Bipartisan HSA Improvement Act of 2018

Mr. Speaker, I yield myself such time as I may consume.

Mr. Speaker, I am pleased to be here with Ms. Jenkins, moving forward on this legislation. It represents an opportunity for us to deal with a series of, as she mentioned, bipartisan ideas, relatively simple, to enhance service delivery.

I state from the outset that I am troubled that we were not able to provide opportunities to pay for these. They carry a cost. In committee, even though I thought they were a good idea, I voted against some of them because they were rather expensive.

In the aggregate, these are things, moving forward, that will improve healthcare, and I am hopeful that, as we move along the process, we can find some ways to offset the costs involved.

Some of us have philosophical questions about the role of HSAs and how it fits overall, but this legislation will make key consumer- friendly improvements to our existing system. Direct primary care medical homes are an important example of successful delivery reforms that will become easier to access under this legislation.

DPC arrangements offer individuals access to comprehensive primary care and prevention services in a medical home setting for a flat monthly fee, as opposed to concierge services that some people have in mind. Most of these practices typically charge a low monthly fee, perhaps $50 to $100, in most cases, and they serve low- and

moderate-income patients. These fees support the delivery of high- quality, coordinated care by providing better healthcare upfront in primary care settings.

DPC practices reduce unnecessary hospital and specialty care, as well as administrative expenses. This empowers the doctor-patient relationship, enabling providers to resist financial incentives that distort the decisionmaking process in primary care.

It also reduces the conveyor belt process, where people are typically shuttled into the office in 8-minute increments. This is not the case in direct primary care. It is not uncommon for appointments to last half an hour or even an hour. So they build a better relationship with patients, and they are able to better understand and address healthcare needs.

By offering a high level of access to primary care, evidence shows that direct primary care medical homes improve health outcomes and reduce costs. Today, DPC medical homes serve individuals of all ages and income in at least 47 States.

This legislation simplifies existing IRS regulations and clarifies that direct primary care medical homes are qualified health expenses-- medical services--and not health plans.

I personally question the IRS ruling. We have debated with them, but we have lost that. We fix it with this legislation.

As more individuals and employers seek to utilize the direct primary care delivery model, it is important that this outdated tax barrier not get in the way of patients accessing this successful model.

The legislation will allow HSA plans to cover onsite employee clinics. Think for a moment about the nursing stations that we have here in the House of Representatives to provide that service. They can offer physical exams, immunization, over-the-counter drugs, drug testing, hearing and vision screening, and other minor primary care preventive services to help employers assemble a benefits package for their employees that is both practical and can give them a competitive edge.

Allowing employees to access this basic healthcare service at work means it doesn't disrupt the worksite. It is more convenient for them; it is better for the employer.

Another key consumer change made by this bill is to recognize that employees change jobs. This bill allows individuals to streamline the conversion of a medical savings account, flexible savings account, or HSA so they won't lose savings when they change jobs. These reasonable changes will help consumers make the most of their employer-sponsored coverage.

Now--make no mistake--while this legislation will certainly help some consumers, it doesn't atone for the systematic sabotage that we have seen of the Affordable Care Act by the administration and some of my Republican colleagues. By zeroing out the mandate penalty, estimates are that insurance premiums will rise 15 percent. None of these bills before us today undo that premium hike that is visited upon our constituents unnecessarily.

These premium increases are coming after Republicans gave insurance companies billions in tax cuts in their tax bills. Republican attempts to expand HSAs is no replacement for the Affordable Care Act's financial assistance. Attempts to expand HSAs are a continuation of a platform of shifting families into health plans which provide fewer health benefits and higher out-of-pocket costs, while providing greater tax benefits for those who need them least.

HSAs and high-deductible healthcare plans shift costs to consumers without bending the cost curve or addressing underlying costs of medical care in the United States. I think we can and should do better.

For instance, the President has promised action on lowering prescription drug costs. These bills today do nothing to lower the cost of drugs consumers buy, and seek to move more people into plans that provide only catastrophic coverage, exposing more people to pay the full freight of drug price hikes.

Now, we have legislation before our committees that could move forward to do something about this, and I am saddened, despite Trump's talking about it, that we have really not taken action to do so. And we could, on a bipartisan basis, if we were enabled to do so.

The collection of bills on the floor this week will reduce Federal revenues by about $90 billion and will do nothing to reduce the number of uninsured people that will increase as a result of policy changes my Republican friends have done in this Congress. Their sabotage efforts under the Trump administration have caused millions of people to lose coverage, and millions more will do so in the future.

Now we are seeing, in the budget proposal, my Republican friends proposing to cut Medicare and Medicaid by nearly $1 trillion to try and pay for the deficits that have been exaggerated by tax cuts they have enacted. The bills that we will be considering, especially the next one, will only add fuel to that fire.

So, I am pleased that we have got some bipartisan pieces that we can move forward. I am hopeful that we don't abandon a sense of fiscal responsibility to be able to work together to pay for them, and I hope that we can encourage some of my friends on the other side of the aisle to dial back the assault on the Affordable Care Act, especially by the administration, so that we don't destabilize the system further, drive up costs, and increase the number of uninsured.

Mr. Speaker, I reserve the balance of my time.

Mr. Speaker, I yield 4 minutes to the gentleman from Wisconsin (Mr. Kind), a senior member of the Committee on Ways and Means, author of several of these reform provisions, and a champion of value over volume in healthcare, as well as fiscal restraint.

Mr. Speaker, I yield the gentleman from Wisconsin 1 additional minute.

Mr. Speaker, I yield myself 1 minute just to respond briefly.

Mr. Speaker, I was here in 2009. The very month President Obama took office, there were 700,000 jobs lost. There was great fear that we were going to have a complete collapse of the auto industry. There was a whole range of things that we were in an emergency situation on, and the worst economic crisis since the Great Depression.

As it was, a major portion of that bill was tax cuts to try and stimulate the economy. I do point out that as we move forward, our healthcare bill was entirely paid for, and that is what we need to get back to.

Mr. Speaker, I yield 3 minutes to the gentleman from Illinois (Mr. Danny K. Davis), a champion of healthcare, dealing with disparities in the healthcare system, a champion for balance and vision, and I appreciate him being here.

Mr. Speaker, I yield myself such time as I may consume.

Mr. Speaker, I take modest exception to the notion that somehow the Affordable Care Act failed. It represents the largest expansion of healthcare that we have seen in decades. It is so popular and important that, when my Republican friends attempted to repeal it, something they have been working on for 7 years, it blew up in their face. Even President Trump said their bill was mean. And it continues, even though they are working to dismantle it bolt by bolt.

I would hope that we will return to sanity to be able to work to be able to move forward on things like some of the elements in this bill here today that we agree upon that could move us forward rather than the continued battle over the notion that the Affordable Care Act is something that needs to be destroyed. The American people deserve better.

Mr. Speaker, I reserve the balance of my time.

Mr. Speaker, I yield myself the balance of my time.

Mr. Speaker, I appreciate the opportunity for us to have this discussion. It has been fun working with the gentleman from Minnesota (Mr. Paulsen) on this notion of direct primary care. It is a simple notion that runs athwart IRS regulations. I still don't fully understand why these should be classified as ``health plan'' rather than ``payment for service.''

But, nonetheless, we were able to work together on a bipartisan basis to move this forward. It is not expensive. The score is less than $2 billion out of $90 billion that we are tossing around here, and I personally believe that it will result in substantial savings in order to provide more efficient coverage.

But I must say that I am a little troubled by the continuing assault on what we are doing with the fiscal future of this country.

We just saw the latest reports that because of what my Republican friends have done with the budget and with the tax bill, we have doubled the deficit this year. It is doubled.

Now, there were complaints from my friend from Kansas about deficit spending when President Obama took office. Remember, he was only President for one-third of that month and lost 700,000 jobs. The economy was in free fall. Absolutely we took steps: cutting taxes and moving in areas to try and strengthen parts of the economy that was posing huge problems for people across the board. And this was broadly supported by people in business. Economic experts actually agree that probably we didn't do enough, and that slowed the economic recovery. But the economy has recovered.

We have seen 9 consecutive years of private sector job growth. That is what Trump inherited: over 7 years of job growth. The economy was strong. It wasn't in free fall. Yet, in that strong position, we are doubling the deficit this year. We are looking at trillion dollar deficits as far as the eye can see.

And we just had the President announce that he wants to spend $12 billion more, not because we are in economic free fall, but because his ruinous trade policies have resulted in losses to the farming sector. They are going to provide extra government bailout, not because farmers want it, but because they are being injured by these ruinous trade policies.

There was a time when most of my Republican friends would rise up in opposition. It is certain that if these were offered by Bill Clinton or Barack Obama, they would be screaming at the top of their lungs. Most of them are strangely silent now, but it is another $12 billion to try to fix a problem that Trump has created by starting trade wars with our friends, trying to punish China, and, in fact, we are punishing our allies. And somehow auto imports are national security.

This is embarrassing that we are in this situation. But it is not just embarrassing, it is dangerous. We are weakening ourselves economically, while we pick fights with our allies, like Canada and the European Union.

Mr. Speaker, on top of all of this, we are going to advance legislation today that have some nuggets of positive things. I have worked with my colleagues on some of them. There are important advances, but they are coming at a price of $90 billion added to the deficit, without even an attempt to work with us to offset. I think we could have offset the direct primary care piece that we are talking about here. It is relatively small potatoes compared to $90 billion, and compared to $12 billion for tariff relief for a trade war we didn't need.

Mr. Speaker, I enjoy the conversation about some of these items. I think it is important to spotlight them. But I am hopeful that we are able to return to fiscal stability, not having bailouts for farmers that they don't want and wouldn't need if we had a rational tariff policy. I am hopeful that we are not going to have a parade of other things that undermine the Affordable Care Act and add unnecessary costs to the deficit.

Mr. Speaker, I yield back the balance of my time.

Mr. Speaker, on that I demand the yeas and nays.

Mr. Speaker, pursuant to House Resolution 1012, I call up the bill (H.R. 6199) to amend the Internal Revenue Code of 1986 to include certain over-the-counter medical products as qualified medical expenses, and ask for its immediate consideration.

Mr. Speaker, I ask unanimous consent that all Members may have 5 legislative days within which to revise and extend their remarks and include extraneous materials on the bill under consideration.

Mr. Speaker, I yield myself such time as I may consume.

Mr. Speaker, I am pleased to come to the floor today to speak in support of the Restoring Access to Medication and Modernizing Health Savings Account Act of 2018.

This legislation makes a variety of simple but much-need changes to health savings accounts, or HSAs, rules to ensure that folks have more access and choice when using their HSAs.

This bill contains five separate bipartisan pieces of legislation that passed the Ways and Means Committee earlier this month. It includes a bipartisan policy by Mr. Roskam and Mr. Thompson that would allow HSA-eligible plans to offer a certain amount of first-dollar coverage in their plan design without losing their HSA-eligibility. This allows HSA plans to offer coverage for valuable services like telehealth or primary care appointments without a deductible.

The bill permits patients with HSAs to access the innovative and patient-centered direct primary care arrangements with HSA plans, provisions championed by the bipartisan team of Mr. Paulsen and Mr. Blumenauer.

The bill also allows coverage for certain medical services from a retail or onsite clinic and permits contributions to an HSA if their spouse has a health FSA, which is prohibited today.

Another commonsense provision in the bill allows rollovers from other tax-advantaged health accounts to be able to fund HSAs. These proposals were included in Mr. Kelly and Mr. Blumenauer's bipartisan legislation.

Additionally, this bill contains the PHIT Act, introduced in a bipartisan manner by Mr. Jason Smith and Mr. Kind, that would allow certain qualified fitness expenses to be eligible items that can be paid for with tax-advantaged dollars, offsetting a portion of their costs and promoting healthy activity.

Lastly, this legislation repeals the Affordable Care Act's unnecessary barriers when it comes to using tax-advantaged health accounts to purchase over-the-counter medicines, something that I have been pleased to work on with my good friend Congressman Kind for the last several years, and I am encouraged that the bipartisan duo of Representatives Meng and Paulsen have also joined us in introducing the underlying legislation.

In addition to expanding access for over-the-counter medication, the bill also allows for feminine hygiene products to be considered a qualified medical expense.

Since the passage of the Affordable Care Act, Americans have had to seek prescriptions in order to use their health savings and flexible spending accounts on safe and effective over-the-counter medicines. This legislation would end the need for those prescriptions.

It doesn't make any sense to require the millions of American families that use HSAs and FSAs to manage their healthcare needs to go to the doctor in order to access over-the-counter medicines for things like basic pain management and cold and allergy symptoms.

Nobody benefits from this nonsensical policy that requires consumers to jump through unnecessary hoops and increases the burdens on the healthcare system, all while providing no medical benefit. Over-the- counter medicines are often the frontline treatment for many common illnesses and for maintenance of chronic diseases, and they should be treated as medically reimbursable healthcare therapies, just as prescription medications.

Mr. Speaker, I am pleased the House is considering H.R. 6199, which gives individuals and families more control over their healthcare spending and increases their options when it comes to health savings accounts.

Today marks a nice opportunity to pass bipartisan legislation to simply make it easier for consumers to meet their basic medical needs. These are commonsense, simple, bipartisan solutions, and I urge my colleagues to support this legislation.

Mr. Speaker, I reserve the balance of my time.

Mr. Speaker, I yield 3 minutes to the gentleman from South Carolina (Mr. Rice), a distinguished member of the House Ways and Means Committee.

Mr. Speaker, I appreciate my friend's point of view on the other side of the aisle. Mr. Kind and I have worked really hard on this legislation for many years. I want to, for the Record, just remind folks that this bill is simply allowing people to keep more of their hard-earned money.

Letting people keep their own money is not government spending that needs to be offset. Each of these bills contained in this package were authored with our Democratic colleagues without an offset. Each of these bills went through committee, with bipartisan support, without an offset. It is ironic that Democrats want to, all of a sudden, claim to be fiscally conservative.

This is the same Democratic Party that passed the stimulus in 2009. Remember, that bill added nearly $800 billion to the deficit.

Mr. Speaker, I yield 3 minutes to the gentleman from Pennsylvania (Mr. Kelly), a real leader on these issues on the House Committee on Ways and Means.

Mr. Speaker, I yield 3 minutes to the gentleman from Kansas (Mr. Estes), my friend and colleague.

Mr. Speaker, I yield 2 minutes to the gentleman from Illinois (Mr. Roskam), who has provided great leadership in this area.

Mr. Speaker, I yield 2 minutes to the gentleman from Minnesota (Mr. Paulsen), who has worked tirelessly in this area.

Mr. Speaker, I yield myself the remainder of my time.

Mr. Speaker, we have heard my friends on the other side of the aisle suggest here, this afternoon, this bill might, in some way, hurt people with preexisting conditions. However, we know that is simply not true. This bill doesn't touch preexisting conditions. It doesn't raise costs or premiums on families. And it doesn't take away anyone's choice of a healthcare plan.

Millions of Americans use tax-advantage healthcare accounts to save and pay for healthcare expenses. In fact, there are twice as many Americans with an HSA than those who get coverage on the Affordable Care Act's exchanges. Almost 22 million people had an HSA in 2017, and there is only about 10 million people enrolled on the exchanges in 2018. Forty-four percent of all civilian workers had access to a health flexible spending arrangement in 2017.

The provisions in this bill allow more things to be paid for out of these accounts, like over-the-counter drugs, feminine products, and fitness activities. This means people are paying less because they are able to use pre-tax dollars or take a deduction for their contribution.

As a reminder, the policies in the bill are all bipartisan. We have worked together to write and advance them.

This bill helps middle class families afford their healthcare expenses, and I hope my colleagues will continue to support this legislation.

Mr. Speaker, I yield back the balance of my time

Mr. Speaker, I thank my friend and colleague from Oregon for yielding me this time. I agree with my colleague.

Mr. Speaker, I rise in opposition to this legislation, not because of the policy initiatives underlying these bills, but because of how fiscally irresponsible it is being done.

This week, out of the Ways and Means Committee, we have 10 bills to be debated and voted on on the House floor, at a total cost of roughly $90 billion. There was no effort made to try to find an offset or a pay-for in order to maintain some fiscal discipline in this place. That is problematic, because we keep digging the hole deeper.

But my name is on a few of these bills. Yesterday we had the repeal of the medical device tax, legislation that I had authored with my friend from Minnesota, Erik Paulsen. But that came at a cost of $20 billion. No offset. No pay-for. Just borrow more money from China and let future generations wrestle with it.

But it made sense policy-wise to try to repeal that in a fiscally responsible manner, because we were taxing these manufacturers whether they were making a profit or not. In fact, the pre-revenue companies were getting hit by the same tax. Policy-wise, it didn't make a lot of sense.

Today, I was happy to introduce legislation from our friend and colleague, Ms. Jenkins, on the Restoring Access to Medication Act. This will make it easier for patients to purchase over-the-counter medicine with their HSA and FSA account money without having to first run to their doctor to get a prescription. Just for the sake of efficiency and the cost savings, policy-wise, that makes sense; but the legislation comes with a cost, and there was no effort to pay for that.

Also part of this package is legislation I have introduced with our colleague, Mr. Smith, called the Personal Health Investment Today Act, or the PHIT Act. This would allow HSA and FSA dollars to be used for physical exercise, for gym memberships, so that we are investing in the front end of wellness and keeping people healthy in their lives rather than the hundreds of billions of dollars we spend at the back end dealing with chronic disease management.

Policy-wise that makes sense, but the legislation, again, comes with a cost. No attempt to pay for it. I think that is fiscally irresponsible.

At the time when we worked on and passed the Affordable Care Act, President Obama had one major request, that all of it had to be paid for, all of it had to be offset. We worked hard to accomplish it, and, in fact, we did, and then some. We did not add one nickel to our budget deficit or to future budget debt forecasts because of how we dealt with that in a fiscally responsible manner.

All we are asking is that our colleagues on the other side who are in charge now and running this place try to practice some semblance of that fiscal discipline that we showed with the passage of the Affordable Care Act.

We ought to be working together, finding out what is working with the healthcare system and fixing what isn't.

What is not working is the elimination of cost-sharing reduction payments that help health insurance providers spread the risk in the health insurance exchanges. That is one of the reasons why premiums are being driven up right now.

What is not working is refusing to provide funding to the navigators, who help people make the choices with the health plans that they have available, or undercutting funding for any education outreach with patients, or the elimination of the individual responsibility component so that young and healthy people don't get to sit around and wait until they get sick or injured and then go out and acquire health insurance. That is not how insurance markets work.

What also doesn't work is an administration that is trying to undermine the protections that are in place under the Affordable Care Act for people with preexisting conditions. There is a lawsuit pending right now. This administration should be defending that preexisting condition exclusion, and they are refusing to do so. That will implicate millions of lives throughout our country.

There is a lot that we can and should be working on together to improve the healthcare system, to reduce healthcare costs for all Americans. This approach, this piecemeal approach, while policy-wise there is a lot of justification and explanation for what is happening, is being done in a very fiscally irresponsible manner, just piling on the debt.

Mr. Speaker, this comes, by the way, on the heels, in this session of Congress, of the passage of a major tax cut last year that will add over $2 trillion to our national debt over the next 10 years because, again, there was no attempt to pay for it. It comes on the heels of the passage of a 2-year budget that will increase spending by over half a trillion dollars, none of it paid for, none of it offset.

Just yesterday, President Trump just announced a $12 billion subsidy bailout program for our family farmers because of the adverse effects that they are feeling due to his tariffs. And that is going to be borrowed money from China, again, to pay our farmers because they can't now sell their product--guess where--into the Chinese market.

How crazy is this? I hope we are not in an era now where budget deficits and debt only matters when there is a Democrat in the White House. Over the last year and a half, that certainly seems to be the case in this Congress.

Mr. Speaker, I thank the gentlewoman for including my bill, H.R. 6305, the Bipartisan HSA Improvement Act of 2018, in H.R. 6199, the Restoring Access to Medication and Modernizing Health Savings Accounts Act.

This important legislation expands access to and enhances the utility of health savings accounts, also known as HSAs.

My legislation gives employers more flexibility to offer quality healthcare in the setting that is best for them, like onsite or retail clinics. Employers around the country are offering innovative ways to deliver healthcare to their associates, and this provision makes sure that individual health savings accounts can utilize these same services.

It also fixes the spouse penalty by allowing individuals to make health savings account contributions if a spouse has a flexible spending account, while preventing double-dipping in tax benefits.

Lastly, it makes it easier for people to save for their healthcare by streamlining the conversion of other tax-preferred accounts to health savings accounts.

Ultimately, this bill modernizes healthcare delivery and gives employers the freedom to innovate and improve their employees' health.

I am also very pleased to see that the PHIT Act was included in this package. I strongly support adding more of an emphasis on exercise and wellness to build a healthy American population.

We spend an incredible amount of money on healthcare but very little on maintenance, like exercise and wellness, before we get sick. The PHIT Act will better incentivize healthy lifestyles.

Mr. Speaker, we are trying to improve healthcare for all Americans.

This means giving consumers a choice in their healthcare by incentivizing wellness and exercise. This is a preemptive effort to build a healthier, stronger America and the freedom to design insurance products that work best for them.

If you want to keep healthcare costs down, let's just make sure people are healthier. That is the best way to do it.

And do you know what? I really like this debate because we talk about how the deficit has grown. And for my colleagues on the other side, I wasn't here at the time, but I watched the deficit grow in the beginning of the Obama administration from $9 trillion to $20 trillion, and I am glad that, finally, somebody has awakened to the fact that we are working with huge deficits.

Now, this bill was passed by the Ways and Means Committee in a bipartisan fashion, and I want to thank my friend Earl Blumenauer for working on this issue.

This issue is extremely important for the 175 million Americans who get their health insurance from their employer. I strongly urge my colleagues on both sides of the aisle to vote in favor of H.R. 6199.

Mr. Speaker, I thank the chairwoman for yielding.

Mr. Speaker, as an advocate for giving consumers more choice in healthcare and lowering costs, I support this bill, which also gives more flexibility for those who have healthcare savings accounts, as well as some of the other provisions that were already just previously mentioned.

I want to highlight my support for one of the provisions in this bill that will allow people to use their healthcare savings account to pay for direct primary care and those arrangements.

The concept of direct primary care is simple, and it is supported by a lot of family doctors, a lot of primary care doctors. People pay a monthly fee to see their physician in this area anytime they choose, over the phone, through telemedicine, or in person, and then they get a whole host of services. It is really important for strengthening the doctor-patient relationship, and it means that more people will have access to primary care services instead of just going to the emergency room in order to get care.

But, unfortunately, the IRS has stated that direct primary care arrangements are essentially health insurance, and they categorize them in this way so you cannot use your HSAs and those funds to pay for direct primary care. That is why Congressman Blumenauer and I authored legislation to fix this and to allow HSAs, health savings accounts, to be used for direct primary care, and I am pleased that it is included in this bill.

Another important reform will allow employers to offer direct primary care arrangements to employees that have an HSA, also. This will let more people have access to direct primary care through their healthcare savings accounts, allowing family practice doctors like Dr. Julie Anderson in Minnesota to expand their practice without having to worry about the headache of filling out mountains of paperwork and excessive insurance forms, because direct primary care let's the doctor work directly with the patient and you don't have to go through extensive billing services and insurance.

Healthcare savings accounts, Mr. Speaker, have already been proven to help lower healthcare costs; and expanding them, giving consumers more flexibility and more choices, will mean families are also going to be better off.

So let's allow healthcare savings accounts to be used for direct primary care and support the underlying bill.