t ttp has the potential to raise standard and open new markets to american businesses workers and farmers. he farmers. he makes suggestions on how to do so and that's why i support the substitute and in the course of the debate and on the trade promotion act, i hope they will say we should have more congressional consideration consideration, transparency and leverage for the congress in that bill. i also want to put to rest him things i have seen lately that democrats voted for fast tracked to president clinton but that really didn't happen. the vote in the late 1990s a bill in 1999 was brought to the floor and only 29 democrats

voted to fast-track and the vote failed and he did not get the vote. in 2001 under president bush 21 democrats voted for fast track. that didn't prevail with the republican votes. there was a tie it was 215 to 214. the republicans were equally divided. we said you can consider these bills in the congress on a fast-track if you abide by the maids have an agreement which we work with the administration on that honored the ilo principles and list of standards that had to be met as well as issues that

relate to endangered species montréal protocol and other environmental issues that were contained in that. i want just to say that we've always had the lively debate on the subject regardless of who was president of the united states. it's not a question of well democrats stuck with president clinton but didn't stick with president obama. that is just not the case. we need to ask what this does to the paycheck of american workers. this is the debate were having. what is being put forth is that better than the status quo? in some cases yes and in some no. what does it come down to four

increasing the paycheck of american workers? that's what we are committed to and he is so eager for us to come together as am i and we just won't give up because we feel it will be a missed opportunity to say not only are we concerned about the food safety coming into our country but in some cases where the bill validates status quo that's not viewed in a positive way. i'll take any questions. were going to fight to see if we can get some of those considerations into the bill. they have 218 republican votes. i don't think they'll pay too much attention to many of our concerns. i don't think they have that

emac have you spoken with him about the bill and it's kind of an interesting place for you to be lobbying for the presidents be i'm not lobbying for the president i'm lobbying for a positive bill. it's the chicken in the egg. if you are asked to fast-track something that is not clearly known to you, you would say why should i fast-track something i'm not inclined to support but maybe you can convince me with the substance before that bill is even finished. some are saying i'm not to give fast-track to something i don't know what it is and others are saying well let's fast-track so we can see what it is and then we can vote it up or down. it may be too late to make any

improvements in the bill so i'm not lobbying anything except for us to arrive in agreement but that may not be possible speed you just called does build a pothole it is a pothole. excluding our house democratic member which can help in proof that bill but they decided they may have had the votes and i think we are asserting the congress where we have a strong prerogative. that bill surrenders much of our prerogative. let's see how we can improve that bill. it's not just argue yes or no on the bill let's put something on

the table and this person has something else on the table. but if they have 218 votes they don't have to care about that but i think they can do much better on that bill and that's no secret i'm not telling. >> i'm not telling you how i'm voting on anything because we don't have anything to vote on yet. i'm not opposing the president. i think the president has what we want which is the tpp. i don't want to make any comparisons or contrast to other presidents but it's important the trade agreements are part of the bill and not a sidebar of other agreements. that's why the environmental concerns are part of the bill. i appreciate that. what is the opportunity that we have and why

can't we take this to a higher place? we need to understand what trade is about and as a california i would a california i would have some concerns about any resolution that says a tribunal will make decisions about our laws in california are prevented from making a prophet and therefore that's a strike against our environmental strand standards in california. the differences we have among them in relationship to the environment, whatever it happens to be. this is not a fast-track thing. this is a very big deal and it's a tremendous opportunity and i hate to see it be a missed opportunity to do something real. we all know i grew up in baltimore our sitter city and

represent san francisco with the same kind of heritage. in terms of being open to trade and to the world president kennedy had made us a country of trade but it has to be fair trade when it comes to our workers. this is about the substance and how it affects american workers and one of the things it has prevented us have from having the full recovery in our recovery has been that paychecks of middle-class americans have not increased. the stagnation of wages. we want a trade agreement that grows our paychecks but does not hinder that growth and i think we have an opportunity to do it

and if they don't have 218, we have a further opportunity to say where are some areas we can come together to ensure while we have trade, which most people think is we buy this from you you buy this from us but it's about insurance and a lot of other things and we don't want some of those other issues to undermine the opportunity for american workers as some people believe our trade agreements have done. >> are there provisions you believe must be in this bill? >> let me say this i have tried to have this as thoughtful and drill down process. if people really knew what they were talking about and not just fighting world wars or whatever and we just don't know everything yet. some of it is in the final

product of the ttp for getting the first part of it, we'll call it fast-track. so the concerns that our members have, concerns relate to as i mentioned earlier manipulation currency manipulation. rather than subsidizing their product their sepsis subsidizing through currency manipulation. another issue is conflict resolution and there have been another number of cases that have left people not to be encouraged.

part of it was taken out of the bill. issues that relate to the environment, food safety, agriculture are not resolved yet in terms of some big countries and issues like food safety and workers rights in a country like vietnam. bill be more in vietnam next week but we have addressed both the issues i just talked to in terms of where they are now. from the administration the paid representative is a remarkable trade. he is boundless and his willingness to spend the time with members to go through all this. it doesn't mean they like all the answers but it's labor environmental and keep the lawyers talk about resolution

conflict. it doesn't make a very informed vote that perhaps past trade bills but we want to be seeing future opportunity. again at the end of the day we waive the equities and is it better than the status quo? how much better or is it a wasted opportunity? right now i'm disappointed in what the two plus one the proposal puts forth. we shall see. i don't think i think there's many people were waiting to see

what happens in the senate and in the committee today. by what but why wouldn't give equal treatment something new and special in terms of trade. we thought may 10 was a breakthrough when we did that with president bush when we said no were not doing fast-track but we will allow the bills to move. move. we have to do better than that on this because those were bilateral bills. >> if we don't like what the senate has come out and we don't like the process, why then with the democrat and the president say we want to do this.

why put this on the republicans? >> presidents are trying to do what they're all trying to do. we all have a different role and have a congressional responsibility when it comes to trade. we have a vote on what that is and people see things from the perspective of their bosses and people they represent. the people they represent in my district is really important to our state of california and there's a whole rebalance to discuss strategically. i just went to the naval base on monday with having been to six or seven posts and we have to understand the west coast.

from the standpoint of trade that's an opportunity for us as well. again president clinton we voted no, president bush we voted no and just seems what it is what we can do to improve this bill. i don't know why it's such a mystery that everybody wouldn't try to get something better where we have leverage. the president is the president. he's there and he signs are not what we send him. we have an opportunity now when they need 218 votes to say this is a possibility. why can't we just all come together and do this in a way that increases the paycheck of the american worker as we further engage in global trade but do not have our workers in the field that is perceived by

some to have missed an opportunity to improve their lives in the field. questions on another subject? >> president obama does not have to worry about running for reelection. do they risk losing -- no they're not talking about that. >> when caleb miller was killed earlier this year they said they would wreak viewed the ghost hostage negotiation and now today it says governments support was disappointing over the past few years and they

called on the government to establish a consistent approach to supporting hostages and their families. do you think they did all they could for the hostage family? >> we just found out about this now so i will be interested to read all i can from an intelligent standpoint but it's bad if they think that because the president said in his remarks for a very long time that they had been trying with the force of what they could do to find him. >> what about regard in regard to the other hostages? >> this is beyond collateral damage. it is something that should never happen. the question is how much intelligence _ my understanding

is they had what they needed to know that led them to believe there was nobody there except their target. again you're asking me a question that i don't like to answer when i don't have the full information and since this is very new -- we all know this is very tragic and sad and people want to make the world a better place and they go over there to work and unfortunately and tragically when they're taken hostage when they cannot be comprehended and saved but yet killed by our own government. the president took responsibility for apologizing and he said words are totally inadequate. you can't imagine the sadness of it all.

especially such a long time. he was captured in 2002 isn't that when he was captured? one was much longer than the other. i better go back to that tv station and see what they said. it's been a while for both and there has been an effort _ you said a couple years so that would conform to the 2012, but it breaks your heart and it takes us back to the fact that the fight against terrorism is a terrible one. that we have to take a look at this and on the subject of

fighting isis and al qaeda. the recommendation from these people from the middle east was we have to start looking at this not as a sunni shiite but as terrorists and moderate islam because that's what is at stake. when you look at who i wrong is supporting those who are supporting people and that behavior can be viewed as terrorists. it's fundamental terrorism.

it's a terrible situation that we have to use all the intellectual resources available to us to fight it because it's a big issue in terms of social media because the terrorists have i don't want to say mastered it but to a certain extent they have mastered social media. their propaganda is something to be reckoned with and we have to deal with this in a way that will address the threat and our national security. it is a tragic terrible,

terrible day. there's no way to say anything less than our thoughts and prayers are with the family. there sacrifices that their family members have paid will always be remembered and that will be part of their legacy and part of their legacy is for us to be better when it comes to fighting the fight and not losing lives of those who are there and in hostage situations. thank you very much. tonight on c-span to a senate hearing on the 2016 budget for the department of health and human services.

president obama reveals details about a u.s. drone strike that accidentally killed two civilians. on the next "washington journal", we look ahead to this weekend's white house correspondent denver. we'll talk to dallas woodhouse creators of the documentary woodhouse divided. we'll talk to the ceo of the mayo clinic who's here to discuss the new medicare law and the future of medicare and the u.s. you can join the conversation with your calls and comments on facebook and twitter. she was considered modern for her time, called mrs. president and was outspoken on her views on slavery and women's right. as one of the most prolific

writers of any first ladies, abigail adam sunday night on c-span's original series first ladies. examining the public and private lives of the women who served as first lady. sundays at 8:00 p.m. eastern on c-span three. as a complement to the series a new book is available providing lively stories of these fascinating stories. it's available as a hardcover or e-book through your favorite bookstore or online bookseller. a senate hearing on health and human services commented on

their budget which includes funds for implementing the affordable care act and building new healthcare centers. the hearing is two hours. >> the appropriations subcommittee on labor, health and human services will come to order. certainly we are pleased to have the secretary with us today thank you for taking your time to be here. one of my concerns that we very talked about is finding out what spending number we actually have to work with and how we can work within the proposal we got from the department which is substantially higher than last year's level. i hope we can find a common ground so we can really prioritize the concerns that we

share with you and get the information to understand where we need more information to figure out why we need to look at this addictive different way, and when we need to look at it a different way. the bill that the congress has passed gives you some ongoing capacity to look at how doctors deliver care in different ways. certainly the community health center element of that bill, the ability to fund the shortfall where the health centers would have been an would have been for the last five years as a significant part of that bill. there bill. there are 23 million patients and 9000 communities are now served by those community health centers. the $150 per encounter cost is a whole lot less than any

alternative, particularly the emergency room as an alternative in this committee and the senate have been very supportive of the concept and we look forward to you continuing to work with us and us working with you to make sure we are fully taking advantage of that. last year the congress overwhelmingly passed reauthorization of the childcare grant to perm improve the childcare programs. it's another area congress has spoken and we look forward to working with you to see what the goals are in that. finally as we continue to work with the limited resources we are likely to have, funding should have, funding should be targeted to programs that have shown proven and effective results and our programs we've all been convinced that they have the potential out there. i'm pleased the department requested a million-dollar

increase for the medical research capacity. one of the things that happened when i was in the house was a doubling of that funding but then once we got to the doubling goal that seemed to that seem to be the place to stop. i know doctor collins and you and me want that do not want that same experience to happen again :

it's good to be here with you again and i'm pleased to welcome secretary burwell today to discuss the fy2016 budget request for the department of health and human services. i really want to thank you for all you do to improve health and well-being for families and communities across the country. there's no question when it comes to health care we have taken historic steps forward in the last few years. as a result of the affordable care act more families are getting the quality affordable coverage they need but the work hidden and with the law that was passed, far from it. focusing on continuing to build the progress made so far to make sure we did keep moving forward with more coverage, not less more affordability, not less and more quality, not less. secretary burwell and a continuing to make our health care system work better for families is a top priority for u.s. well.

roll up your department is of course essential in this effort. the programs administered by the department impact families of a lot of important ways from supporting biomedical research to fighting public health threats to expanding access to quality health care coverage for millions of workers and their families. each of these investments and others as necessary if we want to continue to improve our health care system and ensure that puts patients first. so i'm disappointed that the budget resolution passed in the house and senate really doubled down on the harmful sequestration cuts that are set to kickback and now. last congress i was proud to work with democrats and republicans to break through the gridlock dysfunction and reach an agreement to roll back those harmful automatic sequestration cuts for two years of 2014 and 2015 and i really believe we have got to build on that agreement now and lift the cap so we can invest responsibility in areas that are so important to our country health education

jobs and defense. the president's budget i was very pleased to save does exactly that. he rolls back the unsustainable cuts to defense and non-defense discretionary spending and is therefore able to support critical efforts to help our families and commit to stay healthy. the budget request total $76 billion. that's an increase of $4 billion or 6% over last year. it proposes additional sensible investments in biomedical research and public health, and programs to provide access to affordable health care as well as learning programs through affordable childcare working programs. i'm looking forward to hearing more about many of the elements in the department's budget request in this hearing today. these include an increase of a billion dollars or nih which said -- would support a precision initiative and maintain our country's

leadership in biomedical innovation and their other investments proposed in the departments budget that are important to strengthen our economy now and over the long-term. i was really pleased that the budget includes a $1.5 billion increase for head start. that increase includes $1.1 billion to make sure that every head start program serves children for a full school day and a full year which will help make sure our kids start kindergarten ready to learn. i'm also pleased to see the president's budget includes an increase of $370 million for the childcare block grant to this includes 2669 to implement the safety and quality improvements that were contained in last year's reauthorization of the senate approved last november with an overwhelming bipartisan vote of 88-1 due in no small part to the leadership of vice chairman mikulski and we thank her for that. mr. chairman this bipartisan support shows will agree that

quality childcare is essential to children's learning and their development and it also helps parents to work to attend school and pursue job training so i hope we can all agree that funding is needed to help working families succeed. the budget also requires four to $90 million in funding for departmentwide initiatives to address the growing problem of antibiotic resistance. as you know virginia mason hospital in seattle experienced a resistant outbreak earlier this year which sickened over 30 people possibly contributing to second -- seven deaths. the superbug robertson hospitals are tragic and concerning. secretary burwell i applaud your proposal to address this very serious and increasing threat. i'm also pleased the president budget maintains investments and healthy families getting high-quality affordable health quality affordable health care through the aca including 629 million to operate marketplace functions in over 30 states.

that will allow commerce to continue working to improve quality expand coverage and drive down costs for families. the departments request also takes important step forward in terms of helping seniors get the care they need. every year over 4 million americans an average of 10,000 a day to turn 65. the growing medicare population is straining the operating budget so i'm glad the budget proposes additional resources to support that increased in workload. your budget also includes 875 million in funding for the administration for community living nutrition services. that's a 60 million-dollar increase which provides really vital support for older americans nationwide many of whom are low income. i believe strongly all families should be able to get the health care they need when and where they need it which is why health centers in the health service corps are priorities of mine. the agreement the president signed into law to fix the

broque and sgr system offered support for health centers in the national health service corp.. i'm glad the president's budget would help further expand access to these important resources for families across our country. while i strongly support many of the priorities reflected in this budget i do want you to know i'm very concerned by the proposal to cut funding for and cervical cancels -- cancer screenings from them. affordable care act expanded preventive services to a millions of women and is help them save $483 million on out-of-pocket costs but there still are today an estimated 4.5 million women who remain uninsured and are eligible for the cancer screening services that that program funds. mr. chairman i hope we can work together on way to avoid cutting that important program. our country has come a long way towards providing quality affordable health care but there are many challenges ahead when it comes to making our health care system work for families and put their needs first and

families have made it very clear that they don't want to go back to the bad days when lobbyists and insurance companies not patients in the families themselves have the power and are health care system. secretary burwell i know you share my help the parties can work together to build on the progress we have made and continue to make improvements. that's something i hope we can do in this committee i look forward to working with you and all of my colleagues today in the coming weeks and months. with that i will turn it over to you mr. chairman and thank you. >> secretary of burwell we are pleased you are here and look forward to your opening statement. >> ranking member remembers the committee thank you for giving me the opportunity to talk about the hhs budget. we saw the power of common ground in our's sgr repeal and i applaud your efforts and hard work they got that pass through the presence budget opposes to two and sequestration fully reversing it for priorities and

2016 matched by equal dollar increases for defense funding. without further congressional action sequestration will return in the fall of 2016 bringing discretionary funding to close level in a decade adjusted for inflation. we need a whole of government solution and i hope the parties can work together to achieve a balance commonsense agreement. the budget before you makes critical investments in health care science innovation and human services. it maintains our responsible stewardship of the taxpayer's dollar. it strengthens her work together with congress to prepare nation for key challenges both at home and abroad. the budget proposes 83.8 billion in discretionary budget authority 75.8 billion of which is for activities funded by the subcommittee. as as for printing pretty billion-dollar increase will lower our department to impact

today as well as latest on foundation for tomorrow. it is a fiscally responsible budget which in tandem with accompanying legislative proposals would save taxpayers a net estimated $250 billion over the next decade. in addition is projected to continue slowing the growth in medicare spending. it could secure $423 billion in savings. as we build a better system that is smarter and healthier delivery system. in terms of providing all americans with access to affordable quality health care we build on our historic progress in reducing the number of uninsured and improving coverage for families who are to have insurance. these are recent example of this progress with 11.7 million americans signing up for re-enrolling in the health insurance to the marketplace during this open enrollment. the budget covers newly eligible adults in 28 states plus d.c.

and improves access to help native americans. to support communities and including underserved communities invest 4.2 billion in health centers in 4.2 billion to bolster our nation's health workforce. supports more than 15000 national health service corps clinicians serving nearly 16 million patients in high need areas that helps address health disparities. to advance our common interest in building a better smarter healthier system that supports improvements to the way care is delivered and providers are paid and information is distributed. to advance our shared vision for leading the world in science innovation the budget increases funding for nih by $1 billion to advance biomedical behavioral research among other priorities. in addition to invest $215 million in the precision medicine issue a new cross

departmental effort focused on developing treatments diagnostics and prevention strategies tailored to the genetic characteristics of individual patients. to further comments or some providing americans with the building blocks for success in every stage of life this budget outlined an ambitious plan to make affordable childcare available to every working middle class family with young children. it supports evidence-based intervention to protect you sent.-- youth in foster care and older americans live with dignity in their homes and communities to protect them from identity theft. to keep americans helping the budget strengthens our public health and the structure with 975 million for domestic and international preparedness including critical funds to implement the global health security agenda. its core strategy of prevention detection and response. invest in behavior health services and substance use prevention. includes more than 99 million in

new funding to combat subscription -- prescription opiate -- opioid abuse. i want to thank members of this committee for your leadership in this area. finally as we look to leave our department stronger but budget invests in our shared priorities of cracking down on waste, fraud and abuse. initiatives projected to yield almost 22 billion gross savings for medicare and medicaid over the next decade. we are also addressing their appeals backlog in a coordinated approach rails wants to make sure i personally am committed to responding promptly and thoroughly to concerns within from members of congress. and i want to close by taking a moment to say how proud i am of our employees combating a bullet to assisting unaccompanied children of the border to the commitment they showed day in and day out as they routinely go above and beyond the call of their work to help their fellow

americans obtain the building blocks of healthy and productive lives. i look toward to working closely with all of you as we advance our common interest on behalf of the american people. thank you and with that i look forward to your questions. >> thank you madam secretary. we have votes scheduled at 11:45 11:45 so it's my intention to be done when those votes of her. we will do a five-minute rounds and we will go with senator murray and i am in the ranking member and the chairman of the full committee and we will alternate by order of arrival after that. i should have time for a second round and of course there will be time to submit questions in writing if we don't get to those questions today. to start i'm going to ask a couple of questions about mental health and hope to get other questions in later so that everybody has time to ask questions. first of all you were able to

get passed last year and excellence in mental health act that senator stabenow and i cosponsored in a way that allows states to be part of an eight state pilot. i just want to thank you for your staff working with us on those guidelines. there was one thing that hadn't been decided that was decided yesterday about the groups that applied neat to look like and hopefully we will have the member states applied but some sons there are more states out there in the country is ready to begin to treat these mental health issues like golf other health issues. i think that's a very important place worth to go and we can do what we can in this committee to help us get there. on the gal report on mental

health as it related to the department it could have been better better. i believe just in the last few days the department is going to move forward and look at those gao recommendations. of the 13 programs, the 30 mental health programs out there 13 are under samhsa and four of those apparently, there was no real plan to evaluating his and that was one of the criticisms in the gal report. i'm just wondering as you look at that report and as you look at samhsa and look at mental health generally as it relates to health care one your response to the gal report in two anything you want to say about the direction to hope to go with these mental health issues. >> with regard to the direction it's a critical time of the passage it be affordable care act and other health parity. i believe we are poised to take

the biggest step we have taken in a very long time to put these issues behavioral and mental health issues on parity and make progress on them and we look forward to doing that. with regard to conversations with u.n. senator stabenow we are going to try to beat the statutory deadlines that have been put into them for meir bill. it's one of those things -- so the idea that we can get that done and done quickly and get these things in place so we have these up and running and we have eight states up and running for continuing to do the work it takes to implement mental health parity. it's about payment systems. it's about how we implement grant programs which brings me to the gao issue. the gal report there were two fundamental issues we want to hear and take seriously. one has to do with the issue of coordination and making sure we are coordinating across the government. i've asked samhsa and the

assistant secretary for planning and evaluation to come together to do that injure an intergovernmental coordination. with regard to the question of the evaluation of quality of grant making it think you all know we have a new acting deputy secretary dr. mary wakefield who is the highest-ranking nurse and the federal government. she comes from herself. her son has made progress with regard to the question of grants in the valuation we are going to see if we can share best practices and see how we can continue to make progress on this issue of the valuation. >> thank you and i will look at what we can do to enable you to do except be that. if there are things that need to be said and report language were moved around or in the budget let's talk about that and be sure we get on that track. i'm going to go ahead and go to

senator murray. a lot of questions will be asked bye bye others in we will see what's left to make it back. >> madam secretary for many women the affordable care act expanded coverage of all fda approved contraceptives has reduced their out-of-pocket costs and given them access to more effective methods of contraception. in fact women have saved over $483 million because of that provision. unfortunately there have been reports of women across the country experiencing difficulties in securing guaranteed no-cost coverage from their plans because the family foundation released a report showing there is variation in how insurance carriers are hearing to the aca requirement and not all methods may be covered without cost-sharing by policyholders. as someone who cares deeply about ensuring women have access to comprehensive health care that is very concerning.

has hhs identify the carriers that are requiring cost-sharing or limiting coverage for some of these contraceptive methods? >> the issue has been brought up roughly to us and it's an issue we continue to work on to make sure our guidelines are clear about the requirements of the aca. its it's working class issues of contraception. we have seen these issues arise in drugs for hiv. we are taking steps to be clear about our guidelines. with regard to specific cases those in terms of as the kaiser report was a general report it's about as understanding where those specific issues are and where they're our specific issues we plan to follow up. it is a matter of the specifics being brought to us. we understand it's a general problem so by putting out clear guidelines and requirements and work conversations with the insurers is one of the things i

continuously have conversations to make sure people know making sure whether it's providing transparency about what you do and don't cover making sure there are things like this issue of the covers if we are being clear about what the law is and our guidelines. >> thank you very much. i really appreciate that. i was pleased to see you are requesting $490 million to expand a multiagency effort to address anti--- antibiotic resistance i talk about this in my opening remarks. outbreaks are occurring more frequently at hospitals across the country. talk about virginia mason medical center. in february sent a letter to to the food and to the food and drug administration urging them to take action to improve safety for patients and a follow-up letter in march calling for a review of fda's practices surrounding the type of scopes we are involved in. but we have to do a lot more to prevent these infections from becoming persistent in the first

place and to detect them as soon as possible. how would the additional resources you have requested and your budget help with an outbreak at virginia mason or any hospital. >> the combating antibiotic resistant program has a number of elements in terms of what is going to do. first we need to take the steps that we put out a strategy in 14 and 15 we have put the plan out to to go to strategy and our budget is the budget to support the action plan. the elements are making sure we are reducing the overuse and overuse in humans and animals so my partners tom vilsack at usda because the issue of antibiotics is an animal issue as well. we need to use the ones to support the reduction of that in terms of humans prescribing as well as in terms of animals. epidemiologic way we need to recognize quickly as in the case of virginia and mason says cdc and others need the funding to

make sure we have it epidemiologist to recognize it into a quickly. how quickly our hospitals trained and ready to do that? with bing cary pigman to do is make sure we are doing the research to develop things that aren't persistent as we go forward. those are elements of the core strategy that the funds will go into. it is multipronged approach and much of it sits at the department of health and human services that we work across the other departments as appropriate and is necessary with usda being our primary partner because of the animal connection. >> what about the issue public health like public health programs at washington state and what role can they play? >> that is a place where cdc will work. when one gets to the issue of the prescribing the number one issue making sure the cdc is working with public health organizations as well as medical centers and training facilities to make sure people know about

not overprescribing. part of the problem is overprescribing. it's the demand of the consumer and the patient. they want they antibiotic to treat something. it's also the physician so it's part of the public health and population cdc's ability to make sure the training education and the tracking that's the other thing. we need better monitoring. >> i think we will see a growing number of cases similar to what we saw. >> it's millions already. everyone has a sense, 23,000 people died last year but there are millions of people who are contracting persistent disease and many occurring in hospitals as he reflected with the situation in virginia scopes. >> thank you mr. chairman. senator cochran says he will speak in order of arrival but i wanted to know when it comes time to allocate subcommittee amounts you can talk in this

committee any time you want to. on this side i have mr. langford mr. alexander and ms. capito and senator cochran. over here at senator mikulski senator reid senator schatz involved one and senator merck way. senator langford. >> thank you senator. madam secretary thank you for being here and thanks for the engaged in on this. there is a lot of conversation about the process. in your testimony you have notes of starting in 2009 there's a 1300% increase in medicare and what's happening in the appeals process. there's obviously a problem. while while you work celebrating the appeals process i would like to get down to some of the root causes. there've been multiple changes to the process. what is pending right now to continue to reform the audit process in the days ahead we on the appeals process which we can

talk about separately but the root cause. >> it's important to step back. working on program integrity issues in terms of medicare spending. this is something that dr. coburn and others helped us focus on canvas was put in place so we could do the tracking. it has tracked and return quite a bit of money to the treasury in the billions of dollars into what goes back into the trust fund. there were negative unintended consequences that occurred. the congress put a hold on certain parts of the rack process. we have taken steps to change the route process. >> what is next? what are the changes that are pending still? >> there are constraints by congress at in our ability to go forward. that's something we want to do embarrass contracting. we have had challenges to the contracting so we need to get through those challenges and go through the process. we need to get the rack back up

and running and we need to put in place and implement the administrative changes like if it's not resolved within 90 days we are not able to act on them is fully as we would like. there's only a small part that we are doing. there are a number of changes. if the rack case does not go forward there will be nothing paid. so we tried to fix some of the incentive issues that were causing problems. it is related to the backlog issue in the place where we believe we need some help from congress and have had these conversations across a number of committees are in the backlog process. >> so the recovery audit data warehouse is in place to make sure you don't have duplication of contracts. last year there was a statement that came out to say that is in the process to reform and to make sure the contractors have made progress?

>> that is one i will take back. >> dealing with good providers. obviously they will have a smaller number for any contract pulling files that are being overturned. there's an incentive for the contractors and the way they do it. >> and the provider refused something we have in place that needs administrative changes. >> let me ask about another issue that is not nearly as contentious. the icd-10 in the transition to that. this process of transition everyone is concerned about it. obviously we have been trying to work towards that transition with a lot of conversation about the advance payments and how many small providers will be vulnerable. it's the same issue with the racks.

it's difficult for them to have large files pulled. the concern is out there as well for icd-10 and what happens in the transition, the in between. the discussion out there in advance payments it are their policies in place and are there details coming out or so still being considered? >> we plan to go forward in october. there was a delay legislative the right now the plan is to go forward in terms of moving to icd-10. we have been doing testing testing and communication with large players and small players. most of the small players are ready. the question on the delay has to do with cost as well as the question of fairness and equity for those prepared to make the switch. the hospital associations have done surveys and we have a high percentage of people reporting that they are ready. for those that aren't there in the process of anyone who can provide technical assistance. >> what about the advance payment side of it?

the concern is there's not going to be a smooth transition from one to the other. is your confidence that there will be a smooth transition and there won't be a gap for small providers? >> what we are hearing and responses indicating they're ready and there is only a small group that is not ready but during the period from now out to over we want to work on that. if you are hearing from them we would be interested to know. we are planning to make sure we can go through and people will be ready so they won't be those kinds of problems. >> senator mikulski. >> thank you very much mr. chairman and of course we welcome secretary burwell. before i go to my questions to her mr. chairman i would like to bring to your attention in the committee's attention that dedicated staff member of this committee for 13 years who has

worked for senator harkin and then worked for me was also respected by senator specter will be leaving. he will be leaving to go to the executive branch. actually it's going to nih not for clinical trial but to help dr. collins. i would like if we could give adrian a round of applause. >> and i will say thank you. thank you to the committee. >> madam secretary of course i'm glad to see you. so many of the great federal assets of hhs is in maryland. nih, fda cms just to name the big three. they have a tremendous impact on our economy. the jobs they provide and the jobs they stimulate. we could not have the robust biotech community we have in maryland without you.

we will of course be talking about those issues but i'm going to goods right in the maryland maryland -- right to a maryland issue. my mounting counties in appalachia. either situation where due to the census they are telling me that allegheny county right next to our colleagues in west virginia has lost their designation for federal funding to qualified for the affordable care. i wrote you a letter in february february. your staff has been calling back and forth but we have been told recently there is nothing you can do. madam secretary ned to look into this. you know western maryland. you know those mountain counties. you know they have lost population. you know that they have lost jobs. we don't want them to lose hope in their government. the impact is $2 million. that might not be allowed by our spending up here but that enable

them to attract doctors. it enabled them to harness volunteers like dental visits. could i have your assurance that you will actually look into this and not just have a lot of your critics phonecalls back and forth where they just say no. >> senator i will look into it and see what the opportunities are for us to try to support this county. >> and not just a list of things that they can apply for. they are not an urban county. so let me go on then to another issue which really was the source of great exuberance among many of us. the fact that we work together in a bipartisan basis to pass the childcare development block grant working closely with senators alexander. amber: senator harkin and myself myself. could you tell us now as we pass an authorization what you're doing to implement and where we work so hard on quality

provisions. sure we wanted our money but we focus on a bipartisan basis. could you tell us what is in the money to implement and enhance the quality the quality and safety are large part of implementation and let the money is for and that is actually implementing the standards you all put in. with regard to increasing the questions of safety and quality on an evidence base so that implementation is part of the money. the second part of money and the only part the tenor in terms of implementation and thank you all for your leadership on this is there are funds and is one of the other things were asked to do is to make sure childcare for parents who work different hours for places who are not receiving hard to reach that we do work in to understand understand that we can help and support that. quality in terms of the standards and those were standards we need to apply and implement them we will do that

as well as quality issues. this cuts across the entire suite as one looks at the continuing perch children. home visiting childcare in implementing the authorization that he gave us and also in the budget as a childcare expansion that senator murray mentioned. the 82 billion over the ten-year period a would be for making sure that working families have access to that and we don't -- we want early head start in those partnerships. we work to implement that these in the context of improving quality and safety across all of those pieces. >> in a nutshell 370 billion-dollar increase from last year. is that correct? >> that is correct. >> of that 370 million about 270 million is for the new quality provision. do you feel that's adequate? >> we do to get us started and what we want to do is get the implementation started and as we

look at nature's budget will understand more. >> you have 100 million for pilot programs. i say to my colleagues the days of factories are one thing but for example we have nurses who are working the night shift. i have the national security agency that worked 24/7 and keeping america safe often single mothers. i think we are on the right track. i also hope my time is up but that we could have additional conversation on the work you are doing in foster care and also unaccompanied children. they are in our country and they could continue to come. we cannot turn away from this issue so i look forward to dialogue with you. >> senator alexander. >> thanks mr. chairman and local madam secretary.

senator murray and i found they health committee are trying to get a few things actually done. we have reported it no one elementary and secondary education and we are moving ahead to higher education. it is you know where going to get innovation in medicine. one area that i believe that to get something done is electronic health records. you and i have talked about that. you have talked about a year and nine months left for you and what i would like to do is move up toward the top of your list and our list doing something about electronic health records. big government spent $20 billion subsidizing electronic health records. it sounded like a wonderful idea but half the doctors are choosing not to participate in the program. instead they will face medicare penalties this year. doctors don't like their

electronic medical record systems by and large. they say they disrupt the workflow and interrupted doctor-patient relationship and ama commission grants bound to electronic health records are the leading cause of decisions that dissatisfaction. a medical economic survey last year found 70% of positions found that their health care records haven't been worth it. i've met already with andy and at your suggestion i meeting with dr. desalvo. what i would like to do with the committee here listening one other thing. senator murray and i have formed a working group on the health committee to identify five or six problems in the electronic health record system that we can address administratively. in other words you can do it are legislatively if we have to. what i would like to ask you as we commit putting on your list of things you'd like to get done

in the year nine months he planned to be here, working with us identifying five or six things that would make this promise of electronic health record something physicians and providers look forward to instead of something they endure. >> after meeting and our conversation i think we have a working group of staff ready to go and we are committed to do that. this is extremely important to. we are going to talk talk about so many things that touch us i am sure i'll will hopefully get a question about opioids and heroin. the precision medicine issues were talking about. electronic map -- records -- that issue. creating a system of health care delivery that has better quality and is more effective and efficient. we should focus on it. where health care is going in terms of our ability to serve the consumer of the patient and the way we need to this is a

core part so i welcome the opportunity and look forward to putting the list together and look hoarding to getting it done. we want to work with you on what we need legislatively as well. >> great and there's a lot of interest on the committee. senator cassidy and other members on the democratic side have expressed it. one area that we should work together senator mikulski and i am burr and bennett asked higher education folks to give us a report on what the cost of overregulation. they gave us 59 recommendations about what to do. we are putting it together in and legislation we are going to incorporate these ideas in the higher education act. at the same time the national academy of sciences has said principle investigators of research projects spent 42% of their time on administrative tasks instead of research.

we do a lot of talking about needing more money for research. taxpayers spend 30 billion a year on research at college and universities. nih spends 24. vanderbilt university hired a consulting group to tell us how much it costs vanderbilt to comply with federal rules and regulations and the answer was $150 million for one year. a lot of that had to do with research. that's not all your department and it's not all education but my question is will you work with us and help us work with other agencies to see if we can work with the national academies to take 42% down releasing hundreds of millions were aliens of dollars which could be used for important research of the kind that all of us think there should be more research on. >> having sat on the end where i was at the bill and melinda grant foundation art grantees

would ask us to play -- pay at the federal administrative level level. as a new organization we would work through do we need to do that. we need to work on it and we need to work on it from our end and it will help beyond the work we do. think some of the things we need to figure out where we are willing to take certain risks are not. some of the administrative costs have to do it very import things like tracking conferences and provisions that are put in. i think this is a place that is right for us to have quality conversations about what we can do to reduce some of that word in. welcome a chance and i know our nih colleagues there are a number of things on them as they would like to talk about. >> thank you madam secretary and thank you mr. chairman. >> thank you for your testimony.

let me focus on the topic of why he. senator collins and i issue have been committed to ensure adequate resources. i am pleased to see there's a slight increase by $200 million below the previous authorization and appropriations. what can we do to get why keep further funded? with whether patterns as they are smudges the cold and the northeast it's increasingly hot summers in which air-conditioning is essential to people in the south and the west coast. can you help us? >> in the budget proposal what we did was propose the base level at lester's level. we also propose a contingency fund. this gets to the issue of the variability and what liheap is about and we are having these huge changes. what we were trying to do is

create a responsible way to respond to the type of increasing erratic weather we are seeing in the contingency fund would be our ability. it's obviously scorable in terms of how much money to put in the budget so we have the contingency fund that will allow us to have flexibility. then add a contingency fund that could help us. hours are perched to working to get additional liheap funding. >> senator collins and i both look forward to work with you on this. as a related issue is you have discretionary authority to put aside 1% of appropriated funds in a consistently do that with liheap. today there is the $34 million of liheap money that has not been submitted and kenya were to release those funds are commit them? >> at this point in time we are doing a final review to

understand if and when those funds will go. we are 99% there with $3.3 billion spent and a 34 is the outstanding amount. >> thank you madam secretary. let me turn to another topic. cdc immunization program. a vaccine for maddy -- money low income and middle income families which is a critical public health and one of the most critical public health initiatives we have taken in the history of public health. somewhat disappointed your budget will cut this program by $50 million next year particularly disconcerting and the outbreak of some contagions we thought were in my youth like the measles and section 317 is used to track that response. looking at all these issues.

>> like you we agree and are concerned about the vaccination issue in special in the context of the measles outbreak we have seen and although it seemed happening around that. with regard to 317 there's additional complementary programs the children's vaccine done. when you combine the two programs together there's a net increase of 58 million on the budget overall. with regard to 317 is where implementing the affordable care act parts of 317 are use for those that are underinsured. when ac was past it is required that all plans do no cost-sharing. when i take my child than for wellness visit that vaccination doesn't have a co-pay. because of that reduction the money we reduce was for vaccine purchase that is being reduced because we have those people who are now in a fully insured space. with regard to the funding of 317 that does the kinds of things that are very important which are the issues of

educating and that's something we are doing more of through the cdc with measles outbreaks. none of those funds were cut as part of this. >> and you are doing an analysis to ensure there is no gap and children are getting vaccines through the aca mechanism? >> the problem senator murray raced with regard to contraception we have not seen with regard to vaccination which is that people are in any way not covering that. if that's something that people are hearing about please let us know. it is when we hear that we go back out with guidance. we have not heard that from anyone at this point. this is the part that seems to be implemented correctly but if you are hearing something different we want to know. obviously this is an extremely important issue. the measles issue yesterday i did the formal swearing in of the surgeon general and as you know that is one of the issues he has been focused on including the public service announcement with elmo.

we are trying to do everything we can to work with the states directly epidemiological and to educate, anything we can. >> i think, was a good -- to c-span. >> my children understand my job. when i took a picture of me with elmo day -- >> that's the moment they knew you had arrived. senator cassidy. >> a couple of things. first you had mentioned this question has bugged me for a year so when you mention the effort that cms is made for those unaccompanied children coming to the border when i was in the house last year there was a roundtable, an oversight hearing. as i recall cms at $800 million in the regular budget last year to care for the expected surge of unaccompanied children. there was a physician they are and she had the public health service uniform on. i was a little critical because the response have been sold for.

she said i'm the first doctor and i was just hired two weeks ago and this was july. expect a question for the record, c. m. s. r. hhs had $800 million in the first doctor was hired in the middle of the summer when they had requested a bump up in anticipation of a surge of unaccompanied children. to make the point i would like to follow up and you can follow with that because i don't expect you to have that but nonetheless you mentioned it. it just popped up and it has bugged me ever since. she is a dedicated physician that have been hired as the first position. she said there were two or three nurses but never a physician and only two or three to handle the whole program. no offense to the nurses there was just a few of them. you mentioned the icd-10 effects. i want to speak for that position who is in a smaller

practice. what i'm reading here from athena health cms estimates in the early stages of implementation rates were accounts are stable will grow from 20 to 40% and goes on to explain why. i will just say according to your own web site that doctor in south louisiana who it is and it one or two-person practice she cannot afford to have denials go to 200% and ar growing by 20 to 40%. personally a regional thing to do would be to delay the penalty phase for two years as people transition because it is that doctor is struggling to see how many patients yesodei and comply with h.r. who suddenly is going to have denials grow to 20% not because she's not doing it right

but because the system has changed. unless we are sympathetic we are going to drive her out of practice. i will also put that plug-in as a pre-decor for those physicians who feel it. this is something you perhaps can address. the cbo projected in february 2013 cbo projected the cost of medicaid or just that portion getting acute care for example the expansion population under the affordable care act would the $2500 in 2014 only including estimates for the fully eligible. last month the cbo projected per person cost of medicaid for 3460 including partial eligible and fully eligible. this is a jump of $1000 per beneficiary over the entire

nation which is a 40% increase. we will disagree but the affordable care act is unaffordable for the taxpayer if from year-to-year we have had a 40% jump in medicaid costs. >> i want to go and look at exactly what the cbo references because across the affordable care act medicaid issue probably know is generally the least expensive option in terms of service and care for individuals so i'm surprised by that cbo number. as you and i had the chance to discuss in terms of the net and overall costs we have seen that not happening and in terms of medicaid increases in costs we have seen deep control of costs. i apologize that particular member had not seen and is not indicative of what my understanding of the cost curve is. >> when one more thing to squeeze in because you started

off with the affordable care act. only 2% of those that 40% above thing, i.e. not eligible for subsidies only 2% eligible have signed up for insurance through the exchanges of the middle class is getting host by premiums to -- that have increased dramatically. >> with regard to premiums in the employer-based market. >> no this is an exchanges. only 2% of those eligible for insurance through the exchanges have signed up for insurance. >> i think with regard to the number we have seen in terms of those eligible to receive insurance to the marketplace as we have talked about, it's about 60.4 million people in the reduction which is the largest we have seen as a nation in decades. >> we could debate that because as we talked about cms the cbo reduced their baseline of those

injured in the numbers i've looked at is most of those were newly insured signed up their medicaid amount that exchanges. sprey cbo's. >> cbl in the most recent numbers that came out with reduce the cost of the affordable care act by $23 billion. >> truth in advertising that is because state student of the medicaid expansion. >> the cost of health care cost increases were much smaller and premiums were much lower than they had expected in their original. fewer people moved from employer-based care to the marketplace. it was the combination of those three things. cbo went from a number of about 55 million being uninsured in that's total, that's not eligible for the marketplace to 52 so what cbo did was actually reduce the number and therefore the percentage of uninsured that

we now have in fact it's the percentage in terms of if you want to measure it as a success measure would go up based on the change in cbo. with regard to the question of number people in the marketplace we want that to continue to go up. we want to do everything we can pretty think you saw we worked hard to have an open enrollment to serve the consumer and whether that was having a web site up and analysis highly controversial so i do this at my own peril that is important for us to have a conversation so i welcome it. we were trying to conserve the consumer and i think we saw and continue to see growth. can it be better? we would like to do that and work on the ways we can make war of those consumers comment and find affordability. having traveled around the country and met the woman has had to make you know how you treat ms, working woman with three children. you get sick enough until you

can go to the emergency room and they will treat you and she said and now i have a card. >> i will finish with the woman i spoke to i don't need what i'm getting with the 6000-dollar deductible. >> mr. schatz. >> thank you secretary burwell. i have a question about telehealth. i'm a. i'm a big believer in telehealth telehealth and i believe the va has been -- has done a lot of good work. private health care providers are expanding their services. it's a way to improve clinical outcomes in a way to save money in systems. i just want to know what medicare in particular is doing what you think you can do additionally within the confines of 1834m and whatever statutory restrictions you may have been could you just sort of divide the question into those two categories, where you think the law needs to be changed and what

you think it could be doing within the confines of the statute that you are not quite doing at? >> i think the places we can do more art in our innovation centers of the funding we receive for the innovation and i was part of the affordable care care act that we have been given there we are seeing and doing a number of innovative projects that are including telehealth pray that's one place where we are acting. we have several of the things we have funded that included telehealth components that we think are important and i think you all know the statutory requirements with regard to meeting success are very high so it will take time and measurement to improve that that we want to get those measures because that is where you can scale it. we have to be able to show rightfully come uss to show quality costs that we have to do that. the other place in terms of the authorities we currently have have to do with some of the acl work we are doing. we actually recently put out a

version 2.0 and telemedicine was increased to in that. with regard to the statutory issues there are some places and i think we need to have those conversations about are those places that we can talk about where there might be changes that would free us to do more telehealth and that is on the medicare payment side. >> first of all let's work together and i know senator wicker as the chairman of the subcommittee -- subcommittee on the telecommunications had a good bipartisan hearing on the potential for telehealth. i think there were 17 members of the subcommittee that attended. it was broad enthusiasm on it bipartisan basis. i want to work with him and i know members are anxious to get going in that space and he is going to work on legislation to introduce in this congress in that space. first of all we have to work on whatever changes in the law are necessary and also during that hearing the national

organization for telehealth, think that's what they're called that in any case the national organization of advocates in thinks you can be doing more within the constraints of 1834m grade i know you did this nextgen acl that some of my staff and others are saying that you could move a little quicker and bringing it forward and some other areas. so i'm anxious, i know you believe in a the sign of the administration believes in this and i know there are other executive branch agencies that are moving faster. some of that is because of the law itself but some of it may not be. if you could check with your staff to be sure we are doing absolutely everything we possibly can be doing to advance the ball on this. you are one of the biggest payers around so on the telecom subcommittee a lot of the questions were logistical and clinical and setting up markets. in my view a lot of those problems downstream gets solved

if the payer comes to the table. that'll get settled because there would be a built-in market and i think you can even make additional incremental progress as we work on that in the session together. ..

we were able to recover through another grant process but i am i am concerned about this because of the deep need that rehab in our home state. we had some conversation about why the changes were made and the changes were made in the program to make sure there were some questions about whether we were facilitate the filling the statutory recommendations. there were two elements, one the question of making sure we are getting to quality but the second issue was getting closer to the community when all of the money was being funneled through state grantees. there were grantees in stains that were serving in communities as well. opening the door for others to serve as well i know i know i

looked at our state to see what happened and i think the year before the department in terms of the government, received a grant of 1.4 and two grantees, one and two grantees, one was the state and one was another player so it came to a one two so it was a reduction in terms of what the state received. it was trying to improve quality. the 900,000-dollar cap is just a cap that would go to the actual state government and if there were other grantees you could apply through that? >> yes, that's right. someone had raised this last year with me and i had asked could the state still, if another grantee came forward in the state. because i think the money needs to flow to the need. >> if it's a quality a quality

issue, i understand. >> i did follow up on that issue as well has being from west virginia i argued that everything would be greater need. one of the things i think is difficult to is measure and i think people need to get to a standard where they can measure these things and make decisions that are based on that. sounds good. >> sounds good. >> will be following up on that. >> you mentioned opiate addiction and what you were are doing in that addition again all across america but we seem to be having a difficult problem with prescription drug abuse and the rise in heroine and heroine poisoning and deaths. help me out here, how can we help this? what are you doing in the department? >> building on the work that has been done, since i arrived last june, this was the first thing i asked the team to come together. there were many things going on

and we asked to make that consolidated. we it has three basic elements to it. the first is prescribing. that's where must of the starts. that's the only one that dresses prescription opiates and heroine. we need to get to a better place in terms of prescribing. there is overprescribing that is happening and we need to make sure doctors have the right information and guidance and we need to work on that. number two is access to more locks them. that's an important part of the budget conversation because we need to save some money so they can issue that. we just issued a law that would allow them to continue that. west virginia is good. massachusetts had made it a big priority and were going to do an

event together. the third thing has to do with medicated assisted treatment. sadly for both heroine and opiates we have so many people addicted that we are going to have to use medication to help those who are addicted. with regard to our work with congress, it's about funding and it's also about part of treatment. how weak prescribing how we control prescribing but at this point time it's a little too controlled. the change we need to make should be in conjunction with congress and working with the states to make sure they have the prescription drug monitoring plans. those need to be put in place and are strong and eventually we need to make sure those plans are going across state.

the border is porous and if we don't know what that person in pike county is prescribing in mingo county, people are going county, people are going across. those are the things we need to take. >> thank you, senator baldwin b mack thank you, i am going to follow on that in just a moment but first i want to thank you for being here and share with the committee that i'm hopeful we can find relief from the budget control act to allow this subcommittee to draft a bill that provides the funding that hhs needs for its critical programs and to carry out its mission and serve the people we all represent in our home state. as another side note as someone who was raised by scientists, my grandfather i am certainly a strong supporter of our research

and budget. in particular knowing the impact that our scarce funding has had on young researchers, i'm especially concerned that the budget control act continues for the next generation of researchers at risk. i want to focus on the opioid prescription initiatives that are in your budget. this is an issue that impacts many of our states. i would guess all of our states. i'm interested in hearing a little bit more about the cdc's plan about developing prescribing guidelines. in particular i want to ask pacific questions about that. number one, we've seen in wisconsin particularly tragic cases involving our virginia system. a number of tragic deaths of patients who were treated at our virginia system hospital. will these guidelines be

applicable to systems like the virginia system? guidelines are just that. they're not mandates so we've had challenges when guidelines have been articulated before in getting their wide spread adoption of those in our medical and prescribing community. please be to that to. >> with regard to the guidelines we do think it's one of the things that need more clarity because there are important issues about pain that need to be treated and treated with the types of drugs were talking about so we don't want to a deny those to though's whose daily living is dependent. they will work together with all the other parts to provide those guidelines. with the issue you just a tick a

tick related, this is another space i think we may need to have a conversation about potential legislative help. that has to do with training. even if we put the guidelines out the questions of whether or not those existing positions and those coming through will be trained in these mechanisms and guidelines is a question that is an important one. how that more where that occurs may need to be a conversation that occurs. a conversation that occurs. we have put together the places and spaces that we think legislative, state and what prescribers and others need to do. do. that's how we thought about the strategy and that's a very specific issue that is on our list to continue to have a dialogue and conversation with as well. i would welcome that. >> the tragedies we have seen in our state in my own state deserve a response of the utmost

seriousness. in fact, i think we are coming very late to this issue. your testimony secretary burwell highlights that in 2009 totaled drug overdoses overtook every other cause of injury death in the united states and yet we have yet to implement a comprehensive strategy. in addition to working together on future legislative measures, i want to ask you, how will the administration's proposed initiatives that address this growing wide emergency he impacted if your budget request is not funded? >> it will be very important. the funding is very important to the state. that is the most important part of this because it is implemented on the ground.

the funding goes to the places like the cdc and rectally to the state so having that money available for the purchase of moxa alone and the training is very important. there was a question of what type do you have to be to use it in a number of states? that's prohibited adding it in places like massachusetts and west virginia. they're starting to use it but there are funding issues so it's important we make prize progress this year on these issues. i also think it's important to reflect that this is done with coordination of the office in the white house. that is our policy counsel for purpose of these issues to make sure we are coordinated with dhs and department of justice. there's many law enforcement officials who are the people who need to know how to apply

moloch's moxa. they are the people on the scene when there is a drug overdose. >> do you think you need more authorizing language or are these the kind of help to ask for in the appropriating budget? >> i think we may need further -- it's not just money. it's other questions about how people are willing to implement the guidelines and making sure people are trained. the question of continuing medical education and how this touches upon that are the kind of questions we think we need to talk about. i think the ama and others are thinking through this so let's all understand but i think it's an important enough issue that we as a nation need to make sure that if we have the guidelines people are being educated.

>> mr. chairman, even though i know this question has are ready been asked by one of our members, it relates to the immunization program. funds are provided to all states who provide vaccines to those who are not able to buy them because of their own difficulty in economic challenges. there is a majority of funds that are available to counter vaccinations. our state has to run when the prize as the highest vaccination rate in the system country. people spent a lot of time and effort making that possible but it all depends on funding from the program so in looking at the budget request were disturbed that over $50 million in advance funding is recommended to reduce

funding for that amount would be devastating, we think, to devastating, we think, to the affordable care act. what's your reaction to that and do you have any thoughts? >> what we have tried to do is design a vaccine budget that included both the children's vaccines and immunization, which actually increased well over close to 70 million. the increase in the children's vaccine fund were greater then the degrees in the 317. that meant it was about a 50 million-dollar increase in what we were trying to do was in the places that we were doing decreasing was for the people who were underinsured.

if you have insurance now you would have to pay a co-pay for your child's vaccination, you no longer have to do that. the cost of the vaccines we were purchasing for use in the facilities you are talking about, that's what's been reduced. that's because we believe of a the affordable care act that's been taken care of through private insurance in terms of people who are insured. we tried to implement a policy that would increase the overall vaccination funding that decreases it in an area that provides it for people who were underinsured. >> thank you very much mr. chair and thank you madame secretary for your testimony. as i read your testimony the number that was hard than i've seen before was the 16.4 uninsured americans have now gained healthcare through different facets.

am i interpreting that correctly? >> that number includes the vast mid geordie of ach provisions and i think the economy have recovered so some may have gained insurance because they have jobs now. i think the vast majority is because of the marketplace but some of that could be from a positive thing and that is employer-based care. >> now many are enrolled through medicare and chip so some are those who previously did not have insurance and ballpark numbers. >> yes those numbers. >> yes those have to be derived because we don't ask anyone when they come in. they do not have pre-existing conditions anymore. i'm not sure we have put out a number of those in the

marketplace who are uninsured because we -- >> i was very struck by the statement in the testimony that ate out ten of those go to the exchange after tax credits have insurance for less than $100 from month. so that's out of those 11 million, 80% of them -- there's been a huge change in the uninsurance rate in oregon. our hospitals are seeing a dramatic drop in the coverage of the uninsured which gives them more dollars to provide healthcare and stops the transition in which folks who have insurance have to pay for folks who didn't have insurance. i want to turn to another area that i have concern about. a year ago when commissioner hamburg was testifying, i raised the issue here of the use of

e-cigarette. these are the electronic devices that a prize liquid nicotine that comes in little bottles like this. i showed these empty bottles labeled scooby snacks and jay juice gummy bear and this now has changed dramatically in a single year. we have a new report from the cdc and its titled e-cigarette use triples among middle school and high school students in just one year. it goes on to say that high schools increased in middle schools and it crowd quadrupled in middle school. all of the cdc

studies show that nicotine for adolescent brains is a very bad combination and thus it's very important that we regulate this. in 2009 congress gave power to the fda to mandate tobacco products but now we are here six years later and we don't have those regulations yet and i very much appreciate your call to update me on the process. it goes from fda to omb and has that transition occurred yet? >> we are still reviewing the comments at our and at hhs. >> so it has yet to go to the final review within omb or is that simultaneous? >> know we complete the process of the review. >> you know i was going to ask you about this, but when do you anticipate that will be

completed?? >> the process is about the overall rulemaking. we have a process about that and that will finalize the deeming of these products. it's products. it's our hope that over the summer that we will get to a final stage. >> i hope that it's more than hope. i hope it is a reality. i appreciate your personal efforts to accelerate this process but i still am deeply disturbed that it has taken this long. had this taken two years less four years instead of six years and i don't think anybody thought it needed to take four years, then we would have many thousands of young students who are not being brought into the nicotine addiction flavors through these things that were

marketed to children. you have flavors like gummy bear and chocolate and scooby snacks. 90% snacks. 90% of smokers first began smoking as teens and three out of 14 smokers continue smoking as adults. adults. the industry understands that it's in childhood and teenage years that you must secure the addition the addictions. it has huge consequences on the quality of life and the cost of our healthcare system. this is one of those opportunities to make dramatic improvements that make a tremendous amount of sense from every direction and for every month of delay, it's additional american who are damaged. it's not just in the smoke, it's

in the poisonings. these poisonings have exploded in the state of time since 2011 until now, it's a 14 fold increase in the poisoning because these little jars look very appealing. they look appealing and their labeled juice and called gummy bear and must be something good to drink. do you consider it irresponsible that people are making these things and not putting them in child proof bottles? >> with regard to how everything will be regulated i think i think those are the things were going to have to work to answer and answer question. >> your overtime. >> okay thank you very much. >> thank you for your leadership on this committee. thank you for reaching out to me this week.

i'm very appreciative of the efforts you make to stay in touch and have conversations. i think all have time for a couple of questions. first i'd like first i'd like to ask in early childhood question. this committee last year allocated $5 million to be used to extend access to infant toddler services through early head start. the goal was to expand childcare partnerships. my question is, tell me about implementation and particularly assure me that rule communities where even licensed childcare is a rare commodity, that they are being considered appropriately for those services. >> the issue of we have work towards implementation and because the program had both early childhood education and childcare partnerships, it allows us to expand to communities where various types of care were being provided. in the issue of rule america and

rule access to these types of programs are something you probably know are deeply important to me as someone who participated in head start many many years ago, i understand the question of limited access that anyone has about quality early education. these are issues we are working toward. there are things that you might be hearing that are not consistent with these and please make sure we know that. if there's something you've heard from your state i would like to know about it. >> what is the status of implementation? >> grantmaking. i'd have to check what stage of grantmaking we are in and i'm not exactly sure where we are on the process but i can get i can get back to on that. >> i would welcome that. let me change topics now and talk to you about dietary guidelines. you and secretary ville sac are

charged with developing dietary guidelines and in that process by which you develop those guidelines you have an advisory committee a dietary guidelines advisory committee and they've issued a report. too many of us that's a very controversial report because it includes in their recommendations and they admit their taking into account topics outside nutrition and diet, and specifically considering environmental sustainability. dietary guidelines which in and of themselves are hard to determine what the right answers are at least by your advisory committee is now being expanded to include consideration of inviolable environmental sustainability contrary to the statutory framework which you and secretary ville sac are instructed develop the guidelines. i've had conversation with secretary ville sac in my office as well as during the hearing of

appropriations of agriculture. he indicated to me that he will color it within the lines. by that i assume he is assuring me that he will abide by the statutory framework for those guidelines. i've also asked him if he's had conversations with you about this topic and what is occurring and my impression is that that's probably not at the secretarial level. my question to you is the same as the department of agriculture. i want to make certain that you agree with the sentiment expressed by the secretary of agriculture culture. i want you to assure me that you intend to, in developing the final guidelines, that you will disregard areas that are outside

your instructions in developing dietary guidelines and stay true to the issues of diet and nutritional science and not expand dietary guidelines to something beyond its intended scope. >> i have spoken about this issue and i think i received your letter and a letter that signed by many folks in terms of -- we received two different levels letters. >> we have extended that timeline. for the reasons you have stated that we want to see what the comments are what we get back. when the process comes to hhs, if we receive what the revisory committee does but we will have the full spectrum of our full participants and they will be

part of the conversation when we develop with the usda what we divide and develop. >> i gave you to easy up in and out because of course you would say you want to abide by the statute that guides your actions so the follow-up question would be do you share the view that dietary guidelines are to be developed around dietary and nutritional science and nothing more? >> i have to be honest and say i have not reviewed the statue closely enough to answer the question in the specific way that you have posted. people that are involved in terms of our issue of science and health, fda and ihs those are sweet spot --

>> does not suggest you are going to color within the lines? >> it suggests that i need to read the statute until i know what it says. i apologize but i want to abide by the statute and that something at this point in the process i haven't gone to. but i hear and i hear and understand that is something you will be following up on. >> thank you. >> thank you for being here. let me associate myself -- in regard to e cigarettes more and more children are getting addicted. it is time. i don't know where this has come to a a halt but i'd like to try to find out and move it along. secondly i met with dr. francis collins a couple years ago at nih and i said to him you can't aspire to the glory days when other senators doubled the

budget, but what can we do that will make a difference? he said i would tell you 5% real growth for ten straight years will light up the scoreboard. we would produce solutions that would more than pay for the research. i feel we are falling short of this over the last ten years. we have fallen short by 23% due to inflation. the number of grants that have been warranted have been cut in half and that has discouraged researchers from staying. when i look at the budget request for grants i find them roughly a 3% increase over last year. if you assume 2% inflation i guess no one assumes inflation anymore, but if you and assume

2% inflation you can see the minuscule amount were increasing. i don't ever quote and i rarely ever praised newt gingrich, but i'm going to, he wrote in the new york times this week, we are spending a fortune, what are we thinking. were not putting money into the research to alleviate these diseases. i would go a step beyond that and say he fell short of suggesting how we would pay for that which would be the important ending to the story. i would like to say for the record