but one area that was getting quite a bit of popular attention was the harassment of human rights workers, of journalists, etc. that was raising a great deal of concern inside south sudan. the challenge from machar did, of course, reverberate through because of the history. and i think people recognize that that challenge was going to be a major one to be managed by the government. >> now, the composition of the government delegation is interesting to me, particularly since nile was once part of a faction that opposed garang and kiir's vision for south sudan. what might the composition of the delegation mean in terms of larger regional dynamics? >> you know, it's -- you have

really three parties a year. you have the government, president kiir's supporters. you have machar's supporters. and you have this group of detainees who are not either. that is, they are looking for a broader party role, a broader use of the party mechanisms and authorities. and to make them part of the negotiati negotiations, you have to enlarge those negotiations to allow for views other than just the two contending parties. but you need to do that to give them a role, because there are two things that have to happen. after a cease fire, you have to have an understanding as to what the government's going to look like for the next two years. and that means that those people now detained, and president kiir, and people from machar's

side, have to agree on the structure of a government over the next two years. meanwhile, you have this -- what i think a broad constitutional process that delves into the longer term issues of democracy, human rights, and governance. so this is a complicated negotiation that has to take place. and it needs to involve people who represent several different points of view, both from within the ruling party and outside. >> and that observation brings me to mr. pendergast. after the security council's approval of additional peacekeeping troops for south sudan last month, you commented that the political and diplomatic elements of international responses to most african conflicts have been slow and ineffective. which have put more pressure on peacekeeping missions than they have the wherewithal to fully adept, to which they're totally

unprepared. can you talk about this? i'd like to go into greater depth of the context of the current situation in south sudan. and why it's important for the peacekeeping missions to be accompanied by very rigorous diplomatic engagement from members of the international community, particularly the united states. >> thanks, senator. yeah. you look at the three biggest missions today on the african continent, south sudan, darfur, and eastern congo, american taxpayers on the hook for almost 30% of -- or well over $3 billion a year in supporting peacekeeping missions there. but in all three of those cases, you could argue the corresponding political investment was not equal to the investment in the deployment of military force. in south sudan, everyone has

discussed that there has -- there was probably not enough international efforts undertaken to try to prevent the conflict between -- and i agree totally with my fellow panelists, this political dispute, which goes back, of course, decades between the two factions that are now battling. the lack of an international engagement, a deep engagement, a transparent engagement to try to prevent conflict i think is something we need to look at. in congress, we didn't have much of a political process for years until finally the u.n. appointed mary robinson and the u.s. appointed senator feingold, the former members of this committee. and now we're starting to see the construction of a credible, serious peace process. and b, the deployment of real force that helps change the game on the ground in eastern congo. and in darfur, we have this

endless peacekeeping mission that -- made absolutely no progress in dealing with the political roots, the political drivers of violence throughout sudan. so i think that's where we really are missing -- we invested a great deal. sort of the old military adage. if all you got is a hammer, everything looks like a nail. we just keep throwing these peacekeeping forces into these situations without investing the preventative diplomacy. now princeton was the special envoy for the united states. and when he was in office, until march 2013, he was actively engaging with the parties in south sudan and helping to prevent a deterioration. but there was a long gap between his -- the end of his term and the beginning of the next one, and there isn't another country that's really engaged like we are in that kind of preventative diplomacy. no headlines.

nobody cares that people are out there doing that stuff. and you don't get any credit if you actually prevent something. but that's what we need to be investing in. that's what isn't happening in south sudan because we vn invested the resources in helping to build that real serious political process.haven invested the resources in helping to build that real serious political process. that will allow for the resolution of these horrible, deadly conflicts. >> i smile when you say you don't get any credit for preventing things, it's so true. but yet it is probably the most successful element of what we do. final question, ms. knopf. you made an interesting observation, that for us to be successful in south sudan, you have to have parties that have a history, have an understanding, have an engagement. so i would assume based upon that comment, maybe i'm wrong, that maybe we don't have all the parties that would bring us to

the successful conclusion. are there some missing parties or types of resources we should be bringing that aren't there right now? >> the critical issue at the moment is the drawdown of the u.s. embassy and u.s. aide staff. without having diplomats on the ground, resident there, talking to parties across all sides of this crisis and getting out beyond juba and the capital as well, that becomes very, very difficult to adjust to. secondly, for aid programs to be effective, we need to have both development experts and the humanitarian professionals, most especially at this moment in time, to be as close to the situations that they're trying to ameliorate as possible, and to be in constant contact with local partners with the south sudanese who are at risk and in

need of assistance. daily and hourly coordination with the other elements of the national humanitarian response front. doing this offshore from nairobi at the moment where the disaster assistance response team is based, it takes us back to -- i don't even know, before 2002, 2001 in terms of how we used to manage humanitarian response in southern sudan. it's woefully inadequate and will impact our ability to be effect initiative the long run. we have deep, deep expertise, as was said in the u.s. government and in the international community and with americans in implementing partners such as ngos and other international organizations. they need to be there in order to respond. >> senator? >> sorry i missed the testimony. i'm told about this being a division of ethnicity as well. of course, that's often the

case. what is the percentage of the president's -- well, the dinka tribe constitutes what percentage of the country? >> i don't have that figure, but it's the largest group. there are a lot of subgroups. and that too is a factor. the second largest group is largely supporting machar. but i don't have the percentages, i'm sorry, but i can get them to you. >> we're just consulting. 30, 35% is dinka. 65 tribes and ethnic groups in south sudan. >> 65. >> i was asking the other panel, some of the other questions there, the u.n. peacekeeping forces that are there now, how

effective are they at preventing bloodshed, or what can we do to help that group? is it just a number of numbers or mission? what can we do at this point? >> well, let me comment on that. both of the things you've mentioned -- first of all, they don't have enough troops there, and the action by the security council was important. but it's very hard to get countries to contribute and find air support and equipment. and that just has to take a lot of intensive effort by us and others to make sure they get there. but second, it has to be made very clear that they're going to be aggressively protecting civilians. which means that those compounds will not be allowed to be breached, and they're prepared to defend them with weapons, if that takes place. they have to be aggressively patrolling.

now, they haven't played that role up to now. they haven't seen that as their mission. but i think that has to become part of it, and they have to look ahead to how they will monitor a cease fire. and how they will be out there aggressively doing so and reporting violations to the security council. so these are things they haven't been doing. it wasn't in their original thought. they were now they've got a new desperately important protection role. and they need more people and they need a very aggressive mandate. >> any differences there or comments? >> totally agree. the 32nd footnote -- and again, it's a wider phenomenon. we send peacekeeping forces, missions to do a laundry list of

things, and when the stuff hits the fan, we want them to protect civilians. they're not prepared to do that. you have to organize, as you know, and deploy provision and have the expertise to undertake civilian protection mission. these guys weren't ready for that. so now they have to get up to speed and that's going to taking a while. >> i guess my two cents on this would be, they have what they need to go out and do these things, to defend and patrol and to monitor ceasefires. but the world turned upside down in just under four weeks in south sudan. this is not what they were initially there to do. while the potential for conflict, of course, has been there and is not a surprise, the fact that it has fallen apart so quickly and so dramatically, it takes a moment, i think, for everybody to adjust and to understand and retool for the new challenges and the new

realities. so i don't think -- there's lots that one can say about the performance, but they were there to do a state mission. now they have to do a very different mission. >> so they've got the mandate. it's the numbers issue for the most part. >> the irony is that south sudan opposed the chapter 7 mandate. said we don't have any internal security problems. unfortunately, security council saw otherwise. >> thank you. with regard to u.s. assistance, state building or humanitarian, does that represent leverage that's effective at all? ambassador thomas grayfield seemed to know -- the restrictions we have here in congress, in terms of aid and

assistance after a coup. does that represent the leverage that we can use? is it effective at all? or just on the margins? >> no, i think it was a very important statement by the united states. that we would not recognize a military takeover. president kiir, for all his faults, is a dramatically elected president. and you have to build on that. just saying anybody can come in and take over is going to undermine a lot of things. so i think it was important. whether the aid levels matter to people like machar, it's hard to say. i think secretary greenfield suggested that probably in itself is not. but international recognition is important. so i think making that statement is important. but then the burden falls on president kiir to play his role much more effectively. and here's another irony.

president kiir was proud of the fact and mired for the fact that he was the one that created the unity of all these different groups in the run-up to independence. he brought in all these factions, etc. he created a broad based government. he invited machar to be vice president. it was one of his accomplishments. it was one of the reasons he was so supported. unfortunately, he's moved in a different direction. he sees all his critics as enemies. he's relying on intelligence people and harassers, etc. it's unfortunate, because his original contribution is being lost. >> thank you. >> if i can just add, my personal knowledge of the two main parties here is the threat to cut off our assistance, our development assistance. it's not what's going to motivate them to come to the table and get the ceasefire done, arrive at an interim political assessment. it will hurt the people of south

sudan. we know how to do it in the midst of conflict. we have many modalities for how to provide assistance, either with the cooperation of the government or working through other avenues, local and international partners and sub national levels of government. there are stable areas of the country. we should not stop development assistance in the stable areas of the country. it's very important to help keep the conflict from spreading and to not lose the gains we've already made. as well, united states assistance has been vital with the economy with the central bank of south sudan, picking up the pieces economically when this is all done will be much, much harder if we pull that support out now. so i do think that it's important and imperative that development assistance continue. that the modalities be examined. that the strategies be updated as the situation changes. but that we keep the commitment to the people of south sudan and not harm them further.

>> and one last point. the building leverage is critical. that's what we've got to be looking for all the time. the aid doesn't -- i agree. the aid doesn't make a big difference to these guys. but it does make a big difference to the people of south sudan and to the building of institutions in the long run. pulling that away now would really undermine the long-term stability of the place. our leverage i think should focus on individual culpability. the targeting sanctions, prosecution of people who are found to be committing or planning atrocities and patterns of atrocities. the additional leverage comes if we work much more closely and transpare transparently. collectively pressure the parties when there are key point moments that there needs to be a push. again, i just view a very high level white house to state house

in beijing engagement in south sudan to be a critical thing to do right now in order to show that united front internationally to the parties that we're really going to be pushing for peace, and those that undermine peace are going to have some kind of particular sanction. >> is it your assessment that china is willing to step up to the plate in that regard? >> not as publicly as us. but their interests are much deeper in terms of national security than ours are, and so let's figure out -- and i think that the good news is that our interests in terms of what the end game is line up very clearly with china. so let's take advantage of that moment. it doesn't happen off globally and figure out how we can more deeply work with them. >> thank you. >> thank you. one last question on that issue that mr. pendergast mentioned about looking for leverage and targeting sanctions of those human rights violations, since you've been intimately involved

until very krecently. do you view that as among others a good leverage point? >> i think it's going to be extremely important in another way. i think personally in the process over the next few years of writing a new constitution and laying a new foundation, that that creates the basis for eliminating from future power a lot of people who are responsible, so whether it's in the process of prosecution or some other kind of commission, a lot of people who are very guilty of the kind of terrible violations should not be part of a new government after 2015. and i think that is one of the outcomes that we should see. >> well, with the thanks of the committee for your invaluable

testimony, i expect that the african subcommittee as well as the full committee will lend continuing attention to the challenges in south sudan, and the leaders on all sides need to recognize that reality, not a mont.lar hearing at a sing e here are a few things covering tomorrow on c-span2. at 8:30 a.m. eastern a panel on political strategies and reporters to beat the 2014 political outlook. including the midterm

elections. then a look at the december jobs report. the bureau of labor statistics commissioner will testify before the joint economic committee. that's live at 9:30 eastern. and later, senate majority leader tom dach daschle will talk about the need for bipartisan. in 2006 to september of 2010 i was there as we continued to reduce the level of violence in the sectarian violence was going on. i believe we left it in a place where it was capable to move forward. we have seen it because of several political issues internal to iraq that is security situation is now

duefulled in to some something my mind concerning. it's not just about iraq, in my mind, it's something we have to be cognizant of as we look across the middle east. what is going on in syria, what is going on in lebanon, what is going on inside of iraq. it's this sectarian potential building of sectarian conflict between sunni and shia and the exploitation of demonstrate actors such as al qaeda and other organizations that try to take advantage of this. this weekend on c-span. army chief of staff look at the security situation in the mideast and the future of the u.s. army. saturday morning at 10:00 eastern.

locked republican members from submitting additional amendments, took to the floor for debate. we'll hear from senators rob portman, dan coot. the majority leader decided to fill the tree. which means taking away the opportunity to be offering amendments. i believe there will be a moment to offer some. i'm disappointed. i think we were close to reaching an agreement which would have enabled us to move forward with allowing senators on both sides of the aisle to some of their idea on the unemployment insurance extension inspect is an important debate. we're having for the mesh

people. it's about whether we go beyond the roughly weeks in unemployment insurance to having emergency extension again, and on this side of the aisle there were a few of us who crossed over to the entire democrat majority to saylet have that debate. we thought we were doing so in good faith there would be a debate on two issues, really. one is whether it should be paid for or not. and how it should be paid for. which i'll address in a second. second is how we should reform the unemployment insurance program and do other policy get at the underlying problem, which is a record level. record number of americans who are long-term unemployed. clearly what we're doing isn't working. we believe it's an opportunity help sphwriewf the program to address the problem. the president of the united states wants to do that. he called me on monday and told me that he hoped we would be able to address this issue by voting for the motion to proceed to begin this debate.

so that over the next few months while we had a short term extension of the program, there could be even more details discussed about how to improve the legislation and how to add other elements to it. specifically on how to give people long-term unemployed the skills they need to access the jobs available. unfortunately we're not going have that opportunity, it appears to be able to this debate over how to pay for it. what to pay for it ought to be. and how to improve the program. let me just say, this is unfortune because we had 60 votes to proceed. that include certainly three of us here on the floor today all three of us are willing to move forward with this with a reasonable provision to pay for over the three months. and again during that period to come up with a veteran improved unemployment insurance program. we are not part of the gnat majority leader put forward.

my proposal i have come to the floor to talk about three times now has been previously proposed in the house. if you get unemployment insurance or pay adjustment assistance you don't receive social security disability insurance in the same month. why? these programs are mutually exclusive. if you're on social security, disability, ssdi, that means you not working by definition. if you are working, and lose your job, you are then continuing to look for work. you get paa. if you lost your job and look for work, which is required, you get unemployment insurance. this is why the same general program is laid out in the president's budget and in fact something that i believe the administration supports and others. the proposal to democrats have included if you receive

unemployment insurance in the month you receive social security, then your ssdi is reduced bit amount of unemployment insurance received. why does it matter? it's not the same thing. it matters because the proposal that the majority leader has proposed saves a lot less money according to congressional budget office. my proposal save about 5.4 billion. they would save about a billion dollars. again, i appreciate them wanting to include it. i think it is in the same spirit as the amendment i offered. but honestly we haven't had the chance to sit down and talk about this. i tried today sit down with the democratic sponsor of the underlying legislation. the other senator reid in good faith said he wanted to talk about. we haven't been to be schedule that.

cloture is month afternoon. it doesn't give the other colleagues to offer their good ideas. there are a bunch of them out there. the senator from new hampshire offered hers the day before yesterday. talked about it where she wants to take some of the existing mispayment in the child tax credit. i think all of us want to do that. to preserve the child tax credit for those truly eligible. for those elt jibl shouldn't have accs. it seems sensible to me. i'm a cosponsor of the amendment. senator coast raised some good idea. my hope is we would be able to go back to where we were prior to feeling the tree and let's say have a discussion. there are a limit of number of amendments. i see the -- i think he indicated to me today there are something under 20

amendments offered by the republican side. i don't know how many of those have been filed. if seems to me that we could have had a good debate on that and should. my hope is that we can come up with a solution here. i do think it's going require us providing some opportunity for other people to be engaged and specifically for those of us who want to goat a solution which is a lot of people on this side of the aisle and both sides of the aisle. let's u sit down and talk. we're adults. we are elected to represent the millions of people. it's our responsibility and deployment work these things out across the aisle as you would in any other relationship. your marriage, your business, with your neighbors. .. most basic level of discussion and debate. so i'm open to that. i had hoped to do it today. i put my ideas out there. parts of them have been ack sementd.

i appreciate that. but, frankly, not the way that we had laid it out in my own amendment. and i do believe that we have the opportunity, if we are to back up, to actually solve this problem, meaning provide what the president says he wants -- which is a three-month extension of long-term unemployment -- so that we can sit down, roll up our sleeves, as republicans and democrats, and come up with a better way to address what is a crisis in this country, which is more people long-term unemployed than ever in the history of our country. those people are hurting and clearly the current system isn't working. so just to extend it is not the answer. the answer is for washington to do its job and that is to reform these programs so they work for the people we represent. the presiding officer: the majority leader. mr. reid: it's the same tune time and time again. things are never quite right. they want to offer amendments. we have been waiting here since monday for pay-fors. the only pay-for we've heard realistically to take care of this is something that everyone

knows we disagree, to take away health care benefits from the american people. the proposal by my friend from ohio is not a good proposal. it hurts people who are disabled and that's the fact. we have stopped dual payments, that's what our amendment does. this is something we've been going through and the american people have been going through now for years. my friend worked with the senior senator from new hampshire on energy efficiency. now, if that wasn't quite a show. show. >> the fact of the matter is that this is quite a shell.

and we have it all taken care of. republicans are trying to move forward on this and it went on for weeks and weeks and we never got anything done. so mattern president, we are where we are. and the democrats do not need a memo. we need to be compassionate about those that are disabled and unemployed. we know those that are long-term unemployed are desperate for help. we are compassionate. we do not need a memo to telesat. the american people want to know where we stand. and unemployment benefits are important. people have been out of work and we have been over backwards to come up with a proposal to pay for this for this year.

and we have structural changes in us as well. and we have a vice presidential candidate that is part of the election cycle. he is chairman of the budget committee. so we have done this job and we need to move on. and that is what we are going to do. if there is a proposal that my friend has and we know his expertise. and the time was to officially cut bissonnet can make all of the motions of that they want to try to complain about this and i you used to be senator.

not because of anything that we do wrong, but because of the obstruction of president obama's agenda and everyday there is more obstruction. >> with the senator yield for a question? >> yes, sir. >> mattern president, i would ask the distinguished majority leader whether it is the position of his caucus and him personally that people ought to be able to collect unemployment compensation and disability benefits simultaneously. >> that is why this legislation is part of a. >> i would ask majority leader. it is my understanding that the senator from ohio, his amendment would discontinue this collection of disability and unemployment benefits. but you object to that amendment and instead are blocking that and other amendments by the republican side of the aisle by one that changes the effective date of the bill by one day, in

other words it is purely a bill that had zero substances does nothing to improve the underlying bill. >> the distinguished majority leader. >> the senator from texas. >> is the leader aware that there are 24 republican amendments on file and deal with the underlying bills and it works out for education training and otherwise help the economy

recover so that people don't have to depend upon on employment insurance and they can get a job. are you aware that there are those amendments? >> yes, i am. >> i don't know the exact number, but there is always a lot of proposed amendments around here but what i would say is rather than denigrating our economy and our president and our country, i think that we should ask more constructive questions. for example we had today a conversation for an hour and a half with chairman ben bernanke and he is going to be there until the first of next month. and it was a very good discussion. he talked about the vibrancy of this economy now and he said with a little bit of help it would be on fire. i was on fire agreement because of the obstruction over here. and as you know, the chairman

has also said that unemployment benefits are a great impetus to helping the economy and for every dollar put into the economy of what unemployment benefits, we get a dollar and a half back. this bill recognizes that these benefits don't go on forever and that is why we have made structural changes. we would be happy anytime you sit down and have a good discussion with a senior senator from texas and anyone ask and we have not had a workforce for quite some time. since 1998. we have a lot of programs to deal with job retraining and in 1998 when we did that, it wasn't a bad deal. so of course we need to sit down and talk about this because the

whole country needs out and that is something that chairman ben bernanke said today. so let's start. let's talk about how things are improving and we have 8 million new jobs and there's a lot of good that has happened in let's start working together. >> do you have a question? no commissary. >> is of the majority leader's intent to allow this on the republican amendments? >> on the boletus discussed? >> we have been waiting since monday to get a proposal and we thought that this would be a good way to pay for this. so the answer is we will try on

many different pieces of legislation to say, okay, let's do this. and how about having a specific number. no, we can't do that either. and so as a result of that, we have had a continued obstruction that has taken place in the spotter for five years for its time to get back to the legislative things that we need her. >> i would say to my friend and leader now. >> mr. president, thank you. i want to make to questions. one is the proposal that i did

offer that had nothing to do with obamacare and i thought the majority leader understood and others do not so we do have a number of amendments and good ideas and we had a debate and it is in the president's budget. >> would you yield for a question. >> yes. it calls for revenue in the budget, does not? >> yes, causes major tax increases. >> i would like to also acknowledge that when the president smithies budgets, don't they propose a budget and they are nitpicking the different pieces of budgets one at a time? >> yet you to stand by all of those policies. they would tell you that they stand by these proposals. and so yes, if it isn't because

they think there is a good policy. so i think that we have some good ideas that are not related to obamacare since there seems to be an objection by the majority leader. i hope that we can work something out here. i do think there is an opportunity for us to do so, but i don't think we can do it unless there is a little bit of give and take and some discussion. so for that i yield. >> mattern president? >> the senator from indiana. >> i will be briefed. i know my colleague has travel plans and this is something that we had earnestly hoped that by supporting the motion to proceed, we would have the opportunity to offer an amendment and have our colleagues to vote on that amendment. to simply say that, and i quote him, none of them are

reasonable. is that something that the body is supposed to achieve by something called a vote? and do we have one person here who runs the place is whether or not the amendment is reasonable. along with all the other amendments and we will not have any other ones whatsoever whether someone's office body was reasonable or helpful and it has been talked about here. it was decided by a vote. to have the policy to do what he's doing. and the majority leader says

that he has been waiting to pay for it and i was down here on tuesday offering for options to pay for. and under the majority leader doesn't come here to speak or tune in to the television. and mr. leader, i sent you select the one you think will best reflect the ideas and values of this. and so the majority leader said that we have been waiting for nearly two days so the majority leader can make up his mind in terms of what he wanted to do. and this includes the three of us who were listed and we don't even have to be part of any

negotiation. so we were trying to look for a solution to the problem and have something for colleagues to vote on. so we were not even asked to be part of that. so here we are. i am representing the people of indiana and their voices are shut down. i don't even have the ability to offer an amendment that my constituents sent me here to do. and one person decides this and i'm very disappointed. so i would like to ask unanimous consent. >> there's no objection. >> please withhold it so he can offer his amendment. i do want to say this. madam president, we get nowhere with dealing with amendments. we have learned that in the

past. it doesn't do the trick. the issue is pronounced. and we went a step further and in the past we haven't paid for this and we have signed a bill extending unemployment benefits. again, madam president, we have done a good job and we have a lot more that we can do and we have had almost $3 trillion already. so are we going to extend benefits for people who have been unemployed for a long time. we have been over backwards to try to come up with a compromise with a bipartisan piece of legislation. and i repeat that it is paid for and there are structural changes and it is a pretty good deal. and i'm very disappointed that we are at a point where we have

been for five years. nothing is ever quite good enough they always want more amendments and the issue is here before us. will this body would vote to extending unemployment benefits paid for the paul ryan paid for. and are they going to turn back on people who are desperate. >> majority leader you to set the despotic it's nowhere without amendments. is that the theme throughout this year? it's not nice for republicans offer any minutes for any bills to try to make improvements or to have their voice heard or the voice of the people heard on the floor in my. >> modem president, my friend is one who wishes to be here. we didn't have these kind of amendments that.

that is what we do here. i have been waiting here since monday to understand how we can extending unemployment benefits for these people. and so the amendments are important but i think that we have to go back to the time when the senator was here the first time and start working together to get things done in this body. >> and president remark. >> go-ahead. >> this is 100% different than the time i was here the first time we were able to offer any amendment in the majority leader, both republicans and democrats have allowed us to do that and this is the first time that i have had the experience. i wasn't sure if he objected to my unanimous consent request. >> the objection was heard. >> i was there and things were

different then. they certainly would. because we did not have hundreds of filibusters taking place. and that is why action had to be taken. what my republican friends after realizes that it is not a right but a privilege. i'm happy to listen to his many lectures, but i was here and i know how things work and what has gone on the last five years, >> will the majority leader yields are questions? >> guest. >> he brings up the secretary of defense frequently. >> he was delayed while we had

two wars going on in this country. >> is a member of the president's cabinet, has he ever been defeated in the history of the senate? >> no, in fact what has happened, and we find this with the judges, they saw for weeks and months and sometimes years and when the vote comes, it's well and good. but in the meantime they shouldn't damage our country by stalling in the president has a very difficult time doing his job because the people are not there when he needs them. >> i would ask my friend ben what he finds offensive, the fact is there were debates about these matters and since a lot of these members are being defeated. what is the issue? i'm having a hard time understanding. but there is controversy or debate? since none of them are being defeated, is he suggesting that we have no controversy about

anyone? >> of course not. we need good debate about nominations and everything else. but what we don't need his hours and days and weeks and years of obstruction. and that is what we have here. my friend was talking about something that doesn't exist. there has been obstruction that has been carried to an extent that no one ever dreamed would happen in this republican that is what the objection is. it is to the obstruction. time after time, and it was more than a debate, mr. president some say this is the most important court in this country and they decided that for five

years there is debate. no, it is obstruction. if you turn to the dictionary and look at the civil point lead over here. >> of the majority leader yields another question? >> yes. >> since you have said that no cabinet members have been defeated, is it not the case that 215 of barack obama said his have been confirmed and only two have been defeated? >> mr. president? during this time we have been a country and i can't come up with the right thing the second. there have been 23 district court nominees. twenty-three of them. and 20 of them have rendering the obama administration and so

this is, mr. president, this has been a part of it. the american people know that you can try to paint over a picture. we are stalling the obstruction. and now i just can't imagine how my republican colleagues can justify what they have done. but they do. and i accept that. but i also understand that we have an issue before this body and again they are trying to divert the attention and the issue before this body is where the long-term unemployed get an extension of benefits. as we speak there are people all over this country who are

desperate to be able to get $300 a week to be able to survive for another week and the sad part is making that we need to do something to make sure that these people have a job. and so for every job opening, there are three people that are unemployed that are trying to find a job. >> i have answered the question to the best of my ability. >> new jersey governor chris christie apologize to the people of his state today for his eight they conspired to cause a traffic jam in retaliation to the mayor that do not endorse his reelection bid. here's more from that now. >> good morning.

i cannot hear to this office where i have been many times before. and i come out here today to apologize to the people of new jersey. i apologize to the people of fort lee and the members of the state legislature. i am embarrassed and humiliated by the conduct of some of the people on my team. there is no doubt in my mind that the conduct they exhibited is completely unacceptable and shows a lack of respect for the appropriate role of government and for the people that we are trusted to serve. and two pieces are what i want to talk about today. the first piece is i believe

that all of the people who were affected by this conduct deserve this apology. and that is why i am giving it to you. i also need to apologize to them for my failure as the governor of the state to understand the true nature of this problem sooner than i did. but i believe i have an understanding now of the true nature of the problem. and i have taken the following actions as a result. this morning i terminated the employment of bridget kelly effective immediately. i terminated her employment because she lied to me. and i was getting done with my workout yesterday morning and got a call from mike medications director at around 8:55 a.m. informing me of the story that

had just broken on the website and that was the first time that i knew about this and the first time that i had seen any of the documents that were revealed yesterday. so before i came out and spoke to all of you, i wanted to do the best that i could to try to get to the bottom on some of the soda when it came out i could answer questions as best as i can and take appropriate action if action was necessary. there is no doubt from reading e-mails yesterday in my mind that action was necessary. and that i wanted to make sure that i spoke to those people to make sure there is any other information that they were aware of that i had before it was active. and i will continue this process and i couldn't get it done yesterday. as i said, this is more information and as i uncover it, i will act accordingly and take whatever action is necessary if any action is necessary for any other issues.

also information coming from anyplace else. >> watch all of the news conference at c-span.org. >> maui house now he calloused panel looks at possible changes to medicare and medicaid in these federal programs. this subcommittee hearing is two hours. >> the committee will come to order in the chair will recognize himself in the opening statement. this subcommittee has played a role in convincing the sustainable growth rate, and implemented a sound replacement policy for medicare reimbursement positions. we reported the medicare patient access and quality improvement act of 2013 by the full

committee reported by a vote of 51 to zero as of july. and as we move ahead with a permanent fix, we also need to examine the expiring medicare and medicaid and children's health insurance program and health and human services provisions that have traditionally moved with this. the purpose of today's hearing is to look at these extenders and evaluate whether some of these short-term provisions should be made permanent. if so, how best to accomplish this. the list includes the following. on the geographic adjustment for that fee schedule and annual reimbursement update, there will be exceptions and special needs

plans and medicare reasonable cost contracts and national quality forum in qualifying individuals and transitional medical assistance and the inpatient hospital adjustment for low volume hospitals as well as medicare dependent hospitals in the express lane eligibility as well as outreach and assistance for low-income programs and family to family health information centers and abstinence education and personal responsibility education programs as well at his home visiting programs and special diabetes programs. in our current budget climate, and with the medicare trustees predict insolvency as early as

2026, our decisions will have to be made. in the determination must be part of a data-driven analysis that justifies that the continued existence. i'm looking forward to hearing from our witnesses today, particularly medevac which has come up with its own criteria for evaluating those provisions and this includes action relative to current law. it would improve beneficiaries access to quality care and whether the action would be part of this reform. this is a time for us to be very prudent and even skeptical, given the enormous cost of the policies and do our job on behalf of the taxpayers to ensure that every dollar spent is reviewed for advocacy. thank you and i yield my time to the doctor. >> thank you, mr. chairman.

but i do appreciate that you start your opening statement with this. you're here because of real progress that is on the appeal of the sustainable growth rate which gives us a problem for a lot of us and so it's literally in the oven baking and today we are going to talk about what else may go into that for the process is completed. certain number of policies have a lot of uncertainty that bring to the program participation by provider payment each year. not all of these policies are under our jurisdiction and many of them have proven successful in many of them have proven successful, such as a special diabetes program and special needs program and others are essential to guarantee this with large rural areas such as

hospital programs. others are necessary to block other programs including the libya killing of contract rehabilitative access. the passage of time something tells us it hasn't improved. doctor should be able to provide their patients with therapy and never fear that prior to her or after surgery patient will not be able to access the therapy services that they require. i am appreciative of the work this committee did in moving the reform along as we were the initial subcommittee that passed the sustainable growth rate of one in other jurisdictions have taken up that manner. it all started here and i am appreciative of that. and i would like to talk about

the testimony to be submitted as well. >> without objection. the chair recognizes the ranking member of the subcommittee. >> thank you. i'm pleased to have the hearing today to discuss the programs that we have every year and i think our witnesses also this evening. this subcommittee has an important role in evaluating the health care policies and we will discuss the health care community and the ability to include beneficiaries under medicare and medicaid. we support the health care framework envisioned in the affordable care act including access health care and to encourage more efficient patient care. moving along this year-to-year and we need to set these

policies out for a better sense of stability. that is not to say that i think we should extend every provision but move toward this and we are better able to conduct a proper oversight and consider making changes based on the data collected over time. some of these policies will offset this and we must not talk about those who rely on these programs. wanted to take a chance to highlight how they help and this is not an exhaustive list but certainly one that i would like to urge you to extend. one is the program in medicare by covering the cost of the medicare premiums. these programs help with financial burdens and their include medicare beneficiaries

and in new jersey 40,000 people were able to apply for financial assistance in 2013. another is a program that allows medicaid coverage to be obtained for one year as the income changes. the program helps people to allow for consistent access as well. and i also wanted to highlight to policies that we have implemented in this includes the bonus payment showing that this increases the probability of beneficiaries in at at least one visit to a doctor and this is an important policy that should be part of this because we still

need to understand that in your way. including positions such as neurologist and psychiatrist in ob/gyn that are not included in the bonus payment that should be. also an increased enrollment and streamline procedures for medicaid in new jersey was one of 23 states to receive this payment of 2013 through this program. enrolling coverage makes a difference how many children are enrolled each year and also in receiving the medical care they need. i want to mention that it's part of the grant program and this includes the families of children and youth in making informed choices in health care which provide effective treatment. this provides a unique service

for a firsthand experience in navigating a special-needs health care service and that is why have sponsored this third 2016 and will continue to advocate for this with any package. these are just two examples of the many provisions as we move toward this end i'm impressed with the recent progress and i stand ready to work with my colleagues on this and with our senate to repeal and replace this and continue these extended provisions. i yield back, mr. chairman. >> thank you, mr. chairman. the chair recognizes the ranking

member for five minutes for his opening statement. >> thank you so much, mr. chairman. congress seems to be poised to eliminate this and make it a program so we don't have to go through the torture of trying to make sure that the consequences have not extended and also our committee voted unanimously on us and i hope we can get it across the finish line to get this job done. it is often served as a vehicle to address medicare and medicaid and additional public health-related programs similar time limits in these provisions have been collectively referred to as extended policies.

when we replace this we must also address the extended policies. these policies seek to help those programs that serve them and we cannot afford to leave them out in the cold. in medicare we have health policies that need to be extended and those have been discussed and are well known, some of which have a long history of bipartisan support and i'm generally supportive of these public health programs, but i do want to note that my reservations exist about extending this. but i would like to focus on the medicaid program which is often overlooked because both policies help secure affordability and

streamline the administrative process. it gives us the option of relying on the income data for other federal programs and lowering the state administrative costs and that this should be a permanent option for the state, transitional medical assistance is indispensable for low-income families and we must and the roller coaster and ensure that the coverage is secure going forward. the payments have been successful in getting states to adopt simplifications as a way to get people enrolled. twenty-three states, might than half have qualified under this program and we should continue it with the current authorization. and i've heard a great deal from family doctors and pediatricians about the medicare bonus and it

is something that would provide stability and adequate payment is comparable to what we do in medicare and there is no better way to ensure access and to provide this in making sure that family care and pediatricians will have extra payments allow them to treat patients. so i'm glad that we are holding this hearing and i would like to yield the balance of my time. thank you to you for a number of public health individuals. >> thank you. i want to simply say to the chairmen and ranking member, thank you for holding this hearing today. we have had many situations about this and we are talking about many that have been

mentioned already, we are going along with this and it's small, technical, but critical policies that make a world of difference. i want to stand ready to work with my colleagues on each of these issues and especially those that have already been mentioned in the many critical medicaid and public health individuals and we thank you for your link. you also for holding this hearing today. >> we think the gentlelady and that concludes the opening statements of the members and i would like to thank the witnesses for coming today because we have one panel. we have the chairman of the medicaid payment advisory commission. and we have the associate

administrator with health resources and services administration of health and human services and finally, naomi goldstein, the director of the office of planning research and a valuation for children and families in the department of health and human services. thank you for coming. you're prepared testimony will be made a part of the record and you have five minutes to summarize her testimony. and it will be placed in the record and at this point i would like to recognize the gentleman for his summary. >> thank you. thank you ranking member and vice chairman burgess. i appreciate the opportunity to talk about the tax recommendations on these issues and as the chairman noted, there is a long list of medicare provisions under discussion here

and it is a divorced list and i won't try to summarize this on this provision. but instead i will describe the criteria that we use to evaluate the provisions and we have looked at them in two batches. first it was 2012 the congress focused on a temporary medicare extenders as they are known. by definition these provisions increase spending above the current baseline. and what we did was ask a question, whether there is evidence that the provision in question includes access to quality of care or enhances the movement towards new payment models. we also had a 2011 requests to evaluate various special payment

provisions as applied to world providers and their we used a similar test and we asked whether the provision was targeted so that it provided support to isolated providers necessary to ensure access to care for medicare beneficiaries. whether the level of adjustment was empirically justified or whether it was designed to preserve some incentives for the efficient delivery of care. these tests are tests we believe are consistent by a statutory charge to make recommendations to congress to assure access to high-quality care while also minimizing the burden on the taxpayers. we think this test is particularly appropriate in the current context of the repeal as

the committee well knows. we have been longtime advocates for well over a decade now. we are heartened by the progress that has been made towards repeal and we recognize it's an important part of the remaining challenge and that includes the financing of the repeal. so we think that there is stringent testing that makes a difference from the extenders that is an appropriate test in this context. so i welcome the questions from the committee and those are my summary comments. >> we now recognize doctor roland five minutes. >> thank you chairman and breaking member and members of the subcommittee. i am pleased to be here today to share my expertise is the committee considers extension affecting medicaid and the children's health insurance

program. it was on the rise in 2009 and again in 2010 to provide congress with support on a wide range of medicaid policy issues. the focus of our work is how to improve the effectiveness and administration of medicaid to reduce and improve care for the beneficiaries with medicaid increased coverage. during the coming year we will be looking at the implementations with the patient protection and affordable care act and the coordination of medicaid and we will be looking at the future of this program in the payment system improvement underway in on medicaid administration. today i will focus on issues that are part of the reauthorization, specifically one of the areas that the

commission has looked at carefully is transitional medical assistance. which provides additional months of medicaid coverage to low income parents and children who would otherwise lose coverage due to increased earnings and helps to promote increased participation in the workforce, which is a goal of all of us. it was limited to four months and has since been raised to a six to 12 month period of time as we are discussing today. this provision applies to the lowest income beneficiaries who qualify into the guidelines and helps to reduce this between medicaid coverage and uninsured. it is disruptive for the plans that serve patients and providers and government entities that process the changes as well as for the beneficiaries themselves. we recommend eliminating the sunset for the section that allows six to 12 months coverage

and also provides additional flexibility as people transition from medicaid to the workforce. we also have recommended that one state expand medicaid under the affordable care act, that they are allowed to opt out of medical assistance because in that case there would be no doubt which would bring the end of their earnings in coverage they would provide either through medicaid under the new options or through subsidized exchanges. with regard to eligibility we have looked at ways that the program can be streamlined and eligibility can be improved and it provides children with enrollment with express vehicle that eliminates some of the duplication goes on in programs of termination, including 13 states that have implemented

this method of establishing eligibility and we will continue to monitor the use and effectiveness of this approach and we are in the process of this report by the secretary of health and human services and we will provide a comment on that report as well to the congress. and in terms of this program and outreach and eligibility, we see that this has provided a strong incentive to improve the outreach for children and many of these strategies are required in the new eligibility and enrollment process which is implemented effective 2014 and so we will look at this to try to see how this needs to be restructured in light of the portal track. we also support the developing policies that will help us improve and trent improve the quality of care for children, including the requirement to

develop a core set of quality measures and there is no other way truly be able to compare the quality of care being provided without the standardization and we know that you will be looking for us to do such comparisons and we strongly support having to talk about the inability to do that. with regards to this in the special needs program we have been looking very carefully at the importance of the role of medicaid plays for medicaid beneficiaries by helping the lowest income to not only for their premiums but to get one integrated care and we will continue to try to work to assess how we can improve the coordination and delivery of care for individuals who are duly eligible and are very low income. so we will continue to keep congress informed of our progress and we look to try to find ways to try to reduce the

administrative burdens and streamline the program as well as provide better care to the beneficiaries for a better investment that this government puts into this care. we thank you so much for having us today and we look forward to sharing our work with you in the future. >> we now recognize the doctor for a summary of her discussion. >> thank you members of the committee today. we are improving access and the agency collaborates with government at the federal state and local level to improve health to access the quality services in the health care workforce. i'm i am pleased to provide an overview and update which we have referred to as the home

visiting program and the family to family program. home visiting program works in collaboration with the administration for children and families supports services during pregnancy and young children up to age five years old. providers work to participate and we help them build additional skills to care for their children and their families. includes families with a history of drug use or child abuse and neglect or developmental delays or disabilities. decades of scientific research talk about this with improved outcome and prevention of child abuse and neglect and child

development and school readiness. previous work in this area has shown that amongst 2-year-old girls during their first two years of life, there is a lifetime risk of conviction by more than 80% and teen pregnancy by more than 65% including enrollment reduction in medicaid by 65%. including an essential return on investment. including every dollar in home visiting. early data found within the first nine months of 2012, more

than 175 visits were made 35,000 children in communities across the country. the preliminary data indicates that more than 80,000 parents and children are receiving these services in the program is available in counties across the country which is 20% of all the county in the united states. the communities are building capacity in this area and have demonstrated quality and efficiency and accountability of their home business program and they have the flexibility and are able to choose from 14 evidence-based models to meet capacity and resources.

and we have taken these steps to improve its accountability. including ongoing assistance in promoting the dissemination of best practice and we have monitored this as well on an annual basis and improvement will be demonstrated in this area. this includes the health information center program that provides support and information and resources and training. the centers are staffed with the ability to connect other parents with information and resources. including how to better support

families for their health care needs and developing and implementing a new system of care for these children. in 2012 talks about the activities and accomplishments in june of 2010 and may of 2001 approximately 200,000 families and they receive direct assistance and premiums as well. greater than 90% being able to partner and navigate the services as well. i appreciate the opportunity to speak today and i'm pleased to answer any questions. >> thank you. the turnout recognizes the doctor or a summary of his

testimony. >> thank you for the opportunity to be here today. i plan to speak about three programs as well as a collaboration on the home visiting program that you described. each of these programs uses knowledge from past research and we are carrying out evaluations and are continuing to learn about these programs. we aim to make the evaluations regress and the results are relevant and useful for policymakers and practitioners. the health profession opportunity training is part of high demand health care professions for low-income people uses a career pathway of framework. the program has funded 32 grand including five that tribal organizations and those people can completing the program, many have become employed.

short courses can be the first step in a career path. and last year we published three reports on the outcomes for participants. using a range of creative strategies. for example, one is using google hangout for a real-time tutoring. we plan to lease additional reports this year and next year and we are also setting education, employment, and earnings and how it is affected. this includes the program that is designed on both abstinence and contraception in this includes evidence-based or substantially so. and all models must provide accurate information. we sponsor a systematic review and so far 31 program models have met the review criteria and

we continue to learn about what works. we recently released a report describing program design and implementation, such as how they define and reach target population. their findings will be released in the next couple of years and we are setting the impacts of the local program approaches. states are encouraged to use models of evidence-based and all models must provide medically accurate information. we completed an evaluation of foreign programs which found no effect on abstaining from sex. it also found no effects on unprotected sex. however three models among the prevention models that meet the criteria. ..

>> continual learning through a national evaluation and other activities. hhs sponsored a systematic review of evidence similar to achieve pregnancy evidence so far 40 told visiting models have met the criteria. the design of the national evaluation has been informed by a the advisory committee of experts. most recently they commute -- reputed to endorsed the report to congress in

march 2015 using a rigorous random designed to look to the effectiveness of fraud and the most commonly chosen models by degree anti. hopis proof descriptions of the accomplishments of these programs of the efforts to learn and improve. thank you for inviting me to testify. i will be happy to address it questions. >> the key for your testimony now we will begin questioning in their recognize myself for five minutes. i believe this committee needs to be diligent with its spending priorities and consider every one of these policies carefully before deciding whether they wanted extension. many constituencies are advocating for making these extenders' permitted. it your testimony, you lay out a set of criteria to use when considering these extenders.

using your criteria do you believe all or the majority of these extenders are worth extension? >> certainly not all. i don't have a counter would be reluctant to say but we think many should not be extended. >> in your opinion, based on your criteria, do you have a couple of programs that congress needs to look at with a critical eye as we begin this review? >> let me just focus on pavement provisions. some of which are permanent some event will -- some of them are under observation but with my opening comments we did an extensive review of medicare issues which was published in 2012.

part of that was to examine the special payment provisions against the criteria in my opening comments. we are isolated providers into their retain incentives for efficiency? we found a number of those provisions did not. let me focus on one in particular. there is a temporary low volume assessment of the medicare program. it is a hospital payment adjustment for those that have low volume there are some serious problems with that adjustment. first of all, is based only on medicare discharges. if the issue is small size and lack of the economy of scale be appropriate index is a total discharge.

not medicare. in addition it looks to us like the magnitude of the adjustment is too large. finally, it is not directed only at isolated providers. hospitals within close proximity of critical access can qualify for the low volume adjustment. some hospitals white community hospitals can double dip to get special payments in also low-volume payments as well. >> i will commend you for putting forward the criteria you referenced in your testimony. i believe it will be helpful as we consider the extenders. doctor, is there a similar set of the established criteria by witchhunt to

waive the medicaid extenders' against current benefit that the policy delivers to beneficiaries? if not how you take into consideration issues of cost that mitt pact is advocating? >> we are a much newer by the they and medpac so we are looking at the criteria of the various policies. one is sufficient need -- judaism as she effectiveness and reduce complexity so we would get these extenders in terms of their rule but we just looked at transitional medical assistance or tma as cost or impact of beneficiaries of it to mr. shipp and federal dollars spending.

>> really have 30 seconds but i and the stand you provide technical assistance on a number of issues. very little includes how to encourage more teenagers to choose abstinence or sexual risk avoidance. please describe said technical assistance you provide compared to others such as contraceptives. >> i am actually not prepared to address that but i will take that back to my colleagues and provide an answer for the record. >> the committee published a report that analyzes abstinence or sexual risk avoidance programs and describes over 22 peer review studies that show stiffly -- significant evidence are you familiar? >> i am. >> will you share it? >> i will take a back to my program to provide enough of

lung dash cancer. >> i now recognize the ranking member. >>. >> i have been a number of documents on the extenders and want to ask unanimous consent will not read them all because it will take up my whole five minutes. >> without objection. >> i have a question initially, i have been a doctor -- strong supporter in the past in the program has held so many families in my state and across the country managed special health care needs. that is why i introduced a bill that extends the of funding through 2016. is pleased to see the of the other -- the senate with a further through 2018 with the $1 billion increase. in addition to helping

families could you talk more about the contributions of the program has made to our overall health? >> these are unique that they are staffed by parents with the special health care need date understand the issues of their parents face and they can provide support and help other parents through this larger network of freeways and professionals. they can help the families find the best health care providers and they also partner and in doing so can really improve on the outcomes for the very vulnerable population.

>> you answered my second question but could do talk more how the family to family health information center is different from others and how the staff is uniquely qualified? i know you kind of answer that. >> that's right. it is unique in that they are staffed by parents themselves and in terms of the support, resources, training , they can provide from their firsthand experience. >> mr. chairman of work has been supported by members umbels sides so i'm told the program can be continued when we address the extenders. i want to ask a question also about the bonus payments. established fasces incentivized base to more

effectively been mr. the programs by the states receiving bonuses each year. fiscal year 200910 states received 37 million fiscal year 2013, 23 states received bonuses with a total of 307 million. it is good to keep providing bonuses but they have to implement five activates simplifications now it is required some of these best practices the states have my uniformly adopted all of them. express lane eligibility, a presumptive eligibility, eligibility, 12th month continuous are important for retention of coverage in my opinion. would you agree to encourage states to adopt the simplification is critical in the availability is in part responsible for getting states interested to adopt these best practices?

>> we have learned a great deal and that is why some of them are now required to as we continue to look at ways to encourage states to do outreach of the eligible but not enrolled children is the important way to reduce the insurance, and children. so to be able to look at other incentives and provide in the bonus payments that perhaps the state chooses to eliminate the waiting period that that would be another thing you might want to add on to qualify for the bonus payment. that gives you the ability to give a true incentive to find these eligible but not enroll children read need to look at ways to structure this bonus payment so we tried all the ways to streamline enrollment expected just want to mention currency the chip is authorized through 2015

baidu think we should extend the bonus payments through the life of the program and as we get evidence we want to retool to qualify the threshold to encourage states it would make sense to keep the program going. it is also true that of those that have qualified more than half are led by republican governors. this has good results of rights states and lou states and i hope we can continue. >> i also would like to do what you did and i will give you the last. i have a number of letters to submit without objection. so ordered. the chair recognizes the vice chair for questions. >> dr. rowland, let's stay on the issue of traditional medical assistance for the moment. then the affordable care act has been implemented and we

are lying in the fields of obamacare. is the tma even necessary any longer? >> it depends on the option in this state chose to pursue. said have chosen to do the expansion coverage, there is a way to be eliminate the gap as their earnings go up. but half of the states have not opted to pursue the extension of the eligibility for adults coming through the affordable care acts of dna tma will give them the ability to go into the workforce. >> five understand correctly , the extension of the tma should only be for those states that are not to participating in the medicaid expansion as under the supreme court decision?

>> just some medical assistance exist for all states but this is whether to be extended at the 12th month but also provides states with additional flexibility to do premium assistance as people transitions so it gives the ability to move people from medicating to private insurance and that is important with the transitional medical assistance. >> not to interrupt but i think that was of lot of the affordable care act. we can talk about that but a continuation of medical system only seems necessary in those states that did not participate in the medicaid expansion which was there rights under the supreme court ruling. >> correct part of you were concerned about the cost, it is a higher cost for the federal government to the individuals in the states that do see a transition to

the affordable care act coverage because it is when a depressive federal financing as opposed to shared financing. >> forgive me for it interrupting but that is temporary. we know those that are not participating it will have to change in the future. there is a limit how much the chinese lotus for the program. but one issue that i don't think was never completely will thought through as the affordable care act was discussed. you'll have people that continuously earn at different levels during the course of the year and 137 percent of poverty level may sound great here in a committee or federal agency but in real life, there are people whose income they sexually -- fluctuate wildly. when we have hearings on

those of affected of the deep water rise in or on the gulf coast of louisiana and a shrimper burned fantastic amount of money and maybe he is broke the rest of the year said he will transition from medicaid into the exchange said back into medicaid and that seems terribly efficient as a way to structure that. your program prevents them from happening? >> it helps to maintain coverage so during these lapses one month there is a lot of income than the next month there is less you have continuous eligibility so it eliminates having to transition and helps to manage care plans to be more effectively provide continuous care. >> forgive real think it is our role to help the managed care plans. met me ask you a question. you talk about a study of 19

generals in the lifetime risk of arrest was it diffidently lowered what did this study comprises? >>. >> of the children in families over aid to decade period. >> has to be few deal with 19 golds here received home visits during their just asians with their mothers. but you say the of lifetime of arrests has been diminished. we expect to live longer than two decades so how have you compiled those figures? is there some way to project the lifetime arrest or

conviction at age 19 it? >> i can speak to that. that lifetime arrest is as long as it was through the age of 19 not a projection beyond that fight -- point. >> i am interested in. i yield back. >> i want to draw your attention to a provision enacted into law this past december i fear will have serious consequences for access to care and medicaid. we all agree medicaid should not pay for care that someone else is liable for a and the statue has protections to ensure the state can recoup when other parties are liable financial. but pediatric and neonatal care, more than 20 years the law required the state to

pay promptly and chase other sources of payments later to richer children and infants and pregnant women could access to care with no delay. the law was changed to say that states must delay payments while they chase other potential sources of payment. congress would be outraged for a service provider. but i am concerned this will have a negative impact on providers willingness to participate in medicaid and alarm access to care on children and infants. can you comment? finigan is committee has long been concerned for access to medicaid beneficiaries and the willingness of physicians to participate. one of the areas we have been looking at is what are the barriers that prevent more primary-care and

specialists to participate? we learn from that payment delays and an ability to get payments process is the identifiable issues that doctors raise why they're unwilling to participate in these programs. so one really needs to look at why there's such a delay in payment would affect any access to care that is so important given medicaid substantial role to pay for 50% of all births of the country and a high share of new medicare. this is critical. >> it seems logical we should expect that will happen. if we delay payments just to delay payments. there is no reason to. last month this committee held a hearing where we heard from a number stakeholders' how the changes to the medicare advantage program were

affecting patients. you would think medicare of vintage was withering on the fine as the beneficiaries are no longer able to choose among private plans. interested to hear the current state of the medicare advantage program. are they really in such dire straits? >> enrollments in medicare vintage continues to grow. last year increased 9%. medicare beneficiaries continue to have a large choice of different options. it is down slightly from the year before but just this week the cms actuary's reported in 2012 for the population in newly aging into the medicare program

over 50 percent of the medicare enrollees josie medicare advantage plan that is potentially significant milestone. >> let me ask about the of parity with medicare advantage than fee-for-service. what is the parity between the two or reducing congress should stick to the reform and a forward or is there any justification to repeal? >> we have long advocated advocated, and mr. waxman mr. waxman, going back a decade there is financial neutrality between medicare advantage than traditional medicare. we continue to believe that is the wise course. the affordable care act to moves in that direction we would encourage congress to stick with that course. we expected with fiscal

pressure from the reduction of the benchmarks that they would respond in part by lowering their cost, it did have fallen concurrent with a tightening of the benchmark suez is evolving as we expected and we urge you to continue on this path >> there were recommendations for changes but this deals without medicare vintage plans offered by employers are priced. could you describe this recommendation and? >> we have not yet made the recommendation but it is up for consideration next week but we will vote on recommendations for the march report to congress. the issue here is the bidding system used for employer sponsored plans is different than there is basically no incentive for plans to bid low in the

emplponsoyer sed area which results in higher payments for medicare. we are looking at options fell come from the rest of the medicare advantage program to set payments for the employer sponsored plans that would reduce the outlay somewhat by using the market based bids. >> thank you mr. chairs. >> we recognize the gentleman from illinois for questions. >> welcomed as a great hearing and it is important to remember extenders and of course, tied in. i have a budget number for 2012. just to keep this debate in perspective coming if you look at the budget, a three pooley $5 trillion medicare

is 251 billion. medicaid but medicare's 466 billion and those are 2012 numbers. my first question is legal move any of these extenders and they lapse. what happens to insolvency debate of medicare and medicaid? how much does that improves the extent the life of these programs and how many days or months? >> i don't have in my head with the total spending impact of all the various temporary provisions. my colleagues have that but we can give you the numbers to mckewon to stand where i'm headed i am sure.

doctor, i will go back to you in a minute that you have a response? >> the only estimate we have is the cbo has estimated making that transition -- tma permanent with medicaid spending dollars. >> but in the billions and hundred billions? >> over five years. >> but the point is this. these programs we can debate the relevancy in our federal budget mandatory spending driving national debt, these will hardly affect the solvency debate on medicare and medicaid. would you agree with that? >> they are not large relative to these members and as a potential reference point is how do they compare

to the cost of repealing? how much do they add to the challenge? that is a number that is more significant. >> obviously proportional. >> these are compared to total medicaid spending but they still represent spending that helps. >> the overall debate which we try to raise all the time but if we don't get a hand on our mandatory spending programs, they will end up consuming the small portion of the discretionary portion we continue to squeeze because the red area will continue to grow of a substantial scientific reforms ocher. hand since i have been here in 1996, i started talking

in '92 we are not willing to make those choices for future generations and have a medicaid program. i fear for the future. that is just as the macro debates. it gives me the opportunity to put real numbers on the board because real numbers matter. for our children and our children's children and as the doctor says, who is subsidizing our debt also foreign countries. i represent about one-third of the state's of illinois come in 33 counties, i would hope with these evaluations we'll understand distances come in the importance of rural health care providers and between 30 and 45 miles. what is the cut off?

to medicare dependent hospitals in a low-volume buying understand these reforms. but the importance of this debate is there is nowhere else to go. if they don't have the volume to justify their existence, we need to figure how to make sure those stores stay open. . .