we do not want that from a fiscal responsibility, and we want that ease of the parent can have a child at the right place with the right care even if it's across state line. i would say we look forward to working with you, welcome the opportunity if their questions

in ways we can provide technical assistance and other things as part of this we welcome that opportunity because we agree with the fundamental of what we're trying to do and believe this is something that can approve both cost and quality. >> i would encourage you and your department to take a look at the bill. it's not illegal or immoral for the administration to issue a letter of support. this is one that i think with chairman upton and chairman pitts, ranking member, full committee, subcommittee, leadership on both sides of the aisle in the south this bill could go. that could be part of chairman upton's 21st century effort or could be a stand-alone bill. i also in the brief time i have want to concur with what ranking member green said about community health centers. i hope we can work together in a bipartisan fashion to find answer to keep those funded. i know there's a funding issue this year that we need to address and reauthorize the program. i have a number of those health

centers and my congressional district, and they are very helpful providing indigent care. and, finally, i was going to ask this question but i'm a little bit puzzled. when chairman pitts as to the question about this report that deals with planning in case the health exchange is at the state level under the affordable care act are found to not be legal the way they're currently funded, if the was a plan and if you had seen the plan, i take you that you were that you haven't seen the plan, but don't you think it's prudent that there should be a plan? i mean i hope i don't have a primary opponent. i hope i don't have a general election opponent but i have a plan icky sticky. i know you hope the court uphold your position by shouldn't the administration and your agency have a plan in case it fails because what we state in the letter and what we believe is

if the court decides, which we don't believe there will but if the court decides on behalf of the plaintiffs, if the supreme court of the united states says that the subsidies are not available to the people of texas, we don't have an administrative action that we could take. so the question of having a plan, we don't have an administrative action that we believe can undo the damage. and that's why when i was answering the chairman i think it's important to understand what the damages. because then comes to the question of we don't believe we have any administrative -- >> my time has expired but if the court instructed him from the administration is just going to hold up your hands and saying we surrender? >> what we believe is we believe the law that stance is how it should be elevated. implanted. with regard to when the supreme court speaks, if the supreme court speaks to this issue we do not believe that there is an administrative authority that we

have in our power to undo it. and so that something -- >> thank you, mr. chairman for your courtesy and the minority for letting me have extra time. >> now recognize the gentleman from new york mr. engel, five minutes for questions. >> and give very much mr. chairman. welcome, secretary burwell. let me take you back on the backup plan. i was part of this committee. i participated in months and months of deliberations for the affordable care act. we had weeks of markets this committee did, and not once was there mention of subsidies not being available to individuals and states that it does have their own exchanges. i've heard a lot of complaints on the other side of the aisle about the law but never was this issue discussed until the lost to the supreme court in 2012. some of my friends signed onto amicus briefs and waste

incredible time forcing votes yet their upset the administration doesn't have a backup plan to the supreme court ruled threaten the availability of subsidies. i think it's somewhat ironic that my republican friends are demanding that this administration ask problems that they themselves created. and it shown zero interest in fixing. should republicans get what they want, supreme court rules in favor of king i would urge my colleagues if it should happen to pass legislation to ensure that americans have continued access to affordable coverage through the federally facilitate exchange, just as democrats intended. next month the affordable care act will have been the law of the land for five years. it's not a perfect law and there are issues that need to be changed with it but i would like to see this issues addressed and let those of us in a bipartisan way to our focus on improving the law and enabling more quality coverage options for our

constituents instead of trying to kill it repeal it taken to court and things like the. i just wanted to say i'm sure that you agree with what i just said. >> yes. we look forward to moving forward and want to make improvements if we can. >> i want to use my home state of new york as a good example of what's possible when the federal government has a willing and enthusiastic partner in the affordable health care implementation. as a result of our successful exchange and medicaid expansion more than two for 1 million new yorkers have quality health care coverage. our rate has dropped only 10% and there's clear evidence we are reaching the right people since 88% of people who came coverage through the exchange reported being uninsured at the time they enrolled. so it's really working in new york. the health insurance options available through new york state of health are on average 50% cheaper than the comparable

coverage available before the exchange was established. i want you to know i'm sure you know what that the aca is working and working well in new york. that's why i really think it's terrible that i've been forced to take more than 50 votes to repeal some or all of this law. we should fix what's wrong. but in my state it's really been a tremendous success. >> and fortunately i've had the opportunity to travel the country and see the individuals. those are the numbers and individuals, whether it's lower in florida 26 years old married to someone who's a truck driver who does not coverage, she's trying to be an x-ray tech they did not have insurance but she knows insurance with a premium of $41 a month. or a woman who had ms in the state of texas and for 17 years she had not have health insurance and so how people go about, she traded treated her ms to the emergency room inches for children and she works. and it would get bad enough that

said she would do. the stories of what it means to people in terms of the financial and health security i think the numbers are important but it is those stories which really makes this real. >> and you know, secretary burwell, i understand we've seen robust exchange enrollment nationwide even in states where republican governors refuse to set up a state exchange expand their medicaid programs isn't mr.? >> so the numbers, i spoke to this yesterday when we were able to look at the numbers, 53% of the enrollees in the marketplace this year in the federal marketplace our new enrollments. i think that is indicating that demand for the product and the need for the product. >> thank you. i want to second mr. pallone's positive discussions about chip. i've always been a strong supporter and has a july 2014 and s. metaphor hundred 76,000 children were enrolled in this affordable coverage option for their care in new york and so i

think that is really, really important. i was pleased, therefore to see that the budget proposal for fy '20 six included funding for chip for the next four years through fy 2019. so can you elaborate on why you believe increasing tobacco taxes is a viable means for funding this program while we sort out the transition issues associated with the affordable care act? >> we believe one of the things in trying to be fiscally responsible and indicating how we are paying for things we believe this is a legitimate way to pay for things especially in the context of we are providing health care and something that will hopefully create a deterrent and help health care in terms of the issue of a tobacco tax. as one analyzes across the department and whether it is that cms or cdc the impact that tobacco was on health in our nation and the cost of health care information is one we think is a fair place to go to pay for this care for the children. >> i agree. and, finally want to talk about

graduate medical education because i was concerned that the administration's proposal to cut funding, one in six positions in america obtains training in my home state of new york and we have some of the finest academic medical centers in the country. it requires significant funding and time to develop the infrastructure and expertise necessary to ensure quality care is available. so how do we ensure stability for these academic medical centers and the patients they serve that put gme funding at risk because we believe and hope our proposal does not do that and meets the objectives of making sure we are training a proposition for both primary care and specialty store we don't have as many as we should. at the same time making sure we target it. there's 100 million for pediatrics and a wider pool for competition. it's an issue we want to make to meet the same objective at the same time we do a fiscally responsible it.

>> not recognize the vice chairman mr. guthrie. >> thank you, madam secretary for coming. i look for to work in 21st century chairs and all things we can work on over the next year as vice chair. first of i to direct your attention to the cost share reduction program contained in the aca, specifically sections 1402 and 1412. does any part of this budget that we're talking about today request any new authority including any transfer authority to pay censures under the cosh a reduction program statements with regard to the program which is a program as you know is about making sure that the cost of health care to those individuals that are coming into the market place is something that they afford. that's what it's about we believe we do have the authority to do the cost-sharing. >> is there any authority requested in this budget speak with no new language. >> we do know it's up and running. i think we spent $3 billion already on the cosh a reduction program. the budget that's been submitted

estimates 11.2 billion over 2015-2016. cbo says 175 billion is what is estimated. could you side with the appropriations authority is? you said you to do believe you are the authority. >> i'm sure you know that right now this is an issue that is under litigation and a court case that has been brought. so with regard to that that is an issue i will let our colleagues at the justice department speak to because of the place it is in litigation. >> i understand that but we are doing oversight. i'm not an attorney. when you were at omb in 2014 there actually was a request in the 2014 budget for direct appropriation. that didn't happen for whatever reason that we're spending money. whether we spent the money or $175 billion, we feel like this is oversight hearing so we feel like it's our responsibility to make sure to our taxpayers we have a legitimate, that answers on where this is coming from.

we just asking for where the appropriation comes from. >> understand and appreciate the question, and i'm sorry that it is in litigation. i wish we were not in a place where we are in litigation but once something is entered into the place of those great a difficult -- i respect the issue of oversight but because the litigation has been brought by the house on this issue we are in a place where i think that is the appropriate place for the composition. >> i'm just not aware of any pending litigation exception in oversight hearing questions, and is there like a legal case or authority? >> with regard to issues that are being litigated, generally those are matters that we refer of that the justice department continue on. >> we've never been able to get an answer from the administration for where the language -- no one has been able 2.2 is where the appropriation language comes from. you put us have requested

appropriations. recently you said you received the think 18 employer groups and children urging the small groups be maintained at 50 employees. they were citing an analysis that showed when they go to 51 analysis said that it was estimated that two-thirds of the members that they would receive an increase. and -- of 18%. and i don't believe that the small outpost 50-100 employers can accept an 18% increase in the premiums. also the promise that if you like your plan you can keep it because if they have to go into the new plans they like to meet the requirements of the health care law that cause other people to lose the plans that they like. due to this impact would you support allowing states to keep their market at 50 or below, not go to 51-100? >> this is an issue that we're looking at and examining because we have had a number of comments

on a. i would welcome the opportunity to see these for that you are talking about and referring to so that we can see and understand the. what we want to do is understand the facts around this type of thing so i would welcome the opportunity to see this day and piece of work you articulate. >> it's been said that it from to put but we will make sure that has been forwarded. well, thank you, mr. chairman. i yield back. >> not recognize the gentleman from illinois and she tells the, for five minutes of questions. >> thank you, mr. chairman. and thank you, madam secretary for being here today. i wanted to ask if you are aware of any republican legislative proposals that would keep insurance companies from denying coverage from people with pre-existing conditions like cancer or dropping someone from coverage because they got in an accident or got sick? >> i'm not aware of the piece of legislation that would take care of that issue.

>> and argue over the new republican legislative proposal that would provide access to preventive services like cancer screenings come yearly wellness exams, and do that at no additional out of pocket cost to consumers? >> i am not aware of a piece of legislation that would do that in the fulsomely that the aca does. >> thank you. i wanted to talk a little bit about something that is a growing concern, and that's alzheimer's disease and the cost that it is in our personal lives and also in funding. so scores of public agencies, including many h. s. agencies as well as numerous private and nonprofit organizations are trying to address this challenge of preventing alzheimer's serving those who have dementia day, finding a cure. shouldn't the federal government be coordinating a plan on alzheimer's? >> in terms of the issue of coordination there is a body and

advisory group that includes both people from the federal government as well as external folks to be a part of putting together our thoughts and strategies. it is informed the way we're doing investments. there are members of the federal government across the government as those external bodies that aren't part of the. with regard to the work at the department, the work cuts across a number of different areas, nih and research is jenny what comes to find out where the biggest dollars are spent is actually in cms and making sure we are thinking through the issues in a state because that's where the dollars. the other thing is committee for living where we were going to think about things like those that are caregivers and those that are going through the process of dementia and how they deal with it. as a department we work through all of those. there is this overall advisory group we have externally and includes internal members. >> the population is aging rapidly obviously, and alzheimer's is taking a much bigger poll -- toll and the

number of people living with dementia will continue to grow as baby boomers age. you mentioned the research that is going on, so what is hhs, and h. doing to find if you're? >> in this budget you see a 24% increase to funding for alzheimer's which is much greater than a% increase in within the other nih. focusing keep on doing that but it's also part of the brain initiative as a think through their specific issues but were also making progress on something called -- at protein is indicative of all summers. that's when the pieces of research that is going on if we can make progress there the other piece of research using if there are ways that we can slow the progression by understanding how the channels move and was happening in the disease. those are pieces of research that we are starting we believe that with many were asking for we can move that research and we

can broaden it and we can make it faster. >> damage is a major focus of work in the united kingdom and other developed countries. are we keeping up with the rest of the world in research the world in research act of these an investment? >> no. we believe that we are with regard to that and i have been in touch with my colleagues and the secretary or the minister in the uk and continue to those conversations we make sure we are learning and stay connected to our colleagues, especially that's a particular template have been in touch with minister hunt and will continue to do this we make sure we are learning everything we can former colleagues. in places where we can work together, see if we can leverage the efforts that are going on in each of the countries both across the research, regulation as well as the more social issues. >> is on the alzheimer's advisory committee? i'm asking that because shouldn't there be a person with alzheimer's as part of a group

of? >> i want to get back to directly but it is my understanding that there is a person, that there is a slot and that there is a is or will be a person that does have, but that is part of the committee. i want to get back to you on a specifically. >> i want to thank you for the focus, and as the co-chair of the seniors task force of the democratic caucus i would want to work with you on that because this is a problem affecting so many families and individuals. i appreciate it and yield back. >> now recognize the gentleman from kentucky nestor whitfield, five minutes. >> secretary burwell, i want to thank you for them with us today and i want to follow up on my colleague brent guthrie's question. we are concerned about this cost reduction program because caution program because it's 170 some billion dollars over a number of years. and we understand that that's one of the issues involved in

the lawsuit. but all we are asking it is since you all are dispersing the money, what is your opinion as to where the appropriation is designated you are working from? >> this is an issue understand the question we believe we have the authority. with regard to the specifics of that because we are in litigation -- >> but you can you can't tell us where the money is coming from? >> with regard to having a conversation that is what -- >> were you instructed not to answer that question? >> with regard to that specific issue, that is at the root of the litigation. >> were you instructed by doj not to answer the question? >> with regard to when the are issues of litigation like this, this is our standard disputed yesterday we had gina mccarthy here and we were talking about 11 d. which is before the supreme court right now and she gave us a third of what she thought she was right. we are not saying that we are

right on your right a person by asking what is your theory where does the money come from in your view? >> that is something as i said why don't they work to get back to you on where we do come true with regard where the litigation is an outlet to come back on the. >> i must say i have been oppressed with your facility to use numbers. you are really tuned into the budget can responding to mr. pitts, responding to mr. green about community health centers. i was at a road reef club meeting recently and i was asked the question, they said congressman, can you tell us what dollar amount has been incurred by the federal government as a result of state expansion of medicaid programs person to the affordable care act? because we picked up a larger percentage of the normal cost. and i would ask you that question. i did know the answer but could

you tell me what is the total dollar amount incurred by the federal government by the expansion of the state medicaid programs as a result of the affordable care act? >> in terms of the federal dollars versus state dollars of? >> yes, just the additional dollar amount. >> let me go back and look because the question of being able to disaggregate whether a person came in because of expansion or were under the old rules, i would want to picture we can understand -- >> you don't have a dollar amount for that? >> i don't know. i will check with the department. the one thing -- >> i think you all would definitely know that. we can all talk about the bandages and disadvantages of this program, but there is a big additional cost to the federal government and we're simply asking, i'm asking what is that total dollar amount? >> i think the question i am not sure is how one breaks out the actual number from expansion. because when people, through --

>> let me ask you this question. at what year the states were encouraged to expand medicaid which is fine because the federal government is taking up more of the dollar amount. at some point in the future the federal government is not going to be picking up those additional costs. what you is that? >> what do that is is we never go below the federal government never goes below a 90% of the payment of the additional. and that is -- >> when? >> 2020. so 2016 is the year for which there's 100%. in your own state -- >> do you have any projected cost for the federal government? >> we do have those incorporated in our budget but want one of the things entrance of these cost issues which are important in the state of kentucky -- >> that's okay. you can answer the question but i appreciate it anyway. let me ask you i notice you all made $2.5 billion in loans in the co-op. kentucky is a good co-op program as well. we sent a letter last year and

we're concerned about the solvency of some of these co-ops. federal government has loaned $2.5 billion. we now see that in iowa and nebraska those co-ops are in bankruptcy. have you will done any analysis to project, are there other states that there's a chance that these co-ops could go into bankruptcy? >> we are looking at the co-ops. the one thing that's important to note is the deep cuts in the funny for co-ops. when the program was originally designed and the passage of the affordable care act occurred in nutty buddy for the co-ops to do the loans and the loans in states like iowa felt would've made a difference, at the end because the money was cut, they were part as -- they were cut as part of sequestration. >> are you saying the bankruptcy card because of sequestration? >> had we had more funding in order to provide the additional

loans to the co-ops, it could have made a difference. with regard to the fundamental of your question which is are we looking at the co-ops the are two things we want to do. understand whether they are stable, and then the second is where we can provide technical assistance. >> those questions that you couldn't answer or were not familiar with, i do hope that you'll get back with us with those answers soon. >> be happy to. >> within seven days if possible spin i want to make sure that, we will get back as quickly -- >> because i've got to be back to that rotary club and next week. >> as a neighboring state i appreciate that. >> the gentleman yields back to the chair recognizes the gentlelady from florida for five minutes. >> thank you, mr. chairman. madam secretary, thank you again on behalf of the 1.6 million floridians that were able to buy affordable health insurance in our exchange. i will give you credit and to advocate hhs but i think the real credit goes to our terrific

navigators that were on the ground in hospitals across the state of florida community health centers and family members that probably put in a good word for their sons and otters or ants and locals to sign the. you probably want to give them -- and and locals. you probably to give them a pat on the back. >> i have seen the local stakeholders and met with them across this country and it was the king is coming but it was individuals, people in the committee health centers. as was mentioned it was the business people, everyone when i would visit the hospitals, everyone would be around the table working on this issue together. it was that work and individuals that i visited on the second sunday in texas. actually given the opportunity to speak at one of the churches and it was all of that coming together to give this information to people so they can make choices and have the financial and health security.

>> in florida we have a very competitive marketplace as well. consumers can choose from 14 different issuers in the marketplace. that was up from lester where we had 11. florida consumers could choose from an average of 42 of plans in the county for 2015 coverage. so with 1.6 million now enrolled it demonstrates the high stakes involved with the supreme court case that the court will hear next week. i cannot imagine that the court would rule to take that away from over a million and a half floridians and millions more all across the country. just like mr. engel said, i was here during the hearing in advance of the affordable care act, the adoption during the markup during the amendment process, during negotiations with united states senate. never in those discussions was there any dichotomy between a

state exchange and a federal exchange and the availability of tax credits. have you seen any evidence to the contrary in your review of the record indicates that is before the supreme court? >> with regard i would let the justice department who has reviewed everything, that the thing that i agree with is we don't think that that was, we just simply that's what the law says or what was intended by the law either. >> and i can say straightforwardly as a member of this committee what the legislative intent was. it was for those tax credits to be available to every american no matter if they're in the state market place or federal marketplace. but i would say if the court rules otherwise, they are going to create chaos and they're going to strike right at the heart of the economic security of so many of my neighbors in florida, and many americans. so i know that they will study the legislative intent, and i

hope they will the right way and we don't have to address that chaotic situation. but i think with the affordable care act the real untold story is what has happened to people who have insurance. because i can cheer on the million and a half floridians who now have it but most of my neighbors already had insurance. private insurance or medicare. i notice the more good news that was announced this week for per my neighbors that rely on medicare. just in florida alone floridians have saved almost $1 billion since 2010 because of the aca clinical discount. almost 350,000 beneficiaries saw savings in 2014, to the tune of about $300 million last year. the average discount per beneficiary was $884. then for private insurance, how can we have made able to get the

word out on how much better an insurance policy is? a consumer can't be kicked off if they get sick. in florida alone over 200000 young adults can say on their parents plan. floridians have received millions of dollars in rebates because the law says you have new rights and protections and insurance companies cannot spend that money on profits. it has to go, it can't spend the profits on salaries and it has to go to the health care. what else can the legislation to do to tell this good news story? >> i think we can do a better job of making sure people do know and another area is the issue that prevented care and the importance of the fact that your childhood visits and those things are no longer require co-pays or cost-sharing in terms of when you go in for that or measles. and important thing i think right now at a time within. i think we need to do better job of making sure people know about

those improvements to quality. >> thank you. i yield back. >> chair thanks the gentleman the and recognizes the gentleman from illinois. >> i talk to your staff prior. i appreciate your outreach trying to call but it was a crazy day come at a talk to them before you came to the table. and i do have great respect for the. but i also want to make sure that this has declined to talk about how great health care is in the affordable care act is moderated by real concerns out there. i remember the bill that passed under the we've nothing to do with on the house side but it was a senate health bill that came over to us that we passed. so that's the health care law that we have today, and the language of the law is pretty clear. and i'm a also concerned that the supreme court will rule that the federal exchange is in states are not authorized to

receive subsidies. and we just need, we need to be prepared for that here and i would hope you'd administration would be. i promise to latest my congressional district i would mention their names, and she asked her from apocalypse who is a pro-life strong family and she cannot buy a policy that does not have abortion or abortion coverage. and for millions of america this is a really important issue. she, this is an emotional, just like on the other side, you have this debate is. and i think part of the agreement from so much less like democrats was to ensure that that option would be available and it's just not order. the other one is debbie mckinney have from a town called highland. she's a democrat. are premiums went up astronomically. this should have gone up another

$2000 a $10,000 deductible. she can't afford it. so for all the happy dances that are challenges out there that we don't to our constituents service if we don't understand that there's problems that have to be resolved. there's some budget requests that are want to talk about so i will move forward, but i just put that in the record. i'm a big supporter of medicare advantage. i was here when we passed it. seniors didn't have any prescription drug coverage been very successful, it's very popular. the budget request makes a reduction again in that where the enrollment is going up, favorables are high. 6-under 70,000 people were not able to access medicaid advantage. and if you're from rural parts of this country, that option is very limited. or it doesn't exist.

so i would ask that we look at that so that seniors want to have this option can choose that and our concern is your budget hurts the ability want that to happen. >> with regard to the first issue come in terms of york to constituents, i want to make sure we understand the. on the issue of the question of abortion and -- >> let's just come answer this question because i have two more on budget. >> with regard to the come will to make sure the program during the period of changes we have had, we have seen a large increase in the number of people in medicare advantage blend. i want to understand, 99% of beneficiaries have access and there may be something so i'd like to understand that 670 better to the third thing is we know that this number of plans calling that a conference for stars, have gone to the high ratings, 67% in the two highest rating categories, 17% to 67% so

we are in improving quality more people in the system and there is in control. want to understand the 670. we want to make sure and a listing. we alter our plans as we are concerned. that's what i want to understand that 670. we believe we continue to make these changes comes back to some of the points the chairman gray with regard to deficits of make a shirt we are being responsible. medpac and the gao have recommended a -- >> thank you. are you aware of any efforts by fda took some great the next round of user fee negotiations? and our concern is if they are they are not doing due diligence about the fees and the return on investment, we would hope that they would not accelerate it and tell due diligence is done. the last thing i wanted to address with the biologics price competition and innovation act. stakeholders have to be involved in that. that's really part of the 21st century jurist debate, not just having bureaucrats or panels

but bringing patients, bringing physicians, ring in the like. our concern is that's not happening on this, on the biologics price connotation and innovation act and those concerns. so if you would take that for suggestion and if you want to come back and follow up on a lot of these issues we be happy to talk. again, i appreciate you reaching out personally spent i do appreciate his stakeholder input. you think it's important making sure we get this right. >> thank you very much. >> the chair now recognizes the gentlelady from california, ms. matsui. >> thank you, mr. chairman. secretary burwell, thank you for being here. i want to talk about mental health. when we talk about health we need to consider the whole person. mental health has a stroke of taken a backseat to physical health, but the head is connected to the body and one affects the other. i have been working for years with my colleagues on both sides

of the aisle and both sides of the capital to make changes to fix our broken mental-health system. as you know a demonstration project based on the essence of mental health act that i co-authored with my colleagues here congressman lands, into law last year, and i look forward to working with you and the administration to make sure this is the budget properly in a way that states can demonstrate success. i also look forward to working with you to make further changes to improve our mental-health system. i was pleased to see that the budget will eliminate medicare's 190 to mental-health services more in line and keep it more in line with the physical for which no limit exodus. can you briefly talk about that policy and how it will benefit seniors and people with disabilities who need psychiatric services? >> our overall approach in the mental-health space is one that we consider a priority.

it's to try and get in terms of both care and payment to parity with how we think about other health issues. there are steps we're taking to the budget and whether its implementation of a piece of legislation that you refer to. the issue your college raise about stakeholder engagement and making sure we didn't get it but as a government. so we are implementing a think about the policies to promote behavioral and mental health to our payment system and making sure that there is parity. that seems be something that's been important we are trying to focus on ask is because many people, the question of access to the right types of providers in terms of behavioral health that's something you see in some of our time budgeting work and making sure samsung and others are ensuring that we have providers. then there's access -- samsara. especially young people getting access they need but as we think about all the pieces working together about the funding come about the access and then that the our providers spent i

appreciate that and as we move forward there is a continuum of mental health issues and we need to address. if the competition we certainly would like to work with you as we move forward on that. i would like to talk about seniors. as we consider changes to the medicare program our first query should always be seniors especially knowing that seniors spend about 14% of their income on health care costs compared to 5% households who do not have a medicare beneficiary. we need to find ways to save money in the medicare program and we have been, not by cutting benefits but by realigning incentives to improve outcomes in patients care. if a scene he gets the right care at the right time, it's not only better for the senior but also saved the system a lot of money. i would like to discuss these further with you. the budget seeks to save money

by restoring drug rebates are the dual eligible population in medicare. can you please elaborate on that? >> in terms of the dual eligible policy? the drug rebates, the dual eligible population. >> the dual eligible population has two elements to it. it is both a very complicated population because there are people who have a number of different conditions they're being treated in different ways. it's also very expensive population. as we work to improve both the quality and affordability of the care, that's a weird idea as we look at these proposals. it's all a part of a broader issue deliver system reform which you touched on a bit. we have set out clear goals for the first time ever we have said that any area of medicare, that by 2016 we have set a goal that 30% of all payments will be indifferent payment systems. where we are not paying for volume but paying for value. as a part we move forward to

this system we want to do that, that's about price but it is also about quality and this is a proposal we're trying to move forward on both. >> i know this would be difficult because there are areas we have to look at the budget but as we look at this we also have to look at seniors. that's why women look at this i know you seek to increase skin in the game for medicare beneficiaries, however i would argue that seniors already have a lot of skin in the game in medicare and that additional cost sharing will not bring down costs in the program. as these increased costs you look at most of them are supported by those and security and then what they do is shift over the cost to pay for the health care from social security. i think it's something we have to look at more holistically. they keep very much for everything you're doing. >> now recognize the gentleman from pennsylvania, dr. murphy, five minutes for questioning.

>> i also want to associate myself with the comments of my friend ms. matsui, a california about mental health and look forward to working with you on those things. we've had a number of hearings here regarding mental health and the mungo has been the substance abuse mental health administration. was asked repeatedly for information over almost a year for getting some records. chairman upton and i have asked for these things. we have not gotten of those documents. we're concerned about the delays. i wonder if you could help us get insurance will get those documents from try not? >> and we had the opportunity discussed this is something we're working on and hoping soon you have those documents and we will continue to work with you. >> on another question when we passed the sgr patch that was last year, there's also a demo project which is what ms. matsui was also referring to for behavioral certified health clinics to improve access. as part of this we also have had

something for assisted outpatient treatment four counties and committees who also have access to some grants to facilitate that as long as they also this community health clinics could get those to also for those who are cycling through with violence prison, homelessness et cetera. that's small 1% of 1% or persistent and chronically mentally ill going through the system. what it want to find out for me is the way this was designed is to make sure that only those counties that really have aot would be eligible for those grant programs that they're going to attach those to this committee health centers but is this something you're aware of and can you work with us to make sure those are available in a since? >> do want to work with you on that and just we are working on that and want to work with you to make sure we are the standards in place. >> another one has to do with a program that was discussed by samhsa called eyecare. which is to help with those

going into emergency rooms. to do with those in crisis one of the concerns i have and certainly we've seen headlines the tragic said case, the problems are thousands of times with her simply enough psychiatric hospital beds the people in which emergency rooms often tied down and giving chemical sedatives or could be hours or days or weeks in some cases. we wouldn't have this problem if we had more psychiatric beds. so i'm hoping that since the man per bed the something else you can work with a legislation to say what other place for those in crisis get stabilize, not go to jail, not sit in a jail cell and languish in their or sit in an emergency room. work with us on the would you be will and to work with those on the?

>> yes. >> another issue related to the assisted outpatient treatment grant program, a standalone thing. i think i have a poster. just want to show some of the outcome measures. this comes out of a duke university study. when you have assisted outpatient treatment, so working with a person say you need to stay in treatment for a number of months, outpatient didn't come that inflation. take her medication, see this person the report back like with the mental health courts on the is on a 7% reduction in incarceration, 83% reduction in the rest 77% reduction in psychiatric inpatient hospitalization and 33% reduction in emergency hospitalization. and by the way, the costs are cut in half of these folks. it is one in working with the issues of cdo-squared, et cetera we will have to i think team up together and figure out to be some people to get outpatient care. peer support, social workers people helping with job

training, housing all those things together but there has to be this coordination broken. you will work with us on this? >> we will but i think it's a part of a broader form of how we deliver quality. when we look at diabetes and the clinics i visited across this country can when we get these numbers up and people participating in that use has to do with coordinated care, the that type of interaction and communication you're talking about and we get a tears, less of the disease or problem and we get lower costs because the things that happened was the ethics of go wrong when people are not adhering. >> and i think you may be familiar with hearing we had in the oversight committee two weeks ago. where the gao report identify, i was amazed by this 112 federal agencies and programs scattered across eight departments to deal with mental illness. they said the interagency coordination programs is lacking. it was really to me a really

dizzying and set description of the process. i hope you also work with us as we work to coordinate those programs. can i have that assurance as we'll speak with we will. we do coordinate coordinate across the overarching issue and then within their areas like veterans homelessness and the issues that really. so want to have a conversation about how we think where we can strengthen those thanks. >> thank you, mr. chairman. i yield back. >> now recognize the gentleman from oregon, esther schrader. >> thank you, mr. chairman. thank you for being here madam secretary. >> thank you. >> last year after spending grew at the slowest rate on record since 1960. health care price inflation at its lowest rate in 50 years. acscan a lot of attributions by cbo for making a big difference in that resulted have you seen a republican legislative language that would give us the same result?

>> we haven't seen a proposal that would continue us on a path with the course of the changes we have put in place. >> seniors have benefited dramatically from the aca. prescription drug costs are a big issue for them. over 8 million seniors have actually benefited from and saved over $11 billion as i understand it on prescription drugs since the enactment of the aca. is that republican proposal out there that does a similar thing? >> we haven't seen a proposal that would take care of this issue of the donut hole. actually on tuesday we were able to update our numbers in that space, and it is now $15 billion in terms of the savings. and on average in the country that's about $1600. >> i find it ironic my colleagues on the other side keep asking for contingency plan on this bogus lawsuit. and as yet as a firm believer in article one legislative supremacy, with all due respect i think it's our responsibility

and majority party who controls both chambers, where the heck is the contingency plan? that's a rhetorical question, madam secretary. one of the things that's been really good i think in my state is the expansion of the affordable care act into the medicaid publishing into the private sector. we've had some unqualified success, emergency room visits are down like 21%. we've gotten hospital admissions complications from diabetes alone down 9%, not to mention of the disease. copd, hospital stays down almost 50%. are you getting any of the same the same type of results from other states because we all are and recently actually in the last two weeks out of the state of kentucky we've seen a piece of analysis done by the university of louisville and deloitte. that piece of legislation, that analysis showed they did at the

beginning of expansion and then they did the analysis now. what the analysis showed is that the expansion will country but to 40,000 jobs in the state of kentucky and will contribute to their gdp by $30 billion that's the period to 2021 so that is a period of over -- that is a good overtime. we are start and see the impacts as those health impacts you were describing. >> contrary to popular demagoguery on right wing radio and tv this is a markedly system we set up federal government as the facilitator in that. estate, hopefully some of state exchanges as facility. like everyone i think we all believe in the power of marketplace competition. my own state over the last year instead of seeing double-digit increases in insurance premiums on average ours actually state level or decrease slightly. that king is a key indicator are the working or nonworking affordable care act.

our uninsured rate in oregon went down 63% to and testimonials from and doctors about how people actually have health care access at this point inof time. could you talk about what you seen nationally and increased competition speak with with regard to age of increased competition we saw 25% more issuers come into the marketplace issue. more issuers means more competition. >> it wouldn't be doing this if they want making money and the program wasn't working. >> with regard to the issue of competition what we know is in many plans that are employer-based coming people do not come in and shot. pages automatically reenroll. we have that as part of the market place this year, but we know that actually the majority of people came in and shot, and that i think it's related to the competition and its related to the consumer who wants to make the best choice. actually sometimes based on benefits, sometimes based on cost. cost has a number of different

elements whether that's preening or deductible. we are seeing more players come in and we're also think the consumers behave in a way that is indicative that they want the competition in shopping. >> i would like to call up some kudos on the gma increasing the budget the money you put in for medicare appeals back on the we do a lot of work of course of people having trouble navigating the system. big time. and investment in primary care docs but i think that's important to quick little comment. don't think i'm concerned about is if we're going for bundled payments and increased competition why we're hammering on the medicare advantage plans a little bit? >> as i mentioned to college i think what we're trying to do is out of. >> issues plans are good and strong and we've seen over the period of the changes we've done. we tried to changes in a measured way. that gets two things that i tried to do with what we believe is a strong representation of the taxpayer in terms of place where we believe there are issues like up coding that is occurring.

medpac is articulated those and others but we always want to listen and hear and watch carefully if we are seeing problems that occur that to date we have an. >> now recognize the gentleman from new jersey. >> thank you, mr. chairman. secretary burwell regarding king versus burwell, i understand what you have said, that there can be no administered actions should the plaintiff when the case to you have explained that explicitly and repeatedly, and that is not my question to my question relates back to the chairman who said in his opening line of questioning that we have a specific source within your department that there is a document related to what hhs might do should the supreme court ruled against the administration. i understand that your point of view that there can be no administrative action. ustr that explicitly. are you aware of any such

document, not asking about your position on administrative action, i'm asking about a document in this regard? >> if there is this document and you know of it i would certainly like to know of the document. i don't have knowledge of a 100 page -- >> i didn't say when the page did i? i just had a document. i do know how many pages. you are not aware of any document? >> i have come as i've said there isn't administrative action -- >> i don't, i made it clear that understand your point of view on that. is there a document as to a reaction from hhs should the case be won by the plaintiff in the supreme court's? >> with regard to a reaction, as i said, because i've articulated that, want to be careful because i have articulate speech as i have tried to be careful. >> the problem with regard to this question of what will happen we know many people are in the marketplace, how many -- >> yes, that is filibustering.

i understand that. i'm asking whether there's any document can we have a source indicating there is a document as to what might be the response to hhs. >> i am not the money with the document you are referring to. >> let me say thomas cooley from the bush administration, has said of course they have a document. he said of course they have one i think refer to a document. they should all resign if they don't. i would hope that your department, madam secretary, but of some sort of contingency plan should the court rule pro-plaintiff. do you believe that the suit is bogus? >> with regard to the lawsuit, as i said, what i believe is pathologically -- >> yes, i understand that. do you believe this is bogus? >> that is a characterization. my point about the suit is what i believe is that we hold the right position and that -- >> i understand that and it will be argued next week and a

decision will be made by the end of june. formerly were asked questions about this, not from you that regarding artificial scum it was an impression it was a frivolous suit. deeply the suit is frivolous or bogus? >> what i believe is the we should continue making progress for the mac and people on three things that the affordable care act -- >> i am aware of that. do you believe the suit is frivolous or bogus? >> may i finish, congressman? i believe that we as the executive branch and the legislative branch should be working together on three things we agree with. that's affordability access, and quality. >> i agree with all that. >> and what i would hope we can do is build on the progress that we have seen. and that progress is that 11.4 million -- >> reclaiming my time. do you believe that the supreme court is likely to ruled unanimously on this decision? >> as i've indicated we believe that the court will rule in our favor.

>> do you believe the suit is bogus or frivolous speak with with regard to characterization what i think is vital is that we put that our position is a position that will stand and we believe we are right, that people in the state of new jersey should not have their subsidies taken away because they do or don't have a marketplace when people right across the border in new york would get those subsidies. >> i believe in equal justice under law as inscribed across the street in the supreme court building. i believe this is a very serious case but i think it's closely contested under no circumstances do i believe that plaintiff will win unanimously. i think there are good arguments on both sides i read the briefs, the solicitor general's brief, i've read the briefs of the plaintiff. i think the very series kate and you and i may disagree on the case but i respect and understand that. it's frustrating to me that here in washington there cannot be an

intellectual argument as to pros and cons. and i certainly would encourage the administration to have a contingency plan, and to work with us in congress including the republican majority in both the house and the senate should the court ruled for plaintiff. thank you mr. chairman. >> congress can come up with regard to the question, our authorities can what you just end with was the issue of legislative and i want to make sure that i touch on that but as we've said all along we are willing and look forward to working with the congress on any legislation that would work on those three things we talked about, affordability of axis and quality, and preserve the economy and support the working middle class. we want to do that and we want to do that -- >> and i was part of the group that had an alternative piece of legislation that didn't see the light of day but forced by the tuesday lunch group, of whom i'm a member of that group. it was different from the affordable care act but it was an alternative piece of legislation to of course he

didn't see the light of day any way, shape or form in 2009-2010. thank you, mr. chairman. >> now recognize that gentlemen from massachusetts. >> thank you very much, mr. chairman. you touched on a moment ago about legislation that you said you were eager to work with democrats and republicans on. have you seen any such legislation? >> with regard to legislation that would promote and move forward on those three things the issues of making sure we're expanding that insured population have not seen things that would work towards that. >> madam secretary, are you aware of how many bills were passed and signed, bills passed by the 113th congress? >> i don't know the exact number number. >> ever take a few, 931, sound about right? any idea on how many of those bills were signed into law? to it in 96 sound about right? any idea how many times in my first term in congress we repeal

all or part of the affordable care act? 55 sound about right? if you get how many times those were signed into law? none. are you aware of how many times we put on some sort of replacement bill to the affordable care act that we voted to repeal 55 times to provide americans with quality, affordable access and financial assistance to access to health care that they deserve? spent i think the number is none. >> i would agree with you. ..