Jim McGovern

Mr. McGOVERN

Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentlewoman from California (Ms. Sanchez), the vice chair of the Democratic Caucus.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the American Public Health Association in strong opposition to the Republican bill. American Public Health Association, May 4, 2017. House of Representatives, Washington, DC. Dear Representative: On behalf of the American Public Health Association, a diverse community of public health professionals who champion the health of all people and communities, I write to express our continued strong opposition to H.R. 1628, the American Health Care Act of 2017, legislation to repeal the Affordable Care Act. The amended bill would be even worse for the nation's health than the original proposal and does nothing to improve the health of the American public. Additionally, the bill would have the greatest negative impact on the health of the most vulnerable Americans. According to the March Congressional Budget Office analysis, the legislation would result in 14 million Americans losing health insurance coverage in 2018. By 2026, CBO estimates 24 million individuals would lose coverage, taking the uninsured rate up to a staggering 52 million, nearly double the number of Americans who would lack insurance under existing law. The bill would cut critical premium subsidies for low- and middle-income families and phase out the ACA's Medicaid expansion. Under the proposal, many, especially low-income and older Americans, would pay higher premiums, receive lower subsidies and be subject to higher out of pocket costs, including higher deductibles and co-pays for plans that provide less coverage. Health insurance coverage is critical to preventing disease, ensuring health and well-being and driving down the use of costlier providers of care. Unfortunately, this proposal will result in a greater number of people losing coverage than the number of people who have gained coverage under the Affordable Care Act, putting many at risk of premature death due to the lack of access to critical health services. The amended bill would be even worse for public health than the original bill that was pulled from the House floor in late March. The amended bill would allow states to opt-out of requiring health plans to cover the 10 essential health benefits such as maternity care, mental health and substance abuse disorder services and prescription drug coverage. It would also allow insurers to charge significantly higher premiums for people with pre-existing conditions and possibly allow insurers to charge older adults even higher premiums. The inclusion of a mere $8 billion over five years will do little to help people with pre-existing conditions who could see drastically higher premiums leaving millions in the individual and small group market with no protections from insurer discrimination. The bill would also eliminate the Prevention and Public Health Fund, the first and only mandatory funding stream specifically dedicated to public health and prevention activities. The fund has already provided more than $6 billion to support a variety of public health activities in every state including tracking and preventing infectious diseases like the Ebola and Zika viruses, community and clinical prevention programs, preventing childhood lead poisoning and expanding access to childhood immunizations. Eliminating the fund would devastate the budget of the Centers for Disease Control and Prevention. The fund currently makes up 12 percent of CDC's budget and eliminating this funding stream would force Congress to replace the funding through the regular appropriations process where resources for nondefense discretionary programs are already too low. Not only would the bill phase out the Medicaid expansion under the ACA, it would also make other troubling changes to the Medicaid program, converting it to a per capita program. The most recent CBO analysis estimated the bill would cut federal spending on Medicaid by $839 billion over the next decade, drastically cutting resources to states, many of which are already struggling with tight budgets. The bill would also block Medicaid reimbursements to Planned Parenthood for one year--which CBO estimates will lead to less access to care, more unintended births and more costs for the Medicaid program. While the Affordable Care Act is not perfect, the law has made progress in addressing the biggest challenges facing our health system including the rising costs associated with our health care system, uneven quality of care, deaths due to medical errors, discriminatory practices by health insurance providers and the shrinking ranks of the nation's primary care providers. The ACA has made progress in shifting our health system from one that focuses on treating the sick to one that focuses on keeping people healthy. We ask you to oppose this and future efforts to repeal or weaken the ACA. Instead, we urge you to work on a bipartisan basis to improve and build upon the successes of the ACA and to work to provide health insurance coverage to the more than 28 million who still lack coverage. We look forward to working with you to create the healthiest nation in one generation. Sincerely, Georges C. Benjamin, MD, Executive Director.

Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentlewoman from Connecticut (Ms. DeLauro).

Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the distinguished gentleman from Rhode Island (Mr. Langevin).

Mr. McGOVERN. Mr. Speaker, I yield myself such time as I may consume. (Mr. McGOVERN asked and was given permission to revise and extend his remarks.)

Mr. McGOVERN. Mr. Speaker, I am not sure if my colleagues are aware of this since we are moving so quickly here, but I want to flag for everyone an important op-ed in The Hill by the executive director of the Boston Area Rape Crisis Center. She points out that in the latest version of this legislation, rape can once again be categorized as a preexisting condition as it often was before the Affordable Care Act. I include her column, entitled ``Health `reform' will make sexual assault survivors sick,'' in the Record. Health `Reform' Will Make Sexual Assault Survivors Sick (By Gina Scaramella) So far, we know that about 24 million Americans stand to lose their health insurance coverage if the Affordable Care Act (ACA) is replaced with the American Health Care Act (AHCA). We know that most of those 24 million people will be low-income. We also know that groups of people who experience significant health care disparities, such as lesbian, gay, bisexual and transgender (LGBT) people, and Black and Latino people, will be among those who risk losing the most if the ACA is repealed. To that list, we must add survivors of sexual violence. Before passage of the ACA in 2010, sexual assault survivors who had sought medical care for their injuries could be denied health insurance coverage at a later date. The reason? Health insurers often categorized rape as a pre-existing health condition. In one widely reported case, a 45-year-old woman met two men at a bar in Florida who bought her a drink. Hours later, she found herself lying by the side of the road with injuries indicating that she had been raped and that the men had spiked her drink. Her doctor prescribed a treatment of anti- viral, post-HIV exposure drugs to protect against HIV transmission. When the woman lost her health insurance several months after the attack, she was unable to obtain new insurance due to the health care treatment she had received for the assault. She went without health insurance for three years. Stories like these prompted the National Women's Law Center to launch a campaign called ``Being a Woman Is Not a Pre- Existing Condition.'' It was so popular that then-House Speaker Nancy Pelosi adopted the phrase in her pro-health reform talking points with media, and the New York Times ran an explainer on the ways in which health insurers treated women as if they were just one giant pre-existing condition. The AHCA initially retained the ACA's ban on discrimination against people with pre-existing conditions. But an amendment to the AHCA bill offered last week by New Jersey Congressman Tom MacArthur and North Carolina Congressman Mark Meadows would make it easier for health insurers to deny coverage to people with pre-existing conditions. By letting states waive the ACA prohibition on charging people with pre-existing health conditions higher premiums, protections for those who've previously been medically treated for sexual assault would be gutted. Perhaps more alarming, though, is the MacArthur-Meadows amendment's provision allowing states to also seek waivers from the ACA's requirement that essential health benefits be covered by health insurance plans. Essential health benefits include preventive health care services that most of us take for granted. These include tests for blood pressure and cholesterol, mammograms, and vaccinations. Essential health benefits also include coverage for mental health care and substance abuse treatment. Sexual violence survivors face acute treatment needs in the aftermath of an assault such as care for gynecological injuries, other physical trauma, sexually-transmitted diseases, and pregnancy. But sexual violence takes many forms: incest: ongoing sexual abuse outside of the family, sexual assault, sexual harassment or exploitation, and rape. Each of these types of assault puts the survivor at risk for various potential negative physical health and mental health outcomes. For example, an adult survivor of childhood sexual abuse is at a higher risk for psychiatric disorders. Women and men who have survived rape as adults are at higher risk of post- traumatic stress disorder, depression, anxiety, and substance abuse--any of which can significantly interfere with daily living. No one can deny that there is a direct line between having survived sexual violence, and an increased risk of physical and mental health problems. The mental health impacts of sexual violence are deep and often longstanding. Survivors need long-term access to nonjudgmental health and mental health services to reduce their suffering and mitigate as much as possible the stress that recovery from sexual violence puts on intimate family relationships, and obligations related to school and work. It is hard to see any good coming from this latest attempt to repeal the ACA and all of the care it has brought to survivors of sexual violence.

Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentlewoman from Washington (Ms. DelBene).

Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from Texas (Mr. Castro).

Mr. McGOVERN. Mr. Speaker, wow. I yield myself such time as I may consume, and to rebut the gentleman from Texas, let me include in the Record a letter from the American Cancer Society, the American Diabetes Association, the American Heart Association, the American Lung Association, the Cystic Fibrosis Foundation, the Juvenile Diabetes Foundation, the March of Dimes, the National Multiple Sclerosis Society, the National Organization for Rare Disorders, and the National Coalition for Women with Heart Disease. Leading Patient Advocacy Groups Remain Opposed to the American Health Care Act Eight Organizations Issue Statement Criticizing Upton Agreement Washington, May 3, 2017.--Earlier today, House Energy and Commerce Committee Chairman Greg Walden (R-OR) issued a press release stating that an amendment proposed by Representative Fred Upton (R-MI) to the American Health Care Act (AHCA) provides ``protection and certainty for patients with pre- existing conditions.'' Eight leading patient groups, listed below, issued the following statement in response: Despite the Upton amendment, we remain strongly opposed to the American Health Care Act and urge Congress to consider the people at the heart of this decision. The various patchwork solutions offered by lawmakers would still leave the millions of patients we represent, who have serious and chronic health conditions, at risk of not being able to access life-saving treatments and care. There is no substitute for fundamental, unequivocal protections for people with pre-existing conditions. The AHCA, including the potential amendment, would undermine vital safeguards against being charged more for insurance based on health status. Increasing funding for risk sharing programs and consumer financial assistance does not address the legitimate challenges built into these proposals. The other equally important problems with the AHCA remain, including: Allowing states to waive the guarantee of essential health benefits, which would: Segment the market into plans for sick people and plans for healthy people, driving up the cost of plans for people with serious health care needs Undermine the protection against annual and lifetime coverage caps, a critical safeguard for patients Eliminating Medicaid expansion coverage for millions of Americans and altering the program's financing structure in a way that jeopardizes coverage of new and innovative treatments Increasing out-of-pocket costs for many Americans, including some of the sickest and elderly among us Given the numerous shortcomings of the American Health Care Act in serving the patients we represent, our organizations have no choice but to oppose this legislation and urge all Representatives to vote against it, with or without the Upton and MacArthur amendments. Patient Advocacy Groups American Cancer Society Cancer Action Network American Heart Association American Lung Association Cystic Fibrosis Foundation March of Dimes National Organization for Rare Disorders National MS Society WomenHeart: The National Coalition for Women with Heart Disease Media Contacts American Cancer Society Cancer Action Network, Alissa Crispino. American Heart Association, Abbey Dively. American Lung Association, Allison MacMunn. Cystic Fibrosis Foundation, Jessica Rowlands. March of Dimes, Cindy Pellegrini. National Organization for Rare Disorders, Jennifer Huron. National MS Society, Eileen Curran. WomenHeart: The National Coalition for Women with Heart Disease, Tom Murphy.

Mr. McGOVERN. Mr. Speaker, I also include in the Record a statement from the American Medical Association in opposition to this bill. [From the American Medical Association, May 3, 2017] AMA Warns that Proposed Changes to the American Health Care Act Do Not Remedy Bill's Shortcomings Despite amendments to bill, millions of Americans would still lose health insurance coverage Chicago.--American Medical Association (AMA) President Andrew W. Gurman, M.D., issued the following statement today about proposed changes to the American Health Care Act (AHCA): ``None of the legislative tweaks under consideration changes the serious harm to patients and the health care delivery system if AHCA passes. Proposed changes to the bill tinker at the edges without remedying the fundamental failing of the bill--that millions of Americans will lose their health insurance as a direct result of this proposal. ``High-risk pools are not a new idea. Prior to the enactment of the Affordable Care Act, 35 states operated high-risk pools, and they were not a panacea for Americans with pre-existing medical conditions. The history of high- risk pools demonstrates that Americans with pre-existing conditions will be stuck in second-class health care coverage--if they are able to obtain coverage at all. ``Not only would the AHCA eliminate health insurance coverage for millions of Americans, the legislation would, in many cases, eliminate the ban against charging those with underlying medical conditions vastly more for their coverage.'' ``America should not go backward to the time when our fellow citizens with pre-existing health conditions faced high costs for limited coverage, if they were able to obtain coverage at all. The AMA urges congressional leaders and the Administration to pursue a bipartisan dialogue on alternative policies that provide patients with access and coverage to high quality care and preserve the safety net for vulnerable populations.'' Background on high-risk pools A January report from the American Academy of Actuaries notes that ``enrollment has generally been low, coverage has been limited and expensive, they require external funding, and they have typically operated at a loss . . . Removing high-risk individuals from the insured risk pools reduces costs in the private market only temporarily. Over time, even lower-cost individuals in the individual market can incur high health care costs, which would put upward pressure on premiums.'' According to the Kaiser Family Foundation: State high-risk pools featured premiums above standard non- group market rates--with most states capping them at 150%- 200% of standard rates. Many also featured high deductibles, some $5,000 or more. Despite the fact that many individuals were forced into high-risk pools because of a pre-existing condition, nearly all states excluded coverage for these conditions for 6-12 months. Almost all high-risk pools imposed lifetime limits on covered services, and some imposed annual limits. Some states capped or closed enrollment. Combined net losses for the state high-risk pools totaled more than $1.2 billion for 2011, or $5,510 per enrollee, on average. Furthermore, a 2010 paper by James Capretta and Tom Miller that appeared in National Affairs estimated that the cost of adequately funded high risk pools would be $15 billion to $20 billion per year.

Mr. McGOVERN. Mr. Speaker, I also include in the Record a letter from the American Academy of Family Physicians in opposition to this bill. American Academy of Family Physicians, May 3, 2017. Jim McGovern, Representative, House of Representatives, Washington, DC. Dear Rep. Jim McGovern: Despite recent activities and amendments, the American Health Care Act (H.R. 1628) remains a highly flawed proposal that will destabilize our health care system, cause significant loss of coverage, and allow for the discrimination against patients based on their gender, age, and health status. For these reasons, the American Academy of Family Physicians (AAFP) continues to oppose the AHCA and encourages the House of Representatives to reject this failed policy. The fact remains that the AHCA will: Cause more than 24 million people to lose their health care coverage, including more than 7 million with employer- sponsored coverage. Destabilize the individual health insurance market. Create a race to the bottom by eliminating any standards with respect to minimum insurance benefits. Enact draconian cuts in the Medicaid program that will have an immediate negative impact on low-income individuals, children, and millions of senior citizens who rely on the program. Eliminate community rating and return to medical underwriting, thus allowing insurers to discriminate against individuals based on their gender, age, and health status. Deny individuals protection against annual and lifetime spending caps, thus threatening the financial stability of millions of individuals and families in the future. Over the past few days there has been an effort to advance policies that seek to protect individuals with pre-existing conditions from facing discrimination in insurance underwriting as a result of their health status. Despite a willingness to spend more money on these proposals, the current efforts on pre-existing conditions fail to accomplish their goal. High-risk pools are inherently flawed and expensive. The proposals under consideration provide inadequate funding for an inadequate period of time, thus creating an under-funded and temporary solution for the millions of Americans with pre-existing conditions. We find it regrettable that Congress would seek to relegate individuals with high health care needs to a program that has a questionable history and would face uncertain financial stability in the future. By removing critical consumer protections that collectively ensure that the millions of individuals with pre-existing conditions can continue to purchase affordable health care coverage, the AHCA would result in higher premiums and higher deductibles for millions. Additionally, the negative impact of the AHCA is not limited to the individual insurance market. These policies also may impact the more than 130 million people with employer-sponsored insurance. Thank you.

Mr. McGOVERN. Mr. Speaker, I also include in the Record a statement from the AARP in strong opposition to this bill.

Mr. McGOVERN. Mr. Speaker, if this bill were so great, these organizations would be supporting the Republican bill, not opposing it; and they are strongly opposing it. Mr. Speaker, I yield 1 minute to the gentleman from Texas (Mr. Doggett).

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the American College of Physicians in opposition to the bill. American College of Physicians, April 24, 2017. Hon. Paul Ryan, Speaker, House of Representatives, Washington, DC. Hon. Nancy Pelosi, Minority Leader, House of Representatives, Washington, DC. Hon. Mitch McConnell, Majority Leader, Washington, DC. Hon. Charles Schumer, Minority Leader, U.S. Senate, Washington, DC. Dear Speaker Ryan, Minority Leader Pelosi, Majority Leader McConnell, and Minority Leader Schumer: On behalf of the American College of Physicians (ACP), I am writing to urge Congress to move away from the harmful changes to patient care that would occur if the American Health Care Act (AHCA) were to become law, and to instead work for bipartisan solutions to improve the Affordable Care Act (ACA) rather than repealing and replacing it. We believe that the AHCA, which would repeal and replace the most important coverage and consumer protections created by the ACA, is so fundamentally flawed that it cannot be made acceptable. We understand that the leadership in the House of Representatives continues to explore ways to bring a modified version of the AHCA to a vote, based on a draft amendment reportedly being developed by Representatives MacArthur and Meadows, a summary of which was made available to the public through news organizations. This amendment would make the harmful AHCA even worse by creating new coverage barriers for patients with pre-existing conditions and weakening requirements that insurers cover essential benefits. The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 148,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. The draft MacArthur-Meadows amendment would create what is known as the ``Limited Waiver Option'' that would allow states to eliminate or severely weaken vital ACA Title I consumer protections--specifically, community rating and essential health benefits (EHBs)--returning the country to the pre-ACA days when persons with pre-existing ``declinable'' medical conditions in most states were priced out of the market and the insurance products available in the individual market did not cover medically necessary services. Specifically: The MacArthur-Meadows amendment would create an option for states to obtain Limited Waivers from certain federal standards that would gut existing law consumer protections. Based on a summary of the draft amendment, states could seek Limited Waivers for: Essential Health Benefits (EHBs) Community-rating rules, except for the following categories, which are not waivable: Gender or Age (except for reductions of the 5:1 age ratio previously established) or Health Status (unless the state has established a high-risk pool or is participating in a federal high-risk pool) To obtain the waiver, states would only need to ``attest that the purpose of their requested waiver is to reduce premium costs, increase the number of persons with healthcare coverage, or advance another benefit to the public interest in the state, including the guarantee of coverage for persons with preexisting medical conditions. The Secretary shall approve applications within 90 days of determining that an application is complete.'' [Emphasis added in italics]. In other words, as long as a state attested that there was a ``benefit to the public,'' insurers would be once again allowed to charge more to people with pre-existing conditions, or decline to cover needed benefits like physician and hospital visits, maternity care and contraception, mental health and substance use disorder treatments, preventive services, and prescription drugs. This would take us back to the days when people had to fill out intrusive insurance company applications to document their previous health history, even before being advised what the premium would be based on their individual health risk. Unlike community rating, which bases premiums based on the expected costs associated with all persons in the insurance pool (adjusted only by age, tobacco use, and family size), the Limited Waiver would again allow insurers in states that obtain a waiver to again charge people exorbitant and unaffordable premiums for their pre-existing conditions. Before the ACA, insurance plans sold in the individual insurance market in all but five states typically maintained lists of so-called ``declinable'' medical conditions including asthma, diabetes, arthritis, obesity, stroke, or pregnancy, or having been diagnosed with cancer in the past 10 years. Even if a revised bill would not explicitly repeal the current law's guaranteed-issue requirement which requires insurers to offer coverage to persons with pre-existing conditions like these guaranteed issue without community rating allows insurers to charge as much as they believe a patient's treatment will cost. The result would be that many patients with pre-existing conditions would be offered coverage that costs them thousands of dollars more for the care that they need, and in the case of patients with expensive conditions like cancer, even hundreds of thousands more. An amendment to the AHCA reported out of the Rules Committee on April 6th to establish a ``Federal Invisible Risk Sharing Program,'' which would create a fund that states could use to reimburse insurers for some of the costs associated with insuring sicker patients, would not offset the harm done to patients with pre-existing conditions by allowing the Limited Waiver of community rating and essential benefit protections. The pre-ACA experience with high-risk pools was that many had long waiting lists, and offered inadequate coverage with high deductibles and insufficient benefits. Unless a national high-risk pool is supported with a massive infusion of funding it will not be sufficient to cover the millions of people with pre-existing conditions that would be denied or charged more for coverage under the AHCA. One paper estimates that a national high-risk pool would cost $178.1 billion a year, roughly $176.4 billion more than the annual funding provided to the Invisible Risk Sharing Program. Also, shifting people out of the existing health insurance marketplace to a high- risk pool would undermine the assurance that enrollees could keep their existing coverage. The Limited Waiver Option will also allow states to seek waivers from the essential health benefits required of all plans sold in the individual insurance market, with the result that millions of patients will be at risk of losing coverage for essential services like maternity care, cancer screening tests and treatments, prescription drugs, preventive services, mental health and substance use disorder treatments, and even physician visits, prescription drugs and hospitalizations. Prior to passage of the ACA, 62% of individual market enrollees did not have coverage of maternity services, 34 did not have substance-use disorder-services, 18% did not have mental-health services and 9% did not have coverage for prescription drugs. A recent independent analysis found that the AHCA's repeal of current law required benefits would result in patients on average paying $1,952 more for cancer drugs; $1,807 for drugs for heart disease; $1,127 for drugs to treat lung diseases; $1,607 for drugs to treat mental illnesses; $4,940 for inpatient admission for mental health; $4,555 for inpatient admission for substance use treatment; and $8,501 for maternity care. Such increased costs would make it practically impossible for many patients to avail themselves of the care they need. The result will be delays in getting treatment until their illnesses present at a more advanced, less treatable, and more expensive stage, or not keeping up with life-saving medications prescribed by their physicians. Allowing states to eliminate the EHB will threaten our nation's fight against the opioid epidemic. A study concluded that with repeal of the ACA, ``approximately 1,253,000 people with serious mental disorders and about 2.8 million Americans with a substance use disorder, of whom about 222,000 have an opioid disorder, would lose some or all of their insurance coverage.'' Finally, allowing states to drop important benefits like maternity, substance use disorder treatment, and preventive services will do little to reduce premiums. A report by Milliman found that the main drivers of premium costs were ambulatory patient services, hospitalization, and prescription drugs. These are crucial services that form the core of any health insurance plan. To be clear: while some younger and healthier persons might be offered lower premiums in states that obtained a ``Limited Waiver'' of community-rating and essential health benefits, it would be at the expense of making coverage unaffordable for those who need it most, older and sicker persons, and result in skimpy ``bare-bones'' insurance for many others that does not cover the medical care they would need if and when they get sick. Finally, even without the Limited Waiver Amendment, ACP continues to believe that the AHCA has numerous other provisions and policies that that will do great harm to patients including: The phase-out of the higher federal match in states that have opted to expand Medicaid and the ban on non-expansion states being able to access the higher federal contribution if they choose to expand Medicaid; Converting the shared federal-state financing structure for Medicaid to one that would cap the federal contribution per enrollee; Providing states with a Medicaid block grant financing option; Eliminating EHBs for Medicaid expansion enrollees; Imposing work or job search requirements on certain Medicaid enrollees; Regressive age-based tax credits, combined with changes that will allow insurers to charge older people much higher premiums than allowed under current law; Continuous coverage requirements for patients with pre- existing conditions; Legislative or regulatory restrictions that would deny or result in discrimination in the awarding of federal grant funds and/or Medicaid and Children's Health Insurance Program funding to women's health clinics that are qualified under existing federal law for the provision of evidence-based services including, but not limited to, provision of contraception, preventive health screenings, sexually transmitted infection testing and treatment, vaccines, counseling, rehabilitation, and referrals, and; Elimination of the Prevention and Public Health Fund, which provides billions in dollars to the Centers for Disease Control and Prevention to prevent and control the spread of infectious diseases. The College strongly believes in the first, do no harm principle. Therefore, we continue to urge that Congress move away from the fundamentally flawed and harmful policies that would result from the American Health Care Act and from the changes under consideration--including the proposed ``Limited Waiver'' amendment--that would make the bill even worse for patients. We urge Congress to instead start over and seek agreement on bipartisan ways to improve and build on the ACA. The College welcomes the opportunity to share our ideas for bipartisan solutions that would help make health care better, more accessible, and more affordable for patients rather than imposing great harm on them as the AHCA would do. Sincerely, Jack Ende, MD, MACP, President.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the Cancer Action Network against this bill. Cancer Action Network, American Cancer Society, May 3, 2017. Hon. Paul Ryan, Speaker, House of Representatives, Washington, DC. Hon. Nancy Pelosi, Minority Leader, House of Representatives, Washington, DC. Dear Speaker Ryan and Minority Leader Pelosi: The American Cancer Society Cancer Action Network (ACS CAN) is deeply concerned about the reports of additional amendments to the American Health Care Act (AHCA), including one that would allegedly add $8 billion in new spending for state high-risk pools. This amendment is particularly egregious because it would further incent states to apply for waivers from current-law market rules that protect patients with pre- existing conditions. Historically, state high-risk pools have fallen short of providing coverage of prevention, treatment and follow-up care for cancer patients and survivors. Segmenting people with cancer and other serious illnesses away from the private marketplace and into high-risk pools absent an adequate and permanent source of public funding has never been an adequate solution. Between 1976 and 2010, 35 states created high-risk pools to cover individuals who could not otherwise purchase insurance in the private market, usually because of a pre-existing condition. Every one of those risk pools experienced net operating losses year after year. Furthermore, high-risk pools did not result in lower premiums. All of them set premiums above the non-group market average or standard rate in the state, usually by 150-200 percent. Only a few states provided additional premium assistance for low-income individuals, leaving many who could not afford premiums priced out of the program. Most states also imposed waiting periods before covering preexisting conditions. An individual with a prior cancer diagnosis often had to wait 6-12 months before the high-risk pool would cover the costs associated with cancer treatment or follow-up survivorship care. Most states imposed limitations on coverage with either lifetime or annual limits. And most plans offered deductibles of $1,000 or higher. Neither AHCA, nor the new amendment would fully protect patients from any of those conditions. Cancer patients and survivors need insurance coverage that is affordable, readily accessible, and protects them from pre-existing condition exclusions, annual and lifetime caps on coverage and extraordinary out-of-pocket costs. Past experience has shown that high-risk pools failed to meet these basic needs, yet still were a drain on state budgets. As we have indicated in our earlier letters, there are reasonable fixes that could be made to the current law. We stand ready to work with you to develop policies that improve the law and encourage a robust health insurance market that provides affordable and comprehensive coverage options. Sincerely, Christopher W. Hansen, President.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the American Society of Clinical Oncology against this bill. American Society of Clinical Oncology, April 27, 2017. Hon. Paul Ryan, Speaker, House of Representatives, Washington, DC. Dear Speaker Ryan, On behalf of the American Society of Clinical Oncology (ASCO), I write to express our strong opposition to the American Health Care Act (AHCA), as currently amended. As the leading professional society representing more than 42,000 physicians worldwide who care for people with cancer, ASCO has a unique perspective on the law's potential impact on cancer patients. Our core mission is to ensure every patient with cancer has meaningful access to high quality care. We believe Congress shares this goal and our comments today are in the spirit of advancing that common purpose. In January 2017, as Congress embarked upon the repeal and replacement of the Affordable Care Act, ASCO shared a set of guiding principles that support improvements to the current health care system. We also put forth specific areas where people with cancer need protections. Our principles rest on the belief that any health system reform must ensure all people affected by cancer receive high-quality care. ASCO's first principle states, ``all Americans should have access to affordable and sufficient healthcare coverage regardless of their income or health status. To ensure protected access, the current ban on preexisting condition limitations, elimination of annual and lifetime coverage caps, and maintenance of guaranteed renewability should be preserved.'' We take the position that ``any efforts to reform the healthcare system at the national, state, or local levels should ensure that individuals with healthcare insurance can continue to access affordable insurance without interruption.'' The amended AHCA violates these principles. Studies show that when cancer patients do not have adequate insurance they receive less care, receive it later, and have worse outcomes than those with better insurance coverage. Uninsured and under-insured families facing a cancer diagnosis experience significant stress. They often are unable to meet out-of-pocket expenses and even forgo cancer care in order to pay for necessities of daily living. The AHCA as currently constructed will create or worsen these barriers to care. It will add costs to the system, decrease access to appropriate treatment and increase existing disparities in care. We are especially concerned with provisions allowing state waivers that could erode important protections for patients with cancer, including pre-existing condition safeguards, coverage of essential services, and access to affordable health insurance. Removing these protections from current federal law allows for a weakening of these critical provisions in some states and establishes a system of inequitable protections across state lines for cancer patients. We urge policymakers to ensure that robust requirements are in place to ensure that all insurance products cover the full scope of services and therapies that cancer patients require. ASCO strongly opposes passage of the AHCA in its current form. We welcome the opportunity to address these issues--and to work toward a better proposal--with you and your staff. Sincerely, Daniel F. Hayes, MD, FASCO, FACP, President, American Society of Clinical Oncology.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the American Congress of Rehabilitation Medicine against this bill. American Congress of Rehabilitation Medicine, May 2, 2017. Re Deep Concerns with the American Health Care Act and Related Amendments. Hon. Paul Ryan, Speaker, House of Representatives, Washington, DC. Hon. Nancy Pelosi, Democratic Leader, House of Representatives, Washington, DC. Dear Speaker Ryan and Leader Pelosi: The American Congress of Rehabilitation Medicine (ACRM) writes in reference to the American Health Care Act (AHCA), H.R. 1628, and the MacArthur Amendment to the bill. ACRM is an organization of rehabilitation professionals dedicated to serving people with disabling conditions by supporting research and services that promote health, independence, productivity, and quality of life; and meet the needs of rehabilitation clinicians and individuals with disabilities. ACRM is seriously concerned that current House proposals will undercut the federal coverage standard for rehabilitation and habilitation services and devices established under the Affordable Care Act (ACA). Access to rehabilitation enables individuals experiencing injuries, illnesses, and disabilities to maximize their quality of life by enhancing their health, function, and independence. We believe that any ACA repeal and replace bill that advances in the House and Senate must maintain access to rehabilitation and habilitation services and devices. In particular, the AHCA (H.R. 1628, as amended) includes a provision that would allow states to apply for waivers exempting them from compliance with important patient protections that are required by the Affordable Care Act (ACA), including premium rating ratios based on age, protections for consumers disallowing medical status underwriting (i.e., community rating), and requirements for insurers to cover a defined package of essential health benefits (EHBs), which include rehabilitative and habilitative services and devices. We are deeply concerned these EHB changes will curtail access for both children and adults in Medicaid expansion states, as well as private ACA health plans. ACRM believes that these provisions will significantly undermine the health insurance coverage that patients need. ACRM urges Congress to work in a bipartisan manner to improve access to affordable, comprehensive care for all Americans, including those with disabilities and chronic conditions needing rehabilitation and habilitation services and devices. Douglas Katz, MD, FACRM, FAAN, ACRM President.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the Consortium for Citizens with Disabilities in strong opposition to this bill. Consortium for Citizens With Disabilities, April 28, 2017. Dear Member of Congress: The Consortium for Citizens with Disabilities (CCD) is strongly opposed to the amended American Health Care Act. The amended American Health Care Act retains the original bill's proposals to dramatically cut Medicaid services that are vital to people with disabilities and seniors through per capita caps, which CCD has opposed. The new amendments--including permitting states to seek waivers from the protections for people with pre-existing conditions and from the requirement to provide essential health benefits--makes the amended AHCA even more harmful to people with disabilities. We urge you to oppose this legislation. Medicaid provides services and supports that maintain the health, function, independence, and well-being of 10 million enrollees living with disabilities. For many people with disabilities, being able to access timely needed care is a life or death matter. The American Health Care Act changes the way that the Federal Government funds Medicaid--rather than paying states based on the actual costs of healthcare for people in Medicaid, it sets a cap on the amount of federal support, a cap that is totally unrelated to the actual costs of needed care for enrollees. This cap is designed to cut Medicaid, and the bill uses those cuts to pay for unrelated tax cuts. Slashing federal support for Medicaid, which is already a lean program, will force states to cut services and eligibility that put the health and wellbeing of people with disabilities at significant risk. The newest amendments to the American Health Care Act make the bill even more harmful to people with disabilities. The new amendments would allow states to easily obtain waivers that would allow them to charge higher premiums to people with pre-existing conditions, including people with disabilities. They also would allow states to seek waivers from the Affordable Care Act's requirement to provide essential health benefits, including crucial services for people with disabilities such as mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, preventative and wellness services and chronic disease management, and pediatric services. These waivers jeopardize the Affordable Care Act's protections for people with pre-existing conditions, including people with disabilities, and CCD opposes any roll- back of those protections. The ACA helped millions of people with disabilities and others to gain access to affordable and comprehensive health insurance. The amended American Health Care Act is insufficient to help people with disabilities meet their healthcare needs, and we urge you to oppose the bill should it come to a vote. Sincerely, Health Task Force Co-chairs: Bethany Lilly, Bazelon Center for Mental Health Law; Dave Machledt, National Health Law Program; Peter Thomas, Brain Injury Association of America; and Julie Ward, The Arc of the United States. Long Term Services and Supports Co-chairs: Alison Barkoff, Center for Public Representation; Nicole Jorwic, The Arc of the United States; Sarah Meek, Lutheran Services in America Disability Network; and Laura Weidner, National Multiple Sclerosis Society.

Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from Massachusetts (Mr. Moulton.)

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the Paralyzed Veterans of America against this bill. Paralyzed Veterans of America, Washington, DC, May 3, 2017. Hon. Paul Ryan, Speaker, House of Representatives, Washington, DC. Hon. Nancy Pelosi, Minority Leader, House of Representatives, Washington, DC. Dear Speaker Ryan and Leader Pelosi: Paralyzed Veterans of America (PVA) urges rejection of the latest version of the American Health Care Act (AHCA). PVA is the nation's only Congressionally- chartered veterans' service organization solely dedicated to representing veterans with spinal cord injury and/or disease. Consequently, we are very concerned about the conflicting information circulating about this legislation and the adverse impact it could have on our members and millions of other people with disabilities. As we understand it, the AHCA cuts $880 billion out of the Medicaid program in order to finance tax cuts that will explode the deficit and largely assist upper income individuals, corporations, and providers. The Medicaid changes are particularly devastating to people with disabilities. Under the cap and cut proposal, the federal government would no longer share in the costs of providing health care services and community services beyond the capped amount. This would eliminate the enhanced federal match for the Community First Choice Option under Medicaid that provides attendant care services in the community. Thanks to this program, many poor veterans with serious non-service- connected disabilities have been able to move from nursing homes into their communities. The AHCA also weakens Medicaid by ending the Medicaid expansion earlier and offering Medicaid block grants to states. Data from the Robert Wood Johnson Foundation shows expansion has helped thousands of veterans and their caregivers. For veterans and PVA members in particular, the AHCA continues several problematic policies of the ACA as well as troubling new provisions that could affect the ability of many veterans and their family members to afford health insurance in the private market. The underlying AHCA bill: Continues to exclude CHAMPVA beneficiaries--dependents of the most catastrophically disabled veterans--from the dependents' coverage policy up to age 26. Fails to remove the prohibition on enrollment into the VA health care system for Priority Group 8 veterans, thus denying these veterans access to the principal health care system for veterans. Denies access to tax credits making health insurance affordable to anyone eligible for a host of other federal health programs, including those ``eligible'' for coverage under Title 38 health care programs. This would prevent many veterans who may be ``eligible for'' but not enrolled in the VA health care system from accessing these tax credits intended to help people buy insurance. Not only do the changes made to the original version of the AHCA continue its failure to protect veterans and people with disabilities, they make these circumstances worse. The latest changes would allow states to seek waivers that would allow insurers to charge higher premiums to people with pre- existing conditions, including people with disabilities. The new amendments also would allow states to seek waivers from the ACA's requirement that certain essential health benefits must be provided, including crucial services for people with disabilities such as prescription drugs, rehabilitative and habilitative services and devices, preventative and wellness services and chronic disease management. The combination of these changes would make it nearly impossible for people with pre-existing conditions to find affordable plans that cover basic health care services. Throughout these past few months, the American people have been calling for a bipartisan effort to improve the nation's health care system. Congress should heed these voices, stop its pursuit of the flawed American Health Care Act and work together through regular order to strengthen all Americans' access to affordable, high quality health care. Sincerely, Carl Blake, Associate Executive Director.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the March of Dimes opposed to this bill. [From the march of dimes] Under AHCA, Over 6 Million Women of Childbearing Age Will Lose Health Coverage Dear Representative: Prior to 2010, low-income adult women could generally only obtain Medicaid coverage after they were pregnant. By the time they enrolled in this coverage, many of the best opportunities for guaranteeing a healthy pregnancy and healthy baby had already been missed. Today, states that have expanded Medicaid can extend Medicaid coverage to low-income women of childbearing age, giving them the chance to get healthy before they get pregnant. The March of Dimes estimates that approximately 6.5 million low income women of childbearing age are currently covered under Medicaid expansion, giving them access to treatment for tobacco use, obesity, substance abuse, and other conditions that can have a major impact on future pregnancies. Between 2012 and 2015, the rate of uninsurance among women of childbearing age dropped by 40%, with much of that decline attributable to Medicaid expansion. The American Health Care Act (AHCA) would do away with these advances by rolling back Medicaid expansion. Its fundamental restructuring of the traditional Medicaid program would also likely lead to significant coverage losses or restriction of services to beneficiaries, including pregnant women. These changes do a serious disservice to low-income women and families by denying them access to the care they need to lead healthy lives and, ultimately, have healthy pregnancies and give birth to healthy infants. The MacArthur amendment and other proposed changes to the AHCA do not address these issues. Women, infants, families, and communities will bear the longterm cost if health care for women of childbearing age and pregnant women is shortchanged and more babies are born sick as a result. The March of Dimes urges all Representatives to oppose the American Health Care Act. Sincerely, Stacey D. Stewart, President.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from AFSCME in strong opposition to this bill.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the National Farmers Union in strong opposition to this bill. National Farmers Union, May 3, 2017. Dear Member of Congress: I write on behalf of nearly 200,000 members of the National Farmers Union (NFU) who are engaged in all forms of farming and ranching. NFU has already spoken in opposition of the American Health Care Act (AHCA) because of the estimated 24 million Americans who would lose coverage as a result. The most recent amendment to the AHCA only moves further away from NFU's member-driven policy of affirming ``the right of all Americans to have access to affordable, quality health care.'' Farming is a dangerous occupation, ranking 6th in occupational fatality rates. The injury rate for agricultural workers is also 40% higher than the rate of all workers. Finally, the average age of farmers in the United States is over 58 years. U.S. health care policy must take into account the unique needs of the men and women who provide food and fiber for our country and much of the world. Our current health care system is not without its problems, but progress has been made since the passage of the Affordable Care Act (ACA). The current structure of tax credits and premium subsidies help farmers maintain consistent coverage, especially during downturns in the farm economy. The expansion of Medicaid has proven beneficial to rural communities, where the rate of enrollment is higher than in urban America. The Health Insurance Marketplace, while certainly in need of stabilizing measures, makes coverage more accessible for many farm families. The correlation between a strong Medicaid program and the success of rural hospitals has become evident during the influx of rural hospital closures over the last six years. Seventy-eight rural hospitals have closed since 2010 with over 80% of those located in states that opted out of the Medicaid expansion. With another 673 hospitals at risk of closure, the AHCA's proposed Medicaid cap could have devastating consequences for rural communities. In 2012, 75 percent of farms sold less than $50,000 in agricultural products and 57% had sales less than $10,000. Young farm families that don't receive additional income or health benefits from off-farm jobs would find it extremely difficult to purchase health insurance. The proposed legislation would also hurt older farmers. Easing restrictions on what insurance companies can charge older customers will leave older farmers facing increased premiums of thousands of dollars, despite the larger subsidies some would receive. The modified AHCA bill also has a significant negative impact on those with pre-existing conditions. It's estimated that 40 percent of 50- to 64-year-olds would be denied coverage in the individual market without the Affordable Care Act's protections for those with preexisting conditions. The waiver option would mean that a large number of farmers in many states would be forced into high-risk pools. This legislation is woefully short in funding for those high-risk pools, leaving individuals with preexisting conditions to contend with increased premiums, higher deductibles and longer waiting periods for coverage. Affordable access to quality health coverage is a high priority for all Americans. As you consider how to best improve our health care system, we ask that you give serious consideration to the needs of farmers and ranchers. While there is certainly room for improvement in current policy, the American Health Care Act will only hurt family farmers and rural communities across the country. NFU requests that you oppose the proposed legislation. We appreciate your efforts to provide all Americans with high-quality comprehensive health insurance. Thank you for your consideration. Sincerely, Roger Johnson, President.

Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the distinguished gentleman from Massachusetts (Mr. Neal), the distinguished ranking member of the Committee on Ways and Means.

Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from New York (Mr. Crowley), the chairman of the Democratic Caucus.