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116th Congress    }                                 {     Rept. 116-44
                        HOUSE OF REPRESENTATIVES
 1st Session      }                                 {           Part 1

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



 
      PROTECTING AMERICANS WITH PREEXISTING CONDITIONS ACT OF 2019

                                _______
                                

 April 30, 2019.--Committed to the Committee on the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

 Mr. Pallone, from the Committee on Energy and Commerce, submitted the 
                               following

                              R E P O R T

                             together with

                            DISSENTING VIEWS

                        [To accompany H.R. 986]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Energy and Commerce, to whom was referred 
the bill (H.R. 986) to provide that certain guidance related to 
waivers for State innovation under the Patient Protection and 
Affordable Care Act shall have no force or effect, having 
considered the same, report favorably thereon without amendment 
and recommend that the bill do pass.

                                CONTENTS

                                                                   Page
   I.  Purpose and Summary............................................2
  II.  Background and Need for the Legislation........................2
 III.  Committee Hearings.............................................3
  IV.  Committee Consideration........................................3
   V.  Committee Votes................................................3
  VI.  Oversight Findings.............................................3
 VII.  New Budget Authority, Entitlement Authority, and Tax 
      Expenditures.....................................................
VIII.  Congressional Budget Office Estimate...........................3
  IX.  Federal Mandates Statement.....................................5
   X.  Statement of General Performance Goals and Objectives..........5
  XI.  Duplication of Federal Programs................................5
 XII.  Committee Cost Estimate........................................5
XIII.  Earmarks, Limited Tax Benefits, and Limited Tariff Benefits....5
 XIV.  Advisory Committee Statement...................................5
  XV.  Applicability to Legislative Branch............................5
 XVI.  Section-by-Section Analysis of the Legislation.................5
XVII.  Changes in Existing Law Made by the Bill, as Reported..........6
XVIII. Dissenting Views...............................................7


                          PURPOSE AND SUMMARY

    H.R. 986, the ``Protecting Americans with Preexisting 
Conditions Act of 2019'', was introduced on February 6, 2019, 
by Reps. Kuster (D-NH), Beyer (D-VA), and Courtney (D-CT), and 
referred to the Committee on Energy and Commerce.
    The goal of H.R. 986 is to prohibit the Department of 
Health and Human Services (HHS) and Department of the Treasury 
(the Treasury) from taking any action to implement, enforce, or 
otherwise give effect to the Section 1332 guidance that was 
issued on October 24, 2018. The bill would also prohibit the 
Secretaries of HHS and the Treasury from promulgating any 
substantially similar guidance or rule.

                  BACKGROUND AND NEED FOR LEGISLATION

    On October 24, 2018, the Centers for Medicare & Medicaid 
Services (CMS), HHS, and the Treasury issued a guidance on 
Section 1332 of the Patient Protection and Affordable Care Act 
(ACA) entitled, ``State Relief and Empowerment Waivers'' (2018 
Guidance).\1\ Section 1332 (State Innovation Waivers) of the 
ACA, Public Law 111-148, authorizes states to waive certain 
requirements of the law and experiment with health insurance 
reforms that could improve the well-being and health of their 
residents. The ACA clearly directs states to maintain minimum 
benefits, affordability, and coverage standards and levels for 
state residents.
---------------------------------------------------------------------------
    \1\Department of Health and Human Services and Department of the 
Treasury, Waivers for State Innovation, 83 Fed. Reg. 53575 (Oct. 24, 
2018).
---------------------------------------------------------------------------
    Section 1332 requires states to meet four statutory 
``guardrails'' simultaneously and demonstrate that the proposed 
waiver will provide comprehensive, affordable coverage to a 
comparable number of residents as under the ACA, without 
increasing the federal deficit. In the 2018 Guidance, HHS and 
the Treasury revised the agencies' interpretation of the 
requirements of the statute.
    The 2018 Guidance changes the requirements that states must 
meet in relation to the affordability and comprehensiveness 
guardrails, and it expands the definition of health insurance 
coverage. The 2018 Guidance allows states to demonstrate that a 
comparable number of residents will have access to 
comprehensive and affordable coverage, regardless of whether 
they actually enroll in that coverage, thereby allowing the 
Secretaries of HHS and the Treasury to approve waivers that do 
not provide coverage that is as affordable or as comprehensive 
to the same number of people as under the ACA. The 2018 
Guidance also allows states to receive waiver approval for 
proposals that direct the ACA's tax credit subsidies towards 
short-term, limited duration insurance (STLDI) plans and other 
types of health insurance plans that do not provide consumer 
protections contained in Title I of the ACA.
    H.R. 986 would revoke the revised guidance issued on 
October 2018. H.R. 986 would further prohibit the Secretaries 
of HHS and the Treasury from promulgating any substantially 
similar guidance or rule.

                           COMMITTEE HEARINGS

    For the purposes of section 103(i) of H. Res. 6 of the 
116th Congress, the following hearing was used to develop or 
consider H.R. 986:
    On February 13, 2019, the Subcommittee on Health held a 
hearing on H.R. 986, entitled ``Strengthening Our Health Care 
System: Legislation to Reverse ACA Sabotage and Ensure Pre-
Existing Conditions Protections.'' The Subcommittee received 
testimony from:
           Katie Keith, Associate Research Professor 
        and Adjunct Professor of Law, Georgetown University;
           Jessica Altman, Commissioner, Pennsylvania 
        Insurance Department; and
           Grace-Marie Turner, President, Galen 
        Institute.

                        COMMITTEE CONSIDERATION

    H.R. 986, the ``Protecting Americans with Preexisting 
Conditions Act of 2019'', was introduced on February 6, 2019, 
by Rep. Kuster (D-NH), and referred to the Committee on Energy 
and Commerce. The bill was subsequently referred to the 
Subcommittee on Health on February 7, 2019. Following 
legislative hearings on H.R. 986, the Subcommittee met in open 
markup session, pursuant to notice, on March 26, 2019, for 
consideration of the bill. Subsequently, the Subcommittee on 
Health agreed to a motion by Ms. Eshoo, Chairwoman of the 
Subcommittee, to favorably forward H.R. 986 to the full 
Committee without amendment.
    The Committee on Energy and Commerce met in open markup 
session, pursuant to notice, on April 3, 2019, to consider H.R. 
986. There were no amendments offered during consideration of 
the bill, and at the conclusion of the markup the Committee 
agreed to a motion by Mr. Pallone, Chairman of the Committee, 
to order H.R. 986 favorably reported to the House, as 
introduced, by a voice vote.

                            COMMITTEE VOTES

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives requires the Committee to list each record vote 
on the motion to report legislation and amendments thereto. The 
Committee advises that there were no record votes taken on H.R. 
986 during full Committee markup. A motion by Mr. Pallone to 
order H.R. 986 favorably reported to the House, as introduced, 
was agreed to by a voice vote.

                           OVERSIGHT FINDINGS

    Pursuant to 3(c)(2) of rule XIII of the Rules of the House 
of Representatives, the Committee adopts as its own the 
estimate of new budget authority, entitlement authority, or tax 
expenditures or revenues contained in the cost estimate 
prepared by the Director of the Congressional Budget Office 
pursuant to section 402 of the Congressional Budget Act of 
1974.

                  CONGRESSIONAL BUDGET OFFICE ESTIMATE

    With respect to the requirements of clause (3)(c)(3) of 
rule XIII of the Rules of the House of Representatives and 
section 402 of the Congressional Budget Act of 1974, the 
Committee has received the following cost estimate for H.R. 986 
from the Director of the Congressional Budget Office:

                                     U.S. Congress,
                               Congressional Budget Office,
                                    Washington, DC, April 25, 2019.
Hon. Frank Pallone, Jr.,
Chairman, Committee on Energy and Commerce,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 986, the 
Protecting Americans with Preexisting Conditions Act of 2019.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Kevin 
McNellis.
            Sincerely,
                                                Keith Hall,
                                                          Director.
    Enclosure.
    
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    H.R. 986 would prohibit the Departments of Health and Human 
Services and the Treasury from taking any action to implement 
or enforce the regulatory guidance entitled ``State Relief and 
Empowerment Waivers'' or from issuing similar guidance in the 
future. Under current law and this legislation, waivers are 
required to be budget neutral. Changes to waiver approvals 
could affect direct spending and revenues; however, CBO and JCT 
do not have a basis for estimating that the budgetary effects 
of the bill would be significantly different than under current 
law because no states have submitted a waiver application under 
the guidance that would eliminated by this legislation. As a 
result, CBO and JCT estimate that H.R. 986 would not have a 
significant effect on direct spending or revenues over the 
2019-2029 period.
    The CBO staff contact for this estimate is Kevin McNellis. 
The estimate was reviewed by Leo Lex, Deputy Assistant Director 
for Budget Analysis.

                       FEDERAL MANDATES STATEMENT

    The Committee adopts as its own the estimate of Federal 
mandates prepared by the Director of the Congressional Budget 
Office pursuant to section 423 of the Unfunded Mandates Reform 
Act.

         STATEMENT OF GENERAL PERFORMANCE GOALS AND OBJECTIVES

    Pursuant to clause 3(c)(4) of rule XIII, the general 
performance goal or objective of this legislation is to revoke 
the Section 1332 Guidance issued on October 2018 and to 
prohibit the Secretaries of HHS and the Treasury from 
promulgating any substantially similar guidance or rule.

                    DUPLICATION OF FEDERAL PROGRAMS

    Pursuant to clause 3(c)(5) of rule XIII, no provision of 
H.R. 986 is known to be duplicative of another Federal program, 
including any program that was included in a report to Congress 
pursuant to section 21 of Public Law 111-139 or the most recent 
Catalog of Federal Domestic Assistance.

                        COMMITTEE COST ESTIMATE

    Pursuant to clause 3(d)(1) of rule XIII, the Committee 
adopts as its own the cost estimate prepared by the Director of 
the Congressional Budget Office pursuant to section 402 of the 
Congressional Budget Act of 1974.

      EARMARKS, LIMITED TAX BENEFITS, AND LIMITED TARIFF BENEFITS

    Pursuant to clause 9(e), 9(f), and 9(g) of rule XXI, the 
Committee finds that H.R. 986 contains no earmarks, limited tax 
benefits, or limited tariff benefits.

                      ADVISORY COMMITTEE STATEMENT

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act were created by this 
legislation.

                  APPLICABILITY TO LEGISLATIVE BRANCH

    The Committee finds that the legislation does not relate to 
the terms and conditions of employment or access to public 
services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

             SECTION-BY-SECTION ANALYSIS OF THE LEGISLATION

Section 1. Short title

    Section 1 designates that the short title may be cited as 
the ``Protecting Americans with Preexisting Conditions Act of 
2019''.

Section 2. Providing that certain guidance related to waivers for state 
        innovation under the Patient Protection and Affordable Care Act 
        shall have no force or effect

    Section 2 prohibits the Secretaries of HHS and the Treasury 
from taking any action to implement, enforce, or otherwise give 
effect to the Section 1332 Guidance issued on October 24, 2018. 
Section 2 also prohibits the Secretaries from promulgating any 
substantially similar rule or guidance.

         CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

    There are no changes to existing law made by the bill H.R. 
986.

                            DISSENTING VIEWS

    This legislation would invalidate the Trump 
Administration's guidance for 1332 Waivers for State 
Innovation.
    Section 1332 of the Patient Protection and Affordable Care 
Act (PPACA) established Waivers for State Innovation beginning 
January 1, 2017.\1\ These waivers give the Secretary of the 
Department of Health and Human Services and the Secretary of 
the Treasury the discretion to grant States new flexibility 
within their health care markets as long as the model provides 
coverage that is as comprehensive, affordable, covers a 
comparable number of residents, and is budget neutral to the 
Federal government. If approved, the State may receive funding 
equal to the amount of forgone Federal financial assistance 
that would have been provided to its residents pursuant to 
specified PPACA programs, known as pass-through funding. An 
approved waiver can remain in place for five years and can be 
renewed.
---------------------------------------------------------------------------
    \1\Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 
124 Stat. 119, (2010) (as amended by Health Care and Education 
Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 
(2010)).
---------------------------------------------------------------------------
    The updated guidance focused on loosening restrictions 
limiting State flexibility and consumer choice and providing 
flexibility for States to meet the legislative authority 
standard. More specifically, the modernized guidance centers on 
the availability of comprehensive and affordable coverage, 
expands the definition of coverage to include short-term plans, 
and clarifies that existing State legislation providing 
statutory authority to enforce PPACA may satisfy the 
requirement that each State enact a law to apply for and 
receive a 1332 waiver.
    To date, eight States have active waivers, all of which 
were approved under the Obama Administration guidance.\2\ Among 
these States, for 2018 alone: Alaska experienced a 26 percent 
premium reduction, Minnesota saw its rate increase reduced to 
11.3 percent, significantly less than its 2017 57 percent 
increase; and, Oregon's rate changes ranged from -1.6 to 14.8 
percent, dropping to a range of -9.6 to 10.1 percent for 
2019.\3\
---------------------------------------------------------------------------
    \2\Center for Consumer Information and Insurance Oversight, Section 
1332: State Innovation Waivers, available at https://www.cms.gov/cciio/
programs-and-initiatives/state-innovation-waivers/
section_1332_state_innovation_waivers-.html#Section%201332%20State%20App
lication%20Waiver%20Applications.
    \3\Jack O'Brien. Health Leaders, ACA Reinsurance Waivers Provide 
Relief from Premium Hikes, (Nov. 27, 2018), available at https://
www.healthleadersmedia.com/finance/aca-reinsurance-waivers-provide-
relief-premium-hikes.
---------------------------------------------------------------------------
    While this bill has a catchy title, it does little to 
protect individuals living with preexisting health care 
conditions. House Republicans continue to support pre-existing 
condition protections and have offered solutions to give 
patients this assurance outside of the unpopular, unaffordable, 
and unconstitutional framework.

                                   Greg Walden,
                                           Republican Leader, Committee 
                                               on Energy and Commerce.
                                   Michael C. Burgess,
                                           Republican Leader, 
                                               Subcommittee on Health, 
                                               Committee on Energy and 
                                               Commerce.

                                  [all]