abuse of federal enforcement powers for purely political purposes. .. past using the irs to shut down its critics and opponents and to change the outcome of elections. when i go back home to the town hall meetings or when people come to my office, they will bring up the number 1, 2, 3 issues they are concerned about. there is always somebody in the back that says, wait a minute, what about my free speech rights? why can't congress get to the bottom of this? that takes a rather lengthy explanation. there are those of us that are committed to do that. that is why they are frustrated, concerned, angry. that is why they think the america they have grown up in and appreciated and they want to leap to their kids and grandkids, the very fact they

can't get up and say what is on their mind or take part in the political process, is in danger. has been in danger. this is an attack. that is just the way we have to put it. it is an attack on the first amendment rights of our citizens just because they dared to differ from this administration. i can't think of anything more reprehensible. certainly i am not going to stand idly by when the administration tries to dodge and weave its way out of this. lately the commissioner, the new been a littlehas crafty with his remarks. he made these remarks last tuesday. sort of a verbal somersault to downgrade the problem. whetherically asked him he would put a stop to the regulations he has been detailed to implement, the regulations that would enshrine the stifling

of free speech, at least until we are done in the ways and means committee and at least until we are done in the finance committee and also the government affairs committee in the house. rate, he dodged, he ducked, he told us several times not to worry. these revelations -- regulations won't be finalized until after the election. until after the election. quotehat doesn't put a around it and several outer lines with regards to this being political, i don't know what will. i am not sure that is what he wanted to say. by telling me not to worry, he made it even clearer that the irs's actions are designed to control the battle space of the elections this coming fall. them to keep ducking

and dodging. we have 40 cosponsors. to stop the irs from proceeding with new rules until we have answers, until we have finished our investigation. i vow to put a stop to these regulations so that we can preserve the rights of all citizens and groups to engage in the political process. then i deviated from my prepared remarks and i asked the new commissioner, there is a fox in the chicken coop. you know what foxes do in chicken coops. denying the only right of free speech to the chickens, but they are taking away a lot of other things as well. what you are telling me is, don't worry about it. we have investigations to

determine how the fox got into the chicken coop, who put the fox in the chicken coop, more importantly, how do we get the damn fox out of the chicken coop? he indicated not to worry. we will have those answers down the road. i said, can i have your commitment that you will wait until the end of these investigations? he should deal with it anyway just on the merits of the case. he would not give me that commitment. he kept dodging around the issue. i said, get a fox out of the damn chicken coop. determine who put the fox in and take that person and hold them accountable. or else we have a very damaging situation in this country. i can't tell you how much this affects people in terms of their free-speech. thinks,y automatically it is free speech, first amendment, broadcasters, etc.

it is everybody. groupright, middle, any that wants to express themselves in the political process. it is absolutely fundamental and basic to our rights. jeff and i are determined to do that. we got 40 sponsors. we are working on it. if we ever get to a vote, we could pass it in the senate. we are not giving up. i appreciate being here. thank you. >> senator roberts from kansas. he makes the point that this administration doesn't have a lot of interest in the first amendment, but they are reasonably conversant with the fifth amendment and seem to understand that one if not all the others. the obama administration started off by saying, that he was

outraged at the abuses in the irs and he wasn't going to tolerate it. then he turned around and decided he wasn't outraged anymore. he wanted to codify into law a number of those outrages so that they would be legal to do in the future. 150,000 americans sent in comments on those proposed irs regulations. the folks from the administration have pointed out that they got more comments on this irs attack on the first amendment than all the other proposed regulations going years into the past added together. i think that is very interesting. i would have thought, most irs regulations are about taking more or less of people's money and more or less of their time. i would have thought that would have engendered many comments. it is a very healthy sign that

people got more exercised at the irs for going after their free-speech rights, their freedom, then their money. thought was extremely powerful statement by the american people as to what this is about and what is their first priority. freedom more even than money taken out of their pockets. we are now joined by katie mccullough to talk about what is withning on efforts americans for tax reform. hi, i am katie mccullough, executive director of digital liberty for americans for tax reform. i want to point to a narrower area of tax policies. when you look at taxing the internet, one of the things that people don't know is that there is legislation that prevents states from taxing access to internet. just basic getting online. introducedegislation

to prevent states from doing that. before the legislation was introduced, there were a few states that had already taxed to the internet. that has been reauthorized for a number of years. we now have two bills, house and senate, the permanent internet tax freedom forever act. we also have the internet tax freedom forever act sponsored by widen and soon. that would prevent taxes on internet access at anytime anywhere and would not allow states to continue doing such things. that is great for our economy. it also prevents states from taxing sales that occur online differently from sales, traditional market sales. they could not be taxed higher than your regular sales tax. iss kind of legislation important to keep our tax code consistent.

unless people have access to one of our greatest areas of economic growth, taxing people's ability to get the jobs, to get to education, to further themselves in the way that we think is valuable. thank you. >> thank you, katie mcauliffe with digital liberty. we are now joined by the senator from kentucky, rand paul. >> i am glad to the here to discuss the problems we have an associate myself with americans for tax reform. for 20 years in kentucky i ran a group called kentucky taxpayers united. we were associated with the projects and policies of americans for tax reform. we supported the taxpayer pledge in kentucky as well as supporting a nationally. the thing we need to remember about taxes is that we need to

think about how taxes prevent us from creating jobs. right now we have a tax code that scares jobs overseas. everybody laments jobs going overseas but if you want jobs to stay at home, you need to make money more welcome here. money leaves and goes to where it is welcome. we have a corporate income tax of 35%. canada's is 15%. we wonder why people are going overseas. we have $2 trillion worth of that americant companies have gained overseas. it is not coming home at 35%. we have a bill to bring it home at 5%. jobs can created by reducing taxes. we don't want revenue-neutral tax reform. burden to lower the tax to compete with the rest of the world. we have talked about economic freedom zones where we lower taxes dramatically in

economically depressed areas. you want to fix poverty, lower taxes. i am glad to be here to associate myself with americans for tax reform and for their push for reasonable taxes to help us create more jobs in this country. thank you. >> before the senate, he was the leader of the kentucky taxpayer movement. tea party before tea party. we are now joined by senator rob portman from ohio who serves on the finance committee. >> i am delighted to be here today to support what atr is doing. ohio,n my home state of what they are going nationally to ensure we have a rational tax policy. we are not seeing that now. the president has already raised taxes $1.6 trillion. he would like to rate them another $1.3 trillion.

i hope people see that we have got an administration that would like to raise taxes but what they are at a time of a historically weak recovery, an economy that is faltering, yet they want to tax people more. going toge family is pay about $25,000 in taxes this year. that is already too high for my yet they want to make it higher. the argument is made that we are somehow undertaxed. that is not true. one thing atr has done well is to lay out the historical perspective. even without the tax increases that the president and democrats are proposing, the taxes and the burden on the economy is going to increase. we need to raise taxes to reduce the deficit and the debt. the problem is spending. we are spending too much. until we get spending under control, we are not going to be able to solve this problem. taxes have gone up enough.

taxes make it harder to create a job. taxes are going to make it harder for us to get this economy on track. we have to focus on the problem which is spending. i am for tax reform. we know that we can have a better tax system in this country. this, thatre we do we are not doing just the opposite, making it harder to get america back on track. thank you all for being here today. thanks for making these points. thanks for ensuring that people know that america is not undertaxed. we are spending too much. we have to to get that under control first. >> senator, thank you very much. when you talk about tax reform as a number of the senators have legs, threethree sides to a triangle of actual tax reform.

the first is to take rates down. we are at 35% for corporate business tax rate. canada is at 15%. the european average is 25%. we need to take those rates down. it is not good enough to go to 25%. the average in europe is 25%. 4.8% orlly have about 5% state corporate income taxes as well. when you talk about american taxes on businesses, on average, it is a lot more. it is on average 40%. atare competing with canada 15% and europe with an average of 25%. taking that breakdown is important. maybe 1000e have pages of how we handle issues in terms of depreciation schedules.

expensing sown to that when you spend money to buy a piece of equipment, you expense it that year, not depreciated over many. the third is, what was just referenced by rob portman and by rand paul. that is going to a territorial system. andt now, the united states north korea and not many other people have a worldwide tax system. if you earn money in france, we tax you on top of what the french did. if you are french, the french will lead you alone. we take some, you can take it back to france. that encourages repatriation. we discourage repatriation in the united states. we are now joined by one of the leaders in the fight for tax reform. whoesentative kevin brady is on the ways and means committee. >> thank you, grover.

thanks very much for your leadership on limiting the size of the government, growing the economy and creating a progrowth tax code. the biggest problem facing our country is a federal government living beyond its means. spending cuts can get us halfway back to a balanced budget. to finish the job, start paying down our national debt, we need a much stronger economy. right now our broken tax code is a real drag on america's economy. it is too costly, too complex. mainly it is too unfair. it is unfair to families, to businesses, unfair to america. we are no longer competitive around the world. we need the tax code that is simpler, fairer, flatter, that protects taxpayers not special interest. the ways and means committee has laid out for the first time in 30 years a top to bottom rewrite, a discussion draft on progrowth tax.

it has some strong topline numbers, increasing economic trillion,more than $3 creating almost 2 million new jobs. simplifying the code by about a quarter and allowing more than nine out of 10 americans to file their taxes on the front and back of a piece of paper. it is a good, solid start. more can be done. the reason it was laid out is the discussion draft is that every point along the way, we ought to make it more progrowth. right now because of this draft we are having deeper discussions on tax reform than in the years i have been in congress. it is long overdue. i am a strong supporter of lowering rates for individuals and families. i am a strong supporter of cost recovery as well. it is important we get to all of these elements. i will conclude with this, you have never had a truly love/hate relationship until you have done

tax reform. there is parts of that draft that i love and parts of that draft that i hate. that is probably the case for everybody who is you're working on it or looking at it. that is the point of tax reform, to have that discussion. those who assembled the affordable care act in secrecy, passed it through congress with virtually no one knowing what was in it, we took the opposite approach. draft for discussion all of america to see and analyze. determine what is right and what is wrong and help us shape the future. we have taken the most important step in 30 years. we are going to work hard to advance tax reform. we are hopeful that sometime in the future the senate will join us and ultimately the president. whether they do or not, we are going to advance progrowth tax reform. grover, thank you again for your leadership on all these issues.

>> the safeway to vote, whatever they are asking. thank you. we have talked about tax reform. we have talked about extenders, , bureaucrats irs and political appointees at the irs who brought the ethics of chicago to the irs where they do not belong. they don't belong in chicago either. but you can leave chicago, you can't leave the irs. those ethics need to stay far far away from the internal revenue service and the laws that we all live in. i would like to point out that while we are having this discussion in washington dc, there is a discussion going on in the 50 states. ,hen you look at the states while there is gridlock in washington because you have a

republican house which wants to reform taxes, the democrats are on the senate and iran into fromsenator kerry massachusetts when they were doing the big discussion about getting a tax increase as part of the budget deal in 2011-2012. he said, here is what we need to fix the $1.2 trillion hole. he wanted 1.420 and dollars in higher taxes. -- $1.4 trillion in higher taxes. they got no tax increase, all spending restraint. the sequester holding against tax increases that year. every time the administration or the democrats in the senate discussed tax reform, the first thing they want is $1.2 trillion trip4 troy and dollar --

$1.4 trillion. as part of tax reform. you can't have tax reform if you are just going to be massive tax increase. we have good luck on taxation. at the state level, we have the opposite. red states onthe this map, you have a republican governor, republican house, republican senate. they can cut taxes and virtually every one of those states has. there are 13 states where you have a democratic governor, democratic house, democratic senate. they can agree to raise taxes and they have. at the state level, the we are having a test. just like they tell us in grade school about the democracy. you have an experiment between the 50 states to see what works and what doesn't. half the country's population lives in a red state with a republican house, senate and governor.

one quarter of the country's population lives in the blue states run by democrats. because of distracting and the way things are structured, the red states stay red for a decade and the blue states stay blue for a decade. long driftg to see a in one direction in red states with lower taxes and less spending and a long drift in the other states with an experiment going the other way. we are going to see a very interesting challenge. we have launched a project called 50 in 2050. our goal is to abolish state income tax in all 50 states by 2050. we have to elect different governors and different legislatures. we can already see a number of states. kansas and north carolina have begun that process. announced, we are going to go to zero. louisiana has multiple efforts

to go to zero. nebraska has made the same statement. i think you are going to see a number of states follow the eight states now that have no state income tax and one that has almost no state income tax, that is tennessee. there is a movement there which i will -- only will succeed to phase out that tax so that tennessee will be the ninth state to have ended all state income taxes. i don't think at the end of the day telephone you and new york can continue to have the high when more rates states closer to them are going towards zero at the state level. uph that, i will close today's press conference.

i will take any questions people have now. i will also be available afterwards if you want to have a separate conversation. >> can you talk about the implications of obamacare on this year's taxes and also next year? is this year is going to hit wealthier americans. >> americans for tax reform has put out several lists of the 20 different tax increases in obamacare. they phase in overtime. you're seeing organized labor very unhappy at the taxes they're going to have. expensive insurance funds are going to be taxed. that is not something the labor unions wanted to see happen. it was an idea that mccain had one point endorsed. they spent $2 million trashing the report in 2008 and then they

put it in obamacare. hikes,re a series of tax everything from the tanning tax to a tax on medical devices. any medical devices including in some cases wheelchairs -- how you reduce the cost of health care -- one of the things we were promised was that people who didn't have insurance would get insurance and everybody's health insurance would drop by $2500. it has now gone up. part of it is that we tax health insurance plans now. we are taxing not-for-profit hospitals under obamacare. stuff thatng the goes in. how does that make it less expensive? there are a whole series of those tax increases. they are not just on the rich. 20 would onlye qualify as having high income

people. if you have health insurance, you are paying that tax. if you don't have health insurance, you are paying a tax. if you have health care, you are paying a tax. regardless of how high or low your income is. everybody and all parts of health care. it is a rather massive tax increase inside what we all thought was all about reducing the cost of health care. as far as the lowest murder referral, what do you think the referral,is lerner what do you think the likelihood is? >> i have complete faith in my government following the law. holding itself to the same standard that it would like everyone else held to. yes. >> do you think the irs scandal

is worse than watergate? watergate, they broke into the democratic headquarters and stole some stuff. you are not supposed to do that. the irs is certainly affecting that were justs minding their own business. both were attempts at corrupting the political process and using the power -- actually watergate hired burglars to steal stuff. they didn't use the government. i am old enough to run member watergate. it has been a while. they hired some guys who broke in and stole some stuff, criminals. they didn't use the marines or the irs. they did the proper thing. if you want to be a criminal, you hire criminals. what you don't do is criminalize the government. that is what appears to have happened with the irs.

people working for the american people, paid for with tax dollars, abusing that power for political purposes. senator pat roberts from kansas said, we are going to put off making this decision until after the election. sending up a flare that this is a political decision. not even after november, after the election. it is worse because it is the corruption of much of the government. many people were involved. not one guy telling some bad guys to do something. i hope the prison sentences are at least as long. last questions? thank you very much. grover norquist with americans for tax reform. assumingee you again the present income tax is la

>> the house oversight committee voted to have lois lerner in contempt of congress for refusal to testify. next we'll get an update from the heritage foundation. said from the center for american progress on white house efforts to combat gender pay and equality. we will talk to georgann history professor about the 50th anniversary of the

1964 civil rights act. washington internalize each morning we will also take your calls and join the conversation on facebook and twitter. >> if you continue to send people here who have no real world experience, no hardship, no difficulty, then no success in life outside of politics you will continue to get the same results. that is why we need a constitutional convention to put term limits. once you put term limits you eliminate what goes on here. that will open up seats for

a lot more people to actually have here real thrilled experience to be competitive but that is only one part of what you can't do. you will not fix it in washington today. i am bitterly convinced of that. i spent 60 years in congress and i continue to be disappointed every day at the lack of foresight, lack of judgment, lack of long-term thinking and lack of critical decision making that occurs in congress. hhs secretary sebelius is resigning. president obama is expected to announce the current

white house budget director will replace her. sebelius has been head of hhs since obama took office and has overseen debilitation of the affordable care act. on thursday the secretary testified on capitol hill saying health care insurance enrollment has hit 7.5 million marks. a this hearing is two hours 50 minutes. on our facebook page share your thoughts on secretary sebelius resignation and join the conversation on facebook [inaudible conversations]

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[inaudible conversations] has. >> this morning the finance committee is here to discuss the health care proposal of the president's fiscal year 2015 budget. secretary sebelius thank you very much for joining us this morning.

this discussion will undoubtedly trigger debates about the affordable care act. certainly there will be reasonable differences of opinion and what i would like to do is start with a handful of overlooked fax better not in dispute about what has happened since the affordable care of a act became law. first with the passage of the law, health care in america is no longer just for the healthy and the wealthy. before the law was enacted enacted, insurance companies could discriminate against people with pre-existing conditions. that meant that those who were healthy had nothing to worry about. those who were well off could pay their bills. and everybody else went to bet every day could be wiped out financially. second, the great of roasted medicare is slowing. the fact is that according

to health and human services data a dual medicare spending per senior grew 1.9% percent over a two-year period slower than an overall economic growth and much slower than restore growth. over the previous three decades per senior spending grew 2.seven percentage points faster than the economy. this has the potential to be great news for seniors who want to lower premiums and for taxpayers who want to extend medicare without breaking the bank. third, there are some important reforms that have been launched over the past few weeks. for example, build a and on work members of this committee have done to open the medicare database to americans and thank you senator grassley the obama

the administration yesterday made public unparalleled amounts of information that will help americans make choices about their health care. this will help fight fraud promote competition for medicare services, and be useful tool for the private sector. this information can be used by private employers and others to bring down the cost of insurance. another recent unpromising announcement helps provide patients with life-threatening illnesses with more choices in care. for the first time patients will have access to hospice care without having to give up the prospect of curative treatment. this puts patient a and families first, and it's high time. fourth, congress now has a bipartisan bicameral game plan for dealing with chronic disease. senator isakson and i have legislation focused on improving care for seniors with multiple chronic conditions.

we appreciate the input of senator bennett and warner. its the most expensive than fast as current portion of the medicare population and the seniors deserve better care. fifth, there's plenty of debate about which americans enrolled in the affordable care act and when but the independent data shows that the number of uninsured is significantly lower than it has been in years. for example, a gallup poll released this week shows that the rate of uninsured americans felt so low was since 2008. finally, congress has made real progress on permanent the repealing it replacing the broken and dysfunctional medicare physician payment formula. the reforms agreed to would push medicare to be driven by the quality and value of care. today's volume driven gear isn't good for seniors seniors, their doctors, or

medicare itself. the president's budget proposal endorses the bipartisan bicameral reform package and i look forward to working with secretary sebelius to help push this over the finish line by year's end. that of secretary, the last time you were here before the finance committee i compare the rollout of the affordable care act to the expansion of medicare to provide prescription drugs to america's seniors during the bush administration. like to affordable care act it zeroed in on the same concerns expanding expanding, expanding coverage, a financial assistance to the needy needy, increased market place choices. medicare part d has been a huge success, a godsend to millions of seniors in its costs 30% less than the congressional budget office predicted.

however it had a very bumpy start and many of the news stories from those early days of party resembled what we've seen with the affordable care act. but with congress working across the aisle to make it work, medicare's prescription drug program was able to get off the ground in become the success it is today. and like the medicare drug benefit, and millions of americans now have the economic security of health insurance they didn't have just a few years ago. regardless of politics are feelings about this log that something that's good for the economy and for the country. let me turn now to senator hatch for his comments and also again i want to express our thanks to secretary sebelius for her appearance. we do have a vote at 1030

and it is the intention of senator hatch in an eye to keep this going. senators will, in and out in order of appearance but i want colleagues to know with the interesting subject and with the importance we will keep this going. senator hatch, also we express our thanks to the secretary. >> mr. chairman dinkey for scheduling today's hearing and keeping this going. as of courtesy to the secretary and the members. also secretary thank you for taking the time to be here today. this discussion is long overdue. mr. chairman the president's budget was released march march 4th, 37 days ago. typically these hearings are scheduled within days after the release of the budget. indeed it is generally considered to be routine to

have budget hearings immediately yet here we are more than a month later finally sitting down to discuss the hhs provisions of the president's budget. that type of flag time is disappointing to say the least. that said the delay in holding this hearing is not the only day i am concerned about today. madam secretary to be of appear before this committee i have asked you to be proper responding to our communications especially those dealing with the implementation of the affordable care act. yet numerous increase submitted to hhs by members of congress have been ignored entirely. and had we had yet to receive the answers to questions submitted for the record after last appearance before this committee on november 6 of last year. this committee takes its oversight responsibilities very seriously. i hope that to the future you -- you'll be more cooperative and responsive to these efforts.

mr. chairman given how hhs has responded to our past attempts to exercise oversight we might have to schedule another hearing with the secretary in the near future the only way that we could give the users to the questions they submit after this hearing. secretary sebelius process matters aside i have some specific policy concerns that i hope he will be able to address today. for example, according to the president's proposed budget combined spending for medicare and medicaid is expected to exceed $11 trillion over the next decade. that simply an astronomy -- astronomical number. and road talking about two separate federal programs. the tadema's spending has become a generational challenge that demands all of our attention. however the administration appears all too willing to continue to ignore these problems. the proposed budget was a big one dash meter 14 long

dash $414 billion over the next decade over medicare and medicaid spending and would do so primarily through provider cuts and government price controls. it would respect more than five minutes looking at our budget has concluded that these programs are in serious trouble and that they are along with social security the main drivers of our debts ian deficits. the nonpartisan congressional budget office for example, has referred to the health care entitlements as our fundamental fiscal challenge''. i hope that during today's hearing we can get some answers about entitlement reform because it is quite frankly one of the elephants in the room when we talk about our nation's fiscal future. and other elephant is the implementation of obamacare. last week the president to the rose garden to spike the football and declare his health care law a success'' after was announced that the

7.1 million people had enrolled. so far the administration has spent at least $736 million on advertising for obamacare. some say more than that. the website has cost more than $370 million. the call centers have cost at least another 300 million. using the most conservative estimates the total cost of the web site and the advertising to date amount to just over a 1.$3 billion. that's a lot of taxpayer money especially when you look at all the outstanding questions like how many of these people will actually pay premiums? comedy of them had health insurance before the law went into effect? so far it appears the administration is hoping the public will minorities questions and all the focus on the number of claim did release. in fact, madam secretary in your testimony before a the house energy and commerce committee in response to these questions he stated

that members of congress would have to go ask the insurance companies because you and your department were keeping track of the figures. now is may understanding that the 7.1 billion enrollees are touted by the administration is merely a counter those of selective insurance plan through the exchange is not of this election approaches to unpaid. that seems like an odd number to celebrate. indeed it's like amazon.com taking stock of how many people have placed the items in their shopping carts and then counting them as sales. in other words, it's a false metric. is certainly not one that can justify the president's attempt to declare that the debate over his health care law is officially over. there are many questions eddie answered with regard to obamacare. for example, so far the visitation has made more than 20 unilateral changes to the law. what is the cumulative cost

of those changes? while we're on the subjects how many more delays and changes are yet to come? as you can see there are a number of important matters to discuss today. both with regard to the president's budget and the implementation of obamacare. i hope that we can have a serious discussion about these critical issues. madam secretary i know you have one of the most difficult jobs in washington. i appreciate you being here. thank you once again mr. chairman for holding this hearing. thank you. i know you have bad back-and-forth and not treated as well as maybe you should be but we are grateful to have you here. >> thank you senator hatch.

secretary the topic of health care reform is not for the faint hearted and we appreciate you working with us and i want to know if your focus of the delivery system of the american health care system you have been working on this since the days you were a governor in we are appreciative because it will be more important tomorrow if we replace the flawed system and in particular to zero and on chronic care. we appreciate your efforts and we will take your prepared remarks of their entirety. >> thank you. chairman and ranking member and members of the committee i appreciate the opportunity to join you here today. want to start by thanking members of the committee for your commitment to improve

medicare advantage and today over half of all enrollees receive benefits from four or five star rated the advantage plan from the collaborative work together. the mission is to get the fellow americans to secure the opportunity to live happier and healthier lives to live up to their fullest potential although the hard work is unheralded the efforts benefit millions of americans. nation's seniors benefit from hard work of employees of cns and children benefit from the initiatives like head start and mental-health and substance-abuse treatment and from the efforts of employees across all operations of staff division's. another area that benefits all americans is the implementation of the affordable care act. even prior to open

enrollment in the marketplace millions of americans in families obtained new consumer protection. during the past six months millions have obtained the security and peace of mind of affordable health coverage. many people told me they could get coverage for the first time in years and some have insurance for the first time in their entire life. last week we announced 7.1 million americans have signed up through the marketplace. as of this week 400,000 additional americans have signed up and we expect that number to grow. between october and the end of february an additional 38 million enrolled with medicaid coverage of a total of 11.7 million that were determined eligible for medicaid. now paid know if more states move forward on medicaid expansion more uninsured

americans can get coverage for affordable health coverage, accessible health care and mental health and substance treatment and early childhood and security all issues connect to the president's goal to expand the opportunity, strengthen our security and grow our economy. the budget before you would move these priorities for word. these investments create jobs to strengthen the primary care work force by expanding the house national health service corps. by increasing the number of licensed behavioral health professionals and tear professionals and mental health and addiction specialist. to protect our seniors to invest with elder justice and prevention efforts to protect the health of patients in nursing homes and primary care practices and other health care settings. the proposed expenditures advanced new approaches to the most vulnerable children

, those in foster care. proposing investing of $758 million cms partnership to use screening assessment and treatment of trauma and mental-health disorders with the goal of reducing the over prescription a psychotropic medication i want to thank senator grassley and other members of this committee to express interest in this area and i look forward to working with the committee to address this need. the budget strengthens and expands certain initiatives with strategic objects -- adjustments of the home visitation and early headstart partnerships. the total child care request will enable an additional 1.4 million children to receive assistance. if you move forward with the

president growth and security initiatives we can provide an additional one to thousand children access to high-quality early childhood education through early headstart partnerships. we know these investments were can pay dividends throat education and development and proven to return an estimated $7 for every $1 reinvest. i would say there are a lot of traders on wall street that would be envious of that kind of return. in addition to a profound and a lasting impact on children these investments would also save lives because much of the partnership with states is paid for by increasing the tobacco tax which is one of the most effective ways to prevent smoking especially among young smokers. to debris have 3200 american children trying their first

cigarette and 2100 of those become daily smokers. this no surprise they have broad bipartisan support from governors, ceos from military amazon enforcement. in the global competitors are financing similar opportunities for their children. finally the budget not only in fess but saves we contributed net $369 billion to deficit reduction of the next decade. when you take these factors into account we have a security budget and economic growth and the opportunity budget to put this on a pathway to a healthy and prosperous nation in. thank you for having me here today and of a forward for your questions. >> let's start with it medicare madam secretary because of this special

importance. as you know, for millions of americans medicare is at&t -- a guarantee that it will be there they don't have to worry. of course, the challenge is to protect that medicare guarantee while dealing with historically was a an escalation of cost of the demographics and older people and i am particularly interested by having you analyze the role of growth of medicare spending and particularly the slowdown. the cbo said medicare spending is at a historic low and projected to stay there. justice week we have additional news an actuary from cms said the same thing as part of the every beef up

the it medicare -- medicare advantage announcement. this is just the medicare guaranteed is protected, costs are held down and the needs of seniors are not being compromised. this strikes me as encouraging for seniors who want lower premiums and future generations to have been around when they needed. so i with iq to unpack why you think we see this slowdown and then it can be anticipated? start with that. >> mr. chairman you are accurately reporting what has happened in the nine years between 2001 through 2009. the spending on average for medicare enrollees growing at 6 percent per year. that was above the national gdp and was traditional. what has happened in the

subsequent four years is pretty dramatic. between 2010 and 2012 expenditures grew per capita at 1.6% and significantly below 6% average. in 2012 it grew at 0.7% and what the actuaries said in a recent statement regarding medicare advantage pricing and this will be confirmed with the trustees meet later this spring they now adjust the trend line was skin they think the growth line that the seniors enjoy additional benefits with preventative services with no out-of-pocket cost with more

choices medicare advantage than prescription drugs including the closing of the doughnut hole happening overtime averaging $929 for stager savings doing unprecedented work to do competitive bidding and improving quality and value. of an all it is very good news for seniors. >> another issue is medicare advantage. we've heard repeatedly the legislation would be several when of the country but since it was signed into law of medicare advantage premiums have fallen by almost 10% and enrollment has increased by 30% to the

all-time high of 58 million seniors nastily at 30%. this is important to or again because we have some of the best medicare is vintage in the country and we were pleased that we are rewarding than high-quality four-star plans as well. tell us what you think is ahead with medicare advantage and how the might build this. >> mr. chairman, it was definitely predicted during the debate in 2010 in the proposal to bring medicare advantage payment rates is allied with fee-for-service would destroy their program. would make seniors give up their plants and fired harm medicare advantage. just as a reminder that was put in place as a choice for

seniors and initially scheduled to be paid 95% fee-for-service costs because the promise was medicare is vintage would have better care at lower cost and the competition would be good and seniors could have a choice. . .

>> seniors are paying about 10% less. the access route the country is 991% and seniors have many choices for many medicare advantage plans and 90% of them have access to a 0% medicare advantage plan and quite frankly all seniors at that. 30% choose medicare advantage plans. 70% are subsidizing those costs through their premiums. so that has decreased and the seniors who choose medicare advantage plans are no longer paying $1280.1 than their

colleagues who were choosing other traditional medicare. >> thank you, senator hatch. we're just going to keep this going so everyone will get a chance to ask a question. >> we're not consulting congress, the most recent was the announcement on march 31, the enrollment deadline. but the enrollment deadline would be delayed for those who claim to have technical difficulties signing up. on march 12 we testified before the house ways and means committee and were asked by representative kevin brady, are you going to a delay the open women beyond the march 31.

thirty-two weeks later on march 26, we had announced that the march 31 deadline would be indefinitely delayed. so clearly there is a disconnect on this point. let me ask you two questions. first, will there be any more unilateral to this release any part of obamacare. yes, know, or i don't know are all acceptable answers here, but i need a clear response on this one. and if you do expect more changes in the ways of obamacare, what exactly might they be? >> senator from i need to start with my answer of clarifying what you have already stated. we did not extend the open enrollment period and what we said is that people who are in the system who were trying to get enrolled by the 31st could finish the process. i believe in customer only operations. what we had is 2 million visits over the weekend and 380,000

also call center. and on monday, the 31st, we had 4.8 million visitors to the website and 2 million calls. a number of people were given the opportunity to return to the site, given their e-mail and call number and they are doing now. it has said very clearly that open moment is closed gridley also just had some paper applications which are being processed and states stage of processing applications. the we did not extend the open and roman beyond the 31st. we are giving people a chance to test their purchase and we do not anticipate on this plan additional delays. most of the policy issues are out and what we have tried to do over the course of the courier's implementation is due a gradual transition into a new marketplace strategy as we issue the rules and regulations, making them work for people as much as can possibly be done and we will continue to do that.

but i think that the basic policies are now in place and we anticipate moving forward. >> i estimate a conservative estimate how much we have spent on efforts relating to enrollment totaling over $1.3 billion. these amounts are into in addition to the amounts and i see that in your fiscal year 2015 but you have requested an additional 774 million. by my calculation that adds up to over $2 billion that was spent in a little over two years and as of now hhs has her ordered 7.1 million people have enrolled in private coverage and these are enormous sums of money to be paying for such a small fraction of the population cometh actually considering that estimates show that well over half of these already had health

insurance before the law went into effect in that most of them will obtain advanced premium tax credits which further drives up the cost. given that you propose to spend more than this enrollment, let me ask two questions of you today and can you tell us today how many enrollees the president and for the affordable care act went into effect and how many were worse to give up their insurance under the law. >> 1.7 million enrollees the president mentioned have health insurance, before the affordable care act went into effect. many were forced to give up their insurance mandates under the law. are there any? >> there were a lot of plans that were adjusted to come into

compliance with the law and people that were transition and given options with no plans. and i do not have data to give you right now in terms of who exactly was previously uninsured. we are collecting that. the reason that the study just came out this week says that before even the final surge at the end of march that by mid-march they say that there are additional 9.3 million people with health insurance thanks to the affordable care act. i can tell you that those numbers are going to be much more significant by the time we tally newcomers.

>> several people have signed up since the 15th of march and we are getting that information from intruders or if we don't have individual names and numbers of who exactly was insured prior and who is not. so we will be feeding you information as soon as we get from the company. >> all right. thank you. >> thank you, senator hatch. senator stabenow will talk and i'm going to run and vote and senator rockefeller is on his way. we can go back and forth for the five-minute or left red. >> thank you very much, mr. chairman. and welcome, madame secretary. the ongoing debate on health care reminds me very much of the old saying that it's a lot easier to tear down the house than to build one. and i remember under medicare part d i voted no because of the structure. and i didn't shut him down the

government afterwards because i didn't get the approach on medicare than i wanted. so we are at a point now where we need to be talking about how we move forward and make better something that as than as you have indicated, 7.5 million people are now using to get their health insurance for the first time for themselves and their families. doesn't account for the 3 million young people under age 26 and the millions under medicaid. i have a question but then a common concern and differences in values between this and the ryan budget that the house will be voted on. i think it is stark when we look at this under medicare alone in addition to costs going down area and we have seen is with that in their pocket because they close this gap in medicare. one of the things that we needed to fix after he passed out and

we did fix it. the budget by chairman brian will tell folks to go back and figured out private insurance companies. a big difference. the affordable care act, we are looking at this upwards of 400,000 people who have never had insurance before. forty hours per week, minimum wage jobs are it's still in poverty. this was getting health insurance in the house but they will be voting on medicaid and cutting it by $732 billion over 10 years and a big difference in value and views and finally i would just say that the affordable care act, 7.5 million people being able to get health care for themselves and their

children, many for the first time. the ryan budget repeals that basically takes affect to zero with the health insurance companies in charge of the pre-existing conditions. so a big difference. so i hope that we will really debate how to move forward rather than move backwards to that system. so a couple of questions. one includes two different topics. i talked to you a little bit before about a victory or community mental health that we were able to achieve on a bipartisan basis in medicare with a fixed hell. we now have a demonstration project that will be taking place and rules that need to be written and others want to make sure that hhs and others will be charged with drafting the regulations will work with us and others that care deeply about moving forward as quickly

as possible so that the states and we can strengthen community mental health care and i'd like to have you comment on that. >> senator, i would like to thank you for your leadership in this area. you and i have worked on this for a while and i think this is a big step forward to find out how we can structure programs and actually develop best practices that can be used to take it to scale. so we look forward to working with you and senator roy blunt and others to fashion rules and regulations to get the other he out the door quickly and to actually get those as practices from states around the country to be able to figure out how to make sure that the mental health system, which is in definite need of assistance really is grown and fostered in various regions of the country's thank you. sirach another area we want to talk about costs as well as

saving lives and supporting families that is critically important, is the area of alzheimer's. i'm wondering if you might speak for a moment about the president's budget. we had the alzheimer's association in town and we are all touched by this issue. and as we have a chance to live longer becomes more and more of an issue. one in five medicare dollars is spent on someone with alzheimer's and doesn't count the caregiver responsibilities and challenges to the families so despite the shocking cost of health care system, only .25% is spent on research. so i wondered if you'd speak to this and how we might work together to really open on research and caregiving support for those with alzheimer's. >> well, senator. the alzheimer's action plan, which was put together with a

lot of stakeholder input, and has a number of features in it. research is at the heart of it. and we are trying to figure out what is going on and what stages helping to identify people who may be prone to diagnosed with alzheimer's and whether or not there any effective strategies for dealing with as much lest your thing. and so i think that is an increase in a variety of ways. not only in the brain mapping strategy but nih is proposing to spend an additional $63 million to continue to implement components to address

alzheimer's disease and has a scheduled spending plan up until 2025 and a total of $2.8 billion is in our budget for 2015 on alzheimer's disease, which is an increase and that is under the umbrella of the administration for community living. some of it is with nih and there are other strategies employed as well. so we share the concern that this is a growing issue and as seniors live longer we are going to have mr. kelly moore diagnosis is along the way. so certainly nih has identified that the is a key concern moving into the future. >> thank you very much. and i turn now to the editors thank you, madam chairman area

secretary, i appreciate you being here today. i see in a new health care is program is promoted in your budget like expansion of the national health service and the new targeted to work for graduate medical education and they are included under the purview of the health resources administration. however, according to recent jail analyses of federal health care program, they are already having over 90 programs in the federal government, including more than 50 in hhs dedicated to improving the health care workforce are you to the department assess whether the proposals for new programs would be duplicate of existing efforts before the budget and if not, why not? and are there programs that should be reduced or eliminated as a result of the expansion of the health services or the new funding for the graduate medical education? >> senator, we definitely did an

analysis and worked across the department. frankie the bulk of the work force training effort are in the health resources administration which is why we are proposing that additional effort also be designed and promoted and they are the umbrella agency over the community health centers or a lot of them end up practicing. so it was a logical combination and what we are doing, i would say we are not decreasing funds and certainly targeting those funds. the focus is more physicians to work in primary care. >> i appreciate that what they are aimed at doing. you've done anything duplicate

you eliminate that would help us out in this budget situation? >> again, i don't think that is necessarily duplicate the. it's shifting so that we have been doing this were a couple of years, for instance changing some of the residency slots to focus on primary care and collecting them from institutions were not doing that and refocusing on. so it's not that they have been illuminated. i think everyone would agree with the population and the health needs that we have. we will need more providers not fewer providers. and i would say that we are much more strategic about the way monies being spent. >> so we have 92 programs. the administration announced that it was going to begin open enrollment of exchanges for the 2015 plan on november 15 at 2014. conveniently that date falls

after the election day this year and over month later than the traditional beginning of the open enrollment season for health insurance when, including the exchange. can you explain why the admin is ration would like to begin the enrollment so late in 2014? and you can you assure the committee that this is based on other stakeholders and not simply made to provide political cover for hormonal members? >> yes, sir. i think that the date was very much in collaboration with the insurers looking at their calendar and frankly you cannot bid on the new plants until you know who is in that pool. given the fact that that pool is currently being tallied, this is a multi-month process where they will then be able to access who is in and what their pool looks like and to be able to compete

and offer bids for the following year. there is no traditional open enrollment. this will be the second year. we had a six-month open roman the first time. we always knew that the second time around in subsequent years, we have a shorter open enrollment and so choosing a portion of that window to ordered is exactly what we have done. >> thank you. a number of my colleagues and i express significant concerns with the administration treatment of certain plans and the rules for the insurance program and specifically we were concerned that the administration would exempt certain insurance lands from paying the reinsurance be, many were un-sponsored plans which would create the appearance of political favoritism. sure enough the admin is ration has done just that. can you please line why they believed it was necessary to exempt those plans and not

others? >> a policy decision was that for plans and those that administer their own insurance going forward and do not rely on an insurer and are not covered by the reinsurance see it, there are some union plans in and not in there are others that are a policy decision that ari possible under the law. we have a lot of input from the holders then make that call. >> thank you, my time has expired. >> who is up? >> is your chairman, i am going to yield my time to mr. grassley the president commitment to. >> did he tell you that specifically? >> something about ethanol.

[laughter] >> ethanol and for producers were the two top things. we have an important commitment and could i yield, i would be more than happy to do so. so i hope you will recognize me later. >> and my five minutes start over again? [laughter] >> okay. >> the two things i would like to discuss with you is one of sunshine and the other is an obscure part of obamacare and i welcome you and i'm glad to have you here because i wish we could see you more often. yesterday the department again process of releasing medicare payment data and this is something that the chairman has spoken about. something that we have been working on for years. no one should be afraid of this data coming out and no one

should be afraid of explaining the existing payment structure. the benefit of asking this as we consider the policy changes as needed i believe trent currency works and with us you have accountability and i hope people will now at that work to improve this is some instead of fighting it. context is critical. and i want to bring up about the position payment sunshine act and that kind of thing. it is also a form of payment transparent the and i remain concerned and many providers have raised concerned with me about a journal article being reportable. i want to know if the database will make clear to the readers

what specifically a provider accepts and so i would like to have you tell me the providers can have confidence that the data made publicly available through the sunshine act will have a with the contacts providing details about items excepted and not just dollar amounts. >> senator, i'm not sure that i can answer that. physically i will check on that. and as you know, we are doing the data lection and we are on track. we are doing this the first aggregate data and with more granularity. and i will double check on exactly what will be part of the display without. i agree that people should be able to get in contact. >> i wonder if you could have

someone talk to my staff so we get some idea of where you're headed. not saying you are responsible to us, but we want to make sure that this sunshine ask work i know you're leadership along with the senator and others on this was critical. and so we would be happy to come in and do a briefing on what is exactly being collected and what mks looks like and what that way it is. because the data out there is an interpreted inaccurately. and so now to this issue. i think i have tested the war or maybe written a letter or something. and i would like to turn to the statute and the application to qualify that affordable care act

area and i have three questions and i hope you can give me a short answer to. they are kind of hypothetical. a hospital or other third-party be allowed to pay insurance premiums without payment being considered a kick? >> all, let me ask two other hypotheticals area is a hypothetical, it seems to me that these are things that actually happen. what a hospital or other be allowed to pay co-pays and deductibles without the payment in considered were can a drug party provide this for a patient to use in purchasing prescriptions. >> senator, i don't want to try to give illegal answer because i am not a lawyer and i can tell

you that we have made some guidance available. not-for-profit plans that could help insurance coverage. that has gone on for years and would continue to go on. in terms of the hospital situation we have weighed in and said that they would not be able to do that. at the kick that determination is really it just is determination. the reason, i would tell you, the federal health care program applicability is not able to be applied to the qualified health plans. these are private insurance plans operating with customers paying their premiums. not connected to the trust fund like medicare advantage and not connected to a government program. so it was a determination that

we wanted to make it clear that this is a private market. having a back, we know that it is important that we look at the entire fraud statute. they are not immune from not in any way shape or form area and in fact we have asked her inspector general and others to look at the false claims act and other applicable statutes and we make sure that we hold them accountable. >> mr. chairman, can i have just 10 seconds for a summation and the question? remixers. >> undersecretary for my want to a that with the release of qualified health care plans of the etiquette edge, it's unclear what the federal policy is regarding this and whether we prevent false claims and so this is something that probably i hope i can continue to have a discussion with you on.

>> i think that we have clear sailing on a tour and what we need to do is give every senator here and senator thune is next thank you, mr. chairman and madam secretary, not too long ago aged just finalized a rule and i think the senator touched on this a little bit. but i wanted to just get you on the record on this. something certain self-administered plans from paying the reinsurance tax in 2015 and 2016. which means that there are going to be a number of union groups who will have to pay the tax and will appear on the service to sort of be a political favor. as you know, that tax designed to raise a billion dollars in 2015 and 5 billion in 2016. there is a question posed of an hhs official in which that person when asked for clarification or affect other plans, rates, and fees, she said

it is true that the these will be higher because some plans are exempt and so i'm wondering if you agree with that statement but those plans that didn't get an exemption will have a higher the because the white house is favoring groups. >> i would say that what we did is look at the statutory language and make a determination of the best interpretation and anyone who has this insurance component should be exempted. our legal counsel eldon was wifi the best interpretation of the attitude and this is not a union issue. it was a broad-based issue especially ordered to put out the rules in this includes who is applicable and would not be applicable under the rule of.

>> the question is a very straightforward one. >> there is a dollar amount in the vacuum. >> there were no fees, it was just a definition of who the pool is and who is obligated to pay the fees. >> you distribute that a number of people have shrunk because of the exemption, is it not true that those who are left and will have to pay more? ..

and to that and be the consolidated appropriations act provide an additional $6 million in funding to implement new program integrity efforts in that program. i'm wondering if -- how these funds are being used. can you provide information about verses intentions to use the additional appropriations on the. an example of that, i guess, hhs has already undertaken on its to extend those to manufacturers as well. >> well, senator, i would say that dr. wakefield to his head of her son and did the umbrella agency over the 340 is very much engaged in making sure that the program operates in on more

stringent fashion to a year to the rules. there are artists, as you say, already under way images and a couple of briefings for me, and she looks toward to working with congress to make sure that we are not allocating funds inappropriately and that the pro grams and entitled to receive the discounts are the ones, and fried, receiving discounts. that landscape is being reviewed right now. i can tell you specifically about manufacturers, but i would be glad to follow up and come back to you on that. the opportunity to make sure that we're following rules. a highly important program. >> really quickly, cms 96 greuel regarding inflation reimbursement and critical excess hospitals.

can you comment on that? there are a lot of positions that we deal with. a lot of critical access hospitals to don't think it's fair. there's this -- >> i would say, senator, this is one that while getting a lot of feedback, i do, of our rules the absolutely faith that people have and how important it is to have critical alexis appeared in a profitable manner and stay in the community. so i think the rule was put in place in terms of trying to define inappropriate but. well whether or not that may be too stringent or too rigid. we would appreciate your input and feedback.

as we look toward the future i don't think the intent from anybody is to damage the opportunity for critical access hospitals to remain in place. but in trying to define what is appropriate in terms of a patient's stay i think was the attempt. >> thank you. >> but i just want to let you know, and sympathetic to where you're talking about an interest in working with you and your administration. next in order of appearance would be senator isaacson. he his juggling. would you like to go next? >> i'm going to need a chain saw to get the arms of these chairs of. i apologize. >> thank you. >> secretary, thank you very. as former governor of kansas i'm a question for you, a loaded question of great concern around the country in various states.

the affordable character, an opportunity for states to expand medicaid eligibility. and in that there is a promise for the fence to make a harmless the states for a time. 1978, the current and ministers and we passed, there is a 40 percent federal mandate of increase money or underprivileged and disabled children. the problem is the fed's would run their fair share. they have not. the cost of education is in on higher. do you fear at the end of the hold harmless. states that have taken it will be burdened with an amount of money they cannot afford to pay? >> i certainly was the recipient of the ida promise. >> i can tell you that the decade.

the funds are there to extend medicaid. when the law was passed, don't know when go beyond that. i can tell you that the funding is there. it's part of the law. so unless pieces of the from the europeans along the way for congress decides to change the law that will be done. >> second question, i was one of the republicans in the first series. on two occasions with the president in an ad hoc fashion, if you will, to try and find some common -- coming ground. and this was last year, dealing with last year's recommendations in his recommendations for significant cuts in terms of medicare to out reduce the growth rate of the debt and deficit. one of those was change cpi which of the time of the budget last year was included but has not been this year. does that indicate a reduction

in the interest of the administration to find ways to reform entitlements? without cutting people's ability to get those entitlements we manage them on the basis that makes sense for the future. >> senator, i would say that the president is interested in the possibility of some global approach to deficit reduction. by some recent it inside. where you were that he feels a balanced approach is very important. i think air of a whole series of ideas as part of that cost approach where in some cases captain made in another case is revenues raised. but in that context would to not go forward, i don't think it's a light of interest.

>> well, the debt and deficit call people and both parties, very difficult discussion. one of those will have to be the forest and tournament. i personally think social security and medicare payments a little bit wrong. my income for medicare. people should expect in. the american people will been a. and your department has probably more to do with the way up because of a thing you're doing but because of the demand of health care, medicare, and medicaid. so i would mccourt to working together with you and the of ministration in the years ahead trying to find somewhere to find common ground. >> i would very much look

forward to that opportunity. i think circling back to the chairman's. and the beginning of this discussion, no one is about entitlement reform in the affordable care actor and medicare, and it's working. it is working in a way that was difficult to predict at that point but is happening. i think it is continuing on into the future, and i think the recent prediction of the actuary, and we could just keep medicare spending at the rate that we have seen the last couple of years we would have an enormous change in the overall cost. i think there are some futures in place, some ways to shift from of value payment to a different for as the chairman referred to, the delivery system reform is beginning to show promising results.

i think that we bled very much look forward to talking about a structural change that is on the delivery system payment side and keeps benefits in place for seniors. >> i agree with that comment. adjust to what -- we can read the part where you cut too far and is not reform. thank you very much. >> thank you, sir. >> madam secretary, we talked about crime and disease earlier. senator isaacson and senator to me on that side of the aisle have a great interest to have interests in calling of. center card and his next. >> thank you, mr. chairman, secretary sibelius. let me make one comment about the affordable care act. millions of people who have directly benefited from the affordable care act from the medicaid expansion the talked about which is been a great success to my state, to the insurance reforms and a protected families, to medicare filling in a lot of the coverage gaps that we had for preventive

care and prescription drugs to numb people of affordable options the the exchange to equal the insurance products. i just want to make one observation. it would be, i think, a lot easier for you and we in congress took a look at the wall as to how we can help you in dealing with many of the challenges they have had in implementing the law. instead, we are stuck in this repeal-non repeal mode particularly in the house and representatives which is not doing a service to the people of this country. we should be working together to be the budget support you need an to us take the law as to what we need to do to improve it to make a stronger and easier for the american people. as we talk about a bipartisan budget we'll also talk about working together to make our health care system work in this country. i think the framework of the affordable care act has proven to millions of americans, and i

can give you many, many letters i have received from people whose lives had been changed because and out of the insurance coverage. on the budget -- and we're here on the budget. start with a thank-you. that is to holocaust survivor assistance that is in this budget. for the first time it will provide direct help to holocaust survivors, americans are vulnerable to my real fear of institutional causation. thank you for including and in the budget. on the other side the realities of the budget at home, i think, with the national institutes of health. the budget there to me is entirely too low. i am extremely disappointed that several of the institute's get no increase in their budget and all, including the national institute of minority health and out disparities. you and i have talked about it in the past. i know your commitment to that institute and to the

department's agencies who are directly responsible. i just encourage you to do everything that you can within the budget restraints to continue to make that a top priority. let me ask a question as it relates to the therapy caps and the sdr. i am strongly in support of german wines and senator hatch's efforts that we can get a permanent fix to the replacement to the sgr and at their peak gaps in the other issues. to me that makes the most sense. i hope that we can continue to work on it. in the meantime we are still in that mode dealing with the temporary extension through march of next year. and in that there be caps which makes absolutely no sense whatsoever for a point of view of health policy, we now have the manual medical reviewers you , those that hit the cap at

3700 which could prevent access and timely payment. it's my understanding that you are considering some payment review rather than looking at it and holding of those two are in need of care wondering whether their services will be covered and not. can you just tell us, give us an update as to how the implementation of the therapy cap under the existing law, how you envision that during this time? >> senator, what i would like to do on that is come back to you with a much more descriptive answer what are folks are looking at for, as you say, what may be his interim time. another is been a lot of discussion. i don't want to give you incorrect information about the direction that is likely the go, but i do know it's of great concern in terms of patient care and how it is interpreted. i will circle right back and give you kind of an updated answer from my nicotine on how

they anticipate calling for. >> thank you. i yield back. >> senator robertses next. >> well, thank you, mr. chairman, madam secretary, have a couple of news articles year. maybe you could help us clarify exactly what's going on. rather than meet trying to explain this and just going to read it. americans thinking about buying health insurance on their own later this year may be switching to a different insurer are probably out of luck. policies are going out of the market as a loan of consequence. limited exceptions insurance companies have stopped selling until next year that sorts of individual plans the use to be available all year round. that locks out many of the young and healthy as well as the sick and injured, even those that can afford to buy without the government's subsidy. now they are stuck according to an independent insurance broker in los angeles is as she wonder customers last year of the

change coming. it closes everything down. the next wide-open chance to sign up arms in november when enrollment for 215 begins. companies are following and schedule, even for the plans they sell off some of the federal-state exchanges. there are other news articles that say the same thing, and i will take the committee's time to read them. could you clarify that? i think there has been some misunderstanding or, perhaps, you can shed some light on that. >> certainly, it. as a recovering insurance commissioner, would tell you that rules that you just describe there release said that the state level. you quoted an article from los angeles, and they have decided in california that they will not allow off market plans to be sold. they want to encourage people to buy during open enrollment. this is a state-by-state decision. kansases made a very different

decision. those determinations about the up market plans will be and how robust the market will be are made by individual insurance companies -- commissioners throughout the country. >> we have an expert at the kaiser family foundation that says it is highly unlikely, talking about nationwide, not to state-by-state. companies will offer such coverage after the deadline closes. some still offer temporary plans lesson from a month to year, but they don't cover pre-existing conditions committed buyers of the a. and they're is a window for life-threatening communal, a life-threatening situations. i know you are setting them. they're all different, but i think that this is a national concern. am i wrong on this? >> again, it is my understanding that it is very different state to state. a lot of states will have a

robust off market plan and will actually have a number of consumer protections and features that are in the market, but it is a state-by-state decision. that reference may be too the excepted plans, the kind of mini coverage. those will be less available. the companies are making that determination, not the law. >> well, i think the companies are making that decision due to the law. we will get past that. i want to go back to the 96 hour rule because it gets to the president's budget. the same question that i asked last year about proposals included in the budget a cause disruption to the critical access hospital liver. you are extremely familiar with that. you designated some of these novels. some accountants and the proposals are once again in the presence budget.

is that the mileage limits and reduced the reimbursement for critical of metals. we all know we and 803 in kansas. i would like to know who can get some regulatory relief. in that regard one of the more problematic decisions is based on : and then i wrote, if i can find it. at any rate, it was to a cms and indicated it -- here it is. in the reply was that there are statutory of begin to enforce the new requirements. i don't know where we come up with 96. hundred 20, 72, 48. and then if you have a patient coming to the hospital, they can keep them for those number of hours and it seems to me that it it was not statutory designated to be when i asked if they could waive that and certain

conditions may be of help they said, well, no. that's just once again something that we can do. can we get one years relief from that? you said that maybe mr. bloom could be of help on this. what happens is the patient comes in. they're monitoring that patient. the doctor doesn't give any medicare reimbursement. and so you have to go to another hospital which could be miles and miles away or just out of hospital. you know about hostelry admissions. help me on that. >> well, senator, one of my to do is get a copy of the letter that you're referring to. i will personally follow. i don't know exactly what the questions were, and i don't know exactly what statute they're referring to, but i will defend his circle back and get your response. i agree that we don't want to make it more difficult for patients to access care or for

doctors to be reimbursed. >> i appreciate that. i will provide a letter as soon as possible. >> thank you, senator robert some. >> thank you, mr. chairman, madam secretary, thank you for your testimony in service. i was not here when -- during your testimony regarding the number of folks that have taken advantage of the exchanges. i guess were up to seven and a half million. that's could news. no one to ask you about two questions. on the one hand i can't say enough about the commitment the of ministers and is made to our children on a host of fronts. very substantial commitment on programs and prioritization. i commend you for that, and i commend the president. where have a fundamental disagreement with the administration and where i think we will be probably continue to

be on -- unalterably opposed, we fortunately past and the president signed into law reauthorization. i was happy about that. the board cart on that, but none of going for a debt the position of the administration is to eliminate that funding for the program. i don't agree with that, and i want to ask you about it. we've got right now about 1% of all hospitals trained. about half, 49 percent of all pediatricians. a program of works. pediatric care or the shortage of and if we didn't have a trained specialist. it's bipartisan. it's not expensive, and i don't

understand the opposition to it. i would ask you about the position he administration is taking, wine and is, and whether or not there was in some way that we can reconcile a differences. >> well, senator, and knowing your commitment to this area. as you say, i think the administration also as a command to not only children but to training providers in needed aryans. the budget proposes that there is a hundred million dollars in new targeted support for the hospital programs. additionally with the bigger ball, and a competitive opportunity where are would suggest that i think it's possible the edge of and hospitals receive even a larger

amount than was then the directed program of the past because there's a floor kind of set automatically and then an opportunity. we estimate that the new power in support will be about 13,000 new residencies between 2015 and 2024. i would tell you that the discretionary program in the past, about 26 percent of those slots or non pediatric residents so even though it was an a director program, is nine least a fourth of the slots were filled. so we would love to work with you on ways than we make sure at the financing is going, really directed and training more pediatricians, charles specialists. i think looking at this there's an opportunity to really then target the funding. >> i hope he can.

we have got in our's to. i think we can say this without contradiction. there are very in tune with the program they are concerned that it will give three authorized. so this begin do for the record by where response. many carry vantage, was grateful for the ministrations recent determination. when an premiums are down 10% and an ominous of. but there's still some concern about the near-term and long-term. and abcafive and writing what steps it planned to take.

>> secretary, you can do that briefly and then get to a senator casey in writing. if we spread the canyon everybody in the four secretaries of believes has the leverage is michael. >> that's a good bill. >> is that our right? great. >> thank you, mr. chairman. great to see you. let me first of all say that the numbers you report today of seven half million my hope this will start to change the nature of the debate and of and not here, but i want to commend senator hatch and senator byrd. it and agree with the friend in went out, but they have laid out alternatives. as a group was that of let out a series of targeted changes that i think will improve delivery. ton to touch on one of them's. one of the areas and a year where of, the treasury report

recently finalized reporting rules a lot and force the employer and individual mandates in this challenge by treasury as the reporting in the two just provide the subsidies. trying to make sure there the correct amount. continue from a number of employers and the concern of some of their workers who are offered employer plans might erroneously still apply through the exchange to try to get individual tax credits. with this is setting a potentially it the end of the year a contentious dispute between the business of the irs and the being the referee. nothing this could be prevented if there was more up front accountability on the front in between treasury and hhs. when a personal. you will, there's. we're basically allowing

employers who would be willing to provide information up front some ability to be full word meaning when'd in having this monthly reporting requirement. for small enterprises colombians enormous burden to give them not completely a safe haven but by having this kind of collaboration between hhs and treasury. we might be able to remove one of the administrative burdens. quite honestly we would be in a system that doesn't and his senate bill 2176, one of six or seven different pieces of specific legislation that we would like to advance as we hopefully will move the debate to how do we keep what's good and fix what's wrong. ..