Lower Health Care Premiums for All Americans Act

Floor Speech

Mr. Speaker, when it comes to healthcare, Republicans are focused on lowering costs and expanding choice for all Americans. That is 347 million people, not just 7 percent of the population, which is all you are going to hear from the other side of the aisle, and that is all you have been hearing from the other side of the aisle.

Mr. Speaker, for more than a decade, Democrats have promised that ObamaCare would lower costs. They actually named the bill the ``Affordable Care Act.'' Find one American--find one American who says that their healthcare is now cheaper today than it was when they passed this disastrous bill. You won't. You won't find one.

In fact, the sky is falling because of their enhanced premium tax credits that they made temporary because they decided to make permanent tax benefits for wealthy environmentalists who support them. That is why we are where we are today.

Mr. Speaker, since ObamaCare has passed, we have seen 150-plus hospitals close their doors. Since ObamaCare has passed, we have seen premiums go up more than 80 percent. It doesn't sound like the Affordable Care Act by any means.

Even worse, the Government Accountability Office has confirmed what Republicans have been warning for years: ObamaCare is riddled with waste, fraud, and abuse. The GAO led a covert investigation by creating fictitious ObamaCare applicants with fake documentation where 100 percent of those applicants were accepted and enrolled.

Guess what? A year later, this year, of that 100 percent, 90 percent were still receiving subsidies. That means that insurance companies were still being subsidized for fake accounts where the people didn't even exist.

Data analysis from GAO also finds that 58,000-plus enrollees matched Social Security numbers with death records, with 7,000 of them dead before enrollment even began. There were dead people on the rolls, but what do they want to do? Their answer is to just continue the same old- same old by extending the current program with no reforms.

Mr. Speaker, one Social Security number alone had more than 125 different policies attached to it--just one. This all came from the GAO. This didn't come from the House Republicans.

We should not continue propping up a system that has completely failed to lower costs for Americans. The Lower Healthcare Premiums for All Americans Act takes a much different approach. It is one that delivers real relief.

First, it provides more freedom and flexibility through CHOICE Arrangements, empowering small businesses to offer tax-free benefits so that their employees can find health coverage that works for them.

This levels the playing field for small businesses, putting them on equal footing with large employers when competing for workers. These arrangements are proven to be successful. In fact, 83 percent of employers using CHOICE Arrangements are offering coverage for the very first time.

The bill also brings transparency to pharmacy benefit managers, requiring them to open up the books to finally give employers the data that they need to increase competition and negotiate better drug prices for workers. The result: Healthcare costs and premiums will be lowered for all--for all Americans, not just the 7 percent that the Democrats are fighting for in the enhanced COVID-era premium tax credits, but also for the 300 million-plus Americans.

Mr. Speaker, ObamaCare has driven costs up and choice down. This bill does the complete opposite.

Mr. Speaker, I urge my colleagues to support the Lower Healthcare Premiums for All Americans Act and stand with families, workers, and small businesses who deserve--they deserve a real affordable, accountable healthcare plan.

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Mr. SMITH of Missouri. Mr. Speaker, may I inquire as to how much time I have remaining.

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Mr. SMITH of Missouri. Mr. Speaker, I include in the Record the bombshell GAO report showing the waste, fraud, and abuse within the ObamaCare exchanges. GAO, U.S. Government Accountability Office, Washington, DC, December 3, 2025. Hon. Brett Guthrie, Chairman, Committee on Energy and Commerce, House of Representatives. Hon. Jim Jordan, Chairman, Committee on the Judiciary, House of Representatives. Hon. Jason Smith, Chairman, Committee on Ways and Means, House of Representatives. Patient Protection and Affordable Care Act: Preliminary Results from Ongoing Review Suggest Fraud Risks in the Advance Premium Tax Credit Persist

The Patient Protection and Affordable Care Act (PPACA) provides premium tax credits to those who purchase private health insurance plans and meet certain income and other requirements. Individuals may have the federal government pay this credit to their health insurance issuers in advance on their behalf, known as the advance premium tax credit (APTC), which lowers their monthly premium payments.

Millions of consumers have purchased health insurance plans through the marketplaces established under PPACA. The Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services (HHS), is responsible for maintaining the federal Marketplace and overseeing state- based marketplaces. Under PPACA, states may elect to operate their own state-based marketplace or to use the federal Marketplace. These marketplaces determine eligibility for APTC, based in part on income, and allow individuals to compare and choose among insurance plans offered by participating private health care coverage issuers. CMS estimated it paid nearly $124 billion in APTC for about 19.5 million enrollees for plan year 2024.

Consumers can enroll in health insurance coverage through a marketplace independently or with assistance, such as from an insurance agent or broker. As discussed later in this report, agents and brokers can help a consumer apply for coverage, including for related financial assistance, and enroll in a plan. Assistance from an agent or broker is of no cost to a consumer. Rather, agents and brokers are allowed to receive compensation directly from health insurance issuers in accordance with agreements with those issuers and any applicable state requirements.

Indictments from December 2024 and February 2025 highlight concerns about agent and broker practices in the federal Marketplace. Specifically, the indictments allege that bad actors enrolled consumers in insurance through the federal Marketplace by falsifying information on their applications. Additionally, according to CMS, the agency received approximately 275,000 complaints between January and August 2024 that consumers were enrolled in a plan or had their plan changed without their consent. Such practices can result in wasteful federal spending on APTC for enrollees who are not eligible. Further, such practices can result in harm and unexpected costs for consumers. These can include loss of access to medical providers and medications, higher copayments and deductibles, or repayment of APTC if income or other eligibility was misrepresented.

We previously reported that APTC is at risk of fraud. For example, in September 2016, we found that federal and state marketplaces approved coverage for our fictitious applicants. Nearly all of these fictitious applicants remained covered after we sent fictitious documents or no documents to resolve issues with our applications. Further, in July 2017, we found that CMS did not design processes to verify eligibility for APTC, including preventing duplicate coverage.

You asked us to review issues related to fraud risk management in APTC. This report is based on preliminary results and analyses from that ongoing work. Specifically. this report addresses preliminary results from our

1. covert testing of federal Marketplace enrollment controls'for plan years 2024 and 2025,

2. analyses of federal Marketplace enrollment data for plan years 2023 and 2024, and

3. evaluation of CMS's fraud risk assessment and antifraud strategy for APTC.

To perform covert testing of federal Marketplace enrollment controls, we created 20 fictitious identities and submitted applications for individual health care coverage in the federal Marketplace. We submitted applications for four of these fictitious identities in October 2024 for coverage through December 2024, which was the remainder of that plan year. We pursued coverage for plan year 2025 for all 20 fictitious identities, including the four identities for which we already submitted applications. Our covert testing for plan year 2025 is ongoing, since the plan year is not yet complete. As a result, we will describe additional details of the 2025 applications in a future report.

Our covert testing included applications submitted independently through HealthCare.gov, which is the federal Marketplace's website, and applications submitted with assistance from an insurance agent or broker. For all our applicant scenarios, we sought to act as an ordinary consumer would in attempting to make a successful application. For example, if, during online applications, we were directed to make phone calls to complete the process, we acted as instructed.

For applications for plan year 2024, our covert tests included fictitious applicants who provided invalid (i.e., never issued) Social Security numbers (SSN). Additionally, we stated income at a level eligible to obtain APTC. As appropriate, we used publicly available information to construct our applications for coverage and subsidies. We also used publicly available hardware, software, and materials to produce counterfeit documents that we submitted, if appropriate for our testing, when instructed to do so. We then observed the outcomes of the document submissions, such as any approvals received or requests to provide additional supporting documentation. The results of our covert testing, while illustrative of potential enrollment control weaknesses, cannot be generalized to the overall enrollment population.

To examine federal Marketplace enrollment for plan years 2023 and 2024, we obtained and analyzed federal Marketplace enrollment and payment data, including APTC information, from CMS. We also matched enrollee SSNs in the data to two additional data sources: (1) Social Security Administration's (SSA) full death file, a database containing records of death that have been reported to SSA, as of November 2024 and (2) April 2025 data from the Internal Revenue Service (IRS) on APTC reconciliation from tax forms filed for tax year 2023. We assessed the reliability of all data sets by performing electronic tests to determine the completeness and accuracy of key fields. We also reviewed agency documentation and interviewed knowledgeable agency officials about the reliability of the data. Overall, we found that the data were reliable for our purposes.

To examine CMS's fraud risk assessment and antifraud strategy for APTC, we reviewed documentation of CMS's policies and fraud risk management activities related to APTC. This included CMS's 2018 fraud risk assessment for APTC. Additionally, we interviewed agency officials about CMS's fraud risk management activities in this program. We reviewed relevant reports from GAO and HHS's Office of the Inspector General. We evaluated information from relevant documentation and interviews of agency officials against relevant leading practices in GAO's A Framework for Managing Fraud Risks in Federal Programs (Fraud Risk Framework).

To support all three objectives, we interviewed CMS officials and representatives from seven stakeholder organizations that represent agents and brokers, state insurance regulators, researchers, and one of the entities that CMS approved to host a non-marketplace website where consumers can apply for and enroll in a plan offered through the federal Marketplace.

The ongoing work upon which this report is based is being conducted in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our preliminary findings and conclusions based on our audit objectives. Additionally, our related investigative work is being conducted in accordance with standards prescribed by the Council of the Inspectors General on Integrity and Efficiency. Background APTC Eligibility and Enrollment Processes

APTC Eligibility

To qualify for a premium tax credit, individuals must be enrolled in a qualified health plan offered through a marketplace and meet certain criteria. These tax credits can be paid in advance through APTC. See figure 1 for the APTC eligibility requirements.

The amount of the premium tax credit varies based on household income and the cost of a benchmark plan. The credit limits what the consumer would pay for that plan to be no more than a certain percentage of their household income. The American Rescue Plan Act of 2021 made temporary changes to premium tax credits by expanding eligibility to higher-income individuals and increasing premium tax credits for lower- income individuals for tax years 2021 and 2022. For example, the law increased the premium tax credit amounts for eligible individuals and families, resulting in access to plans with no premium contributions for those earning 100 to 150 percent of the federal poverty level. It also expanded eligibility for premium tax credits to include certain individuals and families with incomes at or above 400 percent of the federal poverty level. Public Law 117-169--commonly known as the Inflation Reduction Act of 2022--extended these provisions through the end of tax year 2025. See table 1.

In 2013, CMS developed the Data Services Hub (Hub) to help verify applicant eligibility in an automated manner. To do so, the Hub matches applicant information, such as SSN and estimated income, against trusted data sources. These sources include records from SSA and IRS. In the federal Marketplace, the system generates an inconsistency when data matching processes are not able to verify applicant information against the Hub's trusted sources. When an inconsistency is generated, applicants are instructed to provide documentation to support information on their applications that cannot be verified by the Hub's data matching.

Marketplaces and Enrollment Pathways

States, along with the District of Columbia, may elect to rely on the federal Marketplace or operate their own health insurance marketplace. Table 2 describes the types of health insurance marketplaces.

The federal Marketplace offers multiple pathways to enroll in health insurance coverage and receive APTC. Consumers in states that use the federal Marketplace may enroll in coverage through the pathway known as HealthCare.gov or an enhanced direct enrollment (EDE) pathway, among others. Table 3 describes examples of enrollment pathways in the federal Marketplace.

Role of Agents and Brokers

Consumers seeking to obtain health insurance through the federal Marketplace may receive assistance from agents and brokers who help them apply for coverage, including related financial assistance, and enroll in a health plan. In return, agents and brokers receive payment (commissions or salaries) from the issuers of the health plans. Agents and brokers must be licensed in the state in which they sell plans and registered with CMS to sell plans through the federal Marketplace. According to CMS, most enrollments in the federal Marketplace are assisted by an agent or broker through the EDE and direct enrollment pathways.

CMS is responsible for oversight of agents and brokers in the federal Marketplace and ensuring that they comply with federal rules. Agents and brokers are required to, among other things, obtain and document consumers' consent before assisting them with applying for and enrolling in coverage through the federal Marketplace. For example, consumer consent is required before the agent or broker can:

collect or use any personally identifiable information, such as name, date of birth, and SSN;

help a consumer apply for coverage or financial assistance by completing an eligibility application on their behalf; and

actively enroll a consumer in a plan offered through the federal Marketplace.

After a consumer has applied or is enrolled, the agent or broker can also update a consumer's eligibility application or plan selection on their behalf, if the initial consent authorized the agent or broker to do so, or if they obtained subsequent consent for any new actions. Agents and brokers are required to make documentation of consumer consent available to CMS upon request in response to monitoring, audit, and enforcement actions.

Fraud Risk Management

The objective of fraud risk management is to ensure program integrity by continuously and strategically mitigating both the likelihood and effects of fraud, while also facilitating a program's mission. The Fraud Risk Framework provides a comprehensive set of leading practices that serve as a guide for agency managers to use when developing efforts to combat fraud in a strategic, risk-based manner. As depicted in figure 2, the framework organizes the leading practices within four components: (1) Commit, (2) Assess, (3) Design and Implement, and (4) Evaluate and Adapt.

In June 2016, the Fraud Reduction and Data Analytics Act of 2015 (FRDAA) required the Office of Management and Budget (OMB) to establish guidelines for federal agencies to create controls to identify and assess fraud risks to design and implement antifraud control activities. The act further required OMB to incorporate the leading practices from the Fraud Risk Framework in the guidelines. The Payment Integrity Information Act of 2019 repealed FRDAA but maintained the requirement for OMB to provide guidelines to agencies in implementing the Fraud Risk Framework.

In its 2016 Circular No. A-123 guidelines, OMB directed agencies to adhere to, the Fraud Risk Frameworks leading practices. In October 2022, OMB issued a Controller Alert reminding agencies that they must establish financial and administrative controls to identify and assess fraud risks. In addition, the alert reminded agencies that they should adhere to the leading practices in the Fraud Risk Framework as part of their efforts to effectively design, implement, and operate an internal control system that addresses fraud risks. The Federal Marketplace Approved Subsidized Coverage for Nearly All of Our Fictitious Applicants in Plan Years 2024 and 2025, Suggesting Weaknesses Persist

Our convert testing of enrollment controls in the federal Marketplace suggests weaknesses have persisted since our tests in plan years 2015 through 2016. All four of our fictitious applications received subsidized coverage through the federal Marketplace in late 2024. Additionally, although our work is ongoing, as of September 2025 18 of our 20 fictitious applications for plan year 2025 were receiving subsidized coverage. We will continue to monitor the status of these applications during plan year 2025. All Four of Our Fictitious Applicants Received Subsidized Coverage in Late 2024

To test enrollment controls, we developed and submitted four fictitious applications to obtain insurance coverage with APTC through the federal Marketplace. We applied for coverage for these four applicants in October 2024. We submitted the applications outside of the open enrollment period, using a special enrollment period for low-income applicants. in two cases, we applied for coverage directly through HealthCare.gov. In the other two cases, we applied via telephone with assistance from an insurance broker. The brokers that assisted us used EDE systems to submit our applications.

The federal Marketplace approved fully subsidized insurance coverage for all four of our fictitious applicants for November through December 2024. The combined total amount of APTC paid to insurance companies for all four fictitious enrollees was about $2,350 per month. While our fictitious enrollees are not generalizable to the universe of enrollees, they suggest weaknesses in enrollment controls--such as identity proofing and income verification--in the federal Marketplace through both HealthCare.gov and EDE systems. Table 4 summarizes the results of our covert testing of enrollment controls for plan year 2024.

The results of our covert testing for plan year 2024 are generally consistent with results of similar testing we conducted for plan years 2014 through 2016.

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Mr. SMITH of Missouri. Mr. Speaker, I have no additional speakers.

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Mr. SMITH of Missouri. Mr. Speaker, we have heard a lot of comments from the Democrats on this side of the floor.

Back where I come from, the comments that I have heard, we call it hogwash, because it has not been true and it has not been factual. This bill before you will lower healthcare costs for all Americans, not just the 7 percent that they are fighting for. It lowers costs for all 347 million.

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