do it. so i appreciate the answer from both of you, and mr. chairman, ideal back. >> thank you. mr. secretary, when you respond to the gentlemen could you also get back to the committee, because i think all of us are having that same problem in our districts. >> i will. >> committee will now stand in recess. we will reconvene at 1215. >> [inaudible conversations] >> and more now on the president 2014 budget request. the housing human services secretary kathleen cities will testified before the house ways and means committee about her department's budget.

the meeting includes $80 billion for the department, up nearly 4 billion from 2012. 1.5 billion would be used to set up insurance exchanges is called for in the 2010 health care law. the budget request for a chess also includes $400 million in spending cuts over 10 years for medicare. and other health programs. the chairman of the committee, dave camp of michigan is in the room. this is live coverage here on c-span. [inaudible conversations] >> here on c-span2 while we wait for the committee to gavel in, the health and human sophists service committee katherine fu senator tester, we will show you the comments of john boehner from wednesday as the president's budget was released.

>> while the president has backtracked on some of his entitlement reforms, and conversations we have, he does deserve some credit for some incremental entitlement reforms. he has outlined in his budget, but i would hope that he would not hold hostage the modest reforms for his demand for bigger tax hikes. why don't we do what we can agree to do? why do we find the common ground that we do have and move on that? the president got a tax hike in january, we don't need to be raising taxes on the american people. so i'm hopeful in the coming weeks, we'll have an opportunity to the budget process to come to some agreement. >> good morning. finally, the president has offered his budget to the american people. and what we see inside the

document is more of the same, spending, higher taxes, more debt. the speaker talked about the fact that there are some things in the budget beyond the tax increases that, frankly, we can find some agreement on. and i share the sentiment that we ought to see if we can set aside this divisiveness and come together to produce the results for the people that sent us here. if the president believes, as we do, that the programs like medicare, medicaid, social security are on the path to bankruptcy, and that we actually can do some things to put them back in the right course and save them, to protect the beneficiaries of these programs, we ought to do so. we ought to do so without holding them hostage for more tax hikes. as the speaker indicated, listen, the disagreements we have in this town are well published and well known.

but let's start a new and say, look, set aside the differences and let's come together on the things that we can agree on. i think most people do that in their daily lives and expect nothing less of us here in washington. >> well, now that we've seen the president's budget, one can the republican has won the past the house. the presidents does not house. this is a challenge that we have. nothing came stronger in showing that until yesterday. yesterday i took a group of freshmen down. we do that every monday and tuesday. other times we expand out another day. we walk into the room and watch the billions of dollars in seoul. and you watch it was buying them. interest rates happen to be low right now. just the increase in interest

rate itself would bankrupt us to put the addition day after day after day, this is the moment, the opportunity, and truthfully, in fairness of the american people, to put us on a path to a balanced budget. i look forward to the day we don't have to borrow an aspect of what we're going to as i took these freshmen members around, they look in -- [inaudible]. how long we are borrowing, for the month. will have to come right back again and do it one more time. pat toomey is a real challenge and the difference between these two budgets. this is an opportunity to come together with one simple goal, find a budget that will balance. as we remember the great leader, margaret thatcher this week, i

thought i would just share a quote in the words of market that you. you may have to fight a battle more than once to win it. as we stand before you today, it's the same battle. it's a battle for america's future, for the policies that are going to make america strong, that are going to create jobs, that are going to make a stronger economy, that are going to keep taxes lower so that families have more take-home pay. and that also that the congress is doing its job as far as putting forward a budget, ours that houses intenders and to a certain confidence so people can make decisions and move forward. the reason it is important is because it does impact of the college graduate trying to find jobs. it infects families that are continuing to struggle. the seniors that cannot have confidence with the safety net programs. when i was home over the break,

i continued to hear this message everywhere i went. the continued concern over our economy, the struggle to find jobs. the uncertainty over what tax rates are going to be are what health care reform is going to bring moving forward. and our responsibility, our basic responsibility is to get a budget in place. and one that balances in 10 years is one that will provide the confidence and certainty for the american people that they need so that america will be stronger and better country. >> all of that in our video library, c-span.org. the hearing getting under way. kathleen sebelius testifying before the house ways speak we have the secretary shear yesterday. we were not able to get entire pentagon will not recognize subcommittee chairman -- for his opening statement. >> thank you, mr. chairman. secretary said this, thank you for joining us today to discuss the president's 2014 budget.

one of the top orders for this committee is to act now, save medicare so every generation of seniors can count on it. a welcome inclusion of some conceptual reforms to medicare including recognizing the urgent need for permit solution to they can continue to treat our seniors. and improvements to the current medicare structure to modernize cautioned. our the president's budget falls far short of what's needed to save medicare. the trustees tell a system portal programs going broke sooner rather than later. the white house and congress need to act together now this year to save medicare for the long-term. i challenge and the president to save medicare for its own state, not conditioned upon tax increases in hard-working americans that has nothing to do with medicare. this committee will act at the direction of chairman camp, will convene issues of hearings

beginning next week to examine bipartisan solutions to save medicare, some supported by the president. i invite you to join this committee in working toward long overdue action to protect, improve and strengthen medicare. both republicans and democrats can agree americans need the right kind of health care reform, reform that lowers costs, improves health and protects the vulnerable. but many americans are concerned the affordable care act may not be able to deliver. they have real concerns about how the law will affect their personal health care. the presence law will cause health care cost to go up while the quality of care goes down. this white house repeatedly promised it would lower costs by thousands of dollars for individuals and families. that americans would not lose the health insurance they have in light, and yet he recently admitted that the mandate in the new law will make health care premiums more expensive. and this week he won almost 25 million americans will lose

the insurance they get at work. clearly, the president's new law is not helping families or local businesses, and this budget does nothing to offer them relief. to add insult to injury, as our economy continues to struggle and millions of americans have given up looking to work, the health care laws resulting in fewer jobs and frozen wages. forcing local businesses to replace full-time jobs with part-time jobs. in one survey, over 70% of small businesses said the president's health care law prevents them from hiring new workers. another study found it would put over 3 million jobs at risk in the franchise industry alone. as one small businessma businesn virginia stated, i'm convinced the primary reason we are seeing a robust economic recovery is the uncertainty and costs associated with this health care law. in a wood pallet plant that i toward in texas, the company owner told me the extra health

care costs and the presidents of new law is equal to opening two new plans and adding 100 new workers. our local businesses and their workers are worried. they're asking what are my health care premiums going up. why am i losing health insurance i had? and why does washington keep steeping on new red tape and keeps me from growing my business? these are series questions i hope you can answer today, madam secretary. on top the $2 billion already spent to set up the bureaucracy for this new law, the president's budget seeks one and a half billion dollars more, including adding 1000 new irs employees to assure americans comply with the new taxes demanded. what we really need are 1000 new doctors and nurses, not more irs agents. and, finally, will the white house be able to deliver on october 1? three full years after the law was passed, this administration seems in disarray as it rushes

to set up the health care exchanges by that date. with just six months ago, no one has any idea how many and which americans will be forced into the changes, how they will operate, what the health insurance plans will look like, or if americans private information will be protected. patients, local businesses and those expected to deliver health care are extremely concerned. many americans believe that so far this has been nothing short of an absolute nightmare. madam secretary we're looking for you to honest, specific answers of we know you will, our families and small businesses deserve to know. i will now recognize ranking member lebanon for his opening statement. [inaudible] >> at this point we recognize the health subcommittee ranking her, mcdermott, to deliver his opening statement. >> thank you, mr. chairman. well, madam secretary. i've enjoyed working with you during the president's first

term, and i'm very pleased that you decided to stay. others have left, and i'm sure that there are things that might be attractive in leaving but your willingness to the stay and serve the people should be recognized because this is a very daunting task that you face. implementing the affordable care act on top of managing medicaid and medicare will not be easy. in rolling millions of people by the end of the year is a herculean task, which is why the leadership you provide is so critical to your experience both as an insurance commission and the governor, you know what it's like on the other and so it's going to be very important to have you at the top talking about what happens. the president's budget really is an effort to reinvigorate common ground and the common good. unlike our colleagues on the other side, the president has been clear about his willingness to tackle the tough issues. unfortunately, it doesn't mean much when the house republicans

leadership refuses to engage in meaningful conversation about shared sacrifice our deficit reduction. you just heard that we are three years into this. well, what they did for the last three years was a would not negotiate. and, in fact, republicans have been unrelenting in their zeal to get rid of the aca even though it's the first serious and successful attempt ever in this country to curb health care costs. it's projected to reduce the deficit, even with its benefit, by more than a trillion dollars over the next few decades. despite 33 house vote for repeal, the supreme court ruling and a presidential election results, their efforts to destroy the law continues. we know they won't get rid of it, and they know they won't get rid of it. john boehner even said the other day that it's a law of the land. i also know that there's more than one way to skin a cut. republicans know that the best way to reach secure a government that won't tax or regulate them

is to create a government that can't do anything. start the programs and people will -- it was obvious they did. they are budget rate has caused by repealing medicare improvement in into medicare as we know it from people nearing eligibility by turning it into a voucher program. ironically, the cbo says the republican medicare voucher proposals would lead to higher national health care spending. we dealt with access with the aca. we now have to deal with costs. that's what is the implementation that we're going to be into presently. their policy is not a clever one. it doesn't lead to better to lead to better get to it isn't these ethically or fiscally

responsible. in contrast, our medicare reform in the aca were based on reality, not rhetoric. through our efforts in medicare's per-person growth rate are historically low and rejected remain so for the foreseeable future. solvency would -- with significant weight expanded. which will create a program that favors value over volume and help drive the right cause, the writer to the right patient at the right time. it hasn't been easy. but that's what i am glad you are still here. no one is better suited for the job that you understand the importance and the complication of state partnership. and you are asking for what you need. one and a half billion dollars to get insurance -- uninsured americans health care, to establish sustainable spending, and tackle the number one cause of pursue bankruptcy, that's a bargain at 1.5 billion.

hhs staff are to be commended, especially those at cms because they worked tirelessly to improve changes that overhauled nearly every medicare payment system. they are doing a whole new infrastructure on the promises of aca, and they have done it on a shoestring. we know you don't have the resources you need, and the job has been made infinitely harder by false and misleading attacks by opponents. enough is enough. it's time for my republican colleagues to work with us and the administration to ensure effective implementation of what the american people are demanding. a simpler, more fair health care system that is established by the affordable care act. they had four years of advertising against it, and they reelected the president overwhelmingly, because he put in place. i hope today's conversation -- and look forward to your discussion. >> thank you. welcome to the ways and means

committee, and we have you written testimony. you are now recognized for five minutes. >> well, thank you, chairman camp and ranking member levin, subcommittee chairs, and thank you ways and means committee for the opportunity to discuss the president's 2014 budget for the department of health and human services. i think this budget directly supports the overall goals of the president, by strengthening our economy and promoting middle-class job growth. it ensures that the american people will continue to benefit from the affordable care act. it provides much-needed support for mental health services, and take steps to address the tragedy of gun violence. we are proposing to strengthen education for our children during the critical early years, to ensure they can succeed in the 21st century economy. the budget secures america's place as a work later and health innovation so remains a magnet

for jobs of the future. and helps to reduce the deficit and a balanced, sustainable way. i look forward, mr. chairman, to answer your questions about the budget, but first i want to just share a few of the highlights. the affordable care act has already benefited millions of americans, and our budget make sure that we will continue to implement the law. by supporting the creation of new health insurance marketplaces, the budget will ensure that starting next january, americans in every state will be able to get quality health insurance that fits their budget. our budget address another issue that's been on all of our minds recently, mental health services, and the ongoing epidemic of gun violence. we know that a vast majority of americans who struggle with mental illness are not violent, but recent tragedies have reminded us all of the staggering toll that untreated mental illness can take on our

society. and that's why we are proposing a major new investment, to help ensure that students and young adults get the treatment they need, including training 5000 additional mental health professionals to join our behavioral health workforce. our budget also supports the president's call to provide every child in america with access to high quality early learning services. it proposes additional investments in new early head start child partnerships and provides additional support to raise the quality of child care programs and promote evidence-based home visiting for new parents. together, these investments will create long lasting positive outcomes for families, and provide huge return on investment. as we prevent the next generation of americans to succeed in the 21st century economy, our budget also makes sure that america remains the world leader in health innovation. a significant new investment this budget contains for nih

reflect our commitment to furthering the biomedical research will help create good new jobs and advance the cause of tours in medical science. the new investments in health i.t. will allow us to continue to support the developed and use of compatible electronic health record systems that have huge potential for improving care coordination and public health. even as our budget invest for the future, it also has to reduce the long-term deficit by making sure that programs like medicare or put on stable fiscal trajectory. medicare spending for beneficiary grew at an historically low rate of .4% in 2012, four-tenths of 1% in 2012. thanks in part to the successful application of the affordable care act's $800 billion in saving provisions have strengthened the medicare program. the president's 2014 budget

achieves even more savings. for example, the budget allows low-income medicare beneficiaries to get their prescription drugs at the lower medicaid rates resulting in savings of more than $120 billion over the next 10 years, without sacrificing their drug benefits. in total, the budget would build on the afford will care ask cost measures generate an additional $371 billion in medicare savings over the next decade, reducing the deficit, including medicare on sounder financial footing. our budget also reflects our commitment to aggressively reducing waste and fraud in all our programs. we are proposing an increase in mandatory funding for our health care fraud and abuse control program. and initiative that last year alone saved taxpayers nearly $8 for every dollar that was spent. and we are investing an additional efforts to reduce improper medicare, medicaid and

chip payments and to strengthen our office of inspector general. what all this adds up to is a budget that will equip hhs to support the administrations north star of a thriving middle class, promote job growth and keep our economy strong in the use to, while also helping to bring down the long-term deficit. and i know many of you have questions that i'm happy to take those now. thank you, mr. chairman. >> thank you very much, madam secretary. >> welcome, madam secretary. i'm concerned about the impact the presence health care law will have on the small business in my district. hhs recently announced the delay of the choice option for small businesses in the 33 federal exchanges. the small business majority, a group that has been a witness before this committee, called your decisions a major letdown for small business owners and their employers.

operational challenges have been cited as the region for delaying the choice option. can you please detail exactly what these operational challenges were, and the specific problem ultimately lead you to delay the program? >> yes, carsten, i would be glad to answer that. bishop exchange will be up and running in every state in the country in 2014. the shop is a small business market exchange. in it, small business owners who now pay about 20% more than their larger competitors for insurance will finally have competitive choices, transparency, and an ability to leverage the kind of buying power of the large competitors have. bishop exchange as written -- the job exchange has to compose, one was a choice for business owners and that will be up and running, and the second was an opportunity to offer those

business owners them to give their employees and provide a choices and plants. a lot of feedback from both insurance companies and from some business groups indicated that that would be a very hard second tier to get set up your one. so what we're determined to do is in at least the federal exchange, and the state basic changes can have the full program up and running because they are just doing one state and the federal exchange, every small business owner will have a choice of plan, will have competition and will be automatically in a larger pool with rates that the small, the congressional budget office has estimated will be significantly lower than what they are able to pay right now. what will happen in year two, congressman, is those employees then come if they choose, can give employees a wide choice of plans with an aggregated premium. that's the only portion that is

being delayed. >> but what specifically led to the decision to delay that program? >> it really was feedback mostly from insurance companies and others that operationally to try and get the aggregated premium, although choice plans available up and running year one, would probably do some major glitches. we really took that advice seriously. so all business owners will have an opportunity to have competition and a choice of plans in the small market. and then again, in year two, offer from then on the opportunity for their employee to choose among a variety of plants. >> due to the delay do you believe that some small businesses will choose to completely drop their health coverage for employees and opt to pay the fine and not pay coverage because i do not, sir, because what what we know is the employer will have its of the employer will have a competitive

market for the first time ever. that will be up and running in every state in the country. was the law then says is that the employer, if he or she chooses, could offer employees a choice of every plane in the market. that's the phase that will not be in place at least and the federal market until year two. so employer choice will still be there. the smallest employers will qualify for and up to 50% tax break to offer their employees coverage through the shop. they will have negotiated rates. they will have to and 50, they will have competition, and be part of a larger pool that right now they don't have. >> do you anticipate making the same decision to delay the implication of the exchanges and the entire affordable care act? >> no serve. will be up and running in every state in the country october 1 for open enrollment in january 1, 2014, for the plans to begin.

>> as a follow-up question, has hhs made any preparation or how to meet the added cost of providing care for the potential 10 or 12 million people that might gain permanent residence status under any kind of immigration bill? >> we don't do anything about what congress may or may not do in the future. no, sir. >> so there's been no preparation made whatsoever or that larger group of? >> we're working with the law as it is right now, and believe me, we have our hands folded on to make sure that the law the land is carried out spent all right. think you. time as expected mr. thompson is recognized. >> madam secretary, thing to do much for being a. i want to second my colleague, mr. mcdermott's comments, on how pleased we are that where you are, you are staying. it's been a pleasure to work with you through the rollout of this measure. and you and your team has been

fantastic. it's going to require that you continue that as we do, as you do the rest of the implementation. it's disheartening to me that so many people are working so hard to discredit the affordable care act, rather than to make sure that it works and that our constituents, the american people have access to quality, affordable health care. that's another reason why your work is so important, to make sure that we get over what i am sure will be a bump in the road when we look back on this. aske..

rod and abuse that are acs are called where you are working with hospitals to figure this out. can you talk about that? >> talk to me about it now or get back to me on it but especially small hospitals where they are having some trouble going through all of the procedures associated with the

racs. i recognize we're saving medicare money doing it and i recognize we have to do it. i just would like to know how it is being done, specifically the provisions on the education and training portion. >> the two facets of the fraud initiative, one is improper payment. as you know, many improper payments are not fraud, they are mistakes and their clerical errors so we are ramping up fairly dramatically the technical assistance, the effort to work in advance with providers to try at the outset the bills are submitted correctly that we pay the proper amounts correctly that we don't spend a lot of time not only dinging hospitals or providers,

and recollects that money and what i was commenting on which saves $0.08 on the dollar, $8 on the dollar, new effort for the attorney general and i to partner and has resulted in amazing collaboration at u.s. attorneys on the ground, state attorneys general with the so-called peak taskforce including our office of inspector general and members of the justice department and ramping up the prosecution of individuals who are bent on stealing health care dollars from consumers so we have had an unprecedented number of not only take down operations, sting operations but returns to the federal treasury in both medicare trust fund payments and medicaid payments to the states that are really resulting in

making sure people understand that this is a bad way to steal money from the government, bad way to seal medical services so we are hoping mandatory requests for new resources would be granted. it is one of the single best investments with an 8-1 return and we have three years of a very impressive track record to share but we would like to ramp those efforts up. >> can you get back to me on the education and training piece? >> i would be glad. >> i yield back. >> miss black is recognize. >> i want to go to the issue of the navigator program. you recently released a preliminary rule for the program that is enacted in the health care law, the effort that was released last week reported you expect to pay these navigators $48 an hour. h h s has not released the estimate of the total number of

workers in this program, it has to be reported that california is requesting 21,000 of these navigators and cost taxpayers 1 five million dollars, and release estimates on how many workers they need to support the navigator program in their state? >> there are two issues. the funding proposals that was released by our department is aimed at states where we, the h h s, will be operating a federal marketplace, that is not california which is going to have a face based market. in california resources, paving the california navigator program. this is really an effort to make sure the 40 one million eligible uninsured americans some of whom never had health coverage before are aware of the law, aware of how to sign up for the law and

have some assistance and help along the way to understand the benefits and make good choices for themselves and their families. we do not have a salary scale sets in the funding proposal. we are trying to make estimates of a range of scales that was recommended to us by community groups on the grounds that that is not an hourly rate. >> you don't have an hourly rate at this point. it was reported as inaccurate. >> we tried to estimate an amount based on what we found community workers and community groups charging on the ground but we are looking at competitive funding proposals and payment to these navigators has nowhere nearly been established. >> so it does things that have chosen to do their -- paying for

their own navigators'. that you go in and run the federal program and pay for the navigators of those states. is that correct? >> yes. >> if the state has chosen to do it they won't get assistance or grants or money to help from with their navigator. >> run by the federal government will be paid. >> states that have chosen to run their state based exchanges have planning dollars available to them and operational dollars, and fully up and running, and the fees for the insurance companies operating in their exchanges with the operational costs. and the affordable care act, this grand announcement is for the states that have -- that we will be operating in a federal marketplace. >> it is a very complex

application from what i and his stand, 15 pages long run by three different agencies. is there a way to take some of the complexity of the the application? >> the navigator application? >> application for someone to apply for the program itself to getting to the exchanges. >> to get health insurance? >> that is right. >> first of all, we are working hard to i think make the application as user-friendly as possible. to give a little perspective, i have seen some reports about how daunting this will be. we look around the country and the average health insurance application, if you would go get a paper file from california or nevada or georgette is in the 20 page range. a life-insurance application is about 23 pages long right now in the market. we are trying to make this a more user friendly proposal.

what we know is this will depend on how complicated the family situation is if someone is single and looking for insurance or has relatively simple tax situations could take 15 minutes to check on line if it is a complicated family situation warranted take longer and require more information. there is a tension between making sure we verify correctly the income levels and what is actually eligible. >> i see my red light. madame secretary, what i would like to know that i don't have time to ask, if you could send to my office in writing i want to know what the qualification, educational qualifications will be pretty navigators'. i also want to know why the brokers that are already educated in insurance are not going to be eligible to be a

navigator. if you the response to my office. >> mr. blumenaublumenaur. >> a must seem thrilled for you because you hear tales of woe and doom and gloom and problems in the health care system all of which were very much in evidence for ten years before we pass the affordable care act. and he made clear in many presentations about s that are already underway. the reforms are making a difference. and this congress chose to accelerate reform, chose to kill the windmills attempting to repeal it. and cutting away the resources you need to do difficult job.

i find no small amount of irony that a congress could not summon the courage to close military bases, instituted independent commissions to help them. now there are howls of outrage that there may be an independent commission if congress doesn't do its job dealing with health care reform costs in the future. but i have two questions i would offer up for you. one deals with the notion of where we are in terms of actual health care savings. it has been documented by independent sources that health care reform will produce approximately $1 trillion worth of net budget savings over the next 20 years. there is work underway and i again deeply appreciate the flexibility and partnership of the department working with my

state in oregon accelerating those reforms and if successful, it is tough but looks like there is an opportunity, it would produce savings if they're taken on a national level that would achieve over $1 trillion in ten years. the first question you might comment on some of the reform opportunities you see in oregon and elsewhere. my second question and i don't think there is time to get into it in five minute that i have, i follow written response, deals with areas that don't have to be partisan and we could move on quickly to accelerate reforms. i suggested to colleagues on the health subcommittee we could take for example a piece of legislation and monitor co-sponsor with my friends that would have a secure id for medicare recipients that might cut down on fraud and mistakes. i have bipartisan legislation

that deals with end of life care. 90% of the american public actually support having some assistance, helping them navigate those difficult challenges. we have bipartisan legislation with dr. rowe, mr. hannah, dr. mcdermott, that would give what 90% of the people want, supported by the hospital association, insurance companies, alan goodman's conversation project that will be coming next year. i would like to know in writing if we can work with you and your department to try to make some progress, helping americans be able to deal with the challenges a case that end of life and making sure they know their choices and whatever those choices are they will be respected. i appreciate that in writing but maybe you can talk about health care reform in the remaining time. >> thank you, congressman. i think while there is a lot of

attention and focus on what is happening in the insurance market which will affect a relatively limited number of americans, what is going on in the delivery system that the offers of the affordable care act and those who support the affordable care act throw into the bill is to me the most exciting and has the biggest potential for long-term gain and it really deals with delivery system reform that affects everyone whether or not they have coverage now and whether they will be in the new market, whether or not they will have new choices for insurance. oregon is one of the country's leaders. no question about it. we are also seeing a number of other states, we are working closely with arkansas, with massachusetts, with others who are really trying to do a couple of fairly straightforward

things, better patient care, better protocol when a patient hits the health care system, better public health, looking at prevention programs that actually lower costs, care improvements that improve the deficit and lower costs. what we are seeing is some pretty dramatic improvement already. there is real hope that those kinds of system changes could produce not only long term financial benefits but long-term health benefits. america still spends almost twice as much as any developed country in the world on health care per-capita. we have more people uninsured than any developed country in the world. without health benefits. and we live sicker and die younger than most of our competitors. that is not a great formula for global competition. >> thank you.

time is expired. mr. young is recognized for five minute. >> thanks for being here today, thank you for your service. today you have a short this committee that the exchanges will be pursuing to the affordable care act, on time and functional october 1st of this year. encouraging to hear because it is in fact the law. i know there's a lot of anxiety with my constituents and other stakeholders about this matter. there's also some anxiety with the release of this budget, certainly the anxiety that i harbor about the costs of these exchanges and implementation. the president's budget has hhs spending $1 billion on exchange grants of 2013, an increase of $300 million compared to last year's estimate for fiscal year 2013. despite the fact of most states have chosen not to create their and exchanges but also

anticipate an additional $2.1 billion in spending on exchange grants in fiscal year 2014. through the or regional what congress appropriated $1 billion for implementation but you, madam secretary, were given unlimited authority to fund state exchange grants through 2015. press reports say there are $235 million left in the law's original implementation fund. can you confirm that number or tell us how much the department has spent on the exchanges so far from other funding sources these expenses are being funded? >> i think that if i heard correctly there were a lot of numbers in your question. you conveyed a fairly accurate picture. when this bill was passed in 2010 the congressional budget

office estimate was $10 billion administrative costs to full implementation of the law. and you are correct. there was $1 billion appropriated. 1/10 of what nonpartisan cbo recommended the the cost. we have done an extraordinary job, frankly, here in 2013, allocating and using judiciously the $1 billion that we had. we do have two thirty million of those dollars left. we will use of those and additional resources in 2013 and we have asked for additionally $1.5 billion in 2014 and that he is really to get the i t hub, the call center, the items up and running and -- >> i am aware of the significant logistical and information technology challenges of this.

some would say the design of the project may have been too ambitious but nonetheless certainly sensitive to that and all the good people who are working on such implementation -- >> the good news is we are well under what the budget estimates were. >> but $1 billion with the originally authorized in the original law, congress provided. that was with -- it was said, was required by this body when it passed the affordable care act. but we have a doubling of the projection for setting of the exchanges by congress and this is with less than half the states participating and i guess i have a concern that if more states did participate, that would cause the cost of exploding even further. is that your estimation? >> no, sir.

i think that characterization is a little bit misleading. we have right now 31 states and the district of columbia running all or part of the up and coming market places. the two thirds of the state are actually engage. some are not running the entire program. they are running the plant management part or consumer outreach or both or running the entire thing. in the remaining states, we will be setting up the entire exchange, but we are in conversation with a lot of states who said we would really wants this gets up and running vcr selves taking it over. >> finally, you receive additional funding requested. is this going to preclude the ability to launch the exchanges on time and if not, what is your contingency plan? presumably there is one. >> we are confident that we will

launch the exchanges for open enrollment october 1st. it is billed and paid for have every opportunity to look at my transfer of authority within hhs and fallers that we have but you are right, we have a law that is the law of the land, the supreme court has confirmed its constitutionality. there are millions of americans looking forward to the benefits and we have requested additional resources to make sure -- >> thanks so much. time is expired. mr kinds recognize for five minute. >> thank you so much, we do appreciate your service. outside the president, john boehner, the last four years, it may be a little tougher, crucial

phases of implementing the affordable care act but just today it is refreshing that we have colleagues on the side, concerned about hhs moving too slowly. i share the concern about the delay, in particular the impact on small business and its and small group markets but i want to ask the question, sustainability and cost containment we are already starting to see with these reforms, it is a great story that really hasn't been told and the law is starting to slow the growth of health care costs. it is the lowest growth rate in over 50 years. medicare for beneficiary spending rose as you pointed out in your testimony 0.4% in 2012, medicaid beneficiary spending dropped by 1.9% in 2012 and one of the great untold stories that happen the little over a month

ago, cbo recalculation is misleading your cost figures on medicare and medicaid, cbo determined medicare and medicaid announced $7 billion less over this next ten year period than previously estimated. medicare would save $382 billion reduction in spending, roughly 3.5%, medicaid $239 billion reduction and the question will be whether this is sustainable but there are more instances of cost containment, cost recapture that you and your department have gone after. nearly $15 billion in fraudulent medicare payments are being recaptured because of the force when we get you on the the affordable care and hospital readmission down $75,000, hospital based rate, and writing that dialogue, and $2.1 billion

in savings, the health care law in health-insurance rates. and and having a real impact. the growth of private plan premiums is also slower. it hasn't in a story told that much. annual premiums, and down 4%, and some of the last 13 years so this is a real progress when it comes to cost containment. especially in budget deliberations where health care spending is the largest and fastest-growing area of spending in the federal budget. we're seeing real progress but we have 250 new affordable care organizations, a new model, delivery system and payments, so it is quality, not quantity based payments anymore. it is striking the president's budget before us finds more

savings in medicare over the next ten years and the republican budget does and that is because we understand as we move forward on reform we don't have the luxury of waiting ten years before we start reforming the entire health care system. we have to be doing that. it has to be a comprehensive holistic approach. this is a tremendous excess initially in the first three years, passage of the affordable care act. i am wondering your opinion will cbo's calculation of reductions, and structural reforms. and that is your opinion. >> i think that you have enumerated. and there is a still positive story to tell on cost-reduction.

and that is with additional benefits for beneficiaries. and with additional coverage, it is not sacrificing the beneficiary for cost savings. and it is really enhancing the benefits that people are receiving. and there's an opportunity with the delivery system reforms that you, mr. kind and colleagues made sure were part of the affordable carry from the outset. driving scores, value based payments, looking at strategy to make sure medical protocol was appropriate and paying for them, reducing, has hospital readmission as in the system. and and bringing them in at a

more expensive that some point in time. and the more expensive, least effective point in time and really working with prevention efforts around obesity and smoking which are beginning to show again positive signs. this has enormous opportunity and potential to make sure cost-containment strategies continue into the future that help improve more americans at the same time. >> mr. kelly is recognized. >> thank you, mr. chairman. thank you for being here. >> one of the questions i have is a company called health patient care.

and rehabilitation facilities. and that was not a gotcha, and to build the economic model based on future payment that will repay, it is difficult for people to develop any type of business. what was the policy that drove that. >> there is an enormous amount of analysis of the health system that goes on with every market update, every market proposal and it looks like, and where we are seeing aggressive coating in some instances, to recover where regions of the company have tremendous differences without variations so i would say there is an ongoing, enormous analysis

and john plomb who is sitting behind me who is deputy in charge of medicare services, and with each market basket update there is also a public display and a lot of feedback because we are always trying to balance the effective cost strategies with beneficiary needs. >> that is one of the things, the patient protection affordable care, the attentions were great. the reality is really staggering and it is the uncertainty, the unknown part of it. and costs keep changing. and and any road will get you there. we really attack providers. i am back home and independent hospitals have health care, we continue to say the problem is, the providers are making too much money. we have to dial that back. they're making too much money. i got to tell you from being in

the private sector my whole life i have never been in a situation where you just don't know what it will cost going into the future and one of the things the patient protection and affordable care act has done, i don't think this is intentional, it has driven a wedge between employers and employees, between the owners and the business and the associates, forcing people who have had long-term relationships, first communions and weddings and funerals and portraying the odor of the business as someone who doesn't want to do something for his associates and a lot of my friends, phil patterson in here for example, what we have to do to meet this, he has got to make some part-time employees. i look at work we, i 540 hours is the work week. no, it is 30 hours. ten or 15 or whatever we need to make the numbers work. this is what bothers me and really scares the living daylights out of small business people they don't know where

they're going. and doesn't know where they're going. and escalating and escalating, other than washington d.c. where all you have to do is fix somebody of to shake money out of their pockets for people who actually have to go to work every day with a plan to be profitable. ..

the bill was 2700 pages and it still being written today? so if i were to ask where do you think this ends? wind we finally know what the cost is going to be? not all these wonderful things that could happen in the future but in the reality of today, for people who have to make a payroll, for people who have to keep their associates in tact. they train them, these educated them, they've provided tools for them and now - we are forcing them to separate that relationship that they had in making them -- they are against each other and that's what i don't like about this. the idea is great. affordable, accessible care for everybody. the reality is it's not affordable. it's never going to be affordable. >> time to start.

mr. pascrell is recognized. >> secretary, thank you for being here again today. many times you've been here before. i have a question on the president's grain initiative. i have a question on the president's grain initiative. one of the investments i think is particularly worthwhile as the co-chair of the traumatic brain injury task force i'm well aware of the advances that we made in research on the brain in recent years. pretty fantastic. some good came out of the two wars will be facilitated and accelerated this effort and got the dod to understand what their responsibilities or but it took us a long time doing it but in a

bipartisan way we have to accomplish that. according to the center for disease control and prevention each year, an estimated 1.7 million people sustained a traumatic brain injury in the country. unfortunately, tbi is a contributing factor to a third of all injury related deaths in the united states. a 30.5 to be exact. beyond these numbers come tbi has become a signature will end of both iraq and afghanistan. 20% of the soldiers deployed are estimated to have experience with some form of brain injury. so it is clear brain injuries can impact anyone at any time. it's really flowed over into the research and development and the sports and our own country, male, female, all kinds of

sports. and we've seen in our lifetime in the last five years the nsl finally owned up and they are doing a great job to reverse what has been become a horrific situation. this is a 100 million-dollar commitment is not just coming from your department, but can you speak to the goals of the brain initiative for all of us? >> congressman, i think it is one of the exciting next to rise and dr. francis that runs the institute of health sees this as a project that has a lot of parallels to the mapping project. we need to map because whether it is looking at alzheimer's disease or the kind of brain injuries that you've identified that wounded four years are suffering or the concussions that affect our kids, we don't know enough about what is both happening to people and how to deal with it, how to prevent,

slowdown, rehabilitate some of these injuries and traumas. there is a public-private partnership initiative announced which will include private foundations that are already working in the brain space. the department of defense who has a great deal of interest in this topic as you correctly outlined the national institutes of health where the institutes are already doing critical research but could accelerate that further and really in a shared collaboration do the kind of multi-year brain mapping accelerated cure strategy that has been successful in a number of other areas. >> i've seen the help now as opposed to six years ago with our service members. and it was a catastrophe in the

beginning. soldiers are now being saved, which obviously was not happening. and this is a tremendous effort with many departments that are involved. how do you think service members are going to be helped potentially? in your mind? >> i've had the opportunity in the not too distant past to visit the amazing research facility at walter reed which is looking at a lot of these cutting edge strategies in terms of rehabilitating the wounded four years, and i think the research going on, again, trying to identify exactly what happens when an ied blows up and what post-traumatic stress syndrome is actually causing to happen in the brain and how that can be dealt with in the future. that has, you know, a clear impact on hundreds of thousands

of soldiers who are returning and trying to resume a normal life. so the faster we can accelerate this, -- i mean, we know how to treat their limb injuries and we know what has to happen if the need to be stitched up. we don't know nearly enough about what has happened to their brain and nervous system, and i think the faster we can get to this research the more help we can give. >> thank you, madame secretary and mr. chairman. >> mr. griffin is recognized. >> thank you, madame secretary, for being here. appreciate your service and answering questions today. i believe and health care reform. i believe we need health care reform. and what i am particularly concerned about is reform of medicare my mother relies on, and medicaid which is not in the committee jurisdiction. what i am concerned about

long-term permanent reforms, not tweaking at the edges i believe that we need to strengthen these reforms so they will be there for my generation. i believe they will be there for my mother but i'm worried about my generation and the next generation. and i am particularly confirmed about what we call in washington mandatory spending squeezing out a lot of the investments that we need to be making in breast cancer research and nih, alzheimer's. a lot of people may not realize that a lot of that is from the discretionary side, and the longer we leave the mandatory side without reform, the more pressure it puts on those critical investments. and so that brings me to -- you mentioned arkansas.

i know there's a big debate going on with arkansas and you've been working with of the governor down there on medicaid expansion or some alternative to that. my view is that we ought to have permanent lasting reforms all over the country like what was approved for rhode island and early 09. but i want to ask a few questions specifically about what's going on in arkansas. did you -- and i have some of the correspondence with the governor. i know you've met with him. have you met with any of the legislators in the house or the senate from arkansas? >> i have not, sir. >> would you like to meet with any of them or be willing to meet with any of them? >> we really delayed the medicaid program runs and we negotiate with the state. >> okay. >> have you seen the bill that is --

>> no, sir. >> -- that is floating around. >> so if this bill and the votes coming up soon pass the senate it's going to come up in the house soon, at least the appropriations for it. the bill itself i think passed yesterday. if this passes, have you decided whether to approve it -- >> no search. >> -- okay. so that's not approved? >> again i may former legislator, former governor. as you well know, anticipating what any legislative body may do before they do it is probably not a very beneficial expenditure. >> i'm familiar with that. so your staff hasn't seen -- i mean, the bill has been published -- >> i assume that my staff is in close touch with the arkansas staff, but again, we have not looked at -- when the bill passes we would be happy to take a look at it.

>> gotcha. i am very concerned about how we pay for the estimated 630 billion that will cost for medicaid expansion. i believe we need to take care of our most vulnerable, but i am afraid that we are setting expectations and making promises that we are not going to be able to keep. and so i would just continue to advocate -- fi will continue to advocate for long-term, lasting permanent reform of medicaid, and i believe you would find a lot of people on this side of the all who are willing to work with you in fashioning reforms that will make our medicaid programs stronger. the same with medicare. extend the life of its and raise the quality-of-care for people. thank you for being here today.

>> thank you very much. mr. davis is recognized. >> thank you mr. chairman. madam secretary, let me thank you for appearing. but more than that, let me thank you and your staff for the way in which you have handled any one of our most precious commodities, and that is healthcare for the people of these united states. i think what you have done and continue to do an outstanding job. i was pleased to note as you explained in the options that exist for small businesses, something that people have been trying to deal with for many years without coming up with anything that was going to be beneficial or helpful. i was also pleased to note the changes across the board seem to be on target.

that is they are moving right along notwithstanding all of the criticism, all of the efforts that they have been to discredit that approach and to discredit them. it to questions that come to mind i am pleased to note that health education and health awareness and promotion, the utilization of individuals that interact with the general public provided them with information come early screening and detection i think all of these things generate cost savings that are sometimes almost in measurable. let me ask you how has the prevention, early detection screening, these aspects of the

plan been working in how people make use of them? >> well, congressman, one of the very important features in the affordable care act is a direction to shift from acute care to preventive care, and that is contained in all aspects of the bill, so insurance policies in the private market now have reduced the financial barrier for people to access the benet care, no co-payments and colon cancer screenings, vaccinations for kids, things we know will keep people healthy in the long-term or identify the problem early enough that it can be life-saving. medicare benefits now have more robust even after strategies including a yearly wellness check up in a plan to sit down with a health care provider and mcginn strategy for the future,

something that we know is benefiting the 54 million seniors who participate in the medicare program. but there are also now community strategies under way and efforts to really through our community health centers, through community health workers try to prevent hospital admissions by delivering care strategies at an earlier point coming getting school based health clinics into underserved areas so that children and their families have access to care providers. so i think all of those strategies are aimed at reducing the health burden that people feel, and that's not just for those individuals. they are more productive workers if they can go to work every day. they are more productive parents if they don't suffer from an illness. they live longer lives, they are more productive and their community. so this has an economic benefit

beyond just the individual family and individual patient. it has an economic benefit for the communities and the country. >> let me ask how have young people, young adults been making use of the provision that they can stay on their parents' insurance policies until 26? >> at last count we think there are about 7 million young adults that are now enrolled on their parents' plan, and over 3 million of those young adults had no insurance at all before this provision came about. so the young adults in america were the second largest category of the uninsured americans, and for a number of them that may have been risky strategy, but it was okay. for others who were identified with a serious illness or in an accident or have a health situation, they are facing a lifetime of bankruptcy.

they made a corrupt their families at the same time. so this provision that allows across the country young americans to enroll in their parents' plan has been enormously successful. >> thank you. i yield back. >> thank you, mr. chairman and madame secretary for being here. thank you for your service. one of my colleagues was talking about small business. of course i was a small business for almost three decades before coming here decades ago. and i know that the biggest problem with jobs and job creators are the unpredictability, and i know this health care rollout is causing a lot of uncertainty and unpredictability. but even in the business world when you have that sometimes you have to redirect and make changes and certain decisions. i want to read to you in e-mail that i received and it's from a worker in my district. he writes that upon returning to work he was told that his hours were going to be reduced from a

full-time 40 plus our a week to 30 or less which for him would result in approximately 25% decrease in income. especially the low-skilled workers it's a higher proportion of their compensation for the highly skilled worker. would you acknowledge that the employer mandate will hurt low-income workers and what is the administration's plan to address the disproportionate impact on affordable group. >> first of all what we know about the market is it falls under the employer responsibility plan is about 94% of business owners who employee 50 full-time workers or more, currently offer health insurance. 94%. if you get over 200 people, it's about 98%. currently offering health insurance. what we also know is they pay

significantly more for that policy that they are offering their workers and their large competitors do because they don't have any market leverage. they can't negotiate with the hospital, they can't negotiate with a drug company to say we will send you a thousand workers and you discount our hospital beds. so, what we are looking at is capturing markets that already exist, that actually giving for the first time people some choices they don't have. they will have competitive plans, transparent plans, they will know what is happening going in, their workers will not be penalized for pre-existing health condition which is a huge issue for a small employer. and they will be able to move forward. the employer mandate only calls on employers who have 50 or more full-time workers, and as i say right now 94% of them are in the market but they are in a market that isn't very cost-effective for them. >> but you would -- you have heard that most companies are

looking to keep their employment less than 50 employees. >> actually, i have not heard that. i've heard a variety of strategies and speculations about what may or may not happen. what we know happened in the one state where this was fully implemented with an employer responsibility provision was massachusetts. and in massachusetts while the predictions were that business owners would drop coverage that people would get out of the market, just the opposite happened. in fact, they have more small-business owners in the market today than they did windel law was first passed. they didn't cut hours or shift rates come they didn't drop employment. and what i also know, congressman, talking to business owners across the country, is the lose good employees every day to a large competitors based on the benefits they can or cannot offer. this is a huge challenge for small-business owners because they can't provide the coverage. for the first time we will have a virtual pool's water than they

have negotiated powers, transparency coming and we think those market strategies will be enormously beneficial. >> i hope you are right. as a small-business owner and somebody that still has a lot of small business friends, you touched on cost and it's kind of interesting because when i talk to my small business owners back in my district figure talking of premiums up to 52%, up 35%. there's a lot of studies out there that say that many under the age of 50 will see rates increased significantly. besio warned premiums would double in some marketplaces and that goes on and on. the president's health care plan at one point in time was a promise of $2,500 reduction in family premiums. will that ever occurred? d.c. the president's promise of the 2500 premium reduction for all american families to looker? >> again i don't think that was the president's promise to begin its with the congressional budget office estimated that people would see a cost decrease as we moved into a fully injured

marketplace. and i think congressman, what we know is the cbo is a nonpartisan objective body. they are looking at strategies in the market. what you are referring to in terms of current rate increases, first of all, is not impacted by the full implementation of the affordable care act because it is not in place yet. and secondly, it is really a situation where there are costs going up and down. but what we know is they are rising at a much slower rate right now than they did three years ago before this was passed. we have insurance departments, many for the first time, with aggressive rate review strategies in place where they are actually looking at their rates, they are rejecting the double-digit increases, and we have the so-called 8020 rule which has never been in place before for the insurance companies where they have to spend 80 cents of every dollar of health benefits, not ceo

salaries or marketing plans, but health benefits. and the companies that didn't meet that threshold returned about $2 billion last year to customers. people all over this country got checks back from their insurance company. so there are some market strategies in place that are cost-effective. >> i yield back. >> ms. sanchez is recognized. >> thank you so much for taking the time to appear before the committee today to discuss the administration's fiscal year 2014 budget. the budget simply put is a reflection of our priorities, and our priorities should be clear protecting the seniors and their holding years giving our children quality education so that they can achieve their dreams, and properly funded health care to keep our families and good health. and i was pleased to see the president's budget does address many of the shared priorities. in particular, i was happy to see that the president's budget has $1.5 billion of new funding to implement the federally

facilitated and state partnership exchanges that would help provide health care insurance for over 25 million people, that the president's budget invests $1.4 billion in new early headstart child partnerships. it is an issue that is incredibly important for southern california. that it increases funding for the food and drug administration by $280 million to improve food and drug import safety, that it continues to invest in the national institutes of health and that it increases funding for vital title ten family planning programs by $30 million over last year's request. all of those i think our important priorities that i think every american family can benefit from. and as a working mom, i have a particular soft spot in my heart that the president's budget would approve both the availability and the quality of child care. i hear far too often from

parents that the lack of affordable and quality child care is a significant barrier for them to work. but what i want to really focus on is something that's been touched on by my colleague, mr. kind and others in passing, and that is the savings that the affordable c.a.r.e. produces. because something that i find somewhat paradoxical as well is that the republican budget that we saw included all of the hca medicare savings and taxes in that budget. so come on the one hand i hear from my republican colleagues they claim that the aca district medicare and levied a heavy tax burden across medicare. but on the of your hand they passed a republican budget that retained the aca savings. so madame secretary, i would be interested in hearing about some of the savings that the aca has produced in your comments on the paradox that on the one hand focusing on repealing the aca

but on the ever had they want to maintain the savings from aca. >> i think the president believes very strongly as we do in the department of health and human services that keeping our commitment to the seniors of this country that was made in 1965 when my father office in this building and sat on the energy and commerce committee and helped write the medicare law and it just turned 92 and he's pretty happy that he did -- >> i'm sure you are, too. >> -- that we are very concerned that on the one hand, medicare beneficiaries continue to receive the commitment and that promise, and that we find strategies that continue to look at deficit reduction and long-term growth in the plan. and i think that is what is captured in the president's

budget. it was part of the affordable care act. $800 billion worth of savings, and we are very much on track to fully implement that with additional benefits. people said you can't do it. it can't be done. you can't deliver good care and cost. i think that we are on our way and we are on year three of doing exactly that. we see that same strategy into the future, where you can actually figure out care strategies that work to benefit a growing number of seniors. we have 11,000 people a day turning 65 in this country. each and every day. as we have the largest number of medicare beneficiaries ever involved in the program, and yet we are on a historic low in spending. .4% in 2012 to lead never been seen before. and as congressman kind said, the cbo has reconfigured their projections into the future

years. so, i think the president's budget captures the notion that there are very effective strategies that deliver appropriate care, make sure that we take seniors needs into account, we continue to update quality programs at the same time constrain the cost and the future. >> all right, thank you. mr. ryan is recognized. >> thank you. i guess i should pick up where ms. sanchez left off. the difference in our budget approach is where we make sure all of the medicare money stays in medicare. the chief actuary of cms was here a year ago saying you can't spend the same dollar twice. on the one hand, you can't count savings from medicare to pay for obamacare and count it as a savings to medicare. so far putting the bendixen the report to that effect the other point is in our budget we put a reserve fund, which is a

budgetary mechanism to address any inadequacies in the provider community that may arise if the case occurs where we feel like providers are restricting access to beneficiaries because of these cuts. so that is just to answer the difference with a paradox. i have three questions, and i just -- you just released your budget this week, madam, good to see you by the way, madam secretary. first, on the means testing before we get mutually agree on policies which $30 billion of savings. where is the delta. where do you make the difference in the 20 billion? >> the difference, congressman ryan, is there is a new formula rather than having i think what was in the past four different categories. it's now nine. the lower limit -- >> was it still 80 or does it go

up to 90? >> the top is 96, 196. >> the percentage of the beneficiary pays. there are more categories -- >> i would love to give you that in writing just so i am a -- >> there are more categories and there is a different starting point and a different ending point. >> different ending point or different thresholds on the percentage of the premiums the person bares themselves? >> the percentage of the premiums that the person bares themselves. >> all right. 20 billy and is a pretty big difference. >> i would be happy to get you all the details. >> the medicare advantage demonstration programs or

$8.5 billion where you are offsetting 71% of the head to the aca in 2012 and then it goes to 32 and 16 if i do recall. i don't see that in the budget. that's a pretty substantial change of mandatory spending for a demonstration program. is that not in your budget? >> it's in the baseline, congressman. and i think the very good news is we are seeing the beneficiaries choose high-quality programs coming and we are still very much on track to actually pay medicare advantage plans at the same rate the fee-for-service plans will be paid on even a faster pace, including the quality demonstration plan. so, it is all working very well. >> you're sticking with the formula of phasing it out in 2014? >> yes. >> i'm trying to watch the timing here to be a i'm not going to rescue the course of your budget. but in the past, you have matt had attributed savings to ipab

in your budget before because your threshold of growth rate gdp plus five was above what you estimate cost growth to be. but now you have savings starting at 2021 come 2022 come 2023. so the ipab is actually starting to score positive savings. how do i interpret that? mean to be these excess cost growth at the end of the budget window is starting to perforate the gdp .5 or are there new proposals associated with ipab that accrue those savings? >> congressman, there are not new proposals that accrued savings except for the fact the budget does capture with the president's belief is which is different than the affordable care act, which is that ipab should kick in at the gdp plus .5 rather than gdp plus one. >> that was in the budget last year as well. >> i understand. this is based on the actuaries

estimate of what will happen in the outlying years, and when right now as they look at the snapshot into the future as you just heard, the cbo estimates have revised the long term strategy to date i think it can be revised again if we stay on a sustained cost reduction. but that is just a reflection of when they feel the trigger point might meet. >> so that is that question. so, the actuary is now saying the ipab mandate, keep the spending within the gdp .5 which the budget didn't have in the first ten years because the cost growth was below that. now they are saying it is being triggered so it is going to occur in 2021? if you could just answer briefly to beat >> can i get back to you on that? my understanding -- >> it has an effect in the out years. >> i thought the old projection was actually 19 and would trigger and it's now been moved to 21. that is what i need to -- that

is certainly my understanding. >> ms. schwartz is recognized. >> thank you. i am pleased to have you and appreciate some of the good information that has been discussed this morning in the particular relationship to the incredible progress that you've made in the last three years and implementing the affordable care act and the continued rate of cost in both the private sector and the public sector and between medicare and medicaid. so, some really important work is going on in this country coming and i think we've moved the dial forward, and the administration has been quite extraordinary ways. it is both well to the future as we stay on this course there are a lot of challenges you face coming and i know in the states like mine where there are real issues the federal government is going to have to step in coming you have to step in to ensure that pennsylvania's benefit from the increased opportunity to buy insurance, and i hope we continue to build on some of the

really important work we are doing in some ways on the health care delivery system reform. so, i wanted to ask you specifically about an issue i've been pushing on pretty actively. i won't be surprised that i would raise this issue. but it's one that has had a bipartisan support as you know which is the repeal of the growth rate finally making a decision, legislatively. i know you need us to do that, which is to recognize we are not going to implement this at the same rate. we are not going to cut the physician reimbursement in this country by ten or 20 or 30% which is all a possibility. and the budget that the president has proposed actually says that we are going to repeal and we are going to replace it. you add it which is important to me not just saying that this failed, but we are going to recognize that. it's really not moving forward in a way that is sort of universalized what you have been talking about from this morning which is that we should be

paying our health care providers differently that would make sure that all providers in this under medicare meet quality standards that are accountable for that and transparent, we help them do that. we are doing that but we approve the health status of our seniors in particular for younger people as well. so but we actually pay it in a way that encourages that and encourages them to coordinate care to meet these quality standards and can contain the rate of growth and cost. i've written legislation to do that. there's been a lot of interest and to pass legislation but would give you the tools to do that that would build on these models so they wouldn't just be interesting demonstration projects that are making a difference in the states where they are doing important work on this. but actually changing the way that we reimburse the positions in this country. and i appreciate the language that you have put in. and what i would ask you to do

is just speak to how we got there. it requires us to take action, and the chairman and i know that mr. brady has been very helpful on this, but to see if we can't get that done this year rather than just yet again saying we are not going to implement but we are going to keep the uncertainty for the physicians and health providers in the country. and my concern is if we do that we hold them back from really embracing some of the new different ways of delivering health care in a way they want to and hope to and actually meets the needs of our seniors in this country. succumb going to help us on that and help us figure out your leadership on this can be very important in moving us in this correction. >> congresswoman, i know you agree to be of interest for a long time, and i appreciate your leadership in this area. i think the president shares the concern that first of all the lingering uncertainty of the sg are cliff is the single biggest

issue threatening the care of our seniors. there's way too much time and energy that frankly doctors spend every year coming to capitol hill trying to get a fix that takes them down the road the next ten or 11 months and they start all over again. so having a long-term strategy we are eager to work on. what we have proposed as a part of this budget and the baseline assumes what we would like to propose is a couple of years of the sort of status quo if you will which has been done by congress a year at a time, and then working carefully with this committee and others that have a great deal of interest in this and certainly the provider community on formulating a value based payment system with that would be our future look at how we pay medicare providers very

much recognizing that payments should be tied to outcomes and should be tied to care delivery and should be tied to pravachol. i think there are ways to do that. we are beginning to see the accountable care organizations and medical home models and a variety of strategies and the other thing that is going to be in place which is a key part of this is the broader implementation of electronic health records, which for the first time will capture and measure what is actually happening in the marketplace. so, we would love to work with you. >> this is a very bipartisan as a chance to get this done. >> is. and we have released memorandum and outlined phase one and phase two with our friends on the commerce committee as well and we are working in a bipartisan way as well as both committees on this issue. dr. price is recognized. >> thank you mr. chairman and welcome, madam secretary.

we are talking about your comments and opening remarks talked about this budget strengthening the economy, providing middle class job growth and a, quote, rising middle class. i just thought i would share with you a couple examples of the real world, car dealer in my town, 168 employees. because of the aca, because of the aca, 166 of those employees will be moved from full-time to part-time, 28 hours a week. some visited my office this week here in washington as a number of burger king outlets. over 900 employees moving all but five of them to part time because of the aca. madam secretary, that isn't going to lead to a thriving middle class does not going to lead to job creation.

it's harmful to the economy and job creation as a physician you and i have had conversations i can tell you i believe it is fundamentally harmful to the quality to the quality and access to care. to that point this has three injured $74 billion in the new reductions in medicare spending, $307 billion of that 374 out of the provider niquette. the guys and gals practicing medicine are looking for the exit door, what is their strategy to be able to survive in spite of all being put in place to get the h.r. is a classic example. we have rural docs in the small communities trying to care for their patience, and this imposition by the federal

government so they have to close their doors because they can't put in place the requirements for the h.r., this piece of legislation. i would urge you to take a peek at that. >> a couple specific questions. the first is on the in office ancillary exception and closing that an office ancillary exception. as you know oftentimes service provided a physician's office are more efficient, our cost effective and higher quality-of-care and any other setting and yet this budget closes the in office ancillary exception for things like mediation services and physical therapy and the like. the payment so that you don't incentivize treatment at one venue or another over the objection of the patient or the physician. is there any rationale to whitey in office ancillary exception is

being closed for? >> maybe you can get back to me on that. >> i just wanted to verify, doctor, what i thought was the case. and what we are looking at is the utilization factor that offer on the same day we are seeing an increased billings. but i would like to get back to you in writing some of the rationale behind what you've just identified. >> in the same day treatment, same-day utilization of services is oftentimes the most convenient for patience. >> that's true. >> it may not be for the government, but for patience. >> we are not trying to diminish the number. we are diminishing the number of killings that occurred when a patient is actually accessing a physician. >> heaven forbid the patient should be cared for in the

physician's office. i understand that. let me please move to medicare part b drugs cancer care. quality-of-care for cancer patient in this country is being harmed because of a decrease in access to care because of a decrease in payment for cancer drugs in the office setting. you're budget proposes a further cut in cancer drugs through medicare part b drug services to bigot is there any rationale for that? >> actually, i think congressman, what you are referring to is what happened to the sequester cuts. but the cuts were a-plus .3%. the cuts in your budget rasp plus 3%. a lower amount. >> of the cuts that are proposed in the budget that we have put forward would not interfere with the administrative service of the cancer drugs. those are held harmless. we are taking an additional cut

from actually the drugs themselves. what we learned during the drug shortage is that it is not the pricing of the medicare drug that has impacted the drug shortage at all. what happened in the sequester with that blunt cut of 2 percent across-the-board is the entire cut actually came out of the physicians side of the puzzle and did not affect the cost of the drug, it affected the administration and the drug and that's why some of the cancer centers they were choosing not to admit medicare patients any longer. >> thank you. mr. reed, you are recognized. >> thank you madame secretary for being here today. i did like to take some of my time to focus on an important issue and that is the solvency of medicare itself. in particular, the part a trust fund. you are a public trustee

obviously for medicare. and the report in 2012 indicates that part a will be bankrupt for 2024. do you agree with that report and is that the bill when the trust fund will go under water. >> this would like into the life of the trust fund. the aca at eight years to the life of the trust fund, so repealing the aca would actually accelerate the timetable significantly. >> the best you did on the budget under your opinion is that you moved to five years. so that means of your body that is four years. so that means everybody that is 51 years of age today and younger are being promised by the president's budget and hafez that medicare part a will be bankrupt, is that correct? >> as you know, first of all it isn't bankrupt. it would bring in less than is

anticipated going out and i think we have to opportunities. >> nope, nope. >> it isn't entirely out of money. >> its 25% short they will be reimbursed. >> so, just in what term would you describe that? >> bankrupt to me means it is out of money. it there is money in the trust fund, but -- >> what term would you describe that? i've heard this with other people d.c. bankrupt isn't the right term. how would you as an official represent that status? insolvent, underwater, underfunded? >> its underfunded i would say based on current projections of what will happen with cost strategies, and i think we have great opportunities between now and then to change the projections dramatically pete >> between now and then. but as of today the best we can do -- >> well, as i say, the vote taken by the majority of this committee would move that insolvency date much closer to

where we are right now. it would actually accelerate the date because eight years of the trust fund were added with the passage of the affordable care act. we would add another for coming and we would love to continue to work on strategies with this committee, keeping the medicare benefits in place, and making sure that we can accommodate them into the future. >> the plan i'm hearing from the administration is we are going to take each year small steps to push the number out one or two years and not fix the problem in perpetuity. >> and fixing the problem in perpetuity i want medicare to be solvent. i don't want people that are 50 or people to look at 2024 date that was in the 2012 report and say i'm a 54 and all you are telling me is that it's going to be bankrupt? i will use the term bankrupt, underfunded. i think that's a problem. i feel that is a real problem to send to american seniors and people that are getting to the point of retiring.

and i want to find out what the plan is. alana hearing as we are going to take it year by year and move the number one, two, three, four years. what is the long-term plan? >> we would love to work with congress on a long-term plan with the contingency that the long term plan is not to destroy medicare as we know it, and that is what has been put on the table, that in the future seniors wouldn't count on a guaranteed set of benefits. what they would have is a voucher. they would negotiate for their care where everyone projects that medicare would pay. >> in the proposals on at the bottom line is that the system has gone bankrupt. it's going to be underfunded. we need to solve it and calling hearing from you today is the administration says we can't change the program. medicare as we know it cannot be

changed. >> bachelet come in the last four years -- >> the question i have for you, madam secretary, and i don't mean to get into this, do you think we can balance or make medicare solvent in perpetuity by leaving the system in the exact same way that it is today? >> i don't think the president or our administration supports leaves and the system exactly as it is, and i'd suggest in the last four years, sir, that with the legislation passed and the budget that is before you, more significant changes are being put forward in have been put forward in decades. we would love to work with you on medicare will lead to the future keeping the promises that we made in 1965. >> thank you. >> now we will go back to the beginning. i want to know for the record our budget does have a guaranteed benefit and -- >> madam secretary, last week

wall street journal columnist peggy noonan dedicated the column to the wisdom of the visionary leader who really created singapore, and in describing his book on the inside in china in the united states in her words, he is bullish on america's immediate prospect but concerned about the long-term future, and she noted he's greatly concerned about the prevailing culture, and to quote him, a major problem is the day-to-day images of the violence that we expose people to through television. and, madam secretary, i've worked on the mental health issues and i am curious what your thoughts are in the linkage between violence and the culture on tv and the movies and video games and mental health for kids and young adults particularly troubled young adults and are you concerned about the pervasive violence in our culture and entertainment industry?

>> mr. chairman, i am concerned certainly about the pervasive culture of the violence, both through the media in the entertainment industry and movies and tv and video games, but also on the street corners the number of children who live in an extraordinary violence day in and day out they don't have to turn on the tv, they have to walk outside. so, i think we have a culture of violence in this country that is alarming. it clearly has a different impact on different people, but there is no question that i think it does have at minimum a decent developing mind about what the impact of violence is, and certainly for someone who is disturbed may have even more frightening impact.

>> does it concern you then that the federal government provides subsidies to some of these industries, often through the tax code and should the federal government be in the business of subsidizing something such as this that may contribute to the breakdown of mental health in this country or contribute to the culture people find out side as you well in the desensitization that occurs on the street as well as in the mind of those that are troubled? >> hee-haw. for those of you looking in the tax code to have, i do feel that there are lots of influences throughout our culture that impact folks and what the appropriate balance is between the industries that we want to encourage, and censorship and what they do i think is always open for the date. but i do share your concern that there is a pervasive culture of

violence both through the media and entertainment industry but also i think america is a violent country and that's acted out in the neighborhoods and on street corners on a regular basis, and that has an impact on our health and of our mental health and on our communities and our kids. >> thank you. mr. levin is recognized. >> i'm glad in a way you kind of shifted the discussion from mr. reed's approach to the issue of violence. because i share your concern and i am hopeful the senate will act in the next week's to bring it up to the house and a look at the tax code, too. i want to say something if i

might because i think we have a friendship. look, the health care reform isn't going to be repealed. i think everybody should accept that as a given. and for those that wanted to repeal, the case has become more difficult because of the diminution in health care cost increases. they've been going down now for three years, madam secretary, and there's some evidence that in part it's because of health care reform. >> will the gentleman yield? >> let me just finish. >> also there's been some clear benefits coming and you mentioned, madam secretary, some of them, the millions of young for people who now insured as an

example, the millions of seniors who now are paying less for prescription medicines. so i think with that situation, it's hard for those who opposed health care reform to be sure what to do. and i just urge that there be resistance to overstating to do mant guilherme -- to doom and gloom and often schering people. that is why the secretary resisted the characterization of medicare going bankrupt. on this committee we have faced

under funding of medicare many, many times. you were in control for a number of years. and there wasn't this perpetual long-term resolution of the problem. but again, many times we faced underfunding, and as a result we have reduced provider reimbursement. what health care reform really does a good measure is to pass the measure of changing from fee-for-service to a very different reimbursement system, and while there is some agreement across party lines on this in terms of scare tactics, sometimes they've described ipab

as a death panel when it's really not that at all. let me quickly ask the secretary, and then i would be glad to yield, i think another kind of doom and gloom approach of those that never wanted health care reform to be field is to talk about premium increases. so just address quickly, if you would, your feeling about what's going on. >> well, congressman, the insurance plans are in the process of beginning to submit preliminary estimates on the rates in the new marketplaces. those will be negotiated by either the state based markets or the federal markets or by later this summer we will have a

clear picture. again, what we know from the congressional budget office is that the estimate is that rates will be significantly more competitive than people find them right now. there will be an elimination in a lot of the overhead and administrative cost. there will be competition as a market strategy, and i've seen this as an insurance commissioner does work. to compete side-by-side it's very transparent that in and of itself drives prices down. and so, we are anticipating having people if you compare policies to policy is what they have now and what they are going to have a very beneficial set of rates and benefits that people will have an opportunity to choose from. some of them for the first time ever in their lives because the price of the market. >> appreciate that. all time has expired. i appreciate ms. reed's concern to save medicare.

the clock is ticking. we need back now republicans and democrats. i don't see that as frightening. i see that as a genuine concern for programs in a very severe financial straits to try to bury our heads in the sand is really the wrong thing for our seniors. .. obamacare. experts don't say that's the case. many of them believe that's because this is the worst

economic recovery in 70 years. 20 million people can't find a full-time job, millions more have given up looking for work. it's the jimmy carter days for them. and since the bottom of the recession you're more likely to be forced to go to food stamps to feed your kid than actually find a new job. and so it's clear that if you can't find full-time work and you can't feed your kids, my guess is you're not going to the doctor. that's what's more likely slow the growth and health care. so i would be cautious at a time when the stimulus claims were exaggerated and the sequestered claims are exaggerated. i think on health care, let's stick to the truth. on this point, mr. chairman, i believe your recognize me, i apologize while you stepped away -- online this is a timeline for the exchanges, and that's for the public, as well as lawmakers to track how the exchanges are on track.

but as a look at what i see is the deadline after deadline missed. it says is if the agency is in disarray trying to meet the october 1 deadline, that the final mark of rules and regulations was missed. the payment notice rule was missed. the business rules for information technology, that's too much delayed. you recently announced a delay in the choice option for small businesses. you've also delay the basic health care plan for your five. and so these delays are having real impact. real people are concerned about these delays, and that failure by the agency to meet these deadlines raises real concern. so my question is, do you have a plan b? do you have contingency if the exchanges are not ready, up and running, with a fully informed public october 1? >> as i entered before, congressman, we will be --

answered before. will be open october, 2013 and will be enrolling americans across the country january 1, 2014. >> so at this point you have had no discussions with the agency on contingency plans. >> we have a lot of contingency plans -- >> for not being the october -- >> no, we're determined and on track to meet the october 1 deadline. >> so you can assure this committee there will be no for the deadline nest, no further delays, and implementation of exchange is? >> we're on track to make october 1 deadline. >> the question again, because i think we're all concerned, republicans and democrats, you can assure -- >> i can only tell you what i'm telling you. we are on track to meet october 1. i can't tell you what exactly will happen at every step along the way, but i can show you that is the determination. we're on track to meet it. we test because you are not on

track, that's the question. you're not on track to meet it. >> we are on track to meet october 1 deadline. yes, we are. >> i'm just trying to get to the bottom line. there will be no further deadlines missed, no further delays is? >> again, i don't know quite what that means. will rule and regulations be a weekly that might be on the paper? it could. we will be open for business october 1. >> so, no delays, that's great news. no further deadlines missed, that's great news. we are still waiting on small business for disinformation notices, two months late. is that been delayed begin this week, next week? so are we seeing another ongoing delay? >> i think that is not ours. it's the labor department's notice, but my understanding is it's imminent. that is not an hhs rule that is coming out.

>> thank you very much, madam secretary. mr. ingalls is recognized. >> thank you so much. and again, thank you for your service. i'm concerned about the american people that are now doubtful as to whether or not they would have health insurance. and also the fact that i don't know whether history will recall such political opposition to any president with a national plan. all of my political life i have hoped and dreamed that we would have universal coverage, and now we have it. and for some reason it's become a political issue. 40 attempts, 39 attempts have been made by the republican party just to repeal it. not to substitute, not to improve it, but to repeal it.

and, of course, they substitute that with just confusion, that it's going to fail. as though there were only democrats or potential democrats that were going to be the beneficiaries of the program. so we have to find some way to bring truth to the american people, no matter what their political persuasion is. and i hope that you can do this by telling exactly how many americans would be affected since we've got to assume that, we've already, the president is one, the supreme court has sustained this, and the first question is, obamacare is here to stay politically speaking. is there anything you can think of besides withdrawing the president, having a recall what the president, or under the case in supreme court, obamacare is

here. so you -- >> yes, sir. >> that's the best we can do if we don't like it, to improve it, to deliver it. instead of just opposing our efforts. my question is how many americans are going to be affected anyway? those that insurance are not going to be impacted, right? >> well, i would say in terms of the new marketplace, a fairly small number of americans will be impacted. about 41 million eligible folks who don't have insurance at all, and another 14 or 15 who in the small market, individual market. >> do you know the political persuasion of these 41 million people that have no insurance at all? >> do i know their political persuasion? no spent either put democratic people here or republican people, or are they just --

>> they are americans. >> right. what could the congress to to make certain that we provide, to help you to provide universal coverage at the least cost and the best quality? what would you expect this branch of government to do to help the executive branch consider this for all of american? >> i certainly think a huge step forward was the passage of a comprehensive health reform bill, which has been proposed by republican and democratic presidents for over 70 years. so we finally have a framework to work on. you asked earlier me people are impacted, and watergate is an answer for the marketplace, then you insurance. i think every american will be impacted and benefited by delivery system changes. better care, better population health, more effective ways to

deliver a care in the future, payment for value instead of volume, and making sure that we no longer continue to be the nation who spends the most with mediocre health results. and that's where we are right now, and we are on track to look at some care strategy, thanks to elements of the affordable care, thanks to the innovation center, thanks to what's going on. that could really change the profile and make us much more competitive in a global society. >> since you have been unable to tell us whether you can give assurances that these programs are going to be open on time, is it safe to say that your assurances say that we're on track would be dependent upon some cooperation from the congress? or is it possible that we could legislate something that

actually awful you follow the guidelines that you have? >> again, i don't know how much more specific i can be, but i think we're definitely on track to implement the law as it is anticipated, and have open enrollment start in every state in the country on october 1. >> the assumption that you're going have a positive support from the united states congress to do this. >> it would be helpful. >> thank you. mr. tiberi for the final question of the morning. >> madam secretary, welcome. it's great to have a buck a year with two as chairman and the ranking member. kind of even it out a little bit. i'd like to send you an article from the columbus dispatch, a paper you're familiar with from either last week or the week before to mr. renacci's point of a small business owner who is less than 50 employees that was planned to go his business beyond 50 employees. and public they said in the

article he is not doing that because of the affordable care act. it is a problem that i've heard about from a lot of small employers with in central ohio. this what happened to be willing to say it to a reporter and explain why. i think they would just be helpful for you to have that. i'm not trying to be political about this. mr. rangel, mr. chairman, just asked about the political persuasion of people without insurance today. i was on this committee when we passed this bill, mr. chairman, and i like you a lot, but there's a lot of concern from everyday people out in my district at least regarding the implementation of this bill. and the president over and over said, if you like what you have you can keep it. let me tell you, madam secretary, a story from my district. from a company that i met with a couple weeks ago, self-insured employer.

and executive team including h.r. person has been looking at this trying to implement this law with their employees. they provide health insurance to their full-time employees. they have a great plan. their employees love their plan. their employees think they will be able to keep their plan. do their ability to look at this implementation, they have found out that the plan with no added benefit to increase i 10% at least. the 63-dollar fee that they're going to be paying alone will cost over $1 million with absolutely no, no change in their policy because they already participate in what's called -- just so i'm clear on this -- the plan that covers people with preexisting conditions an order to take care of their employees through the,

the early recovery subsidy program. they don't, they don't get a penny for that. so they are trying to, mr. chairman, figure out what to do next. what's clear is they are going to be increased costs if they keep what they have to those employees. those employees don't know that yet. and i'm not kind to be difficult. i'm just trying to explain the concern that members on our side of the aisle but i'm not going to defend the old system, but there's t too concerned about te new system because what may happen, madam secretary, and again i'm not trying to be difficult come is that they may choose to put all their employees into the exchange. so their employees may not be able to keep what they like, which was a promise of this committee when the majority was in the minority's hands. and their employees don't even know that yet.

and satisfaction surveys that they receive from their employees for the plan they have are overwhelmingly good, and this is a company that has prided itself on health care coverage, dealing with obesity, dealing with cancer, dealing with preexisting conditions. and the choices, in all honesty, from nonpolitical h.r. people there, i could see in her eyes how troubled they were with where they're going to have to go, and asked me, is there any sort of opportunity to change this for folks like us? and i said, i don't think so. you might want to contact sherrod brown. he might have better luck then we get. not trying to be political, because i think all the money, madam secretary, and i don't revel in this because these are my constituents and the democrats and republicans, independents and not political. their health care is going to change according to their

experts for the worst. so i just like to think that maybe you, because i know your history, and i know you care about this, that maybe you and your team can be more engaged with some of these employers who are very, very nervous about the future of a benefit that they provided, and they are not the ones we're trying to get at in terms of access to health care, if that makes any sense. >> it does. and trust me, we are trying to be very engaged. i meet with employers in various parts of the country on a very regular basis as i travel around, and i think that's as we move into full implication, i'm hopeful that some of the projected fears will be relaxed a bit, and that people have, it's very difficult until, the case are talking about is a

self-insured plan. so they are looking at some certainty in terms of what fees there may be in the market versus the penalty that they would pay if their employees within our tact eligible and they can do some calculation. i'm hoping in the long run that employers who have been in this market voluntarily, because they found a benefit to their employees will indeed move forward with a benefit. that's what we continue to hear from folks, and that's for people who are locked out of the market because they did not have any affordable option. they didn't have any market leverage. they didn't have an ability to provide those benefits, will finally have some choices based on private plans in their states who have to compete for the first time with a new set of rules. but i will continue to do the outreach, and we would love to have a chance to talk to some of these folks about what exactly they're looking at. >> thank you very much.

that concludes today's in but i want to thank you, sector siblings, for time this morning and for your testimony. and with that this hearing is adjourned. >> thank you. [inaudible conversations] >> [inaudible conversations]

>> "the associated press" reporting today that treasury secretary jack lew is meeting separately today with house speaker john boehner and house minority leader nancy pelosi. while on capitol hill the ap says mr. lucas expected to update the house leaders on the state of the economy oath in u.s. and abroad. treasury secretary just returned from europe when he encouraged of this is to promote more growth friendly policies. the president focusing on austerity measures. >> live coverage will continue to on c-span2. at 12:30 eastern when federal researcher ben bernanke will speak about the economy and the role of community development. you can see that live at 12:30 eastern. then at one eastern, ken burns is today's featured speaker at the national press club. he has a new document it out about the central part five, five teenagers were wrongly

convicd ew york city rape in 1989. we talked with him on "washington journal." you can see that segment in the c-span video library but we will have live coverage of his remarks this afternoon at one eastern. then at seven eastern booktv.org will be live as author talks about h about the life of the venezuelan general called t george washington of the south. she is the former editor in chief of the "washington post" book world. her talk at seven eastern online at booktv.org. >> saturday booktv is live from the annapolis book festival with panels throughout the day. at 10 a.m. eastern, maryland in 18maryland in 1812, war, slavery and opportunity. 11, the changing landscape the suburbs and cities. and at noon, america's ongoing involvement in afghanistan. at one, the other involving roles of women in society. then at 2:00 former congressman mickey edwards on politics in

america. the annapolis book festival live saturday, part of booktv this weekend on c-span2. >> orphaned at age 11, she lived with her favorite uncle, james buchanan. years later, she becomes -- he becomes president and because he's admitted she serves as the white house hostess. she's the first to be called first lady on the record basis and the soap opera that she sets trends in clothing and children and ships are named after. we will look at her life and that of her predecessor along with your questions and comments by phone, facebook and twitter. monday night live at nine eastern on c-span and c-span3. also on c-span radio and c-span.org. 's the kentucky center rand paul spoke to students this week at howard university. he talked about the republican party's connection to african-american voters. his comments are about 50

minutes. some people have asked if i'm nervous about speaking at howard. they say, you know, some of th >> students, they may be democrats. my response has been, you know what, the bbb a success and i can get a hilltop to have a headline that says, a republican came to howard but he came in peace. my wife kelley asked me last week do you ever have doubts about trying to advance a message for an entire country? the truth is, sometimes, when i do have doubts, i think of a line from t.s. eliot, how should i presume to spit out all the butt ends of my days and ways, and how should i presume. and when i think of how political enemies often twist and distort my positions, i think again of eliot's words, when i am pinned and wriggling on the wall, how should i presume?

and here i am today at howard, a historically black college. here i am, a guy who once presumed to discuss a section of the civil rights act. that didn't always go so well for me. some have said that i'm either brave or crazy to be here today. i've never been one to watch the world go by without participating. i wake up each day hoping to make a difference. i take to heart the words of toni morrison of howard university, who wrote, if there is a book you really want to read, but it hasn't been written yet, then you must write it. i can recite books that have been written, or i can plunge into the arena and stumble and maybe fall but at least i will have tried. what i am about is a philosophy that leaves you to fill in the blanks. i come to howard today, not to preach, or prescribe some special formula for you but to say i want a government that leaves you alone, that

encourages you to write the book that becomes your unique future. you are more important than any political party, more important than any partisan pleadings. the most important thing you will do is yet to be seen. for me, i found my important thing to do when i learned to do surgery on the eye, when i learned to restore a person's vision. i found what was important when i met and married my wife. many of you still have those things that light energy. although i am an eye surgeon, first and foremost, i find myself at this particular time in a debate over how we heal are sick economy and how we get people back to work. i truly believe that we can have an economy that creates millions of jobs again but we will have to rethink our arguments and try to rise above empty partisan rhetoric. my hope is that you will hear me out, that you will see me for who i am, not the caricature sometimes presented by political opponents. if you hear me out, i believe you'll discover that what

motivates me more than any other issue is the defense of everyone's rights. of strong importance to me is the defense of minority rights, not just racial minorities, but ideological and religious minorities. if our government does not protect the rights of minorities, then democratic majorities could simply legislate away our freedoms. the bill of rights and the civil war amendments protect us against the possibility of an oppressive federal or state government. the fact that we are a constitutional republic means that certain inalienable rights are protected even from democratic majorities. the majority can't go to take away your rights. they are yours. they are given to you by your created. no republican questions or disputes civil rights. i have never waivered in my support for civil rights or the civil rights act. the dispute, if there is one, has always been about how much of the remedy should come under federal or state or private purview.

what gets lost is that the republican party has always been the party of civil rights and voting rights. because republicans believe that the federal government is limited in its function, some have concluded that republicans are somehow inherently insensitive to minority rights. nothing could be further from the truth. republicans do, indeed, still believe many rights remain with the people and states respectively. when some people hear that, they tune us out and say, he's just using code words for the state's right to discriminate, for the state's right to segregate and abuse. but that's simply not true. many republicans do believe that decentralization of power is the best policy, that government is more efficient, more just, and more personal when it is smaller and more local. but republicans also realize that there are occasions of such egregious injustice that require

federal involvement, and that is precisely what the 14th a minute was about and what the civil rights act was intended to do, protect citizens of state and political tyranny. the 14th and it says no state shall. the fourteenth amendment did change the constitution to give a role for the federal government in protecting citizenship and voting regardless of race. i did not live through segregation nor did i experience it first-hand. i did grow up in the south in public schools. i went to school with whites, blacks, latinos. we all pretty much and get along. so, perhaps some will say that i can never understand. but i don't think you had to be there to have been affected by our nation's history of racial strife. the tragedy of segregation and jim crow in the south is compounded when you realize that integration began in new england in the 1840's and 1850's. in 1841, frederick douglas was

pulled from the white car on the eastern railroad, clutching his seat so tightly that he was thrown from the train with its remnants still tightly in his hands. but, within a few years public transportation was integrated in the northeast. it is a stain on our history that integration didn't occur until more than 100 years later in the south. that in the 1960's we were still fighting to integrate transportation and schools and that is and was an embarrassment. the story of emancipation, voting rights and citizenship, from fredrick douglas until the modern civil rights era, is in fact the history of the republican party. how did the party that elected the first black us senator, the party that elected the first 20 african american congressmen become a party that now loses 95% of the black vote? how did the republican party, the party of the great emancipator, lose the trust and faith of an entire race?

from the civil war to the civil rights movement, for a century, most black americans voted republican. how did we lose that vote? to understand how republicans lost the african american vote, we must first understand how we won the african american vote. in kentucky, the history of black voting rights is inseparable from the republican party. after the civil war, virtue all african-americans became republicans. democrats in louisville were led by courier-journal editor henry watterson and were implacably opposed to blacks voting. the democrats to a person were opposed to blacks voting. watterson himself wrote that his opposition to blacks voting was founded upon the conviction that their habits of life and general condition disqualifies them from the judicious exercise of suffrage. this was the democrats. in george wright's "life behind the veil," he writes of republican general john

palmer standing before tens of thousands of slaves on july 4th, 1865, when slavery still existed in kentucky, and declaring, my countrymen, you are free, and while i command, the military forces of the united states will defend your right to freedom. the crowd erupted in cheers. this is the history of the republican party. meanwhile, kentucky's democrat-controlled legislature voted against the 13th, the 14th, and the 15th amendments. in louisville, william worley was a black republican. he was born toward the end of the nineteenth century. he was a founder of louisville's naacp. he is famous for fighting and overturning the notorious label segregated housing ordinance. warley bought a house in the white section in defiance of a city segregation law. the case buchanan v. warley was

finally decided in 1917 and the supreme court held unanimously that kentucky law could not forbid the sale of a house based on race. the republican party's history is rich and chock full of emancipation and black history. republicans still prize the sense of justice that mlk spoke of when he said that an unjust law is any law the majority enforces on a minority but does not make binding upon itself. ..

majority, not just a rational majority but uses of a minority it doesn't make binding on themselves any that's not universally applied if any to bankers would be not just racist but would be unjust. any law that just applied to one particular group would be unjust. he was referring to race that he said something about on just that applies to all. republicans have never stopped believing that minorities whether they derived from the color of your skin or the shade of your ideology showed warrant

equal protection. everyone knows that the citizens in greensboro and national but few remember in alexandria public library in 1938. samuel tucker, a lawyer and a graduate of howard university recruited five men to go to the library, select a book and sit and read until they were removed. he set the stage for students at greensboro that brought down jim-crow in many areas years before the civil rights act of 1964. i think that in our retelling of the civil-rights era we don't give enough credit to the heroism of the civil was obedience. you may say that is all well and good but that was a long time ago. what have you done for me lately? i think what happened during the great depression is african-americans understood the did champion citizenship and voting rights but they became impatient because they wanted economic emancipation.

african-americans were languishing below white americans in every measure of economic success in the depression was especially harsh for those that were on the lowest rung of poverty at that time. the democrats promised equalizing outcome. everybody will get something through unlimited federal assistance. republicans offered something that seemed to be less tangible, the promise of equalizing opportunity three free markets. now republicans face a daunting task. several generations of voters have never voted republican and are not open to considering the options had. democrats still promised unlimited federal assistance and republicans still offer free markets, lower taxes, less regulation, but because we believe it will create millions of jobs for everyone the democrat promises tangible, puts food on the table, but too often i think it doesn't lead to jobs or meaningful success. the republican promises for

policies that create economic growth. we believe lower taxes, less regulation, a balanced budget, is off and social security, salt and medicare will stimulate growth. republicans point to the ronald reagan era when the economy grew at 7 percent. we added 8 million jobs in a few years during the administration. if we did that again we could conceivably create 11 or 12 million jobs creating almost no jobs at this point. today after four years in the current policy, one in six americans live in poverty. more than any time in recent history. in fact the poor have grown poorer in the last four years. black unemployment is 14%, nearly twice the national average. this is unacceptable. using taxes to punish the rich and reality punishes everyone because we are all interconnected. high taxes and excessive regulation and massive debt are

not working. this isn't just democrats cummins democrats and republicans piling on the debt but it is a burden for you. it's an impediment to getting a job when you leave here. the economy has been growing at less than 1% and contract in the last quarter of the last year to the i would argue that the objective evidence shows the big government is not a friend of african-americans to be a big government relies on the federal reserve. our central bank to print money out of thin air to higher prices. with the prices of gas rise to $4 a gallon it's a direct result of your government debt. when food prices rise, it's a direct result of $50,000 we borrow every second. inflation hurts everyone particularly the poor. if you are struggling to get ahead, if you have student loans and personal debt, you should choose a political party that wants to leave more money in the private sector so you get a job when the time comes. some republicans, let's call

them the moss covered friday mistake the war for defense. they forget that he argued through peace through strength, not war. the old guard argues for farming ghadaffi and then we want deutsch on the ground to defend him. they want deutsch on the ground all the time. there are republicans that don't clear for the war and they believe in a strong national defense that serves to preserve the peace. in louisville in the predominantly african-american west end of town and was recently announced 18 school districts are failing. the graduation rate from high school is 40%. the head of kentucky's education called it academic genocide. johns hopkins researchers called the school's dropout factors. i defy anyone to watch waiting for superman and honestly argue against school choice.

a friend of mine on the west end call school choice the civil rights issue of our day. i think he's right. by the sixth grade he was feeling most of his class is but through school choice he was able to attend the catholic school here in d.c. and he learned he had a gift for composing music. for that he wasn't even reading. his reading level was so low that he couldn't write lyrics. he went on to the university and there are countless examples of the benefits of school choice. talk to the parents of these kids, look at the kids that were interviewed in the movie waiting for superman. maybe it's about time we reassess the ideas that are failing our children. every child in every neighborhood of every color, class and background deserves a school that will help them succeed. those of you assembled today are the american success stories. you will make it and do great things. but in every neighborhood, white and black or brown there are kids that are not succeeding

because they made mistakes when they mess up. they had kids may be before they were married the war before they were old enough to support them or they got hooked on drugs or they simply left school. republicans are often miscast or uncaring of kids who make bad choices. i for one plan to change that. i'm working with democratic senators to make sure the kids that have made bad decisions such as nonviolent possession of drugs are not in prison for lengthy sentences. i'm working to make sure first-time offenders are put into counseling and not in prison with hardened criminals. we shouldn't take away anyone's future over any one mistake. let me tell you the story of two young men. both of them made mistakes. both of them were said to have used illegal drugs. one of them was light from a privileged background he had important friends and important father and an important grandfather. you know, the kind of family who university dorms named after.

they had more money than you can count. drugs or no drugs his family could by justice if he needed it. the other man also used illegal drugs that he was a missed the become mixed race from a single-parent household with little money. he didn't have important friends or a wealthy father. you may think i'm going to tell you a story about racism where the rich white kid gets off and the black kid goes to jail. it could be and often is the that's not the story to the and this story both young men were extraordinarily lucky. both young men were not caught using illegal drugs coming and they were not in prison. instead, they went on to become presidents of the united states. barack obama and george bush or lucky. [laughter] adel law could have put both of them away for their entire jongh adulthood. neither one of them have been employed much less president. some argue with evidence that

our laws or by a standing are the new jim crow. but as to simply be against them for that reason this is a larger point. they are on fair to everyone. white, black, brown, largely because of this idea that one size fits all, this idea that federal sentences should have no discretion. our federal mandatory minimum sentences are simply heavy handed and arbitrary. they can affect anyone at any time jody disproportionately affect those without the means to fight them. we should stand and proclaim enough is enough. we shouldn't have laws that ruined the lives of young men and women that have committed no violence. that's why i introduced a bill to repeal the minimum mandatory sentences. [applause] we should not have a drug laws or court system that is proportionately punishes the black community. the history of african-american

repression in this country rose from government sanction racism. it's important to remember that. from government sanctioned racism. jim crow laws for a product of state and local government. big and oppressive government has long been the enemy of freedom to do something black americans know all too well on a personal level. we must always embrace of individual liberty and enforce the constitutional rights of all americans, rich and poor, immigrant and native, black-and-white. such freedom is essential in achieving any longstanding health and prosperity. as tony morrison said, write your own story. challenge mainstream fatah. i hope that some of you will be open to the republican message that there is choice in education, less aggressive foreign policy, more compassion regarding non-violent crime and encourages opportunity in employment. and when that time is right, i hope that african-americans will

again look to the party of emancipation, civil liberties and individual freedom. thank you very much. [applause] the senator has agreed to take a minute of questions if you want to just come up to the microphone. [inaudible] [laughter] >> i heard you because i know we have some students that are going to have to leave. please, questions, not speeches. thank you. yes, ma'am. >> thank you -- >> tell me your name and where you're from. >> - joshua mathis, a student at american university and thank you for coming out. during your speech you mentioned

that you have support that you want a government that leaves you alone. you've been one of the fiercest opponents of federal interference with local autonomy and local rights. so how can you justify killing last year's d.c. budget soltanieh bill and also interfering with the local legislation of our local the elected government? [applause] good question. first of all, when partisan's discuss an issue sometimes you only hear one side so i will tell you the other side. i didn't kill any d.c. autonomy bill. i had no power to stop any legislation. i am in the minority. unlike on amendments that they did not want to vote on. so, they proceeded as killing the bill. but my intention was to get votes on some amendments, and they had the majority, the democrat majority could have easily voted mine down, they didn't choose to vote on that, so it's kind of interesting.

like right now on this debate i preventing the debate from happening. i'm not presenting any debate from happening they just have to agree to vote and to move forward. they chose not to vote. on the d.c. autonomy do i think that maybe d.c. could have more autonomy clacks needy. but i also know that the constitution put d.c. under the congress party of and that we give d.c. money from the rest of the country from the tax receipts. so, i think that oversight on the money that we spend, it is incumbent on it's a responsibility of the constitution and as a budgetary responsibility that we have oversight on the money that we spend from the u.s. treasury in d.c.. so i think it is a tough road to walk, but i'm willing to look at the budgetary authority to see if we can come to a resolution. >> thank you. >> linus julian lewis and a political science major from memphis tennessee. i would like to thank you for coming to the university and speaking to us.

my question is first of all i may former white house intern for president obama and i would like to say the president is doing an excellent job. [applause] and also in national field organizer. one of the only african-american supertax for president obama in the entire country. you said the republican party is a big proponent of voting rights and i've been traveling along with members of my organization all along the country across 30 states, registering african-americans to vote a higher rate in 2012 than in 2008 because the republican party has been using their state legislators and their government to prevent african-americans from voting because they didn't want to elect president obama so i'm asking you how can we believe what you are saying with regard to voting rights when we

feel based on our intellectual ability to engage whether you can connect with us or not. how can you say that? [applause] meeting here today trying to open this dialogue is that i'm trying to say the republican party is interested in the african-american community and convince some ideas. maybe not all immediately but some ideas for people with health and jobs. as first trying to prevent i think it's important to know in the history what happened. democrats in the south were very harsh. that is who ran the government and they did have tests at the polls, literacy tests and special tests and guess what if you're black you had to do the test and you didn't pass the test. people were scared and intimidated and prevented from voting.

i think if you like and using a driver's license to the literacy tests you deneen the horror of what happened in the 40's and 50's probably from 1910 all the way through 1960's in the south. it was terrific. nobody is in favor of that, no republican is in favor of to have an honest election i think is not unreasonable, and i think that is the main thing republicans have been for to it -- thank you for coming to get we appreciate it. i am a junior science major here at howard university and a member of. my question is i believe that we must -- we must first define which republican party, and i want to ask you are we discussing the republican party before 19th century, abraham lincoln republican party or are we discussing post 1968 republican party richard nixon, ronald reagan, and my question

to you is which one do you identify with? [applause] >> i think that is a great question and that hits the nail on the head exactly as to what our obstacles are because people, including those that may have just clapped conceded there are completely different parties and you don't object to the party of the emancipation and voting rights and citizenship and all that of the 13th to 14th and 15th amendment. the argument that i'm trying to make is we haven't changed, we don't talk about it. i need are going to convince you or not, but my argument is there are some of us who haven't changed who are still part of that party that you like they truly believe that ronald reagan was still part of that. we don't see a number of the difference, we don't see all of a sudden -- we see a horrible jim crow and racism that happened in the 40's, 40's and 50's. it was all democrats.

abbas and republicans to do some of the switch over and become republicans? yes but the party primarily we are not those people to a i will give you one example one of the african-american u.s. senators was, in blanking on his name from massachusetts. [laughter] his comment i found a pretty interesting comment, his comment was that democrats had the incredible history of the abolition of emancipation, voting rights for all of the civil war amendments you hear about all the time because democrats are good at talking about stuff like that. he said republicans have done a terrible job and that's why we have to resurrect some of this. if you would have said to be

using the founders of the naacp are, republicans are democrats would you know that they are republicans? all right, you know more than i know. [laughter] and i don't mean that to be insulting. i don't know what you know and you don't. i'm trying to find out what the connection is. but the thing is i think the general public hasn't talked enough about the great history and interaction between the republican party and black history and voting rights in our country, and i would try to make the argument, and it is an uphill battle. frankly it is an uphill battle for me to try to convince you that we haven't changed but that is part of me being here and part of what i am trying to do. >> i am a navy veteran from murray kentucky. [applause] and i made auctorial student here at howard university majoring in political science. my question is that this week in kentucky we've had a lot of

victories this week, including of the legalization of a hemp bill for industrial purposes and what have you. [applause] my question to you is being from kelly county, mccracken county and all those different places in that truck and cranny, there's been such a large number of african-americans that has been incarcerated for drug issues. my question to you is how are you going to take this industrialized new economic boost and actually allow african-americans, other people that have been disenfranchised, the poor to actually benefit from this industrialization that is growing force in our great state? >> thank you for the question. it's also an example if you want to see and i trying to work with other sides, and i different from some republicans that you've met? i signed a letter with our democratic governor to ask for a waiver from no child left behind, and i also lobbying the space government working with

our democratic congressman from louisville on the issue to get a waiver of the federal level. we state law that is passed but we have to get a waiver from the federal level in order to grow it. it is important that we distinguish that they are different things. hemp is a crop, it's not a drug it is a crop. you use it for paper, rope, you use it for clothing, biofuel, there's a lot of stuff. but it was a huge step forward. we won with 90% of the vote, and we started out -- this is something republicans and democrats working together. i hope the growing of it everybody will benefit including african-americans. on the incarceration thing, i've got the ballan mandatory minimums. kentucky has actually made steps forward without having more local drug court. and i also want to distinguish -- and i'm not standing up here saying drugs are good. what i'm saying is even the most benign of the drugs that we talked about, marijuana, i think if you lose it too much you will

lose i.q. points and you won't show up for class. icg will eat too many doritos. [laughter] there are good to eat the things that aren't good about it but if you make the mistake to the kids are forever doing stuff until they are 25 they shouldn't be doing and then all of a sudden they turn 25 and a light bulb goes off and they get married or something and they tend to settle down more. but i don't want to see them in jail and i will do everything i can to keep them on violent criminals out of jail. [applause] >> i'm a freshman of science major from new orleans changing from the more social civil rights talk in. you famously filibustered the obama administration black on transparency and counterterrorism specifically program. my question starts with your fellow senator jon tester gave testimony on the floor of the senate against a recently anonymously added bill with a

provision that is legal precedent to the agribusiness and the provision was quoting senator tester says the usda has the right to ignore any judicial rulings on gmo crops. those in your party, the tea party have spoken out vehemently against it. did you have any provision on the floor, and the testimony of jon tester from montana? if you did why did not deserve the filibuster of the confirmation for is your proposed filibuster of any legislation. >> help me understand in your words again is this about gmo, the genetically modified corn and -- >> it's called the monsanto protection act. >> but explain to me -- we had a lot of those recently and i am not sure i know the details of this. >> senator jon tester, a democrat from montana, as on the senate floor and he pointed out

a provision in the recent appropriations bill i believe it was having to do a lot with the agriculture, and and that there was a provision that basically in his words tells the usda to ignore any judicial rulings are possible judicial rulings gmo food which is to give legal immunity to the agribusiness. >> it was passed and signed by president obama to an estimate by a voice vote. >> i think i'm against giving immunity to the big corporations in general. i think for example, and this is a different subject that may be related is when we get immunity like for google to turnover your records of what you search on your computer i think that is a mistake because then they are going to violate your contract. the same with monsanto or any companies there is an obligation to deliver food that is not

harmful to you and they deliver something that a court says is harmful, then i think we should go to the court and the government should not override that. the specific vote i have to look into because i don't really remember the details. that's the best i can do for an answer. >> thank you very much. >> good afternoon my name is brandon patterson, a sophomore economics major from chicago, and my question is recently the death penalty lot of organizations and putting that i'm a part of the working to get capital punishment repealed nationwide because it is for the racial minorities so i wanted to get your view of the death penalty and the purpose it serves in our criminal-justice system today if any. >> i have mixed feelings on the death penalty. i think of it sometimes in a personal way if someone came into my home and killed my wife if i were there at the time i would have no problem pulling the trigger on them to defend my life.

a week or two later i just don't know if i may for getting enough percent. that's my emotion coming out. but i also realize the court systems make mistakes, and even while i am a big huge fan of our court system of having a trial by jury and having a judge in all these things come still the evidence some of it comes from illinois on some rape cases involving murder also is proven time after time that they were making mistakes, that the courts for making mistakes. so why do have some reservations. i'm not sure i know exactly what the answer is. i think most penalties for crime should be done at the state level, not the federal level. so i'm not a big stand for anything other than maybe for treason. senate hello, senator. i'm a professor here in the criminal business. i thank you for coming despite the fact that you've spoken out against the civil rights act, against of the voting rights

act. you've done it as a champion of individual liberty and states' rights. and so, i wonder aside from the moral reason not to discriminate, of which there are many, when is it okay legally to discriminate according to you? >> i think it is a mischaracterization of my position, and his characterization. i've never been against the civil rights act ever, and i still continue to be for the civil rights act as well as the enforcement of the 14th amendment. >> [inaudible] [laughter] well, there was a long interview that had long extended conversation about the ramifications beyond race, and i've been concerned about the ramifications of certain portions of the civil rights act beyond race as they are now being applied to smoking menus,

you know colistin calories and things on menus and guns, and so i do question some of the ramifications and the extensions but i've never questioned the civil rights act and i've never come out in opposition of the civil rights act were introduced anything all to the civil rights act, so your characterization is incorrect. [applause] >> good morning. i am a native washingtonian living in the colonial city and to correct you, d.c. residents pay more in federal taxes than they get back from the federal government. but my question is this. the 14th amendment was passed to protect those coming out of slavery. do you believe that corporations are people that have the same protections as natural citizens without any of the negativity of natural citizens? and my second question is that the