the secretary of hhs the authority to expand successful demonstrations to a wider range of health care providers so that we can cut costs without compromising care or improve care at the same cost. and i just want to ask about your strategic plan for using your statutory authority to expand these efforts where the data demonstrate that we can get better outcomes at lower costs. >> with regard to my philosophy, and i think it's important to have things be databased. having had the opportunity to do grant making in my other roles where one sees and creates models. what i think you want to do is you want to find the models. there are, i think, conditions with regard to which are the most successful. and then which are the most likely to scale. because that's what we need across the nation. and you have to consider both questions when considering what you would scale. because what you want to do is get the largest impact you can. that impact is a combination of both what the measures are of

success, but it's also your ability to make it go broadly across the nation. and that's how i think about that. >> thank you. the affordable care act gave us tools to help reduce the cost of health care and improve outcomes. and i'm glad to hear that you plan to use them. thank you, mr. chairman. >> thank you, senator. senator isaacson. >> ms. burwell, good morning. >> good morning zpl as you know from our conversations the last couple of days, there's no challenge that i have before me as a united states senator more important, including your confirmation, that gave the savannah harbor project in my state. senator chambliss worked for 16 years to go through all the steps at noaa, epa, omb, corps of engineers, fish & wildlife to get every approval we could get including getting the vice president to join us on the docks in savannah and make his famous quote that we were going to get it done come hell or high water. i'm not one that kills the messenger. but on a sunday night right before the budget came out you

delivered the news to senator chambliss and i that we weren't going to be able to move forward based on a plan we thought through conversations with others, not with you, that we included the right language in the appropriation bill to move the savannah harbor expansion program forward. at the last minute we got the bad news that wasn't going to be the case. in the last two days you and i have had discussions about how important this is to my state. and to my country. it's an issue for the entire trade of the united states of america and the economy of the united states of america. it is a net positive export port. it has met every requirement needed whatsoever. and i don't want you leaving omb until i know that we're going to be able to move forward on the va van na harbor project. i'd for you to respond to that question. >> senator, with regard to where we are in terms of legislation and currently as we have discussed, i think first of all the port is an important effort. it is an effort that i agree with you is not just about georgia, it's about economic

issues and growth for the nation and core infrastructure. it's something that i think we think is a very important project. and president and vice president have spoken to that issue. and want to make sure that we move forward as quickly as possible with moving forward on the port. optimistic that the bill will pass. that that's something that will happen and be a part. and that we can move forward with that project as quickly as possible. and, as i said, we look forward to working with you to make sure under -- once that happens that we can move this project forward because we agree it is a good and strong project. at the same time, my role anld responsibility as the director of the office and management budget, which is why the issue is there, has been to do with protecting the fis k. i think many people on this committee know the army corps has a backlog of $60 billion. and we need the reauthorization. what we need is the congress to speak. when the congress has spoken and we're looking forward to that on this project that we believe is

an important one, we'll look forward to moving forward. >> in a letter sent to you by myself, senator chambliss and every member of the georgia delegation about questioning how the project got stopped all of a sudden, i want to quote your answer. particularly during fiscally challenging times it is essential we do not create special exceptions that could undermine well-established controls of responsible allocation of taxpayer resources. what exception were you referring to in terms of the port of savannah? >> with regard to the question of the exception, it would be waiving the 902. there's a rule that was put in place that said if an army corps project exceeds cost by 20%, the congress needs to speak again. that was a matter that the congress put in place -- that is a rule that is about making sure that we have fiscal responsibility with the army corps. this is a terrific project. and a great project with a very high return on investment. >> as you know -- >> there are many other army corps projects, i'm afraid, that

don't meet that test. having the congress be partners with us in doing fiscal control is something that is important. >> as you know, we think we're within two weeks of the bill passing. the 902 provision is in there. what special exception would lie in our way to go ahead forward if the 902 passes in the bill? is there any impediment you see? >> senator, i look forward to continuing that conversation. i think there are ways this project can go forward. >> i look forward to those meetings prior to the confirmation so we can do everything we can to solidify that. thank you. >> thank you, senator. mcmccullski. >> thank you, mr. chairman and ms. burwell, welcome to this confirmation hearing that focuses on you being secretary of hhs. we welcome your husband, your friends. i'm sure you wouldn't want your mother and father here with you. they worked so hard for you to get the education that you have that helps bring you here today.

ms. burwell, i know you personally. and i admire you professionally. i knew of you when you worked during the clinton administration in these foundations, the two major foundations you worked for. and then got to know you during the year at omb as we went through a very tumultuous time. you were new at omb. and i was new at the chair of this committee. i must say, i really admired, one, your integrity in working with me. you were a straight shooter. what you said, you meant, and what you did. we also appreciated your responsiveness of both senator shelby and i that when we asked questions, we got answers. we didn't always like the answers, but we got the answers. third, we liked the fact that you were competent and that you also had the ear of the president of the united states. so, again, when we needed those answers. so we know that.

but let me tell you where i am as the senator for maryland. we need a ceo. and secretary sebelius has done a great job as -- during a very difficult transition time at hhs. but what we see in maryland is some of your greatest federal assets at hhs are in my state. from cmss that does medicare and medicaid. the national institutes of health. fda. hrsa. i also have some of the highest rates of nobel prize winners and some of the highest rates of poverty. whether they're in baltimore city or mountain counties adjacent to west virginia. so i need a chief executive officer. we need someone who will bring executive skills to this job. 80,000 people work for hhs. you have the largest budget -- other than defense, the largest

domestic budget. we see three issues. money, management and morale. money, that's our job. and sometimes we do it well. sometimes we don't. but we need someone in management who can tackle these tough problems, whether cleaning up the techno boondoggle of the health.gov to also going across the silos of agencies. and then we have a morale problem. because of the way they've been -- my federal employees have been battered by the budget and the uncertainty of funding and the trivializing of them and their work, you and i know that we have a morale problem. whether it's in fda or nih. and people are looking elsewhere rather than bringing their great abilities. so my question to you, looking at your background, particularly in the area of the foundation work with both gates and walmart, could you tell me the executive ability and experience

that you think you bring to this job that can help put this arms around this huge bureaucracy, often siloed, often fragmented, and at the same time help work with congress on a more certain funding that enables these agencies to do the mission? could you? >> first, i think i'll speak to how i think about management and leadership. first, i believe in any organization you need to start with setting goals. defining roles and responsibilities. part of that is an analytical process that includes both listening as well as analytics and data. first, that's the first step. another step is building strong teams and empowering them. and giving them the tools to succeed. that's the second part. the third part, i believe, is a part of thinking through when you need to drive with analytics and when you need to understand there's emotion. because in leading large organizations there's sometimes how people perceive, and it's whether it's in an organization or an issue. the perception is their reality.

so analytics. you need to understand. if people believe that, how do you drive for change? with regard to my own personal experience, i've had the chance to work at the gates foundation where i worked across a number of issues from doing innovative funding to vaccine to actually delivery of health care in the developing world, which is a challenging place to do that kind of delivery. to work on issues of, actually, as the coo, employer based health care, i know what it's like when you have changes in your employee base and what that does to what you pay. at the walmart foundation i was able to work at that time the world's largest grocer and retailer. in terms of both it's an institution that provides health care for its employees, but the work we did in the space of hunger. so those are some of the examples. i'm watching the time, though. >> i appreciate that. my time is up. just know that many people will focus on health care. and i certainly -- it's my passion. but the human service part of your portfolio is absolutely crucial. and today is not the day, but we

really need to work together on this issue of the unaccompanied children coming across our border. so that they have a home and that they have a way to get to a home. and we have a way to get to the funding that ensures that. >> senator, look forward to working with you on that very important issue for those children. >> thank you. >> thank you, senator mi cull ski. senator robertson. >> thank you, mr.çó chairman. ms. burwell, thank you for coming. last august senate majority leader harry reid was asked whether his goal was to move the affordable health care act to a single parent system. his answer was yes, yes, absolutely yes. similar statements were made by former speaker nancy pelosi. your predecessor and the president of the united states. do you agree with that statement, there is a difference between administrating a law and pushing an agenda? is it your end game to see the

affordable health care act expanded beyond the exchanges to a single payer system? >> senator, if i'm confirmed i will implement the law. and the law is a system that is a market-based system. that's what the exchanges are up and running and putting people in systems that are private insurance system. i look forward to, if confirmed, making that system work as efficiently and effectively as possible both in terms of cost and access. >> i appreciate that. one of my biggest concerns with the affordable health care act is the independent payment advisory board, ipab. it was created by the law. the board is supposed to be made up of 15 elected add voi sors who will decide which treatments in medicare coverage should be reformed. i would say terminated. they have no accountability, and their decisions are practically impossible to overturn. now, despite having yet to appoint any ipab members, the president's budget this year proposed to expand ipab's role.

considering the law requires that ipab produce reports in 2014, do you know when the president will make his appointments to this unelected board? and in the absence of a board, the hhs secretary, namely you, will have the authority to act as an ipab board of one. if confirmed, will you activate the medicare reform or, again, what i would call rationing, using your authority under ipab. >> senator, first i think it's important with regard to ipab that one of the most important parts of the provision there is that beneficiaries cannot be impacted. so any changes would not be towards beneficiaries. the other thing i would say about ipab is i actually am hopeful and if confirmed and even in my job at omb that ipab never needs to be used. it can only be triggered, and in the current window that we're -- we're looking at, and in the window if confirmed that i would serve, it is our estimate that actually it would never be activated. what i think is important and at

the root of this is annish shoo u that i think both sides think are important. that's controlling health care cost for the federal government. it's about our fiscal issues for the future. and what i'm hopeful that we can do is make sure that ipab never gets triggered. because we put in place the mechanisms to do that control. right now -- >> okay. that's my hope, too. and i appreciate that. i'm not quite as optimistic as you are. but we can go over that at a later time. according to the galen institute, obamacare has been delayed at least 35 times. 22 of those times were done unilaterally by the administration. since being the director of omb, you have approved 15 of these 22 delays. this included the second delay of the employer mandate. my question is about fairness. and i get that from individual kansans. the administration gave business an extra year and many cases two extra years to comply with the employer mandate. do you think it's fair to give business a delay but not

individual americans? and what further changes, if any, to existing law and regulations do you anticipate having to make before december 31 of this year? >> senator, i think the changes that you referred to are a number of different things that have been taken by different departments, treasury or hhs, and a number of the examples that i think you're referring to, with regard to what is happening as this process goes forward, from the administration's perspective, what we are trying to do is common sense implementation within the law. that's the objective and what is worked on. with regard to the specific issue you raised which is the issue of the employer mandate, and that specific question, as we think through transitioning, one of the things that we've tried to do is listen and hear. and one of the things that private sector has said is, it was difficult to get the reporting to the right place where it could then be applied and done. the changes that were made were to try and do that transition. with regard to individuals, there are a number of other things that are happening to

help with those transitions. and whether that's the hardshippish shoo us or other issues. so this is about transition to a changed system. >> i'd like to see those transitions come back to the congress so we would at least have some consequential involvement. my -- i'm out of my allotted time, mr. chairman. but i will be submitting some further questions in writing that i hope you will respond to in a timely manner. particularly with regard to abortion coverage transparency for insurance plans offered in the federal exchanges. again, thank you for coming. >> thank you. >> thank you, senator roberts. this would be senator bennett. >> thank you, mr. chairman. it's nice to see ms. burwell. thanks for being here today. like others here, i'm very happy that you've got the experience that you do at omb. and i wanted to ask you a couple questions along those lines. when i a number of years ago first became superintendent of the denver public skooms i carried the budget of the school

district around with me for six weeks unable to understand it. i had worked with budgets before in the private and public sector. this was impenetrable. finally six weeks in, i realized that i wasn't reading a budget in the sense you or i would understand it as a management tool. it was an accounting tool. it was a tool to demonstrate compliance with the state regulator and with the federal regulator. but it was not about driving outcomes for kids, which is what we were supposed to be doing. my sense having been here is that we face very much the same thing when it comes to health care. the morass of regulations and the reimbursement policies of cms, the uncertainty that's caused by the fighting up here over budgets that leave people with insecurity about what the future is going to look like, i think creates an environment where people are less capable of getting into a pattern of continuous improvement. i mean people that are out there actually delivering services to

people rather than just yelling at each other in washington, d.c. and they're weary about this. and i think they feel -- they remind me of my teachers and my principals in the district who felt the same way. i wonder if you could tell us a little bit about your theory of the case for attacking that management side of -- of the work that you now will have to do at hhs and cms and how your work at omb is going to inform that. let me just -- sorry. one last point. in this kpi sten shl debate we're having here about the role of the federal government and the founding fathers and all of that, i think what we have lost is what the american people would really like, which is an efficient and effective federal government. and an efficient and effective partner to state and local governments and to others. anyway, just a perspective. i will yield you the rest of my time. >> and i'll speak to that in the context of the "m" part of the

omb. in terms of the role that i've been in in the past year. with regard to the issues of management, when you look at our budget, you will see that we articulate what is a second-term management agenda. the three elements of that -- the four elements of that agenda are efficiency. making sure we use the taxpayer dollars the best. just last week there was an announcement, we have four departments that will be doing shared services, which is a private sector way to get to some of that efficiency. effectiveness which gets to your point about customer service. when we say effectiveness, it's about serving the customer. the customer for the federal government -- number of customers. individuals, states and local governments, and the private sector at times when they interact with people like the fda. how do we make sure we're doing that? the third area is how do we use the management of the federal government to support economic job creation. and on may 9th it will be the first anniversary of the use of open data. and putting that data out there to create economic development. the last is people. and having had a chance to work

on all of those issues and then working with the departments to have their goals connect to their money. to your point about is it a document that is about, you know, checking boxes or is it a document that reflects how we spend dollars to deliver impact. so those are the ways that my current experience has -- >> on that last point, i -- i'm not sure how you want to approach it. but one thought is that without people that are dedicated every day to coming in and thinking about how do we get rid of the check boxing -- or the box checking and replace it with stuff that really matters, in your tenure, you're not going to be able to get it done. i hope you'll do that. i also wanted to mention -- i saw senator bur burr here. i think she's now gone. we've had luck with grapefruit therapies. i talked about it the other day. i would like the opportunity to be able to work with you to see where we could expand the sort of notional sense of that, which

was where possible and where feasible, we should be accelerating approval so that the united states holds on to its leadership in bioscience at a time when there are plenty of other countries in the world that would like to outcompete us. >> welcome that opportunity. one of the things when i think you can have innovations of things that work like that, you look at those innovations then think about how do those apply more broadly to the broader portfolio. the breakthroughs are special cases. but i'm sure there are things we can learn that apply to the broader portfolio. >> i think -- yeah. things that can inform the broader culture of the agency as well. thank you, mr. chairman. >> thank you, senator bennet. senator enzi. >> thank you, mr. chairman. and thank you, ms. burwell, for meeting with me yesterday. i always enjoy the visits with you. i have a few questions. i think i mentioned this topic yesterday. during your tenure at omb, we

saw a massive failure of a website which was healthcare.gov. and that's a website the administration had three years and $600 billion to build. i know from personal experience, first users couldn't logon. then we couldn't see plans available. then we got kicked off. and then user names weren't recognized. and from folks i've talked to, even users who made it to tend of the process often didn't get confirmation they'd enrolled in a plan as obamacare mandates. as director of omb, you were responsible for the oversight of agency performance and information technology. what role did you play in the development, testing and approval of the website? >> senator, first, i think it's important to recognize what the president and the secretary and the administration have said, which was the rollout was unacceptable. with regard to the role that omb plays, the direct implementation on a day-to-day basis of i.t.

projects is done on a department by department basis. omb has a process that is called tech stat which is what happened when we have cases, healthcare.gov being an extreme one, of an approach we take to get in and quickly try and correct the situation by applying high quality resources and a surge of resources to the problem, which is what was done. in addition, at omb, as part of follow-up and part of the end role that i play, we spent time examining very specifically what we think are areas of improvement in i.t. procurement and delivery. and i'd be happy -- i don't want to use all your time, but be happy to articulate what those are. >> continuing on this anyway, the administration contends that many of the highly visible problems with the website have been fixed. but i don't think the work has been completed on the less visible back end information, which, of course, all of us would like to have. and that's necessary for the

programs. i think there have been some warnings from cms that failure to get this fixed by march would mean that, quote, the entire health care reform program would be jeopardized, end quote. is that the reason for justifying the need to award the no bid contract to exsenture? why haven't the problems been fixed? >> if i'm confirmed, the issues of information technology, especially around healthcare.gov would be a priority for me. with the issue on subcontracts that's something a department specifically does and omb doesn't play a role in. i'm not able to speak to the specifics of contracting. if confirmed, though, this is something that, of course, would be a top priority, to make sure that the system both the specifics you're talking about and the back end that you're referring to, are something that i pay attention to. >> okay. i'll have some follow-up questions on that later, then, when you are in that position, i guess. in february "the new york times"

reported that 1 in 5 people who complied with the individual mandate didn't pay their premiums in january. at that time, cms spokesman said the administration couldn't say how many people had paid their premiums. on april 30th the house energy and commerce committee reported that only 67% of the enroll ees had paid their first premium by april 15th. when the administration disputes this figure -- while it's disputed, you haven't released your own official numbers yet, i don't think. when will the government determine who has paid the premiums and, therefore, is actually covered as required by the individual mandate? >> senator, i probably should start with my philosophy about data and information. and it has two fundamental parts to it. transparency and accuracy. and that's how i think about it and how i think about it and speak with congress. at a time in omb, the regulatory agenda, which is sometimes a controversial document, is something i've worked hard to get up in the spring and fall on time and will be again this year. with regard to the specifics of

the data that hhs has at this time, that's not something in my current role that i know. i know that there were hearings yesterday that spoke to this matter where the insurance companies articulated a range. because they are the people providing the information. and so if i am confirmed, that is something that i will want to understand on what pace that happens. >> but you haven't released official numbers yet? >> no, sir. the administration has not. because i don't think that the insurance companies have given final numbers. >> okay. insurance companies. i'll have some follow-up questions on that in writing. thank you, mr. chairman. >> thank you, senator enzi. senator murphy. >> thank you very much, mr. chairman. there was a really remarkable hearing in the house on this subject yesterday in which house republicans called insurers to testify. in part as to what they believe to be incredibly low rates of premium payment. and the headline from the "new york times" this morning is called by republicans health insurers deliver unexpected

testimony. that testimony was in part that well point suggest 90% of their customers paid premiums. aet na suggested the numbers in the low to mid-80% range. they also according to this article declined to endorse republican predictions of a sharp increase in insurance premiums. next year this comes on the heels of a health affairs report that suggests that though there certainly have been cancellations of policies since the law was passed, it's not really out of step with the rate of cancellations that happened before the law was implemented. new gallup survey shows an absolutely astounding drop in the number of people who are uninsured. a 25% drop, according to gallup, over the course of the third quarter into the second quarter of this year. i say all this because i think this increasing avalanche of good news and positive data about the implementation of the affordable care act is going to ultimately lead to a much

broader public acceptance and support for the law. yet we still have sort of a tale of two countries. we have states like connecticut that have worked hard to implement the law. we've doubled our initial expectations in terms of the number of people we thought would enroll. then you have states that are, at best, not implementing the law and in some cases trying to undermine the law. i guess my question is, how do you attack this issue of states that are not doing the things that, for instance, connecticut and california are doing? and maybe response in part to some things you said referring to a question by senator alexander, what are the ways in which we can work in a flexible manner with these states as they maybe wake up to the reality of how well the implementation is going after the initial botched rollout? what are the ways in which we can work with some of those states that haven't done things like connecticut to try to make this work in all 50 states rather than just in the handful

that have set up their own exchanges? >> i think there are two things. it does come back to the point about the flexibility, is one of the points. i think what's important is to send a signal that folks are willing to have the conversations. as i said, it's important if there are fundamental principles to articulate those in terms of the change you're trying to get. but be willing to have the conversations and hear the ideas. i think that's what happened in the arkansas case. if i'm confirmed, that is something that i would hope we as a department can continue to do. with regard to the other thing, that's about the relationship to get that to happen, i think the other thing with regard to how other states will come is, i think that as people see what happens in the form of implementation, and while i understand the point that senator alexander made about costs in medicaid, which is an important one, i think what people are also going to see are the changes in terms of health benefits in t states that have implemented both from a health perspective. and i actually think we're going to start seeing some of the cost benefits in terms of reduction of indigent care. many of us are from rural

places. you know the pressure that that puts on small, rural institutions and hospitals. and so i think both the results as well as a willingness for conversation are the two ways that one can make progress on that front. >> let me ask you a big question about delivery system reform that maybe you can give a short answer to. which is, i think you'll hear a lot from us on our hope that you are able to speed up the pace of delivery system reform changes at hhs. but one of the tensions is between the necessity to build bigger systems that can really track outcomes and coordinate care and the desire to make sure that we have a competitive marketplace. connecticut is a state, for instance, that may ten years from now only have two health care systems. how do you balance ultimately this need to build good integrated systems of coordinated care which may require more doctors working for hospitals, for instance, while making sure that we don't effectively set up monopolies in certain areas of the country

where you may have one big health system that is unavoidable from the perspective of an insurer that's trying to build a robust network? i'm a believer in big, coordinated systems of care. but i think that's a lingering concern that exists as you build out a new system. >> one of the things in terms of philosophy about that is i think that you appropriately said, it's the issue of balance. i think thinking about what are the elements that need coordination in terms of is it information sharing? what is it that creates that level of coordination, at the same time promoting competition? things like the co-ops and other things. how do you get to -- what is the key element that is causing the delivery system efficiency? is it the fact that it is a single provider, or is it the fact that it is an approach -- a standardized approach in information? i think one of the ways you work to get that balance right is by trying to understand as clearly as possible what is driving the change you're getting both in terms of quality and price.

>> thank you. thank you, mr. chairman. >> thank you, mr. murphy. senator murkowski. >> welcome to the committee. as i was walking over here, i accounted a number of individuals that are here on the hill today for als advocacy day. a cause that you and i both share and are committed to and assuming that you're confirmed to this position, look forward to working with you aggressively to make a difference in this horrible disease. we had an opportunity to visit last week. and i appreciate the time that you gave me. in the visit i explained to you the situation in alaska where we are a very high cost state. our insurance costs are equally high. second highest in the nation. our demographics, our geography just cause us to be a little bit different. you mentioned the need for flexibility within rural areas. there's nothing more rural than alaska. we're so challenged with this. i shared with you that we have

over 139,000 uninsured individuals. less than 10% of those individuals have enrolled in health care plans. and in looking at the numbers behind it, it really comes down, again, to the cost. the aca has more than doubled premiums in the state. i shared with you that a 19-year-old alaskan could pay $911 back in 2013 for one of the low cost premier plans. if they buy the most comparable plan now for that same product, the plan is more than double the cost at over $2,300. then i walked through the statistics with 64-year-olds. mr. chairman, i'm going to be submitting for the record a document that my staff has put together with premiere and blue cross that shows the gao recorded data on premiums in alaska in 2013 as compared to where we are now. just so, again, there can be a better understanding as to what we're facing here.

we're not -- we have not worked to reduce the cost of health care, which we must do. and i appreciate what senator murphy has said about -- about delivery reform. but in the meantime, the financial burden to our families is such that they're looking at this and saying, i'm better off just paying the fines that will come with this. so i'm asking you to take a look specifically at what we are facing in alaska. i also want to bring up with you a conversation that i had with firefighters from my state. from different parts of the state. up in the matsu borough. talked to firefighters up there. up in fairbanks, down in the southeastern part of the state, and concerns about application of the aca within the emergency services sector. a concern about employer mandate. a concern about the 30-hour workweek. what i heard from the mayor in

mt. sue was that they have moved their emergency personnel to a 29.9 hour per week cap for nonfull-time employees. many of the stations are reducing the hours beyond the required 29.9 to 24 hours per week to include personnel who work both as emts and as firefighters. this is an issue for us where our -- our growth in these areas are growing. we rely on our emergency services folks because they cover enormous areas. what we're seeing is a real chilling effect here on employment, particularly as it applies to our first responders. so i guess i would ask more of a -- a question in the vein that do you agree we've got a problem with this? there's a few senators, i'm joined with senators collins and donnelly to help address this. do you see an opportunity for us

to address this deaf nation of 30-hour workweek? and the implications that it's having on not only ems but other areas of the economy here? >> senator, i'd like to learn morearticulated. >> i'm happy to provide that. >> the issue of broadly overall in terms of the job creation that's occurred since the affordable care act, 9.1 million private sector jobs with and the san francisco fed just released a report that said that the part-time issues are consistent with a recovery. having said that would like to learn more about the specific issue you've raised. with regard to the specific legislation that changes the numbers, one of the things, there are a couple concerns when cbo scored that legislation in terms of cost. but also that a million people in that setting would also lose their employer-based care. so would want to understand the based care. i would want to understand the specifics of the situation you're talking about as well as coming to understand better the piece of legislation. >> i'm happy to provide that to you as well as the other

information. i'll also be submitted for the record, mr. chairman, a couple of different questions, one on head start. but also one that is very timely and in the news right now and that is the issue of the fda proposed rules on e-cigarettes. i've got a real concern here that we are setting forward a proposed rule that does not look to the flavoring that is going into these e-cigarettes, the impact on our children. some of the studies that we are seen. so i would like your views and your perspectives on that as well. thank you, mr. chairman. >> thank you, very much, senator murkowski. especially on the e-cigarette issue. you're right on target on that one. thank you. senator baldwin. >> thank you, mr. chairman. thank you, ms. burwell for your time here today and talking about your vision for the

department. i appreciate the opportunity we've had to speak in advance of this hearing. i wanted to talk about a couple of different topic. but including the fact that the health care system has been plagued forever with a lack of transparency. and gathering data, dissimulating and sharing data is incredibly key to helping physicians understand where they lie with regard to other physicians' practices, helping understand where hospitals, how they go about pricing things, what their costs are, and helping patients make wise decisions about choosing providers, particularly if they need an operation or a specific treatment. this is an issue where we've

seen some variation from state to state. i'm proud to tell you that in the state of wu wii i think we've within a real leader with an organization called the wisconsin health information organization. it intends to be an all payers claim database that does some further analysis and dissimilar nats the information to increased transparency, help improve quality, help reign in costs. yet we've had frustrations with regard to access to medicare claims data. i've worked with a number of my colleagues on a bipartisan piece of legislation called the quality data quality health care act which would fix this by expanding what's known as the qualified entity program to allow entity to analyze and redistribute medicare data to those who could best use it for

quality improvement and cost reduction purposes. and i was pleased to see that the president's budget supported many of the reforms that are contained within that bill. i wonder if you can speak directly to the issue of expanding the current, what's known as the qualified entity program and its potential to improve quality, to reign in costs. but also to talk more expansively about the role you would play in increasing transsparncy across our health care system. >> with regard to the specifics of the expansion of the program, i would look forward, if confirmed, to working on that issue specifically. as you mentioned in the budget, there are some parts of doing that. the broader issue of the transparency is something we talked about in a number of forms in terms of data and information and also specifically for how it helps with the delivery system issues. so i think getting the information, as i said, that may

be a link that is as important as the issue that we were discussing about how you balance single entities that start developing in terms of the dominance in a market. so i think information in markets is an important thing. and so the better we can get it and the more we can get it to both the individuals, as well as the providers. as you mentioned in the beginning of your comments, it is actually about the doctors also as well seeing the information. so with regard to how i think about the issues, i believe this is an important part of both quality and cost. and it's both important for individuals as well as insurers, as well as doctors. and the more we can have and the information that was provided recently i think was important information that was recently put out by hhs. i think it's also important as we think through the information to make sure that it has context. when we put out the information, making sure that individuals and others can use it in a way that

it is given the appropriate context. because the data without that can sometimes be something that doesn't provide the insights that one would hope it would. >> thank you. i'm short on time. i'm going to place another question before you. we may have to have you answer in writing. but i wanted to get to something very wisconsin specific regarding affordable care act implementation. we had the good news last week that nearly 140,000 wisconsinites signed up in the marketplace. i it was 60,000 beyond the target that was set prior to ten rollment period. and this was despite fierce etiological attacks against the affordable care act both in washington and in your state government. but unfortunately, across america and in my home state of wisconsin some governors have not taken full advantage of the opportunity to expand coverage, specifically medicaid coverage. governor walker is among those

governors and he failed to seize that opportunity and the consequences in my state are fairly severe, 77,000 wisconsinites are losing their medicaid because of that decision. other states are working with the government. iowa and arkansas in particular to find new innovative ways to expand coverage to these vulnerable populations. i want to know if -- you can follow up now or afterwards -- what lopgss will be available to wisconsin that are not currently being pursued? will the department continue to help make sure that these 77,000 people who are losing their badger care are successfully enrolled in the marketplace? and certainly will the state of wisconsin have an opportunity to reconsider their decision at this point, not to expand

medicaid. >> senator, if i'm confirmed, would want to work with cms on those specific issues of the flexibility to help those 77,000. >> thank you very much, senator bad win. senator burke. >> thank you, mr. chairman. director burwell, welcomwelcome. and thank you for the opportunity to meet with you i think last week, to share some thoughts and to hear yours. let me ask you a couple of questions in specific areas. do you consider medical and public health preparedness and response programs to be a matter of national security? and if you're confirmed, how will you ensure that these programs will be prioritized and that the act be fully implemented. >> senator, i do consider it a matter of national security and in my old role at gates have

been exposed to a number of these issues. thank you for your leadership in this base because i think it is very important. i am excited that there was a reauthorization that occurred and that the congress spoke to these matters and now would want to work to implement what was reauthorized in 2013, if i am confirmed on these issues. i think they're very important in terms of how we think about what are the tools that we have and then how we get access to those tools when we need them. and i think you've spent a lot of time, as our conversation reflected, thinking about the best ways to mike sure that we have what we need if something bad happens and then mow how you effectively in the most cost efficient way scale up in a quick time frame to do that. that's something for me i would look forward to, if confirmed, working on. >> thank you for that. what opportunities do you see to improve regulatory certainty and predictability across the department particularly at the fda? >> i think with regard, the

issue of regulation more broadly, just in terms of my philosophy and experience and time at omb, since the year that ied v been at omb, we've reduced the regulatory bag log by almost 75% and have moved to a more timely approach to our regulatory agendas in terms of what i've done. and with regard to the fda and thinking about these issues, i think one of the things as an institution, would want to go and spend time and in conversations like ours learn what people believe are the critical path issues to a more e neck tif system that produces quality and speed. and protects health of the american people but also supports our economy. because it is an important part of economic growth. >> thank you for that. as senator murkowski mentioned earlier, we've got a lot of patients with als here today. we don't know yet what causes it. to unlock the key to a cure, you

first have to figure out what the cause is. and i go through this thought process of what if we got to that point and then all of the sudden the therapy, the counter measure, the cure breaks down at the fda. so i appreciate your willingness to dig into it because i think that certainty drives capital investment in the space and helps these patients. will you give your personal commitment to me that if confirmed ckc and atsr will execute the planned cancer study on the camp lejeune population without delay? >> first i want to thank the senators that have mentioned the als issue. with regard to that specific issue, my understanding is that that work is going forward in terms of the cancer study and if i am confirmed that is something that i would want to work to make sure that we do in the most expedited fashion. >> mr. chairman, on a personal note, i know that the committee

will not vote on director burwell's confirmation but we will in the finance committee. i would like to take the opportunity to say i support her nomination, i will vote for her in the finance committee and it's because she doesn't come with a single experience that would make her a good secretary. he comes with a portfolio of experience that would make her a tremendous asset at addressing some of the challenges that that agency specifically and uniquely has. and i look forward to her confirmation being quick and our ability to then work together to be ever bit as quick. i thank the chair. >> thank you were senator. >> thank you very much, senator burr. senator casey. >> dr. burwell, thanks very much more your appearance here today, your testimony as well as your commitment to do the job that i think you will do at hhs.

but i guess in a larger sense, we thank you for your sub substantial and enduring commitment to public service over a number of years now in all of the positions that you've had. i wanted to raise in the limited time that we have, at least two major questions with regard to children. it's my opinion that our country still lack as real strategy for children. we've made some substantial progress on children's health insurance, i'll talk about that in a moment. still no sub substantial national commitment to early learning, to the extent that i hope we would. the protection of children could use an awful lot of work, as well as strategies to make sure that children can have enough to eat and get nutritious food. on those four indicators i think we're lacking. we lack a basic strategy for our children just like we have a strategy for national defense or

other major priorities. i wanted to start with the children's health insurance program, a substantial bipartisan achievement. as you know from your work during the clinton administration, that was a bipartisan effort here. one of the models, not the only model but one of the biggest and most successful early models before the clinton administration enacted was in pennsylvania, my home state. and because of models like that we now can say i'm told some 8 million children with covered, more need to be covered in their efforts as you know to do that. these aren't exact but around 200,000 children in pennsylvania covered by the children's health up shurns program. having said all of that, the bad news is that the funding will expire for c.h.i.p., expires at

the end of september, number one. number two, there have been efforts made, and i have to say some f this has been in both parties, to intentionally or unintentionally undermine c.h.i.p. in the last couple of years. we're going to fight real hard to preserve it and fund it at all costs. i wanted to ask you about the impact on children's health if we failed to extend the funding for the children's health insurance program and what you would do to make sure that doesn't happen? >> as you reflected, this is a program i had a chance to work on and be a part of the initial passage in the clinton years, something that is very important and what's great is to come back and see the progress. this is a program that's delivering, it is a program that is successful. and in the administration, whether in my omb role or if confirmed in the hhs role, i

would look forward to working with the congress to make sure that we continue what a successful program that is delivering for children in an important way. >> well, i appreciate that. because it's a major priority of mine but i think it's shared by a lot of people across the country. secondly, you and i when we had a chance to discuss your nomination, talked about the so-call chime sh, children's hospital graduate medical education. another area where there's substantial bipartisan support. this committee, members of this committee working with a number of the members of the committee, chairman harkin most prominently, making sure that that program was reauthorized in a remarkably bipartisan effort. it's now been reauthorized for five years. we actually have a copy of the bill signed into law. that doesn't happen too often

around here. that's the good news. the bad news is i think there's still some folks in the administration that have a different view about how to move forward with it. maybe would agree with the reauthorization of it but even would question that. but i think i'm most concerned about the funding of this program which is the one program in tremendously successful that allows us to train graduate medical folks in graduate medical education who will specifically work in children's hospitals that without this program we'd be in big trouble. i would ask you that as you contemplate other strategies on this and other ways to fund it, that you consult closely with me and others on the committee as we move forward. i would just ask if your commitment on that. >> senator, i would welcome that opportunity. >> thanks very much. >> thank you, senator casey. senator hagen.

>> thank you, mr. chairman. and once again, director burwell, thank you for being here today. thank you for your service in the other administrations as well as omb and we look forward to working with you as the secretary of hhs. i wanted to ask about medicaid expansion. last year in north carolina our state legislature and governor decided against expanding the state's medicaid program and as a result, about 500,000 people who would have qualified for coverage through medicaid are not now able to do so. these are some of the most vulnerable visits in our societi who will continue to seek care in emergency rooms and then will leave chronic conditions unmanaged, which we know is detrimental to their health and the economy. and it leads to higher costs for the patients, it drives up costs for hospitals and it drives up costs for the insured who still will pay higher prices to cover

their care. director burwell, can you compare the experience of states that have expanded their medicaid programs to those who haven't, committing specifically on the health of newly eligible enroll lees and whether there's any increased cost to states or health providers like hospitals? >> senator, i think what we're going to do is we'll continue to see data and information as the law is implemented, but i think in states like my own state of west virginia, we've already seen a decrease in the number of uninsured and what that is starting to happen both in terms -- i think it will be two things other time, the increased quality of care for people which translates to their individual lives and the economy in terms of what people are able to do with their productivity. over time we'll see that. i think we're also seeing, over time we'll see the cost issues in terms of the indigent care pressure that's being put awe

cross states when they have people who are coming with insurance. so i think we're going to see more and more of the data over time. in a number of states we see the number of uninsured dropping. >> can you compare -- what happens in an adult, let's say a 35-year-old woman from one of the major cities in my state without children, and this individual falls under the federal poverty line, about 11,000 a year, this individual has heard about the marketplace, she goes to the library, talk to navigators, asks to sign up and yet this person has done the right thing, she sought out coverage to protect her against high medical bills, help her get health insurance, but what options will that woman have if a state like mine doesn't expand medicaid? >> so it will depend in terms of her level. i think you've described a level

that i would want to get the details in each place in each state. it depends on her level of income and whether or not she'd be eligible for federal subsidies. >> this woman will not. she falls under the gap. >> she would receive a hardship. the hardship exemptions. she would have that opportunity. >> so if a state that had expanded it, she would have had access, where in the 24 states that haven't expanded it, there are these huge number os people, in my state 500,000, that are still without coverage, have un -- there's no way for them to turn because they certainly cannot fund a normal insurance policy on 11,000 a year. >> and with regard to what the federal government policy is trying to do is to make sure

that they have a hardship exemption. that's the part. it doesn't address the fundamental issue that you're talking about which is do they have health care coverage. >> right. and just to be sure, if a state expanded its medicaid program last year, what would the cost to a state be for covering that newly eligible population? what would the state have to pay in 2014? >> senator i think on a state by state basis, those are numbers that i would want to look into and get back to you on. ah. with regard to the question of conch, in terms of the state paying because the federal government -- i'm sorry i didn't understand the question. that would be zero. the state doesn't pay. >> so for three years the states pay zero. >> the federal government will pay for those years, right. >> thank you. >> uh-huh. >> now i want to ask a question on the healthcare.gov, on the

rollout. you know, when it failed to launch, i let a group of 15 senators calling on the inspector general to conduct an independent investigation into the causes of the technical design and the imp men station failures. i was really pleased when they agreed to conduct the investigations and i look forward to the reports when they come out later in the summer or the fall. when you are confirmed, what lessons will you take from last year's site failure as you administer the next open enrollment period. how can you improve the management of the healthcare.gov? >> with regard to the lessons of what happened in healthcare.gov, a couple of things that we've examined and looked at, there are a number of things thinking about i.t. procurement. one is you do not connect the business owner and the i.t. that connection does not occur.

it's a problem i've experienced in the private sector. seem say to the i.t. team, here, fix it. versus an integrated approach of the business owner and the i.t. director working together. the problems i'm articulating on ones we need to think about as the federal government specifically. generally in procurement we've traditional done a waterfall approach, a building approach. one tests in small pieces and moves and learns is a better approach to doing procurement, not set up to do that in terms of how we set standards and do expectations. the third thing that is an important part is ownership and accountability in terms of a single individual being the personal that does that integrating of the individual on the i.t. side and the business side. those are all three things that even right now at gsa three weeks ago implemented some of the things that we think will improve availability of providers to get access and work

in that way. >> thank you. thank you, mr. chairman. >> thank you were senator hagen. senator white house. >> thank you, chairman. welcome, ms. burwell. in your summary of your very impressive career you describe yourself as having had the opportunity to lead large and complex organizations and work across a range of issues in each odds my role i worked on forming strong teams, forging relationships and delivering results. has it been your experience that having solid clear performance metrics is an advantage. >> it is a an advantage to know where you're headed. >> that's part of the accountability that you just described to senator hagen, correct? >> yes. knowing where you're headed and how you're going to measure whether you get there or not is important. >> under the affordable care act we've made significant progress

in cleaning up that. that's been good. the access issue i think has been moved in a very good direction with 8 million people signed. that leaves a third very, very big issue, which is the cost of the system. a very well regarded report came out recently that predicted that spending on health care which already consumes nearly 18% of the nation's gross domestic product will continue to grow 1.2 percentage points faster than the economy over the next two years. an expert said this, if we cannot get health care spending under control, there's no hope for the federal budget. the main hope if we don't get health spending under control is global warming gets us all first before health care spending gets us all. so we can work on climate change separately, but there's a win-win opportunity to address the cost of health care by improving the quality of care.

it's been identify by the president's council of economy adviser, the institutes of medicines and an array of private thing tanks and we proceed in that area i believe without adequate performance metrics. i would like to ask you your commitment, if you're confirmed, once you're confirmed, to work with me and work with a considerable number of other senators who share this concern to set some definable metrics for our progress at lowering the cost of health care by improving the quality and delivery of health care. would you be willing to do that? >> senator, if i am confirmed, i look forward to working with you and a number of your other colleagues, actually on both sides have brought up this issue. i look forward to working with you on it. >> to get it done. >> senator, i think the core objective is to improve the way we deliver health care, to

improve quality and reduce costs and that's what the objective would be. >> and you agree that clear performance metrics would advance that objective? >> i agree that metrics are an important part of that. i think one of this things that one wants to do is understand what are the right metrics. in my experience in terms of when you're trying to scale and do change, you need to think about what is the metric that you need to measure against. >> exactly. >> and so determining that you can do that is the other thing that i think is important. one, is it measurable, it is the right measure and then can you scale against what you're trying to do. those are the types of questions that i have historically considered when i think about the issue of metrics. >> good. well i look forward to working with you on these metrics. i this just to give you a preview of coming attractions, i think there should be a cost savings metrics, an actual dollar and a date that can be attributed to this process. and i think it might be helpful in getting to that goal and

articulating it for regular consumers better to have a seethe of subordinate metrics like we're going to knock down hospital acquire infections 80% by this date, we're going to have this many doctors moved off of fee for service and moved on to more outcome baseds payment services by this date. i think we can successfully build a good suite of performance metrics that will address this. i appreciate the attention of the committee to this. it's been something we've looked at repeatedly. we're looking at it very closely from a budget committee perspective. i confer with the senior fellow, if we cannot get health spending under control there's no hope for the federal budget. and there's a good way to get it under control without hacking away aut fees and eligibility and you know, what people are entitled to under their policy, the coverage.

thank you. >> i just have to adds, 75% of spending under medicare are for preventable diseases most of which are preventable. now or own budget person, senator murray. >> thank you were mr. chairman. i am really pleased that the president chose such a qualified competent and experienced nominee, someone obviously i know very well. i've had the opportunity now to work very closely with director burwell for many years during her time as part of president clinton's economic budget team, her distinguished service at the gates foundation and her current position now at the director of the office of management and budget. this is an impressive record and i really applaud you. you've excelled at every step. back in the clinton administration she played a central role in crafting policies that led to broad

economic growth and budget surplus that we all remembered by the end of the '90s. in her foundation work she took on an sbirly different challenge and managed a successful organization with a global reach and for the past year director boar wel worked very successfully here in congress to bring much needed bipartisan back to the budget process. at the same time she was over seeing programs from the medicare to the affordable care act. i really believe she has the necessary qualify sayings and i'm delighted to have just a few minutes here. i don't want to take much time. but i did want to say, take this opportunity and give us the chance to hear from you how your professional experience has really prepared you to meet the challenge of mapping a very large agency with a lot of different critical functions. >> i think that my time at the number of different agencies that i've been at have really

helped with a couple of things. one is clarity of focus on impact. i think that comes back to the conversation we were just having with senator white house and how one needs to get in quickly and make sure that you define very clearly what your goals are and then build the institution, build the team, empower the teams and part of that empowering of the teams is making sure that they know what their roles are and what their responsibilities and accountabilities are. the other thing that i think is a particularly important part that i've learned in working in the foundation space and all of the jobs that aye had, when i think about the problem solving, you think about what is the problem you're working on, what is the solution space and when then the third circle is for whatever entity you are, whether it's at walmart or the bill and melinda gates foundation or in the federal government, what is your institution best at? so you're applying the skills and what your part of the organization, the piece that you're working on or where you are best at. i've had the chance to work in a

lot of private public partnerships both inside and outside the government. and seen a number of different things. but i think really framing core goals, setting out building good teams and then empowering them to do the work are the most important things i've learned. >> i'm looking forward to seeing you do that at this sergeancy. i did want to mention you know i'm a strong champion forearly childhood education. there are several key early learning programs that will be within your purview at hhs if you're confirmed. i wanted to ask you how you're going to continue your agency's work to expand and strengthen those key federal investments. >> i think those are very important investments. and i think we have a start and the process that started with murray ryan and led to rogers ma cull ski, we have proposals in

the budget right now that are important parts of continuing on that that try and build on existing distribution mechanisms so you're not creating new systems. they build through head start and use other things but make sure that the programs in place have quality measures. i'm hopeful we can work with, if i'm confirmed, in my omb slot or hhs can work with the congress of moving those issue of early childhood education forward, as you know, because vi a six and a half and four and a half-year-old -- >> you live it. >> i live it every day and i live that my children are so advantaged in everything they get and how can we make that a reality for all of the children in the country so they have the tools to succeed. >> my time is up. we have a vote coming. it was reported that the uninsured level is at its lowest point since january of 2008 when gallup first started tracking

that. in states like my home state of washington that you know so well where we built our own exchange and expanded medicaid, the rate of uninsured is decreasing even faster where we've enrolled nearly a million people for coverage. so i am delighted by that and i hope that you use my state and your state to really help replicate some of those good experiences across the country and i look forward to working with you. >> thank you, senator. >> thank you, senator murray. and senator sanders. >> thank you very much, mr. chairman. welcome, ms. burwell. unlike senator roberts, i believe in a medicare for all sing payer system. i think there is something wrong when in our great country we are the only nation who does not guarantee health care for all of its people and yet we spend up spending more than other countries without particularly good health care outcomes.

in that regard in the aca legislation i put language in supported strongly by senator harkin that would give flexibility to states to move in different directions, including a single pair. as you know the state of vermont intends to do that. right now we can't do that until 2017. we have applied for a waiver. the president supports that waiver. will you help the state of vermont work with hhs to make sure that we can facilitate that process and give vermont the opportunity to lead the nation in that direction? >> senator, if i am confirmed i look forward to working on that issue with you and the state. >> okay. another issue that is dear to my heart and i know to senator harkin's heart, we've worked together on it and to many people, the crisis in primary health care and the need to go forward with community health centers. one of the reasons i voted for

the affordable care act is that the majority leader and others worked very hard to substantially expand community health centers. in fact in the last four or five years i think we've added 4 million more people to gain access through community health centers, in my state about one quarter of the people will get their primary health care through community health centers. we are in a difficult problem right now because we're facing a cliff, as you know. and that is as a result of the aca funding we were able to expand community health centers. if that cliff goes into effect it will be an absolute disaster. you and i have chatted on this on a number of occasions. you working with the president have provided a strong budget for community health centers and for the national health service core. will you fight to make sure that we continue to strongly fund community health centers throughout america? >> senator, as you and i have

had the opportunity to discuss being from a rural place in the u.s., i actually understand the role of community health centers in communities like the one i grew up in. i believe it's an important part of our system in terms of prevention, a topic we've talked about in terms of treatment, as well as and i believe it is an important part of efficient and effective health care in terms of costs. >> but here's my question. stay with me. we are looking -- and in fairness, the president and you have helped make his budget strong. but will you help us fight to make sure that we continue to have that funding and not see that cliff which would be a disaster for community health centers across the country? do i have your support on that? >> nart you do. the budget we put together is the first step in that process to the that. >> good. okay. in a related issue, we're not

going to have strong community health centers unless we have the phen-ffe physicians and the and the other staff we need. we tripled funding. that's a whole lot of money but i's still not enough. i think as you understanding, and correct me if i'm wrong, we face a crisis in terms of the number of physicians and other health care providers that we have to getting out to underserved areas in america. will you work with some of us, with myself, senator harkin and others, to make sure that we adequately fund the national health service core to do debt forgiveness or scholarships for medical school students who want to practice in underserved areas >> this is an issue that throughout the budget you see support for. and whether that's in the issue that you just raised in terms of the national health core, it's also in how we think about not just positions but there are also provisions that are about

nurses and other people that are part of the primary care system. >> that's exactly correct. >> i think that's another important piece that we need to work on. >> what i worry about -- thank you. i agree with you. we're looking at the expiration of a very important program called the teaching health center graduate medical education program. and that is a program which allows people to get their graduate -- doctors to get their training in community health centers et cetera. are you familiar with that program? >> the graduate medical education program, yes. >> yeah. it is looking to -- it may expire. will you work with me to see that it does not expire. >> the graduate medical education program there are a number of provisions that are attempting to improve and focus on primary care. that's something that's a prt of the budget and a series of bringing pieces together that include how we think about the national health service core as

well. yes, that is something that is part of the budget process and would look forward to working, if confirmed, in a new role. >> thank you very much. >> senator scott, have you voted already? >> no, sir. >> we're down to about maybe three or four minutes left now. i'll recognize you but we're close to be out. we have four or five votes, right? >> four votes, yes, sir. >> senator scott go ahead but we're going to have to be very short. >> i won't take more than five minutes. i promise. the senator time allows for 15 minutes to vote but i also takes 30 minutes to count 15 minute in washington. it's part of the fuzzy math that happens here in washington which really is one of the questions i'll be asking you about. one of the questions will be the fuzzy math about obamacare and the other one about programs made and promises not kept and

whether you'll be the ambassador of health care. certainly you come before us with a great reputation. i voted for you for omb, my good friends have great respect for your intellect and integrity. i'll take that into serious consideration. my questions will focus on obamacare and the dismal rollout and the challenges i've had with the numbers. hopefully you can get us some clarity as we rush to make sure we make the last vote here. in numbers, fuzzdy washington matt, $1.4 trillion price tag, the fact that after spending nearly $1.5 trillion we'll still have 31 million americans uninsured by 2024. the fact that the as b ca as siphoned $716 billion from medicare and somehow that's supposed to improve the outcome of our seniors.

perhaps one of the more frustratings number that i've seen in obamacare is 8 million people have signed up for obamacare. one of my questions will be at the end, how pray tell do we account for 8 million people signing up for a program but they don't pay the premium, yet we count that number as a part of a true number that reflects the number of americans that are actually eligible for health insurance if they don't pay their premium. it seems to me that if mum before 8 million people signed up for obamacare, which when you multiply that by 80% that have paid, it brings the number down significantly. you recognize that about 20% of the people who are paid the premium represent those under the page of 3w5 and that brings into question the whole notion of the sound premise that we need about 2.8 million young folks buying into a program that that hopefully will not have to use. having spent a couple of years

in the insurance industry myself, i find that those who sign up but don't pay premiums don't have coverage. so that doesn't seem to be taken into consideration as we talk about the success of obamacare. i'd love to hear your perspective on that. as i think about that, i'll simply ask the first question. if confirmed as our healthary human services secretary, will you be willing to be clear and honest with the american people, the congress and this committee about the implementation of obamacare regardless of what the administration's policy is? you mentioned during our time that you have a lot of experience, served on metlife gord and others. it would be helpful for the american people to have a clear picture of what is in fact happening with obamacare since we now are relegated to getting our accurate information from the "the new york times" and the "walking post" and not from hhs. >> senator you have my commitment that in i am confirmed the two pieces of prince ls that will guide me are

transparency and accuracy. those are the two things. i will work to do that in due course in terms of speed as well. >> thank you, ma'am. on the issue of promises made, promises not kept. i think about the fact that many americans were promised this notion if you like your insurance you can keep it. that promise has been broken. if you like your doctor, you can keep your doctor. that promise has been broken. if you're looking for affordable health care, the aca is the way to go. that promise seems to be challenged when you think of the actual cost and the price of health insurance, the cost being higher deductibles, higher out of pocket expenses, and a more limited number of doctors to choose from, fewer hospitals in the system and even fewer specialists. so the actual cost of health care i think we'll see it rise as we see the price tag not affordable to more than 50% of

the folks who are eligible for obamacare are not signing up simply because they say they cannot afford it. then having a functioning website, we know how that's worked out. the most challenging part i see from a backdoor perspective from the website is the insureds themselves are complaining that the backdoor operations are simply not set up yet. while we celebrate the success of the health care exchange and healthcare.gov, obviously if you can't get the inner workings pinned down, it's hard to pay claims and do those things that are necessary for the insurers. i'd ask you simply as secretary of hhs, will you in fact be the health and human services secretary for the american people or will you be, as your pred says sore has been, the ambassador of obamacare. >> senator in my current role

and if i am confirmed in this other role it is my objective and as i talked about in my opening statement, i'm here to serve the american people. i am part of the president's administration. i'm honored to be appointed. first an foremost i serve the american people. i believe that the president and his policies are aligned with that and will work. but i am here to serve the american people. >> thank you. >> thank you, senator scott. i would just say that i must say that it is my opinion, based upon the years of work with kathleen sebelius, that she performed her job ad merably and carried out the law as we wrote it. i request that the -- i have a statement of support from president of the international

union and vi a letter from the american public health association, i'd like to include in the record. i request that the record be kept open for ten days for senator statements and that the record stay open until close of business on monday for questions for the record. ms. burwell, again, thank you very much for you outstanding public service through all of your adult life. thank you for your willingness to take on this very important task. we look forward to your very speedy vote and approval and look forward to working with you as the new secretary of health and human services. >> mr. chairman, thank you. , theank you.

former u.s. ambassador to nigeria. thank you for your time. guest: thank you. host: let me turn to nicole. we read in the papers this

morning -- president obama has said the u.s. will send help, a small group from the united states. is the united states doing enough? right now, for what our best opportunity is, i think we are doing the right thing. they are not calling for troops on the ground because that is problematic. givekes sense for us to technical assistance right now. that is what the nigerian people are calling for. strongill, the diplomacy, to make sure the nigerian government fulfills its obligation to its own people. it has been weeks. host: why can't they find these girls? guest: the opportunities were in the minutes, hours, and few days when the girls first went missing. -- biggest problem is

according to the family -- the military on the ground in chibok , there are military outposts in the area. they refused to help. the families were left to figure out what to do for themselves then when they went to the major cities, they were told to keep quiet and not make a big fuss. i think it was their fear that really brought this to the world apostate attention. there has been a lot of discussion about the grassroots campaign. y for people is important when you talk about a movement. some people say the movement began in the united states. really, the origins are from nigeria. started usings the term "bring back our girls."

they knew the power of social media. they knew they were out of options. a lot of the strong, powerful movements come from a place of despair, come from when people do not have any other options. wereknew the governments not paying attention. host: what has been the impact theoko haram on nigeria and surrounding areas? guest: it has had a major psychological impact. thatlk about the 59 boys were killed two months ago, these kidnappings, this is not the first incident of human trafficking in nigeria. think about need to is the fact that leading up to the world economic forum, there were bombings all over the country, specifically targeting the capital. people -- ago, 300 there are reports that 300

people were killed by boko haram . it has an impact on the people who are directly affected. it has a psychological impact on the country. people live in fear. i have been told by many people on the ground that they fear andibution from boko haram the government, being angry at them for speaking out. blame falls on boko haram group that kills girl. how did the anti-western movement began in nigeria? there is a lot of discussion around how boko haram began. had different leaders and has come together as a web, if you will. a part of boko haram started out as what we would consider to be

a motorcycle game. it was young men who drove motorcycles. that is a major form of transportation in nigeria. they thought they were being picked on by the local police and military for infractions that were very small. they banded together. ideology became next. -- ideology came next. isnigeria, the west considered to be part and parcel of the problem of the central government. nigeria is a democracy, but the truth of the matter is, the oil revenue that comes from the multinational corporations that are coming in and doing business in nigeria, that is not trickling up to the northeast. people are living in poverty. they see the west as profiting from nigeria. haram, i do not

believe it has popular support, anti-western sentiment has roots in some of the major problems nigerians experience. host: bochum iran grew out of an altar -- ultraconservative --ement of islamic ultraconservative islamic movement of well-educated students. western education was available only to a small amount of elite who traveled to british universities and returned to roll from the capital over the impoverished north. guest: it is a web. we have to understand is those that do leave nigeria and many other countries and go to western universities and realize the imbalance in the world of -- the economic

-- economic imbalance and the political imbalance, they often have western criticisms. bochum iran has has anyort --boko haram support. it has the language of the people. i believe that is to hide and mask terminal activity. what is the transafrica group? by theit was founded congressional black caucus to be the voice for african-americans foreign policy. when nelson mandela was considered a terrorist, transafrica took up the cause and explained to the people what was going on and why the apartheid regime was so evil. work arounda lot of

democracy in nigeria. we continue to fight to make sure the voices from the ground in africa, latin america, and even in europe are amplified in the united states. this case in nigeria is the perfect example. people need to have an opportunity to be heard, an opportunity to speak. it is amazing that mothers from secluded partll of nigeria are being heard all over the world, especially in washington. host: william, arizona, republican caller. did you notice that the parents wanting to look for their children, they were using bow and arrows. i do not think they had any type of gun. host: that was in one of the stories i read today. the initial search was done by

parents with bow and arrows, going into this for us today has camps,boko haram trying to find their children. guest: they reported the entire and whenunder siege they came back to the town to go to the school to find their daughters, that is when they found they were missing. they went to the military and said we need your help in finding our daughter's. -- finding our daughters. these were civilians. it is so important that we understand they were not armed. they had no hope, no one from the central government willing to help them. they went out with rocks and machetes to try to retrieve their daughters, to no avail. host: michael, california, independent color. caller: good morning. i believe until we have women

running the world, in charge, which is not going to happen anytime soon, man has a problem. i would almost bet my life there was not one woman involved in the induction of those girls. until we have a mental change in this world that men are the problem and women offer the better hope, things like this are going to happen all over the world. guest: i think patriarchy and sexism is the problem. be real allies to women and women can exude sexism. shoulda that young women not be educated is a patriarchal idea. i welcome, when i see countries elect women, and we are seeing countries in latin america and africa electing the women at greater rates. the head of the african union is a woman. women have a place in

leadership, absolutely. we need to promote women leaders. there are terrorist groups around the world that do have women in their ranks. that scares me. that is quite an issue. i do think that women leadership different aspect. we bring a different focus. men are fathers, but women are mothers. women bring that perspective that is so important for leadership. host: the world economic forum is this week in nigeria. all of these different countries and heads of states are coming to nigeria and this article -- goodluck jonathan is scheduled to take the conference stage with the chinese premier, talking about the opportunities of his country. investors from companies, including ge, siemens, they say they plan to invest billions of dollars into nigeria's

powerplants in the coming decade. guest: part of the conversation has to turn to what corporations are doing in nigeria. we know corporate responsibility campaigns can have a major impact. it is going to be interesting to see whether the "bring back our , if itworldwide campaign hasn't impact to make sure that the country as a whole is developing. executives that came to nigeria insist its promise out raise its problem. -- outweighs its problem.

guest: this has to do with the resources. oil nigeria is the largest producer. there's oil all over the continent of africa. the question remains -- are the country's growing to the benefit of their people or is this benefiting the west or is it benefiting corporations in a benefiting corporations and a small elite. numbers are not on their side when it comes to human growth, the ability to get a job, have a home, to have the basic needs met. what theirto do with opportunities are. host: peter, republican, connecticut. my heart goes out to these young girls who are being

abducted. i have two questions. arst of all, we are sending small force, but apparently, we fight. going to help we are just going to provide method so they can track them. send the pentagon will fewer than 10 people to help provide information expert takes -- expertise on logistics and communication. there is a lot of concern about u.s. troops on the ground. on the ground in africa have always come with a lot more then just assistance. arele of the continent concerned about a large u.s. contingency. the africa command, which has

established -- which was established about six years ago, was met with harsh criticism by the citizens and by government. technical assistance is warranted and is appreciated. the nigerian military needs to be -- needs to take the matter more seriously. body can be called in. the answer is not always u.s. troops on the ground. now tosmart right provide any and all technical assistance that is needed. even spy drones, not drones that drop bombs, but spy drones are appropriate right now. to go any further, i think creating a situation would foment more conflict than there already is. host: kathy.

caller: thank you for taking my call. it seems that the west and its are swapping resources with nigeria and the african people. if we go over there to mind something or get something, we are paying for. officials those utilizing all the money flowing into that country to build a proper infrastructure, to benefit the citizens, why is there such a disparity between the classes? why aren't these women having to -- those that wanted to retrieve the girls only had bows and arrows. it is it really such an environment of corruption that they do not want to take care of their own people? things,e purchasing taking something, we are flooding them with resources to improve their lives.

think i wouldt argue that the swap is equal. u.s. corporations do a lot of business and make a lot of money from the resources that come out of the entire continent. any time you pick up your cell phone, the minerals within your cell phone, from the continent of africa. what the raw materials, what they buy the raw materials for and what you buy your phone for is a vast difference. there is corruption at work here. times, this is what we have seen historically, corporations have been a part in the corruption. they have worked with government officials or with elites to take land away from people or to use land that is not being properly used. we have to be clear about the history that the u.s.,

corporations and corporations in .urope from many points of view in -- you mentioned women. the fact of the matter is, they feel the government is at the behest of governments -- of world governments in the international community then working for the people of nigeria. i have to believe we play a role in that. could this be a precedent that is set, the social media campaign, that allows countries to take this example and use it in other ways, to make change on the economy or whatever other problems they're facing. we have seen an

international outcry before. we were talking about the free south africa movement and how that was -- how it ended up being an international movement. it was built by people within south africa first and went globally. social media allows it to happen so much faster. take the next step, not just say we stand with the people of nigeria and we will send up a hashtag, if we take the time to learn about nigeria and the government and corporations and our own role of what is taking place in nigeria, i think this can impact the country. that brings up education in africa. what is the status of women getting an education in africa. the statistics remain

pretty grave. , these know for sure young women were in a catch-22 situation. the context of those girls being at the chibok secondary school was that they only had that one day to have the opportunity to take their exam. meant aics exam completely different life for them. they could become the dr., the lawyers, the economists of the country. it was such a security problem, there were questions about whether or not they should go to school. they would have had to wait a whole mother year without the next step of education. many women in the continent are put in the situation. .omen have to choose in most countries, you have to pay school fees.

you have to choose between your son and your daughter going to school. you have to choose whether or not going to ee or pay the school fees. we were talking about public schools educational for. would radicalize the situation in africa in a positive way. host: united states sends about $700 million a year. does that go to education? most other goes to the emergency relief for hiv and aids and other infectious diseases. host: tammy, alabama. i want to ask a couple

of questions and make a comment. nigeria is a young country and a lot of economical power. it is the most populated country. is part of the problem that they are so young and do not know how to manage and run the country properly and that they are so very rich, also. they are having trouble there. when young kids going to the draft and they are all of a sudden, they come from poverty to millionaires. do you think the problem is there? that they are so very young is a country and do not have the experience. nigeria is a new democracy. 15 years this month.

most countries in africa are coming out of a period of colonialism and are creating infrastructures. there are a couple of things that work that do not have to do the the longevity of country, but the conditions they found themselves. rule was harsh. not a lot of agency was given to the people in africa. colonial rule was harsh. it did not focus on infrastructure. we have emerging countries. colonialism out of -- 150 50 years ago years ago. what makes democracy is people. what makes infrastructure is the ability for people to use democracy to the benefit of themselves. nott of this has to do with

who was young and who was old, but who has the capability to control their own resources? on the most part, the people the continent of africa have not been able to control their resources. when they have, we have seen an impact and a change. the change we see in liberia right now, they are an extremely young country if you do not county dictatorships, and their leader has taken the resources that she has and create futures for people to make sure people can have jobs, that they are building clean water and infrastructures. there are so many countries you can point to that are in the same situation, but because they have control over the resources or are getting control of the resources, they are able to make change. u.n. in this? the they have produced documents and resolutions. i do not believe peacekeepers have been asked for.

there has been both positive and challenging situation with you and peacekeepers. peacekeepers. it is important to push the governing bodies. union, they put out a statement yesterday condemning the kidnappings. she said she is calling upon all countries to get involved and it's -- and assist nigeria. caller:, goodic morning, you're on the air. the girls that have been kidnapped today is not just an event. terrorized the people of nigeria.

the problem we are having is corruption. there is so much corruption in the media, in the congress, in the government. there is corruption everywhere. thatconomy is so corrupt -- one of the major problems boko haram has with the government is corruption. the government is not doing anything to address corruption. think this is why women and men, starting with the families and the communities and spreading all over the country of nigeria took to social media, to say to the world, this is happening and we need your help. i doi find interesting is see that the people of nigeria knew that if people around the

world knew what they were experiencing, knew what they were going through, they would respond and that they would act. it took us a long time to do so. corruption is a problem. one thing being spoken about now is the fact that there is this growing pressure against the government to say boca iran has been target --boko haram has been targeting citizens for a long time. the government needs to act. if they refuse to act, it is not legitimate. a real call see is for the nigerian government to pivot and prioritize. one of the problems has been that in the fight against boko haram, civilians have been caught in the crossfire. it is not just boko haram

killing citizens, it is also the government as well. there will be a lot of pressure brought to bear. nigeria, theyin are looking towards change. i do not think the pressure is going to end anytime soon. i hear a lot of callers calling and making excuses. there should be no excuses. there should be no talks. woman,e was european that they were caucasian woman, or chinese woman, we would be up in a up oroar. there is no way we should stand for this. these are our sisters. could be gone now and mutilated and dead. then what we going to do? say this is what we should have did?

a mother, grandmother, two daughter's, and east. i feel this in my heart. should not be no talking. we could go get any other person -- these are people. sentiment andthe i truly agree that it took way too long for the international immunity to react. when i first saw this come across, i knew this was something important. brazenok boko haram's activities to a new level. while we did see a few media reports, there were not very many. 73 people were killed and a bus station just because they wanted to go to work. they needed to use bus transportation. they experienced a bombing.

there is definitely a bias at work when we talk about what gets covered in the media and what does not. i am glad to see the media covering it now. the sentiment of the caller is something i am hearing from around this country and around the world. we have mothers. care and love women. the fact that this can happen, and there was not any action, that is disturbing to people on a lot of levels. host: tommy, tennessee, independent caller. aller: i would like to wish of the mothers a happy mother's day and the situation to me is very disturbing. i really cannot say what i want to say. i believe the women of this world need to unite on mother's day and say we are going to

ourthe suffering to children by oppressive governments. the women of the world need to stand up and say no. oppressived of governments who continued to mistreat our children and us as well. thank you. have a blessed day. we are seeing that. one of the things i thought was at the rally in washington, d.c. is that it was not just the nigerians. it was not just policy. it was mom's. -- it was moms. they had their kids, pulling them and widens, strollers, ringing them to the nigerian embassy to protest. you cannot imagine what it would be like to have your child kidnapped from you. wouldou think about what you do if you had no government that came to your aid immediately. in the united states, when there is a kidnapping, we see it on

the news. the police come to your house, take a report, say they are investigating. mothers hadt these no one doing anything, i think that is what is hitting people's hearts. host: