John Garamendi

Mr. GARAMENDI

Mr. GARAMENDI. Mr. Speaker, I thank Mr. Raskin so very much. And, indeed, the National Institutes of Health has a stellar representative, as do the American people, and certainly the people of Maryland. As he told his own personal story of one of the dreaded diseases, I am delighted to see him stand here in such good health. Apparently, he has recovered completely from that. I suspect that recovery was, at least in part, due to, first, his good health at the outset, but also to the research that was done in the preceding years through the National Institutes of Health on cancer research. We have seen the decline in cancer deaths as a result of that research. What we would like to do is to deal with this Alzheimer's. I want to take a moment just to talk about where we are. We had a huge debate last week on repealing the Affordable Care Act and what it would mean to Americans, and a lot of that debate centered around the cost of medical services. Tragically, one of the ways that the proponents of repealing the Affordable Care Act would save money is to reduce the Medicaid program in different ways, but the end result was to reduce the Medicaid program. Sixty percent of the Medicaid program is for people in long-term care facilities. A good percentage of those, probably the majority of those, with some sort of dementia or Alzheimer's. What we need to do is to address this issue straightforward. I will tell my own story. My mother-in-law lived the last 3 years of her life in our home. We were in a position where we were able to take care of her, so she didn't go to a long-term care facility. Nonetheless, it was one of the obligations that we felt we had, and many, many other Americans share that obligation. This is 2015. The number $2.026 billion came up during the discussion that we had. That is what we spent in 2016. Some of that was spent by other payors. That would be insurance companies. Some was spent by family. Medicare and Medicaid spent the great majority. As we go through the years, in 2020, we expect to spend $267 billion. And again, Medicare and Medicaid make up the great majority of it. As we move through time, we will see that there will be greater and greater expenses, rising year by year, so that in the year 2050, which is not that far away--that is one generation away--we will be spending over $1 trillion, and Medicare and Medicaid will, throughout this entire period, be the single largest source of money to pay for Alzheimer's. So, if we want to reduce the cost of premiums, if we want to reduce the cost of government, if we want to deal with the quality of life of Americans, then we have to get to this research because there is hope. Alzheimer's is not a hopeless disease. It is not a disease for which there is no cure. It is a disease for which we have not spent money on finding the cure. If we can delay by a year, we will save tens of billions of dollars of taxpayer money in care that has been pushed off into the future. And the quality of life for the individual that has one more year of quality of life ahead of them is enormous and invaluable. Here is just a way of depicting the backward nature of how we are dealing with the research for Alzheimer's. This was originally the 2015. We have been at this a couple of years, and we have seen progress. In 2016, we spent $941 million, just under $1 billion, on Alzheimer's research. At the same time, we spent $153 billion in the care of Alzheimer's in Medicare and Medicaid. It is Federal taxpayer money. Look, $1 billion, less than $1 billion in research, $153 billion in out-of-pocket expense caring for these individuals that have come down with Alzheimer's. A pretty neat equation here, isn't it? If we were to ramp that up, as we would like to see, from $941 million to $1.4 billion, the researchers all across this country--some in San Diego, as we heard from Mr. Scott Peters; others in New Jersey, as we heard from Mrs. Watson Coleman; or in other parts of California, Boston, wherever. If we were to ramp that up by an additional $500 million, the researchers believe that they will untangle the tangles in the brain that lead to Alzheimer's and understand what is going on and, from that point, be able to find a path towards a solution. It is not hopeless. We have seen progress. We have seen research that was done a decade ago. The analysis indicated that it really didn't work too well when they came up with a solution. Another researcher, 7 or 8 years later, went back to that very research, looked at the statistical analysis, and noticed that, for those who had early onset, that particular treatment modality had an enormous effect, not on those that were in later Alzheimer's but those who were in early onset. Whoa. What does that mean? That means that there is a path. That means that there is an avenue towards a solution. However, this Congress, the 435 of us who will be here voting on the appropriations to fund the Federal Government, to fund the military, to fund the highways, to fund the National Institutes of Health, will be given a choice. We will have a choice. Do we increase the funding for the National Institutes of Health and Alzheimer's research, or do we fund a wall on the Mexican border to the tune of $20 billion? We just received that supplemental appropriation request from the administration today to spend $20 billion on a wall. I can talk to you about a wall. I represent 180,000 people just downstream from the Oroville Dam, and I have got a 30-foot wall that needs to be repaired. We are talking about imminent danger, and the rainy season is not over in California. Or, another $5.6 billion for the military for programs that nobody has told us yet should be funded. We are going to make choices here. The President has made his choice. He has shown what is of value in his mind. I challenge that value. I challenge that value statement. I will tell you what is important. What is important are those millions of Americans who face Alzheimer's in the days, the months, and the years ahead. I am looking to the generations that are 40 and 50 years of age today who know, like my wife and I, they will be caring for their parents who are suffering from dementia and Alzheimer's. That is a value that I think is important. Mr. Cohen spoke to the real enemy. Is the real enemy somewhere out there around the world, or is the real enemy the disease that will take us down--in his case, childhood polio? We are going to make choices here, very important choices to the everyday lives of Americans. My choice is to increase, to increase the budget, the appropriation for the National Institutes of Health so that the $35 billion that the scientists--who have already done the peer review on all types of diseases, ranging from Zika, to cancer, and HIV, and Alzheimer's--say are worthy research projects that should be funded. I reject the value that the President has said to strip $5.6 billion out of the National Institutes of Health and transfer it for a wall on the Mexican border or for some spending in the military--some unspecified spending. These are choices. I know where, in my mind, the choice should be, and I reject the choice that has been made by our President. And with that, Mr. Speaker, I yield back the balance of my time.

Mr. GARAMENDI. Mr. Speaker, the gentlewoman from New Jersey pointed out a very important thing here, and that is: When will we get real about this? It is my understanding that many of these budget cuts, the National Institutes of Health and others, were made so that a wall on the Mexican border could be funded. Ponder that for a few moments. Is that really a priority? Do we cut the funding for this basic research--whether it is for cancer, diabetes, even people that are suffering from post-traumatic stress disorder--so that we can fund a wall on the border? That may be what this is all about, in which case it is a terrible, terrible choice. I don't think we are going to make that. I thank the gentlewoman from New Jersey (Mrs. Watson Coleman) for her views. I really appreciate her understanding of this and her participation today. I see next to you our colleague from the great State of Maryland (Mr. Raskin) listening very intently to you and now prepared to jump into the fray here. Mr. Speaker, I yield to the gentleman from Maryland (Mr. Raskin).

Mr. GARAMENDI. Mr. Speaker, I thank Mr. Peters for his comments. His knowledge and expertise in this field is appreciated and, I am sure when shared with the other Members of this House, will have a positive result. Mr. Peters said something toward the end of his conversation that I think we need to drive home. I said earlier that the scientists suggested that instead of a $31.7 billion budget for the NIH, they needed an additional $3.3 billion. It is for those projects that Mr. Peters described as peer-reviewed by peers in the area of science-- whether it is heart disease, cancer, or HIV or Alzheimer's--that are worthy projects for which there is no money. If we could fund those--not reduce the level of funding, as suggested by the President, but, rather, increase it--what would be the result? I am going to toss this up one more time. This is what happens when research is applied to diseases. Breast cancer down, prostate cancer down, heart disease deaths, strokes, and HIV, all down as a result of research, and then the application of that research through the medical community. This is progress. This is what can happen. This is what we want to get to.

Mr. GARAMENDI. Mr. Speaker, I yield to the gentleman from California.

Mr. GARAMENDI. Mr. Speaker, let's move to the other side of the continent. Let's talk about the view from New Jersey. I yield to the gentlewoman from New Jersey (Mrs. Watson Coleman).

Mr. GARAMENDI. Thank you so very much, Mr. Cohen, for your personal story and the effect of research not being available to you in your early childhood and the result of that. We know that all across the United States there are issues that are out there. Certainly Alzheimer's, which is our principal subject matter today, together with the cuts in the National Institutes of Health budget, but also there is this thing called Zika. That is out there, and the research for that, is that going to be forthcoming or is that also going to be cut? I noticed that our co-chair of the Alzheimer's Caucus is here. Ms. Waters, if you would like to join us, the gentlewoman from the State of California with whom I have been able to work now for, well, just a few years, dating back to our time in the California Legislature. I yield to the gentlewoman.

Mr. GARAMENDI. Mr. Speaker, I appreciate the leadership of Ms. Waters. It goes on for many years in this particular area and beyond. Progress can be made. I am just going to take 2 seconds here to show the funding levels for cancer, almost $5\1/2\ billion; HIV/AIDS, almost $3 billion; cardiovascular, $2 billion. This is 1 year out of date. Because of the work of Congress and the leadership of Chris Smith from the Republican side and Ms. Waters from the Democratic side, plus many Members, this number is not 560; it is just under a billion dollars now. We need more, and we need to get at it soon. Mr. Speaker, I yield to the gentleman from the southern part of California (Mr. Peters).

Mr. GARAMENDI. Mr. Speaker, we are going to talk about our health, not about last week's legislation and the effort to change the Affordable Care Act but rather about another part of the health of the American public. The most remarkable proposal came from the President recently in his budget proposals. I know that when I saw what he was proposing, I am thinking: You have got to be kidding. He is proposing a $5.6 billion reduction in the National Institutes of Health's research programs. I want to just take a second here and draw your attention to what research really means. The National Institutes of Health is the principal research arm for healthcare issues throughout the United States. Over the years, we have spent very large amounts of taxpayer dollars dealing with health issues in the United States. The result of those research efforts, together with the implementation, has resulted in breast cancer deaths dropping, between 2000 and 2013, by 2 percent, prostate cancer deaths down 11 percent, heart disease down 14 percent, stroke down 23 percent, HIV/ AIDS down 52 percent. Research pays in better lives, in people living longer and the quality of their life. And yet this 18 percent reduction that has been proposed by the President in the basic funding for medical research here in the United States goes directly against these very important and very impressive changes in the statistics about mortality--HIV/ AIDS, 52 percent. Now, it is not all research, but it begins with research. It is unconscionable that such a proposal would be brought to the House of Representatives. We are going to go beyond these success stories, and we are going to talk about this purple line here. The deaths from Alzheimer's have actually increased by 71 percent in the same 13-year period, in part due to the fact that the population, the baby boomers and those that preceded them, grow old; and that is where Alzheimer's occurs, in the older age groups. So what is the research funding here on Alzheimer's? Well, not so good. But before I go to that, I just want to take one moment and draw your attention to this little chart. This is the funding level for the National Institutes of Health's projected budget: $31.7 billion. The scientists, the researchers out there said that that is underfunding not from their wish list, but from viable, credible research programs that can't be paid for because they have run out of money. So they have suggested that the budget should be somewhere around $35 billion. So what does the President propose? Well, he proposes, instead of going up, going down to $25 billion or just close to $26 billion, $5.6 billion less. The result is that this is not going to come down. We are going to talk about this for the next hour, about research, about the National Institutes of Health, about what it means to your life, to my life, to my colleagues' lives, to be able to extend our lives, whether it might be prostate cancer, heart disease, stroke, HIV, or Alzheimer's. It is a fact that, if we are to increase the research in this area, which, until just last year, was just over $500 million, we can see this begin to change. Joining me today are my colleagues from around the United States. I was looking for a more senior Member from California, Maxine Waters, who is the co-chair of the Alzheimer's Caucus. She is not here, so I am going to go to our next more senior Member, Mr. Cohen from the great State of Tennessee. I yield to the gentleman from Tennessee.

Mr. GARAMENDI

Mr. GARAMENDI. Mr. Speaker, I move that the House do now adjourn.

Mr. GARAMENDI

Mr. GARAMENDI. Mr. Speaker, I see that my colleague from the great State of Ohio (Ms. Kaptur) has arrived. Often we have shared time on the floor. Ms. Kaptur, if you would care to share with us your thoughts on the Affordable Care Act as it exists. I know in your area it is a very important attribute in an area that has been known as the Rust Belt, and the effect of TrumpCare, RyanCare, on your citizens. I yield to the gentlewoman from Ohio (Ms. Kaptur).

Mr. GARAMENDI. Mr. Speaker, I thank the gentleman from Arizona (Mr. O'Halleran) so very much. The stories from the gentleman's constituents echoed across all of our constituencies, all across America. Mr. Speaker, I yield to the gentleman from California (Mr. Costa), who is from the Central Valley.

Mr. GARAMENDI. I thank the gentlewoman so very much for joining us. She asked a little bit about the health care. I am going to do this very quickly, then I want to turn to my colleague from the State of Arizona (Mr. O'Halleran). Under TrumpCare, or Ryan-TrumpCare, as I would like to call it, these huge tax cuts for millions of families, let's just focus on that for a second. It is the largest shift of wealth from the working men and women of America, poor and up through the middle class, to the wealthiest that has ever occurred in any tax break. The Reagan taxes, you name the taxes, including the Bush W. taxes, this is the largest single shift of wealth. It is well over $300 billion in the next 9 years. As I have said before, the 400 wealthiest families, as I said, four of whom are now the President and three in the Trump cabinet, will get over $7 million a year in reductions in their taxes. In addition to that, the top one-tenth of 1 percent will receive over--well, nearly a $200,000 reduction in their taxes. That is the top one-tenth of 1 percent. Beyond that, $300 billion will go to the wealthy. The top 20 percent of Americans will get 75 percent of the tax breaks. The remaining 80 percent of Americans will then share the remaining very small percentage. So it is part of this enormous shift of wealth, and this does not take into account the fact that Americans are going to pay a whole lot more for their insurance. So, in addition to the tax cuts, there is also this issue of having higher rates, less benefits going forward. So just to repeat again, the top one-tenth of 1 percent will receive nearly $200,000 a year in tax breaks. The top 1 percent will get 57 percent. The top 20 percent get 75 percent of the 300-plus billion dollar tax cut, and everybody else, in this case, the lower 90 percent, will then share in the remaining 43 percent. Different ways of looking at these numbers. The fact of the matter is, it is a tax cut that guts the money necessary for Medicare expansion and for the tax subsidies that people count on in order to survive. It is obscene. Mr. Speaker, I yield to the gentlewoman from Ohio (Ms. Kaptur).

Mr. GARAMENDI. I thank the gentlewoman for bringing us the view from Ohio. Let's now talk about the view from Arizona. Mr. O'Halleran, this being your first year in Congress, welcome. I am delighted to have you join us on the floor. Mr. Speaker, I yield to the gentleman from Arizona (Mr. O'Halleran).

Mr. GARAMENDI. Mr. Speaker, I thank the gentleman from California (Mr. Costa) very much for his excellent presentation. The gentleman covered many of the issues. I want to wrap up with just a couple of thoughts. One of my Republican friends came up to me earlier today. He said: I don't understand. I don't understand what our team is doing. All we are doing is changing the name and hurting people. I thought about that for a few moments, and, yes, it is Ryan or TrumpCare, but people are going to be hurt all across this Nation. One more story, and I think we will probably wrap up here, and that is of my wife's hairstylist. She is a young lady, married, private businessowner, trying to get along, and not enough money to buy insurance. The Affordable Care Act goes into place. She looks at the exchange, and she is able to get comprehensive insurance, maternity care, and at an affordable price because of the subsidies that are built into it. She was so happy when she talked to my wife. She said: I have insurance. For the first time in my life, I am able to buy insurance, and I am going to get pregnant. I am going to have the baby that my husband and I have always wanted because now we have insurance--not just for myself, but for my child and my husband. The next visit, she is asking: They are not going to take it away, are they? They are not going to take it away, are they? Well, yes, for 14 million Americans--next year, 2018, 9 months from now, 14 million Americans will begin to lose their insurance. I am not sure if this young lady will be among them or the farm lady that I talked about earlier, but they are at risk all across America--14 million people in less than 1 year, and then, beyond that, over the ensuing years, 24 million Americans. It has been argued that the Affordable Care Act is in a death spiral. I was an insurance commissioner in California for 8 years, and that is not true. It is an alternate fact. The fact of the matter is that the Affordable Care Act is working--not without some problems here and there, but it is working. It is not in a death spiral. That is probably a good place to leave it, except this TrumpCare-- RyanCare--is a problem. You are going to pay more and you are going to get less--24 million people, an age tax on seniors, and a huge tax break for the superwealthy in America. Mr. Speaker, I yield back the balance of my time.

Mr. GARAMENDI. Mr. Speaker, I thank the Speaker for this opportunity to continue the discussion. My colleague from Texas really left here a moment ago with a plea about bringing down the cost of health care in America. Actually, it was the cost of premiums in America. That is a plea that I think all 435 of us would echo. It would certainly be our goal, as representatives of the American people, to find some way to accomplish that, some way to bring down the cost of premiums. I would like just to make a point right at the outset. When discussing health care, there are really two connected, but very separate, parts to the healthcare system. One part is the delivery of medical services. These are the doctors, some of whom are in organizations of doctors of various specialties. Some are in large practices, such as the Kaiser practice. Some are in hospitals disconnected from doctors. But there is just a plethora of different ways in which medical services are delivered. That is the delivery of medical services. That is one part of it. The other part of the healthcare system in America, and really anywhere in the world, is the collection of money to pay for the services. Now, in the United States, we have many different ways to collect the money. One of them is through taxes. And this is how we pay for Medicare and Medicaid, what we call MediCal in California. We pay for the veterans' medical services through the collection of taxes, children's health services, and some other programs that are much smaller. So that is one way in which we collect the money to pay for services. You might call those single-payer taxpayer services, taxpayers' money being spent on services delivered by that whole range of providers, some of which happen to be government providers, for example, the Veterans Administration and military medical services. Now, the other way in which we collect money to pay for services are premiums, health insurance premiums that are charged by health insurance companies. The largest single part of that is from corporations, businesses, that buy health insurance and pay the premiums. And the others are individuals, and this is the individual insurance market. There are some small group markets out there, also. But these two systems, we need to understand that they are different. They are connected, obviously. Now, if we are going to deal with the cost of premiums, you have to go over and deal with the cost of health care, because the health care drives the premiums and also drives the amount of money that we need to raise to pay for the services that are provided by the various governmental programs. Now, in the Affordable Care Act, which is now some 7 years old Thursday of this week, the seventh anniversary of the passage of the Affordable Care Act, there are some very powerful mechanisms to reduce the cost of health care--doctors, hospitals, and the rest. Some of these are electronic medical records so that there is a continuity of knowledge as to what happened, what was provided, what services were provided to the individual. Another one happens to be a penalty assessed on hospitals for hospital readmissions on hospital-acquired infections--profound in driving down the cost; also extremely important for individuals because hospital infection rates dramatically dropped. There are also ways in which we pay for the services. It is very clear that the utilization of fee-for-service drove up the cost. Anyway, as we go through this discussion today on the Affordable Care Act, and I see I am being joined by my colleagues here, I just want us to keep in mind that in order to deal with the cost of premiums, you have got to deal with the cost of services that are provided. Now, in the Affordable Care Act, we actually saw, over the last 5 years as the Affordable Care Act, ObamaCare, went into effect, a decrease in the rate of increase. We haven't seen a decrease in the cost of medical services, but what we have seen is that the inflation rate has significantly reduced, so much so that the financial security of the Medicare program, which is the single biggest expenditure, has been extended by some 11 years because the inflation rate has declined--not decreased, but the rate of inflation has declined almost 50 percent from what it was before the Affordable Care Act. That is a direct result of the many reforms that went into the way in which medical services were delivered. That allowed for a lower inflation rate for premiums and an extension of the financial viability of Medicare and other medical programs. Now, unfortunately, we are now faced with a repeal or a partial repeal of the Affordable Care Act, and the promise has been made by my Republican colleagues that somehow this will reduce the premiums. Well, that is interesting. Now, exactly how are you going to reduce the premiums unless you are dealing with the cost of medical care? In their reforms, there is--as best I can determine and everybody else--no effective way to reduce the cost of medical services and, in fact, the high probability that the cost of medical services will increase, specifically, because, in their proposed reform, men and women that are 45, 50 to 65 are going to find it virtually impossible to continue to buy insurance. They will drop their insurance. That is part of those 14 million Americans that will lose their insurance next year and part of the 24 million Americans that will not have insurance 9 years from now. That population, before they get to Medicare, when they begin to get ill, 40, 50, 60, they will not be able to afford insurance. It is something like a $12,000 increase in cost to them. It is what is known as the senior tax. Now, that will drive up the cost of medical services. Because they will not be able to have continuity of care, their diabetes, their heart issues, their high blood pressure, and on and on will not be treated. Similarly, in the proposed reform, there is a significant reduction in the number of men and women across this Nation--and we are talking probably in the range of 4 to 6 million in the next 2 years that will not be covered under the Medicaid program. Those people, not having access to continuous medical services, will not seek treatment for those illnesses that can be treated effectively or held in abeyance, such as diabetes, heart disease, and the like. That means that the cost of medical care for them will rise. Where will they go to get medical care? Not to worry, say our Republican colleagues. They can go to the emergency room. We have been there. We have seen what that means. The expansion of the Medicaid program is unraveled by the proposed TrumpCare. I am going to come back to this. I would like to ask my colleague from Texas to carry on here, if you would. I yield to the gentlewoman from Texas.

Mr. GARAMENDI. I want to thank the gentlewoman from Texas, Sheila Jackson Lee, for her consistent and constant caring for men and women in this Nation that are on the outside, that are not among the wealthy, that are struggling with their families to improve their situation. You are always there. And here you are once again this evening laying out the problems that we are going to see with TrumpCare. Let me just very quickly run through this, and then I would like to turn back to my colleague from Rhode Island, Mr. Cicilline. The proposal that is on the floor, we could just lay out five very succinct arguments on why it doesn't work. I was going through a rather complete explanation of how the healthcare system works because it is kind of a basic understanding, but clearly, under the legislation that is going to be taken up this Thursday, Americans are going to pay more for less. And it is not just a few. The senior citizens in Medicare are going to see a diminution in their benefits. We are looking at the 40-to 50-years-olds, which I have already discussed. We are looking at other individuals. Pay more for less, we are looking, over the next 9 years, that 24 million Americans will lose their insurance or their opportunity to get insurance. And just this next year, just 18 months from now--excuse me, not 18 months from now. Nine months from now, we are going to see 14 million people begin to lose their insurance. I talked earlier about this age tax, which speaks to those people that are 50 to 65 years of age. They are, under this legislation, going to pay up to five times more than someone who is between 20 and 30 years of age. Present law says they can be charged no more than three times what a 20- to 30-year-old pays, and so this is what is known as an age tax. It simply shifts the cost to those 40-, 50-, 60-year-old people who happen to be the most expensive. And I talked about the $12,000 that they will have to pay in addition to that. It guts Medicaid. We call it Medi-Cal in California and Medicaid across the Nation. The expansion of Medicaid was an extraordinarily important event that provided insurance not only to men and women who had no income, but to 85 percent of the people on Medicaid across this Nation who are elderly, in nursing homes, or elderly poor, unable to provide sufficient income from just their Social Security--those are called the dual eligible--or children. Now, in the Affordable Care Act, there was what was known as Medicaid expansion; and those are the working men and women, families, who have less than 138 percent of the poverty rate. So those are the low-income working men and women who are able to get Medicaid, or Medi-Cal insurance in California. It simply guts it in a variety of ways, which we will come back and discuss a little later. You can bet and you can count on there being less support for the elderly that are in nursing homes. There will be less support for the young families; the single-mother families who are struggling to get along, probably going to school, trying to learn skills; and for the working families who are at $10 an hour minimum wage. Finally, this is the one that ought to drive Americans right off the rails. This is a whopping $270 billion tax reduction for the top 1 percent of Americans. It is for 400 families in America, the richest 400, four of which are in the current Trump administration, including the President himself. They will see a $7 million a year decrease in their taxes. Now, that is great. I am sure the President will enjoy that $7 million tax reduction, along with the $3 million or $4 million he is getting from the taxpayers every year so he can go to his home in Florida. This is obscene. This is obscene because the way in which this thing works, working men and women and families across America at every income level are going to get less. They are going to pay for more, and yet the superwealthy in America are going to get a whopping tax reduction. This is the income distribution that we should never have, to take from the poor, to take from the middle class, and give to the superwealthy. I will come back and discuss this. Mr. Speaker, I yield to the gentleman from Rhode Island (Mr. Cicilline).

Mr. GARAMENDI. Mr. Speaker, there is no better fighter than the gentleman from Rhode Island (Mr. Cicilline) in the representation that he gives to the people of Rhode Island and beyond. The gentleman couldn't be more accurate about all that he said. I was listening carefully to the story the gentleman from Rhode Island told of the individual who wrote him an email. I, too, have received many, many emails. I was thinking, as he was describing the situation, of a woman who runs her own small farm near Marysville, California, in my district. For years, she could not afford insurance. She had a small orchard farm. She couldn't afford insurance. When she got sick, she went to the emergency room. She was able to get along. But she knew that, as she approached 50 years of age, she would be facing a bad medical situation, and she did. She had cancer. She couldn't get a policy prior to the Affordable Care Act because she had a preexisting condition: she had cancer. Emergency rooms are not treating that. She wasn't able to get on a program, and she was going to die. About that time, we established, in California, a covered California program that is an exchange based upon the Affordable Care Act. She, because of her income, was able to get a comprehensive insurance policy and a subsidy for her premium. She then had quality insurance, and she was able to get the cancer treatment because her insurance had no preexisting conditions and she was able to afford it. She had to pay a little bit, but she had a subsidy that made up the difference. She is now looking at a situation, because she is in that age 50 to 65, where she will not be able to afford a $12,000- or $14,000-a-year premium because the subsidies were taken out and because of this age tax, the 1-to-5 ratio rather than the 1-to-3 ratio. It is horrific. She knows what she is facing. She is facing the loss of her insurance and, quite possibly, the loss of her life. This is wrong. This is wrong. I thank the gentleman from Rhode Island for joining us tonight. I yield to the gentleman from Rhode Island (Mr. Cicilline).

Mr. GARAMENDI

Mr. GARAMENDI. Mr. Speaker, I thank the gentleman from Virginia (Mr. Scott) for expressing Virginia's view. From California, it is, whoa, wait a minute, let's be careful. Mr. Speaker, I yield back the balance of my time.

Mr. GARAMENDI. Mr. Speaker, I thank the gentleman from Virginia (Mr. Scott) for joining us this evening. This is a fundamental part of American life, that is, our health care. It is about 18 percent of the total GDP, gross domestic product. It is extremely important in terms of the total well-being of our society and our economy. Changes to the Affordable Care Act that are being proposed will have a dramatic effect. And what we do know about it is that there will be a massive shift of wealth from working men, women, and families to the superwealthy. We know that from the tax proposals that have been made in the analysis of the tax. We also know that there is a very, very high probability that perhaps 11 million people will lose their insurance coverage, either in the private insurance market through the exchanges or through the Medicaid programs across the Nation. And the effect on the providers, the hospitals, the clinics will be profound. So when we have something as important as this, it is just wrong. It is wrong for the majority in this House to put this legislation before the committees without a full hearing on what the effect will be. But it appears that tomorrow, Wednesday, we will have the first markup in this process. What I want--and I think the gentleman from Virginia (Mr. Scott) does, too--is for the American public to hear the debate, to understand the implications where we are today with the Affordable Care Act and what it has brought to us in terms of quality and accessibility to health care and what it would mean with the proposed changes. Mr. Speaker, I yield to the gentleman from Virginia (Mr. Scott).

Mr. GARAMENDI. The fundamental nature of insurance is you gather a large population of healthy, not-so-healthy, and perhaps some very sick people into a large population, and the cost is spread across the entire population. What we may be ceding here in this particular proposal is the unravelling of that fundamental insurance concept with young people, healthy, not bothering to buy insurance, staying out of the market; and then, eventually, when they become ill, they will get back into the market, leaving everybody else to pay for it. There is another piece of this shifting of cost that did occur prior to the Affordable Care Act--significantly reduced, as a result of it-- and that is the uninsured still get sick. The gentleman mentioned the emergency room a while ago, and for the most part, in America, a person can get to an emergency room with or without insurance; but if they don't have insurance, there is still a cost associated with the visit to the emergency room and any other thing they may need. They may need to have their leg repaired, a broken leg, or maybe they need an appendectomy or whatever. That is still a cost. The question is: Who picks up that cost? That is called uncompensated care, and it was a huge problem prior to the Affordable Care Act. I had hospitals throughout my district and throughout California coming to me and saying: We can't afford this because we are not able to cover that uncompensated care for people that didn't have insurance that showed up at the emergency room. Now, we know that from the early analysis done of the proposed legislation by our Republican friends that the number of uninsured is likely to increase, perhaps as much as 11 million people--maybe more, maybe somewhat less. Those people will still get sick. They may have money of their own to cover their costs, but the chances are they don't. That uncompensated cost will then be borne by the people who do buy insurance. It is a cost shift to those who have insurance.

Mr. GARAMENDI. Mr. Speaker, that is exactly right, and I see that in my district. I have a large rural district in California. And, even today, there are areas where it is difficult to find a physician to get medical services. This is one of the things, as you so correctly pointed out, the Affordable Care Act had a part of that. One of the titles dealt with the education of medical personnel. And so what we have seen, at least in California--and I suspect across America--with the Affordable Care Act in place, we are seeing that one of the fastest growing areas for new jobs is the healthcare sector because we are adding a lot of people--we need more--and then the educational programs that you talked about, which comes under the jurisdiction, I believe, of your committee. That is an important part. One of the things that I hope the American public comes to understand is this is not just a sound bite that was used in a political campaign. We are going to repeal the ObamaCare and we are going to replace it is a nice sound bite. But we are talking about the lives of Americans, we are talking about their health, their ability to stay healthy, their ability to get medical services. When you start tinkering with something that is so personal--that is what people say in my district: This is about my ability to stay healthy, my ability to get medical care. That is what I hear. They are saying they are frightened. They are concerned that the legislation and all of the discussion in the political campaigns has been so heated that they are afraid they are going to lose what they presently have. A quick look at what has been presented to Congress just in the last 24 hours indicates that a couple of facts are clear. First of all, there is an enormous tax break for the very, very wealthy, probably to the tune of 3- to $400 billion over 10 years. That is an incredible tax break for the superwealthy and for the health insurance industry. That, we are pretty sure, is in this legislation. We don't know the exact numbers; but we do know that early indications are that there is a shift, tax breaks for the wealthy, and cost increases for everybody else. That we know. We also know that there are certain elements of support for individuals that will be removed. As we go about debating this and understanding the full import and get the Congressional Budget Office information, I think we are going to find that Americans are going to say: Well, wait. Wait, wait, wait. You are doing what to me? What are you doing to me? You are taking away my health insurance? I suspect that will lead to a rebellion of some sort. Certainly it has agitated a lot of people in my communities about the justifiable fear of what may be coming to Americans. Mr. Speaker, I yield to the gentleman from Virginia (Mr. Scott).

Mr. GARAMENDI. There are so many pieces to this healthcare system. One thing that I want to put on the table here from my experience as insurance commissioner in California is that there are two fundamental parts to the healthcare system in the United States, and really around the world. One of those two parts is how we collect the money and then pay for the services. We call that insurance. It is also Medicare, Medicaid, veterans' programs, and the like. These are the way in which we collect money and pay for the services. The other part of the healthcare system is the delivery of services; these are the doctors, the clinics, the hospitals, and other providers, mental health providers, and the like. We often get confused by putting these two things together. There has been a lot of talk about what we are doing with the Affordable Care Act. It is essentially a mechanism to pay for services. It is an insurance mechanism. Using the private insurance system, these various exchanges are set up to pool the population of people who do not have insurance from their employer, the individual people, individual coverage. It pools them so that you have that large population so that the cost is spread out across that large pool and the insurance becomes affordable. That is an insurance mechanism. That is a pooling. It has nothing to do directly with the provision of medical services. The medical services are then provided out of that pooling arrangement by the individual doctors, maybe clinics, maybe hospitals, maybe group practices. Some of that will be capitated pay, and others will be a fee-for-service. We haven't changed directly the way in which services are provided, that is, the delivery of services. And this is found in hospitals. In the Affordable Care Act, there was a penalty for hospitals that had readmissions for infections. What we have seen, as a result of that provision dealing directly with the way in which services are delivered in hospitals, is a dramatic decline in readmissions for hospital- acquired infections. What that means is some 60,000 people are still alive today because they didn't get a hospital-acquired infection. Mr. Speaker, I yield to the gentleman from Virginia (Mr. Scott).

Mr. GARAMENDI. The gentleman is correct on that. I was just looking at some statistics here a moment ago about the shifting of cost. Under the Affordable Care Act, there are many, many benefits for Medicare. Leaving aside the Medicaid population for a moment, the Medicare population, available to every individual 65 and older, there have been significant improvements. You mentioned the doughnut hole earlier, the drug benefit. If you run up heavy expenditures on your drugs, you would come to a point where you had to pay 100 percent. Medicare didn't cover it. Well, that doughnut hole is collapsing, and in another 2 years, the Medicare program will cover all of the drug costs without limitation. Also, there is the free annual checkup that is available to everybody that is on Medicare. The result of these kinds of things, where drugs are available, blood pressure drugs, diabetes and the like, has led to--together with the additional taxes that the superwealthy are paying--has increased the solvency of Medicare by 11 years. Now, the fiddling that is going on with the proposal that our Republicans have put through, it is not clear exactly what the result would be; but we do know that one of the major tax cuts is the elimination of this Medicare tax that the superwealthy have been paying, and that is over--together with one other tax is almost $340 billion. So the support for Medicare and the solvency of Medicare becomes a question mark as a result of the proposals. We don't have all of the answers to this, but we do know that a 60- year-old presently getting an insurance policy from the Affordable Care Act, from ObamaCare, and making somewhere around $40,000 a year-- perhaps working at Walmart--they are going to see a 57 percent reduction in the tax credit that is currently available versus what the Republican bill has. So a 60-year-old making $40,000 a year under the ACA, ObamaCare, will receive somewhere around a $9,000 tax credit to support the purchase of insurance. Under the Republican bill, they are looking at $4,000--not $9,000, but $4,000--so 57 percent reduction in the support that they receive, probably leading to them not being able to afford insurance and winding up in your emergency room example.

Mr. GARAMENDI. Well, let me make sure I understand. I was 60 a while ago, but let's say I am 60 and I am getting a health insurance policy under ObamaCare, the Affordable Care Act. I may have to pay three times what a 25-year-old pays, but under the proposal that has been brought to us by the Republicans, I would pay five times?

Mr. GARAMENDI. Mr. Speaker, the gentleman from Virginia is absolutely correct about that. Unfortunately, my understanding is that as early as tomorrow--that would be Wednesday--that the committees intend to mark up the legislation. Normally, that means the version of the legislation that will pass out of committee is completed. And, I suspect, usually it is associated with a vote that takes place in committee. We don't know for sure if it is tomorrow or the next day, but we do know that if it is this week, we will not have the Congressional Budget Office information. The gentleman mentioned something that I probably should have jumped on immediately because of my rural district, and those are the clinics. As a result of the Affordable Care Act, there are now seven significant clinic organizations that provide services to about 23 specific sites around my district. They are providing, really for the first time in many of the communities that I represent, immediately available healthcare services to a variety of people, some of whom have had an employer-sponsored health plan and others of whom are on Medi-Cal in California. The apparent reduction in the Medicaid, Medi-Cal for California, support from the Federal Government that will occur over the next 2\1/ 2\ to 3 years will eliminate one of the principal ways in which those clinics have been able to continue to operate and, that is, the expansion of the Medicaid population in California. It appears that the legislation that is proposed will shrink the Medicaid program across the Nation and severely curtail in California the support available for people who are currently on Medi-Cal. That will be devastating to these clinics in these rural areas. We have had discussions about this. They say: Watch carefully. If this is what happens, we are going to be out of business. We are going to shut down our doors. Mr. Speaker, I yield to the gentleman from Virginia.