PROVIDING FOR CONSIDERATION OF H.R. 2192, PUBLIC HEALTH SERVICE ACT AMENDMENT, AND PROVIDING FOR FURTHER CONSIDERATION OF H.R. 1628, AMERICAN HEALTH CARE ACT OF 2017
(House of Representatives - May 04, 2017)

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[Pages H4114-H4138]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




  PROVIDING FOR CONSIDERATION OF H.R. 2192, PUBLIC HEALTH SERVICE ACT 
   AMENDMENT, AND PROVIDING FOR FURTHER CONSIDERATION OF H.R. 1628, 
                    AMERICAN HEALTH CARE ACT OF 2017

  Mr. COLLINS of Georgia. Mr. Speaker, by direction of the Committee on 
Rules, I call up House Resolution 308 and ask for its immediate 
consideration.
  The Clerk read the resolution, as follows:

                              H. Res. 308

       Resolved, That upon adoption of this resolution it shall be 
     in order to consider in the House the bill (H.R. 2192) to 
     amend the Public Health Service Act to eliminate the non-
     application of certain State waiver provisions to Members of 
     Congress and congressional staff. All points of order against 
     consideration of the bill are waived. The bill

[[Page H4115]]

     shall be considered as read. All points of order against 
     provisions in the bill are waived. The previous question 
     shall be considered as ordered on the bill and on any 
     amendment thereto to final passage without intervening motion 
     except: (1) one hour of debate equally divided and controlled 
     by the chair and ranking minority member of the Committee on 
     Energy and Commerce; and (2) one motion to recommit.
       Sec. 2.  During further consideration of the bill (H.R. 
     1628) to provide for reconciliation pursuant to title II of 
     the concurrent resolution on the budget for fiscal year 2017, 
     as amended, pursuant to House Resolution 228, the further 
     amendments printed in the report of the Committee on Rules 
     accompanying this resolution shall be considered as adopted.

  The SPEAKER pro tempore (Mr. Poe of Texas). The gentleman from 
Georgia is recognized for 1 hour.
  Mr. COLLINS of Georgia. Mr. Speaker, for the purpose of debate only, 
I yield the customary 30 minutes to the gentleman from Massachusetts 
(Mr. McGovern), pending which I yield myself such time as I may 
consume. During consideration of this resolution, all time yielded is 
for the purpose of debate only.


                             General Leave 

  Mr. COLLINS of Georgia. Mr. Speaker, I ask unanimous consent that all 
Members have 5 legislative days to revise and extend their remarks and 
include extraneous materials on House Resolution 308, currently under 
consideration.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Georgia?
  There was no objection.
  Mr. COLLINS of Georgia. Mr. Speaker, I am pleased today to bring 
forward this rule on behalf of the Rules Committee.
  Over the past few weeks, the Rules Committee has had the opportunity 
to hear from numerous stakeholders, from the chairs and ranking members 
of committees of jurisdiction to the Members who have offered 
amendments.
  Most recently, last night we heard testimony from Mr. MacArthur and 
Mr. Upton to explain their amendments and address any questions from 
the committee members, and from Ms. McSally to explain her legislation.

                              {time}  0915

  This rule provides for further consideration of H.R. 1628, the 
American Health Care Act, and incorporates three amendments--the 
Palmer-Schweikert amendment, the MacArthur amendment, and the Upton 
amendment--that strengthen the underlying bill.
  It also provides for consideration of H.R. 2192, legislation authored 
by Representative McSally, with 1 hour of debate equally divided and 
controlled by the chair and ranking member of the Committee on Energy 
and Commerce.
  Mr. Speaker, all across our country, the Affordable Care Act 
continues to strip hardworking Americans and families of access to 
affordable, quality medical care and offer them skyrocketing premiums 
and anemic provider networks in return.
  Democrats smuggled ObamaCare through with little regard for the 
procedure, left lofty and empty promises that benefit simply a 
bureaucratic machine. Seven years later, we have seen these promises 
evaporate as ObamaCare patients lose access to their doctors and lose 
the very insurance plans they were promised would remain intact.
  Our friends across the aisle claim that coverage has been expanded 
and individuals who never had quality health care before now have 
access. Mr. Speaker, I wish that were true, but it is not. I wish my 
colleagues and I didn't hear from neighbor after neighbor who can't 
find a doctor to accept ACA insurance or who avoids medical care 
altogether because their deductibles reach higher than the clouds. But 
we do hear from them because Americans are suffering as insurance 
providers flee from the not-so-free market.
  You see, coverage doesn't mean access to care. Unfortunately, we have 
heard all too often that individuals may have health coverage, but they 
can't use it because their premiums and deductibles are too high for 
them to actually afford the care.
  What good does the coverage do a woman who earns $22,000 a year and 
has a $5,000 deductible?
  What good does it do a young family to have insurance that no 
provider in their community accepts?
  What good does it do to say we want to grow the economy and create 
jobs when American businesses are struggling to keep their doors open 
due to the ObamaCare mandate?
  We have witnessed insurers dropping out of the exchanges and seen 
premiums climbing while consumers are left with less and less choice. 
Five States have one option and no choice for health insurance, and 
nothing guarantees that their residents will keep that much.
  ObamaCare has hijacked the free market, and it has taken some 
Americans' liberties with it. We must remember that exchanging freedom, 
choice, self-determination for securities at the hands of Big Brother 
too often leaves us with neither liberty nor security.
  We know that ObamaCare was designed to make a single-payer system 
inevitable. And to the extent that a single-payer system means a zero-
choice system, the prophecy has already come true.
  Families can no longer choose to save for retirement or pay their 
mortgages because premiums suck up all the oxygen in their budget. 
Individuals who want to purchase a PPO cannot because their county only 
offers HMO plans. Disabled Americans who depend on Medicare find that 
ObamaCare has given more Federal funding to able-bodied Americans than 
our more vulnerable neighbors.
  In my district, a young mother who wants to take her young son to the 
family doctor post-ObamaCare can't because she can't find a physician 
who accepts her new insurance.
  Brittany Ivey and her husband have struggled under the consequences 
of the Affordable Care Act. Mrs. Ivey was working part-time at a small 
business that provided her family with health insurance until the 
effects of ObamaCare on the insurance market raised her premiums 
sharply. This drove the Ivey family into the individual market, where a 
midlevel plan took 65 percent of her monthly gross income, even after a 
small Federal subsidy. Unable to afford insurance through her employer, 
Mrs. Ivey turned to the Federal exchange, where she obtained a plan 
that neither she nor her children's doctor would accept.
  The Affordable Care Act robbed Americans of the ability to choose 
health care that worked for them, and the Affordable Care Act destroyed 
the insurance market along with the benefits that competition and 
innovation offer all of us. The American people deserve better. 
ObamaCare replaced our doctors with bureaucrats because that is what 
socialized medicine does.
  The American Health Care Act is our last chance to get off the 
Federal ferris wheel before we are locked into a healthcare system that 
takes us nowhere and offers neighbors nothing but heartburn.
  The American Health Care Act guts the most egregious provisions of 
ObamaCare, rolls back the law's taxes, restores flexibility to the 
States, and helps to make quality care more accessible and affordable.
  Mr. Speaker, one of the reasons I came to Congress is to repeal and 
replace ObamaCare and rein in our Nation's bloated, ballooning 
entitlement system. The American Health Care Act does that by, for the 
first time, making major reforms to an entitlement program--Medicaid. 
It rolls back the Medicaid expansion under ObamaCare, one of the 
fundamental pillars, and it makes structural changes to the program to 
ensure it only goes to the individuals it was intended to help.
  The American Health Care Act allows States to establish work 
requirements for able-bodied adult Medicaid enrollees. It lets States 
choose between the per capita cap and a flexible Medicare block grant, 
and it increases the growth rate to cover disabled and elderly Medicaid 
populations.
  The bill enacts patient-centered reforms, increases access to 
healthcare savings accounts, and creates a Patient and State Stability 
Fund to help stabilize insurance markets that have contracted during 
ObamaCare.
  Over the course of the last several weeks, we have worked in this 
House to strengthen the bill. We have listened to feedback from 
constituents, neighbors, stakeholders, and each other.

  Importantly, coverage for individuals with preexisting conditions is 
maintained as a baseline within the bill. An

[[Page H4116]]

amendment from Mr. MacArthur further protects individuals' preexisting 
conditions from being denied coverage.
  While the amendment provides States with additional flexibility by 
allowing them to seek a waiver, individuals with preexisting conditions 
will not be left out to dry. In fact, there are conditions attached to 
the waiver that ensure States use funds provided by the bill, should 
they receive a waiver, to set up high-risk pools for those very 
individuals. With the addition of the Upton amendment, the bill 
provides $108 billion to help States fund programs such as high-risk 
pools.
  Mr. Speaker, my home State of Georgia has very different needs than 
California. That is why I think it makes sense to give States more say 
in what works for their populations. Our plan does this, but it does so 
in a way that ensures protections exist for vulnerable populations like 
the elderly, disabled, and children.
  The rule also provides for Representative McSally's legislation to 
ensure that Members of Congress are treated the same as all Americans. 
I fully support this bill and firmly believe elected officials should 
be required to live under the same laws as those they were elected to 
represent.
  President Trump has made his support of the American Health Care Act 
and its strengthening amendments clear, and I stand with him in 
supporting this legislation to gut ObamaCare and rescue the American 
people.
  Mr. Speaker, average premiums rose by 40 percent or more in 11 States 
just this year. The statistics and the stories speak for themselves. We 
must act to dismantle ObamaCare, and the Affordable Care Act does that.
  I support the rule before us today to provide for further 
improvements to the bill and look forward to supporting both the rule 
and the underlying bill.
  I reserve the balance of my time.
  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. I thank the gentleman from Georgia (Mr. Collins) for 
the customary 30 minutes.
  Mr. Speaker, pathetic, that is the word to describe this process and 
this bill. If the American people could sue Congress for malpractice, 
my Republican friends would be in deep trouble.
  How could you do this? How could you do this to the American people? 
How can you do this to the people you represent?
  You are taking away essential healthcare protections. You are 
allowing insurance companies to discriminate against people with 
preexisting conditions. You are supporting a bill that will throw 24 
million people off of their health care and cut Medicaid by $880 
billion to give a $1 trillion tax break to the wealthiest people in 
this country.
  What is wrong with you guys?
  Today's rule self-executes three of the newest Republican amendments 
to the Republican health plan. This means, without any sort of debate 
or discussion whatsoever, the Palmer, MacArthur, and Upton amendments 
will magically pass the House.
  What I find so hard to believe about this latest backroom deal is 
that they actually make this bill worse. I didn't think that was 
possible, Mr. Speaker.
  To shore up support amongst this Chamber's most conservative faction, 
Representative MacArthur and others made a deal with President Trump to 
gut protections for individuals with preexisting conditions and to 
eliminate essential health benefits like maternity care, mental health 
treatment, and prescription drug coverage, just to name a few. These 
are among the most popular provisions of the Affordable Care Act.
  The American people were justifiably outraged, and they showed up by 
the thousands to townhalls to express their anger. And there were some 
on the Republican side who actually got it. They listened to their 
constituents and they had the courage to stand up and say no.
  But when Republican leaders came up short in their whip count, 
Representative Upton ran to the White House and concocted a deal with 
President Trump to try to win back votes. His amendment adds a measly 
$8 billion spread out over 5 years in a futile attempt to soften the 
devastating effect that this bill will have on millions and millions of 
Americans with preexisting conditions.
  Now, $8 billion over 5 years sounds like a lot, but when we are 
talking about an entire country, it really isn't. Don't take it from 
me. Robert Graboyes from the conservative Mercatus Center said:
  ``The $8 billion amount is a pittance. Spread over 5 years, it's a 
fifth of a pittance.''
  This is not a leftwing organization. This is an organization funded 
by Koch Industries, the Koch brothers. My friends love the Koch 
brothers.
  What's more, some analysts have already estimated that an additional 
$200 billion will be needed over a decade to adequately fund high-risk 
pools. So this amendment is billions upon billions upon billions of 
dollars short. And as the Center for American Progress points out, the 
Upton amendment ``will have almost no effect.''
  Now, my colleagues who have been won over by this should be ashamed 
of themselves. We are supposed to fix problems and help people, not 
merely settle for political cover that can be used in a press release. 
$8 billion to cover a $200 billion shortfall? Back where I come from, 
we call that being a cheap date. I guarantee you, your constituents are 
going to figure this out, and they will not be happy.
  So to so-called moderate Republicans who have contorted themselves 
this week to try to find a fix to the damage being done to the people 
with preexisting conditions, I have breaking news: I have a magic 
bullet fix if Republicans really want to protect people with 
preexisting conditions. Are you ready? Brace yourselves. Don't change 
the law. Everyone is already protected by the Affordable Care Act, 
including people with preexisting conditions and those who struggle to 
find affordable care. Let me say to my colleagues that to claim or 
imply that this Republican plan covers preexisting conditions is a lie, 
plain and simple.

  Now, let me say a few words about the process that has been used to 
bring this bill to the floor. It has been a disaster from start to 
finish, with secret negotiations, backroom deals, and bribes to buy off 
factions within the Republican Conference. There have been no hearings 
on this bill whatsoever. And the Republican leadership couldn't even 
slow down long enough to receive a score from the CBO.
  I have one simple question: What is the rush? Wait a week and get a 
CBO score. Why is that such a radical idea?
  Mr. Speaker, are Republican leaders jamming this bill through to 
appease Donald Trump?
  Are they concerned that a new CBO score will confirm what we already 
know is true, that this bill will be devastating to the people of this 
country, force even more people to lose their health care, especially 
to older, sick, and low-income Americans.
  Or maybe, Mr. Speaker, Republican leaders are worried that their 
colleagues will go home over this weeklong break and actually hear from 
their constituents who overwhelmingly oppose this effort to repeal the 
Affordable Care Act.
  Honestly, I don't know how my Republicans friends can defend this 
terrible, closed, authoritarian process. It is an absolute disgrace.
  I urge my colleagues to vote ``no'' on this bill, or, better yet, I 
urge my Republicans colleagues to do what they did a couple of weeks 
ago and pull this disastrous bill.
  I reserve the balance of my time.
  Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my 
time.
  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from 
Kentucky (Mr. Yarmuth), the distinguished ranking member of the 
Committee on the Budget.
  Mr. YARMUTH. Mr. Speaker, the question every Member of Congress 
should be asking themselves today is: Who in the world is better off 
because of today's bill?
  It is not the 24 million people the CBO says will lose their health 
coverage if this bill becomes law.
  It is not the seniors who will be priced out of the market by an age 
tax or the millions of families who will see their health care gutted 
by the more than $800 billion in cuts to Medicaid.
  It is not the 881,000 non-elderly adults in Kentucky with preexisting 
conditions who would, once again, face

[[Page H4117]]

staggering health costs with reduced care.
  So who is better off? Well, certainly corporations and millionaires 
who will see nearly $1 trillion in tax cuts from this bill.
  And at least, in their minds, a few Republican Members are so 
desperate for some type of political victory they are willing to risk 
the health and well-being of their constituents to ram through a bill 
without hearings, analysis, or, most alarmingly, any sense of morality. 
That is the cruel tradeoff my Republican colleagues have decided to 
make.
  Our families deserve far better. I urge my colleagues to exercise 
better judgment and vote ``no'' on this bill.
  Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my 
time.

                              {time}  0930

  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).
  Ms. DelBENE. Mr. Speaker, this destructive legislation hurts middle 
class families and threatens massive disruption to our healthcare 
system. And it has only gone from bad to worse.
  Stripping protections from 133 million Americans with preexisting 
conditions isn't just wrong, it is inhumane. Nobody in this country 
should go bankrupt trying to afford the medical care they need to stay 
alive.
  This isn't about politics; it is about human decency and who we are 
as Americans. It is about people like Jackie, a cancer survivor from 
Snohomish who says the Affordable Care Act saved her life.
  She wrote to me saying: ``My cancer recurred, but I was covered. I 
was able to complete my treatments without having to worry about how to 
put food on the table. Or being left to die. Because of the ACA, I 
survived.''
  We all have stories like this in our districts, but some of my 
colleagues aren't listening. I hope they find the courage and the 
wisdom to vote ``no'' on this dangerous legislation.
  Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my 
time.
  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from 
Texas (Mr. Castro).
  Mr. CASTRO of Texas. Mr. Speaker, Republicans, over the last few 
months, have said that they would fundamentally change health care in 
the United States, and it is clear today that they have. They have made 
it much worse.
  I want to highlight one provision that allows for States to permit 
insurers to get rid of essential healthcare benefits and charge people 
more who have preexisting conditions. Think about that for a second.
  In my home State of Texas, the Governor and other State leaders have 
already turned their back on so many people, allowing foster care 
children to sleep in State offices, allowing sex trafficking and human 
trafficking victims to go to jail because there is nowhere else to put 
them.
  You should ask yourselves: What will your leaders do? Will they allow 
insurers to charge you more for preexisting conditions like diabetes 
and hypertension and cancer and asthma?
  Do you think, and do you trust, that they are going to do the right 
thing by you? Because today, this plan allows them to abandon you.
  Mr. COLLINS of Georgia. Mr. Speaker, I yield myself such time as I 
may consume.
  At this time, I think one of the interesting things is, as discussed, 
the criticism of this. I think it was just a reminder, Mr. Speaker, of 
what happened 7 years ago when our healthcare market, which could have 
been helped by many good ideas, was decided to be taken on a very 
unhealthy bent. We are now paying the price for that. We are going to 
continue to see that unless we change it. We are changing that for the 
better.
  One of the strongest voices that we have had in this body is someone 
who has actually taken it as his living to take care of people. Dr. 
Burgess not only came to this Congress with a strong voice of not only 
what doctors and the medical profession have, but I think it gives us 
an insight into what patients need as well. He has been a clarion voice 
through this whole process, before ObamaCare, during the disaster of 
ObamaCare, and now as we look to fix the problems that have existed.
  I yield as much time as he may consume to the gentleman from Texas 
(Mr. Burgess).
  Mr. BURGESS. Mr. Speaker, how did we get to this point?

[[Page H4118]]

  The Affordable Care Act is simply not working for the American 
people. It is limiting choices. It is raising costs. It is leaving 
millions without access to care. And unfortunately, these are not just 
talking points but very real issues affecting very real Americans.
  The Affordable Care Act has left the individual market in shambles 
and has driven insurers away from offering coverage. Now, we are seeing 
one-third of all counties in the United States of America with only a 
single insurer. And among the plans that have chosen to remain in these 
markets, there have been widespread, double-digit premium increases. In 
Texas, premiums have jumped 29 percent a year, on average, from 2014 to 
2017.
  The markets are in difficulty. They are failing to live up to the 
promise made 7 years ago, that Americans would be able to receive 
``affordable care.''
  As we knew then, and we still know now, this was an empty promise and 
has priced over 19 million Americans out of the market. What is worse, 
these individuals are forced to pay the individual mandate penalty or 
seek a hardship exemption because of the cost to purchase and use their 
health insurance.
  Mr. Speaker, 11 months ago, Speaker Ryan released the Better Way plan 
to save the Nation's healthcare system and to bring relief to the 
American people. This plan, which served as the blueprint for the 
American Health Care Act, laid out policies to stabilize the markets 
damaged by the Affordable Care Act, repeal the burdensome Affordable 
Care Act taxes and mandates that have hindered innovation and limited 
access to care. So let's take a look at what the American Health Care 
Act does.
  First and foremost, the American Health Care Act provides immediate 
relief to the State insurance markets. As Republicans, we know that 
one-size-fits-all works for no one, and certainly did not work for the 
individual markets. The States should have the flexibility to support 
their insurance markets and ensure that plans can continue to provide 
options for coverage.
  To do this, we relax two of the more egregious market regulations 
that were imposed under the Affordable Care Act: the mandate that 
premiums cannot vary for younger and older Americans by more than a 3-
to-1 ratio and the mandate creating fixed actuarial values for plans.
  The mandate limiting a plan's ability to set premiums by age has 
driven up the cost of coverage for younger and healthier Americans and, 
subsequently, pushed them away from seeking coverage by the millions. 
Of the over 19 million Americans who have sidestepped the individual 
market, it is estimated that as many as 45 percent of these individuals 
are under the age of 35. Without these younger Americans seeking 
coverage, the markets have plunged, as insurers have hiked up premiums 
year after year to compensate for unhealthy risk pools.

  To change this, there is relaxation of the 5-to-1 ratio. It will 
lower premium costs and provide necessary opportunities to stabilize 
markets. We also give States the option, the choice to go higher or go 
lower, which honors the spirit of federalism.
  Additionally, we are repealing the actuarial values mandate to 
provide insurers with additional flexibility to offer more coverage 
options. The requirement for insurers to offer specified Bronze, 
Silver, and Gold level tiers has limited consumer choice, driving even 
more individuals away from seeking coverage and further contributing to 
the collapse of the healthcare markets.
  To further supplement these efforts, we are establishing the Patient 
and State Stability Fund. This fund provides States access to a total 
of over $140 billion over 10 years to promote innovative solutions to 
lower costs and increase access to health care for their unique patient 
populations.
  Mr. Speaker, the goal is simple, to provide States with maximum 
flexibility in how they address the cost of care for their citizens. 
The American Health Care Act provides States with options for how to 
use funds, including providing financial assistance for high-cost 
individuals, incentivizing insurer participation in those markets, 
reducing the cost of insurance, promoting access to preventive 
services, and reducing out-of-pocket costs for patients.
  The Congressional Budget Office estimated that a combination of the 
Stability Fund and other proconsumer changes would reduce premiums by 
10 percent below current projections of 2026.
  We want patients to have access to high-quality, affordably priced 
health coverage. The Patient and State Stability Fund can help States 
lower costs and can increase access to high quality health care for 
their citizens.
  In addition to supporting the insurance markets, the American Health 
Care Act creates needed reforms to the Medicaid program itself. Without 
any changes, the current Medicaid expansion is expected to cost $1 
trillion in 10 years' time--$1 trillion a year in 10 years' time. 
Medicaid needs reform so that States can continue to provide coverage 
to children, people with disabilities, and other vulnerable groups, the 
very populations that this safety net program was created to serve.
  To address these concerns, the American Health Care Act first phases 
out the Medicaid expansion, not traditional Medicaid but Medicaid 
expansion. The expansion has hurt State budgets and limited States' 
abilities to ensure that resources will continue to be available for 
the vulnerable populations for which Medicaid was designed. By phasing 
out expansion, we are providing States with greater budget autonomy.
  Additionally, our bill helps further bend the Medicaid cost curve by 
shifting the program toward a per beneficiary allotment. Per 
beneficiary allotments set limits on the annual growth for per capita 
expenditures for which the States will receive matching funds from the 
Federal Government. Per beneficiary allotments create greater fiscal 
accountability and ensure that the program can continue to exist for 
years to come.
  This is not a new idea. This was an idea put forward by President 
Bill Clinton and, at one time, supported by every Democratic Member of 
the Senate in 1995.
  Second, the American Health Care Act increases the amount of 
flexibility that States have in managing their Medicaid program. The 
bill scales back the Affordable Care Act mandates that have limited a 
State's ability to tailor plans toward the needs of beneficiaries. 
States can and States should be trusted to effectively manage the needs 
of their Medicaid beneficiaries. The American Health Care Act will 
allow them to do so.
  Additionally, the American Health Care Act furthers the goal of 
providing the States with greater flexibility in managing their 
Medicaid programs by providing States with the option to implement two 
additional opportunities: work requirements and block grants for 
Medicaid.
  When the Affordable Care Act was being debated, some of the most 
consistent complaints that we heard throughout the discussion came from 
Governors and State representatives expressing concerns about the 
negative consequences that they saw on the horizon.
  This time around, we chose to engage our State counterparts in the 
discussion and listen to their input as we designed the bill; and at 
the top of their list was a desire to see the work requirements built 
into the Medicaid and the expansion populations, and the opportunity to 
work with Medicaid as a block grant.

  Republicans trust that States know what works for their respective 
populations, and we are not going to stand in the way of States seeking 
to design Medicaid programs that work for them.
  Finally, the American Health Care Act provides additional resources 
to bolster State safety net providers. The bill provides increases to 
the Community Health Center Fund, offers enhanced funding to support 
the safety net providers in States that did not expand Medicaid, and 
ends the cuts to Disproportionate Share Hospital payments, cuts that 
are going to occur under current law on October 1 of this year.
  We are committed to ensuring that our local providers can continue to 
deliver lifesaving care and that the American Health Care Act turns 
this commitment into action. For the millions of Americans in rural and 
medically underserved areas, these actions

[[Page H4119]]

will provide needed relief that was undercut by the Affordable Care Act 
and will allow these Americans to continue to have access to care.
  Moving forward, together, these efforts will provide meaningful 
reform and relief for the States and for the individuals seeking health 
care. We are stabilizing the markets, reforming Medicaid in the most 
substantive and consequential way in its 52-year history, and ensuring 
that all Americans can maintain access to care through local safety net 
providers.
  We do recognize there is still more work to be done in health care, 
and that is why we only consider the American Health Care Act to be the 
beginning. It is the key that gets us through the door into additional 
health reform. From here, we will work with Secretary Price at the 
Department of Health and Human Services to further deregulate the 
marketplace and increase consumer choice in the healthcare markets, and 
we will enhance the American Health Care Act with additional 
legislative efforts to further the goal of lowering healthcare costs.
  Mr. Speaker, this should be a very exciting time in health care. With 
all of the knowledge that has been gained over the years in the 
practice of medicine, I am humbled to be here today speaking in support 
of this legislation.
  It will begin the much-awaited process of unwinding the Affordable 
Care Act and will finally return patients to the center of health care.

                              {time}  0945

  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

[[Page H4120]]

     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.

                                                         AARP,

                                                      May 3, 2017.
       Dear Representative: Older Americans care deeply about 
     access to and affordability of health care. With the addition 
     of the Upton Amendment, as reported, we once again write to 
     share our opposition to the American Health Care Act (AHCA) 
     and urge you to vote NO. Changes under consideration that 
     would allow states to waive important consumer protections--
     allowing insurance companies to once again charge Americans 
     with pre-existing conditions more because they've had cancer, 
     diabetes or heart disease--would make a bad bill even worse. 
     This would be devastating for the 25 million Americans 50-64 
     who have a deniable pre-existing condition. The Upton 
     amendment would do little to reduce the massive premium 
     increases for those with pre-existing conditions.
       Throughout consideration of the AHCA, we have been 
     expressing serious concerns about the impact that this 
     legislation will have on older Americans. The Congressional 
     Budget Office (CBO)'s last estimate further demonstrates the 
     harmful impact of this bill on older Americans and some of 
     our most vulnerable. Specifically, the American Health Care 
     Act will weaken the fiscal sustainability of Medicare; 
     dramatically increase premium and out-of-pocket costs for 50-
     64 year olds purchasing coverage on the individual insurance 
     market; allow insurance companies to once again discriminate 
     against those with pre-existing conditions; substantially 
     increase the number of Americans without insurance; and put 
     at risk millions of children and adults with disabilities and 
     poor seniors who depend on the Medicaid program to access 
     long-term services and supports and other benefits.
       Our members and others 50 years of age and older care 
     deeply about health care and want to know where their elected 
     leaders stand. Recognizing the importance of the upcoming 
     vote on the American Health Care Act, AARP intends to inform 
     our members, and others over age 50, how their elected 
     officials voted. We'll communicate the results of the vote in 
     our widely-circulated publications, in e-mail alerts, in our 
     online channels, and through the media. Again, we urge all 
     Representatives to vote NO on the American Health Care Act in 
     its current form.


                                Medicare

       The American Health Care Act repeals provisions in current 
     law that have strengthened Medicare's fiscal outlook, 
     specifically, the repeal of the additional 0.9 percent 
     payroll tax on higher-income workers. Repealing this 
     provision would remove billions from the Hospital Insurance 
     trust fund, hasten the insolvency of Medicare, and diminish 
     Medicare's ability to pay for services in the future.


                  Individual Private Insurance Market

       Currently, about 25 million Americans age 50-64 have a pre-
     existing condition, about 6.1 million purchase insurance in 
     the non-group market, and nearly 3.2 million are currently 
     eligible to receive subsidies for health insurance coverage 
     through either the federal health benefits exchange or a 
     state-based exchange (exchange). Since passage of the ACA, 
     the number of 50-64 year old Americans who are uninsured has 
     dropped by half. We are deeply concerned that the AHCA would 
     be a significant step backwards and result in millions of 
     older Americans who cannot afford their health care, 
     including many simply losing their health care. Based on CBO 
     estimates, approximately 14 million Americans will lose 
     coverage next year, while a total of 24 million Americans 
     would lose coverage over the next 10 years.
       Affordability of both premiums and cost-sharing is critical 
     to older Americans and their ability to obtain and access 
     health care. A typical 50-64 year old seeking coverage 
     through an exchange has a median annual income of under 
     $25,000 and already pays significant out-of-pocket costs for 
     health care. We have serious concerns--reinforced by the CBO 
     estimate--that the bill under consideration will dramatically 
     increase health care costs for 50-64 year olds who purchase 
     health care through an exchange due both to the changes in 
     age rating from 3:1 (already a compromise that requires 
     uninsured older Americans to pay three times more than 
     younger individuals) to 5:1 (or more) and reductions in 
     current tax credits for older Americans. CBO concluded that 
     the bill will substantially raise premiums for older people 
     and force many into lower quality plans.
       Age rating plus reduced tax credits equal an unaffordable 
     age tax. Our previous estimates on the age-rating change 
     showed that premiums for current coverage could increase by 
     up to $3,200 for a 64 year old. In addition, the bill reduced 
     the tax credits available for older Americans to help 
     purchase insurance. We estimate that the bill's changes to 
     current law's tax credits alone could increase premium costs 
     by more than $5,800 for a 64-year old earning $15,000. 
     Overall, both the bill's tax credit changes and 5:1 age 
     rating would result in skyrocketing cost increases for older 
     Americans. In their analysis, CBO found that a 64 year old 
     earning $26,500 a year would see their premiums increase by 
     $12,900--758 percent--from $1,700 to $14,600 a year.
       Current law prohibits insurance companies from 
     discriminating against individuals due to a pre-existing 
     condition. The bill would repeal pre-existing condition 
     protections and would once again allow insurance companies to 
     charge Americans more--we estimate up to $25,000 more--due to 
     a pre-existing condition. As a result, the 40 percent of 50- 
     to 64-year-olds (about 25 million people) who have a deniable 
     pre-existing condition risk losing access to affordable 
     coverage. The Upton Amendment, which would add funds to 
     address the impact of premium increases for those with 
     pre-existing conditions, would do little to mitigate the 
     massive premium increase for some of the most vulnerable 
     Americans. AARP strongly opposes any weakening of the 
     law's pre-existing condition protections which benefit 
     millions of Americans.


              Medicaid and Long-Term Services and Supports

       AARP opposes the provisions of the American Health Care Act 
     that create a per capita cap financing structure in the 
     Medicaid program. We are concerned that these provisions 
     could endanger the health, safety, and care of millions of 
     individuals who depend on the essential services provided 
     through Medicaid. CBO found that the bill would cut Medicaid 
     funding by $880 billion over 2017-2026, about 25 percent less 
     than what it projects under current law. Medicaid is a vital 
     safety net and intergenerational lifeline for millions of 
     individuals, including over 17.4 million low-income seniors 
     and children and adults with disabilities who rely on the 
     program for critical health care and long-term services and 
     supports (LTSS, i.e., assistance with daily activities such 
     as eating, bathing, dressing, managing medications, and 
     transportation). Older adults and people with disabilities 
     now account for over sixty percent of Medicaid spending, and 
     cuts of this magnitude will result in loss of benefits and 
     services for this vulnerable population.
       Of these 17.4 million individuals: 6.9 million are ages 65 
     and older (which equals more than 1 in every 7 elderly 
     Medicare beneficiaries); 10.5 million are children and adults 
     living with disabilities; and about 10.8 million are so poor 
     or have a disability that they qualify for both Medicare and 
     Medicaid (dual eligibles). Dual eligibles account for almost 
     33 percent of Medicaid spending. While they comprise a 
     relatively small percentage of enrollees, they account for a 
     disproportionate share of total Medicare and Medicaid 
     spending.
       Individuals with disabilities of all ages and older adults 
     rely on critical Medicaid services, including home and 
     community-based services (HCBS) for assistance with daily 
     activities such as eating, bathing, dressing, and home 
     modifications; nursing home care; and other benefits such as 
     hearing aids and eyeglasses.
       In providing a fixed amount of federal funding per person, 
     this approach to financing would likely result in 
     overwhelming cost shifts to states, state taxpayers, and 
     families unable to shoulder the costs of care without 
     sufficient federal support. This would result in cuts to 
     program eligibility, services, or both--ultimately harming 
     some of our nation's most vulnerable citizens.

[[Page H4121]]

       The bill also repeals the six percent enhanced federal 
     Medicaid match for states that take up the Community First 
     Choice (CFC) Option. CFC provides states with a financial 
     incentive to offer HCBS to help older adults and people with 
     disabilities live in their homes and communities where they 
     want to be. About 90 percent of older adults want to remain 
     in their own homes and communities for as long as possible. 
     HCBS are also cost effective. On average, in Medicaid, the 
     cost of HCBS per person is one-third the cost of 
     institutional care. Taking away the enhanced match could 
     disrupt services for older adults and people with 
     disabilities in the states that are already providing 
     services under CFC and would result in a loss of about $12 
     billion for HCBS over ten years.


                           Prescription Drugs

       The AHCA would repeal the fee on manufacturers and 
     importers of branded prescription drugs, which currently is 
     projected to add $24.8 billion to the Medicare Part B trust 
     fund between 2017 and 2026. Rather than repeal this fee for 
     Medicare, AARP believes Congress must do more to reduce the 
     burden of high prescription drug costs on consumers and 
     taxpayers, and we urge action on bipartisan solutions.
       AARP remains willing to work with you to ensure that we 
     maintain a strong health care system that ensures robust 
     insurance market protections, controls costs, improves 
     quality, and provides affordable coverage to all Americans. 
     However, the AHCA does not accomplish these goals, and we 
     continue to urge you to vote NO.
           Sincerely,
                                                 Nancy A. LeaMond,
                                Executive Vice President and Chief
                                  Advocacy and Engagement Officer.

  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. DOGGETT. Mr. Speaker, the harsh indifference of these Republicans 
to the well-being of so many Americans is startling. Trump may 
temporarily bury the lies central to this plan with a tweet storm--with 
fake news. But these Republicans who follow him will not be able to 
find an excuse as one family after another suffers.
  Today's surprise attack on American health care has been widely 
condemned by healthcare professionals across the country and those who 
represent the disabled and sick, like the American Cancer Society and 
the March of Dimes.
  Jimmy Kimmel, know that your baby was fortunate, but others born with 
a disability will face the barrier of preexisting conditions.
  They didn't listen to the AARP, which knows that those Americans too 
young for Medicare by a few years will get socked with unaffordable 
premiums. They don't know what this monstrosity of a bill costs to the 
taxpayer. They don't know how many families will lose coverage or how 
many jobs will be lost. They don't really know what is in this bill. 
They know only that the Pied Piper of Trump Tower is playing a tune 
today and they must dance.
  There is much talk about high-risk pools. The real high-risk pool is 
the one that everyone who votes for this outrageous proposal is about 
to plunge into.
  Mr. McGOVERN. Mr. Speaker, I yield 3 minutes to the distinguished 
gentlewoman from New York (Ms. Slaughter), the ranking member of the 
Rules Committee.
  Ms. SLAUGHTER. Mr. Speaker, I certainly thank my colleague for 
yielding to me.
  Mr. Speaker, I was fortunate enough to bring the ACA to the floor 
after years of working on it and experts writing it. It had such 
incredible things in it. I think it would behoove us this morning to 
talk about what every one of us who has health insurance is going to 
lose because the benefits of the ACA accrued to all of us.
  Now, you need to know first that we are going to lose the fact that 
85 cents of every premium dollar will go for health care. It will go 
back to insurance profits. We are also going to lose the fact that 
families could no longer go bankrupt because of health care.
  The largest cause of bankruptcy are families with medical bills, and 
the ACA took care of that. Nobody ever talks about that much, but if a 
single person spent $4,500 a year on health care, a family $12,500, the 
insurance companies picked up the rest of it.
  How about that? That is a pretty good loss that we are going to face. 
So why in the world are we rushing into this thing?
  Well, the President of the United States, Donald Trump, verified as 
recently as last Saturday evening in Pennsylvania that we have to do 
this first because $800 billion has to come out of health care so that 
they could do the tax bill with great corporate tax relief for the 1 
percent. So as you lose your health care, your ability to go to the 
doctor, and your preexisting conditions because risk pools don't work, 
be comforted by the fact that we are in the hands of people who put the 
needs of corporations and wealthy people ahead of the citizens of the 
United States.
  Just in case you think people aren't paying any attention, for the 
first time in my life, my office has 185 applications for six seats as 
interns in the summertime. It is unheard of. Calls in my office have 
gone from about 10 a day to 80, all of them talking about this. I have 
never seen political suicide in my life like I am seeing today. I think 
our leader put it so succinctly: you are tattooing that on your 
foreheads.
  Now, those people out there who have really gotten sort of used to 
this, all we have heard all the way through is that this is going to 
fall apart. The problems going on with the ACA right now are that the 
insurance companies have uncertainty because of what has been going on 
here.
  I need to bring up one of the greatest hoaxes in America in any 
institution that passes laws. For over 60 times, you brought to the 
floor of this House and we debated bills to do away with the health 
care. ``Repeal and replace,'' you shouted. Millions and millions of 
dollars' worth of time on this floor were spent on what was absolutely 
a hoax because you had no repeal-and-replace plan. It was simply all 
talk, and now you have got to rush through this so you can do your big 
tax bill.
  I am sorry to see this happen. It is a sad day for the United States.
  Mr. McGOVERN. Mr. Speaker, I feel bad for the gentleman because it 
appears as if he only has one speaker supporting this rule and the 
bill, and nearly our entire caucus wants to speak on this against the 
Republican healthcare repeal bill. So I was wondering whether the 
gentleman might consider sharing some time with us?
  Mr. COLLINS of Georgia. Will the gentleman yield?
  Mr. McGOVERN. I yield to the gentleman from Georgia.
  Mr. COLLINS of Georgia. I thank the gentleman for yielding. As a 
wonderful manager of time, he will be able to parse the time as best he 
may see fit. I have other speakers who probably will be coming by, so I 
will just encourage the manager to manage his time well.
  Mr. McGOVERN. It looks kind of lonely over there. It speaks volumes 
about how much support there is for this bill.
  Mr. Speaker, I yield 1 minute to the gentleman from New Jersey (Mr. 
Pascrell).
  Mr. PASCRELL. Mr. Speaker, now I have to say to my friends on the 
other side: You sold out cheap--as we say in New Jersey--all to give a 
tax cut to insurance companies and the most well off. The Upton 
amendment is, of course, an admission.
  After 7 years, you came up with this?
  You have got to be kidding me. This is worse than a Fellini movie. At 
least he didn't take 7 years to distinguish between fantasy and 
reality.
  For a New Jerseyan with asthma, this will mean a $4,340 premium 
surcharge; for autism, $5,510. The list goes on and on--60, $70,000 if 
you have cancer.
  But less discussed is their attempt to rid the essential health 
benefits which removes yet another ACA protection for everyone. So now 
the Republicans have hit for the cycle.
  You hit for the cycle. You jeopardized the health care of nearly 
every single American--those on Medicare, those on Medicaid, those in 
the ACA exchanges, and now 150 million people with employer coverage. 
You sold out. It is a shame. I like most of you, but you are on the 
wrong path.
  It took you 7 years for this?
  I will never yield. I will never yield.
  The SPEAKER pro tempore. Members are reminded to direct their remarks 
to the Chair, not to each other.
  Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my 
time.
  Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the

[[Page H4122]]

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

[[Page H4123]]

     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,

[[Page H4124]]

     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. MOULTON. Mr. Speaker, there is only one reason this bill is on 
the floor today: the President cares more about cutting a deal than 
keeping his promises.
  He promised we would lower costs. That turned out to be a lie. He 
promised we would expand coverage. That turned out to be a lie. He 
promised we would protect millions of Americans with preexisting 
conditions. That, too, was a lie.
  Back in Massachusetts at the Agawam Diner, I met a veteran named 
Clif, who told me when I was on my way to Washington for the first time 
to go to Washington as an American--not as a Democrat or a Republican, 
but as an American.
  To my Republican colleagues, heed Clif's advice today. Don't vote as 
a Republican. Vote as an American. Don't throw away your credibility to 
give a legislative victory to a President who will never stick his neck 
out for anyone other than himself. For what? To betray the people who 
trusted them?
  I urge my Republican colleagues to put country before party. Vote 
``no'' on this ridiculous bill.
  The SPEAKER pro tempore. Members are reminded to refrain from 
engaging in personalities toward the President.
  Mr. COLLINS of Georgia. Mr. Speaker, I think it is interesting today 
since we would not be here today if there was not the problems that 
you, Mr. Speaker, and I have seen.
  One-third of this country has one insurer, premiums with double-digit 
increases, people who can afford--maybe even with subsidies the amount 
of their plan can't afford the deductibles and co-pays. They go to 
doctors who won't take their insurance.
  We are not here by mistake, Mr. Speaker. We are here because 
ObamaCare is an abject failure.
  Mr. Speaker, I reserve the balance of my time.
  Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from 
Children's Leadership Council opposed to this bill.

                                Children's Leadership Council,

                                                      May 1, 2017.
       Dear Representative: The Children's Leadership Council 
     opposes the American Health Care Act (AHCA) because it would 
     jeopardize health care for millions of babies, children, 
     youth and families. We urge you to vote NO on this 
     legislation.
       The Children's Leadership Council (CLC) is a coalition of 
     organizations dedicated to improving the lives and 
     opportunities of America's children. Nationwide, CLC members 
     work to advance the health, education and well-being of 
     babies, children and youth in order to prepare them for 
     school, work, and life. The CLC is the only national 
     children's coalition solely dedicated to supporting 
     investments in our nation's children and youth; and 
     collectively, CLC's members have affiliates, partners, and 
     members in every state in the nation.
       The Affordable Care Act and Medicaid play a crucial role in 
     the lives of children, including those facing the greatest 
     challenges such as children in poverty; children suffering 
     abuse and neglect; children in foster care, and children with 
     disabilities. Medicaid, for example, provides coverage for 
     approximately 37 million children, including children with 
     disabilities, children in foster care and children from low-
     income families. Children are the largest group of Medicaid 
     recipients, and nearly 40 percent of all the nation's 
     children rely on Medicaid and CHIP for their healthcare. 
     Medicaid provides health care treatment and preventive 
     services, mental health care, case management and 
     transportation services to and from medical appointments for 
     children who are low-income or disabled. The AHCA's changes 
     to Medicaid would radically restructure a program that has 
     worked for more than 50 years to support children's health. 
     The Medicaid cap would shift $839 billion to stages, forcing 
     them to cut eligibility, benefits, or provider rates that 
     could have disastrous health consequences.
       There is no question that the massive cuts to Medicaid, 
     increased premiums likely for millions of families, and 
     eliminating the Essential Health Benefits requirements under 
     current law will seriously harm children and families. 
     Maternity benefits would be among the many medical services 
     no longer guaranteed if this bill were to become law. The 
     massive Medicaid reductions in substance abuse treatment will 
     add to the increases nationwide in the need for child welfare 
     services because of the surge in opioid addiction. Families 
     caring for children with disabilities will find supports for 
     care at home jeopardized.
       With a record 95% of children with health coverage in our 
     country, the AHCA would turn back the clock on progress for 
     children. And recent proposed changes to the bill would 
     further undermine consumer protections that make health care 
     out of reach for low-income children and their families--thus 
     making the already harmful bill worse for children. Polling 
     conducted by the Children's Leadership Council found 71 
     percent of parents, including 67 percent of Independent 
     parents (of children under the age of 18), want increased 
     investments in programs that help children in the areas of 
     education, health and nutrition, not less as proposed by the 
     AHCA.
       Congress has a strong history of working on a bipartisan, 
     bicameral basis on issues, policies and programs important to 
     children. It is our hope and expectation that members of 
     Congress continue this history, as Congress works on 
     improving our nation's healthcare system. This legislation 
     would be a dangerous step backward. We strongly urge you to 
     vote NO.
           Sincerely,

                                                Randi Schmidt,

                                    Executive Director, Children's
                                               Leadership Council.

  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

[[Page H4125]]

     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.

                                                       AFSCME,

                                                      May 3, 2017.
     U.S. House of Representatives,
     Washington, DC.
       Dear Representative: On behalf of the 1.6 million working 
     and retiree members of the American Federation of State, 
     County and Municipal Employees (AFSCME), I am writing to 
     express our continuing opposition to the American Health Care 
     Act (AHCA), notwithstanding the addition of the Upton 
     amendment.
       The harm that AHCA will impose on ordinary Americans is 
     breathtaking in scope. As the Congressional Budget Office has 
     detailed, 24 million will lose their health care coverage. 
     The Medicaid program will be cut by $839 billion and 
     restructured, ending the guarantee that the federal 
     government will fund a specified share of state Medicaid 
     costs. The bill makes coverage more expensive, especially for 
     lower-income families and older workers and it undermines the 
     financial strength of Medicare. And the MacArthur amendment 
     makes a very bad bill worse by allowing states to opt out of 
     Affordable Care Act protections that ensure that people with 
     pre-existing conditions will be able to obtain comprehensive, 
     affordable health care. Moreover, the MacArthur amendment 
     would allow insurance companies to re-impose caps on annual 
     and lifetime limits, even in employer-sponsored coverage, 
     putting the health care of those with catastrophic illnesses 
     or injuries at risk.
       Under the Upton amendment, grants to states that could be 
     used for high-risk pools will be increased by 6% or $8 
     billion over five years. This is a paltry increase. Even the 
     conservative Mercatus Center described the increase as a 
     ``pittance.'' High-risk pools would still be grossly 
     underfunded, even if states put all of the $138 billion in 
     grant funding into them. We urge the Congress not to ignore 
     the previous experience with state high-risk pools. By 
     segregating those with pre-existing conditions into separate 
     coverage we know they will face higher premiums, benefit 
     exclusions, annual and lifetime limits on coverage and 
     waiting lists.
       It is unacceptable that this bill eliminates $500 billion 
     in taxes on the wealthiest 2%, health insurers, 
     pharmaceutical manufacturers and medical device makers, while 
     taking health care away from millions. Moreover, the bill 
     retains the 40% tax on high cost health plans, which will 
     undermine employer-sponsored insurance for working families 
     by hollowing out coverage and increasing out-of-pocket 
     expenses, although it delays the implementation for six 
     years.
       The bottom line is that this bill would cause millions to 
     lose their health coverage. Most of those with pre-existing 
     conditions would return to the days when even inadequate 
     coverage was unaffordable. The bill would drive up costs for 
     those who are older and lower-income, shift costs to states, 
     fail to protect employer-sponsored coverage, weaken public 
     health and undermine the solvency of the Medicare trust 
     fund--all the while providing tax cuts for the wealthy and 
     well-connected.
       The priorities demonstrated by this bill are upside down. 
     We urge you to oppose this bill.
           Sincerely,
                                                       Scott Frey,
                           Director of Federal Government Affairs.

  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

[[Page H4126]]

     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. NEAL. Mr. Speaker, this procedure that we are witnessing here 
this morning, based on what happened at the White House for the last 48 
hours, has all the charm of a ransom note.
  The idea that this is put in front of us so that they can provide a 
tax cut at the expense of middle class Americans is really what we are 
voting on today. So that child who is born with diabetes across America 
can no longer be guaranteed health insurance if we turn this option 
over to the States. Anybody who comes from local or State government 
knows this: that money will be used to balance the budgets in economic 
downturns at the expense of those who need it for health care.
  Another essential point here as I think we go forward, the other 
side--by the way, there are only two on the other side. What is amazing 
about this is--when you consider that argument that they had with us 
yesterday about national defense, understand this: real national 
defense also includes providing health care for members of the American 
family. That is a very important consideration. They are about to 
subtract from guaranteed benefits to the American family for the 
purpose of offering a tax cut to people at the very top, again, at the 
expense of middle class Americans.
  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from New 
York (Mr. Crowley), the chairman of the Democratic Caucus.
  Mr. CROWLEY. Mr. Speaker, here we go again. The majority thinks they 
have finally found the right combination of political giveaways to pass 
their bill, a bill that we have to remember still kicks 24 million 
Americans off their healthcare coverage. It still charges seniors more. 
It still takes away some of the most basic protections of your health 
plan that it should cover. Despite what you hear, this latest Band-Aid 
amendment is not going to change any of that.
  That is just what we know so far. Since this bill was built by 
backroom deals and haphazard guesses, we don't even know how much this 
bill will cost America--not just dollars added to the deficit, but the 
human cost of how much more damaging this bill will be.
  It is the height of irresponsible governing, not just rushing 
something through without full and fair consideration. Frankly, we are 
getting used to that on our side of the aisle. But to force through a 
bill that you know is going to hurt 24 million Americans is more than 
irresponsible; it is just plain wrong.

                              {time}  1000

  Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my 
time.
  Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the 
National Education Association in strong opposition to this bill.

                                                      May 3, 2017.
     Hon. James P. McGovern,
     House of Representatives, House Office Building, Washington, 
         DC.
       Dear Congressman McGovern: On behalf of our three million 
     members and the 50 million students they serve, we strongly 
     urge you to oppose H.R. 1628, the American Health Care Act as 
     amended. The Congressional Budget Office (CBO) found that by 
     2026, the original bill would provide $883 billion in tax 
     cuts while taking health coverage away from 24 million 
     people, including some of the most vulnerable among us--the 
     poor, the sick, the elderly, and the children who constitute 
     more than half the current Medicaid enrollment. Votes on this 
     issue may be included in NEA's Report Card for the 15th 
     Congress.
       The April 25 amendment made the original bill even worse. 
     It allows states to jettison existing essential health 
     benefit requirements, thereby permitting health plans 
     covering millions of people once again to exclude coverage 
     for maternity and newborn care, pediatric dental and vision 
     services, mental health and substance use services, and other 
     crucial benefits. The May 3 amendment is the equivalent of a 
     tiny bandage on a gaping wound. The cost of setting up 
     separate pools or premium assistance programs for people with 
     pre-existing conditions far exceeds the $8 billion spread 
     over five years the amendment provides--nationwide, at least 
     $25 billion per year would be required, according to the 
     Kaiser Family Foundation.
       Both the original and amended American Health Care Act 
     threaten to return this country to the days when annual and 
     lifetime dollar-based limits on the use of essential health 
     benefits shifted tremendous financial and health risks to 
     working families. Insurance companies could charge people 
     with pre-existing conditions many times more than they charge 
     healthy people--just as they did before the Affordable Care 
     Act. Millions of Americans with pre-existing conditions would 
     be at risk of losing health coverage or face premiums so high 
     only the very wealthy could afford them--the same people who 
     benefit from the massive tax cuts in the original bill.
       Specifically, we are concerned that this legislation will: 
     Lead to drastic cuts in Medicaid benefits and eligible 
     beneficiaries. The American Health Care Act radically 
     restructures how Medicaid is funded. Instead of the federal 
     government paying a percentage of actual Medicaid spending, 
     each state will get a set amount. States will choose between 
     a block grant, a lump sum payment, and a ``per capita cap,'' 
     a flat amount for certain Medicaid beneficiaries. Either way, 
     state budgets will take a big hit: the share of revenue spent 
     on Medicaid will rise from 24.5 percent in 2017 to 28 percent 
     by 2025, according to Moody's Investors Service. To 
     compensate for the loss of federal support, states are likely 
     to divert money from education to health care as well as 
     limit the number of Medicaid beneficiaries, the scope of 
     Medicaid benefits, or both.
       Hit the students most in need the hardest. Under the 
     Individuals with Disabilities Education Act (IDEA), Medicaid 
     reimburses schools for mental health care, vision and hearing 
     screenings, diabetes and asthma management, wheelchairs and 
     hearing aids, and more. Federal support is substantial--for 
     example, in 2015 California schools received about $90 
     million from Medicaid, Florida schools about $63 million, New 
     York schools about $137 million, Pennsylvania schools about 
     $131 million, and Texas schools about $250 million (Source: 
     Centers for Medicare and Medicaid, compilation of 2017 data). 
     Capping federal support for Medicaid will shift costs to the 
     states, jeopardizing services essential for students to learn 
     and thrive, especially those with disabilities.
       Increase the cost of health care for those least able to 
     afford it. The American Health Care Act provides largely age-
     based tax credits ranging from $2,000 to $4,000 per year--far 
     less than today's subsidies. For example, according to Kaiser 
     Family Foundation calculations, a 60-year-old earning $20,000 
     a year in Lincoln, Nebraska, now gets $18,470 to help buy 
     insurance and additional subsidies to help with deductibles 
     and co-payments. Under the American Health Care Act, she 
     would get a $4,000 tax credit for the premium and nothing for 
     other out-of-pocket health

[[Page H4127]]

     care costs. By 2026, the average subsidy under the American 
     Health Care Act would be half the average subsidy under the 
     Affordable Care Act, according to CBO.
       Tax ``high cost'' employer-sponsored health coverage. We 
     recognize that the American Health Care Act postpones the 
     effective date of the 40 percent excise tax on such plans 
     until 2026. But this tax--a back-door pay cut for millions of 
     working families--needs to be fully repealed.
       Enhance tax breaks for the rich. The American Health Care 
     Act nearly doubles the amount of money that can be socked 
     away in tax-free health savings accounts--at least $6,550 for 
     individuals and at least $13,100 for families in 2018. It 
     also repeals a 3.8 percent investment tax and 0.9 percent 
     surcharge on wages above $250,000--a savings of about 
     $195,000 per year for the top 0.1 percent of earners, 
     according to the independent Tax Policy Center.
       Weaken the individual insurance market and employment-based 
     coverage. The American Health Care Act eliminates penalties 
     for individuals not buying--and large employers not 
     providing--health coverage. But premiums go up 30 percent if 
     coverage lapses for more than 63 days--for example, when 
     someone loses her job and cannot afford to buy health 
     insurance until she gets another one. Overall, CBO predicts 
     substantial increases in out-of-pocket costs for low- and 
     moderate-income people due to the decline in subsidies and 
     increase in deductibles and other cost-sharing. Some 
     employers may gut their health plans or stop offering 
     coverage altogether, since they will no longer be penalized 
     for doing so.
       The American Health Care Act plays Robin Hood in reverse. 
     It reneges on the promise to deliver better, cheaper health 
     coverage for all Americans, giving the richest among us 
     massive tax cuts while causing the number of people without 
     insurance to rise from 28 million today to an estimated 52 
     million in 2026, according to CBO.
       We strongly urge you to oppose the amended American Health 
     Care Act--deeply flawed legislation that is even worse than 
     the original bill.
           Sincerely,

                                                    Marc Egan,

                                 Director of Government Relations,
                                   National Education Association.

  Mr. McGOVERN. Mr. Speaker, I include a letter from the American 
Academy of Pediatrics, American College of Nurse-Midwives, American 
College of Physicians, American Congress of Obstetricians and 
Gynecologists, National Association of Nurse Practitioners in Women's 
Health, National Partnership for Women & Families, and Planned 
Parenthood Federation of America.
                                                      May 1, 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: On behalf of 
     physicians, certified nurse-midwives/certified midwives, and 
     nurse practitioners who provide care for the women of 
     America, along with our patient partners, we stand together 
     for women and families and against House passage of the 
     MacArthur (R-NJ) Amendment to the American Health Care Act 
     (AHCA, H.R. 1628). Rather than support recent gains in 
     women's access to healthcare and coverage, the MacArthur 
     Amendment and AHCA turn back the clock and reverse hard-won 
     progress. We stand ready to continue work with Congress to 
     advance legislation that promotes women's health, healthcare 
     and coverage.
       In our letter of March 22, 2017, we expressed opposition to 
     the AHCA because it threatened women's access to care 
     protected by Essential Health Benefits (EHBs) requirements, 
     eliminated the Medicaid expansion, cut qualified providers at 
     Planned Parenthood from the Medicaid program, and made severe 
     reductions to Medicaid and other programs critical to women 
     and newborns. We said that important health initiatives for 
     women and newborns should be built upon and improved--not 
     rolled back.
       However, the MacArthur Amendment to AHCA places women's 
     health and coverage at even greater risk. The MacArthur 
     Amendment would enable states to waive EHBs including those 
     for maternity and newborn care, preventive services, and 
     services for mental health and substance use disorders; to 
     waive community rating rules; and to shunt patients with 
     costly healthcare conditions or illnesses into unproven 
     government high risk pools. Supporters of the bill claim this 
     bill maintains protections for those with preexisting 
     conditions, but allowing states to waive coverage of EHB and 
     charge people more based on their health status renders the 
     promise of coverage for preexisting conditions to be 
     meaningless. If all that the Secretary may require of a state 
     waiver application is an un-validated attestation 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 pre-
     existing medical conditions, it is meaningless in protecting 
     health, quality healthcare and coverage. Women and families 
     must not be made to suffer, lose access to care and coverage, 
     and pay higher healthcare costs.
       EHB is a critical protection that ensures women have 
     guaranteed access to a robust set of health care services. 
     Making certain categories of coverage optional--such as 
     maternity care--would not substantially lower the premiums 
     that people pay for health coverage. For example, the 
     requirement for maternity care as an EHB is not a source of 
     health cost growth. Rather, by sharing risk across a broad 
     population of beneficiaries it provides vital protection for 
     women and families from the risk of tens of thousands of 
     dollars of out-of-pocket costs associated with normal 
     physiologic labor and delivery, cesarean section, and birth 
     complications. In exchange for monthly premium costs of just 
     $8-14 according to one recent analysis, the maternity care 
     EHB provides significant security for people wishing to grow 
     their families in the U.S. Furthermore, since everyone is at 
     some point a newborn, childbirth affects all of us. Enabling 
     exclusion of maternity care from health coverage denies 
     people access to the care that everyone deserves for the best 
     start in life.
       Congress should move to protect and advance health, quality 
     care and coverage, particularly for women and newborns, and 
     not to endanger them as the AHCA and the MacArthur Amendment 
     would do. Americans of both parties agree. A recent Kaiser 
     Family Foundation poll found ``relatively few Americans want 
     to see the president and Congress decrease funding for a 
     variety of different health priorities--including spending 
     for reproductive health services for lower-income women (21 
     percent).''
       When women have access to quality, evidence-based, 
     affordable care throughout their lives, they enrich our 
     workforce, achieve higher levels of education, reach their 
     goals, and actively contribute to the success of their 
     families and their communities. We urge the U.S. House in the 
     strongest possible terms to get it right, not fast. The AHCA 
     and the MacArthur Amendment turn the clock back on women's 
     health and should not move forward.
       We stand ready to continue assisting Congress in advancing 
     health policy that supports women's access to high quality 
     healthcare and coverage, and is effective at controlling and 
     reducing the costs that people pay for their healthcare.
           Sincerely,
       American Academy of Pediatrics, American College of Nurse-
     Midwives, American College of Physicians, American Congress 
     of Obstetricians and Gynecologists, National Association of 
     Nurse Practitioners in Women's Health, National Partnership 
     for Women & Families, Planned Parenthood Federation of 
     America.

  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentlewoman from 
Texas (Ms. Jackson Lee).
  Ms. JACKSON LEE. Mr. Speaker, I want you to look and keep your eyes 
on who will feel the TrumpCare's mother of all bombs of health care 
dropped on the American people. God have mercy on your soul.
  I am a person living with a preexisting disease. I am a breast cancer 
survivor. This heartless and callous bill, with 24 million-plus people 
being thrown off of health care and the reverse Robin Hood of stealing 
from the poor and the seniors laying in their beds, and you are doing 
an age tax that is five times more than any other young person has to 
pay, is disgraceful, as well as the pittance that you have given for 
preexisting conditions, which is $8 billion. They say you need $25 
billion.
  Then you are telling the States to get a waiver. They are going to 
celebrate. And then you are saying to Trump, the king, that we have the 
votes to drop that mother of all bombs of health care.
  Let me just simply say: I want to stand with the people. I want her 
to live in dignity and to be able to get well. I want to make sure that 
Medicaid is provided for working families. I don't want the poor to 
sleep under bridges, to beg in the streets, to steal bread from the 
market because they can't get any health insurance.
  God have mercy on your soul.
  Mr. Speaker, as a member of the Budget Committee and the 
representative of a congressional district that has benefitted 
enormously from the Affordable Care Act, I rise in strong and 
unyielding opposition to H.R. 1628, the so-called ``American Health 
Care Act,'' which more accurately should be called ``Trumpcare, the Pay 
More for Less Act.''
  I oppose this third and latest reincarnation of Trumpcare for several 
compelling reasons:
  1. Trumpcare forces families to pay higher premiums and deductibles, 
increasing out-of-pocket costs.
  2. Trumpcare will take away health care from 24 million hardworking 
Americans.
  3. Trumpcare would gut Essential Health Benefits and protections for 
Americans with pre-existing conditions.
  4. Trumpcare forces Americans aged 50-64 to pay premiums five times 
higher than what others pay for health coverage, no matter how healthy 
they are.

[[Page H4128]]

  5. Trumpcare shortens the life of the Medicare Trust Fund and 
ransacks funds that seniors depend on to get the long-term care they 
need.
  Mr. Speaker, 85 months ago, on March 23, 2010, redeemed a promise 
that had been unfulfilled for nearly a 100 years, when he signed into 
law the landmark Affordable Care Act passed by the Democratic 
controlled 111th Congress.
  Seven years later, the verdict is in on the Affordable Care Act: the 
American people have judged it a success.
  As reflected in the most recent public opinion polls, 61% of 
Americans approve of ObamaCare and oppose efforts to repeal it, the 
highest approval rates on record to date and continuing an inexorable 
upward trend over the past several years.
  Mr. Speaker, the reason Americans are adamantly opposed to Republican 
repeal efforts, including the third iteration of Trumpcare now before 
us is that Obamacare is no longer a bogey cooked up in Republican 
talking points but a life-saving and life affirming measure that they 
experienced in their own lives.
  Americans think it is beyond crazy to repeal a law that has brought 
to more than 20 million Americans the peace of mind and security that 
comes with knowing they have access to affordable, high quality health 
care.
  Before the passage of the Affordable Care Act, 17.1% of Americans 
lacked health insurance; today nearly nine of ten (89.1%) are insured, 
which is the highest rate since Gallup began tracking insurance 
coverage in 2008.
  Because of the Affordable Healthcare Act:
  1. insurance companies are banned from discriminating against anyone, 
including 17 million children, with a preexisting condition, or 
charging higher rates based on gender or health status;
  2. 6.6 million young-adults up to age 26 can stay on their parents' 
health insurance plans;
  3. 100 million Americans no longer have annual or life-time limits on 
healthcare coverage;
  4. 6.3 million seniors in the ``donut hole'' have saved $6.1 billion 
on their prescription drugs;
  5. 3.2 million seniors now get free annual wellness visits under 
Medicare, and
  6. 360,000 Small Businesses are using the Health Care Tax Credit to 
help them provide health insurance to their workers;
  7. Pregnancy is no longer a pre-existing condition and women can no 
longer be charged a higher rate just because they are women.
  We are becoming a nation of equals when it comes to access to 
affordable healthcare insurance.
  With all of this progress, and the prospect for more through further 
refinements, who in their right mind would want to go back to how it 
used to be?
  The answer seems to be only the President and House Republicans who 
call the Affordable Care Act and its enviable record of success a 
``disaster.''
  Americans know a disaster when they see one and they see one in the 
making: it is called ``Trumpcare,'' masquerading as the ``American 
Health Care Act,'' which will force Americans to pay more, get less, 
decimate the Medicare and Medicaid programs, and give a massive tax cut 
for top 1 percent.
  Americans are right to be alarmed and angered by what the Trump 
Republicans are trying to do by rushing to vote on a Trumpcare bill 
before it can be scored by highly respected and nonpartisan 
Congressional Budget Office.
  What we do know for sure is that this Trumpcare bill is a massive 
$900 billion tax cut for the wealthy, paid for on the backs of 
America's seniors, the vulnerable, the poor, and working class 
households.
  Trump gave the game away on March 20, 2017 in one of his trademark 
pep rallies:
  ``We want a very big tax cut, but cannot do that until we keep our 
promise to repeal and replace the disaster known as Obamacare.''
  This ``Robin Hood in reverse'' bill is unprecedented and breathtaking 
in its audacity--no bill ever tried to give so much to the rich while 
taking so much from the poor and working class.
  When they were forced to pull Trumpcare 1.0 from the floor because 
they lacked the votes to pass, House Republican leaders responded by 
adding an amendment (Trumpcare 2.0) that made the original bill even 
worse.
  Trumpcare 2.0 would allow states to jettison existing essential 
health benefit requirements, thereby permitting health plans covering 
millions of people once again to exclude coverage for maternity and 
newborn care, pediatric dental and vision services, mental health and 
substance use services, and other crucial benefits.
  All this accomplished was a hemorrhaging of support from the moderate 
wing of the Republican Conference who feared the repercussions of 
leaving millions of Americans with preexisting conditions without 
health insurance so the Trump Republicans invented Trumpcare 3.0 to 
provide $8 billion over five years to offset the cost of setting up 
separate pools or premium assistance programs for people with pre-
existing conditions.
  This pittance is not designed or intended to help real people with 
preexisting conditions, but to provide cover for House Republicans to 
walk the plank.
  According to the Kaiser Family Foundation, at least $25 billion per 
year would be required, not $8 billion spread out over five years as 
provided for in Trumpcare 3.0.
  Trumpcare represents the largest transfer of wealth from the bottom 
99% to the top 1% in American history.
  This callous Republican scheme gives gigantic tax cuts to the rich, 
and pays for it by taking insurance away from 24 million people, 
leaving 52 million uninsured, and raising costs for the poor and middle 
class.
  In addition, Republicans are giving the pharmaceutical industry a big 
tax repeal, worth nearly $25 billion over a decade without demanding in 
return any reduction in the cost of prescription and brand-name drugs.
  To paraphrase Winston Churchill, of this bill, it can truly be said 
that ``never has so much been taken from so many to benefit so few.''
  The Pay-More-For-Less plan destroys the Medicaid program under the 
cover of repealing the Affordable Care Act Medicaid expansion.
  CBO estimates 14 million Americans will lose Medicaid coverage by 
2026 under the Republican plan.
  In addition to terminating the ACA Medicaid expansion, the bill 
converts Medicaid to a per-capita cap that is not guaranteed to keep 
pace with health costs starting in 2020.
  The combined effect of these policies is to slash $880 billion in 
federal Medicaid funding over the next decade.
  The cuts get deeper with each passing year, reaching 25% of Medicaid 
spending in 2026.
  These steep cuts will force states to drop people from Medicaid 
entirely or ration care for those who most need access to comprehensive 
coverage.
  The Pay-More-For-Less plan undermines the health care safety net for 
vulnerable populations.
  Currently, Medicaid provides coverage to more than 70 million 
Americans, including children, pregnant women, seniors in Medicare, 
people who are too disabled to work, and parents struggling to get by 
on poverty-level wages.
  In addition to doctor and hospital visits, Medicaid covers long-term 
services like nursing homes and home and community-based services that 
allow people with chronic health conditions and disabilities to live 
independently.
  To date, 31 states and D.C. have expanded Medicaid eligibility to 
low-income adults, which, when combined with the ACA's other coverage 
provisions, has helped to reduce the nation's uninsured rate to the 
lowest in history.
  Trumpcare throws 24 million Americans off their health insurance by 
2026 according to the Congressional Budget Office.
  Low-income people will be hit especially hard because 14 million 
people will lose access to Medicaid by 2026 according to CBO.
  Trumpcare massively shifts who gets insured in the nongroup market.
  According to CBO, ``fewer lower-income people would obtain coverage 
through the nongroup market under the legislation than current law,'' 
and, ``a larger share of enrollees in the nongroup market would be 
younger people and a smaller share would be older people.''
  The projected 10% reduction in premiums is not the result of better 
care or efficiency--it is in large part the result of higher-cost and 
older people being pushed out of a market that is also selling plans 
that provide less financial protection.
  People with low incomes suffer the greatest losses in coverage.
  CBO projects the uninsured rate for people in their 30s and 40s with 
incomes below 200% of poverty will reach 38% in 2026 under this bill, 
nearly twice the rate projected under current law.
  Among people aged 50-64, CBO projects 30% of those with incomes below 
200% of poverty will be uninsured in 2026.
  Under current law, CBO projects the uninsured rate would only be 12 
percent.
  Being uninsured is not about ``freedom.''
  Speaker Ryan has argued that people will happily forgo insurance 
coverage because this bill gives them that ``freedom.''
  The argument makes as much sense as the foolish claim that slaves 
came to America as ``immigrants'' seeking a better life.
  The freedom to be uninsured is no freedom at all to people in their 
50s and 60s with modest incomes who simply cannot afford to pay 
thousands of dollars toward premiums.
  They do not really have a choice.
  The claim of our Republican friends that Trumpcare provides more 
freedom to all Americans calls to mind the words of Anatole France:
  ``The law, in its majestic equality, forbids the rich as well as the 
poor to sleep under bridges, to beg in the streets, and to steal bread 
from the market.''

[[Page H4129]]

  Trumpcare raises costs for Americans nearing retirement, essentially 
imposing an ``Age Tax.''
  The bill allows insurance companies to charge older enrollees higher 
premiums than allowed under current law, while reducing the size of 
premium tax credits provided.
  Again, these changes hit low-income older persons the hardest.
  A 64-year-old with an income of $26,500 buying coverage in the 
individual market will pay $12,900 more toward their premiums in 2026, 
on average.
  Trumpcare raises costs for individuals and families with modest 
incomes, particularly older Americans.
  A recent analysis found that in 2020, individuals with incomes of 
about $31,000 would pay on average $4,000 more out of pocket for health 
care--which is like getting a 13% pay cut.
  And the older you are, the worse it gets.
  An analysis by the Urban Institute estimates that for Americans in 
their 50s and 60s, the tax credits alone would only be sufficient to 
buy plans with major holes in them, such as $30,000 deductible for 
family coverage and no coverage at all of brand-name drugs or many 
therapy services.
  Another reason I oppose the Trumpcare bill before us is because its 
draconian cuts in Medicaid funding and phase-out of Medicaid expansion 
put community health centers at risk.
  Community health centers are consumer-driven and patient-centered 
organizations that serve as a comprehensive and cost effective primary 
health care option for America's most underserved communities.
  Community health centers serve as the health care home for more than 
25 million patients in nearly 10,000 communities across the country.
  Across the country, 550 new clinics have opened to receive 5 million 
new patients since 2009.
  Community health centers serve everyone regardless of ability to pay 
or insurance status:
  1. 71% of health center patients have incomes at or below 100% of 
poverty and 92% have incomes less than 200% of poverty;
  2. 49% of health center patients are on Medicaid; and
  3. 24% are uninsured;
  4. Community health centers annually serve on average 1.2 million 
homeless patients and more than 300,000 veterans.
  Community health centers reduce health care costs and produce 
savings--on average, health centers save 24% per Medicaid patient when 
compared to other providers.
  Community health centers integrate critical medical and social 
services such as oral health, mental health, substance abuse, case 
management, and translation, under one roof.
  Community health centers employ nearly 100,000, people and generate 
over $45 billion in total economic activity in some of the nation's 
most distressed communities.
  Mr. Speaker, community health centers are on the front lines of every 
major health crisis our country faces; from providing access to care 
(and employment) to veterans to addressing the opioid epidemic to 
responding to public health threats like the Zika virus.
  We should be providing more support and funding to community health 
centers; not making it more difficult for them to serve the communities 
that desperately need them by slashing Medicaid funding.
  Trumpcare Republican plan leaves rural Americans worse off.
  Mr. Speaker, health insurance has historically been more expensive in 
rural areas because services cost more and it is hard to have a stable 
individual market with a small population.
  Under the Affordable Care Act, premium subsidies are tied to local 
costs, which helps keeps premium costs down.
  But they are not under the Republican plan.
  So, under the Republican plan residents in rural areas, who tend to 
be older and poorer, will pay much more and get much less health 
insurance.
  What the Affordable Care Act, and its repeal means in the lives of 
real people:
  At the end of the day, Mr. Speaker, the powerful and compelling 
reasons to reject Trumpcare lie in the real world experiences of the 
American people.
  Let me briefly share with you the positive, life affirming difference 
made by the Affordable Care Act in the lives of just three of the 
millions of Americans it has helped.
  Joan Fanwick: ``If Obamacare is repealed, I don't know if I'll live 
to see the next President''
  ``After nearly a decade of mysterious health scares, I was diagnosed 
with an autoimmune disorder called Sjogren's syndrome last year, when I 
was a junior at Temple University.
  ``It's a chronic illness with no known cause or cure, and without 
close medical surveillance and care, it can lead to life-threatening 
complications (like the blood infection I frequently experience).
  ``For me, having this disorder means waking up every morning and 
taking 10 different medications.
  ``It also means a nurse visiting my apartment every Saturday to 
insert a needle into the port in my chest, so I can give myself IV 
fluids throughout the week.
  ``Without insurance, my medical expenses would cost me about $1,000 
per week--more than $50,000 per year. And that doesn't even include 
hospitalizations.
  ``My medical bills aren't cheap under Obamacare, but I can afford 
them.
  ``Under Obamacare, insurance companies aren't allowed to cut you off 
when your costs climb so right now, the most I personally have to pay 
out of pocket is $1,000 per year.''
  Brain Norgaard: ``I am a small business owner and leadership trainer 
who Obamacare has helped tremendously.''
  Brian Norgaard, a Dallas, Texas resident called my office to express 
his opposition to Trumpcare and to offer share how the Affordable Care 
Act has helped small business owners like himself:
  ``I am a small business owner and leadership trainer who Obamacare 
has helped tremendously.
  ``My wife and I both own small businesses in the Dallas, Texas area 
and as a result of the huge savings we received after paying lower 
[healthcare] premiums under Obamacare, we were able to reinvest those 
saving into both of our businesses and the community.
  ``And the healthcare we received was quality, at that.''
  Ashley Walton: ``For cancer survivors, we literally live and die by 
insurance''
  Ashley Walton was 25 when a mole on her back turned out to be 
melanoma.
  She had it removed, but three years later she discovered a lump in 
her abdomen.
  She was then unemployed and uninsured, and so she put off going to a 
doctor.
  She tried to buy health insurance. Every company rejected her.
  Ashley eventually became eligible for California's Medicaid program, 
which had been expanded under the Affordable Care Act.
  The 32-year-old Oakland resident credits her survival to the ACA.
  Without it, ``I would likely be dead, and my family would likely be 
bankrupt from trying to save me.''
  Before any of our Republican colleagues supporting this bill cast 
their vote, I urge them to reflect on the testimony of Joan, Brian, and 
Ashley, and on this question posed by a constituent to Sen. Cotton of 
Arkansas at a recent town hall:
  ``I've got a husband dying and we can't afford--let me tell you 
something.
  ``If you can get us better coverage than this [Obamacare], go for it.
  ``Let me tell you what we have, plus a lot of benefits that we need.
  ``We have $29 per month for my husband. Can you beat that? Can you?
  With all the congestive heart failures, and open heart surgeries, 
we're trying. $29 per month. And he's a hard worker.
  $39 for me.''
  Like a horror film of yore with monsters and vampires, both the 
original Trumpcare and its sequels threaten to return this country to 
the days when annual and lifetime dollar-based limits on the use of 
essential health benefits shifted tremendous financial and health risks 
to working families.
  Insurance companies could charge people with pre-existing conditions 
many times more than they charge healthy people--just as they did 
before the Affordable Care Act.
  Millions of Americans with pre-existing conditions would be at risk 
of losing health coverage or face premiums so high only the very 
wealthy could afford them--the same people who benefit from the massive 
tax cuts in the original bill.
  I urge all Members to reject Trumpcare, one of the most monstrously 
cruel and morally bankrupt legislative proposals ever to be considered 
in this chamber.
  To paraphrase a famous former reality television personality, 
``believe me, Trumpcare is a disaster.''
  We should reject it and keep instead ``something terrific'': and that 
is the Affordable Care Act, regarded lovingly by millions of Americans 
as ``Obamacare.''
  Mr. COLLINS of Georgia. Mr. Speaker, I yield myself such time as I 
may consume.
  Mr. Speaker, if I had to defend ObamaCare, I would go into hysterics, 
too.

       Since ObamaCare went into effect, the insurance choices and 
     coverage have gotten lower and the costs have gotten higher. 
     Virtually no doctors take the marketplace insurance so I'm 
     left to change doctors who I've seen for over 30 years and 
     switch to ``new'' doctors who I don't trust, and who cannot 
     provide the same healthcare benefits I've received in the 
     past. I have a brain tumor that I have monitored by a very 
     skilled neuro-oncologist. Not anymore. The three choices I 
     was given via healthcare.gov aren't even honored forms of 
     insurance for this doctor.


[[Page H4130]]


  Yes, it left them out again.
  Mr. Speaker, I yield 2\1/2\ minutes to the gentleman from Indiana 
(Mr. Messer).
  Mr. MESSER. Mr. Speaker, despite the rhetoric on the other side of 
the aisle, today is an exciting day for those of us who have been 
working and fighting to end ObamaCare's reign over this country.
  It is race month in Indiana, and I want to remind my colleagues that, 
as exciting as today is, today's vote is a green flag, not a checkered 
flag. It is the beginning of the race, not the end.
  Today, the House will vote to move legislation forward that will 
repeal ObamaCare and replace it with something far better. The bill 
will surely undergo more changes as we continue this process in the 
Senate, but it is on its way to the finish line.
  There are some really strong policies in this bill. It cut taxes by a 
trillion dollars on the American people, and government spending by 
hundreds of billions, too. Despite the rhetoric, it keeps preexisting 
condition prohibitions. No one with a preexisting condition will be 
denied coverage because of the policies in this bill. Insurance 
companies cannot raise premiums on individuals with preexisting 
conditions as long as they maintain coverage.
  The bill will also make sure 26-year-olds continue to stay on their 
parents' healthcare plans as they enter the workforce. Most 
importantly, though, the bill unshackles American families from the 
mandates, taxes, and penalties that are costing these families 
thousands of dollars each year.
  Though ObamaCare helped some, we have to remember that ObamaCare made 
things worse for millions of America, and that is where the national 
anger has come from. I have heard from countless Hoosiers who tell me 
the stories of their premiums going from $500 a month to $1,500 a 
month, with deductibles that are through the roof, at $10,000-plus a 
month. They have to spend $30,000 out of pocket before they even get to 
their insurance. For a middle class family, that means they have no 
meaningful insurance at all.
  We can do better, and we will. That starts today.
  Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the 
National Rural Health Association opposed to this bill.

              [From the National Rural Health Association]

                Vote NO to the American Health Care Act

       The National Rural Health Association urges a NO vote on 
     the American Health Care Act (AHCA).
       Rural Americans are older, poorer and sicker than other 
     populations. In fact, a January 2017 CDC report pronounced 
     that life expectancies for rural Americans have declined and 
     the top five chronic diseases are worse in rural America. The 
     AHCA does nothing to improve the health care crisis in rural 
     America, and will lead to poorer rural health outcomes, more 
     uninsured and an increase in the rural hospital closure 
     crisis.
       Though some provisions in the modified AHCA bill improve 
     the base bill, NRHA is concerned that the bill still falls 
     woefully short in making health care affordable and 
     accessible to rural Americans. For example, the modified bill 
     contains a decrease in the Medical Expense Deduction 
     threshold from 10% to 5.8% in an attempt to assist Americans 
     between the ages of 50 and 64 who would see their premiums 
     skyrocket under the current plan. However, this deduction is 
     not a credit and therefore would be of little use to low 
     income seniors that are in very low tax brackets or do not 
     pay income tax at all. Additionally, the new amendments to 
     freeze Medicaid expansion enrollment as of Jan. 1, 2018, and 
     reduce the Medicaid per-capita growth rate will 
     disproportionately harm rural Americans.
       The AHCA will hurt vulnerable populations in rural 
     Americans, leaving millions of the sickest, most underserved 
     populations in our nation without coverage, and further 
     escalating the rural hospital closure crisis. According to 
     the Wall Street Journal, the ``GOP health plan would hit 
     rural areas hard . . . Poor, older Americans would see the 
     largest increase in insurance-coverage costs.'' The LA Times 
     reports ``Americans who swept President Trump to victory--
     lower-income, older voters in conservative, rural parts of 
     the country--stand to lose the most in federal healthcare aid 
     under a Republican plan to repeal and replace the Affordable 
     Care Act.'' Let's be clear--many provisions in the ACA failed 
     rural America. The lack of plan competition in rural markets, 
     exorbitant premiums, deductibles and co-pays, the co-op 
     collapses, lack of Medicaid expansion, and devastating 
     Medicare cuts to rural providers--all collided to create a 
     health care crisis in rural America. However, it's beyond 
     frustrating that an opportunity to fix these problems is 
     squandered, and instead, a greater health care crisis will be 
     created in rural America.
       Congress has long recognized the importance of the rural 
     health care safety net and has steadfastly worked to protect 
     it. And now, much of the protections created to maintain 
     access to care for the 62 million who live in rural America 
     are in jeopardy. We implore Congress to continue its fight to 
     protect rural patients' access to care. Three improvements 
     are critical for rural patients and providers:
       1. Medicaid--Though most rural residents are in non-
     expansion states, a higher proportion of rural residents are 
     covered by Medicaid (21% vs. 16%).
       Congress and the states have long recognized that rural is 
     different and thus requires different programs to succeed. 
     Rural payment programs for hospitals and providers are not 
     `bonus' payments, but rather alternative, cost-effective and 
     targeted payment formulas that maintain access to care for 
     millions of rural patients and financial stability for 
     thousands of rural providers across the country. Any federal 
     health care reform must protect a state's ability to protect 
     its rural safety net providers. The federal government must 
     not abdicate its moral, legal, and financial responsibilities 
     to rural, Medicaid eligible populations by ensuring access to 
     care.
       Any federal health care reform proposal must protect access 
     to care in Rural America, and must provide an option to a 
     state to receive an enhanced reimbursement included in a 
     matching rate or a per capita cap, specifically targeted to 
     create stability among rural providers to maintain access to 
     care for rural communities. Enhancements must be equivalent 
     to the cost of providing care for rural safety net providers, 
     a safeguard that ensures the enhanced reimbursement is 
     provided to the safety net provider to allow for continued 
     access to care. Rural safety net providers include, but not 
     limited to, Critical Access Hospitals, Rural Prospective 
     Payment Hospitals, Rural Health Clinics, Indian Health. 
     Service providers, and individual rural providers.
       2. Market Reform--Forty-one percent of rural marketplace 
     enrollees have only a single option of insurer, representing 
     70 percent of counties that have only one option. This lack 
     of competition in the marketplace means higher premiums. 
     Rural residents average per month cost exceeds urban ($569.34 
     for small town rural vs. $415.85 for metropolitan).
       Rural Americans are more likely to have obesity, diabetes, 
     cancer, and traumatic injury; they are more likely to 
     participate in high risk health behaviors including smoking, 
     poor diet, physical inactivity, and substance abuse. Rural 
     Americans are more likely to be uninsured or underinsured and 
     less likely to receive employer sponsored health insurance. 
     Rural communities have fewer health care providers for 
     insurers to contract with to provide an adequate network to 
     serve the community.
       Any federal health care reform proposal must address the 
     fact that insurance providers are withdrawing from rural 
     markets. Despite record profit levels, insurance companies 
     are permitted to cherry pick profitable markets for 
     participation and are currently not obliged to provide 
     service to markets with less advantageous risk pools. 
     Demographic realities of the rural population make the market 
     less profitable, and thus less desirable for an insurance 
     company with no incentive to take on such exposure. In the 
     same way that financial service institutions are required to 
     provide services to underserved neighborhoods, profitable 
     insurance companies should be required to provide services in 
     underserved communities.
       3. Stop Bad Debt Cuts to Rural Hospitals--Rural hospitals 
     serve more Medicare patients (46% rural vs. 40.9% urban), 
     thus across-the-board Medicare cuts do not have across the 
     board impacts. A goal of the ACA was to have hospital bad 
     debt decrease significantly. However, because of unaffordable 
     health plans in rural areas, rural patients still cannot 
     afford health care. Bad debt among rural hospitals has 
     actually increased 50% since the ACA was passed. According to 
     MedPAC ``Average Medicare margins are negative, and under 
     current law they are expected to decline in 2016'' has led to 
     7% gains in median profit margins for urban providers while 
     rural providers have experienced a median loss of 6%.
       If Congress does not act, all the decades of efforts to 
     protect rural patients' access to care, could rapidly be 
     undone. The National Rural Health Association implores 
     Congress to act now to protect rural health care across the 
     nation.

  Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the 
American Thoracic Society opposed to this bill.

                                    American Thoracic Society,

                                                   April 27, 2017.
       Dear Representative: On behalf of the 16,000 members of the 
     American Thoracic Society (ATS), I want to voice my grave 
     concerns with the latest legislative proposal developed to 
     repeal and replace the Affordable Care Act (ACA). While CBO 
     estimates are not yet available for the most recent 
     legislation proposal being considered in the House, we remain 
     concerned that the bill, if enacted, will result in a loss of 
     health insurance for millions of Americans. Should the 
     proposal come up for a vote in the near future, we urge you 
     to vote ``NO'' on the American Health Care Act.
       The ATS opposes any legislation that does not ensure 
     affordable health insurance coverage for Americans currently 
     insured under

[[Page H4131]]

     the ACA. We are concerned that allowing states to waive 
     important insurance reforms in the Affordable Care Act will 
     lead to reduced coverage for many Americans and significant 
     price increases for patients with pre-existing conditions. 
     Further, we are concerned that reliance on ``high risk 
     pools'' will not adequately meet the health insurance needs 
     of many Americans with pre-existing conditions. We note that 
     previous attempts at implementing state-based high risk pools 
     have been largely unsuccessful. Members of the ATS serve a 
     large and diverse patient population, including patients with 
     respiratory diseases, critical illnesses and sleep disorders 
     such as asthma, COPD, pneumonia, sepsis and obstructive sleep 
     apnea. Our patients cannot afford to lose affordable health 
     insurance coverage for any period of time.
       The ATS looks forward to working with Congress to improve 
     our health care system and ensure health insurance coverage 
     for all Americans. If you have questions or need additional 
     information, please contact Nuala S. Moore, Associate 
     Director of Government Relations.
           Sincerely,
                                             David Gozal, MD, MBA,
                                                        President.

  Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the 
Academy of Nutrition and Dietetics opposed to this bill.

                                              Academy of Nutrition


                                                and Dietetics,

                                      Washington, DC, May 2, 2017.
     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: Nutrition services 
     save money, improve chronic disease outcomes and save lives. 
     For this reason, the Academy of Nutrition and Dietetics, the 
     nation's largest organization of food and nutrition 
     professionals, remains opposed to H.R. 1628, the American 
     Health Care Act (AHCA) as amended by the MacArthur amendment.
       The Academy and our 75,000-plus members believe that all 
     Americans should have both coverage and access to high-
     quality health care. The Academy urges Congress to support 
     measures that include nutrition services and prevention that 
     reduces the cost of health care and improve patients' lives.
       The new proposal set forth in the AHCA not only fails to 
     improve the health of all Americans, but it will worsen 
     patient care and public health by removing vital resources 
     that are currently effective in improving health across the 
     country.
       This legislation continues to eliminate investments in 
     prevention and public health, reverse advancements made in 
     disease prevention and chronic care management, and according 
     to the Congressional Budget Office, would result in the loss 
     of health care coverage for at least 24 million Americans 
     Allowing states to waive pre-existing conditions and 
     essential health benefits will lead to decreased coverage and 
     utilization of vital nutrition services.
       Individuals with chronic disease such as diabetes and 
     hypertension benefit from medical nutrition therapy and 
     nutrition services to lower their blood sugar and blood 
     pressure, while reducing reliance on expensive medications. 
     The cost of these services is inexpensive and replaces more 
     costly interventions that are necessary as chronic disease 
     progresses with many complications.
       The Academy holds five key tenets for analyzing any 
     legislation to reform health care:
       1. The health of all Americans should improve as a result 
     of our health policy choices. Sufficient resources must be 
     made available to ensure optimal health.
       2. Access to quality health care is a right that must be 
     extended to all Americans.
       3. Nutrition services, from pre-conception through end of 
     life, are an essential component of comprehensive health 
     care.
       4. Stable, sufficient and reliable funding is necessary for 
     our health care system to provide everyone access to a core 
     package of benefits.
       5. Health care must be patient-centered.
       Affordable access to care is an ongoing challenge that any 
     reform legislation should address. Although this legislation 
     purports to provide access, it fails to make coverage more 
     affordable; unaffordable access to coverage is really not 
     coverage at all. The proposal fails to maintain a core 
     package of benefits that improve the health of Americans, by 
     removing a basic floor of services that should be provided 
     without cost-sharing to the Medicaid population.
       Additionally, the new proposal would allow states to opt 
     out of requiring that health plans cover the Essential Health 
     Benefits which help reduce longer term health care costs, 
     allow insurers to charge people higher premiums based on pre-
     existing conditions like nutrition related diseases like 
     diabetes and heart disease and increase out-of-pocket costs 
     for vulnerable older adults.
       By repealing the Prevention and Public Health Fund, the 
     proposal eliminates the sole federal investment in 
     prevention, which will harm our state and local communities 
     that depend on these effective public-private partnerships to 
     improve the health of their communities.
       The AHCA as currently drafted fails to meet the Academy's 
     five tenets, and therefore we cannot support the passage of 
     these proposals.
       The Academy urges Congress to not hold future votes without 
     an evaluation of the proposed amendments from the 
     Congressional Budget Office estimating the budgetary impact 
     of the amended legislation and the anticipated effect on 
     coverage for Americans. We look forward to continued 
     collaboration to improve the health and nutrition for all 
     Americans.
           Sincerely,
                                                  Lucille Beseler,
                                                        President.

  Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from The 
Jewish Federations of North America opposed to this bill.

                                            The Jewish Federations


                                             of North America,

                                      Washington, DC, May 2, 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: The Jewish Federations 
     of North America (JFNA) remains staunchly opposed to the 
     American Health Care Act of 2017 (AHCA), even with the 
     recently released amendment proposed by Representative Tom 
     MacArthur (R-NJ). We are disappointed that AHCA retains the 
     devastating cuts to Medicaid included in the earlier version 
     of the legislation, cuts which are the result of the 
     legislation's proposal to dramatically restructure Medicaid's 
     federal financing structure and roll back coverage for 14 
     million people covered by the state Medicaid expansions. The 
     amendment does nothing to alleviate these concerns.
       JFNA represents 148 Jewish federations and 300 network 
     communities that together support 15 leading academic medical 
     centers/health systems, 100 Jewish nursing homes, and 125 
     Jewish family & children's agencies, providing health care 
     for more than one million clients, Jewish and non-Jewish 
     alike. Medicaid is a lifeline for more than 80 million 
     people, including low-income children, older adults, and 
     people with disabilities nationwide. Medicaid is a vital 
     program for Jewish federations throughout the country and 
     particularly for our communal health and long-term care 
     partners that care for the most vulnerable in our 
     communities.
       JFNA is deeply troubled by the findings of the 
     Congressional Budget Office (CBO) that AHCA will cause $839 
     billion in reductions--about 25 percent--to federal Medicaid 
     funding and a loss in coverage for more than 14 million 
     Medicaid beneficiaries. We believe that converting Medicaid 
     to a block grant or per capita cap will cause irreparable 
     harm not only to the millions who depend on the program, but 
     also to our large network of providers who care for them.
       AHCA would convert the long-standing and fundamental 
     federal-state partnership of the Medicaid program to a block 
     grant or per capita cap system. Under either approach, states 
     would receive a limited amount of federal money for their 
     Medicaid programs. As CBO found, even under a per capita cap 
     system, the federal share is lower than the average annual 
     increase in Medicaid spending and will not be sufficiently 
     flexible to address a variety of key factors affecting 
     Medicaid spending, including major disasters, economic 
     downturns, unexpected health care cost increases, and 
     demographic changes, such as the rapidly aging baby boomer 
     generation. CBO projected that AHCA's $839 billion cut in 
     federal Medicaid funding will shift substantial costs to 
     state and local governments, our providers, and our patients, 
     thus exacerbating the existing strain on the program. We 
     agree with CBO's conclusion that, due to these reductions in 
     funding, states will be left with no choice but to reduce 
     Medicaid enrollment, eligibility for Medicaid benefits, and 
     payment rates. Many people who now qualify for Medicaid could 
     end up uninsured or losing access to critical health and 
     long-term care services.
       JFNA is concerned by many of the unintended consequences of 
     this legislation, such as:
       People who desperately need Medicaid and who are currently 
     eligible will become uninsured;
       States will be forced to cut back on crucial Medicaid 
     services, such as home and community-based services, 
     effectively forcing people who are capable of living in the 
     community with proper home and community-based services into 
     nursing homes;
       States will be forced to reduce already low provider 
     payment rates, thus further decreasing the pool of providers 
     serving Medicaid beneficiaries and increasing waiting times 
     for services; and,
       Health care providers and entities that care for these 
     vulnerable populations will suffer additional financial 
     strain. As a result, these agencies will be forced to lay off 
     staff or close their doors altogether, resulting in 
     significant job losses and further hurting state economies.
       For these reasons, we must oppose the legislation as 
     currently written and urge the House of Representatives to 
     reconsider moving forward with it. We stand ready to work 
     with you, in tandem with our Jewish communal health and long-
     term care providers, to promote more targeted ways to reduce 
     Medicaid spending and develop a new framework of policies to 
     improve Medicaid quality, efficiency, and sustainability.
           Sincerely,
     William C. Daroff,

[[Page H4132]]

       Senior Vice President for Public Policy & Director of the 
     Washington Office.

  Mr. McGOVERN. Mr. Speaker, I include in the Record an article in The 
Wall Street Journal today stating: ``. . . employers looking to lower 
their costs could impose lifetime limits and eliminate the out-of-
pocket cost cap from their plans under the GOP legislation.''

                     [From the Wall Street Journal]

  Little-Noted Provision of GOP Health Bill Could Alter Employer Plans


    Last-minute amendment would allow states to obtain waivers from 
                certain Affordable Care Act requirements

               (By Stephanie Armour and Michelle Hackman)

       Many people who obtain health insurance through their 
     employers--about half of the country--could be at risk of 
     losing protections that limit out-of-pocket costs for 
     catastrophic illnesses, due to a little-noticed provision of 
     the House Republican health-care bill to be considered 
     Thursday, health-policy experts say.
       The provision, part of a last-minute amendment, lets states 
     obtain waivers from certain Affordable Care Act insurance 
     regulations. Insurers in states that obtain the waivers could 
     be freed from a regulation mandating that they cover 10 
     particular types of health services, among them maternity 
     care, prescription drugs, mental health treatment and 
     hospitalization.
       That could also affect plans offered by large employers, 
     health analysts said.
       The ACA prevents employer plans from putting annual limits 
     on the amount of care they will cover, and it bars lifetime 
     limits on the 10 essential benefits. But in 2011, the Obama 
     administration issued guidance stating that employers aren't 
     bound by the benefits mandated by their state and can pick 
     from another state's list of required benefits. That guidance 
     was mostly meaningless because the ACA established a national 
     set of essential benefits.
       Under the House bill, large employers could choose the 
     benefit requirements from any state--including those that are 
     allowed to lower their benchmarks under a waiver, health 
     analysts said. By choosing a waiver state, employers looking 
     to lower their costs could impose lifetime limits and 
     eliminate the out-of-pocket cost cap from their plans under 
     the GOP legislation.
       The measure would give employers added flexibility to take 
     steps that could lower costs by limiting more-expensive 
     coverage areas. And it would lessen the federal regulation of 
     insurers, a goal of GOP lawmakers who believe the ACA is an 
     example of government overreach.
       The impact on employer plans expands the scope of the 
     health bill to affect, potentially, everyone not insured by 
     Medicare or small-business plans, since the bill also 
     includes cuts to Medicaid and changes to the individual 
     market. Employer health plans are the single largest source 
     of health insurance in the country, with about 159 million 
     Americans receiving coverage through their jobs.
       ``It's huge,'' said Andy Slavitt, former acting 
     administrator of the Centers for Medicare and Medicaid 
     Services under President Barack Obama. ``They're creating a 
     backdoor way to gut employer plans, too.''
       But some experts say the impact could be less.
       ``The real question is, would employers do this? Many 
     wouldn't,'' said Larry Levitt, a senior vice president at the 
     Kaiser Family Foundation. ``Many employers offer quality 
     benefits to attract employees. But employers are always 
     looking for ways to lower costs.''
       Fifty-nine percent of employers had a lifetime limit on how 
     much their insurance plans would cover before the ACA, Mr. 
     Levitt said.
       The potential impact on large-employer plans was picked up 
     on by health analysts including Matthew Fiedler, a fellow at 
     the Brookings Institution. It is possible the Trump 
     administration could minimize the impact by barring employers 
     from picking plans across state lines, he said, but there is 
     no sign that that would occur.
       ``The core goal of insurance is to ensure that people are 
     protected if the worst happens, and these protections are 
     crucial to achieving that goal,'' Mr. Fiedler said.
       Potentially, the new provision could play out this way: If 
     a state did away with a requirement to provide mental health 
     and substance abuse services, employer plans using that 
     benchmark could impose lifetime caps on the amount of mental 
     health coverage they are willing to pay for.
       One trade group representing employers said the amendment's 
     effects on people with employer-sponsored health coverage 
     would be minimal. Most large employers didn't impose annual 
     or lifetime limits before the ACA was implemented, according 
     to James Gelfand, senior vice president of health policy at 
     the Erisa Industry Committee.
       ``Even if self-insured health plans are no longer banned 
     from imposing annual or lifetime limits, they're unlikely to 
     attempt to squeeze the toothpaste back into the tube,'' he 
     said. ``The benefits of reimposing limits are questionable.''

  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the distinguished 
gentleman from Michigan (Mr. Levin).
  (Mr. LEVIN asked and was given permission to revise and extend his 
remarks.)
  Mr. LEVIN. Mr. Speaker, it has just been said that no one with a 
preexisting condition will be denied treatment. That is a cruel 
falsehood. Roughly 129 million Americans today have a preexisting 
condition.
  Here is what the AMA says to refute what was just said: ``The history 
of high-risk pools demonstrates that Americans with preexisting 
conditions will be stuck in second class health coverage, if they are 
able to obtain coverage at all.''
  Now we have a proposal for $8 billion. That is a deceitful fraud. I 
intend going back home to travel the State of Michigan and elsewhere 
and tell the American people that although those who have said that are 
simply not being truthful, they essentially are turning their backs on 
129 million Americans. We Democrats will never turn our back on the 
people of the United States of America. When it comes to health care, 
it is a vital need.
  Mr. COLLINS of Georgia. Mr. Speaker, I yield myself such time as I 
may consume.
  Mr. Speaker, even with, again, the muddled hysterics, there is 
nothing in this bill, even if you have preexisting coverage now, there 
is nothing that says you lose it. Let's at least get the facts 
straight.
  Also, let's talk about families and why we are here.

       Despite Obama's promises, my plan was canceled at an 
     affordable $450 a month when ObamaCare was implemented. My 
     new plan has gone up every year and for 2017 will be over 
     $1,300 a month. My husband and I cannot keep up with these 
     increases. Soon it will be a choice between food and housing 
     or health care.

  Virginia from Florida.
  Mr. Speaker, I yield 1 minute to the gentleman from Michigan (Mr. 
Mitchell).
  Mr. MITCHELL. Mr. Speaker, my question today is: How long will the 
opposition try to hold on to the failing Affordable Care Act? How long 
will they desperately try to hold on with their fingernails, screaming 
and thrashing at something that is failing so miserably?
  Just this week, it was announced that 94 of 99 counties of Iowa will 
not have a carrier at all. In Michigan this year, individual policy 
premiums went up 20 percent, never mind deductibles and copays.
  While currently 26 million Americans do not have coverage, 19.2 
million either claim a waiver or pay a penalty that last year was $3 
billion. Yet somehow the other side claims the Affordable Care Act is 
some form of nirvana.
  The American Health Care Act guarantees issuance of coverage and 
targets assistance to those who have health challenges, in contrast to 
the Affordable Care Act that just thinks we should throw money at it. 
What amazes me, in my first few months here in Congress, if there is a 
problem, we will just throw money. The opposition wants a blank check, 
which will not work in this country. It is going to kill this country.
  Let me suggest to my colleague from Michigan, my neighbor, that if he 
wants to schedule to go around the State and talk about the benefits of 
this program, the Affordable Care Act, I will go with him. We will go 
anywhere he would like to go.
  Mr. McGOVERN. Mr. Speaker, I include in the Record a statement from 
the Children's Hospital Association in opposition to this bill.

                 [From Children's Hospital Association,

                             Apr. 27, 2017]

      Children's Hospitals Urge House to Vote Against Amended AHCA


               Lawmakers should know bill is bad for kids

       Washington, DC.--On behalf of our nation's children's 
     hospitals and the patients and families they serve, 
     Children's Hospital Association (CHA) continues to oppose the 
     newly modified American Health Care Act (AHCA) and strongly 
     urges the House of Representatives to reject the bill. 
     Recently adopted changes only worsen the AHCA by putting 
     children with preexisting conditions at increased risk of 
     losing health care coverage and failing to correct the 
     Medicaid cuts that would impact over 30 million kids.
       The legislation the House might consider for a vote as 
     early as the weekend would impose over $800 billion in cuts 
     on states by fundamentally changing Medicaid--a program over 
     40 percent of the children across the country depend on for 
     their health care coverage and access to medical care. Under

[[Page H4133]]

     the bill, Medicaid would no longer be able to flex with the 
     needs of enrollees, instead becoming a severely restricted 
     system of per capita caps or block grants.
       The block grant option in particular would be devastating 
     to children as it eliminates Medicaid's EPSDT (Early and 
     Periodic Screening, Diagnostic, and Treatment) benefit which 
     ensures children receive immunizations, mental health 
     assessments and vision, eye and hearing exams as well as 
     other medical services they might need. A block grant would 
     also remove cost-sharing protections for children, 
     essentially creating new barriers to care for low-income, 
     working families.
       CHA urgently asks members of Congress to vote against the 
     AHCA. Medicaid must be maintained to ensure children receive 
     the coverage and medical care that return lifelong benefits 
     into adulthood. Investing in children's health advances a 
     better future for our nation.

  Mr. McGOVERN. Mr. Speaker, I include a statement from Families USA in 
opposition to this bill.

                           [From FAMILIESUSA]

  Latest House GOP Proposal--``Upton Amendment''--Still Leaves People 
              with Pre-Existing Conditions Out in the Cold

       Washington, DC.--Republicans in the House today are 
     discussing a so-called compromise that ostensibly adds $8 
     billion to their Affordable Care Act (ACA) repeal bill in an 
     attempt to appease members worried that the bill strips 
     coverage guarantees for people with pre-existing conditions. 
     Below is a statement from Families USA Executive Director 
     Frederick Isasi.
       ``Despite today's wheeling and dealing, the GOP repeal bill 
     still drops the coverage guarantee for people with pre-
     existing conditions, strips coverage from millions, and 
     drives up costs for millions more. A measly $8 billion 
     handout isn't going to change that. The bill also decimates 
     Medicaid--more than $800 billion in cuts. That hurts seniors, 
     people with disabilities, and children like Jimmy Kimmel's 
     son who he so eloquently spoke of Monday night. Remember, 
     half of the births in America are reimbursed through 
     Medicaid.
       ``The Upton $8 billion is a non-solution--money thrown at 
     `high-risk pools' that experts on both sides of the aisle 
     have warned lead to higher costs, fewer benefits, and waiting 
     lists rationing care for those with pre-existing conditions.
       ``Republicans in the House can do all the backroom vote-
     trading they want; their bill will still harm millions and 
     millions of people in America and breaks President Trump's 
     promise to cover everybody and protect people with pre-
     existing conditions. This isn't what people in America want. 
     It is time for the GOP to drop this deeply flawed legislation 
     and move on to efforts that will help, and not hurt, 
     America's families.''

  Mr. McGOVERN. Mr. Speaker, I include a statement from the Association 
of American Medical Colleges in opposition to this bill.

                        [From AAMC, May 2, 2017]

 AAMC Statement on the MacArthur Amendment to the American Health Care 
                                  Act

       AAMC (Association of American Medical Colleges) President 
     and CEO Darrell G. Kirch, MD, issued the following statement 
     regarding the amendment to the American Health Care Act 
     (AHCA) introduced by Rep. Tom MacArthur (R-N.J.):
       ``This week, the House could vote on a new version of the 
     American Health Care Act that includes the MacArthur 
     amendment. Unfortunately, the amendment does not address the 
     limitations in the original measure, such as making high-
     quality, affordable health insurance available to all, and 
     maintaining programs to support the health care safety net--
     at least at current levels--until other comparable coverage 
     expansions are available.
       The amendment's treatment of essential health benefits and 
     health status underwriting dilutes protections for many 
     Americans and would leave individuals with preexisting 
     conditions facing higher premiums and reduced access to vital 
     care.
       The shortcomings in the underlying bill remain the same. 
     The original analysis from the Congressional Budget Office 
     indicated that 14 million Americans would lose their health 
     insurance coverage as early as next year, and as many as 24 
     million by 2024. Nothing in the bill has changed that alters 
     the fact that this legislation would lead to fewer Americans 
     with quality insurance, less affordable coverage for those 
     who have it, and the destabilization of the current Medicaid 
     program.
       We continue to urge members of Congress to engage with the 
     nation's medical schools and teaching hospitals and other 
     stakeholders to find ways to achieve high quality health care 
     for all Americans.''

  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentlewoman from 
California (Ms. Sanchez), the vice chair of the Democratic Caucus.
  Ms. SANCHEZ. Mr. Speaker, I can't believe we are here again to vote, 
or not, on the Republicans so-called healthcare bill.
  Let me remind my colleagues that we are finally here only after 
Republicans failed to even hold a vote on March 24, and then offered 
extreme, multiple amendments to appease the furthest right of their 
party.
  But I have to give it to them: it takes real cojones to stand here 
and vote on a bill that they know provides nearly zero healthcare 
benefits for the American people. It takes real fortitude and 
conviction to stand up for a bill that cuts coverage for 24 million 
Americans, guts Medicaid, reduces the solvency of Medicare, and 
segregates the sickest.
  The truth is, Republicans lack the bravery to call this bill what it 
really is: a massive tax cut for the rich on the backs of working moms 
and dads and the sick. They lack the integrity to do the hard work that 
it takes to craft an actual healthcare bill that would build upon 
current law and improve the health of Americans.
  I implore my colleagues to come to their senses, vote against this 
terrible bill, and work with us to continue to improve health care in 
this country for all Americans.
  Mr. COLLINS of Georgia. Mr. Speaker, I yield myself such time as I 
may consume.
  Mr. Speaker, I have been waiting also for my friends across the aisle 
to stand up and say that ObamaCare is a failure. I guess they can't. 
For the last 7 years, the voters have.
  Small business owners and American entrepreneurs:

       As an entrepreneur with two special needs children, the ACA 
     is an expensive nightmare. Both my husband and I are small-
     business owners and must pay for individual insurance. We are 
     on the highest deductible plan offered to us, a monthly 
     premium over $1,000, and outstanding medical bills that we 
     are struggling to pay off. We have seen our premium go up at 
     least 14 percent and the expenses of care, lab, et cetera. 
     With all exceptions, to the President, he is offering to his 
     corporate friends. We are the ones who get ignored.

  That is the true face of ObamaCare.
  Mr. Speaker, I yield 1 minute to the gentleman from Texas (Mr. 
Barton).
  (Mr. BARTON asked and was given permission to revise and extend his 
remarks.)
  Mr. BARTON. Mr. Speaker, mandates seldom work. Markets do work.
  My friends on the Democratic side of the aisle haven't pointed out 
that 19 million Americans have chosen to pay the tax penalty to the 
IRS, rather than be forced into one of these ObamaCare plans.
  They talk about all the people who have gotten coverage. Most of them 
got coverage when the bill that is now called ObamaCare expanded 
Medicaid to healthy adults and paid 100 percent of the cost to cover 
those individuals at a cost right now of about $70 billion a year.
  Mandates don't work; markets do. I choose less government mandate, 
more personal freedom.
  Vote for the rule; vote for the bill. Let's restore markets and 
freedom to health care in America.
  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentlewoman from 
California (Ms. Judy Chu of California.)
  Ms. JUDY CHU of California. Mr. Speaker, yesterday, Kate called my 
office, worried for her son who is 1-year-old and was born with 
muscular dystrophy. He will need care for the rest of his life.
  Without the ban on preexisting conditions, the cost of insurance for 
her son will be astronomical. She is paralyzed with fear about how she 
is going to be able to care for him for the rest of his life. Under 
TrumpCare, the healthcare bill written for Donald Trump and not the 
American people, insurance companies will be able to charge Kate's son 
more because he has a preexisting condition.
  Imagine that. Her son's health care will be out of reach, his 
precious life endangered. That is unimaginably cruel, especially when 
we have a system in place right now that gets Kate's son the treatment 
he deserves.
  That is why I am opposing this bill today. I cannot support a measure 
that we know will cost sick people more money, will force families to 
pay higher premiums and deductibles, will force 24 million people off 
their insurance, and guts essential health benefits.
  I urge my colleagues to vote ``no'' on this horrific bill today.

                              {time}  1015

  Mr. COLLINS of Georgia. Mr. Speaker, I believe probably the reason 
they won't vote for it is they don't understand it, because preexisting 
conditions

[[Page H4134]]

are covered. If you have coverage now, nothing in our bill, no matter 
what would come from the State or anyone else, would lose the 
preexisting conditions. I guess it is just easier to talk your talking 
points and have your poster and go from there.
  Mr. Speaker, I yield 1 minute to the gentleman from Florida (Mr. 
Mast).
  Mr. MAST. Mr. Speaker, I, too, am a person with preexisting 
conditions, and I believe it is not just something that I should do; it 
is a responsibility for me to be the staunchest advocate for people out 
there who have preexisting conditions. That is why I am such an ardent 
supporter of this bill.
  I think every American and every person out there with preexisting 
conditions should be asking themselves: How is it that they have 
coverage if every single insurance provider has pulled out of the 
market? If there is no entity to go to out there and provide insurance, 
how is it that preexisting conditions could possibly be covered?
  I have had the question constantly: How is it so difficult for 
Republicans to get this bill passed, to get this through the floor? The 
answer is this, and this is again the question that every American 
should be asking themselves: Who is going out there and saying that 
preexisting conditions won't be covered? It is the exact same group of 
people that went out there and lied to the face of every single 
American, telling them that if they liked their plan, they would keep 
their plan; if they liked their doctor, they would keep their doctor; 
that the average American family was going to save $2,500 or more on 
health insurance.
  That was a bold-faced lie. It was orchestrated by architects who 
specifically went out with the intention to prey on the American 
people. That is who is going out there selling these lies against my 
party. I resent that completely because we have come up with a plan, 
with a strategy to go out there and save health care for the American 
people, and I couldn't be more proud of that.
  Mr. McGOVERN. Mr. Speaker, maybe the gentleman hasn't been listening 
to all the organizations and healthcare advocates who have come out 
strongly opposed to the Republican bill, that I have read into the 
Record, who know a lot more about health care than anybody in this 
House, who spend their lives protecting people and protecting people's 
healthcare rights. They are all in strong opposition to the Republican 
bill because you take away the protections for preexisting conditions, 
plain and simple.
  Mr. Speaker, I yield 1 minute to the gentleman from Oregon (Mr. 
Blumenauer).
  Mr. BLUMENAUER. Mr. Speaker, we began this debate listening to my 
friend from Texas talk about how he was humbled to be here today 
supporting the Republican bill. Well, frankly, I think he should be 
embarrassed, embarrassed that my Republican colleagues are afraid to 
have a full, open, lengthy debate about these impacts. We are taking a 
consequential piece of legislation, and Republicans are jamming it 
through without a CBO score so they don't know the impacts, and we 
don't have the confidence.
  We do know, however, my friend from Massachusetts has read into the 
Record item after item, the medical association, disease advocacy 
groups, the American Association of Retired People, it is an honor roll 
of people who know about health care, who fought to preserve and 
protect and enhance, and the Republicans have no answer to refute this 
litany of experts who are independent, who are professional, who care. 
Who are opposed. That is something that I think Republicans should be 
ashamed of.
  They have had 7 years chipping away at the Affordable Care Act to try 
to make it worse, yet it still is supported by people who know. The 
Republican approach should be rejected.
  Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my 
time.
  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).
  Ms. DeLAURO. Mr. Speaker, the Republican healthcare bill is reckless 
and heartless:
  It increases the cost of premiums and deductibles;
  It imposes an age tax on older Americans;
  It unravels protections for patients with preexisting conditions;

[[Page H4135]]

  It eliminates maternity care, substance abuse treatment, and 
prescription drug coverage;
  It does away with lifetime limits and annual caps.
  President Trump's claim that people with preexisting conditions will 
be covered is false, and it is a betrayal. It will have threatening 
consequences for millions of Americans. It will cost lives.
  If this passes today, the American people should be in the street to 
call out the immorality of this legislation. They should decry this 
offense against humanity and this offense against the American people. 
I call on the American people: Do not let them get away with it.
  Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my 
time.
  Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the distinguished 
gentleman from Rhode Island (Mr. Langevin).
  Mr. LANGEVIN. Mr. Speaker, I rise today in strong opposition to the 
Republicans' latest plan to dismantle the Affordable Care Act. After 
Republicans failed to earn the votes to pass their American Health Care 
Act in March, I thought that we could finally move forward to find 
bipartisan solutions to improving health care in America. Instead, 
Republicans have revived their partisan goal of ACA repeal by adding 
provisions that have made a bad bill even worse.
  Mr. Speaker, make no mistake about it; the bill before us today will 
make Americans' health care worse in this country:
  This legislation will cause 24 million people to lose coverage, while 
drastically increasing healthcare costs on everyday families;
  It eliminates Federal safeguards that prevent insurers from charging 
older Americans higher premiums;
  It guts essential health benefits, like maternity care and 
prescription drugs;
  Further, it removes crucial patient protections that prevent 
discrimination against people with preexisting conditions, leaving our 
most vulnerable populations with a false promise of sufficient coverage 
through these failed high-risk pools.
  Mr. Speaker, I am saddened that so many Republicans appear willing to 
place hollow partisan victories above the health of their constituents. 
I oppose the Republican AHCA in the strongest possible terms and urge 
all of my colleagues to put the health of Americans first.
  Mr. COLLINS of Georgia. Mr. Speaker, 7 years ago, our friends across 
the aisle put partisan interests above the health of the American 
people, and we are seeing the results of that today. In fact, a small-
business owner from Missouri says:

       I recall the days before the ACA when we would receive a 2-
     inch notebook that contained multiple quotes from different 
     health insurance companies. Now our options are listed on a 
     single legal-sized sheet of paper. We only received three 
     quotes for 2017, and just two of them were adequate for our 
     region. In 2013, our insurance cost $180,000 for 92 lives 
     with a $2,000 deductible. In 2016, we paid $252,000 for just 
     61 lives who face a $5,000 deductible. Our options are 
     dwindling, our costs are skyrocketing, and our employees are 
     ultimately suffering because of the ACA.

  Again, a defense of the defenseless or a positive solution for 
America; that is what we are offering.
  Mr. Speaker, I reserve the balance of my time.
  Mr. McGOVERN. Mr. Speaker, I yield 30 seconds to the gentlewoman from 
Wisconsin (Ms. Moore).
  Ms. MOORE. Mr. Speaker, analysis of health insurance coverage for the 
past 30 years, analysis of data from the New England Journal of 
Medicine shows that, for every 455 people who are insured, one life 
will be saved. With the repeal of the Affordable Care Act, it is 
estimated that 43,956 people a year will die.
  Long live the Republican Party.
  Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my 
time.
  Mr. McGOVERN. Mr. Speaker, I yield 30 seconds to the gentleman from 
Vermont (Mr. Welch).
  Mr. WELCH. Mr. Speaker, President Trump was elected by rural America. 
This bill betrays rural America three ways:
  Health care, 24 million-plus are going to lose their health care, 
many of them in rural America;
  Second, it takes healthcare dollars and it turns them into a $7 
million tax cut for the wealthiest 400 families in this country;
  Third, the tenet of rural America is: we are in it together. That 
means if you are born with a preexisting condition, you have a 
preexisting condition, we are going to be there for you.
  This bill turns its back on rural America, the people who stand up 
for one another and believe we are in it together, you are not on your 
own.
  Mr. COLLINS of Georgia. Mr. Speaker, I appreciate it, but it is 
amazing the concern for rural health care now under ObamaCare when much 
of rural America has been down to one provider. That is not a choice.
  Mr. Speaker, I yield 45 seconds to the gentleman from Pennsylvania 
(Mr. Rothfus).
  Mr. ROTHFUS. Mr. Speaker, I am listening to this debate and I am 
hearing a lot of demagoguery and no solutions, no solutions for people 
who have seen skyrocketing premiums, no solutions for people who have 
lost their healthcare plans, no solutions for people who have lost 
their doctors, no solutions for people with preexisting conditions who 
are subject to the same skyrocketing premiums as everybody else, no 
solutions for people with preexisting conditions who don't even have an 
insurer in their exchanges.
  I, too, have a preexisting condition. I am a cancer survivor. I am in 
the individual market. I am seeing the same skyrocketing premiums as 
everybody else. We are moving legislation today that will not only 
protect those with preexisting conditions, but will work to bring down 
premiums.
  Importantly, those defending the Affordable Care Act had a goal: 
single-payer, socialized medicine, and this legislation will stop it.
  Vote for this legislation, save our healthcare system, and have a 
much better result for the American people.
  Mr. McGOVERN. May I inquire of the gentleman how many more speakers 
he has?
  Mr. COLLINS of Georgia. Mr. Speaker, I am still waiting on a couple 
more speakers, but I am ready to close whenever the gentleman is.
  Mr. McGOVERN. Well, I am not really prepared to close because my side 
has a ton more to say, but I am out of time.
  Mr. COLLINS of Georgia. Mr. Speaker, I will tell Mr. McGovern, it is 
his time to manage.
  Mr. McGOVERN. Mr. Speaker, I yield myself the balance of my time, and 
given the fact there were no hearings or anything else, it would have 
been nice to have a little bit more time.
  Mr. Speaker, if we defeat the previous question, I will offer an 
amendment to the rule that would change the rules of the House to 
prevent this bill or any other healthcare-related legislation from 
being considered if it does not have a CBO cost estimate or if it would 
deny health coverage or require higher premiums due to preexisting 
conditions; impose lifetime limits on health coverage; prevent 
individuals under age 26 from being covered under their parents' plan; 
reduce the number of people receiving health care under the Affordable 
Care Act; increase costs to seniors by reopening the doughnut hole and 
raising prescription drug costs; require people to pay for preventive 
services, including cancer screenings; reduce Medicare solvency or 
change the Medicare guarantee; or reduce Federal taxes on the 1 percent 
of the population with the highest incomes or increase taxes on the 80 
percent of hardworking Americans earning moderate to low incomes.
  Mr. Speaker, I ask unanimous consent to insert the text of my 
amendment in the Record, along with extraneous materials, immediately 
prior to the vote on the previous question.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Massachusetts?
  There was no objection.
  Mr. McGOVERN. Mr. Speaker, none of us on this side are claiming that 
the Affordable Care Act is perfect. In fact, for 7 years, we have been 
prepared to work with our Republican colleagues in a bipartisan way to 
make it even better, to cover more people, to find ways to lower costs; 
but for 7 years, my Republican colleagues had no interest in doing 
that. All they wanted to do was repeal the bill, repeal the bill, 
repeal the bill and offer no alternative.
  Now we see their alternative, and it is an awful alternative. It is a 
disaster. It is an alternative that came not out

[[Page H4136]]

of a deliberative process, but out of some back room somewhere. People 
haven't even read this bill. They don't even know what it does because 
we are not even waiting for a CBO score. This is a pathetic process 
that everybody should be ashamed of.
  Let me just say, to claim or to imply that the Republican plan covers 
people with preexisting conditions, it is a lie. It is a lie. Let's be 
honest about it. This does not cover people with preexisting 
conditions. To come on the floor and say it does, to try to fool 
people, well, you may get away with it in the short term, you may get a 
headline, but I will tell you, people will figure out soon enough when 
they are denied healthcare coverage, when they see their costs rise and 
rise and rise.
  To have a healthcare bill that throws 24 million Americans off of 
health insurance, you should be ashamed.
  To have a healthcare bill that cuts Medicaid by $880 billion to give 
a tax cut to the wealthiest people in this country, you should be 
ashamed.
  I spent a good deal of my time reading letters from organizations 
like the National Farmers Union, the AARP, the Cystic Fibrosis 
Foundation, Paralyzed Veterans of America, March of Dimes, the American 
Medical Association, on and on and on, organizations that have 
dedicated their lives to helping people in this country that know 
something about this subject.

                              {time}  1030

  And when it comes down to who do I trust, them or you, on whether or 
not your bill covers people with preexisting conditions, there is no 
contest. I trust them. They see what you are trying to do. They 
understand that this bill is a fraud.
  It is unconscionable to not only me and to people on our side, but to 
people who are watching this debate--Democrats, Republicans, and 
independents alike--that we would be spending time debating a 
healthcare bill that will make life worse for people in this country. 
Any kind of healthcare bill that came to this floor ought to be about 
expanding coverage and lowering cost. We want to work with you on that. 
Instead, you come to a bill that is going to rip health care away from 
tens of millions of people.
  How can you do this? How can you do this to the American people? How 
can you do this to your constituents?
  This is a terrible bill. You should vote ``no'' on it or, better yet, 
pull it.
  Mr. Speaker, I yield back the balance of my time.
  Mr. COLLINS of Georgia. Mr. Speaker, I yield myself such time as I 
may consume.
  What we have seen for the last few minutes, I would probably get up 
and cheer, too. Because now you look at it this way. What they want to 
claim as a disaster or recognize as a disaster, they didn't recognize 7 
years ago. They chose to cram it down America's throat, and for 7 years 
the American people have said: No. Stop it. We don't want a healthcare 
system from government that takes freedom away from us and that removes 
it from us.
  We have been presented with a list of letters from folks who are 
against this bill. Well, it is just a quick reminder to those, Mr. 
Speaker, who may be wanting to remember. Some of these same folks were 
the same folks who said ObamaCare was great, and who gave letters of 
support. I guess they are trying to cover up for 7 years of their first 
mistake.
  When we understand this--let's go to some experts. I will just 
clarify them as experts, Mr. Speaker.
  President Bill Clinton calling ObamaCare, last year, the craziest 
thing in the world. He summed it up pretty well. Because what summed up 
here is they forgot the American people.
  Republicans have decided that we are going to put the American people 
back in control. We are not going to continue to hear from Pam in 
Nebraska, who is self-employed and lost her insurance four times under 
ObamaCare and twice because of the Nebraska failed startup.
  If we are going to talk about misleading the American people, it 
started 7 years ago, and it ends today. It ends today. The American 
people deserve better. They have been thrown under the bus for 7 years. 
They deserve an insurance market that is open, that is accessible, and 
that does cover preexisting conditions.
  If you want the deception, follow the other side. If you want the 
truth, follow this side.
  Mr. Speaker, if I had to defend the last 7 years and offer nothing 
into the faces of these, yeah, I would have been hysterical on the 
floor this morning, too. And that is exactly what we have seen.
  So for those who may be, it is time to vote ``yes'' on the rule, 
``yes'' on this bill, and start giving back to America the liberty and 
freedom for a healthcare system that is the best in the world and has 
been attacked for 7 years. Again, that ends today.
  The material previously referred to by Mr. McGovern is as follows:

          An Amendment To H. Res. 308 Offered by Mr. McGovern

       At the end of the resolution, add the following new 
     section:
       Sec. 3. Rule XXI of the Rules of the House of 
     Representatives is amended by adding at the end the following 
     new clause:


    RESTRICTIONS ON CONSIDERATION OF CERTAIN LEGISLATIVE PROVISIONS 
                         RELATING TO HEALTHCARE

       13.(a) It shall not be in order to consider a bill, joint 
     resolution, amendment, or conference report which includes 
     any provision described in paragraph (b).''
       (b) A provision referred to in paragraph (a) is a provision 
     which, if enacted into law, would result in any of the 
     following:
       (1) The denial of health insurance coverage to individuals 
     on the basis that such individuals have a pre-existing 
     condition or a requirement for individuals with a preexisting 
     condition to pay more for premiums on the basis of such 
     individuals having such a preexisting condition.
       (2) The elimination of the prohibition on life time limits 
     on the dollar value of health insurance coverage benefits.
       (3) The termination of the ability of individuals under 26 
     years of age to be included on their parent's employer or 
     individual health coverage.
       (4) The reduction in the number of people receiving health 
     plan coverage pursuant to the Patient Protection and 
     Affordable Care Act (PL 111-148) and Education Affordability 
     Reconciliation Act of 2010 (PL 111-152).
       (5) An increased cost to seniors for prescription drug 
     coverage pursuant to any changes to provisions closing the 
     Medicare prescription drug `donuthole'.
       (6) The requirement that individuals pay for preventive 
     services, such as for mammography, health screening, and 
     contraceptive services.
       (7) The reduction of Medicare solvency or any changes to 
     the Medicare guarantee.
       (8) The reduction of Federal taxes on the 1 percent of the 
     population with the highest income or increase the tax burden 
     (expressed as a percent of aggregate Federal taxes) on the 80 
     percent of the population with the lowest income.
       c) It shall not be in order to consider a measure or matter 
     proposing to repeal or amend the Patient Protection and 
     Affordable Care Act (PL 111-148) and the HealthCare and 
     Education Affordability Reconciliation Act of 2010 (PL 111-
     152), or part thereof, in the House or in the Committee of 
     the Whole House on the state of the Union unless an easily 
     searchable electronic estimate and comparison prepared by the 
     Director of the Congressional Budget Office is made available 
     on a publicly available website of the House.
       (d) It shall not be in order to consider a measure or 
     matter proposing to repeal or amend the Patient Protection 
     and Affordable Care Act (PL 111-148) and the Health Care and 
     Education Affordability Reconciliation Act of 2010 (PL 111-
     152), or part thereof, in the House or in the Committee of 
     the Whole House on the state of the Union, that is called up 
     pursuant to a rule or order that makes an amendment in order 
     or considers such an amendment to be adopted, unless an 
     easily searchable updated electronic estimate and comparison 
     prepared by the Director of the Congressional Budget Office 
     reflecting such amendment is made available on a publicly 
     available website of the House.
       (e) It shall not be in order to consider a rule or order 
     that waives the application of paragraph (a), paragraph (b), 
     paragraph (c), or paragraph (d). As disposition of any point 
     of order under paragraphs (c) through (e), the Chair shall 
     put the question of consideration with respect to the order, 
     conference report, or rule as applicable. The question of 
     consideration shall be debatable for 10 minutes bythe Member 
     initiating the point of order and for 10 minutes by an 
     opponent, but shall otherwise be decided without intervening 
     motion except one that the House adjourn.

        The Vote on the Previous Question: What It Really Means

       This vote, the vote on whether to order the previous 
     question on a special rule, is not merely a procedural vote. 
     A vote against ordering the previous question is a vote 
     against the Republican majority agenda and a vote to allow 
     the Democratic minority to offer an alternative plan. It is a 
     vote about what the House should be debating.
       Mr. Clarence Cannon's Precedents of the House of 
     Representatives (VI, 308-311), describes the vote on the 
     previous question on the rule as ``a motion to direct or 
     control the

[[Page H4137]]

     consideration of the subject before the House being made by 
     the Member in charge.'' To defeat the previous question is to 
     give the opposition a chance to decide the subject before the 
     House. Cannon cites the Speaker's ruling of January 13, 1920, 
     to the effect that ``the refusal of the House to sustain the 
     demand for the previous question passes the control of the 
     resolution to the opposition'' in order to offer an 
     amendment. On March 15, 1909, a member of the majority party 
     offered a rule resolution. The House defeated the previous 
     question and a member of the opposition rose to a 
     parliamentary inquiry, asking who was entitled to 
     recognition. Speaker Joseph G. Cannon (R.-Illinois) said: 
     ``The previous question having been refused, the gentleman 
     from New York, Mr. Fitzgerald, who had asked the gentleman to 
     yield to him for an amendment, is entitled to the first 
     recognition.''
       The Republican majority may say ``the vote on the previous 
     question is simply a vote on whether to proceed to an 
     immediate vote on adopting the resolution . . . [and] has no 
     substantive legislative or policy implications whatsoever.'' 
     But that is not what they have always said. Listen to the 
     Republican Leadership Manual on the Legislative Process in 
     the United States House of Representatives, (6th edition, 
     page 135). Here's how the Republicans describe the previous 
     question vote in their own manual: ``Although it is generally 
     not possible to amend the rule because the majority Member 
     controlling the time will not yield for the purpose of 
     offering an amendment, the same result may be achieved by 
     voting down the previous question on the rule . . . When the 
     motion for the previous question is defeated, control of the 
     time passes to the Member who led the opposition to ordering 
     the previous question. That Member, because he then controls 
     the time, may offer an amendment to the rule, or yield for 
     the purpose of amendment.''
       In Deschler's Procedure in the U.S. House of 
     Representatives, the subchapter titled ``Amending Special 
     Rules'' states: ``a refusal to order the previous question on 
     such a rule [a special rule reported from the Committee on 
     Rules] opens the resolution to amendment and further 
     debate.'' (Chapter 21, section 21.2) Section 21.3 continues: 
     ``Upon rejection of the motion for the previous question on a 
     resolution reported from the Committee on Rules, control 
     shifts to the Member leading the opposition to the previous 
     question, who may offer a proper amendment or motion and who 
     controls the time for debate thereon.''
       Clearly, the vote on the previous question on a rule does 
     have substantive policy implications. It is one of the only 
     available tools for those who oppose the Republican 
     majority's agenda and allows those with alternative views the 
     opportunity to offer an alternative plan.
  Mr. COLLINS. Mr. Speaker, I yield back the balance of my time, and I 
move the previous question on the resolution.
  The SPEAKER pro tempore. The question is on ordering the previous 
question.
  The question was taken; and the Speaker pro tempore announced that 
the ayes appeared to have it.
  Mr. McGOVERN. Mr. Speaker, on that I demand the yeas and nays.
  The yeas and nays were ordered.
  The SPEAKER pro tempore. Pursuant to clause 8 and clause 9 of rule 
XX, this 15-minute vote on ordering the previous question will be 
followed by 5-minute votes on:
  Adopting the resolution, if ordered; and
  Agreeing to the Speaker's approval of the Journal.
  The vote was taken by electronic device, and there were--yeas 235, 
nays 193, not voting 2, as follows:

                             [Roll No. 252]

                               YEAS--235

     Abraham
     Aderholt
     Allen
     Amash
     Amodei
     Arrington
     Babin
     Bacon
     Banks (IN)
     Barletta
     Barr
     Barton
     Bergman
     Biggs
     Bilirakis
     Bishop (MI)
     Bishop (UT)
     Black
     Blackburn
     Blum
     Bost
     Brady (TX)
     Brat
     Bridenstine
     Brooks (AL)
     Brooks (IN)
     Buchanan
     Buck
     Bucshon
     Budd
     Burgess
     Byrne
     Calvert
     Carter (GA)
     Carter (TX)
     Chabot
     Chaffetz
     Cheney
     Coffman
     Cole
     Collins (GA)
     Collins (NY)
     Comer
     Comstock
     Conaway
     Cook
     Costello (PA)
     Cramer
     Crawford
     Culberson
     Curbelo (FL)
     Davidson
     Davis, Rodney
     Denham
     Dent
     DeSantis
     DesJarlais
     Diaz-Balart
     Donovan
     Duffy
     Duncan (SC)
     Duncan (TN)
     Dunn
     Emmer
     Estes (KS)
     Farenthold
     Faso
     Ferguson
     Fitzpatrick
     Fleischmann
     Flores
     Fortenberry
     Foxx
     Franks (AZ)
     Frelinghuysen
     Gaetz
     Gallagher
     Garrett
     Gibbs
     Gohmert
     Goodlatte
     Gosar
     Gowdy
     Granger
     Graves (GA)
     Graves (LA)
     Graves (MO)
     Griffith
     Grothman
     Guthrie
     Harper
     Harris
     Hartzler
     Hensarling
     Herrera Beutler
     Hice, Jody B.
     Higgins (LA)
     Hill
     Holding
     Hollingsworth
     Hudson
     Huizenga
     Hultgren
     Hunter
     Hurd
     Issa
     Jenkins (KS)
     Jenkins (WV)
     Johnson (LA)
     Johnson (OH)
     Johnson, Sam
     Jordan
     Joyce (OH)
     Katko
     Kelly (MS)
     Kelly (PA)
     King (IA)
     King (NY)
     Kinzinger
     Knight
     Kustoff (TN)
     Labrador
     LaHood
     LaMalfa
     Lamborn
     Lance
     Latta
     Lewis (MN)
     LoBiondo
     Long
     Loudermilk
     Love
     Lucas
     Luetkemeyer
     MacArthur
     Marchant
     Marino
     Marshall
     Massie
     Mast
     McCarthy
     McCaul
     McClintock
     McHenry
     McKinley
     McMorris Rodgers
     McSally
     Meadows
     Meehan
     Messer
     Mitchell
     Moolenaar
     Mooney (WV)
     Mullin
     Murphy (PA)
     Noem
     Nunes
     Olson
     Palazzo
     Palmer
     Paulsen
     Pearce
     Perry
     Pittenger
     Poe (TX)
     Poliquin
     Posey
     Ratcliffe
     Reed
     Reichert
     Renacci
     Rice (SC)
     Roby
     Roe (TN)
     Rogers (AL)
     Rogers (KY)
     Rohrabacher
     Rokita
     Rooney, Francis
     Rooney, Thomas J.
     Ros-Lehtinen
     Roskam
     Ross
     Rothfus
     Rouzer
     Royce (CA)
     Russell
     Rutherford
     Sanford
     Scalise
     Schweikert
     Scott, Austin
     Sensenbrenner
     Sessions
     Shimkus
     Shuster
     Simpson
     Smith (MO)
     Smith (NE)
     Smith (NJ)
     Smith (TX)
     Smucker
     Stefanik
     Stewart
     Stivers
     Taylor
     Tenney
     Thompson (PA)
     Thornberry
     Tiberi
     Tipton
     Trott
     Turner
     Upton
     Valadao
     Wagner
     Walberg
     Walden
     Walker
     Walorski
     Walters, Mimi
     Weber (TX)
     Webster (FL)
     Wenstrup
     Westerman
     Williams
     Wilson (SC)
     Wittman
     Womack
     Woodall
     Yoder
     Yoho
     Young (AK)
     Young (IA)
     Zeldin

                               NAYS--193

     Adams
     Aguilar
     Barragan
     Bass
     Beatty
     Bera
     Beyer
     Bishop (GA)
     Blumenauer
     Blunt Rochester
     Bonamici
     Boyle, Brendan F.
     Brady (PA)
     Brown (MD)
     Brownley (CA)
     Bustos
     Butterfield
     Capuano
     Carbajal
     Cardenas
     Carson (IN)
     Cartwright
     Castor (FL)
     Castro (TX)
     Chu, Judy
     Cicilline
     Clark (MA)
     Clarke (NY)
     Clay
     Cleaver
     Clyburn
     Cohen
     Connolly
     Conyers
     Cooper
     Correa
     Costa
     Courtney
     Crist
     Crowley
     Cuellar
     Cummings
     Davis (CA)
     Davis, Danny
     DeFazio
     DeGette
     Delaney
     DeLauro
     DelBene
     Demings
     DeSaulnier
     Deutch
     Dingell
     Doggett
     Doyle, Michael F.
     Ellison
     Eshoo
     Espaillat
     Esty (CT)
     Evans
     Foster
     Frankel (FL)
     Fudge
     Gabbard
     Gallego
     Garamendi
     Gonzalez (TX)
     Gottheimer
     Green, Al
     Green, Gene
     Grijalva
     Gutierrez
     Hanabusa
     Hastings
     Heck
     Higgins (NY)
     Himes
     Hoyer
     Huffman
     Jackson Lee
     Jayapal
     Jeffries
     Johnson (GA)
     Johnson, E. B.
     Jones
     Kaptur
     Keating
     Kelly (IL)
     Kennedy
     Khanna
     Kihuen
     Kildee
     Kilmer
     Kind
     Krishnamoorthi
     Kuster (NH)
     Langevin
     Larsen (WA)
     Larson (CT)
     Lawrence
     Lawson (FL)
     Lee
     Levin
     Lewis (GA)
     Lieu, Ted
     Lipinski
     Loebsack
     Lofgren
     Lowenthal
     Lowey
     Lujan Grisham, M.
     Lujan, Ben Ray
     Lynch
     Maloney, Carolyn B.
     Maloney, Sean
     Matsui
     McCollum
     McEachin
     McGovern
     McNerney
     Meeks
     Meng
     Moore
     Moulton
     Murphy (FL)
     Nadler
     Napolitano
     Neal
     Nolan
     Norcross
     O'Halleran
     O'Rourke
     Pallone
     Panetta
     Pascrell
     Payne
     Pelosi
     Perlmutter
     Peters
     Peterson
     Pingree
     Pocan
     Polis
     Price (NC)
     Quigley
     Raskin
     Rice (NY)
     Richmond
     Rosen
     Roybal-Allard
     Ruiz
     Ruppersberger
     Rush
     Ryan (OH)
     Sanchez
     Sarbanes
     Schakowsky
     Schiff
     Schneider
     Schrader
     Scott (VA)
     Scott, David
     Serrano
     Sewell (AL)
     Shea-Porter
     Sherman
     Sinema
     Sires
     Slaughter
     Smith (WA)
     Soto
     Speier
     Suozzi
     Swalwell (CA)
     Takano
     Thompson (CA)
     Thompson (MS)
     Titus
     Tonko
     Torres
     Tsongas
     Vargas
     Veasey
     Vela
     Velazquez
     Visclosky
     Walz
     Wasserman Schultz
     Waters, Maxine
     Watson Coleman
     Welch
     Wilson (FL)
     Yarmuth

                             NOT VOTING--2

     Engel
     Newhouse

                              {time}  1055

  Messrs. LAWSON of Florida and FOSTER changed their vote from ``yea'' 
to ``nay.''
  Messrs. AMODEI and DIAZ-BALART changed their vote from ``nay'' to 
``yea.''
  So the previous question was ordered.
  The result of the vote was announced as above recorded.
  The SPEAKER pro tempore. The question is on the resolution.
  The question was taken; and the Speaker pro tempore announced that 
the ayes appeared to have it.


                             Recorded Vote

  Mr. McGOVERN. Mr. Speaker, I demand a recorded vote.
  A recorded vote was ordered.
  The SPEAKER pro tempore. This is a 5-minute vote.
  The vote was taken by electronic device, and there were--ayes 235, 
noes 192, not voting 3, as follows:

[[Page H4138]]

  


                             [Roll No. 253]

                               AYES--235

     Abraham
     Aderholt
     Allen
     Amash
     Amodei
     Arrington
     Babin
     Bacon
     Banks (IN)
     Barletta
     Barr
     Barton
     Bergman
     Biggs
     Bilirakis
     Bishop (MI)
     Bishop (UT)
     Black
     Blackburn
     Blum
     Bost
     Brady (TX)
     Brat
     Bridenstine
     Brooks (AL)
     Brooks (IN)
     Buchanan
     Buck
     Bucshon
     Budd
     Burgess
     Byrne
     Calvert
     Carter (GA)
     Carter (TX)
     Chabot
     Chaffetz
     Cheney
     Coffman
     Cole
     Collins (GA)
     Collins (NY)
     Comer
     Comstock
     Conaway
     Cook
     Costello (PA)
     Cramer
     Crawford
     Culberson
     Curbelo (FL)
     Davidson
     Davis, Rodney
     Denham
     Dent
     DeSantis
     DesJarlais
     Diaz-Balart
     Donovan
     Duffy
     Duncan (SC)
     Duncan (TN)
     Dunn
     Emmer
     Estes (KS)
     Farenthold
     Faso
     Ferguson
     Fitzpatrick
     Fleischmann
     Flores
     Fortenberry
     Foxx
     Franks (AZ)
     Frelinghuysen
     Gaetz
     Gallagher
     Garrett
     Gibbs
     Gohmert
     Goodlatte
     Gosar
     Gowdy
     Granger
     Graves (GA)
     Graves (LA)
     Graves (MO)
     Griffith
     Grothman
     Guthrie
     Harper
     Harris
     Hartzler
     Hensarling
     Herrera Beutler
     Hice, Jody B.
     Higgins (LA)
     Hill
     Holding
     Hollingsworth
     Hudson
     Huizenga
     Hultgren
     Hunter
     Hurd
     Issa
     Jenkins (KS)
     Jenkins (WV)
     Johnson (LA)
     Johnson (OH)
     Johnson, Sam
     Jordan
     Joyce (OH)
     Katko
     Kelly (MS)
     Kelly (PA)
     King (IA)
     King (NY)
     Kinzinger
     Knight
     Kustoff (TN)
     Labrador
     LaHood
     LaMalfa
     Lamborn
     Lance
     Latta
     Lewis (MN)
     LoBiondo
     Long
     Loudermilk
     Love
     Lucas
     Luetkemeyer
     MacArthur
     Marchant
     Marino
     Marshall
     Massie
     Mast
     McCarthy
     McCaul
     McClintock
     McHenry
     McKinley
     McMorris Rodgers
     McSally
     Meadows
     Meehan
     Messer
     Mitchell
     Moolenaar
     Mooney (WV)
     Mullin
     Murphy (PA)
     Noem
     Nunes
     Olson
     Palazzo
     Palmer
     Paulsen
     Pearce
     Perry
     Pittenger
     Poe (TX)
     Poliquin
     Posey
     Ratcliffe
     Reed
     Reichert
     Renacci
     Rice (SC)
     Roby
     Roe (TN)
     Rogers (AL)
     Rogers (KY)
     Rohrabacher
     Rokita
     Rooney, Francis
     Rooney, Thomas J.
     Ros-Lehtinen
     Roskam
     Ross
     Rothfus
     Rouzer
     Royce (CA)
     Russell
     Rutherford
     Sanford
     Scalise
     Schweikert
     Scott, Austin
     Sensenbrenner
     Sessions
     Shimkus
     Shuster
     Simpson
     Smith (MO)
     Smith (NE)
     Smith (NJ)
     Smith (TX)
     Smucker
     Stefanik
     Stewart
     Stivers
     Taylor
     Tenney
     Thompson (PA)
     Thornberry
     Tiberi
     Tipton
     Trott
     Turner
     Upton
     Valadao
     Wagner
     Walberg
     Walden
     Walker
     Walorski
     Walters, Mimi
     Weber (TX)
     Webster (FL)
     Wenstrup
     Westerman
     Williams
     Wilson (SC)
     Wittman
     Womack
     Woodall
     Yoder
     Yoho
     Young (AK)
     Young (IA)
     Zeldin

                               NOES--192

     Adams
     Aguilar
     Barragan
     Bass
     Beatty
     Bera
     Beyer
     Bishop (GA)
     Blumenauer
     Blunt Rochester
     Bonamici
     Boyle, Brendan F.
     Brady (PA)
     Brown (MD)
     Brownley (CA)
     Bustos
     Butterfield
     Capuano
     Carbajal
     Cardenas
     Carson (IN)
     Cartwright
     Castor (FL)
     Castro (TX)
     Chu, Judy
     Cicilline
     Clark (MA)
     Clarke (NY)
     Clay
     Cleaver
     Clyburn
     Cohen
     Connolly
     Conyers
     Cooper
     Correa
     Costa
     Courtney
     Crist
     Crowley
     Cuellar
     Cummings
     Davis (CA)
     Davis, Danny
     DeFazio
     DeGette
     Delaney
     DeLauro
     DelBene
     Demings
     DeSaulnier
     Deutch
     Dingell
     Doggett
     Doyle, Michael F.
     Ellison
     Eshoo
     Espaillat
     Esty (CT)
     Evans
     Foster
     Frankel (FL)
     Fudge
     Gabbard
     Gallego
     Garamendi
     Gonzalez (TX)
     Gottheimer
     Green, Al
     Green, Gene
     Grijalva
     Gutierrez
     Hanabusa
     Hastings
     Heck
     Higgins (NY)
     Himes
     Hoyer
     Huffman
     Jackson Lee
     Jayapal
     Jeffries
     Johnson (GA)
     Johnson, E. B.
     Jones
     Kaptur
     Keating
     Kelly (IL)
     Kennedy
     Khanna
     Kihuen
     Kildee
     Kilmer
     Kind
     Krishnamoorthi
     Kuster (NH)
     Langevin
     Larsen (WA)
     Larson (CT)
     Lawrence
     Lawson (FL)
     Lee
     Levin
     Lewis (GA)
     Lieu, Ted
     Lipinski
     Loebsack
     Lofgren
     Lowenthal
     Lowey
     Lujan Grisham, M.
     Lujan, Ben Ray
     Lynch
     Maloney, Carolyn B.
     Maloney, Sean
     Matsui
     McCollum
     McEachin
     McGovern
     McNerney
     Meeks
     Meng
     Moore
     Moulton
     Murphy (FL)
     Nadler
     Napolitano
     Neal
     Nolan
     Norcross
     O'Halleran
     O'Rourke
     Pallone
     Panetta
     Pascrell
     Payne
     Perlmutter
     Peters
     Peterson
     Pingree
     Pocan
     Polis
     Price (NC)
     Quigley
     Raskin
     Rice (NY)
     Richmond
     Rosen
     Roybal-Allard
     Ruiz
     Ruppersberger
     Rush
     Ryan (OH)
     Sanchez
     Sarbanes
     Schakowsky
     Schiff
     Schneider
     Schrader
     Scott (VA)
     Scott, David
     Serrano
     Sewell (AL)
     Shea-Porter
     Sherman
     Sinema
     Sires
     Slaughter
     Smith (WA)
     Soto
     Speier
     Suozzi
     Swalwell (CA)
     Takano
     Thompson (CA)
     Thompson (MS)
     Titus
     Tonko
     Torres
     Tsongas
     Vargas
     Veasey
     Vela
     Velazquez
     Visclosky
     Walz
     Wasserman Schultz
     Waters, Maxine
     Watson Coleman
     Welch
     Wilson (FL)
     Yarmuth

                             NOT VOTING--3

     Engel
     Newhouse
     Pelosi

                              {time}  1103

  Mr. SUOZZI changed his vote from ``aye'' to ``no.''
  So the resolution was agreed to.
  The result of the vote was announced as above recorded.
  A motion to reconsider was laid on the table.

                          ____________________