Transcripts For CSPAN2 Senate Finance Committee Considers Graham-Cassidy Health Care Bill 20170925

[inaudible conversations] [inaudible conversations] if you want a hearing, you better shut up. Okay,. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] the committee will be in recess until we get order. You just heard the chairman on hatch try to put the committee in recess. You can see, weve been watching some of the handicap activists protesting in the room. As we stand by to see if the hearing gets underway, lets show you whats going on in the hallway outside the office building. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] no cuts to liberty, no cuts to medicaid, they were liberty. No cuts to medicaid, save our liberty. No cuts to medicaid, save our liberty no cuts to medicaid, Civil Liberties no cuts to medicaid save our liberty. No cuts to medicaid save our liberty. No cuts to medicaid save our liberty. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] no cuts to medicaid, save our liberty. No cuts to medicaid, save our liberty. No cuts to medicaid save our liberty. No cuts to medicaid, save our liberty. No cuts to medicaid, save our liberty. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] no cuts to medicaid, save our liberty. [inaudible conversations] [inaudible conversations] lets have order and show some respect. A lot of us are on your side. Lets have some order. If you cant be in order, get the heck out of here. The committee will come to order. I would like to welcome everyone to this afternoons hearing where we will discuss and examine the bill. Given the challenges we are facing to healthcare and this proposal, the Senate Republican leadership, as well as members of the committee have asked for hearings so we can get a better sense of how it is intended to work. Toward that end, we have to distinguish panels of witnesses before us today. The first will feature statements from two of our colleagues. Please remove that person. We would appreciate it. Keep the door shut. The second panel will feature another colleague who is also a member of this panel. Joining him at the table will be experts and stakeholders here to share their views on the proposals. The purpose of the hearing is to respectfully discuss ideas that become better informed on particular issues. [inaudible conversations] the purpose of the of the hearing is to respectfully discuss ideas and become better informed on particular issues. It does not mean that everyone shares the same views and opinions. In fact, i expect that if you disagreements will be expressed today, and thats okay with me. Ive been in the senate for four decades now and in that time ive been part of some difficult and contentious debates. Early on was part of a fierce debate over labor reform. Over the years i participated in some of the most Heated Supreme Court hearings. I was here to take part in drafting, debating and passing the americans with disability act, one of my proudest accomplishments. I was here when we debated obamacare before past. Ive been here for every debate about it since that time. There i understand there are some strong opinions about this issue. I understand why opinions are so strong. When we talk about healthcare policy, were not just talking about a theoretical concept for legislation that impacts a single isolated industry. This has a Significant Impact on the lives of every person in this country in ways that can make or break their health and livelihood. Frankly, this is a personal, everyone has strong feelings. If we could shut that door and keep it short, i would appreciate it. Two members of the committee and those in the audience and any person who may watch or read about todays hearing at some point, let me say this, i respect your opinions on these issues. While a rich expressions of goodwill could fix our nations problems, that is not the case. We have to do the work. On these issues the work is particularly hard. Today we are here to discuss the most recent healthcare proposal drafted by some of our colleagues and i commend them for their efforts and their willingness to put forward ideas to address these very difficult problems. My hope is to spend our time today questioning our witnesses about substance in policy, not on scoring political points, particularly when we have distinguished colleagues at the table. I know for the both sides of this debate, passionate demonstrations and righteous indignation, particularly when the there are cameras in the room make good fodder for twitter and commercials especially when the topic is healthcare. Our committee is generally above such shenanigans although we havent been entirely immune to these theatrics in the past. Today, let me say this. If the hearing is going to devolve into a sideshow or form simply for putting partisan points on the board there is no reason for us to be here. I wont hesitate to adjourn the hearing if it gets to that point. It had gotten there yet but its close. Lets have a civil discussion. I have no objection to having a spirited debate on these issues. I was the author of the americans with disability act. I have very deep feelings about these issues. I think most on the committee have deep feelings as well. My hope is, in the end, our efforts would generate more light and less heat than weve seen in the most recent episodes of healthcare debate. We can have that we should all spend our time on something more productive. With that, i turn to our Ranking Member for his remarks. I would like to bring up several points about the process. I understand weve agreed to that. That would be fine. Colleagues, no one has to buy a lemon just because its the last car on the lot. The strum care bill is a healthier lemon. Its a disaster in the making for the fact that its the last republican revealed the standing doesnt make it okay. It will be a nightmare, tens of thousands of americans and it makes a mockery of the president s promise of better insurance for everybody at lower cost. The bill sponsors arent even waiting for the official facts and figures from the scorekeepers. Version after version of the bill is floating around in the pork parade is up and running. The process that has brought this bill to the brink of passage has been laughable of the wellbeing of tens of millions of americans wasnt in the balance. Want to blow the whistle on a few key points at the outset. The American People do not want this bill. In the last few days, the committee has received more than 25000 comments from people who want it stopped, as with every other version of trump care, this proposal is about as popular as prolonged root canal route work. There is one group cheering the bill on. The right wing republican donor class. The big donors on the Affordable Care act in the trash i wanted it from the beginning, but it didnt work. Turns out it takes healthcare coverage away from tens of millions of americans and raises cost for virtually everybody else. The new strategy is essentially repealed by a thousand cuts. It would be National Repeal and it would be statebystate repeal. The heart of this bill is a scheme that punches at the states that work hard to build strong market to make healthcare more affordable. Your words the states where lawmakers have sat on their hands mildly rejecting opportunity to improve the lives of millions of people they serve. Thats our proposition that gets much support. Instead the committee will hear a lot of hocuspocus about the word flexibility. The story goes flexibility for the state at the local level. Lets be up front about what it means in practice. It is the option for states to do worse so americans are forced to pay more for less care. They got funding for healthcare in the new block grant. Governors and state legislators build new systems and are basically going to have to make hunger game choices, deciding which Vulnerable People get care in which dont. The ironclad and those with preexisting condition will be gone. The bill sponsors will tell you otherwise, the colleagues, the facts and no one will be gouged due to a catastrophic illness due to cancer because it will be gone. The bill opens the door to annual lifetime limits on care. Prescription drug coverage would be on a chopping block along with Maternity Care, Mental Health and Substance Abuse treatment and a lot more. The guarantee that nobody could be charged higher premium because their Health Status or other job also gone. Bottom line, this bill is an allout assault on vital consumer protection. It provides some of the worst Insurance Company abuses banned under the Affordable Care act and will make the healthcare unaffordable. No, it does not adequately protect people with preexisting conditions. What the bill does include our two plus lines on affordability and access. That is supposed to be protection for people with preexisting conditions. Theres no enforcement mechanism. No real definition. States can then get a rubber stamp from team trump. There is an attack on womens health. Hundreds of thousands of women will lose the right to see the doctor of their choice. the process that led to this moment has been an abomination and we have just seen colleagues, some of the frustration that our people have at closed door government that lacks americans out of the democratic process. This just isnt serious, its a talking point today, it lets senators go home to fearful constituents and offer assurances, false assurances that this bill got a fair examination and went through the regular order. It is not true. Senate republicans havent gotten answers to the most basic questions about the real world effects of the bill, how many people will lose coverage, by how much will premiums increase, will the Healthcare Market survive next year. Will the indus Budget Office says it will be weeks before they can put forward estimates of coverage and cost and their job gets tougher because this bill just changes by the hour as the majority throws around in the scramble for votes. Why the rest drop . It is because the coach turned back into a pumpkin at the end of the month. Thats when the reconciliation fasttrack to pass the partition bill expires. We want to be clear. On this side, we think we ought to be working on 500 bipartisan priorities. We have a good bill for kids, Childrens Health insurance plan, 9 million kids and the funding for that Program Colleagues runs out in just a few days at the end of the month. Wed like to be working on that in a bipartisan way and wed like to be working on stabilizing the private Insurance Market. I have heard about that this weekend at town Hall Meetings in central or gun. Thats what we want to work on and we want to do in a bipartisan way with her Sister Senate committee instead of what is on offer is trump care bill that will trigger a healthcare disaster and a death spiral in the Insurance Market and tax credits and costsharing, payments go way and Healthy People flee and cost go into the stratosphere. Democrats on this side of the dice want to continue to do everything. Want to stop this dreadful proposal from becoming a lost and to get down to the serious heavy lifting of passing Bipartisan Legislation for kids number one and for adults in the individual Insurance Markets. With that, mr. Chairman, id like to wrap up with a few quick points about procedure for this hearing. This is. Our agreement. Mr. Chairman, you know that we are disappointed in to hold this hearing in a larger room that could accommodate more members of the public. I ask unanimous consent that a letter outlining this request be included in the record. Without objection. This is the first and only hearing that will be held regarding a bill affecting more than 320 million americans in 16 of our economy. As we just saw there is enormous public interest. We have seen hundreds of people today, many in wheelchairs lined up in the hall hoping to get into the hearing. However, after you take account of the Committee Members, staff and witnesses, members of the press, the room we are in only has space for about 30 members of the public. Thirty for a hearing of this import. Normally when Congress Holds hearings and attracts enormous public attention we have our hearings in large hearing rooms. The largest hearing room to accommodate hundreds of audience members. My understanding is those rooms are available today so the question i have is why not move the hearing they are so more people can attend. Otherwise, it sends one more signal that the majority wants to keep the bill under wraps rather than opening up the process to the American People. Finally, mr. Chairman, i understand that sanit senator cy wants to participate in this hearing as a witness providing testimony and is a member of the Committee Asking questions of the same Witness Panel he is part of. I suspect we will hear a lot today from senator cassidy about flexibility. I gather he is a big fan of flexibility. He approaches flexibility so much he wants to apply it to self. However, to my mind dashing back and forth between the witness table and the dais is not proper decorum for a hearing. I would like to make clear, chairman, my understanding with respect to the rule is i have to leave it at that. I sure think it is more appropriate that senator cassidy where one hat during this hearing rather than two. Thank you. Thank you, senator. I think senator cassidy ought to be able to do what he wants to do but ill make sure he doesnt ask questions of himself. Interesting. [laughter] maybe i should withdraw that. I picture your comments and good remarks. Because of the high interest and the importance of this hearing and overflow room has been secured, not to mention it will be televised on cspan and available for Live Streaming on the senate Mass Committee websites. To my colleagues complains about the process we are setting up this hearing i will say that many senators have expressed a desire to examine details of the proposal we are discussing today. Todays hearing is being held to allow members of both side to delve deeper into the policy and gain a better understanding of what our colleagues proposal hopes to achieve. I do not expect this hearing to go on forever. We will certainly get good opportunity. I would like to welcome each of our witnesses to her hearing today to start off on the first panel we will hear from our good friends and fellow senators, senior senator from South Carolina Lindsey Graham. He is the coauthor of this bill and junior senator from hawaii. The opening remarks, we are grateful to have such a passionate and wonderful senators join us today to share their views. Senator graham, will you share with us your remarks and we will go to the other senator. Thank you mr. Chairman. First remark i would like to share with you is why i am here. I am here because obamacare is a disaster in my state. It is not your job to take care of South Carolina. Is mine and i intend to do that. Maybe we will find a common way forward i dont know but i wont be deterred. I intend to help. Thank you. In 2014 there were five insurers offering plans to South Carolina customers under the exchange. Today we are down to one with a 31 increase announced friday. Do you expect me to walk away from that, you are sadly mistaken. I dont know how it is looking in your state but in my state it is a disaster. Why are we in finance because healthcare does affect federal finances. Most of you know that by 2042 the entire revenue stream will be consumed by medicare and medicaid spending unless someone does something about it. There will be no money for the military, department of education, and are eight or anything else. What i do i deal with the problems. Nationally obamacare premiums are going up 13 in the individual marketplace and 45 of the counties in america are down to one choice and 45 counties in this country have no choice under the plan you designed. The bottom line is i dont doubt your intentions to help people but i do question whether or not it is working as intended and you can question my motives and quite quickly, i dont care. I know why i am here. Years they designed it . Wasnt mine. I know mr. Chairman. The two problems. If someone doesnt fix obamacare soon the majority of counties in this country are going to be down to one provider. It is collapsing as i speak and medicaid, medicaid is on an unsustainable path and by 2027 we will spending more on medicaid than the military. By 2042 medicare and medicaid combined take all the money that will be sent to washington and what do we do . In year eight of the block grant we get flexibility control to the states over the Medicaid Programs like they havent had before but they have to spend it on the population in question. We begin to slow the growth down to make it more sustainable but the flexibility we give will allow us to get better outcomes. Medicaid spending and medicaid outcomes are not matched up to where everyone should want them to be. When it comes to obamacare if you dont find a way to stop the bleeding then it is going to basically collapse before our eyes and here is what we do im getting a lot of pushback for my republican colleagues because i lead the taxes in place. Heres the idea of Graham Cassidy, we repeal the individual mandate in point mandate but you can reimpose in your state if you like. If you want to go to singlepayer health care you can do it in oregon but you have to did not drag me with you. Heres the deal. We leave the taxes in place and its one point to trillion and we block grant it out through the states in a formula that i think is fair. Under obamacare between 2026 for states get 35. 4 and maryland and massachusetts, new york and california and their 22 of the population. Good deal for them, not so much the rest of us. Under this block grant they get 29 , not 35. Still more than the preparation and what if i learn . Why is the next was placed by medicaid. Its an expensive place to provide healthcare. Its an expensive place to live. Alaska has 750,000 people, to have times the size of texas. Under this bill be with you, rather than some bureaucrat in washington that is all the money in the power and we will turn it back to you, your state legislator and your governor and ask the following questions at lunch not long ago. How many of you know your state house member and almost everyone raise their hand. How many of you know the governor of doctor lena, everyone raise her hand and asked the question how many of you are in know who is in charge of obamacare is off the line and no one razor hands. That is a problem. On the 20 back to the states and you cant spend it on roads and bridges but spent on healthcare. You will have flexibility but you also have accountability for the first time in healthcare someone will listen to you. If you dont like the healthcare you got you can complain to somebody you vote for. As to the opposition of this bill. To the Ranking Member every major Insurance Company opposes art bill why because we take hundreds of billions of dollars away from them that we were going to them from the federal government and give it to the states. Guess what they dont like that. If i were a major Insurance Company i would hate my bill because that takes money and power away from you and i give it to the states. Washington is wired when it comes to health care and everyone opposing this bill is a big winner of obamacare and my goal is to get the money and power out of washington closer to where people live so they will have a voice about the most important thing in their life. I dont need a lecture from anybody about healthcare but what you have created is not working and its time to try something new and i believe with all my heart and soul that if we took the money and power out of washington and got closer to the patient and we put in the hands of somebody you would have a relationship with and you could actually vote for if you dont like the product and we will get a better outcome and this is not the last chance this is the best chance and to my friends to the left i will do everything i can to stop and put a stake in the heart of single barrel healthcare. You dont like obamacare and you dont like the as big of her enough but i will here to stop you. If you care as much as i do about healthcare but going beyond obamacare is a nightmare for this country and it will ruin healthcare and bankrupt the American People and this is a debate worth having. Thank you very much. God bless you all. Thank you senator graham. Thank you Ranking Member chairman. Thank you for inviting me to testify. When i was diagnosed with stage iv Kidney Cancer about five months ago two things. The first was the diagnosis came as a total shock to me. It came about incidental to a physical checkup that involved an entirely different procedure that i was facing. This is how a lot of people learn about the serious illness or condition and out of the blue, bang and you cant plan for it. Second i received letters, cards and no two people found out and i was touched by the hand reaching out to me and the show of compassion including from so many of my colleagues, including members of this committee emphasize of the aisle. Every day now people come up to me at airports, grocery stores, restaurants to tell me that they too are cancer survivors. There is a connection there. It is never a good time to have cancer but what i am experiencing through my cancer is the care and concern expressed by total strangers. This is compassion. It helps me a lot. What we do as leaders affects everyones lives and should we replace compassion, sadly that is not in this bill. In the greatest, richest country in the world compassion for our fellow men and women should not be so elusive or indeed missing. After all the compassion and care that i received from my colleagues after i disclose my diagnosis the Graham Cassidy proposal reflects neither care nor compassion for millions across the country. Healthcare is a right it is a rights, it is not a privilege reserved for those who can afford it. Graham cassidy treats healthcare like a commodity that can be bought and sold. This is fundamentally wrong although nearly all of us will face a serious illness during our lifetime, it is also possible to budget and plan for the cost associated with treating it. Once diagnosed, you cant put it off because she cant afford it. For the Affordable Care act. [inaudible] since the law went into effect weve seen a huge reduction in personal bankruptcies and their his a causal relationship. When people get healthcare. If you dig into the details and numbers it is clear this bill is much worse than the bill we defeated in july. Under the thin veneer of states rights and local control the Graham Cassidy bill imposes a radical overhaul of 16 of the american economy. According to the Brookings Institution 32 Million People will lose their Health Coverage under it. There is so much wrong with this bill that its difficult to find my remarks to only the short time ive been allowed to testify. Contrary to promises made by the bills authors this proposal undermines protections for the close to 600,000 people in hawaii and 135 million in the Country Living with preexisting conditions. This undermines Consumer Protections that require coverage for preexisting conditions and prohibits Insurance Companies from charging people more for care which is exactly what they will do believe me. The process requires a pro forma explanation of how it would maintain coverage for those with pre existing conditions. It is really a box that they check off. There is nothing here that ensures the level of protection that the Affordable Care act does. Sure, the federal government can deny a state waiver application but the very people who would be making this decision at the federal level are long time opponents of the Affordable Care act. Sadly, the American People cannot trust this administration to do the right thing regarding their healthcare. We dont have to look to see what the result would be and if the state granted a waiver. Insurance committees could use Health Status and age and other factors to determine what premiums to charge. They could set annual and lifetime limits on care and could refuse treatments because of how much they cost. Believe me, i have a complicated illness and i would reach lifetime limits and practically a nanosecond. I intend to live longer before that day comes. Under this bill coverage might be available but it would be prohibitively expensive and able to be taken away in a summons moment of greatest need. This bill dismantles medicaid as we know it in the bill converts medicaid into block grants, states and cut funding to buy hundreds of billions of dollars by 2026. It punishes states like hawaii that expanded medicaid i cutting federal funding and redistributing it to those states that did not expand medicaid and therefore hundreds of thousands of people in the states dont have the coverage that hawaii provided. For hawaii we are looking at around 4 billion in cuts and 91000 fewer hawaii residents having healthcare because of this bill. Because states receive so much less money they will no longer be able to provide quality, adequate care for as many people as possible. Instead they will face the Impossible Task of choosing who should lose interest in which services to cut. Even then the most vulnerable members of our society, the elderly and disabled, children will not receive the care and services they need. Mr. Chairman, we are all one diagnosis away from a major illness and i certainly found that out. With so much uncertainty right now in our country the one thing that people should be able to count on in the richest country in the world is getting the care they need when they need it. Healthcare is a right, not a privilege for those who can afford it. Healthcare is personal to every single one of us. I would like to conclude with a call to action. This bill would be devastating for millions of people across the country facing dire health conferences. Millions of lives are at stake and lets return the bipartisan negotiations led by senator alexander and murray to stabilize the Health Insurance marketplace. This is something they are doing together in a bipartisan way. This is exactly how we should approach healthcare in our country. Focus on the people who were elected to serve. Focus on those elected to serve. Show them the compassion that they are expecting from their leaders. They expect us to Work Together and come up with a bill that we can get behind. Thank you mr. Chairman. Thank you senator hirono. We appreciate your remarks and thank you for sharing your remarks to the committee today. I think i speak for all of my colleagues when i say that we are hopeful in pain for senator hirono your quick and total recovery from cancer. We do appreciate both of you for taking the time to be with us today. Youre both welcome to stay for as long as you wish. Now we will turn to the panel too. Next will hear from the six witnesses that stood before the committee today. I will introduce witnesses briefly and then have each of you provide your testimony in the order you are introduced. First we will hear from our good friend, colleague and fellow Committee Member doctor cassidy. Prior to coming to the hill in 2015 senator cassidy provided care for uninsured and underinsured patients for nearly 30 years. He is a cofounder of the Greater Baton Rouge Community clinic, created a private Public Partnership to vaccinate children against hepatitis b and in the wake of Hurricane Katrina he led a group of healthcare volunteers to convert an abandoned kmart building into an emergency healthcare facility. He has also taught at the lsu medical school and is a former member of both Louisiana State senate and the us house of representatives. Senator cassidy attended the Louisiana State university where both his undergraduate and medical degrees. Secondly we will hear from our good friend and former colleague rick santorum. Former senator santorum served in the us senate from 1995 until 2007, prior to which he also served in the us house of representatives from 1991 until 1995. Senator santorum and his wife karen are also coauthors of the bestselling book. [inaudible] senator santorum received his bachelors degree from penn state university, his mba from the university of pittsburgh and his law degree from Dickinson School of law. Next will hear from mr. Dennis smith. Senior advisor for healthcare reform and medicaid at the Arkansas Department of Human Services and a visiting professor at the university of Arkansas Medical Sciences Culture College of public health. He spent most of his career in Public Service and at the federal level he is worked in both the executive and legislative branches including ten years on capitol hill and ten more years at the Us Department of health and Human Services. In fact mr. Smith headed the Medicare Agency for nearly seven years the longest tenure of any medicaid director at the federal level. Mr. Smith also worked in both the u. S. Senate and the us house of representatives from 1989 to 1998. Our fourth witness will be missed teresa muller, the acting secretary of the commonwealth of Pennsylvania Health and Human Services, previously with muller served as the pennsylvania insurance. [inaudible] additionally, she chairs the senior task force and its longterm Care Innovation subgroup at the National Association of Insurance Commissioners or an aic. Prior to her working in pennsylvania she served as acting director of the state Exchanges Group and the Oversight Group and the Insurance Programs group and the center for medicare and Medicaid Services at the Us Department of health and Human Services. She also served as the administrator of the oregon insurance division. She received her degree from pacific learned lutheran university. Next to hear from ms. Cindy man, former deputy administrator and director of the center for Medicaid Services at cms. Prior to her apartment at cms she was a Research Professor at the Georgetown University Health Policy institute. There she was the founder and director of the center for children and families. She previously worked as a Senior Advisor at the Kaiser Commission on medicaid and the uninsured. She is now a partner at the health. She received her bs from cornell university. Last, but not least, dick woodruff, Senior Vice President for the American Cancer Society. Cancer action network, altogether mr. Woodruff has more than 35 years of experience in congress, the executive branch and the notforprofit world. Including serving as the chief of staff and legislative director from the us as well as the senate. He also serves as the director for Congressional Affairs at the National Endowment for the arts. Mr. Woodruff is a graduate of Miami University in oxford ohio. I will think each and every one of you again for taking time out of your busy schedules and coming here today. I look forward to hearing every one of your remarks. Senator cassidy, will you please get us started . Thank you. I cannot tell you how honored i am to testify for my colleagues. I respect you so much, you are knowledgeable and passionate about healthcare. You are knowledgeable and passionate about her country and i hope that you took that i have also studied healthcare and am passionate about caring for the uninsured. My work for 30 years and california and louisiana was spent caring for those who has left. Let me say first that i am so sorry about this process. I would have preferred hearings, a markup, a democratic cosponsorship. For three years i have gone around two democratic colleagues, several in this ro room, have met with you and asked could you please Work Together. Susan collins and i came up with legislation which was so bipartisan in which a state like oregon could keep obamacare if they wanted. If its working for you, thats fine but my faith in the independent marketplaces clapping and i could go down the list. Perhaps usually different. It was praised by both the left and the right that this was a bipartisan attempt sincere. All ten said they could not help. Now, after the healthcare vote failed in august i was assured that now bipartisan corporation would begin. That is not happens. In the meantime, individual markets in my state is collapsing. If youre not getting a subsidy you cant afford your coverage. There i put it on my Facebook Page that no one believed me. He is paying 39000 a year for his premium. People ask us wait, how do you ensure affordability. Just 39000 affordable . That is not including his deductible. So, when i ask people will you help me . Three years i have been doing this and for three years i was basically told nice try. Do i say im not going to help so i could try to help those who cannot afford policies my state . Thats not why im sincere. I was sent here to work for them and if this is the only means by which i shall do so, i shall. Again, before being senator cassidy i was doctor kathy caring for the uninsured on medicaid in the Public Hospital system. My patient had multiple diseases and multiple conditions and i did my best to serve my fellow americans. I truly believe that Graham Cassidy service by other means. The aca promised Affordable Health care coverage, freedom to keep your doctor and to keep up your cost down. In reality, on the exchange middleclass families have skyrocketed premiums, individual mandates that they hate him a 6000 deductibles with cost inflating and doubling into short time frames. Indeed, this is one thing we agree on in a bipartisan basis. Obamacare is failing. Fifteen democrat senators recently declared such while endorsing the singlepayer system. The problems of obamacare require a path forward. On a positive note i was presiding the other day with senator wyden that was pretty much a program. We agreed. Graham cassidy hellard johnson passes a flexible block grant through the chip program keeping the protections and the requirements of the chip program. We combine the expansion dollars in tax credits and costsharing subsidiaries and distribute it in these means. By the way, its a mandatory appropriation and yes, the chip Program Requires the authorization. This will too but it doesnt mean the money goes away automatically in ten years as some have absurdly stated. Let me address the inevitable comments by the way, we dont affect 6 of the economy. Thats a misstatement. We are not touching medicare, employee response insurance we are in the individual markets and were in the Medicaid Expansion in traditional medicaid. This is not 16 of the economy. But the inevitable comment that we are at the Medicaid Expansion. Actually, this data takes the dollars that we are giving and continues the Expansion Program as they have it now. They have the flexibility and i can tell you despite me pointing this out it will be. To help states many of which are not able to meet their expansion match in 2020 the Medicaid Expansion match. The bucs will block grant functions like a combined 11151332 waiver. We reserve protections for Mental Health care prohibit charging women more and no longtime caps. States apply for waivers must prove that the americans with preexisting conditions have access to affordable, adequate coverage the end and you to find affordable as able to afford. Contrast that with 39000dollar year of premiums. This is an issue and it could end here. Many on the left a friend that we give states and powers and that obamacare concert. Under this narrative corrupt governors deprive the citizens of their state of protections and patience only get better told what to do. This amendment rejects that narrative. By the way, bipartisan virginia gets a 4 billion, florida 15 billion more dollars, missouri 5 billion more dollars, increasing access to Cancer Screening in Cancer Treatment for folks in those states who currently do not have. I wonder if those opposing this amendment care about those in that state. Right now those in virginia will have more for these cuts. We need to pass this bill, return power to the patients. Thank you. Thank you. Senator santorum. Thank you. Its an honor to be here before my former committee and im here because i am a father. A father of a child who like many of my this room is in a wheelchair because she cant walk. She cant talk either. I am trying to speak for her and others like her. I see the hysteria that has been developed around this bill and its disturbing to thats what is a clearly responsible proposal that as many on the right have criticized keeps 90 of the taxes and 90 of the spending will cause everyone who was ever covered by obamacare to be without insurance. That just doesnt make any sense. It is irrational, its not supported by any facts or any of the evidence and it shows the frustration that Many Americans have is outside of washington and seeing something put together by not two of the most conservative members of the republican caucus, Lindsey Graham and bill cassidy who sponsored a plan with Susan Collins to try to get bipartisan support. These are the sponsors of this legislation. People who are not on the far end of the public and party yet it is being treated as this draconian slashing. This is not the first time that i have experience with this type of reaction to it change and entitlement programs. Twentyone years ago i was in the United States senate and had the privilege of managing the bill on the floor of the senate to reform welfare. The very same organizations and groups that are out in the halls and others complaining about this bill were saying that people would be sleeping on grades and gridlines and we would be coolly cutting people off all of the services that they so badly hated. The reality is that we are doing the same thing in this bill as we did in 1996 and that is the idea when i talked to lindsay and bill and others about this idea was based on the success of the 1996 welfare law, a bill that got bipartisan support even though there was hysteria there was a recognition that this program is not doing as well as it could be and that there were innovations at the state level that can be replicated and done better. The care for People Better and get people off of work for and we shouldnt measure the success of welfare as to how many people are on it but how they transition often get to work and lower poverty rates. In the same this year, it should it be how many people we are getting into a Government Program but how much affordable insurance we are providing for an entire market. Like myself, who is on the Obamacare Exchanges and pays around 30000 a year for our policy. Now, i dont know how families do that. That to me this is not a four affordable. I came forward based upon the information that i had an experience i had in working on welfare and suggested that we can do the same. I did, by the way, with welfare when i was on the committee and even for i had nine people on my office that i hired who were former welfare recipients and i take this responsibility to get engaged in Public Policy whether in or out of office that the primary purpose here is to make sure that we have a system that works well for americans and the hysteria that is being developed here, the bill that candidly is modest in its reductions in spending, modest in its reduction in taxes and even modest in the flexibility that we give to the states outside of the aca to be able to provide care for those who are in need and fall through the cracks. This legislation is in two parts. One is a block grant of the aca monies that has doctor cassidy described and the other is the medicaid cap and is everyone was proposed by president clinton. Now its seen as a jacobian measure. It ties the rate of growth. Capita at around the level of medical inflation. We have advocates who have gotten up and said we need government run healthcare for everybody and that is the most efficient and effective way yet when we put the cap on healthcare on medicaid at the rate of inflation for healthcare we are told that this Government Program will collapse. How can you have it both ways . Government healthcare is the most efficient but if you put it at the rate of medical inflation which concludes all these inefficient private plans, you will collapse . You cant make that argument and say you are the best but you cant keep up with inflation. On the second block grant is very simple. We give states an enormous amount of money. People say this would go back to the old system. The old system didnt have one point to trillion dollars to be spent by the state to be able to make the system work. I look forward to the opportunity of getting into the details of how we designed this to make sure that dates who are expanded medicaid are not disadvantaged over the long term and that we gradually ramp down the formula and we do a lot of things that doctor cassidy and others work on to make sure this is a fair system that all poor people in america and those in the individual market get the opportunity to get help in the federal government so we can have affordable and stable Insurance Markets. Thank you, mr. Chairman. Thank you. Thats interesting, as far as i am concerned. Lets turn to you mr. Smith and take your testimony at this time. Thank you very much, mr. Chairman. Its privileged to be with all of you today and i am here to discuss the Graham Cassidy Heller Johnson and im pleased to convey governor hutchinson support for this proposal. We believe it makes a great deal of sense that will protect interest, individuals on medicaid as well as those who are subsidized in the private sector, as well. In 2017 cbo estimates that on the Medicaid Expansion the premium subsidies and the tax credits, cross sharing will spend about 111 billion of the federal government. 2026 under the proposal it will be 190 billion thats a 70 increase in the amount of federal spending available to provide this coverage. In the original estimates the congressional budget act and the congressional Budget Office when it modeled the Affordable Care act for what the coverage would look like in 2017, in this year, they modeled the seven years ago and what they predicted then was very much in accurate in that cbo had in its baselined by 2017 there would be 35 million nonelderly individuals on the Medicaid Program under current law baseline. Under the Affordable Care act 15 million would be added to that number. If you recall that is when Medicaid Expansion was mandated under the legislation which is, of course, not to be true. Today we have a 69 million nonelderly individuals on medicaid and chip of which 13 have been made eligible by the aca. So, the individuals that cbo predicted would be receiving subsidies over in the marketplace and in fact are in medicaid instead. This legislation puts those two populations together so again now when you form a pool of 22 million lives of which are relatively young and healthy and that would be the new pool. Everyone keeps talking about how we would destabilize the premiums for this population. We keep trying to throw more money at it so the solution is put more people into it. That is what will be truly stabilize the pool. Also, i have my remarks on the chip program. Again, i was privileged to be 20 years ago with chairman hatch and senator grassley at the time to create the chip program. I believe it is a great vehicle to use for that purpose and to build upon that and has the benefits of having a structure already in place. Chip is a very Popular Program and people know what it is but it is also a allotment to states and taxability it is deferring to the states on many of its decisions that have been made and i would suggest chip has been wildly popular on a bipartisan basis for 20 years. The third point i wanted to talk briefly about his. Capita caps and virtually every thing that has a. [inaudible] we are living under a per capita cap and if we see that cap we are at risk for every dollar above that cap. States will manage the programs to those caps. Those caps, by the way, of the offices of actuary now produces an annual report on medicaid spending and in 2015 the actuary made their productions out through the year 2024 for what medicaid was going to be spending. Last year they reduced their production spending for medicaid by 140 billion. Nobody is arguing that there is somehow 140 billion has been lost. We revise the baseline in the baseline change. In many respects the baseline is changing and it is lowering because of the states do not have their share of the funds and it will accelerate medicaid spending at the rate it is. So, the Consumer Price index of medical inflation plus one for the disabled and Elderly Population for that the proposal provides for when they were asked to report there is a higher growth rate than when cbo estimated that it is every elderly. [inaudible] again, the reality is slowing on a is lower than what the bill is providing for. The last point on work requirements is a feature of the bill and again we have passed with governor hutchinson leadership past work with requirements which received overwhelming bipartisan support in arkansas. Again, this is a vehicle that states will be able to readily adapt to and will be able to put into place and will continue the tradition of this committee in extending coverage to the most vulnerable americans. Thank you so much. Ms. Miller, will call and you know. Good afternoon, chairman hatch. I sit here today honored to have this opportunity but also very concerned about the potential for this legislation to become law. What that will mean for the millions of americans who rely on the Affordable Care act for quality, Affordable Healthcare insurance. Since passage of the aca pennsylvanias experience an alltime low on uninsured rates. We Just Announced that we have gone from over 10 uninsured before the aca to 5. 6 today. As we face an Opioid Epidemic that is devastating our communities 175,000 people have been able to access Substance Abuse treatment inks to the aca and governor wolfs medicare expansion. I could go on and on about all the benefits of people in pennsylvania and around the country have realized because of the aca but its important to point out that it is not perfect and i had the opportunity to testify a few weeks ago that way so we can Work Together to stabilize individual markets. This is really the limited area that needs to attention. A group of Insurance Commissioners from red and blue states alike talked about targeted reforms that could be put in place to stabilize our markets to ensure the aca works for everyone going forward. I was optimistic about that hearing because for the first time in this debate it appeared that senators from both sides of the aisle were genuinely interested in focusing on the problem, and the need to stabilize the market and find a solution rather than using the problems of the individual market as an excuse to repeal the aca entirely and the National Association of medical directors put it the largest intergovernmental transfer of finance responsibly from the federal government to state in our countrys history. Now, i find myself here again talking about a proposal that would make taccone in cuts to medicaid and force governors to make gut wrenching decision second base. According to an analysis, pennsylvania would lose 50 billion in federal funding in the next decade, the foundation put at at 22. 7 billion. Our own analysis estimates that we would lose 30 billion assuming average cost growth. This forces governors across the country to make impossible decisions. Who should receive healthcare . A child born with a disability, a young adult struggling with an opioid addiction, mom fighting breast cancer, a senior who is worked hard all his life and needs access to quality healthcare, to eat with dignity. Having been a state insurance regulated into different states and having spent time as a federal regulator i truly believe states are in a better position to make decisions impacting our residents. We know our markets better and we are more nimble and able to respond to issues impacting our consumers so when we hear that you want to give us more flexibility, you do pique our interest. I gave the Senate Health committee some ideas for ways the federal government could streamline the 1332 waiver process and make it easier for states to get these papers. But cutting billions of dollars. Medicaid in giving states reduced funding in the form of block grants, funding that goes way after seven years is not the kind of flexibility we are looking for. I have been thinking a lot over the past few days about what we would do in pennsylvania if this still becomes law. I am honestly struggling to figure out how we would response. We would have two years to completely revamp our Healthcare System, work with stakeholders to figure out what a new system could look like, develop whatever infrastructure would be needed to make system changes required, pass legislation, get necessary federal waivers, and a host of other activities. All of this would need to happen apparently without federal funding to support these essential planning activities. The aca gives states almost four years and a lot of funding to support their work. After seven years, the funding disappears and the state would be left holding the bag to fund whatever system we put in place. That alone makes it highly unlikely we would get anything in place in pennsylvania by 2020. In my expense, state legislators dont want to put a system in place with federal dollars if you dont want have a way to ensure that it is sustainable after lose those federal dollars. Let me be clear, providing implementation funding or extending this funding indefinitely into the future would not fix the insurmountable flaw in this bill, the staggering cut in federal funding. Pennsylvania is facing a 2 billion structural deficit in our budget now. We dont have a balanced budget for this current fiscal years, three months into it. We certainly dont have the ability to cover the loss of anywhere from 15 30 billion in federal funding over the next decade. We have had less than two weeks to analyze this bill. Its a bill that would have a devastating effect on the more threepoint to million pennsylvanians with coverage through medicare and on the federal exchange. Please, dont paper over these taccone and spending cuts which will inevitably increase the uninsured under the guise of state flexibility. On behalf of pennsylvania, on behalf of children, seniors, individuals with disabilities, are most vulnerable population, i implore you to return to the bipartisan process that the senate was engaged in earlier this month and craft a compromise bill to stabilize the individual market and improve our Current System. Thank you. Thank you, ms. Man we will turn to you now. Good afternoon, chairman hatch. This nation has made enormous progress in increasing the number of people who have health care and moving healthcare to a system that provides greater value with lower total cost but we still have a long way to go in virtually every major Healthcare Provider and Plan Association in Consumer Group from the ama and American Hospital association and the American Cancer Society and the American Academy of pediatricians, those are just some in the a category have voiced opposition to this bill. None of these groups however would say there isnt a need for ongoing reforms and improvements in our Healthcare System. Graham cassidy however would inevitably take a step back in a reckless and dangerous matter. It would create chaos and uncertainty, new levels of marketplace instability, higher premiums and outofpocket costs for many and increase instability throughout our system. Sorry, my notes are off. It would also and probably most significantly take away the financthefinancial resources and certainty about those resources that are critical for states to maintain coverage. It would continue to move forward and as a group of ten governors, both propaganda and democrats wrote earlier this month Graham Cassidy is not the answer. Instead we need bipartisan efforts to make healthcare more available and affordable for all people including americans taxpayers. My remarks look at the key implications of this proposal on medicaid in the 73 Million People covered by that program. We focus on three points first, its important to keep in mind that the Graham Cassidy proposal builds on the better care and reconciliation act that was voted down by the senate in july. This proposed deep cuts to the Medicaid Program and so does Graham Cassidy. Cbo estimated that it would have cut medicare by 756 billion over ten years and those cuts grow over time because of the per capita cap in both proposals gets tighter in the years. The cusp. [inaudible] the Graham Cassidy proposal maintains and deepens the cuts to Medicaid Expansion that were in the other bill. Not only would it states no longer get the enhanced funding that was provided and provided under the aca but under the Graham Cassidy proposal states would not even get funding at regular mass rates to be able to cover very low income adults. Graham cassidy, would propose arbitrary cap on every population under official medicaid. That means the federal government would end its commitment to share the full cost of providing coverage for pregnant women, for children, medicare covers one out of three children in this country and for people with disabilities and for the elderly, six out of ten of the dollars spent in the Medicaid Program is for people over 65 and people with disabilities. If congress adopts the proposal it will cut funding for the very beneficiaries who are the supporters of this legislation point to as those who medicaid ought to protect. My second focus is on the block grants that it creates in place of the Medicaid Expansion dollars in the tax cuts subsidies and costsharing reduction. Lets start with basics. First, it is a block grant which means the dollars do not grow based on actual cost of care or based on enrollment. Overall, at least looking at the version of the bill that was released on september 13, the block grant cuts about 82 billion between 2020 and 2026 but if healthcare costs are higher the need for coverage of subsidies is greater than anticipated the gap between actual needs and funding widens. The second basic fact is that the funding for this block grant has been pointed out is timelimited. Lets go beyond the basics. Graham cassidy reshuffles the deck allocating dollars, not based on historical projected need or cost, but to the point where everybody gets every estate gets the same level of funding for every poor person. You could say it creates a onesizefitsall funding formula. The problem is one size fits all makes little sense. Our analysis in a report attached to my testimony is similarly directionally to other analysis. Twentynine states would receive less federal funding than they would under current law with an average reduction of 19 . In 202,618 states plus the District Of Columbia would lose one quarter or more of their funding including six states represented on this committee, delaware, colorado, michigan, new jersey and washington. Six states including alaskan, oregon with the funding cut by half or more. There would be adjustments but in some cases whether those adjustments are made and in all cases how those adjusted are made would be less to secretary discussion. States dont know but wont know what those allocations will be but most notably those adjustments would be budget neutral. Upward adjustments for one states means downward adjustment for another states. The block grant does provide states with broad flexibility, except of course with respect to whether a state can continue to rely on planned parenthood to provide Women Health Care services. How many of us really believe that a state that loses one fourth to one half of their funding will be able to replace the lost coverage and to improve stability and cost in the marketplace. That kind of flexibility only means that states will be able to decide which group the people wont get coverage, which Services Wont be covered and how many people will see their premiums and outofpocket costs go up rather than down. Finally, i want to touch briefly on the issue of implementation. Simply stated Graham Cassidy would create chaos in our Healthcare System with frightening implications, 23 Million People are projected to receive coverage through the marketplace and the Medicaid Expansion in 2019. On january 1, 2020 by the terms of this proposal that coverage and those subsidies will end. It is simply impossible for states to make their plans and have new programs in place by then. Even without considering that they wont know how much money they have from yeartoyear or whether they will have any money in 2027. On this point, let me quote. [inaudible] with respect to implementation it is not just impossible but delusional. There are no winners in this bill but there are many who will lose and many others will be at great risk. It is instructive to consider the array of special fixes in this bill. There are many and they are growing with every version. All aimed at softening the blow for one estate or another and whatever else you may think about these special deals for certain states they do help us appreciate just how flawed the underlying structure of this bill really is. Thank you for your time. Esther woodruff, will take your testimony. Thank you, chairman hatch. I appreciate the opportunity to speak about the needs of Cancer Patients today and other patients with serious and chronic illness. First, i want to say that as you said this committee has a long tradition of bipartisan achievement and working effort and passing the chip built many years ago and funding the tobacco tax and im honored to be here before you today. Let me start with a short personal story. Im sure everyone in this room has one given that one into men and one in three women are diagnosed with cancer in their lifetime. My mother was diagnosed at the age of 48 with breast cancer. In 1963 the standard treatment was radical vasectomies and massive radiation. She survived and lived to be 93 which was a wonderful thing but she was lucky. For 45 years thereafter she lived with a preexisting condition. My dad had a good job with insurance that kept her covered until she reached medicare so she was lucky again. My point is until 2010 Cancer Patients and survivors had to be lucky to get coverage and access to care. Those who had to buy in the individual market were mostly priced out of it. Others states annual and lifetime limits on their benefits and as a consequence of many families with cancer based medical bankruptcy. That all changed with passage of the Affordable Care act. Patient had certainty and stability and they could buy insurance to cover their care to matter their Health Status. Very low income, working single men and women had access to coverage for the first time through the medicare expansion. Yes, the Current System has flaws, premiums are far too high for some families. In 19 estates expanding medicaid has left over 4 million low income citizens uncovered. That medicaid tax work created by the 2012 Supreme Court decision is revealing of what could happen at the Graham Cassidy bill is passed creating a new. [inaudible] the bill before you would completely restructure the individual markets in medicaid, as others have said, around the table here. How that would come out in each state is not known. What is known is the proposed cuts to medicaid delivered to the park grants will end medicaid coverage for millions of working men and women and children and disabled citizens the mandatory patients protections in current laws that prohibit pricing based on Health Status essential Health Benefits that are tied to those benefits all of those would become discretionary depending on what state you live on and now the states could decide not to cover Preventive Services like Cancer Screenings routine mammographys and prevention is the key to cancer and to treating cancer and it is really a way to have healthcare much more extensively if we cover it. A couple of weeks ago i was struck by the common statement that was made by former governor and hhs secretary mike leavitt during his testimony before the health committee. He was asked about the appropriate balance between federal and state health care he said we need to have National Health standards and state solutions because about a National Standard that ensures adequate and affordable coverage how do we really make sure that people get the treatment they need when they get sick. As others have said, the time timeline. [inaudible] it is not realistic and likely feasible. In the words of the state medicaid directors states will need to develop overall strategies, invest in infrastructure and negotiate provider in managed care contracting et cetera et cetera. This is not a group with a reputation for hyperbole. We are worried that the Cancer Society for millions of people that they lose their insurance and hundreds of billions will be taken out of healthcare if this bill passes. At the ehp goes away so does the section on annual and lifetime caps. Because the caps are tied to those benefits ensures will offer plans and dont cover treatment and all of the services of the Cancer Patients need. In that situation the planet they need may not even be off on offered or maybe two expensive for them to four. Then they go without coverage and this is what happens. Their cancers are discovered later, theyre more expensive to treat and they have a lower chance of survival and their medical cost force them to debt and were right back to where we were seven years ago. With healthcare what people want is stability and certainty. Our goal is to relieve patients of their fears. Cancer is scary enough but what is frightening is not been able to afford to fight it. American Cancer Society. [inaudible] we believe the only way to resolve this long impasse over healthcare coverage is a bipartisan solution. We like to work with finance Community Going forward to help you find solutions that improve the current healthcare law. We want to make premiums affordable for all americans. Thank you, sir. Thank you for this panelist and let me just start the question by asking the question, senator cassie, can you walk us through the changes made to the posted on your website this morning so we have a clear understanding. What we found as we introduced our first bill is that the regulatory inflation was far higher for the individual market then we have anticipated and that rate of inflation did cause a transfer of dollars between those expanded in those not. We want equities so that anywhere unamerican leaves they can get care. We did a couple of things at the frankly at the expense of the non expansion states, equity only occurs out in ten years now and six. Secondly, we capped the amount of money the state to see as an increase to 25 so mississippi, for example, the goes up dramatically because they are so low now is capped at 25 a year. They do well and the folks in mississippi will have far more resources to screen and treat for cancer than they do now but nonetheless it prevents a dramatic shift for other states. In that way, we went around and looked at some states and they were outliers for whatever reason so why in alaska have federal poverty levels one and a half times that of the other states but they only get paid by medicaid as if they were the same as the other 48. We those two states we corrected the amount they get for medicaid so that hawaiians and alaskans will have a more appropriate reimbursement for the cost in their state. We did other things like that trying to minimize whether it was a blue state or red state and the problem may have with this new formula. Let me ask you this, mr. Smith. How can the federal government work with states to promote private markets for low income individuals while preserving it in the most vulnerable . I think mr. Chairman that states are already experimenting with those strategies now including arkansas, in which are arkansas elected to have Medicaid Expansion under the Previous Administration and we had continued to refine that and development but the reality is public and private partnerships that we have been finding in medicaid for the last 20 years in which private sector managedcare companies are now delivering a great deal of the services to the medicaid population. In arkansas the private qualified health plans marketed on the exchange, 80 of of the subsidy and the amount of subsidies has medicaid eligible population but again i think where we are in these private and Public Private partnerships have been underway for 20 years and there is a platform to build upon. Thank you. Mr. Chairman, first of all when this hearing was announced we set up on our side a website so we could hear from the American People almost 27000 citizens commented. I would ask for our agreement and unanimous consent all email sent to our site but the start of this hearing be entered into the record. Without objection. Thank you. Before i get into my questions i want to make two points that i think my colleagues will echo. First of all we feel strongly on our side that we ought to be working on a bipartisan basis today. There are two clear opportunities for the senate to do that. The first is our bipartisanship bill where we will run out funding at the end of the week and second is working to stabilize the private Insurance Market. That is what we are for on the side of the aisle. We think this process is just been an abomination and we are talking about something that will affect millions of americans and we dont have any objective information about what it will mean to peoples premiums and what it means with respect to coverage and we dont know whether the Health Markets will survive in the next year and we ought to have that information if you take the time in the regular order. Senator cassie, let me start with you. You manage to bring together people and organizations in the healthcare field who rarely agree. Congratulations are in order because they all think what you are talking about is a disaster. They particularly agree that americas Healthcare System is going back into the business of charging folks with preexisting conditions more for Health Insurance. I would like a yes, sir no answer to this question. The question is do you continue to believe that the thousands of doctors and hospitals and patient groups who are writing us saying that you are wrong and if you continue to believe as of today they are wrong and that is a yes, sir no question. That is begging the answer. I think if you are in an orange state in which you did not expand medicaid there for the patients and hospitals in your state do not get benefits and if you are in maine or missouri or florida or virginia you are pleased about this. [inaudible conversations] i think it is more important to have the right answer. I dont mean to be disrespectful but if you are the tennessee governor said this is a gold mine or a god said or Something Like that for tennessee. If you are a doctor or hospital in tennessee or missouri or maine, youre pleased about it. Mr. Chairman, let it show that r kelly does not want to answer the question and it appears to me that the revised bill, the one we got this morning, indicates that a state could allow insurers to set higher premiums based on a persons Health Status. That is not true, by the way. You are entitled to your opinion. Senator, let me interrupt. Ill give you the extra time. Look, i want our colleagues treated with respect. It is not easy for him to testify on this although it is because he is a doctor and he understands this better than anyone in the room. I was a medical Liability Defense lawyer so im not some neophyte here and i strongly pass healthcare bills since early in the senate. So, lets show some respect for senator cassidy. This is not easy for him. The fact that you disagree with him is fine but he ought to be able to disagree with you also. Go ahead. One of our past great chairman, pat moynihan said everyone is entitled to his own opinion but not his own facts. Lets hear from the American Cancer Society with respect to the real fact. They have a lot of members who understand the hurt that comes from being disseminated against for having a preexisting condition. Mr. Woodruff, what you think in respect to this bill and what it will do for people with cancer fight on their hands . It doesnt protect them, senator. It basically makes the patient protections that were enacted into law in the Affordable Care act discretionary on the part of each state. Each state can decide to keep those patient protections were not. What is important about the act achieved was a created a definition and a National Standard for what is adequate and what is affordable. So, with the essential Health Benefits we actually have an insurance that says when you buy insurance it will cover the services that you need when you are sick whether your cancer or any other disease. Its an essential Health Benefits are there to protect you. Thank you. I want the American People to understand the consequence of that statement in the Cancer Society knows about what it means to get clobbered by an extraordinary illness and what they have said is that it opens up to charging those people more and let me ask one other question if i might senator cassidy. We are trying to make sense out of all of the bills that have been released. Here is the first to bill and this is posted on your website on september 13th and this is the second bill that was on senator grahams website and that was on september 13th and we got a third version last night at 7 30 and we got a fourth version last night at 7 50 and we got a fifth version at 9 23 this morning. If this bill the one that the United States senate is going to actually be voting on because i think the American People would like to know what we are on the cusp and the eve of voting on this extraordinary piece of legislation and were trying to sort out whether people will vote on let alone the fact that we dont know what is their premiums or their coverage and we dont know what will happen in the individual market and is this what we will actually be voting on that is a yes, sir no question. I apologize if i was rude to you and i do not intend to be. The last version was correcting. [inaudible] lastly, i would say its 148 pages, not 900 pages as was the Affordable Care act. The American People should be able to read this and comprehended. Is this last version . I believe it. There may be a drafting error but i hope a correction in a drafting error does not constitute a whole another version. I want to highlight that we have one of our colleagues and i want to treat every member of the senate with the opportunity to be heard, we got this at 9 2g about a bill of this magnitude and our colleague is saying he believes that this is the final version that that is good enough when we are talking about putting at risk millions of americans. Thank you senator. Senator grassley. For the people that introduce this bill, i want to thank you for your leadership truly in improving the amount of Healthcare System. The point has been made that senator wyden make a point about all the stakeholders that are involved in this and against it and they have concerns about it. I think that those of us are in washington know that when all of those strong forces speak up it is to protect the status quo or protect our answers. Its not about providing adequate healthcare for americans. What i care about is what happens to iowans. Obamacare has failed in iowa. There are only one Company Planning to offer insurance in 2018 in iowa and that company has premiums over 50 increased. People and i will tell me their copays and deductibles that obamacare make it too expensive to use. These are issues that must be addressed today despite our ideological differences. We are able to have a discussion about a path forward. Doctor kennedy, if i could have your attention this bill spend more dollars in 2026 in iowa than it does today in medicaid . It does. Well, obviously is not a cut in. Isnt this slowing the rate of growth . It does slow the rate of growth across the country. It does. Doesnt everyone agree that we need to slow the rate of growth in healthcare spending . Apparently, not everyone but i would. By the way, i can also say that i have words from senator wyden when he previously introduced a medicare bill in which he said a cap on growth serves as a backstop and the best way to hold down healthcare costs is to give americans the ability to hire and fire their insurance committee. I think these caps on growth which has had bipartisan support in the past. To you also, do states have the rights under the current Medicaid Program matching funds, systems to control. [inaudible] you can empirically say they do not. That is the costplus program the more the state send, the more they get in the only limit is on the ability of the state to support their end of the match. Lobbyist for the American Hospital association and the American Medical Association and the aarp and the Insurance Companies all endorsed obamacare. Could you say that these folks have a financial interest that does not take into account individuals in iowa . If you look at the stock prices of Insurance Companies, pharmaceutical companies and forprofit hospitals since obamacare past they have done extremely well. In parallel, premiums have risen for those who do not get subsidies and tax outlays have risen for the american citizen. Is that a direct relationship between the two prospective done extremely well under the Affordable Care act. Ive timer for three questions. I hope i can ask for answers. I want to ask mr. Smith is medicaid sustainable as current inflation rates . Whether you look at the Government Accountability office or the National Association of state Budget Officers, the answer would be no. This mann, is medicaid sustainable at its current inflation rate . States are working very hard right now and have been to be able to improve their programs through better delivery of care and different payment mechanisms that reward value rather than volume. Taking away the foundation of coverage will only make cost bro because people only come in when care is needed and more expensive. We need to control the rate of growth but do it in a way that improves care rather than takes away. The same question to you, ms. Thank you senator. I would anchor this mans comments and say that this whole debate for the last several years has been about the coverage and we havent been talking about the cost of healthcare. At the end of the day, insurance is a reflection of the cost of healthcare. If we dont have a debate in this country and discussion about how we get at the underlying cost of care we have a major problem. That is the debate we should be having in the discussion we should be having. Okay. Thank you very much, is determined. Im not sure where to talk about and begin but i want to talk about provisions and thank you for being here. I feel like i need to talk numbers even though this has got to be about people not numbers. Let me say the truth of the matter is that we cut down the number of people walking into Emergency Rooms they dont have insurance which is what is happening in michigan. 50 fewer people walk into Emergency Rooms and cant pay. State of michigan saved money. Republican governor working with democrats and republicans in the legislator did the right thing and made sure that people who are minimumwage workers could receive healthcare and take their children to the doctor. We save 435 million in taxpayer money because people can go to the doctor instead of using the most expensive way to get healthcare which is the emergency room. Let me also say that we came across the news that. [inaudible] said this bill would cost 580,000 jobs in 2027. 580,000 jobs, so that is something we certainly want to look into. I think i want to take a moment to go to this whole question of whether or not this as senator santorum said is a modest change and welcome back to the committee or as ms. Miller said a staggering cut because that is a pretty big difference. Senator cassidy has indicated that it is a block grant. After ten years we can just continue like we do other block grants. Here is the reality. In ten years, in order to continue that block grants would cost 190 billion for that next year at level funding. The entire health and Human Services budget for our country is 164 billion. If we stop doing Everything Else in education, health and Human Services you couldnt pay for extending that block grants. It is not believable. It is just not credible. I want to show one other thing. These are the staggering numbers for me in michigan because the cuts to michigan when this is fully implemented according to. [inaudible] is 140 billion. Our governor just signed next years budget, 56 billion. There is no way, there is no way that we will not see peoples healthcare, nursing home care, Childrens Healthcare cut as a result of this bill. Let me get into specifics. Let me talk about something near and dear to my heart and that is under essential benefits we have said that Maternity Care would be covered. As a result of that and i do ask that Maternity Care was a major debate in this committee is one of the ten essential Health Benefits trying to make sure that being a woman would it be viewed as a preexisting condition or somehow women have to pay more for a writer if a young family wants to have a child. Interestingly, my staff tells me it was eight years ago today in this committee when the former colleague from arizona had a debate back and forth whether we can cover Maternity Care. He said he didnt need it and it should be covered and i reminded him that his mom probably did. We ended up putting it in. So, now here we are and we have a situation where we could very easily be going back to pre Health Reform days where in michigan only 4 plans that it young couple could get would cover Maternity Care and we know from studies that young couples get married do not have plan on having a child for very long time and theres an unplanned pregnancy and then she has a preexisting condition and prior to the Affordable Care act couldnt find any care and we also know to get an average coverage writer at that time was over 17000. If you couldnt find coverage youd be paying from 30000 up to 50000 outofpocket. So, ms. Miller, i wonder if you might respond to the issue of Maternity Care and your experience as an insurance commissioner. Can you talk about what the individual market looks like for women a few years ago before maternity coverage was a basic benefit. Thank you, senator. My experience is similar to what you indicated. I think women before the aca, if they had coverage in the individual market, often did not have an option to purchase coverage that included maternity as a benefit. We have a lot of discussion about what the essential benefits package should be and theres a lot of but where i struggle is i dont know which one is not truly essential. Maternity coverage is certainly one of those benefits that in my mind is absolutely essential and i worry that if we go back to the world work that we had before the aca where women in individual market couldnt get coverage to cover Maternity Care then they are left paying outofpocket tens of thousands of dollars if they have a baby. I think then we return to a world where we see people going bankrupt because they simply cant pay for the medical bills that they have. Thank you very much. Thank you, mr. Chairman. The acting presiding german it recognizes senator roberts. Fact, the Affordable Healthcare act i object, im kidding. That was a joke. [laughter] with the time or not count the senator from colorados untimely insertion of his remarks. This is about much more than trying to fulfill Campaign Promises i think. Simply put, the Affordable Healthcare act is not affordable. It is feeling very people that a promise to help insurers continue to pull out from coverage in states they are requesting dramatic previous increases for next year. In kansas, premiums have doubled since the law has been in effect and we assume all the plans that have filed rates in the states sign the final contract in the next few days. Kansas will only have two options of insurance carriers on the exchange. One is on a teeter totter. They also base premium increases up to 29 . When i was back home at the state fair in hutchinson, kansas a couple weeks ago there was nothing but concern and frustration and anger from my constituents over the laws failures and questions. They demand to know why we here in the senate have not successfully passed form. I do believe as has been pointed out we reached a bipartisan agreement that but is not working and it has been pointed out that the numerous hearings that have review proposals to address premiums, instability and individual market next year. Unfortunately, many of our colleagues simply wanted more money to pass this problem, not proposals to address money of the laws fatal flaws. There is another alternative. Longtime champion of singlepayer Bernie Sanders has recommended rec government run healthcare and reintroduce his proposal with 16 senators, my friends across the aisle endorsing that idea. I am continuing to review the proposal before us from senator graham and kassie and others. Im getting feedback from actuaries at the congressional Budget Office and most importantly kansas. What i am positive of is that this proposal we have before us is certainly better than his socialized medicine. Senator cassie, one provision that is included in your proposals to address the increasing growth in the Medicaid Program and i am being repetitive but i think it needs to be repetitive and that is switching from an open and entitlement to what is known as per capita caps. Would you constitute such a reform proposal for spending continue to increase every year as slashing the program. Watch is online at cspan. Org or listen to cspan radio out. The senate will gavel in considering william emanuels nomination to the National Labor relations board. He will then give the republican majority. The vote is scheduled for about 90 minutes from now at 530 eastern. Live from the senate floor here on cspan2. The president pro tempore the senate will come to order. The chaplain, dr. Barry black, will lead the senate in prayer