as the students. women students. i thought that was a pretty good idea. i went to the library and in the space of one month i read every federal decision that had ever been written involving women's rights or the lack thereof. ..

>> and a brilliant lawyer who wrote for -- he did not work for pay but the general counsel he spotted what he said would be a determinative gender discrimination case. 1970 and the and the supreme court had never seen an gender classification. this case was decided by the supreme court of idaho. it was about a woman named sally lee who was divorced

when her son was a tender years so sally got custody. when the boy became a teenager he now needs to be prepared for a a man's world so the father wanted him to live with him. the boy one day take out one of his father's many rifles and killed himself. sally wanted to be appointed administrator of his estate not because of monetary gain but for sentimental reasons. he had a guitar record collection a small bank account. that was it. her former husband applied to the administrator. a couple of weeks later

sally thought she would get the appointment because she applied 1st but the probate court judge said this leaves me know choice. entitled to administer the estate. .. she was abused by her philandering husband and one day

he brought her to the breaking point. she was beside herself. it was kind of like the story of billy. he is unable to speak. he is unable to speak so he strikes. gwendolyn saw her sons baseball bat in the corner of the rim. she took it and with all her might hit her husband and he fell to the ground. it was the end of his life in the beginning of the prosecution. it's important for me to have women on the jury because women would better understand the state of mind and the rage that

i felt. but hillsborough county florida in those days county florida about that woman on the jury. that was supposed to be a favor to women because as the supreme court said in gwendolyn's case we went on the center of home and family life. therefore they don't need to be distracted. gwendolyn foot's lawyer tried to get the court to understand that citizens have obligations as well as rights and one obligation is to participate in the administration of justice by serving on the jury. the law said women are expendable. we don't need them to serve on juries. while the supreme court rejected supreme court rejected gwendolen voids plea in 1961 and what

happened in those 10 years in between there was an enormous change in society. women were entering the workforce in increasing numbers. women were living many years longer than the day the youngest child left the nest. birth control was more freely available. all of those changes in society led the law to catch up and that is what was happening in the 1970s. so i was fantastically lucky to be born when i was when i was still a lawyer and in the brief that to women on the cover

mcmurray and dorothy kenyan were women who were saying the same things that we were saying. dorothy kenyan's mission was to put women on juries in every state in the country. and pauline mcmurray was an african-american woman who had herself, she wrote an article called jane crow and the law in which she compared the disadvantages that african-american space with the disadvantages that women face for women as well as members of minority groups they were closed doors. dorothy couldn't enter for a reason that had nothing to do with her ability and not because of your skin color, your gender.

we put their names on sally reads brief as if to say they are too old now to be working with us but standing on their shoulders. we are saying the that they said but now at last society is ready to listen. >> there are six cases story cases that you argue before the court. he do have an overall strategy about what you are trying to do? >> none of the cases in the women's rights project for test cases and the sounds that they went out and try to manufacture a case. these were people, everyday people. we wanted to have cases with people everyday people so the court could see the

arbitrariness of the gender lines in the law. one of those important pieces was stephen weiss and cough's case. some people criticized me for bringing men's rights cases. i describe stevens case to you and you decide whether it's a women's rights case or peoples rights case. stephen was married to a high school math teacher. she had a healthy pregnancy. she taught into her ninth month. she went to the hospital to give birth and the doctor came out and told stephen you have a healthy baby boy but your wife died of an embolism so stevens vowed that he would not work full time until this child was in school full-time and he

figured he could make it between social security benefits and blood he is allowed to earn on top of those benefits. he went to the local social security office to apply for what he thought were benefits for soul surviving parent with a child under 12 in his care. he was told we are very sorry. these are mothers benefits are not available for fathers. so in this case we argued first it was discrimination against women. women are required to pay the same social security checks that men paid with their families did not get the protection that male workers had. then it i was discrimination against the mail as parent because men would not have the opportunity to get -- for their

children and let me say the unanimous judgment force the majority who thought it was discrimination. discrimination started with a couple of them that thought it was discrimination against the mail as a parent and one later became my first and justice rehnquist said this is totally arbitrary from the point of view of the baby. why should the baby have a chance to be taken care of by a parent i soul surviving parent only at that. as female and not a mail. so that was our illustration to the court. it's bad for women bad for children, bad for men. the idea was to break down the

stereotype division in the world and home and childcare mothers and work outside of the home fathers, that pattern. so with great rapidity states and congress change the laws that had once been based on this model of home caring mother working father and took away those gender labels and made it a worker, a taxpayer, a parent. >> was the court receptive to

your arguments and specifically i'm thinking mostly right now in terms of the oral arguments. >> they didn't ask as many questions. you could get out a whole paragraph and even the one case was the one that i lost and we won't go into the details of that. maybe there was a half a minute left and the justice asked a question and i answered it and chief justice let me go on for five minutes beyond a half hour. that wouldn't happen today. [laughter] >> and where they receptive, yes to a point but the very last

case i argued was a 1978 and it was another one of the women on the jury's cases. this was from missouri. i had just finished my argument and i was about to sit down content that i had made all the essential points when justice rehnquist said and so mrs. ginsburg you won't be satisfied with susan b. anthony's face on the new dollar. so still make jokes about treating women as less than full citizens. >> did the presence of women on the court have a profound influence in terms of changing back?

>> i think now that we are one third of the court justice o'connor was the lone one on the court for 12 years and when i was appointed there was a renovation. up until then there had been a bathroom that said men. they rushed through this renovation and created a women's bathroom equal in size to the men's and that was the way for the court to say now we know the women will be part of this institution. during the years that we served together invariably in one way or another would respond to my

question, justice o'connor and occasionally would say i am justice o'connor. she is justice ginsburg. it doesn't happen now with the three of us. [laughter] i think the worst time was when i was all alone. the public perception sought eight-man and there was this little woman hardly to be seen. but now because i am so senior a set toward the middle. i have justice kagan at my left, justice sotomayor on my right and if you come and watch proceedings in our court you really should come as quite a show. [laughter] my newest colleagues are not shrinking violets.

so the public will see that women are all over the bench. they very much are part of the colloquy. people ask me sometimes when do you think it will be enough? when will there be enough women on the court? my answer is when there are nine. [applause] [laughter] and some people were taken aback. so we remember for most of our countries history there were all men on the high court bench. >> i want to open the floor for questions but one last question

as you are about to come alive for students here are about to start their legal career and you have had such an extraordinary career is there one or two pieces of advice if you would like to give them as they are about to begin? >> i have loved everything that i have done. it's a great profession but i will say that if all that i was in cobol business for would be to turn over a -- i don't think i would have had nearly the satisfaction that i had. yes you need a job but if you don't do something outside of yourself something that will repair the tears in your communities that will make life a little better for other people

you are not really a true professional like a plumber who has a great skill but that's all you are. if you think of yourself as a true professional you will take talent education and use it to make things better for other people in your local community your state, your country, the world. >> it's very powerful and inspiring and your career has been inspiring for each of us. of course what you have done is to be transformed or so we would like to take an opportunity to give you the chance to ask the justice questions. while we are waiting.

[laughter] how does it feel to be an icon? [laughter] >> when all of this started i had to ask my law clerks what is this notorious rvg? [laughter] and now i had no competition because it notorious vig is no longer part of this world. [laughter] >> i think we will have a question now. please say your name. >> justice ginsburg thank you for coming. my name is chloe white why. i'm the co-president of the rights group here on campus so my question tends toward the hobby lobby ruling with some of the rulings coming out of texas how do you feel are you pessimistic about the direction of reproductive rights in this

country and that includes abortion and contraception parents and so on? >> you ask in my pessimistic? i think it would depend upon women of your age if you care about this. there will never be a time when women of means will lack choice because take the worst case scenario, roe v. wade overruled by the supreme court. there will be states sizable number that will not go back to the way it was. at the time of roe v. wade there were four states that gave women access to abortion without any questions asked in the first trimester. those states are not going to change. what it means is a woman who can

afford a plane ticket, a bus ticket will be able to decide for herself whether to have an abortion. but the women who won't have that choice are poor women and that doesn't make a whole lot of sense. so if the women of your generation care about this issue the best message that i don't see talked about a lot is who will bear the brunt if roe v. wade is overruled, who will bear the brunt? so if we care about her sisters who are less fortunate than we are we will do what we can to

say that they have roughly the same choices in life. >> in the back. please state your name. >> i am an afghan american. for those of us as women who have been inspired by you justice ginsburg for opening the doors for women over the course of the last few decades there is another group of us who are inspired to do work for women overseas whether it's in afghanistan, throughout the middle east and i would like to hear from you what advice you might have for those of us who wish to see the role of women growing ants to a place where

they can look at their sisters in the united states or in the western countries and say we are getting there. what advice would you give for lawyers who would like to dedicate their lives to women's economic empowerment and social empowerment in developing countries? >> i would say first don't go there to preach to people about how they should do things. we should try to get to know the local community to understand what their priorities are and to help them to help them accomplish an agenda that they set. there have been some great strides made and the name of the man who was setting up, funding women who are starting small businesses and he was amazingly

successful. the women paid back so when they got their resources they worked very hard that i would say that's the main thing. i worry about some people who go off to various places and had no correspondence to that society. they are working abroad and try to work with the women in that culture to accomplish what they see as the most helpful to them. >> another question. >> hi justice quince bird. it's an honor. my question is you have kind of become known as the voice of the powerful dissent over the past

few years perhaps unfortunately but if you could pick one decision over the past 10 years that you could waive a magic wand and overturn what would it be and why? >> i would have to say citizens united because i think the system is being polluted by money. it gets pretty bad when it affects the judiciary to in some 39 states where judges are affected at some level and cost millions of dollars to fund a campaign for a state supreme court. something is terribly wrong. i think we are reaching the saturation point and a great man that i love dearly, marty, often said the true symbol of the united states is not the bald eagle, it is the pendulum.

when it swings too far one way it's going to go back in the other direction. >> so you think that it will swing back? >> i can't say when that one day sensible restrictions on campaign financing will be the law of this land yes it will happen. one of the hard things to explain when i go to florida and i'm proud of being a citizen of the usa they ask questions like how do you allow people with money to have access to the decision-makers and ordinary people don't have how do you

have a system where legislative districts in the house are so gerrymandered that people don't vote and he said the low rate of voting in the united states many democracies the turnout is much higher. people have a sense why bother it's a foregone conclusion who is going to win. so i think we need to get our democracy where it is a democracy for all of the people. there's important work to be done. >> i think we have time for one last question. on the far side.

while we are waiting to you have any recommendations what can lawyers do for fun? [laughter] >> whatever is your passion. i told the vet i'm a monotone but i do love opera so i have been a super now three times for the washington opera. i am also every year i participate in the shakespeare theatre moot court and i guess my best part of the shakespeare theatre was in henri iv. the director of the shakespeare theatre asked me if i would have a cameo appearance and i said on one condition. i know just what i want.

i want to see the famous line the first thing we do -- [inaudible] [applause] now our last question. >> thank you justice ginsburg. my name is alexander bertone and the question wants to ask is if you were back in your role as a civil rights activist what kind of case would you be looking to bring today and what sort of story would you be looking to bring to the floor that you would advocate for? >> i'm glad you asked that question because i want to tell everybody here that you don't start with the courts. the judiciary is a reactive institution, doesn't set its own agenda.

our first effort in the aclu women's rights project was the opinion that tried to influence public opinion. people have to want change before it's going to be reflected in legislation or her decisions then you try to get the legislature to write laws that are family-friendly and the court is really the third audience. in the 70s there was kind of a dialogue going back and forth between them. the court would say there would be some changes in the law and then it would be stephen weiss and felp's case and there would be more changes in the law. the court in the legislature were in tandem at that time.

but i would express that first you need popular support. that is what existed in the 70s and it didn't exist before that. while all this was going on and these cases were being brought to court the states were reviewing lawbooks to arbitrary gender classifications. congress did the same so don't think about the court is your first audience. people have to want to have to change before it will happen. >> i have to say this has really been extraordinary. we have a small token of our

appreciation. we have a plaque. second annual dean's class justice ruth bader ginsburg and i have to say the privilege of listening to you and the wisdom that we are all benefiting from i am so grateful and i know we are also grateful so i would like to lead us all in a round of applause and thanks for justice ginsburg. >> thank you. [applause] [applause] this is perfect.

next health secretary sylvia burwell testifies about the 2016 badger quest for the department of health and human services. the white house is asking for an increase of 4.8 billion in discretionary spending from last year. senator orrin hatch of utah chairs the senate finance committee. >> the committee will come to order.

good morning it's a pleasure to welcome everyone to today's hearing on the fiscal year 2016 budget for the department of health and human services, hhs. i want to thank you secretary burwell for being here with us today. this is your first time before the committee since been confirmed so welcome back in your official capacity. i told you when we were talking at your confirmation hearing that the job you now have would be a thankless one and that you are undertaking an enormous responsibility. at that time we also discussed three main areas that i incurred to do focus on during your time at hhs responsiveness accountability and dependence. i would like to talk about more of each of these areas today. let's start with responsiveness. during a hearing i raise the importance of being responsive to congress and to this committee in particular. you assured me that this would be a top priority of yours as well and under your watch we

would see a marked improvement. the pass to this committee has written at least 20 letters to hhs for cms asking questions about serious issues such as fraud prevention hacking of healthcare.gov web site medicaid expansion and many others. i understand we have now received answers to nearly every one of those outstanding letters just in time for your appearance here today. with the last few responses coming just last week. this is a great improvement over what has been in the past and i perceived efforts being made to provide these answers to us however hope it will not require coming to testified before the committee to assure timely or sponsors going forward. if it does i suppose we'll have to look forward to seeing you were hearing every 30 to 60 days and you don't want that and they get worse over time. thank you for continuing to make this a priority. good communication between hhs and this committee is paramount to a good relationship and you

understand that i know that. let's talk about accountability. one of the big issues we discuss at your confirmation hearing was the absolute need for fiscal accountability given the huge breadth and scope of hhs' programs and budget. overseeing them requires constant vigilance and effective management. when looking at the size of the budget for hhs for this coming fiscal year we see just how good your job really is. in fact the expression quote too big to fail unquote does not does not apply is the hhs is so big one would argue that it's destined to fail. hhs budget for fiscal year 2016 is just over a trillion dollars. in real terms of hhs were a country and its budget for its gdp would be the 16th largest economy in the whole world. i think we have the charter were there the shows where the red arrow is you would be the 16th

largest economy in the world. to put it in a more american context the total budget of hhs has more than doubled that of walmart and five times of apple. my concern is the savings and efficiencies in the overall hhs budget are very small when compared to the overall spending spending. the president's proposed budget would save just under $250 million over the next decade which sounds like a lot but that's only a 3.8% of total medicare and medicaid spending. more accountability is critical to ensure these programs have sufficient resources to continue to provide benefits for years to come. on the policy front administration need to be upfront with congress about their contingency plans and at the king versus versus burwell cases not decided in its favor. depending upon what happens in the supreme court in late june

probably late june the hhs could have to figure out how to provide services for millions of americans currently receiving tax subsidies that enable them to pay for tax and -- health insurance. i can only assume the agency has a plan in place for dealing with this. secretary burwell i hope you will share that with us today. that brings me to independence. for some time now i've been concerned about the amount of influence hhs and the administration have or have over the operations and policies that impact the entitlement programs and certainly those run by cms. the budget released this week indicate spending on just medicare and medicaid is expected to exceed $11 trillion over the next decade. in fact cms accounts for 35% of the total hhs budget and these are astonishing numbers. they also ran forced something that i've long believed it's time to start talking about making cms and any agency a part

of hhs. nearly 20 years ago congress passed the president signed into law, a law that social security improvement act of 1994. that law separated the social security from hhs and made it an independent agency. at that time as essay was largest operating division within hhs and accounted for about 51% of hhs' total staff and more than half of its total annual budget. i intend to introduce legislation to remove cms for hhs. whether or not cms becomes an independent agency is something to consider going forward but the accountability and transparency problems we see in cms programs cannot wait. i hope we can work together in the coming months on the affordable care act and issues to create situations and solutions that work for all

americans. finally i want to note that while there is much in the president's budget with which i disagree there are areas where i think we can find common ground. for example i appreciate the provision in the budget that addresses the issue of overreliance on comfort care facilities in group homes for children and youth in foster care. for years i've been working to call attention to the deplorable conditions in many of these group homes. recent research indicates these group homes or unsafe expensive and too often contribute to profoundly negative outcomes for the children and youth who are placed in them. i look forward to working with the administration to end the over reliance on group homes to secretary burwell i look forward to your testimony and working with you to ensure her most horrible citizens get the care that they deserve and i do appreciate identical your job is and appreciate the openness with which you have have considered

with senator wyden and others on this committee. senator wyden. >> thank you mr. chairman and secretary burwell let me start by saying that my assessment is that you have set a new bar for cabinet secretaries in terms of reaching out and trying to be responsive. i care about it with respect to citizens. apparently you are in virtually every corner of the country taking your family and i can only imagine the challenge of that. you are getting back to senators senators. i hear senators of both political parties conserved in liberal saying the secretary actually got back to me. it was such a quaint idea that somebody of what equity that could understand you have got discussions coming are you have again with governors so my sense is you have really set a new bar in terms of reaching out and it's obviously very welcome.

not too many people in america including millions in our country and at my home state feel like they are falling behind. they just feel like the economy picks up steam they are not getting ahead. it's our job to make sure that doesn't happen in the finance committee has played a big role and it's almost like we are having a tripleheader this week. we had mr. costin and yesterday u.n. secretary lew tomorrow. the budget obviously articulates the priorities of today but it also talks a lot about what our priorities are for the future and we are looking forward to having you play up our proposal would strengthen health and human services programs promote economic mobility and assist their middle-class families. i do want to take a minute just to talk about where i believe american health care has been and then talk briefly about

where it's going. this year marks the 50th anniversary of medicare and medicaid and a lot has taken place since those programs were created. congress came together to create the chip program,, and has reauthorized it three times. congress has improved expanding medicare and medicaid. the affordable care act gives access to high-quality care wider than ever and what i think is particularly important at this signal that america is not willing to go back to the days when health care is for the healthy and wealthy. that's the way it was when people had a pre-existing condition. up is that the job is not done so there's a twofold challenge. in my few first protect the progress that has been made in second to clear the way for more progress in the future. for medicare that means guaranteeing that the program's benefits fully meet the needs of

this era's seniors and the demands on medicare are clearly very different than they were 50 years ago. the big-ticket medicare cost of 2015 are no longer things like kidney stones and broken ankles. they are chronic conditions like cancer diabetes and alzheimer's and those conditions are tougher and more costly to treat. the hhs budget and my few begins to acknowledge that reality but clearly there's a lot more to do. in treating chronic disease in my view is the future of the medicare program. so it's needed is a roadmap to efficient and effective care for chronic disease that boldly moves away from the outdated fee-for-service model. patients and providers told this committee last summer about the need to address chronic care in

a different way. there's bipartisan support for this in congress and i look forward to working with you in the administration to make that a reality. i was also thinking about the announcement last week about precision medicine because this too helps to provide something of a roadmap for the future. medical professionals understand that the treatment will often affect susan and a different way than it affects george and with the right research it will be possible to learn what drives the differences in how it tailors treatments to fit an individual patient's needs. precision medicine initiative that's in the president's budget follows an innovative test program that was really created in this debate. as part of our discussion tonight don't see senator carper here who is very interested in that issue but we have another big challenge. the next step will be to design a payment system for this

innovative field of the precision medicine that can do so much in the future for patients and taxpayers. the president's budget proposal progress made to award the quality of care rather than the quantity. congress can do even more by passing bipartisan bicameral legislation to improve the way medicare pays physician and chairman hatch obviously had a lot to do with putting a proposal together. the present proposal takes a vital step by including four years of funding for chip. they're more than 10 million kids in america who get health insurance the through chip including more than 75,000 minorities. a better shot at a successful middle-class life. for renewing chip in my view is a no-brainer. families and state agencies are

waiting for congress to step up and act on chip. there are also steps congress can take to help guarantee our health programs remain strong for generations to come that her life plans for countless americans and as a result money to families will never have to choose between paying for a loved one's care and sending kids to college. millions of americans will grow up with access to quality care that keeps them healthy and out of emergency rooms whenever possible. of course its importer member that health and human services does a lot more to oversee medicare medicaid and chip. a department plays a bigger role in america's safety net. this committee has a long history of working on bipartisan basis on policies to strengthen our federal child welfare programs for vulnerable kids. just five months ago congress enacted to prevent sex trafficking and strengthening families act. the department is helping turn this bill from a piece of paper signed by the president and the

new tools that will help states move over buckets out of harm's way into safer in permanent homes. the president's budget proposal shows it's possible to build on this momentum by expanding programs in keeping kids and families together and healthy with a special focus on getting involved early with former beau families in programs like home visiting. this is especially important for the first time parents. we are talking about multigenerational supports and those prevent the long-term -- associated with abuse neglect in foster care so we are talking about the people who are trying to get ahead in a tough economy and have just not seeing a recovery make it to their neighborhood. thank you for joining us here today. we have a lot of opportunities

for working in a bipartisan fashion and i will have some questions but i do want to wrap this up by saying by having been in public life and work with the member secretary said think at the end of the day there will be big differences of opinion. the only way to really make progress is by reaching out. i look forward to working with you. thank you chairman hatch. >> thank you senator. sylvia matthews burwell, secretary burlison leaving the department of health and human services since june of 2014. ms. burwell has a long history of public sector service including those recently serving as director of the office of management and budget under president obama did in the clinton administration ms. burwell served as deputy director of omb deputy chief of staff to the president chief of staff to the treasury secretary and staff director of the national economic council all of which are very important positions.

she also has extensive private sector experience including serving as the present of the walmart foundation and before that the present of the global development program of the bill and melinda gates foundation. we are honored to have you here and thank you for being here today and you can proceed with your opening statement. >> thank you chairman hatch and ranking member wyden and members of the committee for having me here today. i want to thank you for the opportunity to discuss the president's budget for health and human services. i believe firmly we all share common interests and therefore we have a number of opportunities to find common ground for preventing and treating substance abuse to advancing the promise of precision medicine to building an innovation economy and strengthening the american middle class.

the budget before you makes critical investments in health care science innovation and human services. maintains our sponsor bolster a chip of the taxpayer dollar. strengthens our work together with the congress to prepare our nation for key challenges at home and abroad. for hhs proposes $83.8 billion to discretionary budget authority and this is a $4.8 billion increase that will allow our department to deliver impact today and play a strong foundation for our nation for tomorrow. it's a fiscally responsible budget which in tandem with accompanying legislative proposals would save taxpayers an estimated $250 billion over the next decade. in addition it is projected to continue for slowing the growth in medicare. he it can secured $423 billion

in medicare savings as we build a better smarter health delivery system. in terms of providing all americans with access to quality affordable health care it builds upon our historic progress in reducing the number of uninsured and improving coverage for families who already have insurance that extends chip for four years, covers newly eligible adults in the 20 states plus d.c. which has expanded medicaid and improves access to health care for native americans. to support communities throughout the country including underserved communities it invests $4.2 billion in health centers and 14.2 billion to bolster our nation's health care workforce. it supports more than 15,000 national health service corps clinicians serving nearly 60 million patients in high need areas with the funding streams in 2,016,000,000 stand to lose

primary care services and providers have been unable to take action. advance our common interest in building a better smarter and healthier delivery system that supports improvements to the way care is delivered providers are paid and information is distributed. on an issue for which there is bipartisan agreement replaces medicare's flawed sustainable growth formula and supports a long-term policy solution to fix the sgr. the supports the type of bipartisan bicameral efforts congress undertook last year. advance our shared vision for leading the world in science and innovation increases funding for nih by $1 billion to advance biomedical research in behavioral research among other priorities. in addition it invests 215 million for the precision medicine initiative a new effort focused on developing treatments diagnostics and preventative strategies tailored to

individual characteristics of individual patients. to further our common interest in providing americans with the building blocks of healthy and productive lives this budget outlined an ambitious plan to make affordable quality childcare available to working and middle-class families with young children. it supports evidence-based intervention to protect youth in foster care. it invested help older americans live with dignity in their homes and communities and to protect them from identity theft. to keep america's healthy the budget strengthens her up health infrastructure with 975 million for domestic and international preparedness including critical funds to implement the global health security agenda in its core strategies for prevention, detection and response. it also invests in behavioral health services and substance abuse prevention.

includes more than 99 million in new funding to combat prescription opioid and heroin abuse dependency and overdose. finally as we look to leave our department stronger that the budget invests in our shared priorities addressing waste, fraud and abuse initiatives that are projected to yield 22 billion gross savings for medicare and medicaid across the next decade. we are also addressing our medicare appeals backlog with a variety of approaches. taken together this budget advances our broader goals of making a 21st century workforce providing americans with the building blocks of healthy and productive lives and delivering impact that allows everyone to share in the prosperity of a growing america. as i close i want to assure you that i am personally committed to respond quickly and thoughtfully to concerns of communications for members of congress. we make progress and we can do more. i also want to take a moment to

thank the employees of hhs from their work on combating ebola to the work they assist the unaccompanied children of the border to the commitment they show day in and day out helping fellow americans obtain those building blocks of healthy and productive lives forever were look forward to working closely closely with you to advance our common interests for the american people. thank you and with that i am happy to take questions. >> thank you ms. burwell. as you know the supreme court will soon decide the l.a. -- legality of health insurance subsidies to individuals in states with federal exchanges in the burwell case. the legislation itself the affordable care act talks only about these exchanges being created in the states so it is important in my opinion the regulations violate the constitution's powers by exceeding the executive branch is regulatory authority.

we will find out what the courses soon enough. yesterday's ways & means hearing secretary lew repeatedly refused to say whether the has a contingency plan if the supreme court rules against the administration. secretary burwell this administration have a contingency plan in case the courts invalidate premium tax credits and penalties and states that the federal exchange and you can say yes or no. >> senator right now the position we hold in the justice department will represent them from the supreme court is the correct position and we believe that in terms of the spirit of the law and the intent of congress as well as the letter of the law and the justice department will make that argument. turso we believe in c. that is happening is the idea that tax credits would be provided by

congress for individuals in the state of new york but not the state of new jersey is something we don't believe that congress intends in any way and we believe the letter of law supports that. >> there's a lot of indication that congress did intend that so would force the state to form state exchanges rather than have the federal government do it for them. so it's a big issue and the language is unambiguous in my opinion. i don't want to speculate on it but assuming the court does find the language is unambiguous and only state exchanges could be formed do you have a contingency plan? >> right now mr. chairman what i am focused on everyone knows that february 15 is the end of open a moment and in terms of providing quality affordable

access to health care my deep focus right now is ensuring as we have seen in today the leader will announce their 7.5 million people who have come into the federal marketplace in addition to the 2.4 million that have come into the state exchanges and large majorities of those people are receiving the financial assistance that is being provided. right now my focus is to focus on completing in implementing the law which we believe is the law. >> you don't have a contingency plan. that's all i'm asking. >> right now what i'm focused on is the opener moment. >> so that means you don't have contingency plan. i would suggest the administration not to get one just in case. it's something that seems to name that you know what kind of have to have because the possibilities that millions of people will need coverage when the floor and that.

let me ask you this as your department communicate with insurers who participated in healthcare.gov in the possibility that the subsidies could become illegal and have you made plans they are? >> what we continue to do was work with the insurance providers to implement the affordable care act. we are working closely with them as part of this open enrollment. one of our focuses to suspend the consumer and as part of the focus of the consumer we have been working closely with insurers on making sure we are focused on everything from how enrollment works. >> i'm more concerned about this issue right now. i'm limiting my comments to this issue and i'm sure you're working you know what the various states in every way you possibly can but again are you planning for anything if the court decides the other way? >> senator right right now we are focus deeply on those issues

that i have articulated. >> okay well i have to say the insurers to my knowledge haven't been given any guidance about what to do at the supreme court invalidates subsidy payments so it's something i hope you will get on top of just as a contingency plan to make sure you can handle waste matters. secretary burwell baca included more than $100 billion in appropriations. over 1 billion of that money went to states that willfully negligently spent funds for development of a failed state exchange. in your may 14, 2014 confirmation hearing before this committee i asked you if that these states would be required to reimburse taxpayers. he said quote for the federal government taxpayers had funds refuse we need the full extent of a lot to get those funds back. i agree with you.

has hhs recovered any of these funds and do i have a commitment they will take action on enough of the american taxpayers to collect from the states the money contingent. >> at this point we have not received tons. with regard to funds they are made in contracts only issue those and do those to the states and a states issue the contracts so our grant making to the states is the part that we have control over. as part of that though a number of the states are taking action both in oregon as well as in maryland. efforts are being made in terms of the follow-up. the question on what the federal government can get back in terms of these funds is about whether or not in the grant-making that things were done that were not in line with the terms of the grant. right now our inspector general at hhs is looking into these issues to see if there are places where they think that is happen.

>> my time is up senator. >> thank you mr. chairman. obviously madam madam secretary weir and tax filing season and there are lots of issues with respect to premiums and credits and obviously secretary lew and the commissioner play out key role but you are involved as well. i does have a couple questions here. you have any sense at this point of how many people might be entitled to a refund under the law because of that is certainly one possibility and how many people might go something? do you have any sense of numbers they are because that's an idea of? >> where the sense that three-quarters of people will check a box those that have existing insurance-3/4 of the people will check a box. with regard to the other category 1 that you are referring to which is those of the marketplace and whether or not they have underpaid or overpaid with regard to the subsidies they have received we

don't have a sense because this is the first time through. we consult with their colleagues at the irs and because of the first time through i'm sure commissioner koskinen as well as secretary lew have spoken to that. >> would be doing to make sure this is consumer friendly for people who are going to have to wrestle with these issues? >> we have worked together as the department of health and human services, the treasury department and irs to make sure we are getting information out as quickly as possible. with regard to those who will be finding the category you were just describing 91% of those filers use some type of software to file. within the software it's incorporated as everything else is incorporated and we work to do that. we have been working with the tax filing organizations whether that's at the end of the h&r block to the five dissenters that i think many of you know are the centers that help provide lower-income people so

we are close communication. secretary lew and i have done calls with the vita commission. we want to make sure the questions they are getting we understand so we can provide answering those if we can. >> let me move on to the chronic care issue which is you and i have talked about is the future of medicare and i look back at talking about broken ankles. no one is talking about broken ankles that drives medical future periods about diabetes and cancer. you run a number of programs that hope for the future to address the concerns of the chronically ill. when can we expect to see some of those results? i know you have programs that you would like to see look at a variety of different conditions and the challenge of course is you have this horribly frightening delivery system and

that's one of the things legislators on this committee are trying to change in trying to change in a bipartisan way but tell me about the programs you all operate that target the chronically ill which i think is going to be the future great challenge of american health care. >> with regard to the chronically ill and the things we do for the part that cuts across various parts of the entire department. there's the work we are doing in terms of esoteric medicare and medicaid are working on innovation and. we are working on addition with the states through the state innovation model grants where were we are granting money to a number of different states to try notations in terms of some of those into the medicare space received the work we are doing in the innovation center. with regard to the legislation that gave us conditions that said you cannot decrease quality were increased price so we are measuring those as we go forward. i would also mention in these areas of chronic there's also the work the cdc is doing and some of this is about

prevention. as we think for some of these conditions such as diabetes heart disease and some of those is about prevention and cdc plays an important strong role as we go forward with that. >> let me ask about the precision medicine initiative and began begin what we are looking at for the future. i think this too is a key part of the future of america's health care and for families to have confidence that when a loved one gets sick their treatments can be targeted imprecise based on their genetic makeup this is pretty important. this is about as important as it gets for a family but if we are going to tap the potential of precision medicine the big payers and your department around several of those programs medicare and medicaid and private servers are going to need to pay for it. i know you are just getting started in this area but what progress are we making in terms of setting up payment systems and as with this committee try

to do an affordable care act to make sure you can actually get paid for innovation and the services that help patients. >> i think the question of payment gets to the announcement i made last week which for the first time we have the government are committing that we have set a goal for ourselves to change the way we are paying medicare and we have set the goal that they will have alternative payments that are based on value instead of volume volume. we set the goal for 2016 that 30% of those payments and by 2018 that 50% of payments. as part of moving forward to alternative approaches to payments that is where we are going to try to bring in some of that innovation. the other thing i think is important as we consider costs in the space is this type of approach to medicine hopefully can for the individual because we can trade in ways that may not be as costly as you are talking about in your earlier question. >> thank you mr. chair. >> senator grassley.

>> thank you secretary for appearing in more portly i appreciate it very much the frequent phonecalls where you call give me updates. i only have one question at the end but i have a lead-in so be patient with me. i am concerned about the recent failure of a co-op created through the affordable care act operating in iowa and nebraska. co-opportunity was one of 23 co-ops formed under that law and the federal government loaned money through cms. i understand seamus played a significant role in overseeing the co-ops including the ultimate authority over setting the rules. co-opportunity was successful in training beneficiaries of the second most covered of all the 23 co-ops. it was more successful than they anticipated. in the summer it became became

obvious company opportunity and the iowa insurance commissioner that co-opportunity would need additional loans from cms to stay in business. both the iowa commissioner commissioner and company opportunity frequently inquired with the mess about their capital position and the need for certainty ahead of open enrollment as was clear that crisis was developing. cms nucor opportunity was going to be in trouble if it didn't get loans. co-opportunity was allowed to be in the iowa nebraska marketplace when it opened on november 15. cms finally let go opportunity that no further loans would be coming right before christmas and the iowa insurance commissioner was forced to take over go opportunity december 24. i'm concerned about cms is role as a regulator of co-opportunity and of all co-ops.

there are about $2 billion of taxpayer money loaned that depends on the success of the co-ops for the federal government to get its money back but cms did not distinguish itself in its actions with co-opportunity. i will have more questions for you for the record regarding cms action but my question for you today is on behalf of shane and betty -- of milford iowa is an example of people who have real problems because of co-opportunity bankruptcy. they paid their premiums and renewed the coverage with co-opportunity as they expected it to be there for them in 2014. unfortunately shane had emergency surgery january 3. portia and mr. bush is recovering but the care was not an expensive. the bushes have already hit kept their out-of-pocket maximums. opportunity. ..

>> >> that is our number one priority as we work with the

state insurance department in iowa so the consumer is the number one priority to think through what authority we have to help support all of the consumers like the family you just described. we look forward to responding to the questions that you have or any others you as aha line dash add to the list there were many rescissions' to have additional support. to take additional dollars and we are concerned right now. we look forward to working with the states of iowa the way we can help those

consumers. >> thank-you mr. secretary. >> thank you for the hard working and your staff. sova two underscore the good news the cbo projections showing that many more people are finding more work. see where americans are going into vagrancy because of medical crisis. tax credits help people afford and now people can get a new opportunity for preventative care. frankly those are guaranteed what they are paying for.

it is all good news. also to the people of michigan and the chief affordability tax credit at the time the chairman introduced me it was the badge of honor but just for the record the affordability tax credits are working as redrafted them and intended them for all americans. not just some of them. if the entire bill is repealed like we have seen introduced with those

republican co-sponsors so far as far as not having access of the affordable health care. but one piece of that of the plan that goes by a state by state to get affordable health care. that is medicaid. when we put this together we know 80 percent of the money is seniors and nursing homes and reassume their families get help under medicaid. in those seven roles in the plan.

so when i look around the panel with 11 states represented in the finance committee's that still have not provided access with the expansion of medicaid but to speak to what is happening to families and those were talking about those coming into the emergency room rather them through a doctor in a way that is better for them to curtail costs. but states are not given access. >> we have to do as much

with the individual and economic impact. in terms of the health and financial security yesterday we had folks of the white house. a woman went to the marketplace because she thought she would pay a fee and found out was medicaid eligible. never had a history of breast cancer in her family actually he had part of a mammogram and it is covered and found out she has breast cancer. but in terms of financial security the ability to pay for for the individual. so with their rural hospital closing it is affecting states across the country

with the production of care costs. with examples of what is happening in communities where more care is paid for. then with regards to the states themselves they see those benefits. it is a rural health issue also is an herb bed hospitals because there is only one hospital that tends to take care of the into j care so that could be dramatically affected. the there is less indigent care from the employer base system.

>> 84 holding the hearing. you are a star. to decrease significantly but the budget. $600 billion less through 2020 and 5 million injured in the state of new york we have done a good job. our health exchange has signed a 2 million people for low cost of coverage. 80% said they were previously uninsured. in their appreciate the emphasis.

i am now a sitting or senator rockefeller center and i reminded of ship all the time. where i oppose the administration strongly and vehemently with gme i don't understand the logic. medicare payments to the teaching hospitals for indirect costs of medical education exceeded patient care costs. to correct this imbalance reducing payments by 10%. the budget proposal recognizes a physician and a shortage. we do. it is one of the places it did not choose a job to add insult to injury to cut the payments to teaching hospitals.

to make them become doctors. i believe current funding levels are critically important to maintain a state of the art environment we do need a majority of those that our trained overseas that would be a direction and that they are headed. so what seems to be counterproductive to cut teaching hospitals. college you reconcile? >> the specific gme area what we try to do is balance the need those that go into specialties with shortages. with the proposal that affords the opportunity but

the question is in direct purses direct and additional funds that would help to targeted efforts. so the national health service corps to try to make sure we're supplementing primary care if we have proposed the extension of the medicaid primary care funding. >> if the queue are robbing peter to pay paul. they have been around for a while. and what we proposed to increase the number of slots and allocate half of that for primary care. to say we rely o these new

programs that don't fill the gap i is what used to space be initially opposed the proposal and hoped the administration reconsiders. with ebola of the cdc has done a great job. the number of cases here in america is to the three hotspot countries has declined to did not happen by magic that the federal, state, and local levels. in new york city hospitals did amazing job. 47% that flew in landed at kennedy airport for city state or federal governments to make sure we didn't have the situation rehabed

initially. so can you just tell us? with many of my colleagues and hospitals around the country get reimbursed many have to create anti-contamination rooms and had to buy equipment and to treating. cannery make sure they get appropriate reimbursement? >> we're working to have those members because we will have a contractor do that on a hospital by hospital basis. states and communities will receive other parts of funding. said those have a tremendous job and the others that treated patients around the

country. we are appreciative of the funds to move as quickly as we can to have reimbursement to help those to get ready and be prepared. >> thank you. i will echo the sentiments for the job you're doing. during the confirmation hearing talking about affordable health care the independent advisory board you said the u.s. open never has to be used to the nab triggered an estimate said it will never be accurate a light dash activated. but here we are with the

budget request acting to expand this a story for savings so how can you explain hoping and never had to be used now doubling down to expand savings? >> with regard to what we're trying to do is get to the core of what it was about to make sure we can work together to continue to do keep the cost of medicare in the entitlement space per barrel just in the period from 2010 medicare spending is 116 but -- billion below what was supposed to be so that is why we move that out. of the proposals to expand the life of the trust by five years and we want to put specific policies that will continue to move out that timeframe we're hopeful we get those enacted to

continue the and cattle and savings from what we are seeing but we want to continue on a path with regard to spending. >> i am worried about the independent payment of advisory board with the task force have the patience center outcome research institute although well intended this to the four horsemen of the regulatory apocalypse. so you are depending on something called iraq and that is a recovery on it contractor when they ride into to town in western kansas the doors shut and i hope nobody comes to rock. they've put hospital

administrators of the rac and tyre appreciate to address the appeals process they have a choice to pay the fine and a cold -- the contractors with critical star but it is also rationing. cms presented a settlement with over 2,000 hospitals under the process the chief administrative law judge griswald noted as of july last year there were 800,000 pending appeals but my question is ephemeral complete the settlement process how many claims would be from the backlog? >> as one on the committee knows why we have reached out to talk about the issue before today.

with those that comes through settlements the strategic approach is threefold to redress what is an extremely important issue about balancing those and program integrity and at the same time the concerns you have articulated how it feels. those three strategies like the of mistreated tools that there is funding needed to clear out that backlog so others can and process it is a specialized person and the third is there are legislative proposals to extend our ability to get rid of the backlog. we had conversations with this committee because we have included the seven proposals to be specific to

work with you all how to do that but it to be honest it will take all three to get rid of the backlog. >> dire appreciate your response i am not sure i follow you with all the specifics. but i just have to tell you when you have contractors race rather health delivery system, is seen as they don't trust the hospital an administrator or the doctors in return they don't have trusted the government and that is not a good thing for policy here if we can have a better situation. >> good morning. on december 17 the number of

senators sent a letter to you and teeeighteen about the king forces for will case. because you did not answer a single one about contingency plans for those who might lose subsidies for health care. has hhs taken steps to inform all exchange enrollees about the suits and how ruling against the administration might affect them? >> we believe we implement the law as it is intended and that is what we talk about. >> if the administration and loses, have we taken steps to revise federal enrollees' of the consequences that

might apply to them losing fat lawsuit? >> greg now mentioned we focused on our responsibility to implement the al lot to focus our the consumer experience in working toward that deadline >> you are a highly intelligent and charming person be refused to answer our questions and that does not strike me he was trying to work with congress but contemptuous of our oversight responsibilities. so i will ask if the administration loses the case, if you plan to ask congress for additional legislation? >> with regard to that question we're at a stage or even oral arguments have not been made. >> that is not my question. >> my question is if you lose all you come to congress to ask for additional legislation? to make with regard to the

issue of legislation and the affordable care act well we have always said is the things that will improve the act we are open whether that is the reason. at for veterans and those that have to deal with the firefighters and we will work with congress does it increase access? >> you are not answering my question. if this administration loses the case you intend to come to congress to ask for additional legislation to redress the decision by the supreme court? to make we hope it is the correct position. >> my question is if you lose when you come to congress to ask for additional legislation? >> what we know right now it is devastating in terms of loss of premium or individuals.

we're focused on implementing though lot before us. >> city will ignore the supreme court decision in july? so since you won't answer my question about a legislative solution do you believe your agency has the authority to make the administrative fix to use of lot? >> as i have said right now the current implementation of the al lot that is a question. >> i am focusing on if the administration loses in the refuse to answer my question like if you want to cooperate when i don't understand is why you continue to refuse to answer the question. if the administration loses loses, led to believe you have the authority to make

the administrative fixer will you come to congress for additional legislation? >> i am focused on implementation with regard to those questions we believe that the law will stand civic and asking if you are wrong if the supreme court disagrees do you believe you have the authority to issue the administrative fix or need additional legislation? >> what i am saying is focus on implementation not on that question. >> secretary for well is charming and obviously intelligent but these hearings are absolutely no use to us of the witnesses refused to answer the straightforward question that this witness is doing for quite not sure the proper solution but i would like to visit about that

because it seems this administration continues to parade witnesses in front of committees like this one to deny a straightforward answer to straightforward questions. >> this senator robb like to comment. >> i just want to make clear what i think today is all about. it is the hhs budget, the multibillion-dollar budget that involves millions of americans. that is a topic at hand and i am very interested to work with my colleagues at the other side of the ideal i have shown that and so have my fellow democrats but the idea we will ask the witness to speculate about a court case about something hypothetical that misses the

appliance of the challenge at hand it is about the budget. we have plenty of colleagues who want to ask questions to talk about the topic that was scheduled the was the budget and lot hypothetical. is not the department of justice budget but hhs and i hope we can stay on budget and not as a recitation of a parade of hypothetical is. >> if i could just respond to the ranking member it is the same question you have asked. we are not limited as senators to the topic of the budget we can ask questions questions, any questions about the agency this individual is responsible to

administer to reeved repeated the refusing to answer the questions is as nothing less than contempt and it is the serious matter i am shocked they would take this position and i find it unacceptable. >> to say that this committee would hit with contempt for what we're talking about four weeks. this official has reached out to this committee and people in this country in the unprecedented way and arguing because she will not speculate meaning that it is a contempt is way off base. >> cabbie made any recommendations from your

department that handles these matters better so important as to how they will handle it if the case goes against the administration or the affordable care act is the issues. >> with regard to where i am now with the issues i focus on a. >> wait. wait. wait. we got that point. these are not stupid people up here and you were not as stupid so just say that is up to the president or the justice department and that gets you off the hook. it does not solve the problem because you should be recommending what should be done. >> the justice department is the next of. >> why did you say that? did the justice department. >> i am tired of bailing out

you democrats all the time. [laughter] i think it is the sense of humor that sometimes does not come across. >> i don't think the secretary needs bailey now we have the judiciary committee was speculative matters for i hope we can handle the budget today. but as she continues to answer she is not focused on this, i understand that. then tell us who wishes it is important thing to throw you and all kinds of turmoil and we are concerned. it is a legitimate concern of this committee. to make a long story short the senator raised an important issue.

>> after that. i want to use second what the member -- with the members have said with your engagement of the accessibility has said the new standard and i think we all appreciate that i don't know when you sleep but i know how active you have been and will continue to be but i want to second what the chairman and others have said not to ask the question again but to say we all those his health care proposal has been one of the most impact will pieces of legislation ever enacted by any congress handed affects tens of millions of

americans directly in terms of health care which goes right to the essence of who we are as human beings. and clearly there is a collision potentially coming with the supreme court decision it is probably not likely given the president's very clear admonition how he would not expect any peace that modifies this in any significant way through repeal and replacement but there is a potential collision coming and it would be responsible not to have a plan to address that should that decision come down the way the you like it is just a statement to a firm it would cause great chaos and me totally irresponsible somebody ought to look at what do we do if?

that is the question here. i want to thank you personally for your engagement for almost two years of the engagement for the state of indiana our former governor put into place something called health the indiana plant it has been proven to provide health care for a number of hoosiers there are 350,000 that will benefit at the minimum from your agreement to work with us. there are innovative reforms year on traditional medicare. some are the first-ever. i think it is important for our state to be responsible to prove these innovative

solutions can be of benefit to all medicaid recipients and in that regard i would like to have your assessment of the first of the kind proposals you have agreed to that will hopefully prove their worth to be duplicated in other states or throat the system of the co pay the patient participation or the option to choose a plan the contribution that helps the of modification of health savings accounts and of the referral process for job training or searching it is all combined to we're pretty excited about it i would like to get your thoughts

those of looking at better access for a lower-cost. >> we are able to come to an agreement to work with the governor. one of the first things i did is met with the national governors' association expressing the willingness to work state-by-state process line is to do agreements on a state-by-state basis in terms of continuation to build on the health the indiana plan and there are other approaches that our important to those states waivers are a means by which we can test if they work and how we would scale as a nation if they do we're looking forward to work with the governor to make sure he

could implement quickly and we will find out what are the things we could do better as the program and that effort with the waivers is complemented by a with the association asked us to do so at the time we try things we're doing innovation with payment models to help with financing the state's number of those have received those >> i know those that have proved participated with their contributions to the program we hope to be able to deliver innovative successful solutions. >> is a pleasure to have to before the committee and thank you for your leadership fran service to

our country under challenging circumstances per car want to talk about the issue dealing with community mental health services there is a challenge for people who are suffering from severe depression and getting the type of help they need is a community setting going to primary care there is lack of capacity to deal with their needs they go to the emergency room is empty efficient way in most likely inadequate. there have been some demonstration programs dealing with the collaborative care model where they could get help from a mental health specialist to keep people healthy less costly and better services there are obstacles as medicare and medicaid for this model and

i welcome your thoughts how we can work together to expand these opportunities to offer incentives for collaborative care to provide better services at less cost. >> the issue of available to major payment joker's been a way that is equitable for other types of care is what we are working on and we welcome the opportunity to have a conversation with you as you know, we're also focused on how we can do more community based care that touches all of the delivery reform so we're creating a home health systems in there is communication between physicians sometimes that is

one of the missing links. >> if you need congressional help let us know what obstacles need to be addressed and how we can expedite that collaborative care model. >> i have a particular interest in nih funding i was pleased to see increased by $1 billion their returns are incredible and i think this is a bipartisan interest with the institute for minority health is one that i take pride in that congress created with the affordable care act to receive a slight increase so can you share your commitment to the nih

funding specifically how you see the office functioning under your leadership? >> and whether it cuts across the entire department it has an important part of that approach with regard to that the disparities are great but working through nih and research on the science is what i think about that particular piece to make sure minorities are a part of the system than is in a clinical setting but researchers that are a part of the process that come from these communities and at the same time focused on what we can do is the disparity of coverage and we

focus on as well. >> key we informed with the different offices for retiree health i appreciate that. put on your radar screen pediatric coverage it is more seamless and what we were concerned about with the policies offered and as you know it has been a particular issue so i would urge you to monitor how the private market is working for pediatric dental since this is a required coverage will want to be sure that it is taken the advantage of the those who has gotten coverage through the exchange. >> i have the opportunity to meet with of woman who took

her child to is the dentist for the first time prior to coverage. >> mr. chairman thanks and also secretary i read a bloomberg article i would like to enter but the headline was u.s. overhaul medicaid payments so that was music to my ears than the first graph said the bombing administration makes historic changes how the u.s. pays its health care bills to curtail the costly have it without regard to quality then goes on to say we will tie billions of dollars of payments so actually that was all a quotation from that news article from any state that

makes its way down the fact that the administration says its typical of 30% tuesday alternative payment models is a terrific goal and we worked very closely on that modifier as a way to make sure we're focusing on quality and not quantity. so instead details one of the things we had discussions year is i want to make sure we're setting a big goal to have the incentive to be so small that we're not changing behavior so people talk about 4% or penalty gaps

that we want to see good behavior reworded and bad behavior discourage so what can you tell me how aggressive can read the? >> some of those things to help us get there is the incentive like rewarding good behavior that they will take a hit for doing that and there are tools like that that we see the private sector is moving to care because it is better quality in more affordable for them we have received help than support with legislation as redo accountable care organizations we may need additional flexibility as we learn to what people react

to with incentives i would like to say the pressure of the private sector right now also helps because they're moving in this direction with how they negotiate their payments. >> you think it could be more than a few percent? >> i think that depends on which incentives you are using so those details matter. >> braddish 2016 you can say 30% direct the alternative model only shifting and water to%? that is not interesting to us because we are penalized all the