Oklahoma, Mr. Mullin, for his 5 minutes of questions.
    Are you with us, Mr. Mullin?
    I don't hear his voice or see his face, so we will move to 
the gentlewoman from New Hampshire, Ms. Kuster. You have 5 
minutes for your questions. Great to see you.
    Ms. Kuster. Great to see you, Madam Chair. And thank you so 
much to you and the ranking member for holding this critical 
hearing on the Affordable Care Act. I have said it before, I 
will say it again, that across this country, 135 million people 
under the age of 65 have a preexisting condition. So we know 
the total number is much, much higher.
    In New Hampshire, over 500,000 Granite Staters--and that is 
over half the population that are nonelderly--live with 
preexisting conditions every single day, and could be denied 
access to healthcare, either prior to the passage of the ACA or 
if the ACA is repealed by the Supreme Court, as we now know our 
Republican colleagues are rushing to make happen.
    So even today, during this pandemic, COVID-19 would be a 
preexisting condition for an additional 7 million Americans. 
That is why I introduced the Protecting Americans With 
Preexisting Conditions Act, which has passed the House twice 
and still sits on Mitch McConnell's desk.
    And I want to particularly address my colleague, Mr. 
Carter, who said that Democrats are trying to create an 
illusion that Republicans oppose protections for preexisting 
conditions. It is no illusion, Mr. Carter. You and your 
colleagues have voted twice against my bill, and it is very 
clear that you do not want to protect Americans with their 
preexisting conditions, even COVID-19.
    Despite what this administration has claimed, this 
administration does not support protecting Americans with 
preexisting conditions. They haven't supported it when they 
encouraged repeal and replace without a replacement plan, or 
when they issued destructive guidance through the 1332 waivers, 
or when they fight in the courts to dismantle the entire law. 
And we now know that that hearing is coming just one week after 
the election in November. This is dangerous and destructive to 
the lives of the American people.
    They certainly have not supported the ACA in the midst of 
this global pandemic, which has needlessly taken the lives of 
now over 200,000 Americans. And because the stark reality is 
that every year of the Trump administration, the rate of 
Americans without health insurance has increased, this year has 
proven no different. So today, I will focus my remarks on the 
ways this administration has continued to sabotage the ACA.
    Over 40 million Americans have filed for unemployment 
benefits during COVID-19. Millions of Americans and their 
families have lost job-based healthcare, and yet this 
administration refuses to establish a broad special enrollment 
period which would allow uninsured Americans to sign up for 
coverage in the Federal marketplace. It is especially critical 
in States like my own that depend on the Federal Government as 
a partner in the ACA marketplace.
    So, Dr. Sommers, most State-based marketplaces established 
broader enrollment periods. Can you briefly discuss how 
enrollment in State-based marketplaces has compared to the 
Federal marketplaces like our own right here in New Hampshire?
    Dr. Sommers. Yes. So 12 of the 13 States that fully run 
their own marketplace have created COVID-specific special 
enrollment, and what you can see in the enrollment statistics 
that are available through the middle of the year is that there 
has been about a 15 percent increase over the open enrollment 
totals in those States. And that compares to just 11 percent in 
the States that are on the healthcare.gov platform.
    And of note, you know, the ranking member asked about 
flexibility, more than a dozen States on the healthcare.gov 
platform requested that flexibility to create a new special 
enrollment period for COVID, and so far, CMS has not granted 
that.
    Ms. Kuster. And, Mr. Lee, Covered California established a 
special enrollment period for COVID-19. How many individuals 
signed up for coverage during this period?
    Mr. Lee. Yes. About 300,000. And I want to underscore, it 
is both a special period, because 20 percent would have been 
ineligible, and they were healthy and needed coverage, but the 
rest were eligible but needed marketing, needed to be told to 
come in the door. And they doubled our enrollment from the 
prior period.
    Ms. Kuster. And based on your analysis, how many 
individuals could have gained coverage if the Federal 
marketplaces experienced the same level of growth as your State 
did during this special enrollment period?
    Mr. Lee. Yes. Our analysis is, if Federal marketplaces had 
done what we had done, half a million Americans would not be 
uninsured today. They would have insurance during a pandemic 
when you want them to have insurance to be able to get tested 
and get the care they need.
    Ms. Kuster. Madam Chair, I apologize, I have lost the clock 
on my screen. Should I yield back or if I have----
    Ms. Eshoo. Well, let's see. My clock has zeros going 
across.
    Ms. Kuster. All right. I will yield back and submit my 
questions. Thank you, Madam Chair, for your patience.
    Ms. Eshoo. Thank you. Thank you for your important 
questions and your great work at the committee.
    It is a pleasure to recognize the gentleman from Montana, 
Mr. Gianforte, for your 5 minutes of questions. And please 
unmute.
    Mr. Gianforte. Thank you, Madam Chair. I appreciate the 
witnesses being here today.
    I first want to say that my State has expanded Medicaid 
eligibility. I support a social safety net for those who need 
help, and I voted to protect coverage for individuals with 
preexisting conditions.
    Today we keep talking about coverage. Coverage does not 
equal access to care. Montana faces a provider shortage, and 
many individuals travel hours to receive the care they need. 
Besides protecting individuals with preexisting conditions, my 
guiding principals for healthcare are improving rural access to 
care and reducing cost.
    In the CARES Act, we voted to waive several rules regarding 
the provision of telehealth services. We waived rules regarding 
the origination and requirements for physicians to be 
reimbursed for services provided by audio and video. I think 
this is a great first step, and I hope we can build on ways to 
improve these waivers.
    Director Cameron, what can you tell us about what you are 
seeing as far as telehealth utilization in Idaho?
    Mr. Cameron. Thank you, Congressman, and thank you for your 
comments, and thank you for what you did pass in the CARES Act 
to eliminate some of those rules, because that has been very 
helpful, along with, as a State, we also eliminated rules.
    We really believe telehealth will provide that affordable 
access, particularly to rural States like yours and mine. We 
went from--we had a 250-fold increase. We went from--up to 
28,000--where is my numbers--we went from 28,503 televisits in 
the month of April, from the previous year was 233. Dramatic 
increases in those that are accessing telehealth, and we think 
that will continue to grow.
    Mr. Gianforte. Great. Do you have any indication that 
emergency room utilization is down with the increased use of 
telehealth?
    Mr. Cameron. Thank you, Congressman. We do have that 
indication. I don't have those numbers in front of me. We could 
certainly provide that, but we have seen dramatic increases 
in--or decreases in the emergency room utilization, but a lot 
of that is driven based on what was having to happen with the 
pandemic, who could access the emergency room. And so it might 
be a little difficult to pare out whether that is caused 
because of telemedicine or whether it is caused because of the 
pandemic. And people themselves did not want to go to the 
emergency room where they could potentially be exposed. They 
could sit at their home and they could talk to their doctor and 
get their treatment needed.
    Mr. Gianforte. Yes. In my own experience, talking to 
emergency room docs, they tell me that up to 80 percent of 
emergency room visits could have been handled through 
telehealth, if it were generally accepted, and that is 
particularly helpful in States like yours and mine where the 
farm or ranch house might be hours away from the emergency 
room. It is certainly more convenient, higher quality of care. 
Certainly, the emergency room needs to be there for folks that 
need it, but having that telehealth option can provide more 
immediate care and also lower our costs.
    In a followup, what else could we do in Congress to help 
advance telehealth adoption?
    Mr. Cameron. That is an excellent question. I think, first 
of all, continue to make those rules you have set aside more 
permanent, and continue to encourage and allow for carriers to 
be able to handle those visits through the marketplace. 
Additional support towards the technology that is needed in 
order for those providers to be able to offer telehealth 
services. I think all of those are solutions. And then, really, 
flexibility in the marketplace, allowing the marketplace to 
work, it will work. It can work.
    Mr. Gianforte. OK. So the temporary waivers we put in place 
in the CARES Act, you are saying we should consider making 
those waivers permanent. Is that correct?
    Mr. Cameron. Absolutely.
    Mr. Gianforte. OK. Well, I appreciate your testimony today.
    And with that, Madam Chair, I yield back.
    Ms. Eshoo. The gentleman yields back. And it is a pleasure 
to work with you on telehealth, which is so important and has 
really worked into its full benefits during the pandemic. We 
need to make sure that that continues.
    The Chair is pleased to recognize the gentlewoman from 
Illinois, Ms. Kelly, for your 5 minutes of questions. And 
please unmute.
    Ms. Kelly. Thank you, Madam Chair. This is a very, very 
important hearing.
    And to Rep. Gianforte, I would love to work with you also. 
I have legislation, I work a lot with Congressman Will Hurd, 
but he is leaving me. So I would love to work with you on the 
telehealth issue.
    I am chair of the Congressional Black Caucus Health 
Braintrust, and Black Americans make up 12.5 to 13 percent of 
the U.S. population, but we have accounted for 22.4 percent of 
COVID-19 deaths.
    Dr. Sommers, given the number of minority individuals who 
gained coverage under the ACA and the decreases we have seen in 
the last few years, if the ACA were to be rolled back, how 
would that affect the already severe health disparities we are 
seeing because of the emergence of COVID-19?
    Dr. Sommers. We know that the Affordable Care Act produced 
particularly large coverage effects in communities of color, 
and helped narrow, though not eliminate, the large disparities 
in coverage rates in the U.S. So any effort to undermine or 
repeal the ACA would likely worsen those disparities 
dramatically at a time when communities of color have been hit 
particularly hard by the epidemic.
    Ms. Kelly. Thank you.
    And, Dr. Aron-Dine, without opening a new enrollment period 
for individuals and the increase in the FMAP included in the 
HEROES Act, how can we prevent the deaths and health 
disparities that we see from the lack of insurance coverage and 
healthcare access, frankly, that disproportionately affect 
communities of color?
    Dr. Aron-Dine. Well, I think you would want to start with a 
do-no-harm principle. So the most important thing is to make 
sure that the coverage options people currently have don't go 
away. And then as you alluded to, it is also important that 
States not be making cutbacks in coverage in this time, and 
that is going to require additional funding to States.
    But more affirmatively, there are lots of things that could 
be done to make progress on coverage, especially for 
communities of color, including improving affordability and 
making it easier for people to access these programs.
    Ms. Kelly. I know we have gone back and forth and everyone 
has their opinion about the ACA, and who knows what is going to 
happen with the Supreme Court. But just to all the witnesses, 
if there was one thing you could suggest to improve the ACA, 
what would that be? I know you are not in a line, so----
    Dr. Sommers. I can start. I would find ways to get the 12 
States that have not expanded Medicaid to do so. And these 
States have some of the most restrictive Medicaid policies in 
the country, even before the law. These are very low-income 
populations. They are disproportionately communities of color, 
concentrated in the South. There are large health disparities, 
and Medicaid expansion could be a life-saver.
    Ms. Kelly. Next.
    Dr. Aron-Dine. And I think the second place you would go 
after that is to sort of fill the next coverage gap, which is 
low-income people who are eligible for the ACA as marketplace 
coverage but aren't enrolled, and could start by addressing 
affordability issues as a number of States have done.
    Ms. Kelly. OK.
    Mr. Lee. And if I could, I would build on those two, with a 
third of addressing needs of lower income underinsured people 
with employer coverage. Twenty-five percent of people with 
employer coverage have coverage they can't afford to get access 
to. Those people need accesses to have a choice to get to a 
marketplace or get affordable coverage that addresses their 
income, which is done in marketplaces, but not by most 
employers.
    Ms. Kelly. Thank you.
    Mr. Cameron. Thank you for the question, a very insightful 
question.
    First of all, I would work on affordability, and I would 
work on drawing those young and healthy people back into the 
risk pool, creating one singular risk pool, regardless of the 
product style, adding flexibility. If you are going to have 
subsidies--and I think we need to have subsidies--Idaho's 
market is mostly a subsidy market, but we have got to figure 
out how to fix the cliffs and the mechanisms to keep people 
from taking advantage of those subsidies or keep them from 
being able to access those subsidies.
    Ms. Kelly. Thank you.
    Dr. Holtz-Eakin. Never go last on a panel like this. I just 
want to echo----
    Ms. Kelly. You can say ditto or----
    Dr. Holtz-Eakin. I will echo number one and number two. In 
particular, you know, half of the 30 million people who were 
uninsured prior to the pandemic were eligible for the ACA. That 
is low-hanging fruit, and there is no reason not to pursue 
that.
    And then just keep an eye on the underlying competition and 
the value proposition in the delivery system. That remains the 
place that the ACA just really was not aggressive enough, and 
that has to be the challenge going forward.
    Ms. Kelly. Thank you all so much. Thanks for your patience.
    And to all my colleagues that are leaving the E & C 
Subcommittee, I wish you well, I wish you the best. Thanks for 
all your input and insight. And, of course, a special shout out 
to Rep. Shimkus because he is from my home State of Illinois, 
so thank you.
    And I yield back.
    Ms. Eshoo. That is really lovely. We really are going to 
miss the colleagues that are leaving the Congress. There is no 
question about it. And as I said earlier, they are really value 
added, not just to our internal work, but once those words 
become law, they walk into people's lives, and they are a part 
of that.
    And we are--I think I speak for all of us when I say that I 
think that we have been blessed to have you on the committee. 
It is where we really get to know each other very well when you 
serve on the committee together.
    Now I would like to recognize Mr. Mullin, the gentleman 
from Oklahoma. You have 5 minutes for your questions. And 
please unmute.
    Are you there?
    Mr. Mullin. Madam Chair, thank you so much. And you are 
right, it is bittersweet to have people leave our side.
    On one hand, I hate to lose them because they are a value 
and an asset to Congress. On the other hand, I get to move up 
on asking questions. So there is a side of me that is very 
selfish about that.
    But I do--I will say, Madam Chair, you are right, when we 
are able to meet in person and we are able to have these 
hearings in the hearing room, it is something that adds a lot 
of value and friendship, from my friendship with Lisa to Joe 
Kennedy, to even yourself and Diana DeGette, and just a whole 
host of people to everybody on our side, it is something that 
is tough to replace.
    And as you know, the stuff that I am going through 
personally with my son, our committee has just been phenomenal 
to me, so I will do the same. I will miss everybody that is 
here and we look forward to meeting everybody in person again.
    To jump into where I am going with these questions, we have 
heard a lot about ACA, and I think we all agree people with 
preexisting conditions need to have the access to market. I 
think we disagree on how to do that, obviously, and a one-size-
fit-all approach doesn't work, and we have seen that in Idaho, 
as Mr. Cameron has pointed out in your testimony. You stated 
that in your collaboration and regulatory approach, that it has 
led Idaho to have one of the most successful exchanges in the 
country, and it is because you went at it on your own. You 
designed it specifically for the people of Idaho, and that 
approach has been very successful.
    Could you kind of point out to us, what regulatory actions 
you have taken to improve the outcomes for your patients during 
the pandemic?
    Mr. Cameron. Certainly. Thank you for the question.
    As I mentioned earlier, we began meeting with the carriers 
and talking about issues that were barriers to our consumers, 
things like prescription drugs, being able to obtain their 
prescriptions both early, both in larger supply, 90-day supply, 
and both without signing signature logs.
    We said to the PBMs and to the carriers that were 
contracting with them, You can't require a signature log and 
you can't go back and audit them. We also worked with the 
carriers in expanding how people who are on coverage, how they 
could stay on coverage, and if they left coverage, how they 
could get back on coverage without going through all of the 
hoops and the previous provisions.
    So employees that were furloughed could stay on coverage. 
Employees that lost coverage and went to a special enrollment 
period, we made it easier for them to make that transition, 
working with our State-based exchange because we have that 
connection that was able to make it helpful.
    And then we made sure that people had access to coverage. 
We actually considered an extra special enrollment period, but 
in conversing with a lot of our colleagues found that, for most 
of our citizens, it really wouldn't address the numbers like 
Mr. Lee is talking about in California. And I am glad, happy 
for him, but it wasn't what fit for us. So we believe that we 
have taken care of our consumers.
    We issued about 12 different bulletins that lightened the 
load or the responsibility on carriers and encouraged them to 
give money back to consumers, helped them so that they could 
give money to providers without it showing up as an adverse 
asset or giving back to consumers without it showing up as a 
rebate or an illegal inducement. We had them work through all 
of those things.
    Mr. Mullin. Well, can you maybe help us on the Federal 
level, we see a lot of States that only have one choice in the 
markets. How could the Federal Government help maybe 
incentivize competition in the individual markets like you have 
in Idaho?
    Mr. Cameron. Yes, I think that is a great question and one 
that warrants a lot more deeper discussion than what I am going 
to be able to give you in less than a minute.
    First of all, collaboration and working in the regulatory 
environment, discussing those rules that are keeping carriers 
out of the business, looking at their profitability and how--
you know, in our case, we have a co-op that we share with 
Montana. We have two not-for profits. All of those aren't 
really interested in making profit, but they are not interested 
in losing hundreds of thousands of dollars either.
    So you have got to provide a balanced approach by which we 
are bringing young and healthy in order to help that risk pool 
be more stable.
    Mr. Mullin. Well, thank you. And we look forward to working 
with you more going forward.
    Switching gears real quick, just in closing remarks here, I 
heard Gianforte and Lisa both talk about telemedicine. I have 
got a whole new approach to it because the way my son has been 
having to receive healthcare lately with specialists all over 
the country through telemedicine, and it is something that is 
underutilized and something that we as a Federal Government 
should be playing a huge role in.
    It is something that has become very passionate, and I 
would like to maybe have a deeper discussion. So, Lisa, I look 
forward to working with you moving forward on this thing, too.
    With that, Madam Chair, I yield back.
    Ms. Eshoo. The gentleman yields back. And know, Markwayne, 
that our prayers follow your son every day, every night, all 
week long, all month long. We are with him, and we are with 
you, and I couldn't mean that more.
    Mr. Mullin. Well, thank you. I will tell you real quick, my 
son is going to be discharged from up here October 8.
    Ms. Eshoo. Isn't that wonderful? See?
    Mr. Mullin. And so we get to come back home, so we are 
super excited. God has just been so good to us. It has been a 
miracle throughout the whole process.
    Ms. Eshoo. And that is wonderful news. And we always have 
to remember to go back and say prayers of thanks. We are good 
at asking. We have to remember to say thank you.
    I just want to add something--and I appreciate Mr. 
Cameron's work--I also think we need to highlight what 
California has done. Idaho has a population of 1.7 million 
people. The State of California is a Nation State, 39.5 million 
Californians, and we are a highly diversified state. I don't 
know how diversified Idaho is. But the more homogeneous a 
population is relative to an insurance pool, frankly, the 
easier it is.
    So I tip my hat to Mr. Cameron for his work. But I also 
want to highlight what is taking place and has taken place in 
the largest State in the Union. If the ACA can succeed in 
California, my contention is it can succeed anywhere.
    With that, it is a pleasure to recognize the gentlewoman 
from Delaware, a wonderful, wonderful member of our 
subcommittee, Lisa Blunt Rochester.
    Ms. Blunt Rochester. Thank you so much for the recognition, 
Madam Chairwoman, and for your incredible leadership on this 
subcommittee, and thank you to the witnesses that are here 
today.
    The passage of the Affordable Care Act ushered in a new era 
for healthcare and expanded coverage to more than 20 million 
Americans. This landmark law resulted in the highest insured 
rate in our Nation's history. It included a comprehensive set 
of measures to protect Americans with preexisting conditions. 
Millions of Americans have access to affordable quality health 
insurance because of the law. The law's tax credits make 
healthcare affordable for millions of Americans, but millions 
more are still under or uninsured.
    Unfortunately, Republican Governors continue to refuse to 
expand Medicaid in some States, as was mentioned, and the Trump 
administration has deliberately made attempts to undermine this 
law.
    My question is for Mr. Lee, my first question. Mr. Lee, 
your State implemented a new program that provides enhanced 
subsidies for low and middle class consumers. How many 
individuals have benefitted? And can you briefly discuss the 
program?
    Mr. Lee. I can. Thank you very much for the question.
    I appreciate Chairman Eshoo's note about California's 
breadth of diversity. We are a very diverse State with about 30 
percent of our role is Latino, about a third Asian Americans, 
many African-Americans, but we know the ACA is not enough. So 
Governor Newsom and the Legislature expanded subsidies that 
about 600,000 or 1/3 of our enrolled has benefitted from, 
600,000. But it included having element of having subsidies for 
people that are above that 40 percent poverty clip. They now, 
instead of spending 10, 15, 30 percent of their income, are 
getting financial help, on average $500 a month to lower their 
coverage. That contributed to our last open enrollment period a 
40 percent bump of new enrollment, healthier people, and lower 
costs for everybody, as well as the unsubsidized.
    And if I may, just very briefly. We have heard all about 
healthcare costs, and we should. The healthcare costs are a 
problem. But recognize, in the last six years, while premiums 
have doubled in much of the Nation, they have risen at half 
that rate, half that rate in California because of what we have 
done to implement the Affordable Care Act.
    So, yes, let's address pharma cost, let's address 
consolidation, but recognize getting people insured is a 
benefit to everyone by a better risk mix as well.
    Ms. Blunt Rochester. Great.
    And I want to shift a little bit to the marketing and 
outreach that was mentioned before. And I know Covered 
California invested in outreach during the COVID-19 special 
enrollment period and I know--and is increasing their marketing 
and outreach budget by $30 million for fiscal year 2021.
    What benefits has Covered California seen from their robust 
investments in marketing and outreach?
    Mr. Lee. So I want to be really clear. If you are a Nike, 
if you are--I think Timberline is in your State, if you are a 
Ford Motor, you don't say people knew about us a few years ago, 
we stopped marketing. You always had a market. But beyond that, 
healthcare is different. People don't want health insurance 
because they don't think they are going to get sick. They need 
to be convinced, reminded, cajoled, nudged. We spent a lot of 
money on marketing, but for every dollar we spend on marketing 
$6 or $7 comes back to the State by lower premium costs, by 
enrolling healthier people. It is the right thing to do and 
creates a virtuous cycle by lowering healthcare costs.
    Ms. Blunt Rochester. And, Dr. Aron-Dine, how could 
investments in the ACA's marketing and outreach and in consumer 
assistance play a role in helping people recently uninsured 
because of this pandemic? Talk to me a little bit about that in 
the minute that we have.
    Dr. Aron-Dine. I think restoring funding for outreach and 
marketing could play a very big role, so could opening up a 
special enrollment period, so could improvements in premium tax 
credits, similar to what was done in California.
    And if I could just say one word about unsubsidized 
marketplace premiums, because that has come up a lot, when 
studies have looked at this, unsubsidized marketplace premiums 
are ballpark in line with premiums for comparable employer 
coverage. But people don't see the sticker price for their 
employer plan. They don't see the $7,000 because their employer 
is paying part of it, plus we provide a tax subsidy for those 
plans. And so, of course, people are surprised by those sticker 
prices in the marketplace and some find them unaffordable.
    You can go two directions with that. You can eliminate 
protections for preexisting conditions with the risk pool and 
make things a little cheaper for the healthy at the expense of 
the sick, or you can extend premium tax credits to people at 
higher income levels as the bill passed by the House earlier 
this year would do. I think that is a more logical solution.
    Ms. Blunt Rochester. Thank you so much for all of your work 
and to the panelists, and now is not a time in a pandemic to 
get rid of the Affordable Care Act, this landmark piece of 
legislation.
    Thank you, and I yield back.
    Ms. Eshoo. The gentlewoman yields back. We thank her for 
her excellent questions.
    And it is an honor to recognize another outstanding member 
of our subcommittee, the gentlewoman from the State of 
Washington, Mrs. McMorris Rodgers.
    Mrs. Rodgers. Thank you, Madam Chair. It is great to be 
here today, and I appreciate you holding this hearing and to 
all of the witnesses for participating today.
    It has been more than ten years now since the ACA was 
signed into law, and yet today Americans are still left to deal 
with expensive and burdensome policies. The ACA, Obama Care, 
was well intentioned, but it has failed in meeting many of its 
goals and failed in meeting many of its promises. Obama Care 
promised affordable health insurance for every American and 
even penalized those who refused to buy it.
    The law has distorted markets and not controlled the 
underlying costs of care. Tens of millions of Americans today 
cannot afford health insurance, and the number of people who 
delay doctor's visits because they can't afford care just keeps 
going up.
    In 1 of 5 counties, a 40-year-old making $50,000 would have 
to pay more than ten percent of their income for the lowest 
cost plan in the Obama Care marketplace. According to 
healthcare.gov itself, this is considered unaffordable.
    Unfortunately, some of my colleagues refuse to acknowledge 
some of the issues that continue to plague the ACA, such as 
higher premiums, higher taxes, and tax penalties, and even more 
Federal regulation of health insurance.
    I believe that this type of government-knows-best approach 
is what is leading to more support for one-size-fits-all 
government takeovers of healthcare like Medicare for All.
    All Americans deserve a health insurance system that 
embraces transparency and choice, protects Americans with 
preexisting conditions, like my son, supports medical 
innovation for better care and, most of all, lowers cost across 
the country.
    To Dr. Holtz-Eakin, what changes in the way that private 
health insurance has covered certain services, such as 
telehealth visits, have you seen in your examination of the 
market? And what effect are those changes having on patients, 
the delivery of care, and the costs of care?
    Dr. Holtz-Eakin. Well, again, telehealth has come up a 
number of times, and it is a really good example of a loosening 
of the regulations that allows a new service to be offered that 
is now a competitor service to the existing delivery system.
    It is not going to compete on everything. It is not a great 
way to do an initial intake of a patient, a lot of other 
examples. But in many situations it can provide a lower cost 
alternative to an in-office visit, and that is something that 
we want to always allow to flourish wherever possible.
    And we shouldn't rely on the people at CMS to sit and think 
what could we provide to. We should simply have a regulatory 
structure that is flexible enough that if someone decides they 
want to do telehealth, they can start up and do it. And I am 
hoping that what we will learn from the experience of this 
pandemic is that a lot of the restrictions on the delivery 
system are really unnecessary. The notion that scope of 
practice laws are as tight as they are really restricts 
competition.
    In the pandemic we saw doctors cross State lines and 
practice with zero problem whatsoever. There is a lot about 
this that I think is a real wake-up call to how we deliver 
health in the United States.
    Mrs. Rodgers. Thank you.
    And as a follow-up to you and to Director Cameron, 
obviously, this pandemic is tragic, and we can't underscore the 
personal costs and the toll that it has had on our country. 
From a healthcare policy perspective, it has forced us to adapt 
in ways to the environment and change the way healthcare is 
delivered in some cases.
    Using telehealth in my rural district in eastern Washington 
as an example, there are many ways that healthcare is covered 
or paid for and, in the long run, would improve the efficiency 
of this system and improve patient access. In other words, 
there is lessons that we can learn and any policies that we 
have implemented on a temporary basis I think we should 
consider for a permanent basis.
    And I would just like to ask both of you to highlight, what 
are those temporary policy changes that we should consider to 
make permanent?
    Dr. Holtz-Eakin. Want to go first, Dean?
    So I would encourage you to take a look at the list we 
compiled at the American Action Forum. We have a list of all of 
the emergency waivers that HHS has done using the health 
emergency declaration and go through that list, and anything on 
that list is fair game to be made permanent.
    I think that that has been--you know, if you needed to do 
it to address the biggest crisis we have seen in America, then 
it is something that needs to be gotten rid of permanently.
    Mrs. Rodgers. OK. Well, thank you. Thank you very much. 
Always good to hear your insights.
    And with that I will yield back. Thank you, Madam Chair.
    Ms. Eshoo. The gentlewoman yields back. It is great to see 
you.
    And now it is a real pleasure to recognize just an 
outstanding member of our committee. We are really lucky to 
have him, always thoughtful.
    Mr. Welch, you have 5 minutes, and we want to hear 
everything that you say, so unmute.
    You need to unmute. Can't hear you.
    Mr. Welch. Well, I said I was----
    Ms. Eshoo. There you are.
    Mr. Welch. I was listening to you, and you embarrassed me 
with that introduction. I am not quite sure you got that right.
    But I am actually delighted to be here, of course, with my 
colleagues on the committee, and I am not going to rehash the 
ACA issues. I want to focus on some of the things we can do to 
address the high cost of medical care. In this country, as we 
know, we pay the most and get the least. And whether we have a 
taxpayer-funded system, an employer-based system, or an 
individual pay system, if the cost of healthcare keeps 
escalating like it is, none of us are going to be able to 
afford it.
    I am going to ask, Dr. Holtz-Eakin, you make some very good 
comments, and I really do always enjoy your testimony. And the 
question I have is this. Some of the information we have now is 
that easing regulations helps. It helps on delivery and it may 
help on the cost. You mentioned telehealth, something that I am 
a very strong supporter of. But here is the question.
    If you ease regulations, do you maintain standards? 
Because, for instance, if you allow for insurance companies to 
sell policies that deny preexisting conditions, then that is an 
option for somebody. But then when they get sick, they may well 
not have coverage.
    My view--and I want your reaction to this--is that if you 
are going to ease regulations, you have to have standards so 
that a person, whether he or she is in Texas or in Vermont, has 
confidence that they will get the healthcare they need when 
they need it.
    Can you comment on that tradeoff between regulations and 
standards?
    Dr. Holtz-Eakin. So I think of this in two different areas. 
One of it is the insurance arena, as you mentioned. There is a 
difference between saying this is insurance that you are 
allowed to offer, having a strict regulatory structure that 
says what you may or may not offer, and a set of standards to 
say, OK, you can offer insurance with a minimum standard, it is 
not really insurance if it doesn't cover anything, so that is 
minimum standard to get Federal subsidies and preferred tax 
treatment.
    And then you get into transparency and consumer protections 
and adequate financial backing for the insurance company 
itself. You can't--
    Mr. Welch. OK. Let me interrupt here because that is a very 
good point. But all of those things that you just mentioned do 
require some kind of governmental action, not just free market 
action, correct?
    Dr. Holtz-Eakin. Free markets operate within a legal 
structure and the legal structure is essential. There is no way 
around that.
    Mr. Welch. Correct. No, I appreciate that.
    And I want to go to Dr. Lee. I was extremely interested in 
the point that you made that, despite the escalating premiums, 
your increase in premiums has been half of what the national 
experience has been. Is that what you said?
    Mr. Lee. That is absolutely right, Congressman Welch. I 
think it is important to note that underlying costs are still 
too high in California. We have consolidation problems, but 
premiums would have gone up half as much in the rest of the 
Nation if the rest of the Nation had implemented the Affordable 
Care Act that we did, marketing, Medicaid expansion, getting 
everyone in the door to have a healthier risk mix.
    Mr. Welch. And, Dr. Aron-Dine, could you comment on steps--
well, first of all, just comment on what is the incredible 
pressure of high costs on any kind of sustainable healthcare 
system, number one, and, number two, what recommendations you 
would make to bring down the costs.
    Dr. Aron-Dine. Sir, I think you really put your finger on 
it. High costs are a systemwide issue, and they need to be 
addressed in large part on the provider side of the system, 
thinking about prices, thinking about utilization, thinking 
about delivery system reform.
    And so I just want to contrast that with the sort of 
implication that somehow ACA costs are especially high or the 
marketplace costs are out of control. We have a systemwide 
healthcare cost issue and then we have some affordability gaps 
in the ACA structure that are pretty easily solvable and could 
address the concerns of unsubsidized marketplace consumers.
    With respect to continuing to work on costs, I think we 
actually have a lot--there are many ideas in common among the 
panel. I was also really struck by--in thinking about 
regulatory barriers and other barriers that have been relaxed 
during the pandemic.
    Many States have also relaxed access barriers in Medicaid 
and changed and streamlined their eligibility procedures to 
make sure that people could get coverage during this period. 
And I think similar to how there are lessons on scope of 
practice, there is some lessons on eligibility there, practices 
that we could continue to take nationwide and get eligible 
people covered without compromising program integrity.
    Mr. Welch. Thank you.
    My time is up, but I want to acknowledge the testimony of 
Mr. Cameron and the successes that he was able to talk about in 
Idaho. Thank you.
    Ms. Eshoo. The gentleman has completed his questions.
    And it is a pleasure to welcome back to the subcommittee, 
she is an honorary member of our subcommittee, Ms.Schakowsky of 
Illinois, who waves on, and we are happy to have you, and you 
are recognized for 5 minutes for your questions. Please unmute.
    Jan, we can't hear you. You need to unmute.
    Ms. Schakowsky. I should be unmuted now, I hope.
    Ms. Eshoo. You are.
    Ms.Schakowsky. Thank you so much. I really appreciate your 
indulgence to let me wave on, and it has been an amazing, 
amazing hearing.
    I don't want to go over old testimony--or I mean old 
messages, but I do want to say that on this day when there are 
now 201,000 people who now have died from the COVID crisis, and 
I just want to say they deserve recognition and mourning, the 
families who have lost their loved ones, the essential workers 
who have died, and the nursing home residents that we have been 
trying to focus on who failed to be protected.
    And the one bright light really has been the Affordable 
Care Act. No one disagrees that there aren't ways that it could 
be improved; but, thank goodness, for the Affordable Care Act 
and the difference that it has made. And really the terrible 
travesty of the sabotage that we have seen--I mean, I listen to 
all of the complaints about the Affordable Care Act, and still 
there is nothing else right now that has been suggested.
    But, Mr. Lee, I have a very specific question that affects 
my State of Illinois. According to your testimony, California 
has done a number of things on its own, spent the past decade 
protecting, building on and going beyond the ACA. But my home 
State of Illinois still relies on the Federal Government 
exchange. We don't have our own exchange in Illinois.
    And so what I really wondered was how has your State-based 
exchange allowed you to do better to serve Californians, 
especially during this COVID crisis? And what would you 
recommend to other States in terms of relying just on the 
Federal exchange and instead moving toward having its own 
exchange and the options that become available?
    Mr. Lee. Well, thank you so much for the question, and 
thank you also for your observation about taking a moment to 
mourn the losses we have seen around the entire Nation.
    California is an independent exchange, but from day one we 
said we are committed to building on and making the Affordable 
Care Act work, building on. Covered California has patient 
centered standard benefit signs. There are great economic 
theories about more choices, better, but we want consumers to 
choose between plans with good choices. We have robust 
competition.
    We bring health plans in, but we also hold the health plans 
to account to make sure they deliver quality care. It is not 
just about people getting an insurance card. So we look at 
health equity. We hold our health plans to account. We have 
very robust competition. 80 percent of our enrollees have four 
or more carriers to choose from, 99.8 multiple plans. We have 
competition.
    But it is also about marketing. It is about marketing and 
getting the word out and promote it. As I note, we spent a lot 
of money on marketing. We spent $150 million in marketing and 
outreach in the coming year, and it lowers costs. It is not 
extra Federal money. It is coming out of the premiums, but the 
premiums are lower because of that spending, but part of it is 
we have navigators, we have 10,000 insurance agents.
    We have storefronts with Covered California's name on 
streets across California, 500 storefronts. Behind those 
storefronts are not government workers, but some of our 10,000 
independent insurance agents. It is navigators we fund.
    And these are the investments that the Federal Government 
should be making to stand up and make sure that all Americans 
get coverage or saving marketplaces many are doing similar 
things, and this is about getting everyone insured something we 
have wanted to do from day one.
    Ms. Schakowsky. I thank you so much. I really think that--I 
would hope that we could get Illinois to follow your lead and 
to adopt many of the suggestions that you have already 
implemented. So thank you so much.
    And I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    I am sure that Peter Lee would be happy to assist you, Jan, 
but here is a warning. Do not take him away from us. He is far 
too valuable. We need him.
    I don't think that--oh, I thought that we were finished. It 
is really a pleasure to recognize a long-standing member of our 
committee, really salute him for the work that he has done over 
so many years, his conscientiousness, his friendship, his 
effectiveness, his caring for his constituents and country.
    I am pleased to recognize the gentleman from New York, Mr. 
Engel.
    Mr. Engel. Thank you, Madam Chair, and thank you for those 
kind words, and thank you for being such a good friend of mine 
all of these years.
    You have done a terrific job as Chair of this subcommittee, 
really making the subcommittee rise to an eminent place.
    We all know healthcare is just so important, and we come 
with a whirlwind of knowledge, and you actually feel it when 
people are suffering. I think you have done a fantastic job as 
Chair of the subcommittee, and I was proud to be part of it.
    This may be the last time I speak, so I want to say that 
the fight, obviously, that we have all been doing for 
healthcare and other things needs to go on because there are 
many people that want to kill it, and we know that that would 
be a tragedy.
    The ACA has helped nearly 20 million Americans get covered, 
including nearly a hundred thousand of my constituents. Many of 
these Americans gained coverage through the ACA's landmark 
Medicaid expansion.
    If the remaining 12 nonexpansion States would join the rest 
of the country, an estimated two million more Americans would 
gain coverage, and during the current COVID-19 pandemic in 
which millions of Americans have lost their health coverage, 
this would provide many low income and working families peace 
of mind.
    House Democrats passed the Heroes Act, which would provide 
a trillion dollars in State and local relief to help support 
Medicaid expansion.
    Let me ask Mr. Cameron, could you describe why Federal 
dollars to State and local relief are critical to supporting 
Medicaid expansion?
    Mr. Cameron. Well, excellent question. Certainly Idaho is 
one of those that did expand Medicaid, although we took our 
time in doing so, and certainly the increased FMAP has 
certainly been very helpful to us, and we have seen dramatic 
improvement in the number of folks--or dramatic number 
increases during the pandemic in the number of folks who 
actually accessed Medicaid.
    We do see some that prefer not to, and the way the laws 
are--the way the ACA is drafted, it doesn't give them a choice.
    So we do have some consternation over that. We would like 
to give consumers the opportunity to choose whether to be on 
Medicaid or to choose whether to be on a private sector plan 
and think that there is a solution there as well.
    Mr. Engel. OK. Thank you.
    Millions of Americans have lost their job-based health 
insurance through the economic crisis caused by the coronavirus 
pandemic, and Congress has taken steps to preserve their health 
coverage by providing more funding to States with Medicaid 
coverage.
    Like my home State of New York, we have also opened up 
special enrollment periods for the Affordable Care Act's 
exchanges to enable individuals to purchase high quality of 
coverage. And so far, 8,000 New Yorkers have used this 
opportunity to get coverage. So it is really something that is 
really important.
    Thank you, sir, for your good work.
    And I yield back the balance of my time--oh, I am sorry; 
one more here.
    Dr. Aron-Dine, what steps can States which run their own 
exchanges take to inform their residents about their special 
enrollment periods? And piggybacking with that, what else 
should Congress do?
    Dr. Aron-Dine. I think there are a lot of lessons for 
Congress in things States have successfully done to expand 
coverage, both before the pandemic and during the pandemic.
    I would put those in a big bucket of improving premium tax 
credits, improving affordability, both for the lower income 
people who are still most likely to be uninsured and also for 
people who are not currently eligible for subsidies but could 
be offered subsidies if premiums are unaffordable as a share of 
their income.
    Another big bucket is improving access, making it easier 
for people to access both Medicaid and marketplace coverage. 
That is something that New York has really been a leader on 
through its basic health program where people can enroll all 
year and can more easily move between different types of 
coverage, and then, of course, making sure that the remaining 
States expand Medicaid.
    I wonder if Peter Lee would like to answer your question 
about the best ways to promote a special enrollment period.
    Mr. Lee. Well, if I may very briefly. It really has to be 
about being all in every channel. Again, we spent $150 million. 
That is a lot of money, but we are a really big State. Any 
State should be spending, to our mind, about one percent of 
your premium dollars on marketing, and that means TV, radio, 
social media.
    In California, it means material in Spanish, in Korean, in 
Vietnamese. It is in language; but it is also on the ground. It 
is so important. We have learned half of our enrollment is 
through insurance agents and navigators. These are people in 
communities.
    Now, you cannot be a storefront and have our name emblazed 
unless you agree by our rules. But the fact that we have these 
storefronts, you know, in every community, we have got them on 
Wilshire Boulevard in L.A., Mission Street in San Francisco, 
but we have got them on Roscoe Boulevard in Panorama City, Q 
Street, in every city, which means people know we are there, 
but it is because we support agents and navigators.
    So it needs to be everything from social media to on the 
streets, which right now people still use the phone.
    So thank you for that handoff, Aviva.
    Mr. Engel. OK. Thank you very much.
    And thank you to all our witnesses again, and thanks to 
Chairwoman Eshoo.
    Obviously, we need to protect not dismantle the ACA. And, 
frankly, what the President is doing now is really a disgrace, 
and I just cannot believe that a government which is supposed 
to protect the people would do something to take away people's 
coverage which they rely on. It is absolutely mind-boggling. So 
we need to be vigilant.
    We need to make sure that these things are not taken away 
and that the American people can get equality of coverage.
    And I yield back the balance of my time.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the gentleman from Arizona, 
Mr. O'Halleran. Please unmute. You have 5 minutes for your 
questions.
    Mr. O'Halleran. Thank you very much. Good afternoon. And, 
Ranking Member Burgess, thank you for allowing me to wave on 
today. It is an important hearing, and I appreciate the 
subcommittee's attention to the importance of the Affordable 
Care Act as our Nation is grappling with the COVID-19 pandemic.
    The lifeline caps on healthcare cannot be imposed by 
insurers and that young people can remain in their parents' 
healthcare until they are 26, these are a couple of the issues 
that are basically different than what we knew before 
affordable healthcare, along with preexisting conditions. And 
for the healthcare industry, it is costly.
    Something that is seldom discussed is the Affordable Care 
Act's role in addressing healthcare disparities among racial 
and ethnic groups, as well as by income.
    Dr. Sommers, as you note in your testimony, a staggering 
19.6 percent of Native Americans lacked health insurance, 
according to a 2018 American Community Survey, public data.
    The COVID-19 pandemic has hit Indian country hard, with the 
per capita rates in the Navajo and the White Mountain Apache 
Tribes in my district, both of which had suffered amongst the 
highest in the Nation at their peaks.
    A lack of preventative healthcare, lack of clean drinking 
water, and access to healthy food, and a high number of 
individuals without high quality health insurance worsened the 
impacts of COVID-19 in these communities. Much work still needs 
to be done, especially in light of COVID-19.
    I sponsored the legislation that would fully fund Indian 
Health Services facilities construction program to contract and 
improve the critical issues, projects across Indian country. 
The urgent need for attention to this matter is why I am proud 
to serve on the Racial Disparities Working Group led by my 
colleague, Congresswoman Clarke, and Congresswoman Kelly, which 
provides an outlet to dive deeper into some of these issues and 
work to ensure access to quality healthcare and insurance for 
all.
    Dr. Aron-Dine, thank you for joining us and for all of your 
work showing how important the Affordable Care Act has been for 
millions of Americans. My district is larger than the State of 
Illinois, meaning that we have a lot of particularly rural and 
underserved areas. We have broadband issues that I and this 
committee have been working on since I came to Congress and 
before.
    Clearly, more needs to be done. I would like to hear more 
about what ACA could do to be improved to ensure that community 
health centers, rural hospitals, and rural providers can 
continue to provide important care that those living in rural 
areas need desperately.
    Dr. Aron-Dine. It is no urging that the ACA has improved 
coverage and access to care for people in rural areas similarly 
to people in nonrural areas, and that is especially noteworthy 
given the people in rural area disproportionately live in 
States that haven't expanded Medicaid, and so they have been 
left out of some of those potential coverage bands.
    I think one of the most urgent needs right now, 
particularly to address or at least make sure some of these 
rural access issues don't get worse, is to address the State 
fiscal crisis that States are facing, which could easily become 
a healthcare crisis, particularly as States look to their 
Medicaid budgets as a place to cut, look to provider rates as a 
place to cut, and look to nonMedicaid health programs as a 
place to cut.
    Mr. O'Halleran. Thank you.
    Dr. Sommers, the pandemic has had economic impacts 
throughout our country, but that impact has been particularly 
felt throughout poor and underserved areas, including many 
Native American communities. What specific improvements can we 
see Congress take to make the Affordable Care Act work better 
for these underserved communities?
    And I wish to point out one other issue, and that is that 
some of my constituents have to drive 10 hours round trip to 
see a specialist. Many of them do, in fact. Many of our 
veterans have to do that, too. And this is just unacceptable in 
the America that we all love. And please help us, give us some 
concepts and ideas.
    Dr. Sommers. I think there has been a lot of bipartisan 
support during the discussion today on the bolstered efforts 
for telehealth, which are critical in rural areas and 
especially in some of the communities that you are talking 
about, you know, where you have things of value, commutes are 
hours from the nearest provider in some of the reservations, in 
the Navajo Nation, for instance.
    The ACA has produced substantial gains in coverage. A study 
we published looked at coverage for Native Americans and found 
that not only did Medicaid expansion lead to big increases in 
those with insurance, it was particularly a large increase for 
those living on or near reservations.
    And then the final comment I will make on this topic is the 
Representative from Montana raised a very good question of if 
you give people insurance but they can't see a provider or 
there are shortages, does it matter? Well, when we looked at 
impact of giving people Medicaid expansion in counties that had 
specific provider shortages, we still found that coverage was 
better than being uninsured. People were better able to get 
care.
    So shortages matter. We need to address them. But having no 
coverage, you don't even have an entry into the system, whether 
there are shortages or not. So coverage first, and then we need 
to also bolster the work force.
    Mr. O'Halleran. Thank you very much.
    I would just end with saying that we can have all the 
coverage in the world, which is extremely important, especially 
in Indian country because the Affordable Care Act is so 
important to it.
    But it doesn't do as much good as it needs to in light of 
the needs of the size of the State of Illinois, you know, 
750,000 people, they have to travel a long way. There is not 
enough specialists. People are sick in those areas. And we have 
to find a better way to address the needs of all of our 
citizens, not just some of them.
    I think the Affordable Care Act is the way to do it, but 
changes do have to be made in light of the need for covering 
all of Americans.
    So thank you very much.
    I think you had something to say?
    Dr. Sommers. Congressman, I was going to say one other 
thing is the chronic underfunding of the Indian Health Services 
is something that we have to talk about in this context, too, 
and that is direct funding to creating the infrastructure that 
can then provide the care that is needed. Health insurance 
coverage is important, but the Indian Health Services plays 
such a critical role, too.
    Mr. O'Halleran. And we are doing that.
    And, Madam Chair, I yield. Thank you.
    Ms. Eshoo. The gentleman yields back. And it is always a 
pleasure, we want you to know, to have you wave on.
    Mr. O'Halleran. Thank you.
    Ms. Eshoo. You are an honorary member of our subcommittee. 
How is that?
    Mr. O'Halleran. That is great.
    Ms. Eshoo. Exactly.
    It is wonderful to recognize the colleague from California, 
Dr. Ruiz, for his 5 minutes of questions. Please unmute.
    Mr. Ruiz. Thank you, Chairwoman.
    I want to also echo the sentiments of our colleague, 
Congressman O'Halleran, who has been a champion for Indian 
country and health equity in our Nation.
    You know, it is kind of stunning to me that we still have 
to hold these hearings on the importance of the Affordable Care 
Act, that the Affordable Care Act is still under attack, that 
it is still under the threat of repeal.
    Even now, during this nationwide pandemic, where families 
all across the country have relied on coverage through Medicaid 
expansion and subsidies and exchange plans, many after having 
lost employer insurance, this pandemic has laid bear the 
importance of access to affordable healthcare with 
comprehensive benefits.
    House Democrats tried to expand that access in the Heroes 
Act, which included my bill, the Care for COVID Act. The Care 
for COVID Act expands access to healthcare by creating a 
special enrollment period for anyone without insurance and 
requires insurance plans to cover treatment for COVID with no 
out-of-pocket costs for their patients so that co-pays or high 
deductibles would not be a deterrence for seeking care.
    You know, as an emergency medicine physician, I know we 
need more access to care, not less. But you don't need to be a 
doctor to get that. You don't need an M.D. To realize that 
during a pandemic we want to get more access to the proper care 
and precautions, not less.
    And yet this administration and some House and Senate 
Republicans continue to try to chip away at the ACA, while also 
attempting to completely overturn the law in court, completely 
overturn the law in court.
    We have been fighting this for years, even as millions more 
Americans have insurance because of the ACA, even as 130 
million people with preexisting conditions across the country 
can no longer be denied health coverage just because they had 
been sick before.
    But the Trump administration and if these Republican 
leaders get their way and the ACA gets overturned, there will 
be no protections for people with preexisting conditions. Keep 
in mind that anyone who has had COVID will have a preexisting 
condition.
    This means that they may have to pay much higher premiums 
for their coverage, possibly even be denied or that coverage 
might not cover anything related to their COVID illness, which 
I should add we do not know the full scope of the long term 
affects of COVID-19 yet, or they will be subject to annual 
lifetime caps or what insurance will pay. That is if they will 
be able to get insurance at all, because without the 
protections of the ACA, all of those scenarios are possible, if 
not likely, as we all remember from pre Affordable Care Act 
days.
    Dr. Aron-Dine, can you just expand on some of the impact on 
individuals with preexisting conditions if the ACA were to be 
struck down by the Supreme Court?
    Dr. Aron-Dine. I think you described we would really be 
reverting to a pre ACA world, where the individual market 
really didn't work for people with preexisting conditions or 
others with serious health needs because they could be denied 
coverage, charged higher premiums and because plans could have 
massive benefit gaps or caps on coverage.
    And if you don't mind, if I could say one word about the 
idea that we have been hearing that there are proposals out 
there that would replace the ACA's preexisting conditions 
protections. Looking at one of those bills introduced by 
Ranking Member Walden, I have some real concerns.
    Not only would it not replace the Medicaid expansion in any 
way, which is, first of all, the loss of people with 
preexisting conditions, and not replace premium tax credits in 
any way, which is crucial to making a market that protects 
preexisting conditions actually work.
    Even if you just look at the impacts on the market, on the 
insurance market reforms, people with preexisting conditions 
could still be charged more either on the basis of their 
condition or certainly on the basis of gender or age, and plans 
could leave out high-cost drugs, could leave out any other 
benefits, or just cap coverage with low annual and lifetime 
limits, so back to the economic logic that pushes you to a race 
to the bottom in an insurance market without standards and you 
really haven't protected people with preexisting conditions in 
any way.
    Mr. Ruiz. You know, this attempt to repeal the ACA through 
the courts is opposite of what health equity means because it 
is precisely people with underlying illnesses, precisely with 
people that have chronic illnesses that are most at risk of 
dying from COVID-19.
    Repealing and chipping away from the ACA will add to the 
numbers of those who die and who suffer from this pandemic, 
which would only prolong the pandemic and its economic 
devastation for our Nation. It is the opposite of doing good. 
It is doing harm.
    Mr. Lee, good to see you again. Can you talk about how 
individuals who have had COVID will be impacted by not having 
preexisting coverage protections and what this might mean with 
any long-term health effects of COVID-19? Since we know it can 
cause scarring of the lungs, this could lead to longer term 
health effects.
    Mr. Lee. So, Dr. Ruiz--I am not sure which is a better 
honorific, Congressman or Doctor, but first it could have 7 
million people not just being precluded from getting coverage, 
but potentially being charged higher premiums, imposing higher 
out-of-pocket costs and, if I may, and Aviva noted this, but 
remember, under the pre ACA, being a woman was treated as a 
preexisting condition.
    Women were charged more for insurance. And returning to 
that reality, to my mind, would be virtually medieval.
    If I may, saying that you have a policy that could preserve 
preexisting condition protections of the ACA without addressing 
the other elements is like saying, We will keep this plane in 
the air by committing to not chopping off its wings, but not 
address that you have an engine, the need to have flaps and 
rudders to steer, the need to have a landing gear to land. 
While an airplane needs wings to fly, it also needs other parts 
to keep it in the air to get passengers on the ground safely.
    You can't separate out preexisting condition protections 
from subsidies, insurance rules. So to say you can do one thing 
alone is just both an economic and healthcare fallacy.
    Mr. Ruiz. Thank you very much.
    I yield back.
    Ms. Eshoo. Thank you very much for that exchange and, Mr. 
Lee, for, I think, really an outstanding description that 
really speaks to this whole notion of I am for preexisting 
conditions and that somehow that that is something that can 
just take place like this without any other architecture 
relative to insurance surrounding it.
    I don't see any other members that are waiting to 
participate in the hearing. So I want to request unanimous 
consent to enter into the record the following documents: An 
April 2020 letter to CMS Administrator Seema Verma from Members 
of the Energy and Commerce Committee on establishing a special 
enrollment period; a letter from AFSCME Council 57; a statement 
from Margaret Murray, chief executive officer of the 
Association for Community Affiliated Plans; an August 2020 GAO 
report entitled ``Private Health Coverage, Results of COVID 
Testing for Selected Offerings''; a letter from the National 
Taxpayers Union; a statement from Community Catalyst. And 
without objection, hearing no objections, so ordered.
    [The information appears at the conclusion of the hearing.]
    Ms. Eshoo. Let me just close on this note, and it really is 
with all of my thanks, and that is on behalf of all of the 
Members of the Subcommittee.
    Dr. Sommers, you spoke so clearly and with a knowledge that 
is so broad and deep because you are caring for patients every 
single day, and you know their stories and you related them to 
us so beautifully. Thank you. Thank you for being willing to 
testify and for the quality of your testimony.
    To Mr. Holtz-Eakin, you are always welcome at this 
subcommittee. Both sides of the aisle draw a great deal of 
every testimony that you have offered, so thank you for doing 
that today. You are always thoughtful. And you are direct in 
your answers. Which we all appreciate.
    To Dr. Aviva Aron-Dine, you are outstanding. You are 
absolutely outstanding. You have deepened and broadened our 
knowledge, never being menacing in terms of your responses, but 
with a knowledge that is dazzling, and that for those of us 
that think that we understand these policies really quite well, 
you did something today to really deepen it and broaden it. And 
you are always welcome back at the committee. You added so much 
to our hearing.
    To Mr. Cameron, thank you for your testimony. To have an 
individual that represents, even though the population of Idaho 
is relatively a small one in comparison to my home State of 
California, your experience and your work to help insure people 
was high value testimony, and we appreciate it. And I think you 
have a good sense of that because you evoked important 
questions from both sides of the aisle.
    And to Peter Lee, there simply is no one like you. There is 
simply no one like you. As when we opened the hearing and I 
introduced you, I spoke you are one of the most distinguished--
you come from one of the most distinguished families in 
California, in our country, and at the heart of their service 
and their care was healthcare. You are all physicians. So you 
are--you stand on the broadest shoulders.
    You have not disappointed anyone in generations of your 
family. You carry on that tradition, and Californians are 
deeply grateful to you. Our entire delegation from both sides 
of the aisle are grateful to you and grateful to you not only 
for your knowledge and your know-how, but that all of us can 
really sense and feel from a deep place what kind of commitment 
you have. It is called the Lee commitment, your fortitude.
    So bless all of you for working with us to really make our 
country better. We are in troubled times. It is up to us to 
help bring the American people through.
    And at the heart of that, at the heart of that, is the 
dignity of each human being. Each one has a spark of divinity 
to them, and honoring that spark of divinity is that they will 
have healthcare that they and their families can depend on. 
That is the way that we honor them.
    So thank you to all of my colleagues. Thank you to the 
witnesses.
    And with that, the Health Subcommittee of Energy and 
Commerce is now adjourned.
    [Whereupon, at 1:58 p.m., the subcommittee was adjourned.]

                Prepared Statement of Michael C. Burgess

    Thank you, Madam Chair. I would like to set the stage by 
walking through the robust support that Congress has provided 
already this year to protect American patients during this 
novel coronavirus pandemic. In various supplemental relief 
packages, Congress has provided or required coverage for 
different coronavirus-related services. For example, Congress 
has required that commercial insurance cover coronavirus 
testing.We have also waived all cost sharing requirements for 
Medicaid and the Children's Health Insurance Program for labs 
and diagnostic services related to a coronavirus diagnosis. 
Uninsured individuals are protected because we allowed states 
the option to pay for these individuals under Medicaid and 
established a separate funding stream for provider relief to 
ensure that physicians, hospitals, and other providers are 
reimbursed for the care that they provide to uninsured 
patients. We have provided similar protections for Medicare 
beneficiaries, in addition to increasing access and 
reimbursement for telehealth services.
    We have championed policies that would keep money in 
American patients' pockets. We allowed high deductible health 
plans to cover telehealth under the deductible for two years, 
and we allowed patients to use funds in Health Savings Accounts 
and Flexible Spending Accounts for the purchase of over-the-
counter medical products, including those needed in quarantine 
and social distancing, without a prescription from a physician.
    You have called this hearing today, in part, to celebrate 
the Affordable Care Act. If it is so comprehensive and working 
so seamlessly, then why have you called us here to discuss how 
it has struggled to provide adequate protections for 
individuals during this pandemic? From what I have heard, 
states and insurance plans have been able to adapt quickly to 
ensure flexible yet comprehensive coverage for individuals.
    My constituents continue to tell me how unaffordable the 
Affordable Care Act is. Many of those laid off because of the 
economic impact of the virus are eligible for a special 
enrollment period to sign up for an ACA plan or have become 
eligible for Medicaid. If they are choosing not to enroll, that 
is probably because of the astronomical cost of doing so.
    I would like to make it clear that there is vast, 
bipartisan support for protecting coverage for individuals with 
pre-existing conditions. Many of us on our side of the dais 
have experience with pre-existing conditions in our own 
families or providing insurance for the employeesof their 
businesses. If there was a real concern about addressing this 
issue, the Majority would have voted with Republicans on 
numerous occasions this Congress to support protections for 
individuals pre-existing conditions. They also could have 
called a vote on a severability clause bill to ensure that if 
the Affordable Care Act were struck down, these protections 
would stand. They have not taken any of these actions.
    The constituents in my district are struggling to afford 
their health insurance, and I am sure that my district is not 
the only one suffering from sky-high premiums and deductibles. 
What good is healthcare insurance if you are afraid to use it 
because you can't afford your deductible? This is an issue that 
I would like to see us tackle.
    This hearing is also in direct contrast with the hearing 
that Chairman Pallone and Chairwoman Eshoo called last 
December. The hearing notice for the December 19, 2019 hearing 
stated, ``universal healthcare coverage has long been the North 
Star of the Democratic Party.'' Their agenda is to pave that 
road to the North Star--to accomplish one-size-fits-all 
healthcare coverage. The reality is that one-size-fits all is 
really one-size-fits-no one.
    It is critical that states maintain the flexibility to 
address the unique needs of their citizens. Forcing every state 
and every American to fit into the same box will not work. 
Americans need and deserve to have choices that will work for 
themselves and their families. They should not have to worry 
about spending a substantial portion of their income on health 
insurance to have an unreasonably high deductible such that 
they fear using the insurance they pay for.
    With that, I yield back.
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