4.5 years, we have worked diligently to change that. just like we did to help people in the private sector get it done. the first chief technology office, sinatra took office, i did. today our chief technology officer, todd park, and our chief information officer are working to integrate and apply the best technology to help solve some of our biggest challenges from jobs to health care cost to keeping our nation secure. we are the first to confesshe progress has not always come quick and major challenges still remain. we have made huge loss of your government more efficient and we

have done it by focusing on three areas. we expect services and smarter and faster ways. for example, when a natural disaster struck, teams from fema had to rely on inspections to figure out which families needed help. now they analyze imagery and get images that are needed most were quickly. most folks were able to sign up using the mobile and web apps, checking the status of helping with internet access to sign up for disaster relief without leaving their homes. making sure that we are

delivering services better and faster and more efficiently. >> we have identified more than 2.5 billions of dollars across the federal government and that is just the beginning. i have signed into law dozens of federal programs and have cut even more that were duplicate or not working no longer needed the basic principle is tax payers deserve the biggest bang for their buck, especially at a time when budgets are tight and we have to do more with less. anyone can visit whitehouse.gov to see the taxpayers see. it tells you just how and where your tax dollars are being spent. finally, for the first time in

history, we have opened up huge amounts of government data to the american people and put it on the internet for free. data.gov, you can search and you know what they charge for different procedures to whether and climate measurements. what is happening is that entrepreneurs are using that data, the people's data, to create jobs and solve problems the government canceled itself or do as efficient. it is used more than $300 million is what we hope to save on energy bills. there is another company about triaged donning my two emergency

room doctors that is using downloadable data about health care providers from the department of health and human services. helping 2 million people i'm closest doctors and hospitals and list goes on. hundreds of people are still hiring. so we have made some good progress so today i met with my cabinet, including a number of new cabinet members, some who have extraordinary experience. i directed the cabinet to deliver a smarter and more innovative and more accountable government. we will continue to adopt good idea from the private sector. i have asked the director of the

office of the management of budget to lead us. she was part of a team that presided over three years of budget surpluses in the 1990s after philanthropic work at the wal-mart foundation she has come back to help us move this effort forward. she is not the only one. we have also welcomed a new class of presidential innovation fellows. and i would love for the press to meet some of these folks because they are extraordinary. americans with vast technology expertise who have volunteered to serve their country in the private sector. scott helped found a company that helps recent graduates turn their good ideas into businesses and she used to manage product design for everything from mobile phones to video games and darren gibbons found an

innovative shopping site that helps your taste as you browse. they are taking this expertise and bringing it into the government. and making it smarter and more user-friendly. many online shopping websites help fill in some of your information so you don't have to enter it every time you log in. as a consequence, we are working on a project called my usa that will help you with government forms. and if you are applying for federal benefits, we think you should be able to track the status of your application in real-time, just like you can with the location of a package on which your doorstep. these are things that are in the pipeline right now. currently when our government ask for bids on a project, it is usually complicated requirements that most people don't understand. we are working to make things simpler so it is easier for more small businesses across the country to bid on projects.

helping businesses to create projects that need to be done and opening up more government contracts and we will save them money in the process. we recently relaunched an upgraded easier health care.gov. october 1 americans can logon and comparison shop with private health insurance plans side-by-side, does let you go online and compare the best deal on cars or the best deal on computers. because you will finally be part of a new pool with millions of other americans, insurers will want to compete for your business. we have worked really hard to make these user-friendly. when the prototype came at 21 pages, we rejected it and said, let's do better, it is now three pages long. by the way, that is a lot shorter than the application

itself or the private insurance. and last year i also asked congress for the authority to reorganize and consolidate federal bureaucracy and we are doing a lot of this work administratively. unfortunately, there's still a bunch of rules and lots of legislation that has poorly designed some of our agencies and forces folks to engage in bureaucratic hoop jumping instead of just going ahead and focusing on delivering good service to our citizens. so what we have asked its clean this up and consolidate. most every president from herbert hoover to ronald reagan have this authority to redesign the federal government, the executive branch to deliver services better. just like every business owner seeking to make sure that his or her company keeps pace with the times.

currently we do not have that capacity. so i will keep on doing what we can administratively, but we sure could use congresses help, particularly at a time when congress is saying they want more efficient government. they give a lot of lip service to it. and we are operating under severe fiscal constraints and it makes sense for us to be able to redesign government so that it can deliver on the functions of the american people are looking for. we should all want a government that is more responsive to the needs of the american people. the good news is that america is full of public servants who are working really hard every day to pull the public trust. those of us that believe they have a responsibility to guarantee some level of security and make sure that everyone gets a fair shot at success in iraq are the upper going to want to

start a business to the workers were working on business, does have a responsibility to make sure that government works. it is one glad that we have people like scott and claire and aaron and so many other idealistic men and women who have signed up to help us tackle these challenges. that is why we are so cowed that sylvia will be heading this up. i will be asking more people around the country, entrepreneurs and visionaries to sign up for service. we have to have the brightest minds to help solve the biggest challenges. it is a reminder that in this democracy we, the people, we recognize this government belongs to us and it's up to each of us and every one of us to make it work better and you can't just stand on the sidelines. you cannot take comfort in just being cynical. we all have a stake in government success. because the government is us. we are doing things right. we are tracking whether more

effectively and that saves lives for folks who are in the path of a tornado. when we are delivering effectively data on improved health care choices, that will save lives and reduce costs. we have the potential non-for profit, most, we want to make sure that we are empowering folks are sitting here today to make sure they can deliver on the 21st century that the american people want. thank you so much, everybody, keep up the good work. [applause] >> house gop leaders today called upon president obama and senate democrats to reduce student loan interest rates. rates on new subsidized stafford

loans doubled to nearly 7% after congress failed to reach an agreement by the july 1 deadline. as of 10 minutes. >> thank you for coming. [inaudible conversations]

[inaudible conversations] >> good afternoon. the senate has taken action for students all across the country. they have known for many months on july 1, many student loans, federal student loans would double and they have been more involved in internal bickering rather than addressing the issue. the students that are surrounded with us today, they are all suffering because of it. one example is a gal from eastern washington who is working at a local mcdonald's

drive-through to help pay for rising tuition at washington state university. she is an aspiring economist and a public servant and i'm not sure, but she will be able to hope that she can finish school. unfortunately, that is repeated among many students across the country. i was the first in my family to graduate from college and graduate school and i can tell you firsthand how difficult it is it is not fair for democrats who want washington to stand in these students ways. about 20 million students are in college and 60% have to take out student loans. when harry reid tells us that he is not looking for a compromise, i would encourage him to think

about haley and these college students and many others across the country. as members of congress, we are here to make life easier for students who want to go to college, those who want to get an education, they want to find a job. instead, we see just the opposite, we see fighting internally instead of passing a solution. i urge them to act quickly. put students first and not washington politics. >> republicans are back and interest rates are being stopped from dublin. to make college more affordable for students across the country, including the students right behind me. the white house and senate democrats have let these students down. i think that they deserve better. it is time for the president to lead, it is time for him to bring the senate democrat leaders together and develop a

solution. it is time for the senate and white house they are the biggest issues facing our country, jobs and the economy. everyone deserves a new normal is better wages. >> being very direct, the house has acted in the rates are being doubled. to deter? students across america. they want to have a fighting chance for future and we asked terry reed to take some action. do not stop this.

america is looking at the students most important. don't punish them for his inaction. >> my colleagues have pointed out the problem. july 1 is behind us now and interest rates on subsidized stafford loans have doubled. the house passed legislation to keep that from happening. to tie us to the market come into the ten-year treasury to make a long-term solution a bipartisan group of senators in the senate have proposed a similar solution. yet there is no action from the senate majority leader.

>> what makes you think in your statement today in your statement earlier this morning that they would be able to come together based upon criticisms of how they progress. >> the house has done its job. the fact is that the students were going to pay the price, when they see the interest rate on their loans doubling. it is time for them to act. we have a bipartisan group in the senate, we have a solution that was not far off from our solution. yet it was shot down by the majority leader's and he began to wonder whether they are looking for a solution. >> do think would have happened is the united states aid to egypt?

>> what is respected in the country is the military and i think that there our military progress in terms of replacing elected president. i think it is part of how we would move ahead. >> the house does not intend to do this. they intend to do their own job on developing an immigration bill. the american people expect that we will have strong border security in place before we begin the process of legalizing

and fixing illegal immigration system. we will have a conversation with our members on wednesday on how we can move ahead. i think it is going to go away. it is time for congress to act. i believe congress has adopted when we were to work out. [applause] >> more on the cost of college and a meeting with the students of the university of maryland and steny hoyer. this is one hour.

>> the first thing i thought we would do is -- hello, how are you? >> how are you? >> okay, the lady with the money, how? [laughter] to basically advice of how to get the money, sarah has been wonderful, she does a great job here at the university. let me start by telling you as some of you may know. it is true depending on how late your parents have you in your life.

my first semester cost me $86 for 15 credits. i didn't start to concentrate until my second year here. and in any event, we got into the university of maryland. if you had a see average, you got it. no questions asked. and i was a commuting student, obviously. >> it was just incredible. i think now the costs are so

much with higher. especially the state colleges. they were, theoretically, they have all been very affordable. and we still have state colleges that are open to all. they are very affordable. but they have gotten a lot more expensive. some are relative to even when i went to school. it is very important that we keep college affordable. not just for you, but for you. it is important that we do so for all of america. because all of you will make a difference for america. if we don't make sure that the best and brightest can get into school and can afford school,

yes, i went into public service is probably some of you know, and i graduated from georgetown after that. it was a pretty quick transition. i practiced law, but i didn't know that georgetown was more expensive i remember it was about half an hour from here. my neighborhood where i live. september of 1957. in 1940 dodge coupe. and the russians have launch vehicle called sputnik and it was circling the globe.

america was shocked. america was shocked that is why it is called a defense education. it was perceived to be part of her national security so the debate that is going on in washington today is about how we

make this affordable and accessible and make sure that they don't graduate from school so they can go into public service and can be teachers. tearing a 65, 75, 95,000-dollar debt load is thinking to themselves, how can i earn enough money. we have tried to work on that by working on the percentage of income. but we have just had a debate that i wanted to talk you to you about. i wanted to talk to particularly about your situation. because although we talk a lot in the abstract, ultimately the policies that we have adopted our discrete on their impact of individuals.

this is how we structure the various loans that we have, whether we let them float or we cap them at the time you take the loan, all sorts of different alternatives. and consumers are part of the lowest parts of interest rates. which is why we are refinancing them. because interest rates the interest rates keep going down. i wanted to hear from you. in and the first thing we will do is start and just go around and i have sort of already introduced sarah. we will go around the room. >> hello, i am sarah and i am the assistant vice president for financial aid here at the university of maryland.

>> i am a senior fellow. >> i am from chicago illinois and i'm a student. >> okay. >> i am from annapolis, maryland. i am a student in government politics. >> okay, my name is patrick and i am a resident sophomore, a politics major. and i live in maryland. >> hello, my name is mark and i am a student here at the university of maryland. [inaudible conversations] >> i am serving as a student body president here. hello. >> thank you, i am a french

double major here at the university of maryland. >> hello, i am a graduate of st. louis college and i am from baltimore. >> i'm from east brunswick, new jersey. >> i graduated a year ago. >> we have spent some effort trying to encourage people to participate. what i like to do is have tom speak. ..

>> ultimately policy means something to somebody to some circumstance. we want to hear that. >> [inaudible] >> i did not know that. come on up. we have enough seats are we will move some up. here you go. move a chair here. we have room here. does everybody know the doctor by the way? should make sure i do the right thing.

[laughter] who wants to be first to tell me your situation and what your challenges are and why it is important to you? as you know, we have a bill , some of us that freezes for a least one year, and maybe two years of 3.4% of the subsidized loans thomas stafford loans for another year which we also did last year. there are other proposals that has a floating market value and it continues to float even after you take out the loan with my house fixed-rate mortgages were float based on the market. the president has a market rate for the establishment of the rate but then frozen

at the time you take it. that is the major one. i know you have been talking about this and it is important your education i could not have completed doorjamb without my loan. i think a bar of $1,000. that was for two years. 500 per semester but i was working so i could hit make up the cost myself i biota negative teacher. i paid it back in tenures. imagine that. of cannot even remember what i paid. said this is not so much for you. want to make that point in the people watching but it is for our country. it is so critical that you young people be given the best education that we can

give you comment bright minds develop to contribute to our country so this is about investing. who has a thought or challenge? i have read some of your resonates so i know that some of you do. go. >> i have a question. i am now currently a grad student but i went to georgetown previously for a master's. and while there i encounter the fact grad students and do not have access to subsidized stafford loans and what is the reasoning? if we are to eat concern to avert future you have to go to grad school to career in most fields so why is that not available? >> even bill gates is not sure that is correct in

e there but as a generalt rule, you are correct. now dealing in a world of alternatives there are x number of dollars available and the congress made a judgment getting the undergraduate degree was the priority. to have more resources you could subsidize more loans but that was the priority so i think that is is essentially the shorthand answer. it was the most efficient use of resources to ensure the undergraduate degree believe the graduate degree degree, while loans are available they are not subsidized on the theory that the graduates would make more money as they go up the educational ladder ladder, everybody knows if you don't graduate high school uric chances of making a decent wage or

reduce pressure in high-school will do better. some college or community college you will do better and on up the chain as you point out but that is the reason. there was a sense, let me cheops that what i did not say, i believe because this is in the best interest of the country that we should not look at student loans as a deficit reducer. it should be neutral that is to say at worst law ought not to lose any money or make any money at best so what ought to be neutral. the reason for that is we should not ask students to deficit -- subsidize the deficit as no other generation incurred that debt and we encourage you to go to school we want to make it as affordable as possible

and reducing the deficit should not be your responsibility but our generation to do so. that is one of the debates by the way if this president democrats republicans for $5 billion of deficit reduction. >> even if somebody's goal was to reduce the deficit it would only put a bandage on the larger problem. i am a graduate student but my friends are in the working world and i have friends who pay more in loans than their rent or cannot read to or buy a house and so they live with their parents they cannot buy a new cars you just created generation of adults that cannot put any money to anything but the student loans you hurt the economy. the free up money that young adults today that put toward the student debt but now

people are able to put money on a house or a new car or supporting local business or any business. >> that is an excellent point* to the extent we put our most capable people deeply in debt in economy 70% driven by a consumer spending we undermine their ability to purchase cars, houses, necessities come and have children, we have diminished our ability to grow our economy. good point. >> also undue strain on those parents so not only crippling one generation but several. >> you are right. good point. i'm glad you made it. >> i know every month i will

pay $750 in student loans but as you were saying it does make it more difficult to buy a car or a house and that is more than my ranch. if i get a note to every month, to would have to pay that is so much more stressful i would not be able to live for i am living now because i don't know month-to-month i could afford it. it is important that we have the fixed-rate as has been in the past not based on conditions that are out of my control. >> i agree 100 percent and the president does but what rate do you use? but once you take out, again made mortgages fixed-rate. i know what i will pay from now until satisfied.

i have the confidence i will set aside this much money every month to pay the mortgage. >> when everybody comes back from recess thinking they will have eight solution that is retroactive is seems like everybody is on the same page but they ran out of time. >> it will be retroactive because i don't think we will take something that isn't and resolve it between now and august 2nd? may be august 3rd or whenever that friday is, it will be retroactive so although everybody said the deadline was july 30th unsubsidized stafford, that

is true but i think we will bollenbach in review are i think republican or democrat that we address it as of july 1st. i cannot imagine that we would not make that retroactive. >> i am a junior with criminal-justice major. you asked for a more personal opinion and you want to know how it affects us directly i could give you a background in you could sum up, it would affect me. the estimate -- both my parents from louisiana, new orleans and the mother was diagnosed with multiple

sclerosis so-so those titles of a major college and the youngest of 12 my parents put six kids through college and now i have to find a way to make it for myself whether scholarships which come rare typically out of high school into college my grades in high school were much better than migrates in college but i think they do pretty well but malone's themself, my parents are back in new orleans so once a graduate college within the year i will have to make do. so to try to find an apartment or a car to have a job or just enough money to have an apartment or metro access would be difficult

paying back student loans. i just want to give you that little tidbit of my life. >> you have tasted alone now? >> yes. >> every semester? >> yes. >> if you don't mind, what approximately do you think if you are a rising junior? said you have another two years to go, would you estimate your debt will be when you graduate? >>. >> i take about 3,000. >> so another 12,000. >> yes. $25,000 by the time they graduate. you can see how that would affect me once they graduate many students like we would

try a to stay in school and i will graduate but i know a lot of students would rather try to take an extra year or more class's just so they have enough time to produce enough revenue to even live at sea level and below it. >> were you studying? >> criminal-justice. >> you said that. i am sorry. that is one of the more affordable colleges that rehab and you get a good education there but affordable is in the eye of the people there or the thickness of the wallet. you have to have it to spend it even if it is a loan.

$86 come i think my first job maybe $60 per week. >> afternoon lyonnais psychology major and also raising junior. >> where you from? >> washington d.c.. for me it is a little bit different i support fixed-rate. and i am in the way i don't have the means to commune so i pay 13,000 per semester to attend a. it is more affordable for people who were in state i have taken out loans since my freshman year and to have the etf and the interest rates fluctuate -- as fluctuating is a bit scary. my mother is also seeking a

higher education so she has her own loans to pay back so the idea of me having loans to pay back once i graduate this year will be harder because i don't get the grant any more. so it feels like it will be a constant struggle for my mother and i once i graduate and it is scary i support dat of fixed-rate. >> something i heard this is a family decision i have been in financial aid 22 years you can see how the culture has changed over time that the decision all the wit is called a student loan you are basing your repayment online at the family's circumstances which is an interesting concept how student loans are working today. >> is a family issue. i am sure you had your

expected family contribution based upon your family's salary. that does not take into account all the bills or expenditures you'll house side of that so i do think you're absolutely right. >>. >> i love my 82 just as i have met some great people and i have learned a lot but it will make a harder for me to be in school and graduate on time and also i know from and to go to law school or grad school or take a couple years of that depends on the interest-rate i also work a lot with ice coolers and spend might spring break in philadelphia. talking about college, not a lot graduating go to college and when you attend university the main reason

they don't attend is the cost. i feel if we would increase the loans, we increase those nationally so any school in the country it would not apply because they don't think they get the aid so talk about national defense we're discouraging future generations for higher education. >> that is bad for the country. that is my point. i agree with you. >> it is important also to look at this conversation in the context of higher education because right now we talk just about the interest rates in maryland has done a great job to keep college affordable compared to other states around the country but we have a fight over interest rates not even keeping college affordable

and what students are looking for is a permanent deal. we fought this battle when year ago we did all this work and stephen advocates and we don't want to be wrong to work on youth unemployment to keep college affordable so it is important to see a permanent deal, fleet is the one real looking for but i don't think anybody wants to be at this table a year from now or the next year or the next year. >> absolutely correct. unfortunately we have been doing too many things on a temporary short-term basis. for instance will be compensate doctors for for medical care to medicare is done on an annual basis.

we give the tax credit to business for research and development to develop the products for ways of creating jobs and making many. that is increased every year. none of that leads to confidence. so i can plan around that. >> you're absolutely right we need to do this on a permanent basis but frankly all parties, not political parties but i believe we all want to do it on a permanent basis. that is not a good solution so this is what the deal is

a and guess what? now has been recent -- risen up to what i don't know what it will be so you are absolutely right. >> i of the oldest of three and i have 2 degrees a year and my sister could only afford her dream school because of the full athletic scholarship in my little brother very talented student interested in engineering and does not know what he will do if he can afford to go to a school that has an engineering program. it affects the way my family has their income on a daily basis the way we make our decisions the way he goes about school every day. motivation to do extremely well is not a bad thing but the anxiety that a company's

ice cooler these days could i afford college and how hard do i have to work and can i afford to pay off my long as it is too much for the young people to bear. they should be worried about what major they will go into in school. >> for mayor unexperienced let me say this is not a new problem however. the magnitude is new but it is that a new problem. i of the $1,400 scholarship out of high-school not too far from here graduated high-school and i got a $1,400 scholarship to lafayette university. good school in pennsylvania. it would have required me to get another $1,800. there is no way i could get 1800.

so i went to work one year starting the first year between 80 and 12 because my family had zero many. ahead zero many for college. not that they didn't want to but they did not have any. said they would have come up well on the family contribution but i never did that index because i get the money with a semester of working but this is not a new problem. it is just that the magnitude has gone up so much that while my problem was relatively stoppable there was the affordable alternative now that is not necessarily the case and maryland is extremely competitive because of the affordability. students who otherwise would

choose the school, or affordability has to fight to get in. >> it is very, very tough competition. i could not have gotten into maryland ahead 2.a graduating high-school. i would not have been able to get in. i graduated with high honors est the graduating wheel. it did not predict. volume apathetic to kids because it did not predict what i would do but i could not have gotten into maryland today. no way. maybe another school the second year because it is easier to get in but no way the first year note with the standards that now exist with a 3.six or 3.seven. you guys are also smart and your sats are off the charts. i did okay with those of my grades were not that great. who wells?

you are participating to look at this. right now i have grandchildren but they are not yet going to college in my children are already through college although my oldest daughter went to university of richmond which we believe was far enough away we would not visit on the right regular basis but close enough when she was homesick she could come home but that was $10,000 per year and that was in the late '80s and we can see how it has escalated blame sure it is in the 40's now. >> usage you could have gone to private university for more many of you went there because it was the affordable alternative? >> i said it was the only alternative because i cannot afford the others that happened to be one of the

best decisions that was made for me. >> my mom is a single mom putting all my -- all her kids to college when i was applying it was apparent that i will have loans pretty much wherever i go but she laid it out in the excel spreadsheet homage milo's a bfi chose to go to each college i ended up applying to all state schools because they knew i did not want to have six figures of loans and went to university of maryland partially because of the tuition because i fell in love and i loved my decision but i was educated right off the bat to know how much i would have to pay when it was clear my peers did not realize the decision they were making they got to go to the dream school which is fantastic but when they got out they graduated with six figures lausanne summer

unemployment they did not know about the affordable alternative like going to a community college. view we have a culture of not educating our youth as much but telling them you can go wherever you want to then have them be saddled with all the debt because they didn't know what they were signing up for. talking about interest rates there is also another problem here. >> you are absolutely right. it is a bigger problem is his serve on the board of trustees at st. mary's college and was in the regions for a period of time. until it became majority leader. but st. mary's college we pride ourselves to be a affordable quality institution but we're having a struggle to keep prices down with quality up. is a problem for the entire

higher education system in america. and we will have to grapple with it. is not the interest rates next year type of problem of how we make sure all of you can afford to get in next year or the year after or the successors. >> with affordability, i wasn't academic advisor to columbia which is very affordable be served nontraditional were first-generation students but even with those students with financial aid they were very adverse to us and for many of them the only way they could is to that telegram and is there anywhere ripple in the house to increase the amount of pell grants? even with an affordable institution they still could not manage to pay the extra

mike defease, books come the metro transit. i think they go hand in hand to a certain degree because he can't just be keeping the rate fixed for financial aid we also have to look capital grants as well. >> -- the reason we have the program and is it is a grand but the bad news is the debate in congress is about freezing dollars at 2008 levels. i know how many of your families think they're making $2,000 they could afford to live in 2013 and five years later. some of them are probably doing that but they find it tougher every year. most people are not living on the same income five years later. they have to keep up with

inflation if nothing else. the debate in washington is not about increasing that pell grant but cutting the pell grant. in 2009 and 2010 be increased to six. when they were adopted 30 years ago for the sake of argument. 65? they replaced essentially took care of about 72%. i was kind of labor health education subcommittee 23 years and it eroded over that period of time to where it was less than 30%. so about half of the dollars may have been incremental but we increased it significantly but it is tel

starting to wither away because the number of how much money have we decided is available to spend to invest in discretionary spending has been substantially reduced. belabor health education bill is projected to be decreased. nih, cdc, and other matters dealing with education by almost 25 percent will put it back unless they and 2008. but what is happening when you're deciding the -- deciding to spend not so security or medicare.

but say that it is half. 54 billion from the side of non-defense implicit on the defense side of 54 billion less which is a 10 percent cut. so that makes the adverse ability not only decreasing decreasing, not in terms of dollar amount but if you don't raise them by a inflation you increase the value. but not just you before the country if we're going to compete in the global

marketplace it will because we graduate our young people to be the growing economy we need not only for all of you but for the millions of people who don't go to college but have skills and the wherewithal to work hard to be a welder. gina how much they can make? eighty or $90 an hour. and master wilder again and make things they're all sorts of ways to do it but maybe it will all be done but you get my point. so pell grants is something we should increase and not decrease. those students have a lot of ability but not many means so we can use their talents.

>> it is interesting. >> main forward. [laughter] cheryl says she is the ceo of facebook to read a book about leaning in. am an avid student stay here at maryland. from new jersey. >> maryland is a magnet for new jersey. >> it is one of the top five. all across the east coast but what i think is interesting about affordability utah you could make $86 and one negative is

tween the socio-economic class that people can afford to use the unpaid internship that is the way they get their work done is creating these further divides by working job during the school year usually to jobs and then take credit to the internship to right now between the internships and a paid job i work 65 hours a week i am only paid for half

of the soil make minimum wage in by the way it might not cover like pay for the tuition. million vs to go to university of delaware she was brilliant to take a program in high school to graduate with a high-school diploma and her associates degree so she could graduate with less debt because she can do only two years of regular college but the parents are an encouraging her to do all four years but she really cannot afford it because of the loans she has to take out for college. >> that leads to a broader discussion. wife for years? have you thought about it? is four years the magic number? three years?

two years? that is part of a larger discussion but we talk about higher education? i went seven but actually it was nine because i did part-time and i did terrible my first year. but that is a lot of schooling i was 26 by the time i got out. but a lot of countries have three years of higher education than a transition with for years of medical school that adds to the expense to say we need a larger discussion how long enough to lot of big issues to discuss any per your

finger on a. and i did not know about the delaware program but that is fantastic. i don't think we have such a program that is what i meant. i said delaware but i know you came from new jersey. we should be thinking along those lines. clearly some people can take the first year of college in their junior and/or senior year because they're gifted. we ought to take a vintage of that to save them money but also to save us money. does anybody know friedman nebraska? you know, who he is? he graduated college at 19. he is particularly gifted. he has amassed genius. but having said that, think

of how much money he saved civic and know that governor o'malley is interested to look at programs like what her sister did to do course redesign but we can cut costs at the university level and get kids out quicker. we're not mac be yourselves money but also the taxpayer with in-state tuition to talk about we're subsidizing every betty's education so we can have a better work force. i think we're looking at that here but to be supported on the national as well. >> one thing we have to do this to exhilarate people getting out of school, have a job. one of our principal objectives in america is to create jobs and grow the economy faster. i have paid making an american agenda that i talk about which is in the may fracturing field but if you

grow jobs in every sector of the economy, and as a result really do need to focus on that. not as much as we ought to be so that's when you get the accelerated education there is a place to use your talents. i am sure your brilliant as well. shula someplace to use her brilliance to make things happen. of anybody else? what is our timeframe? we have to wrap up? sam odyssey is the president here who had the unpaid internships in my office. [laughter] that is a really good point about the unpaid internships.

it is like a volunteer army. and you get the connection? from the economic standpoint we haven't army that is not nearly as diverse as it used to be. rotc was mandatory there were 4,000 male students in rotc here at maryland. it was mandatory. and that is part of the reason i think cost was deferred and kept costs down because the federal government participated because it was useful for the country. but you make a very good point and we should look at that and not necessarily involved with student loans but on the ability to take the internship which is a very good credentials and experience critically

important work, i essentially was an interesting started to work on capitol hill when i was a senior. i did not do fancy work. i was not writing great reports or speeches but i was being exposed to something that was helpful to me through the years. view cannot afford to take the nonpaying internship how many hours? >> over winter break so it was four deep ---- per week. >> some people cannot afford to do that. what is the option? cost. old discussion in washington is not about increasing but decreasing cost. we need a big balanced a deal by the way

simpson-bowles, a gang of six comaneci rivlin, you name it we need a big deal. we don't have to agree with every point where every recommendation but we need a fiscally sustainable path with certainty so that you know, year-to-year what the tax rate will be in the budget ax and three. the uncertainty is hurting the country. this is just one facet of that. and not the big picture. i want to thank all of you for what you do every day. with your peers and for what you do for your country in terms of making yourself more able to contribute and participate in a productive way in the life of our country. i really mean that very sincerely. i almost lost out of maryland and it made a

difference when you open a book. it really did. i was okay in high school but i came here, i worked less. [laughter] then it dawned on me on my second semester which would have been my sophomore year that if you don't get your act together you will be digging ditches. we do need those dug. i don't criticize those people but i just did not want to be the ditch digger so i got my acting here. you have your act in gear. your outstanding students. so thank you very much. i also want to think sarah who has been here for some period of time and we have done a lot of work together she is very helpful to our office and to our students

for she is extraordinarily conscientious and focused to help young people get a good education. thank you for all you do. i appreciate it and also your efforts to help us get the extraordinary people together. we will take your comments. we have been writing notes and we will add those into the debate and i am hopeful we will resolve this. it is so insightful to say just a facet of the problem of higher education cost. that is the big problem like health care. medicare and medicaid to betty says you have to deal with them but if costs are contained you will be fine. the government is 50 percent of the peso we need to deal with that.

thank you all. best of luck to you and if we can help, give us a holler. thinks a lot. [inaudible conversations] >> the white house says cutting aid to egypt is not in the benefit of the u.s.. you can watch the press conference in its entirety online. here is some of what he said >> just to be clear, it is the administration actively considering cutting off aid to egypt? >> what i would say, is we are monitoring the situation in egypt in taking the time necessary to make the determination about what happened and what to label

it and we will work with congress when dad and further assistance but i would point out our relationship is not limited to zero word defined solely by the assistance that we provide it is broader and deeper and it is found in america support for the aspirations of the egyptian people for democracy, a better economic and political future. we support that process. our decisions with regards to the events of how we label them and analyze them are made with the policy objectives in mind without consultation of congress. >> a thank you answered it but 1.$5 billion in the long

dash in aid to egypt is under active consideration to cut off that aid? >> i think it would not be in the best interest of the united states to immediately change our assistance programs. rethink. not just die, we think it would not be in the best interest of the united states. we are reviewing of obligations and rebuild the consulting with congress moving forward with the assistance package that the provides vivid no immediate cut off? >> we think it is not in our best interest. >> you said in a statement over the weekend with the desire to return to a democratically elected government. half the white house is not calling for the return of the democratic elected president morsi? >> we call for a return to democratically elected government is for the

egyptian people to decide who their leaders are but the president has expressed his concern about the actions of the egyptian military. but we are mindful it is not about the polarization in egypt in the use of millions of egyptians about the undemocratic governments of the morsi government and their demands. and again, i tried to be candid you will get no argument from me if you go on the air to say it is a highly complicated situation that requires very careful monitoring and engagement. we want to take action to make decisions that helps egypt to move forward in this process and the egyptians to reconcile as the move forward with democratic governments in

the future cement is deeply concerned as you are how morsi was removed you do not call for him to be reinstated? >> a return to democratic governance is democratically elected government.

saving seniors of the most vulnerable citizens from the atomic crisis and the hearing of june 12 with the need for reform and also complements the commerce committee medicaid check a report from march making

medicaid work, in the committee's recent idea on the program. medicaid was designed to protect the most vulnerable americans including pregnant women coming dependent children and the blind and disabled. nearly one of four americans was an old and the medicaid program at some point making medicaid the largest government health care programs are passing medicare. we have an obligation to insure the program provides quality health care and has flexibility to better serve the population. as we have seen, we're feeling on both counts. only 70% of positions are accepting patients needing to problems with accessing care after initially seeing a provider the beneficiaries often lack access of

preventive services and a twice as likely to visit the emergency room and in some cases outcomes for medicaid patients are worse than those who have no insurance at all. regarding flexibility, incentives encouraging the states to pursue innovative models of care, we have locked them into the one-size-fits-all program dictated by washington with the states try to tailor programs to the individual population they serve the often spend years waiting for medicated medicare services to approve their waivers. before reemployment an expansion which a fully adopted would add another 26 million americans to the program, we must first address these issues in the current program. look forward to hearing from our witnesses today for ideas how to strengthen this vital safety net and i

welcome all of them to our subcommittee how. i yield the balance of my time civic the current debate over reform brings to mind a and i paraphrase, no one likes change even from worst to better even to support obamacare and the medicate components as they would never have designed medicaid today as it was designed 50 years ago so there is many issues of the current medicaid program to serve children and a dirty and pregnant women and long-term care and able-bodied adults if the intent is to take care the most vulnerable then i raise this issue with the child with a dramatic break in injury to compete with limited funds with the healthy childless adults. also how much money state

receive with the beneficiary is evident the five wealthiest receive twice as much in contributions to the care of their low current one negative but income residents than the five poorest states. with is to provide a baseline of coverage, why should the disabled recipients in your creasy twice as much federal government aid as a disabled person in california? problems include quality and access to doctors. a recent study found major -- medicare patients have higher costs and a worse outcome than the uninsured by yet despite being a high cost program hit frequently pays below a physician's cost which effectively denies them access. medicaid is the illusion of coverage without the power of access. i applaud the chairman for

holding that committee we cannot just add or subtract cashman call it reform but we have to reexamine the effectiveness of our structure in regional legree medicaid should be structured in a way to provide benefit to individuals a the most effective way. also recently introduced the medicaid accountability care act that can be considered and i yield the balance of my time. >> or medicaid program has continually underperform for the most needy and is it a focusing medicaid dollars but healthy people as with the health care law that should be directing attention to the outcome of the existing population, we must allow the states to experiment to improve results with the overly bureaucratic waiver process does not show the of care to

the most vulnerable it is time to repeal the provisions of obamacare to release the states to investigate novel ways to improve on the system occurred the fails its participants. thank you for the extra time. i yield back. >> we now recognize the ranking member for five minutes for an opening statement. >> mr. sarbanes is filling in for the ranking member today. >> 84 convening this subject of the medicaid program. as yourself said it is an important program we viewed as a critical safety net for health care coverage for those who have been shut out of insurance because it is not affordable were not available or does not cover the benefits that they need. it is important to recognize

when we talk about the medicaid program will not just talking about a program that covers low-income families but a program that covers children with adults with disabilities and pays for nearly half of all long-term care services. i have the privilege for 80 years to represent health care providers does an attorney and in particular those that provide services to our elderly and i stand how critical the support is for a lot of services that are provided to those most in need but in order to understand the full dimension of the medicaid program, we're talking about community-based and services, rehabilitative therapy and caregiver respite. . .

receive is in school-based health clinics. the coverage for children under medicaid is really one of the most important aspects of the program. i'd like to enter into the record, without objection, testimony from the american academy of pediatrics.

on this issue of why it's so important just both to pediatricians and to children as well. this is from robert hall, with the american academy. >> without objection, so ordered. >> the affordable care act, as we know, includes an expansion of the medicaid program, to include more low-income adults can taking it up to 138% of the poverty rate. half of today's uninsured have incomes below the new medicaid limits so they will benefit. we do have states across the country who so far have declined to become partners in this effort and take advantage of the medicaid expansion. the result of that is you will have men low-income adults who will likely remain uninsured, with predictable results for them and our society. we also have to look at this

through an economic lens, and as the economy continues to improve, more and more people are still finds themselves in need of this very orbit health care safety net. if you cut medicaid, that's essentially cutting jobsment medicaid stimulates the economy. every dollar spent is good economics. according to one study, by the kaiser family foundation, every dollar cut from medicaid means up to 2.76 cut from the state economy in which that occurs. the loss of federal medicaid dollars means a loss of health care jobs and health care economic activity across the country, which means you're moving states in exactly the wrong direction that we want to be pushing them in terms of our economic recovery. states and the federal government need to focus on creating jobs an incentivizing economic growth, not on cutting the most vulnerable programs such as medicaid.

i believe the expansion of the medicaid program is not only something that makes tremendous sense for the health of vulnerable populations across the country, but state economies as well, and i look forward hearing from our witnesses today as they discuss this critical program and how we can all push for quality affordable health care for our our children. i yield back. >> now yield to the subchair of the committee. >> thank the chairman for yielding. meet here today to discuss medicaid, recognize it was created to protect and care for some of the poorest and most needy in our nation, however, in reality, the program, because of weak oversight, chronic underpayment of providers, lack of coordination of benefits, ends up being another empty promise made by the federal

government. the ability of medicaid to provide healthcare coverage is further threatened by the affordable care act and the drastic expansion of the program to nearly 72 million americans in 2014. medicaid currently consume almost a quarter of state's budgets, surpassing expenditures on transportation, education, and emergency services. many states have been forced medicaid reimbursement rates to providers to address budget shortfalls. someone who has provided services to medicaid by-riz, i understand first hand that coverage does not guarantee access. medicaid low reimbursement actually creates increased barriers to care. limiting beneficiaries access because medicaid pays less for comparable service than private insurers, even medicare itself, making finding providers and appointments hard and sometimes impossible. escalating costs and shrinking access are symptoms of the

greater sncc -- systemic problems. weed in to move beyond small reform and instead address the underlying structural problems. we sat here in this very room with the health subcommittee hearing in 2008, and talked about this very problem. you'll remember it was a day that he lehman brothers chanced and the economy was headed for a crisis. we heard in that hearing that day that if you wanted to do healthcare reform on the cheap, you just expand medicaid. you're not peaking the providers to see the patients but that's not a critical. it's critical we provide the coverage. anybody who has practiced in the medicaid system will tell you that the ability to meet the cost of providing the care is critical for a hospital, clinic,

doctor's office, and if you can't meet that your doors will quickly be closed. as we sat here in that room that day in september, never even asked ourselves, is the best we can do medicaid? and wouldn't we be better to reform the program before we expanded it? but unfortunately the questions were never answered. so i submit today it's time for us to get back to the basics. we need to ask yourselves what medicaid was created to do and is it doing the best it can do under the circumstances. we know the structural and fiscal problems of the healthcare system. how long will america tolerate staring at the problems without fixing them for future generations. it's time not just to reform medicaid. we actually need reboot the entire system. we have seen from the events of the last week and a half, the problems in the affordable care act are beginning to mount, reaching critical mass. this subcommittee has it within its power to take up the issue

and act. i thank the chairman and yield the balance of my time. >> recognize the ranking member for opening statement. >> thank you very much, mr. chairman. the hearing today is called "making medicaid work for the most vulnerable." i think that's a good topic. i do want to talk about what the republicans have proposed. they have proposed making medicaid a block grant so the states would be told, this is the amount of money you would get, no more, no less. you don't have to do anything. no requirements. do the best you can. and if you can't afford to do what you've been doing, well, you do less. that's up to you. what the republicans in effect are proposing is to shift the

responsibilities to the states, the costs to the patients and providers, and avoid federal responsibility. block grants are per capita grants or increases in beneficiary premiums and copays do not reduce healthcare costs. but simply shifts the cost on to the beneficiaries, providers, and states. and they make it less likely that people will be able to access care when they need it. are the things we can do to improve the program? certainly. one thing is make it a federal program, not have state differences. have a federal medicaid program. guaranteed that providers get the same reimbursement rates as medicare providers get paid. that would improve the program. but i don't think that's something that we're likely to hear much support for from the

majority party that is in control. i think this is a good hearing to have. i know that we have a number of witnesses, particularly interesting in hearing from mr. ralph on what the states have beenable to do to be -- make the program innovative and effective and efficient. cover low income by-riz within the flexibility of the state medicaid programs right now. things the states can do today. i believe mr. wild will tell us that states continue to advance medicaid programs by implementing innovations such as the multipayer collaborative. efforts to increase access to higher quality, lower cost developmental and oral health services, and others for the prevention ofchronic disease. multiple studies have shown that

medicaid enrollees have comparable access to care as those with private coverage, and much more reliable access than to those who are uninsured. when we hear complaints about medicaid, the republicans are forgetting that before medicaid, these people were uninsured. and they didn't have access to any care. and under the medicaid program, it's beneficiaries can get access, lower cost sharing. if we make poor people, which is the bulk of who the medicate patients are, have to come up with more money out of pocket, they just won't have access to care because they can't afford it. not only does the medicaid program ensure equal access to care, it operates with efficiency. medicaid costs are nearly four times lower than average private plans.

and there are other proposals that i think will streamline state payment systems, improve provider reimbursement timelines, increase their participation in state programs. one thing i am very proud of is that at least we're going to, for a couple of years, require that the preventive and primary carry providers be paid the same rate as medicare. we didn't make that a permanent change, which would make a lot of sense. we put it in for a couple of years only. in hopes that after it's in, people would either at the federal level or state level, would try to keep it in place because it makes a lot of sense. if we can't afford to pay everybody a medicare rate, medicaid patients, at least paid those for whom we would like people to have access the most, those people who provide primary and preventive care. the affordable care act expands

the medicaid program. i think this is a good thing to do. and i'm proud of the affordable care act. i think it's going to mean for millions of people they're going to have access to care, access to health insurance, whether it's the medicaid, if they're lower income, or through the purchase of a private health insurance plan in the market place exchanges. let's stop complaining. let's make this law work. because the republicans don't have anything to offer but driving costs and shifting them over to people who can't afford to pay them, and thereby denying them the services they need. thank you, mr. chairman. >> chair thanks the gentleman. that completes the opening statements of the members. we have one panel today. i'll ask them to take their seats. first we have miss nina ochorinco, director of the center for health policies

studies of the heritage foundation. secondly we have mr. allen wheel, executive director of the national academy for state health policy. and finally, mr. taryn bragon, and crowe foundation for government account ability. thank you for coming today you'll each have five minutes to summarize your testimony. at this time, we'll recognize you for five minutes for your opening statement. >> make sure you -- >> okay. chairman, ranking member and members of the committee, thank you for having me today. it's already been well node noted the challenges facing the medicaid program are not new. they're unavoidable and raise serious concerns whether medicaid will be able to meet the needs of those enrolled in the program today.

the program serves a very diverse group of low income people, children, pregnant women, disabled and elderly. the affordable care act adds to the program by expanding eligible to all individuals with incomes below 138% of the poverty level, and like traditional medicaid, eligibility is based on income alone. i see three major challenges facing medicaid in the future. democratic, structural, and fiscal. the demographic challenges. with the addition of the new medicaid expansion, the centers for medicare and medicaid report projections one in four people will be on medicaid by 2021. children will remain the largest and primary category of medicaid enrollees, although it's worth noting that as a result of the affordable care act, able bodied nonelderly adults will be a close second. while only 16% of total enrollment, 64% of spending for

2011 was for the aged and disabled. as these competing trends continue medicaid will be more diverse and complex to administer. structural challenges. payment rates are one of the key indicators for access and physician participation. in its annual report, they note that while varying by state, medicaid fee for service payments to physicians on an average two-thirds those of medicare and even worse for primary care services. a 2006 published survey found that 21% of physicians reported they were not accepting new medicaid patients and only four reported not taking new private pay, and 3% reported not taking new medicare patients. the affordable care ability did provide federal funding to boost payment, the funding is temporary. and also as noted by the report, several states have already indicated it is unlikely they will be able to maintain the new

rates. therefore, access and quality issues will remain a challenge for medicaid beneficiaries in the future. fiscal challenges. entitlements. including social security, medicare and medicaid, are feel fueling this country's spending crisis. these programs represent 62% of the federal budget in 2012 and will absorb all tax rev enough by 2024. by 2021 total federal and state spending on medicaid alone is projected to reach $795 billion and 3.2% of gdp by 2021. for states which have to operate under a real budget, the fiscal situation is no better. when the federal contributions are included, medicaid is the largest budget item for state budgets representing 24% in its recent fiscal report, the gao warned that absent any intervention or policy changes, state and local governments would face an increasing gap between receipted and expenditures in the coming

years. this is glue large part to rising healthcare costs for medicaid and health benefits for government employees and retiree. although the fiscal challenges are well-established the lack of action makes the future outlook worse for method okayed and its beneficiaries. i suggest there are a few basic principles that should guide efforts to address key challenges. one, meet current obligations. rather than expanding to new purchase -- populations populations should be prioritized based on need first. return medicaid to the safety net. it should be safety net for those who cannot obtain coverage on their own. careful substance should be given to transitionings though into the private market. patient centered reforever. efforts to to shift from traditional fee for service to managed care have accelerated.

empowering patients with more choices and spurring competition will help to deliver better quality of care at a lower cost. fur, ensure financial sustainability, similar to other entitlement reforms the open end needs reform. sound budgeting at the federal and state level choo provide a predictable and sustain able path for the program and taxpayers alike. its encouraging to see the efforts aimed at addressing these serious challenges facing medicaid's future. with federal and state policymakers together, meaningful change will make sure the most vulnerable are not left behind. thank you. >> the chair recognizes mr. wild. five minutes for opening statement. >> thank you, mr. chairman. members of the commitee. i appreciate the opportunity to appear before you today. i'm the executive director of the national academy for state health policy, nonprofit, nonpartisan organization that works with state leaders to

promote excellence in state health policy and practice. my own experience includes a cabinet position in colorado. ten years ago i wrote the medicaid is the workhorse of the healthcare system and that's true today. unambiguous evidence demonstrates medicaid's success in providing access to care and relieving the financial burdens associated with the care. my testimony is a report from the field where i observe a medicaid program that is dynamic, continually evolving to meet the changing needs needs of vulnerable populationses, leading how care is structured, and delivered and participating in transformations of care delivery that are occurring around the country. for example, medicaid led the we to identify children who benefit from early enter intervention services. the number has grown from under 20 to more than 30% inch north carolina it's 75%. nationwide children with public

health insurance are actually more likely to receive critical developmental screening than children with private health insurance. in 2000 the surgeon general called poor oral health america's silent epidemic. medicaid programs are active will you pursuing efforts to ameliorate this situation. washington state and maryland among others have innovative programs designed to increase access to dental care for vulnerable children. medicaid is the nation's primary payment source for long-term services and support, and now states are spending more than a third of their long-term service budgets on home and community-based support that meet people's needs more effectively and more humanely. in the area of eligibility and enrollment, louisiana has led the way in streamlining processes for medicaid applicants and those seeking to renew their coverage. oklahoma launched the first

real-time online enrollment but some of the most exciting work in medicaid is how it works with other private and public programs. all but three states now rely on managed care for delivering dire some medicaid enrollees, two-thirds of medicaid enrollees receive most or all of their benefits in managed care and states are relying on managed care programs for complex'm populations such as children with special needs and people with a variety of disabilities. medicaid hard's a leader in developing -- the children's health insurance program to promote patients in their home. in 18 of the states and can private payers and prefers are working together to support the medical home projects and in 15 of those initiatives, medicare is also a participant. the health home model is an extension of the medical home that integrates physical health,

behavioral health, long-term services and reports to meet the needs of the most complex populations. a dozen of states are pursuing these models. back in 2006, when massachusetts reformed its healthcare system it took a blended personal health and public health approach to smoking cessation services for medicaid enrollees in massachusetts, smoking prevalence among enrollees dropped by 26% in two years with significants health cost savings as an add benefits. around the country medicaid programs are pursuing new models of care that encourage providers to organize and coordinate care that aaccept financial risk and accountability for health outcomes. the structure of the program. is it as varied as the states pursuing them. new jersey, minnesota, illinois, colorado, oregon, the states are taking approaches that meet their own needs. 25 states received support to test or further develop

comprehensive multiple pay forms. these states are pursuing the shared aim of better care, and improved population health as a lower cost, using their medicaid programs as a catalyst for system improvements that embrace not just medicaid but medicare, and private payers and private providers as well. medicaid is surely a complex program, but it is also a very dynamic program. its its also surely open to improvement as is anything we created, but fundamentally, as i look out at the experience of the states and what is going on in the field i see a program that works for america's most vulnerable. thank you, mr. chairman. >> chair thanks the gentleman and now recognizes mr. bragdon. five minutes for opening statement. >> thank you, mr. chairman. members of the committee.

i serve as the ceo of the foundation for government accountability. we're a florida-based free market think tank specializing in state health and welfare policy solutions. medicaid in its current form or old medicaid, represents as you have heard, the single largest and fastest growing line item in state budgets, consuming one in four state dollars temp federal level method okayed spending represents a quartser of deficit spending and is projected to double over the next decade. given these costs projections, medicaid is failing the american taxpayer. more importantly, it's failing the patients it's supposed to represent. poor access to specialist, the inability to personalize care, and perverse eligibility requirements keep too many americans poor and sick and rob them of the hope of a better life and for many americans old medicares not a safety net but a

tightrope and patients are falling off. because of the affordable care act many states are debating whether or not they should expand their broken old medicaid systems. this debate is a misguided priority. the real priority for states be not expansion but, rather to make medicaid work for the most vulnerable. and congress can help state leaders by crediting more flexibility at the federal level to do that. when states have flexibility to inmotivate and reform old medicaid, truly patient are centered care can be a reality. and one strategy gives medicaid patients the power to choose from competing private plans. old medicaid forces patients into one or two government run programs and ignores medicaid patients have uinstinct -- unique need but in states where there's a robust plan, such as

florida, kansas, and louisiana, patients patients patients or a priority in florida, patients can choose from 13 different private plans and 31 different customized benefit packages. the common sense funding formula in these states features risk adjusted rates to the private plans earn more money to enroll sicker patients and have innocentstives to improve health and disincentive to cherry pick. because plans compete for patient enrollment they're also constantly striving to improve access to specialists, and enhance their customer service, and patients like this choice, with 70208% -- 70 to 80 patienteds choosing a plan. theirs choice structure also promotes better health outcomes inch florida's reform pilot, the private plans in the reform outperformed old medicaid on 22 of 33 widely tracked health

outcomes and 94% of those health outcomes improved since 2008. and when this reform goes statewide in florida, taxpayers will save a billion. my written testimony includes details of other strategies that states have embraced, including imgreating work, promoting specialty plans and inleashing innovation to better serve patients. but federal rules and regulations can make it different for states to inmotivate, including the slow and inflexible waiver process, new taxes on private method okayed plans and additional cost shifts to the states. this committee is exploring ways that congress can make state reform easier, and grant additional flexibility and many of these reforms are detailed in my testimony, including allowing waivers to be incorporated into

state plans, providing better flexibility and creating an offramp that lets patients transition off medicaid towards self-sufficiency and the hope of a better life to make method okayed work for the most vulnerable, congress should recognize that proven pro-patient, pro-taxpayer solutions are out there and strategies can make it easier for medicaid to work for patients and taxpayers, and i'm happy to discuss that more in the questions. thank you. >> chair thanks the gentleman and thanks the witnesses for their opening statements. we'll now begin questioning. i'll recognize myself, five minutes for that purpose. for the nation's vulnerable citizens, having medicaid does not always result in good health care. studies have shown that while enrollment is greg rapidly with more than 70 million americans enrolled in medicaid at some point in 2012, access to quality

care is still a struggle for most. the new healthcare law proposes the largest expansion of medicaid in history. an expansion that is clear live built on a framework that is already failing to meet current obligations and helping our most vulnerable citizens. mr. bragdon in your testimony, you note that states should be cautious in opting into medicaid expansion. ...

>> they did cut services to the most honorable. arizona stopped covering heart and lung transplants and may propose cutting services to those with brain injury and stopped paying their hospitals altogether and mounting into unpaid bills leading over five years. what happened is that the most vulnerable was mentioned. there were services that cut back on those individuals first. >> would you respond that question as well? >> yes, i think that the primary caution that i would give to the states is you have to take the long view over what the future of medicaid will look like over the temptation of it.

it will be the but and federal dollars but it has a very short-term impact in states need to take a longer view, not only for their own state taxpayers, but for federal taxpayers who their constituencies are as well. those are what the implications are, understanding that our country cannot survive under the spending cut that we have today. >> and your testimony you mention some of the reforms that the states are pursuing. and what are some of the barriers that they face and pursuing new and innovative delivery models. >> too many times the states have to figure out which holes to jump through. and even if we think they are making progress under current rules, we have more innovative

federal requirements on there. >> now, each of you have highlighted the value of care the fee-for-service history of medicaid. and it improves care and reduces costs. given one opportunity, what would be an important policy reform that would allow for states to pursue managed-care models. >> i think expanding and i think that the states know best when they are trying to develop the most honorable and which groups they think are best suited for the managed-care approach. it is not just good enough to have one managed care plan and what you want is insurers competing against each other. making sure that there is

competition in the each state. >> the rapid movement of states makes it hard for me and this makes the primary area that remains a challenge and we do have some demonstrations designed between medicare and medicaid. and i think that we are going to have to see how it evolves. that, to me, that the population >> i think there are a few different things. i think the robust competition, nobody is suggesting that it should be available and as that builds on top of that, and we can provide much more

comprehensive care that old medicaid does not. ged services so that individuals when you give people choice and choice counseling, we hope patients can understand the differences among those private plans. lastly there is this mandatory versus voluntary care. patients appreciate this. native americans are choosing only 12 that stayed in old medicaid. louisiana is 0.3% of people who chose old medicaid versus five different private plans. >> thank you. the chair recognizes the

gentleman. >> i thank our panelists today. this is part of the program and i would like to know what is the reaction to this. obviously this demographic challenge of this coming at us. and this notion and this is part of the medicaid program. these are realities that we are going to have to deal with in my sense is an expanded medicaid program that we are trying to make better everyday.

she spoke of structural challenges relating to payment rates and there was an attempt made for primary care and is a good step in the right direction. then spoke of the fiscal challenges ahead of us with entitlement programs and benefit programs in some instances. but your testimony suggested that in some ways medicare and particularly care that one might put with public health with children and developmental screening. what this does is really cutting edge ahead of this and potentially even medicare.

these are things that can improve efficiency is over the long run, and it is really because of this because we will see this. so why an expanded medicare program could be best equipped to handle them. >> the demographic challenges are real. we are aging and i think against that backdrop, it is worth noting that medicaid has stayed flat despite the aging of the use grows of the services and

they show us how to not just prevent people from going into nursing homes in the first place, that with respect about expansion, i think we need to be careful as is if someone doesn't need health insurance. so it seems like we shouldn't be so worried about providing coverage. sometimes more than others, or they may have treatment that could reduce the overall cost and we know that there is growing prevalence in the population for the medicaid expansion. the issue here is are we going to move this population into a system where there is someone responsible for managing their

care and the state in government responsible for a private plan. a private plan that is interested in maintaining health or do we just leave them the alternative. similarly, i will readily admit that medicaid payment rates are above commercial and low medicare rates. these are people who would otherwise be uninsured. dear mission drivers and they have a broad cross-section that understand that they are going to subsidize care for some in order to serve others. medicaid helps to alleviate the burden, although it does not completely eliminate it. so these are challenges, but my experience is that states

observe and look ahead and are doing what they can to tackle it within the design of the current programs here thank you very much. >> thank you,. >> we thank the chairman for the recognition. we've heard it mentioned several times and i believe in your testimony about providing and how that affects access for medicaid patients. how can the federal government ensure that they are at levels that will encourage for dissipation. >> well, i think that we have to contrast it. we are not paying providers enough and the easy solution is

that we pay them more. so someone is going to have to pay for that. the states have decided in many instances that they are not willing to spend money for medicare level. otherwise we wouldn't have had them come in to the temporary boost. what happens when the boost is gone? and they continue to provide that kind of a level of reimbursement? i think that is that the whole problem that we have with medicaid in the long-term. is it sustainable from a fiscal standpoint. >> let me just ask you for that two-year interval. who is responsible for paying those increased rates. >> the federal government and federal taxpayers. >> it will go back to the states. many states are already saying that they don't think that they will be able to sustain that level and the challenge will be back here in washington, saying that we need more federal dollars and we want them permanent. well, then it will have to be

found with money and i would argue that they don't have the money today to be continuing that type of spending. >> we have actually seen it before. the stimulus provided an 18 month up bump up in medicare reimbursement rates. it was about to run out in august of 2010, as i recall. we had to have an emergency meeting of congress. one of the few times that has happened except for the purpose of that is to pass a stimulus bill at the medicaid rates. we have states that have agreed with medicare and medicaid expansion and some that have not. and the supreme court in their wisdom has said that you could not make acceptance of the standard medicaid contingent

upon acceptance of the expansion. so the states actually have some leeway there. the deadlines for the exchanges since this expansion of medicaid was not sudden federal statute but by a court directive, that there are no dates and so actually what in the state be well advised to see what happens before they jump into this? >> i think with the complexity that we should health care while facing, it would be wise for states to think about this for a long time and i think that this will be an annual debate moving forward as well. >> there is no penalty for state that does not now. >> that is correct. >> big noise revisited as well. >> that is correct. >> you know, when you get back to getting the providers to get back into the system is states

that we will cover your first $100,000 of medical liability cases but it seems something that would encourage them to come back into the system and make sense. is the flexibility that would allow states to do that? >> i am not familiar with this at this time. >> you mentioned something about the center for medicare and medicaid innovation and the use of what you would describe as multi-payer systems. can you provide us a reference for that, i would be interested in what the data was to make that determination, how much was forwarded. you have any information available, if not today, could

you make it available to us? >> yes, i would be happy to. that is public information. we are quite early and with the states intend to do with the funds, that is all public, it is available. >> i would appreciate that. this seems to be a bureaucracy that not even a bureaucrat can love. i'd be interested debases statements on. >> the chair thanks the gentleman and we now recognize the gentleman for questions. >> this is a critical program that hides health insurance to most horrible society. currently deciding whether to it expand the medicare program sunday affordable care act.

it is the right thing to do because it will expand health care. the insurance coverage is correct. >> children and their parents account for 75%. is that correct? >> yes, that is correct. >> this population comes to only 34%. is that correct? >> yes. >> medicaid has been promoting the detection of health care programs. this is a part of routine exams.

>> we require this kind of work. is that correct? >> 2007 to 30.8% in 2012. and this is a great improvement. innovation has helped increase the number of children undergo developmental tests. is it correct that a child is now more likely to receive this been a tablet i've soon get. >> is another area where state medicare programs have been successful and is not so? >> yes, it is.

>> do believe those in north carolina and washington that you have described in your testimony and our models for other states. is that right wrong? >> yes it is. >> the impact of expanding medicaid and what it has on mortality rates, do you agree that expanding medicaid will lead to lower rates within the state to do a? >> i believe the strongest evidence is that this will reduce mortality. >> it brings will health benefits to the population, and we have innovative strategies, including my own state of michigan and i hope that they will look at this to improve health outcomes for millions of

americans. >> we should also consider the financial methods for expanding medicaid as well. in michigan alone could save 1 billion over the next few years, which i hope they will do. >> hope this committee will continue to examine this issue, you've been most helpful to us. thank you, mr. chairman. i yield back one minute 15 seconds he meant the chair thanks the government. we now recognize the gentleman from georgia for questions. >> mr. chairman i would like to address this. much has been said that the medicaid waiver program, all the flexibility that they need to improve the program, as you know, this administration is a

strong supporter of the medicaid population expansion up to 138% of the federal poverty level. we hope that the state does not have to endure the. >> there is no time limit for the complexity of the waiver. but we also need to recognize that it is dictated by the statute and there are certain things that can be waived. to the point that you want to do something above and beyond and that is still a limitation. >> we have seen this administration continually, to aid implementation of the law, allowing medicaid waivers it is

a situation that is ripe for abuse. this is why we need to repeal the maintenance and give them a chance to innovate. the maintenance has not only been costly, but a barrier to reforms and that is why i've introduced hr 1472, the state flexibility act, to repeal and repeal the effort. these states often must make cuts to other mitten on mandated programs such as education. because they don't have the flexibility to improve the existing medicaid programs and

it shouldn't be that way. these people were eligible. and they are frozen on the program. would you please explain to the panel how these provisions increased cost of both the states and the federal government and actually hamper patient outcomes. >> i would say that it really does take up to offer this that states have to work within their means and budget to provide what they feel are the most horrible and needy. getting back to the flexibility of the states, the closer the policymakers are what is going on on the ground at the state level, the better the adaptation will be. scaling back.

>> and i'm just thinking that if they didn't have this provision, they were able to clean up this, may be they could expand. >> would you like to comment on that as well? >> can be retouching on an important point. when you look at how states can customize medicaid programs, and you also need a dynamic two okay, if you will. in florida the average mother that is on welfare is on the program for five months. for those individuals, it is also creating some sort of offramp.

there is no ability to keep that once you got the program. there is no ability to become aware. >> i'm going to interrupt because i just have 30 seconds left and i want to make this comment. i thought about this three and half years ago when we were in the minority on this site. this medicaid expansion, where would those people get those care unchain care if they were not eligible for medicaid the provision would be all federal dollars. they would not be state dollars. so it is really a game of moving the hat around. clearly that was set up so there would be less federal costs and

more burden on the backs of the state. i go back. >> the chair thanks the gentleman we now recognize the gentleman from florida. >> thank you, mr. chairman. thank you to the panel. this is a very important topic. as was testified, there are so many exciting innovations going on all across the country when it comes to medicaid. that is the lifeline for families and seniors and others. i think it's very important that we share and understand this and what has happened in these innovations. we do this on a regular basis for those who are interested in the children's health care that i have cochaired with dave reichert from washington state where we educate those across capitol hill and other policymakers and we have another of our medicaid matters here in the rayburn building at 12:00 o'clock. i would like to thank the campaign for children and first

focus across the country. the pediatricians and those helping to organize this very important medicaid educational session. the one on friday is called unlocking ideas to improve care for kids on medicaid. one of the most exciting innovations that i know of in my hometown is a complex, chronic complex program for children. it provides continuous care after years of watching children cycle throughout the emergency room without an ongoing focus on the health care needs, they wanted someone to provide them with automated care, so the clinic came together and now serves over 1000 children in the

tampa bay area with a great team of pediatricians and pediatric nutritionists and nurses and social workers and others. the families in my area wellness clinic. we also appreciate the fact that it saves those in hospital costs alone in some say that we are saving closer to 10,000. that is one of the innovations that i am a part of. where things are going right under medicaid and this is an important partnership. >> i think the exciting work is in the area of patience with what we are trying to do is take the health care system not just in medicaid but the system at large that primarily sends its resources for institutional care.

and builds out of this and infrastructure of the kind of care that people need at a better touch and it's closer to the community. it is less expensive. it is let episodic and more continuous. i think some of the best innovations going on now for about bringing in mental health to how we think about things and delivering things and we traditionally have had very strong winds and barriers between the systems and programs in the understanding those with untreated health care conditions and the relationship requires a different model of care. i have included a few examples in my written testimony and what is great about these kinds of innovations that medicaid is a part of this sometimes it is a

leader, other times it is a follower. the most providers of services within medicaid also provide services to privately covered folks. and if it is not pediatric care, they are usually part of medicare as well. interesting and exciting innovation in the most exciting one is on medicaid as part of a broader conversation across private and public payers and others to fundamentally rethink how people get care. and it pays in a way that supports that as opposed to just writing checks for services. >> i think you're right. i know you did not mean to mislead the committee by heralding the great success of florida's medicaid privatization. it was just approved a couple weeks ago.

so the pilot program event was known as a real disaster. the state's own study condemned the results and we have patients unable to gain access and private providers leave the state. so be careful when he testified before congress when they say it is a great success when the evidence and everyone across the board had really condemned what has happened it is like night and day. brought new conditions exist with consumer protections and providers if they back out and we will be penalized and the medical loss ratios could be part of it. these are some innovations that can happen with that important federal state partnership. but you have to -- you really have to do your homework on what is actually a