get our complete schedule at c-span.org. >> both the house and senate are not in session today

but lawmakers will return next week. senators plan to continue work on a measure that requires the obama administration to submit any nuclear agreement with iran to congress and will attempt to override the veto disapproving the national labor regulation board regulations issued last year live on c-span2. house members will meet with senators for a joint meeting of congress to here marchand japanese prime minister for would say before returning to work on 2016 federal spending for military construction, veterans affairs command energy work development. >> next, health and human services secretary sylvia burwell testifies other departments 2016 budget request this totals $84 billion.

she spoke for about two hours. >> the appropriations subcommittee on labor, health, human services and education related agencies will come to order. pleased to have the secretary with us today. thank you for taking your time to be here. one of my concerns is finding out what spending number we have to work with and how we can work within the proposal that we have got from the department which is substantially higher than last year's level. i hope that we can find common ground so that we can really prioritize the

concerns that we share with you and get the information and understand where we need more information to figure out why we need to look at this a different way when we need to look at this a different way. the bill that congress is passed on the sgr issue i think gives you ongoing capacity to look at how doctors to the care in different ways. certainly the community health center element of the bill the ability to fund the shortfall and where the health centers would have been an further have been for the last five years was a significant part of the bill. 23 million patients and 9,000 communities are now served by those community health centers. the $150 per counter cost is obviously a lot less than many alternatives, particularly the emergency room.

and this committee and the senate generally have been supportive of the community health center concept, and we look forward to continuing to work together to be sure we are fully taking advantage of that. last year congress overwhelmingly passed reauthorization of the child care and development block grant to improve health and safety standards and overall quality child care program to another area where congress has spoken and we look forward to working with you to see what we can do to meet the goals and that. finally, as we continue to work with limited resources we are likely to have funding that should be targeted programs that have shown improvement or effective results were programs we have become convinced have that effective result potential out there. i am pleased the department has requested a

billion-dollar increase for nih with the focal.of our nation's medical research nation's medical research capacity. one of the things that happened when i was in the house was a doubling of that funding. once we got to the doubling goal that seems to be the place to stop. i no i know doctor collins and you and i and others don't want that same experience set set a worthy goal but don't understand the importance of having medical extend beyond achieving the 1st marker in the goal. so we will continue to work with you and nih on that as well. pleased to be working on all these issues with sen. murray. we are also lucky on this committee to have sen. senator mikulski, the vice chairman, and senator cochran -- senator cochran often attends as does sen. alexander. a lot of people interested in what you are doing and appreciative of the work you have done in

italian have been there. senator murray. >> mr. chairman, thank you very much. good to be here with you again. i am pleased to welcome secretary burwell to discuss the budget request for the department of health and human services. i want to thank you for everything you do. there is really no question that when it comes to health care we have taken historic steps forward last few years as a result of the affordable care act more families are getting the quality affordable coverage they need but the work does not end with the lobbying past. far from it. i am focusing on continuing to build on the progress made thus far to make sure we keep think forward with more coverage, more affordability command more quality. sec. burwell,. secretary burwell, i know continuing to make our healthcare system work better is a top priority for you.

the role of your apartment is absolutely essential in this effort. the programs administered by the department department impact families and in important ways from supporting biomedical research the 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 is necessary if we want to continue to improve our healthcare system and ensure it puts patients 1st. i am disappointed the budget resolution passed in the house and double down on the harmful sequestration cuts set to kick back in. last congress, as you know i was proud to work with democrats and republicans to break through the gridlock and dysfunction and reach an agreement that rollback those harmful automatic sequestration cuts for two years. i believe that we have got to build on that agreement and with the so we can invest responsibly in areas that are so important to our country's health and education and jobs and defense. the president's budget does exactly that.

it is able to support critical efforts. budget request for programs totals $76 billion that's an increase over last year. additional sensible investments in biomedical research, public health programs that provide access to affordable healthcare as well as learning programs and affordable childcare for working programs. i am looking forward to hearing more about many elements of the department's budget request. these include an increase of the billion dollars for nih which would support a knew precision medicine initiative and help maintain country's leadership biomedical innovation. there are other investments proposed in the department's

budget that are also important to strengthening the economy now and over the long term. i was pleased i was pleased the budget includes one and a half billion dollars increase for head start. $1.1 billion to make sure every head start program service program to conserve children for a full school they and a full year which will help make sure kids start kindergarten ready to learn. i am pleased to see the president's budget increase $370 million. this includes implementing safety and quality that were contained in last year's reauthorization. due in no small part to the leadership of vice chairman mikulski. mr. chairman, this bipartisan support shows we agree quality child care is essential the children's learning and development and help parents to work.

i hope we can it be that funding is needed to help working families succeed. the budget requests 490 million in 90 million in new funding for department wide initiatives to address the growing problem of antibiotic resistance. as you know, there was a resistance outbreak earlier this year which sickened over 30 2nd over 30 people possibly contributing to several deaths. these outbreaks and hospitals are tragic and concerning. sec.. secretary burwell, i applaud your proposal to address this serious and increasing threat. i am pleased the president's budget maintains investments and helping families get high quality affordable healthcare including 629 million to marketplace functions which will allow congress to continue working to improve quality, expand coverage, and drive down

costs. the department's request to take important steps forward in terms of helping seniors get the care that they need. every year over 4 million americans, an average of 10,000 per day turn 65. the growing medicare population is straining the cms operating budget. i'm glad is additional resources. your budget includes 875 million in funding for the administration for community living nutrition services. a 60000000 no increase which provides 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 needed which is why health centers in the national health service our priorities of mine. the agreement the president and offers important support for health centers in the national health service court and i'm glad the

pres.'s budget will help further extend access to these important resources for families across the country. while i strongly support many priorities reflected in the budget i want you to know that i am concerned by the proposal to cut funding for breast and cervical cancer screenings for women. the the affordable care act expanded preventive services and has help them save $483 million on out-of-pocket cost. there is still today an estimated four and a half million women who remain uninsured and are eligible for the cancer screening services that that program funds. i hope we can work together on a way to avoid cutting that a program. our country has come along way toward providing quality affordable health care that there are many challenges ahead they don't want you back to the bad old days.

secretary burwell, i no you share my hope. i look forward to working with you in my colleagues today in the coming weeks and months. with that i we will turn it back over. >> thank you. sec. burwell, we secretary burwell, we are pleased you are here and look forward to your opening statement. >> thank you for having me out today that have the opportunity to talk about the hhs budget. we saw the power of common ground command i applaud all of your effort and hard work that got that past. the pres.'s budget proposes to in sequestration, fully reversing it for domestic priorities in 2016 last by equal dollar increases for defense funding. without further congressional action sequestration will return in

the fall of 2016 bringing discretionary funding to its lowest level in a decade adjusted for inflation. when you hold a government solution and i hope both parties can work together to achieve a balanced commonsense agreement the budget before you makes critical investments in health care science guy innovation, and human services maintains responsible stewardship of the taxpayer dollar strengthens our work with congress to prepare our nation for key challenges at home and abroad. for hhs the budget proposes 83.8 billion in discretionary budget authority for 75.8 billion of which is for activities funded by the subcommittee. this increase will allow our department to deliver impact today as well as less lay a strong foundation for tomorrow. it is a fiscally responsible budget which in tandem with

accompanying legislative proposals would save taxpayers an estimated $250 billion. in addition it is projected to continue slowing the growth in medicare spending, secure 443 billion in savings if you -- as we build a better system that is smarter and healthy. in in terms of providing all americans with access to affordable quality healthcare it builds on our historic progress in reducing the number of uninsured and improving coverage for families who already had insurance. we saw a recent example of this progress with about 11.7 11.7 million americans signing up or re- enrolling in the health insurance through the marketplaces during open enrollment.

improving access to healthcare. supporting communities throughout the country, investing country's, investing 4.2 billion in health centers and 14.2 billion to bolster our nation's health workforce supporting more than 15,000 national health service corps clinicians serving nearly 16 million patients in high need areas and helps address health disparity to advance common interest in building a better smarter, smarter, healthier delivery system that supports improvements to the way care is delivered providers are paid command information is distributed. to advance our shared vision the budget increase funding for nih by 1 billion to advance biomedical and behavioral research among other priorities. in addition, it invests 250 million in precision medicine from a new cost of poor mental effort focused on developing treatments

treatments, diagnostics, and prevention strategies tailored to the genetic characteristics of individual patients. to further our common interest in providing americans with building blocks for success in every stage of life this budget outlines an ambitious plan to make health care affordable. it supports evidence-based interventions to protect youth in foster care and invests to help older americans live with dignity in their homes and communities to protect them from identity theft. to keep americans healthy the budget strengthens our public health infrastructure with 975 million for domestic and international preparedness including critical funds to implement the global health security agenda. core strategy core strategy of prevention, detection command response. it invests in behavioral health services and includes more than 99 million in new funding to combat prescription opioid and heroin abuse, dependence and overdose top priority for

our department command i want to thank many members on this committee for your leadership in this area. finally, the budget and shared priorities of cracking down on waste, fraud, and abuse initiatives projected initiatives projected to yield almost 22 billion in proceedings for medicare and medicaid. we are also addressing are meant -- medicare appeals backcourt with a coordinated approach. i am personally committed to responding promptly and thoroughly to concerns and communication with and from members of congress" by taking a moment to say how proud i am of our hhs employees on there work combating ebola to assisting unaccompanied children at the border to the commitment they show day in and out as they routinely go above and beyond the call of there work to help their fellow americans obtain the building blocks of healthy and productive lives. i look forward to working closely with you all as we

advance common interests on behalf of the american people. thank you, you and i look forward to your questions. >> thank you. we have a vote scheduled for 1145. it is my intention to be done when those which occur. we will do five-minute rounds and go with senator murray myself, the ranking member, the chairman of the full committee, and then we we will alternate by order of arrival. i should have time for a 2nd round. of course there will be a week to submit questions in writing. so to start i we will ask a couple of questions. there now everyone has time to ask questions. first of all we were able to get past last year the excellence in mental health fact that senator stamina know and i cosponsored in

the way that allows states to be part of an eight state park. i want to thank you for working your staff working with us on those guidelines. there was one late thing that had not been decided that was decided yesterday about what the boards of groups that apply need to look like. hopefully we will have that only a number of states apply both some sense that there are more states out there and the country is ready to treat mental health issues like all other health issues. i think that is an important place to go and hopefully we can do what we can in this committee to help us get there. on the gal report on mental health is related to the department it could have been better. i believe just in the last

few days the department department is going to move forward and look at those gal recommendations. of the 13 programs of the 30 mental health programs out there 13 are under samsung. four of those apparently there was no real plan to even evaluate them which was one of the criticisms. as you look at that report, as you look at mental health generally as it relates to health care one your response to the gal report and, and two, anything else you want to say that the direction you have to go. >> with regard to direction it is an important and critical time. i believe that as a nation we are poised to take the biggest that we have in a long time to put these issues on parity and make progress on them and look

forward to doing that. with regard to our conversations with you and senator stamina we will try to beat the statutory deadlines that have been put into implement your bill because it is one of the things. so the idea that we can get that done and done quickly and if these things in place we have those eight up and running in the states but continuing to do the work that it takes to implement mental health parity payment systems, stigma, how we implement our grant programs which brings me to the gal issue. i think there i think there were two fundamental issues we want to here and take seriously. one has to do with coordination. i i have asked samsung and the assistant secretary for planning and evaluation to come together to help do that in turn and

intra-government coordination. with regard to the question of grantmaking abilities and the evaluation and quality of grantmaking you all probably no we have a new acting deputy secretary doctor mary wakefield, the highest ranking nurse in the federal government. and she comes from herself. they have made progress with regard to this question of grants and evaluation evaluation, and we will see if we can share some of the grants our department and continue to make progress. >> thank you. i think that we want to look at what we can do to help enable you to do exactly that. >> thank you. >> if there are things that need to be set and report language were moved around in the budget let's talk about that and be sure that we get on track. i will go ahead and go to senator murray. we will see what is left. >> thank you, mr. chairman.

the affordable care act expanded coverage of all fda approved contraceptives reducing out-of-pocket cost and giving them access to more effective methods of contraception. women have saved over $483 million because of that provision. unfortunately, there have been ongoing reports of women experiencing difficulties in securing guaranteed coverage from their plans. the kaiser foundation just released a a report showing there is still variation in how insurance carriers are hearing and not all methods may be covered without cost-sharing. as someone who cares deeply about ensuring women have access that is very concerning. has hhs identified the carriers that are requiring cost-sharing or declining coverage or otherwise limiting coverage?

>> the issue has been brought up broadly and is one we continue to work to make sure guidelines are clear about the requirements and working across the issues of contraception, we have seen some of these issues arise for things like hiv and others. we're taking steps to reinforce and be much more clear about our guidelines. with regard to specific cases as they come in the kaiser report was a general report about understanding where the specific issues are. >> and you plan to follow up. >> we do but it is a matter of specifics being brought to us. what us. what we're doing right now is probably understand it is a general problem. being clear about guidelines and conversations with insurers, it is one of those things i continue to know -- i continue to i continue to make sure people no whether

it is about providing transparency or the issue of the coverage, being through but the line the guidelines. >> i appreciate that. i was pleased i was pleased to see that you are requesting $490 million to expand the multi agency effort. i talked about this in my opening remarks. outbreaks of these outbreaks of these dangerous superbugs are occurring more frequently in hospitals around the country. in february i sent a letter to the fda urging them to take action to improve safety for patients and a follow-up letter calling for a review of fda practices surrounding the type of schools scopes involved at virginia mason and other places, but we must do more to prevent infections from becoming resistant in the 1st place.

how would the additional resources that you request and your budget help with an outbreak at virginia mason or any of these? >> combating antibacterial resistance program has a number of elements in terms of what it will do. first, we need to take steps and actions. we put out a strategy and 14. in 15 we put out the action plan command our budget is the budget to support the action plan. making sure we reduce the overuse both in humans and animals. my partner the issue of antibiotics is an animal one as well. some of the funds will be used to support the reduction in terms of both humans and prescribing, and terms of animals. second, epidemiological we need to recognize quickly. cdc and others need funding to make sure we have epidemiologists to recognize when we do it quickly. how quickly our hospitals trained and ready to do

that. the 3rd is to make sure we're continuing to do research to develop things that are not resistant as we go forward. those are elements of the core strategy. >> multi. and much of it sits with the department of health and human services. usda being primary partner because of the animal connection. >> the issue of public health public health programs for washington state. >> that is a place where the cdc will continue to work and education is an important part. when one gets to this issue of prescribing, 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 over prescribing. part of the problem is

actually over prescribing. the ability to go in and make sure the training education, and tracking. >> this is important. thank you. >> it is millions already. everyone has a sense. 23,000 people died last year. millions and millions are contracting resistant disease and many of that is occurring in hospitals as you reflected with the situation at virginia mason in the scopes. >> thank you, senator. senator cochran says he will speak in order of arrival, but i want him to know when it comes time to allocate you can talk anytime you want to. on the side i have mr. langford alexander, until.

mikulski, read, baldwin, and berkeley. langford. >> thank you. thank you for being here and thank you for the engagement. let me engagement. let me go through a couple of quick questions. there is a lot of conversation. that is not a knew conversation. in your testimony you know that starting in 2009 their is a 1300 percent increase in medicare and auditing and what is happening in the appeals process. there is obviously a problem well you are accelerating the appeals process a while to get down to some of the root causes. there have been multiple changes. what is pending right now? beyond just the appeals process, but the root cause of this. >> with regard to direct process is important to step back.

we work on program integrity issues. this is something that doctor coburn and others helped us focus on. and this was put in place so that we can do the tracking. it has tracked many, many -- and returned quite a bit of money to the federal treasury in the billions of dollars. there were negative unintended consequences. the congress is but a hold on certain parts. administratively we've taken steps. >> there are some constraints. we have had to the contrary. implement changes.

we've done in administratively. we can't act on them as fully as we would like. it is only on part d. the the other thing is it actually does interact. if the case does not go forward there will be nothing paid. and so paid. and so we tried to fix the incentive issues that were causing problems. it is related to the backlog issue. the place where we believe we need help from congress and have had conversations across a number of committees. >> the recovery audit data warehouse putting that in place to make sure you don't have duplication of contracting and such. last year there was a statement that came out to say they are trying to reform that to make sure the contractors -- you know if there has been any progress? >> i will have to get back to you on that. >> dealing with good providers. obviously this process coming through.

a smaller number. any kind of consequence for contractors pulling a lot of files being overturned. on both sides there is an incentive from the contractor. >> and the provider. >> and the providers. >> and the provider review is something we have put in place. >> okay. let me ask about another issue that is not near as contentious. icd ten in the transition. this process of transition everyone is concerned about it obviously. a lot of conversation about the advanced payment what happens in the transition, how many small providers will be vulnerable. the same issue. managed by large providers. very difficult. the concern is out there as well. what happens in the transition?

the discussion has been out there on advance payments. payments. is there a policy in place process, details coming out? >> we now plan to go forward in october. there was a legislative delay but the plan is to go forward in terms of moving to icd ten. really doing testing and communication with large and small players. most have been and are ready the question of delay has to do with cost as well as fairness and equity for those prepared to make the switch. hospital associations have done surveys command we have high percentages of people reporting that they are ready. we are in the process and will provided technical assistance. >> what about advanced payments? is that still being discussed? the concern is that there will not be a smooth transition from one to the other. is it your confidence that there will be a smooth

transition? >> the numbers we are hearing and what we are hearing in response is indicating that they are ready. during the time from now until october we want to continue to work. if you are hearing from the -- >> it is important for us to know that you are confident they will not be a a gap in payment. >> we are planning to make sure we can go through. >> madame. >> thank you very much, mr. chairman. before i go to my questions i would like to bring to your attention a very dedicated staff member of this committee who has worked for senator harkin and me was respected by senator specter.

adrian how it can work for the committee for 13 13 years will be leaving to go to the executive branch. again help doctor collins. i would like the community to give adrian a round of applause. >> and i will say thank you to the committee. >> i'm glad to see you. so many of the great federal assets of hs's is in maryland. just to name the big three. a tremendous impact on our economy. the jobs they provide and the jobs they stimulate. we could not have a robust biotech committee without you. we will be talking about those issues but i will go right to a maryland issue in the part of the state that is familiar. mountain counties and

abolition. i have a situation where due to the senses they are telling me that allegheny county right next to our college in west virginia has lost there designation federal funding to qualify for the affordable care. i wrote you a letter in february. staff has been going back and forth. we have been told recently that there's nothing you can do. i need you to look into this you know western maryland the mountain counties. they have lost population lost jobs. we we don't want them to lose hope in their government. the impact is $2 million. that might not be a lot by our spending appear but that enable them to attract doctors, harness volunteers like mercy that reduced dental visits. can i have your assurance

that you will look into this and not just have bureaucratic phone calls back and forth with a just say no? >> senator, i will look into it. >> and not just a list. they are not an urban county so let me go on to another issue. great exuberance among many of us. we work together in a bipartisan basis to pass the childcare development block grant working so closely. passing authorization. we work hard when the quality provision. sure, we want more money but we really focused on a bipartisan basis.

enhance the quality and safety of children. >> the quality and safety are a large part of the implementation. that is implementing the standards that you put in. with regard with regard to increasing the questions of safety and quality on an evidence -based. that is part of the money. the 2nd part of the money in terms of implementation and thank you for your lead on this, there are funds one of the other things we were asked to do. childcare for unusual circumstances places that are not receiving an hard-to-reach that we do work in that space to understand how we can help and support. quality in terms of standards that we need to apply and implement and will do that as well as the quality issues very cutting across the entire suite as one looks at the continual for children home visiting, childcare in terms of

implementing authorization also the childcare expansion that senator murray mentioned. the eight-point 82 billion over ten years for making sure that working families have access. and then we don't want to forget head start and early head start and those partnerships. this is a continual. we work to implement that piece. >> in a nutshell, $370 million increase from last year. is year. is that correct? >> correct. >> of that 370 million about 270 million is for the knew quality provision. >> correct. >> will we want to do is get the implementation started and as we look at next year we will understand more. >> a hundred million for pilot programs.

i say to my colleagues, we think of ship work, we had nurses who were working the night shift. i had a national security agency that works 24 seven, many are women cryptographers keeping america safe, often single mothers. i think we mothers. i think we're on the right track and hope that -- my time is up but we could have additional conversation on the work you are doing on both foster care and also with unaccompanied children though the children seem to not be at the border the way they are they are in our country, could continue to come. we cannot turn away from this very important issue. i look forward to dialogue with you. >> thank you. >> senator alexander. >> thank you, mr. chairman. welcome, madame secretary. senator murray and i on the health committee are trying to get a few things actually done.

we have reported a bill on elementary and secondary education moving ahead to higher education. it will get into innovation and medicine. and one other area where i believe that we could get something done is electronic health record. you and i have talked about that. you talked about a year and nine months left for you. i would like to move out of the top of your list and i was doing something about electronic health records. the government spent 28 billion subsidizing electronic health record. cells ago wonderful idea. but but half the doctors are choosing not to participate in the program doctors do not like the electronic medical record system by and large. large.

they say they disrupt the workflow and are not worth the effort. ama commission study found electronic health records are the leading cause of physician dissatisfaction. a medical economic survey found 70 percent of physicians say their electronic health records have not been worth it. i have met already with andy slavik and at your suggestion will meet with doctor disalvo. what i would like to do -- one other thing. we formed a bipartisan working group to identify five or six problems in electronic health record system that we can address administratively. you list of things that you would like to get done working with us identifying

five or six things that would make this promise something that physicians and providers look forward to instead of something they endure. >> yes. after our meeting in our conversation i think we have a working group ready to go and are committed. this is extremely important in and of itself. we will talk about so many things that it touches. i'm sure will get a question about opioids and harold. the precision medicine issues, electronic records touch that issue. delivery system reform creating a system of healthcare delivery that has better quality and is more effective and efficient touches that. we should we should focus on it in and of itself. where it is going in terms of our ability to serve the patient. welcome the opportunity, look forward to putting the list together and getting it done. we will work with you on

what we need legislatively. >> good. there is a lot of interest on the community. one other area i think we should work together command we have talked about it senator mikulski and i and burner and bennett asked higher education folks to give us a report on what it costs -- the cost of overregulation. they gave us 59 recommendations about what to do. they're putting it together and we will incorporate ideas as much as we can. at the same time the national academy of sciences has said that principal investigators are federally sponsored research projects and spent 42 percent of the time on administrative tasks we we used to do a lot of talking about needing more money for research. taxpayers spend 30 billion a year on research and development.

nih spends about 24. vanderbilt university hires a boston consulting group to tell it how much it costs vanderbilt to comply with federal rules and regulations, and the answer was 150 million for one year a lot of it had to do with research. that that is not all in your department but will you work with us to see if we can work with the national academies and take that 42 percent down releasing hundreds of millions, maybe billions of dollars that could be used for important research.

two we need to do that. from our end of the federal government. some of these things we need to figure out where we are willing to take certain risks or not. some administrative costs have to do with important things. this this is a place right for us to have quality conversations about the things we can do to reduce the burden and cost and make sure we're clear. welcome that chance, and i know our colleagues there are a number of things that are already on there list. >> thank you. >> thank you, mr. chairman madame secretary. let me focus on a topic that senator collins and i have been committed to ensuring there are adequate resources

i'm pleased to see your budget request is a slight increase the still 200 million below the previous authorization and appropriation. what can we do to further fund? it is not just the cold in the northeast. it is increasingly hard summers in which air conditioning is air-conditioning is essential to people in the southeast, southwest command west coast. can you help us? >> in the budget proposal what we did was propose the base level. last year's level and we proposed a contingency fund which gets to the issue of variability in that we are having huge changes. but we were trying to do is create a fiscally responsible way to respond to the type of increasing, erratic whether and that the contingency fund would be our ability in terms of how

much we need to put in the budget so that we have the contingency fund that would allow us to have flexibility, so fond of the base level and data contingency fund. that was our approach. >> i commend you for the increase. i think we need to do more and we look forward. a related issue can you work to release those funds are commit them to make sure they are committed? >> at this time we're doing the final review. we will work with you on that issue. 99 percent there.

the 34. the 34 is the outstanding amount. >> thank you. let me turn to another topic cdc section 317. many middle and low income families provides a structure for vaccination which is a critical public health, some would argue one of the most critical public health initiatives we are taken in the history of public health. some were disappointed that your budget will cut this program by 50 million next year, particularly because we're seeing the outbreak of some contagions that we thought were in my youth like measles. section 317 is used to track that response. looking at these issues, while we cutting this program? >> like you, we agree and are concerned about the vaccination issue especially with regard to the

vaccination a break. there is a couple of entry program. when you combine the two together there is a net increase of 58 million in the budget overall. with regard to 317 as we implement the affordable care act parts were used for those underinsured. because when the aca was passed is required that all plans do know cost-sharing. when i take my child in for wellness visit, that vaccination does not have a co-pay. because of that reduction the 317 money was for vaccine purchased that is being reduced because we have those people now in a fully insured space. the kind of things that are important this issue of educating which is something we're doing more and more of none of those things work cut as part of this.

>> and you are doing analysis to ensure there is no gap and in fact children are getting the vaccines through the aca mechanism. >> the problem that was raised with regard to contraception we're not seen with regard to vaccination which is that people are not covering that. it is the way -- it is when we here we go back out with guidance. we have not heard that from anyone at this time. it seems to be being implemented correctly. if you're hearing something differently want to know is obviously this is an extremely important issue. the formal swearing in of the surgeon general genealogically. >> it's a good.

>> i agree that stuff that's that that's -- >> a couple things. you mentioned the effort made for unaccompanied children coming to the border. last year there was a roundtable. care for the unexpected surge of children. there was a physician there had the public health service uniform on. i was critical because the responsibility for. she. she said well i'm the 1st dr. and was only hired

two weeks ago. and this was july. cms or hhs had $800 million, and the 1st dr. was hired in the middle of summer with when they requested a bump up in anticipation of a surge of unaccompanied children. just make that. and follow-up. nonetheless you mentioned it. it just popped up and has bugged me ever since. she was a dedicated physician but had been hired as the 1st. there have been two or three nurses but never a physician no offense against the nurses. they were just a few of them secondly, you mentioned the effects. i want to speak for that physician in small practices. and small practices. the big hospital chains are ready, but what i am reading here cms estimates that in

the early stages of implementation rates will rise and the days and accounts receivable we will grow from 20 to 40 percent. it goes on to explain why. i will just say, according to your own website that urologist in south louisiana , one or two person practice she cannot afford to have denial go from 100 to 200 percent and her ar going by 20 to 40 percent. personally, i think the reasonable thing to do would be to delay the penalty phase for two years as people transition because that dr. struggling to see however many patients she has a day and comply with the hr will suddenly have her denials grow not because she is not doing it right the because the system is changed. changed. unless we're sympathetic, we will drive her out of practice i put that plug-in.

this is something you can address. the cbo projected in february 2013 the per-person cost of medicaid bridges that portion that the expansion population under affordable care act will be $2,500 in 2014 only including estimates for the fully eligible. last month the cbo projected an average per-person cost of 3460. this is a jump of a thousand dollars per beneficiary which is almost a 40 percent increase. medicaid. we will disagree.

you had a 40 percent job. >> i want to look at what that references. across the affordable care act medicaid is generally the week -- the least expensive option in terms of service and care. i am surprised by that number because if you and i have the chance to discuss in terms of the net and overall we see that not happening. in terms of our medicaid increases that and medicare we have seen deep control. >> let me squeezing again. a.out apparently only 2 percent of those 400 percent income only 2 percent of those eligible

sign up for exchanges. getting hosed by premiums. we will just leave the middle class behind. >> this is in the exchanges. >> with regard to the number that we have seen in terms of those eligible to receive insurance through the marketplace as we have talked about, about 16.4 million people the largest. >> as we talked about cbo reduce the baseline. >> they reduce. so with the most recent

numbers reduce the cost of the affordable care act by approximately 300 billion. .. that we now have that makes actually new jersey we -- in terms if you want to pleasure it as a success measure would go

up based on change that cbo did. so with regard to the question of number of people in the marketplace, we want that to continue to go up. we want to do everything we can. i think you saw we worked hard to have an open enrollment that served the consumer whether that was having the web site up -- i know this is highly controversial so i do this at my own peril -- it's important to have the conversation so i welcome it. we were trying to serve the consumer, and we saw and continue to see growth. can it be more or better? we'd like to do that and like to work on the ways we can make more of those consumers come in and fine that affordablity. having traveled around the country and spoken to a working woman, three children, you get sick enough to go to the emergency control and they'll treat you, and she said now i have a guard. >> you're three minutes over. the woman i spoke to says dish. >> we actually are three minutes

over. >> i'm paying 500 bucks a more for insurance and i don't need what i'm getting with the $6,000 deductible. >> mr.shot. >> thank you mr. chairman. thank you secretary burwell. i have a question about telehealth. i'm a big believer in telehealth. the va has done a lot of good work. the dod has done good work. private health care providerrers expanding services, the way imto improve clinical youngs and 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 kind of statutory restrictions you may have, and could you just sort of divide your question into those two categories, where you think the law really needs to be changed and you're stuck and what you think you could be doing within the confines of the statute you're not quite doing yet. >> i think the places where we can do more are in our innovation center and so the

funding we received for the innovation and that was partr(w of the affordable care act we have been given. we're seeing and doing a number of innovative projects that are including telehealth. that's one place where we're acting. we have several things we have funded that include telehealth components we think are important andow all know the statutory requirement for regard to meeting success are very high circuit will take time and measurement to get there and prove that. but we want to work to do that. his those measures because that's when you can scale them. we have to show -- you asked us to show quality and cost so we have to do that. the other place in terms of authorities we currently have, half to do with aca work we're doing, pioneer acos and others. the accountable care organizations. we put out a version 2.0, and telemedicine was increased in that. with regard to 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. >> right. okay. so, let's do two things. first, let's work together, and ill know senator ricker, the champion of the subcommittee, on telecommunications, had a really good bipartisan hearing on the potential for telehealth, i think there were 17 members of the subcommittee who attended. there was broad and deep enthusiasm ondé#ñ a bipartisan basis. i want to work with him and other members are anxious to get going in that space, and i think he is going to work on legislation to introduce in this congress in that space. so, we have to work on whatever changes in the law are necessary. i i'd also encourage you, because during that hearing, the national organization for telehealth -- i that's that what they're called -- the national organization that advocates in this space -- thinks you can do more even win the constrains of

1834m. i know you did the next jen aco but some of my staff and others are saying you could move quicker and go forward and some other areas. so, i'm anxious to -- i know you believe in this i know the administration believes in this, and there are other executive branch agencies that are moving faster. now, some of that is because of the law itself, but some of it may not be. if you can check with your staff to see that we're doing absolutely everything that we possi4lp7á we doing to advance the ball on this. you're one of the biggest pairs -- biggest payers around. a lot of the questions were logistical and clinical and setting up markets and a lot of those probelines downstream get solved if the pair comes to the table -- the payer comes to the table. that gets settled but there will be a built-in market and you can make incremental progress.

>> the payment has to do with is it something that exists or does it have a certain proof point. those are the places where there's room to see if we can push our authorities. if you have ideas, we welcome that. >> thank you very much. >> senator capito. >> thank you mr. chairman. if it's not lost on anybody of this committee to know we're both daughters of west virginia and i'm very proud of the secretary. she does a great job representing our state and nation so it's an honor for me to be here with you. the question i had specifically -- i mentioning this the other day, about the black lung clinics. hersa made a change in their allocations to cap it at 900,000, which actually costs west virginia some federal dollars trying to make sure we meet the challenge of ridding ourselves and treating black lung disease, which unfortunately has.vr0c

what's the rationale before the program is? this going to continue? we were able to sort of recover a little bit through another grant process, but i'm concern about this because of the deep need that we have in the state, our home state. >> following in on our conversation -- went and had conversations why the changes were made, and the changes were made in the program to make sure -- i think there were questions about whether or not we were fulfilling the statutory obligations with regard to the quality of grantmaking. that was a very large portion. 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 throughç mainly straight grantees, there were also other grantees in states that actually were serving communities as well. and so opening the door for others to serve as well, and i know i went to look at our state, to see what hat happened, and i think in the year before the state, the department, in

terms of the government, received the grant of 1.4 and in the end what happened was two grantees, one was the state and another was another player came to one, too. so it was a $200,000 reduction in terms of what the state received, but the objectives were to try to improve quality and get some grantees that are closer to the local communities. >> is the interpretation i'm making. the $900,000 cap, is just the cap that would go to the actual state government and if there oar grantees, you can apply through this? >> that's right. and in west virginia we did. we actually were very fortunate -- no. i actually -- someone also raised this last year with me and i actually had asked could the state still -- another grantee came forward in the state. >> okay. i think the money needs to flow to the need, obviously, and i'm sure that's -- the quality issue i understand. >> i did follow up on that issue, too i did ask them about the question of need. being from west virginia i argued every from our type of coal to the population we have

would be greater needs. >> right. >> so one of the things is i think there is difficulty in measurement, and we do need to work and get people to a standard where they're able to measure these things so we can make decisions better based on that. >> sounds good. thank you. we'll be following up with you on that. >> that's where we made need help, the measurement. >> you mentioned opiode addiction and what you're doing in that area all across america. we seem to be having a difficult problem with illegal prescription drug abuse and heroin, the rise in heroin and poisonings, and deaths in the population. help me out here. how can we stop this? what are you doing in the department? >> building on the work that had been done but being very focused about -- distance i arrived and last june june 9th this one of the first things i asked the team to come together. many thats going on in the department. consolidated strategy because we have a short period of time and we need to be focused witch

congress and governors. it has three basic elements. the first is prescribing. that where is much office this starts. and that is the only one that addresses prescription opiodes and not heroin. we need to get to a better place in terms of prescribing. there's overprescription occurring and that is driving a large part of it. we need to make sure the doctors have the right guidance. the head of the ama spoke about this issue at the sdr event in terms of they need the rightgate guidance. prescribing, number one. number two i is access. that's part of the budget conversation we're having weapon need to give the states money so they can access the -- >> our state just passed a state law that allows them to carry that. >> west virginia is good. massachusetts -- i'm doing on event next week with governor baker, the any republican governor in massachusetts, who made this a big priority and in his state of the state, and we'll do an event together. the third thing has to to do with meds indicated assisted treatment, because sadly, for both heroin and opiodeses we

have so many people addicted we have to use medication as part of the treatment. those are the priorities that i think we all node work on together. with regard to our work with the congress, it's about funding in terms of the conversation we're currently having. it's also about something called -- also part of treatment, and how we prescribe and how we control prescribing. i think at this point in time there's general agreement it's a little too controlled. but the changes we need to make we need to make in con justification with the congress. the other thing is working with the states and making sure that they have the prescription drug monitoring plan, pdmps, put in place and are strong and eventually we need make sure the plans are going across states. kentucky, west virginia, the border is pourous, and if we can't know what that person in pike county is prescribing in mingo county, those are the kinds of steps we need to take. >> good. thank you. >> thank you. senator baldwin.

>> thank you, mr. chairman. and ranking member. i am going to follow on senator capitos questions in just a moment. before die 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 draft a bill that provides the funding that hhs needs for its critical programs and to carry out its mission and serve the very people that we all represent in our home states. as another side note, as someone who has raised by an nih-funded scientist, my grandfather i am certainly a strong supporter of our research and nih budget. but in particular knowing the impact that our scarce funding has had on young researchers, i'm especially concerned that the budget control act continues to put our next generation of

researchers at risk. as i said i want to focus in on the opiode prescription initiatives in your budget. this is an issue that obviously impacts many of our states. i would dare say all of our states. and so i am interested in hearing a little bit more about the cdcs plan to develop opiode prescribing guidelines, and in particular i want to ask some specific questions about that. number one we've seen in wisconsin some particularly tragic cases involving our va system. a number of deaths of -- tragic deaths of patients who were treated at our va center, and so part of my question is, will these guidelines be applicable to systems like the va system

and then secondly, guidelines are just that, guidelines. they're not mandates. and so we have had challenges when best practices when guidelines have been articulated before in getting the wide-spread adoption of those in our medical and prescribing2gs community. please speak to that, too. >> so, with regard to the guidelines, we think it is one of the things people feel is that they do neat more clarity because there are important issues of pain that need to be treated. and treated with the types of drugs we're talking about. so we don't want to deny those who their daily living is dependent. so getting clarity in the guidelines. cdc will work with fda, nih, all the other parts to provide those guidelines. with regard to the issue you just articulated with guidelines, this is another space that i actually think we may need to have a conversation about potential legislative help. and that has to do with training.

because even if we put the guidelines out, the questions of whether or not those existing physicians and even those coming through, will be trained in these mechanisms and attend in these guidelines, is a question that is an extremely important one. and so how that and where that occurs may be a conversation we need to continue weapon have put together the places and spaces where we think legislative state, and what prescribers and others need to do. that's how we thought about the strategy. that actually is a very specific issue that is on our list to continue to have a dialogue and conversation with you all about. >> i would welcome that followup, because the tragedies we have seen in our states, that i've seen in my own state, deserve a response of the jut most seriousness. and in fact i think we're coming very late to the issue.

your testimony secretary burwell, highlights that in 2009 total drug overdoses overtook every other cause of injury deaths in the united states. and qb%u yet we have yet to implement a comprehensive strategy. so in addition to working together on future perhaps legislative measures, what i want to ask you is how will the administration's proposed initiatives that address this growing nationwide emergency be impacted if your budget request is not funded? >> it will be extremely important. the funding is very important to the states. that's one of the most important parts of this. because it is implemented on the ground, and so the funding goes to samsa and cdc and that's where the money is going directly to the states. so having that money available for the purchase and use of

nelan there are there was a question of what type of emt did you have to be to use it in a number of states and that's prohibiting a number but west virginia massachusetts, kentucky, there are places making good progress, but even when they make the progress there are funding issues so becomes very important we make progress this year on these issues this is done in cordation with the national drug coordinator in the white house our policy counsel to make sure wore coordinated. hhs, dhs and department of justice, mainly us and justice are the two places that interact. it's many law enforcement officials who are the people who need to know how to apply nalofan. they're on the scene when there's a drug overdisease.

>> on your work with connecting people with places and spaces and what they need to know. do you need more authorizing language? >> we need further dirk it's not just money. i think it is other questions about how people are willing to implement the guidelines, and make sure that people are trained. the question of continuing medical education and how this touches upon that are the kinds of questions we think we need toathathathathvs-

our state has to win the prize as the highest childhood vaccination rate in the country. we are proud of that. and because a lot of people spend a lot of time and effort in making that possible. but it all depends on funding from the program and so in looking at the budget request, we're disturbed that over $50 million in advance funding is recommended. to reduce funding for that amount would be devastating we

think to the affordable care act. what's your reaction to that and drew have any thoughts? >> we have tried to design a vaccine budget that included both the children's vaccines and immunization, which actually increased well over -- close to i think 70 million -- the increases of the children's vaccine fund that we do were greater than the decreases in 317, the place where the decrease. so net-net a $50 million increase, and what we were trying to do is make sure that the places where we did do decreases were for the funding we were doing for those who were underinsured and those who are underinsured because of the affordable care act, that is not occurring becaused it is covered. if you have insurance now there isn't an uninsurance issue and you have to pray copay for your child's vaccination. you no longer have to do that. that's where we were. this cost of the vaccines we were purchasing for use in the

facilities you're talking about, that's what has been reduced and that is because we believe because of the affordable care act, that's being taken care of through private insurance now. in terms of people who are insured. so we try to implement a policy that actually increases overall vaccination conditioning and decreases its in places because of the affordable care act anymore people who were underinsured are now covered. >> thank you. >> thank you very much, mr. chair, and thank you madam secretary, for your testimony. and the number that was -- i'd seen before 16.4 million americans who were previously uninsured have now gained health insurance coverage through the different facets of the aca. aim interpreting that correctly? >> because i want to be careful with numbers. that number includes -- we think

the vast majority of that includes all aca provisions, but i think the economy has recovered so some of those people may be people who gained insurance because they have jobs now with insurance. the vast majority -- we know that because of the marketplace but a portion could be something that is a positive thing, people who have employer-based care. >> so you go on to have numbers 1, -- 11.2 million individuals insured through medicaid or chip, and the five million of the 11 million on the exchange are folks who previously did not have insurance in ballpark numbers? >> yes. we don't -- those have to be derived because we don't ask anyone when they come in because there are no preexisting conditions to anything. you can get on if you are aren't,. >> that the right ballpark? >> i'm not sure what we have -- i don't think we have put out a number of exactly the number in the market place that are uninsured because -- >> let me continue then. the -- i was very struck by the

statement in the testimony that said, eight out of ten of those that go to the exchange, after tax credits get health insurance for less than $100 per month. >> that's correct. >> that's out of that 11 million, 80% -- >> eligible, can find a plan that is $100 or less. >> well, it'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 health care and stop the transition in which folks who have insurance had to pay through their rates for the folks who didn't have insurance, the uncompensated care. 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 concern over the explosion in the use of e-cigarettes and these are the -- or vaping, the electronic

devices that vaporize liquid nicotine that comes in little bottles like this. i showed the same two bottles, j juice, scooby snacks and j juice, gummy bear, and this now has changed dramatically in a single year. we have a new report from the cdc do itled e-cigarette use triples among middle and high school students in just one year. and it goes on to detail that for high schoolers it's gone from 4.5% to 13.4, middle schoolers, from 1 .1 to 3.9. almost a quadrupling for middle school. and all of the cdcs studies show that nicotine for adolescent brains is a very bad combination. and thus it's very important that we regulate this. and back in 2009 congress gave power to the fda to regulate

flavors and basically all aspects of tobacco products. so now we're here six years later, and we don't have those regulations yet, and i appreciated your call to update me on the process. the process goes from fda and then goes to omb, and has that transition occurred yet? is omb now reviewing -- has the fda shift the draft to owe mb. >> we're still reviewing comments at hhs. >> at hhs. >> yes. >> so it has yet to go to the final review within omb. >> that's correct. >> or is that simultaneous? >> no. we complete the process of the review. >> and you know i was going to ask you about this, but when do you anticipate that will be completed? >> so, the question is is the overall process of the rulemaking, and i think everyone knows we have a notice of proposed rulemaking ex-we're in

the middle of receiving comments on and that it will finalize the deeming for these products and other products as well. it's our hope that over the summer, that at some point this summer we will get to a final stage. >> well, i hope that it's more than hope. i hope it's a reality. and i appreciate your personal efforts to accelerate this process. but i still am deeply disturbed by the fact it has taken this long. had this taken two years less four years instead of six year -- i on the think anybody thought it would need to take four years -- we would have many thousands of high school and middle school students who are not being basically brought into the nicotine dangerous world through these flavors designed specifically to appeal to children. these are -- you have chocolate and strawberry and gummyber and

scoopy scooby doo, and the statistics to the 90% of smokers fir began smoking -- i'm including vaping -- as teens and three out or teen smokers continue smoking as adults. the industry understands that it's in childhood, in the teenage years you must secure the addiction, which then has huge consequences for the quality of life of the next generation and huge consequences nor cost of our healthcare system. so this is one of those opportunities to make a dramatic improvement that make a tremendous amount of sense from every direction, and for every month of delay, it's additional americans who are damaged. and it's not just in the smoking. it's also in the poisonings. the poisonings have exploded in the space of time since 2011 until now it's a 14-fold

increase in the poisonings because these little things jars look very appealing. they look very appealing and they're labeled juice and they're called gummy bear. must be something good to drink. and do you consider it irresponsible that people are making these things and not putting them in child proof bottles? >> with regards to that, think the question of how everything will be regulated once we get to the deeming, i think those are the questions we're going to have to work to answer and answer quickly. >> well, -- aim over time. >> you are. >> thank you very minute. >> mr. chairman, thank you diagnosis you and senator murray for your leadership on this subcommittee, and secretary burwell, welcome. thank you for reaching out to me. it's my fault our conversation didn't happen. i'm appreciative of your efforts to stay in touch and contact and have conversations. just by -- i think i'll have time for a couple questions. let me ask an early childhood

question. this committee last year allocated $500 million to be used to expand access to infant toddler services, through early head start. and the goal was to expand child care partnerships mitchell question is tell me about implement addition and particularly assure me that rural communities where even licensed child care is a rare commodity, that they are being considered appropriately for those services. >> the issue of -- we have worked towards implementation and i think because the program had both early head start and child care partnerships, that expanded our ability to serve in communities where various types of care would be provided. we want to make sure we're meeting standards in terms of the conversation we had earlier but our work. the issue of rural america and rural access to these types of programs are something i think you probably know deeply

important to me as someone who participated in head start many years ago. i understand the questions of the limited access anyone has to quality early education so issues we'reworking towards -- we're working towardses there's things you're hart aren't consistent, make sure we know. we haven't heard this issue so if there's something you have heard from your state, i'd like to know. >> what's the status to of implementation. >> grantmakeing is occurring. i have to check exactly what stage of the grantmaking we're. my can remember the point which the announcements went out to solicit brants but i'm not sure where we are in the process. >> let me change topics now and talk to you about dietary guidelines. you and secretary of agriculture are charged with developing dietary guidelines and in the process by which you develop those guidelineslines you have an advisory committee the dietary

guidelines committee, they issued a report and at least to many of us it's a very controversial report because it includes in their recommendations -- they admit they're talking into account topics outside nutrition and diet -- and specifically considering environmental sustainability. so dietary guidelines which are hard to determine what the right answers are at least by your advisory committee, is now being expanded to include consideration of environmental sustainability, contrary to the statutory framework by which you and secretary of agriculture are instructed to develop the guidelineses. i've had conversations with secretary vilsac in person in my office as well as the hearing in front of the appropriations subcommittee on agriculture in which he indicated to me that he

will he will color within the lines. but that i assume he is assuring me that he is going to abide by the statutory framework for those guidelines, and i've also asked him if he has had conversations with you about this topic and what interface is occurring, and my impression is at this point that probably not occurring, at least at the secretarial level. so my question to you is the same as to the department of agriculture. i want to make certain that you agree with the sentiment expressed by the secretary of agriculture. 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 and developing dietary guidelines, that you will stay true to the issues of diet and nutritional science and not expand the dietary

guidelines to something beyond its intended scope. >> so, actually secretary and i have spoken. it was' an issue that he spoke with me and then i received your letter, and the letter signed by many folks in terms of -- received two different letters and we extended the period of comment. rights now we're in a period

way -- the dietary guidelines are to goaled around do it at the science and nothing more? >> i have to be honest and say i have not reviewed the statues closely enough to answer that question.

>> i want to abide by the statute and that's something i apologize, i haven't gotten to. so -- but i hear and understand that's something you will be following up on. >> thank you secretary. senator durbin. ,. >> thank you for being here. let me associate myself with the remarks of senator merkley as we delay these implement addition of deeming as to e-cigarettes, more and more children are getting addicted. it's time. i don't know where this has come to a halt, whether it's in your agency or omb or some other place but i'm going to try to find out and move it along. secondly i met with dr. francis collins out at nih and i said to him, we can't aspire sadly to those glory days when harken and specter and porter doubled the budget for the nih -- >> i was as omb. >> you were at omb. what can we do that will make a difference? he said i would tell you, five

percent real growth for ten straight years. he said we'll light up the scoreboard. we will provide cures that more than pay for the cost of this research. and alleviate the human suffering involved. so i've been watching that standard and i have to the you that we're falling short of it. over the last ten years we have fallen short by 23% of keeping up with inflation at the nih, and so the number of grants that have been awarded have been cut in half. and that has diskinder researchers from -- discouraged researchers from staying. when look tet president's request for nih and cdc i see roughly three percent increase over last year. i if you assume two percent inflation and i understand omb no longer assumes inflation. that's how hey avoid that decision. if you assume two percent inflation you can see the minuscule amount we're increasing nih and cdc. i don't ever quote and i rarely

ever praise, newt gingrich but i'm going to. he writes in the "new york times," what are the thinking? we're spending a for on all the medical care associated with illness, disease and yet we're not putting money into the research to alleviate it as we should. i would just go a stepon that and say, he fell short of suggesting how we would pay for that, which would be the important ending to a story. but i would just like to say for the record -- i've spoken to senator murray and senator blunt, to senator alexander and others about this. i think it is time for us to step up as a congress and do something truly bipartisan the american people will applaud, and say we're going to start a commitment of five percent plus inflation to key medical research, and we're going too do it on a bipartisan basis no ifs, ands or buts. i would would just say for the record, since i'm the ranging member on the defense appropriations subcommittee, if

there's conversation about riding to the rescue of the pentagon i want to be part of the situation but i want to stick to the basic rules that paul ryany patty murray came up with, it's shared equally with nondefense. we make sure there's money comening back into the nondefense side of the equation which is so important. so i hope the administration will take the same position. if we can kind money to help the pentagon, i'm for that. let us not do that at the expense of nondefense, and i hope, i hope that we can come to a conclusion that we're going to make our mark in bipartisanship when its comes to biomedical research. can't think of a more bipartisan issue. i'm open to any comments you would like to make. >> one is we, too, believe that in terms of the numbers and the investments and the tradeoffs and choices that we need to make those in terms of getting the nation to function right now, but presenting for the future in the way you're -- preparing for the future and that's why we make the choice's we do in the

president's bug, and i repeat what you just said with regard to the match of increases in spending in defense spend'ing and nondefense spending. we saw what happen when ebola comes to our border and that's ha health and national security issue, but it's one that is funded on the nondefense discretionary side. so making sure we keep those two things moving and moving together is something i think we think is extremely important. >> i was just -- one other unrelated issue. wic program, believe in it. i hope we can make its better. any idea what the eligible income is for qualifying for wic in the state of iowa? >> no. i do not. >> $90,000 a year. it turns out when we coordinated the eligible for medicaid and wic, there's a great disparity among the states as to whether or not you qualify for wic and i would like to suggest that the statutory standard that we used

to have is somewhere near 45,000 as a maximum income that you can qualify for wic, and because of this in other words indication of the medicaid eligible and wic eligible, there appears to be some gross disparities in some states. would you look at that? >> i'm happy. to wic would -- work with secretary vilsack on these issues and don't see that in tanf. but certainly this is a number i've never seen. so want to look at it and will understand it. >> thank you. >> uh-huh. >> thank you. we have a little more time on the vote than we thought we had so there's time for a second round here and ten, 11:55 is the scheduled time for the vote. so hopefully we, work with that time. on the issue of dietary standards that senator mirand brought up, he brought up the same issue at the fda hearing, and the commissioner hamburg

stated she at any time have a direct role and was an adviser. today you have stated you hadn't really looked at the law yet. seemed like there's a certain running for the hills here. secretary vilsack said that sustainability falls outside the guidelines. so the one person we have talked to who has looked at the law appears to think that sustainability is not an issue. you maybe want to argue it should be and all you have to do is change the law for that to happen, not add it to the law. so we'll be watching that, i'm sure. on -- another question on -- i have a couple of questions for the record. on risk corridor -- the risk corridor program secretary the affordable care act -- at least last april -- let me be sure i'm right here -- the department released guidance stating the risk corridor program would be implemented in a budget neutral

manner. my impression from what -- the discussions i'm hearing now that somehow the risk corridor program would find revenues somewhere else to make up the difference. is that your view? >> with regard to i think the guidance put out at that point in time -- i think that i'm trying to -- i was at that point in time going between but with regard to risk corridors, a program that is about making sure we have premium control and put downward pressure on premiums, which is something we all think is important. with regard to program we believe it will be budget neutral. cbo scored it as budget neutral. the question i think --or followup question will be, what if it is not? at this point in time, what we have said is it is our expectation it will be budget neutral. cbo agrees it should be budget neutral. certainly in this year, what would happen if it weren't is it

would fall over into the next year in terms of payments that come in to pay that. but in the end -- the end is 2017 -- if there were any issues i think the insurers believe that commitments have been made, and at that point one would have to find appropriated funds. >> 2017 is the end of the program. >> yes. these are -- >> by then insurance companies should have figured ute how to set up -- figured out how to set up the structure in the markplace. >> that's right. with regard to the three rs risk corridors re-insurance and risk adjustment two of those go away on that timetable, and one of them was based on what we use to medicare part d that actually didn't go away and that kind of a short time frame but, yes, the ideas by that time people understand the marketplace well enough to get this. >> well, let me -- money from dregs discretionary dollars would be something we would talk about next year.

you would think. >> the question of -- >> how would -- >> i think the question is do you need appropriated dollars? i don't know we'll have any signals -- we certainly won't have a signal even about this year until about the end of the summer, and then we'll know what the first year. a three-year program and right now all the data is starting to come in. >> designed in this scoring of the affordable care act not to cost money. >> budget neutral is where it has been at this point in time. >> we'll see on rack audits, i think what i heard you saginaw response to senator langford, one thing you were looking at was the incentive structure to bring these cases? >> yes. what we're looking at in terms of the structure bring the case and bring any case you wouldn't win. so if you bring in a case you're not going to win, you're not getting anything. if you bring a case that you can't get done in a set period

of time, you don't get anything either. so changing some of those incentive structures in terms of the things we can do administratively is important. i think the other thing in terms of the increase that occurred in cases, we kind of didn't get into this because he distinguished win the backlog issue. part of the backlog occurs because there's no real cost for a provider to bring all their cases to appeals so many, because there's only upside as a provider, and so making sure that we have any size and amount -- the amount, the cutoff is very low, and i think we need to look at questions of what should the cutoff by for how little money you can appeal for because of the question of the processing, and then the second question is what are the steps for you and there is any bar in terms of you appealing everything? so, there's the issue of the racks, the issue of the providers, and there's the issue of our processing, and all three of those things we can put in place improvements to both

reduce the backlog which is essential, and have been working with the congress and working with others about in a bipartisan way to make those improvements. funding will be important from the perspective of this committee. funding additional ability to review those cases because i think you know those are judicial -- it's a judicial process, and we have to have a certain type of judge an appeals judge that can review. so we have a strategy that is about taking administrative actions, things that can get rid of some of the backlog, additional hires we need to do, to process the cases that are before us and creating prevention in the pipeline so that people aren't as encouraged to do certain types of things, some of it related to racks to come into the system. >> are you allowing new cases to be brought while you have this huge backlog out there? >> the issue is how the cases get brought in terms of the rack. it's divided in terms of the way the legislation was passed and

what it bans that racks can do. there's a limitation a time limitation, some things are coming through but portions are not. >> senator murray. >> thank you. as you know this year marks the 50th anniversary of head start, very exciting. and i'm really pleased to see the administration's for significant investment to make sure head start kits get actos full-day program. some of the early childhood research on this is incredible, that an extended day learning full day, pre-k and effective teaching practices strongly suggesting the current minimums of three and a half day is inadequate. this is an important step in making sure head start prepares our children for success in kindergarten and later in life. what is the administration doing to improve quality and make head standard more effective? >> the quality progress has been over a number of years, and part

of it is that we are requiring that certain of the grantees we -- we are reviewing grantees with regards to quality and people have to re-apply. we have seen that happen cross the country in terms of those that aren't meeting the standards so we're enforcing the quality standards. so that's in the head start space. in the child care space the work you did -- thank you -- in terms of authorization last year, has also given us guidance in that space as well. >> one thing thing i'm hearing at home in washington states is the lack of retaining -- getting and retaining quality teachers. what this department doing to deal with that? >> right now -- that is actually part of the quality standards in terms of what types of degrees and training that teachers do have, and that is a part of what we are trying to do and we are seeing some increase. in terms of measurement of quality and in terms of educational background of teachers, i know that is not the

only measure of quality but we are seeing some progress in that number. >> i think that's important. my last question, and one that is important is the fy2015 i'm any bus represented the first time -- omnibus runted the first time they utilized the budget control act, cap adjustment to fight fraud and abuse in medicare and medicaid since 2011. current data indicated that for every dollar sprint to address fraud, 7.60 is recovered by treasury. so using that cap adjustment, omnibus should create over $5 billion in deficit reduction. that's a goal we all think is critically important. i don't understand why anyone who wants to cults the deficit would not -- would oppose additional dollars for that fund. i know neither the house or senate budget resolution include funds for that. you've did. can you talk about how you can use these targeted resources to help us save money?

>> so, the amount we put into the budget, we estimate based on the return that we have been seeing -- we have used the conservative end of that do the estimates -- it would be $22 billion in terms tv the proposal from the president in terms of savings if we continue on our path in terms of medicare issues. having seen and had the privilege to the awards for public servants across the entire fer -- federal government. when those awards went to the people wore called the miami heat, the heat task force across the department of justice as well as hhs, pursuing the fraud when we can see that kind of success, that cross-government work, we want to do more of it and we also know the issues of fraud and improper payments and medicare, it is a large portion of what we see in the entire government having come from my omb hat and spent time with -- with mr. carter, hopefully we

can bear down and make progress. >> if the cap judgment is not allowed to be utilized we will see an increase in spending. >> we won't sew the benefits we would have gotten and we see the benefits every year. we report the numbers every. it was one to eight ratio last year. this past year it's been a one to almost eight, 1.7 ratio. in terms of the return that we're getting. >> okay, thank you very much. >> thank you mr. chairman. i had an additional question. in your statement you talk about the aca provides full funding in the medicaid area, all the way through 2016 and then 2017 the states share then goes to 90% or less. -- no, 10% or less. the state of west virginia, the legislature this year before the expansion had to fill an

80 million -- hole in their medicaid budget this year with no cost of the 140,000 new expansion medicaid recipients. i raise this question when that's was going through, when we were voting on this, when it was passed. how are the states, my state, our state, going to be able to meet these budgetary expansions that they've taken on themselves because they've expand medicaid by 140,000 people when they're already short 80 million this year without expansion. >> so, i think two things are -- as we think about the answer to that question of how do you financially do the medicaid expansion in the state. the first is when -- in kentucky they did a baseline study before expanded met candidate and the did a study with the university of louisville. three months ago in terms of what actually has happened with

he medicaid expansion and how do you predict that economically. in the state of kentucky, what the study showed is there would be 40,000 more jobs and $30 billion to the state's coffers in terms of expansion and growth and that's one part of the answer. the other part of the answer to at the question, which is important, has to 2005 delivery system reform. and that has to do with why we are so deeply focused on changing the way that care is delivered, and the quality of that care. you and i had an opportunity to talk about one of the things that drives this is emergency room use, and while the analytics are not strong enough yet, we are starting to see the indications where people who -- some placed that are ahead, that we decrease that. i think what we're trying to do to make sure that we get to the place where people are not using the most expensive care and using the care in ways we can save and have quality, prevention, is coverage to care

and that is an effort that right now we're very focused on with cms and moving people to understand -- new people what have never been insured before, not one-third us except to go to the emergency room, how to use the care in ways they understand how to access care and how to read bills and understand there are tools to keep them health. >> diabetes numbers we're seeing out of the city states of that have expands, it's increase budget they're actually getting the care and hopefully that's going to drive down a part of the cost. >> i would say that that all sounds like it's going to solve the problem but we're talking about -- this is on the horizon here and $80 million budget hole shortfall already without the expansion, you're talking about changing behaviors and this -- we know, it's not going to take a year, it's probably going to take five ten years. with the creation of 40,000 jobs i wish i saw jobs growing in our state.

but unfortunately that is not happening. and we have a lot more people unemployed in higher paid areas and you know what i'm talking about. we have a real problem here. and i am very concerned about that. by this time the president and you will be gone by the time 2017 comes along and we'll have a new governor and that's going to be a very difficult challenge for the governor. last question, this should be a simple answer. if you expand medicaid, which we have in west virginia, and you have asked for an increase in budget in children's health insurance program sizable 3.9 billion, looks like if i'm reading the numbers right -- somebody asked me this. if you're expanding medicaid, which is pulling in those families and those children wouldn't the cost of the children's health insurance program go down because a lot of those children are being pulled into medicaid expansion? >> so, the children covered by chip are staying in chip, and that was part of what the

extension that the sgr bill just did. those children are actually not moving over. that's why. >> they're not required -- if you're in chip and your mom and dad go into made okayed, you're not required to pull that child into medicaid with you. you stay in the kip program. >> that's right. >> i worked on the chip program as a state representty. i'm a big believer in and it always voted for the expansion because it is important in our state. i guess you antimy question. i guess my followup question would be from an economic standpoint is it more beneficial to the state and the federal government to keep that child in chip financially -- i'm not talking about quality of care and all that -- or to go over into the mid -- medicaid probably? >> that is a piece of work i think actually is coming out in the next week in terms of analysis that we have been asked to do. with regard to the question of does chip -- i think the basic of your question is, chip costs

more, and that's something that is coming out in the next week. is part of the followup to the aca. >> i look forward to seeing the report. >> one last question, and then there will be questions for the record. i'll have them and others will as well. the next thing on my schedule is to go to a meeting of senators talking about what to do based on the results results of king very burwell in the past you have said there really -- you were not looking at options if the court rule this subsidies aren't valid in a number of states. is that still your position? >> what i have said is that the three things -- i think it's important for me to state we believe we would win the case and that based on both the letter and the intent as well as cbo scoring over the period's time in terms of interpretation of the lawsuit that we hold the correction position, but with regard tonight the court would

decide and decide against and for the plaintiffs, at that point the court will have said that we cannot provide those subsidies, and the point at which that happens our ability to have authorities to do the subsidies is not something that exists. so the real problem, which is people lose subsidies, they then become uninsured because they were insured because of the affordability. the question of a death spiral in the marketplace because now sicker people are in, drives peoplums up, and the question of how that affects stateses in terms of costs, issues we were just talking about with the senator. all three of those things result from the loss of subsidy. that's the problem we're trying to solve, and the question is, if the court says we don't have the authority the question of a plan for me to have an authority that if the court says i don't, and so that's why, when asked about the question of a plan tree solve the massive damage, that is not necessarily something that thecourt makes that kind of decision that we

believe or have seen we have an authority. >> we'll see what the law says. there will be -- the record will stay open for the court -- the court says the record will stay open for one week for additional questions. the sub committee stan inside recess until 10:00 a.m. thursday april 30th. [inaudible conversations] c-span2 providing live coverage of the senate floor proceedings and every weekend booktv, now for 15 years, the only

television network devoted to nonfiction books and authors. c-span2 2, created by the cable tv industry and brought to you as a public service with your local cable or satellite provider. watch is in hd, like us on facebook, and follow us on twitter. >> next, religious leader sunday the upcoming supreme court oral argument concerning same-sex marriage. followed by a preview of the oral argument nets the case scheduled for a tuesday. after that the supreme court oral argument in horn versus the u.s. department of agriculture, dealing with u.s. raisin farmers and the fifth amendment. >> on tuesday, the supreme court will hear oral argument on whether the 14th amendment requires states to license marriages between two people of the same sex. and whether states are required to recognize same-sex marriages performed in other states. already people are lining up in front of the supreme court to hear tuesday's oral argue. ahead of the argue amount group called