aware. .. the child in the supermarket finds you. i am also stepfather as well

and have still children. every stepchildren. every time i get a sporting event or hide my stepchildren i am reminded that i am not able to give that same love and care to my own biological children. i i think all of us feel that way constantly reminded of your parents. you don't lose that. it is a biological imperative, part, part of our fabric part of the fabric of our beings. that love is being denied. then you start feeling the empathetic pain's for the child and that's true. we are victims crime victims, but our children have no choice in this matter. you emphasize you emphasize with them, they are missing, the sporting events they are you have. the opportunity to speak your native language.

it would be great if at some time we could find a justice system that would give us back that time. the truth is congress cannot give us back that time got himself cannot give us back time. so we're left with the pain-and-suffering give back and help prevent these things will happen to other people and work together to help attorneys children i think again i am i am just reminding that this is the human problem if you just focus on that and try to decouple it with law and the policy and everything else

geopolitical power drain everything else that we can solve it as long as the stuff is out there in terms of technocratic stuff. really missing the. improve the performance of the convention. again i would say this is a source of encouragement if we get the report right. it's awful. the recall earlier i did ask

that they go back and we look at it and reissue portions they got it wrong. there's nothing wrong with the definition of unresolved production cases. make that clear. they made that clearly. it's for your answer, i am concerned that a previous hearing. ambassador jacobson i don't think there going to section japan or threatened them with sanctions because of the bold detrimental law based on honesty, clarity and not putting uncomfortable truths on the table.

parents of parental child reductions. reductions. same on us. working them straight in the eye of this asked to improve and this is a very serious issue because we care about the kids the abducted children and (parents'. >> you know as you stated and i reiterated several times and testimony a tool of mentioned. the most promising differences that been slow steps for improving relations response. i have indicated that the information the national center submitted regarding active cases were 50 out of

54 act of cases have been ongoing 51 out of 50. india. all six were currently working on a been active for longer than one year's area does not company information we are happy we are happy and pleased with the opportunity to present that information and to give that perspective and pictured other parents and to the community as you try and get a real perspective on whether or not these countries are compliant but that remains a picture. i am hopeful and optimistic but the active cases remain the way that they are. >> as you all know for the next shoe to drop be on the sanctions portion vis-à-vis

the 42 nations were taught to be 23. and they are very serious repercussions' and they will hopefully here from a message jacobson sanctions serve the country there are two other areas i have worked closely. an opening for the administration. if you use the toolbox right say we mean business taxes will be report. the quickest way to get those of the is the obviously resolve the cases in a way that return is the ultimate resolution of the

case. its corruption abroad. judicial system, judges, foreign minister that might not be susceptible to corruption. a huge problem in many countries. it's probably are. for would for would you say to that? has that caused some of this? >> to some extent i will try to answer your question. the reality is that individual parents of faced and so enough to speak to each individual situation you the pieces of information's detailed descriptions of the performance problems.

previous reports listed concerns about judicial performance there was significant detail provided for country that has not been spoken about today such as costa rica. detailed descriptions of the problems that the united states notice in the application of the treaties principle that the courts. you know they remain loaded in the current report. however to some extents of the detail on on level of depth and will lead to the resignations is not exist in the current report. as. as i look at this as a useful tool to educate to make everyone aware not just existing problems with how to get this is important to make sure that the level of depth in the level of detail remains. >> report is extremely well taken the judicial

performance, law enforcement and of course persistent failure to reduction cases. when you turn to the next phase brazil a cd to india to me. that level needs to be broken out's so that we know there is real transparency about what is the depth of the problem. to keep referring back.

>> i. it's. >> i would not describe it is corruption's. the fix is in. the law doesn't allow for this to happen. as a problem the following rule of law. >> what you pointed out we need to get to have become a tailwind. if we put zero for unresolved cases will we really helping? >> we take the wind out of the sails. the chief justice is that he's speaking to the family court judges in his country 's you have to get with it. there it. there are some laws that could be used in the books. the lawmakers put some things in the. it's been reform the health visitation. the parental rights haven't changed.

the courts themselves are not cooperating. when you have this kind of interagency and cultural recalcitrance is not technically corruption, but it is an official problem that we have. by calling out by calling out japan with this problems for what is and saying girlfriend. by calling out japan with this problems for what is and saying girlfriend. i don't think were hurting japan. were helping japan and have think -- helping japanese people the same time. >> thank you for the question. question. i would echo that statement. i'm not sure it would be corruption. the descriptive word i would use, but there is certainly an issue in tunisia with

rule of law when you have tunisian presidents visiting with us senators and acquiring to them that there is no final judgment and an abduction case where the supreme court is made a ruling declaring that the best interest is served to repeatedly to various members of the administration up to the newly elected president to respond to any request by government officials to say that there is a final judgment is absurd. you just instilled a knew constitution that directly oppose the supreme court and his ruling and then turn around and say we don't have a ruling call we don't have a final judgment. if you if you supreme court

is in the final judgment and what is? personally i applaud the tunisian judiciary following international law in the case of what is very obviously an interest of society. they do not see them as individuals. they give us his children. the family heard of both the mother and the father. it's -- the united states the american courts have ruled that is simply time that those judgments be enforced. i don't know if you call that corruption. i certainly cause a problem.

>> gentlemen, there's a lot of commonality. it's hard it's hard for us to define whether we face corruption are not, but for example, laws that have no clear guidelines so that from one judge to the next under the same set of circumstances you get different release. the fact that even after for example in india there has been a progressive part in 2,006 while the report said that india should exceed and make changes to the sole custody laws for the joint custody is allowed. fortunately there has been movement. they have placed the change

in attitude approach to. it might not be in overt decision to harm somebody that is the lack of our ignorance of the issue. the trafficking victims protection act which i wrote in the year 2,000 requires member study country by country which breaks out prevention prosecution of protection. every country has a monologue a box of recommendations and then there's a tier system. if you're at your three country you're in egregious violator and the issue of human trafficking and you get sanctioned.

this did this did not start out as this book but it quickly became the. data calls going out embassies in the goldman act new line someone in every embassy working the issue. my hope is that again correcting deficiencies currently right now and we we will. secretary kerry, likely a reasonable man and he will hear that appeal and hopefully will take it to heart and make sure that on japan and india where there are no unresolved cases according to this. we will look to fix it get it right for accuracy and again to the courts how important it is for current cases before judges that this report the correct so

that they make informed decisions about the vulnerabilities of someone. >> am happy to speak to that just yesterday wednesday of this week i was on the phone and speaking to a family court in the state of washington had to the litigants and attorneys requiring that case and describe in answering questions related to the risks of production objection to particular country, but one that has been spoken about are represented but the resource the limited information that are company obtains but aside from that information that we have firsthand the most important and comprehensive source i have i have to.to is the information that comes from the us state department, and i value that information and the completeness of that information in there 14 states plus the district of columbia that have adopted uniform child abduction prevention laws that

encourage or require family judges to receive information about whether or not a countries signatory and more importantly whether they are living up to the terms of that treaty and what it means. that is built-in. a factor for that court to decide are. so i know firsthand and our center knows firsthand that there are interested parties, government entities parents, attorneys, advocates for the agencies who are desperate for information and love as much information as can be provided. we do our best to provide were limited info we can answer that with the subcommittee. that is where i will leave it. information is important. it's still important. >> yesterday an individual contacted me about the

report and in that i would testify today. very much on. it's prior to japan have been granted sole custody of his children with supervised visitation because there was a threat of objection to now the japan has signed the hague the other side is now petitioning to have the supervised visitation. under the premise of japan is now i hate country and is compliant and therefore we don't have to worry about this anymore. very much to that.if this report is not accurate answers 000 those children may well be abducted's and be abducted with the judge's permission. because he or she will rely on this report saying there is no problem.

and you no 90 days is actually not enough time to correct that. the other side can prevent this report as evidence with an expert witness edge of the and to the court and putting on the record and now kind the japan has a flawless record in this area where we although that is not the case. so that is very real a real, a very real concern that has created a very real concern for this particular individual in texas and was worried that this report may have given the other side may have nefarious intentions the ability now to legally abductees kids right out from under us. >> that is also the case. zero abduction cases unresolved cases. >> you offered to have a closing statement. a closing statement. i will take you up on that offer and thank you for the

opportunity. i just want to reiterate that ms. christiansen in her testimony asserted that the mission of oci is to assist children and families and to prevent its occurrence. the simple mission that does not mention recovery. my assumption is that the assistance to children and families means that they are offering assistance for recovery and all that i heard the testimony and all that i see through the compliance report is an interest in prevention. i stated in my testimony but want to restate that the convention is a powerful tool but it is not a tool that will result in the return of our already abducted children. while i advocate strongly for its use in future cases i wish for it to be made crystal clear the record

that as written it's a fair and powerful on that includes strong remedies which if applied will result in the return of our illegally retained abducted children abroad. as request to this committee would ask that in the future you ensure that i is implemented with the spirit in which it was created. if necessary and be updated with an explicit requirement of accountability for the total existing cases by country including newly reported cases and the total number of children's is important that they represent individuals and it must count.

>> i will end on a couple of items from the recommendations that i have. a path forward for while we're talking about the report 30 years the hague convention has been in place we have not had consolidation of data sources. the department should expand and enhance the data gathering and tracking of objection cases by leveraging sources such as the us family court police department records, the ncm ec, fbi and other sources that they can then have a more consolidated reporting instead of waiting for the parents report the case. one of the other recommendations i would like to highlight is in returning the children especially to the top destinations the department should consider deploying a permanent attaché at the us mission who will be on -- will

ensure the pending cases are being worked on in a fair and quick manner. the children actually come home is the bottom line. and the 3rd request is with you and the rest of congress to really take the leadership on this and make an amendment for both the us and india and really engage with the on this issue just like you would engage with them on any other strategic and economic issue. if you make it important i am sure that it will be important for them as well. >> i could just put on the congressional record one last request to be able to say that i love my children isaac and rebecca and i will never stop fighting for the ability to be involved in their lives and and i look forward to the day that all of us can be reunited with

them and thank thank you for your support and try to make that happen. >> thank you. thank you all for your extraordinarily compelling testimony. i can assure you the subcommittee will be unceasing in my efforts. as you know i learned the deficiencies and gaps in what you face on a day-to-day basis through david goldman's case. very good welfare and whereabouts but not much we can do policy and trying to effectuate the return of his son. from that ordeal i learned through him and his son and now all of you just how agonizing it is. that is what we have a lot of the tenacious and making sure it is faithfully implement it. you are heroes in the thank you for your leadership.

it is irreplaceable. the hearing is adjourned. [inaudible conversations]

the progress being made in the understanding of heart health. >> this actually is a valve that has been cramped on to this catheter that is being now positioned and to the diseased valve, and it will be deployed here in just a 2nd with the balloon being inflated and a new valve will be inserted inside. and as you can see, the delivery system is being withdrawn and the wire will be withdrawn, and what we have just seen his replacement of the diseased aortic valve in a manner that does not require open-heart surgery. we're trying to become smarter about predicting who will get disease, become

smarter as to identifying the most effective means to prevent or attenuate the disease and then smarter about following up. so so we are currently in an era where we are trying to harness the promise of the human genome research project that has now been in existence for more than a decade. all the dramatics that can be driven. information about sociology geography, demographics to where you live for the railroad tracks are, what your likelihood to get diabetes on the basis of your educational background and what is your likelihood of developing something like diabetes or hypertension if you live in a certain part of the city we have less access to the right kind of food for the right kind of instructions for sodium consumption, little things

like that that could have enormous impacts >> the committee will come to order. on a tight timeline today.

that is why the ranking member and i discussed that we will limit numbers questions to four minutes to accommodate as many members as possible. let me start off by thanking our witness. you have to get going. move as quickly as we can. it should not surprise you that we are more interested in talking about obama care especially given the president's remarks week. i hope it gives you a medal for this job. it is no easy task. any objective observer would say that this law is on the fritz. the whole.of obama care was to make healthcare more affordable. premiums are not going down. they're going out.

proposing double-digit. increases. close to 30 percent. tennessee 36 percent, south dakota 42 percent. tax season was like a bedroom for. now it's a total nightmare. people could never afford these plans on the run. the law gave subsidies. now two thirds of the people who got them had to pay the irs back on average over $700. for all of this hassle for all of this what are we getting? the argument was a a people had insurance they go the doctors to the emergency room. now even more people are going to the emergency room. the lesson is absolutely

clear we're not talking about a day or a fender bender or a flat tire. it's a central principles government control. higher prices fewer choices and lower quality not just a few screws but to tweak it here and tweak it there. the answer is to repeal and replace. i don't have to convince the administration was broken.

the most egregious example the subsidies federal exchanges and yet hhs has sent millions of subsidies of the door putting millions of people at risk. not so much is implementing the law as they are improvising it. using one account to pay for multiple programs that congress never funded. one of the main reasons for holding this hearing today. congress that yields the power of the purse. the american people deserve better. they deserve lower prices, more choices.

>> (this hearing. i think that's a good idea. not aca the attacks on it. never coming up with a single comprehensive alternative. i'm sure to vote on fair critics. never had it before kids who would not otherwise about it people who have

pre-existing conditions for longer or canceled or can't even get insurance. the donut holes on. millions of people in our income categories are now insured through medicare. millions and millions and millions. cost containment is beginning to work. it's beginning to work. the increasing cost. so you are the it's getting better. and i'm not surprised at your server. it will be glad to take it on. glad to take it on.

and i think you just need to understand what this experiment is all about. it was combining increased access to medicare medicaid with an increased reliance on the private insurance sector. is this is all about. an experiment. we talk about government control. more and more people are getting a chance to the private sector. the states that are denying the citizens further coverage under medicaid are essentially telling people well, get lost. and you have a governor mr. chairman who is running

around this country talking about the evils of healthcare when millions of people are benefiting from what happened. you decided to turn this from budget to aca. the frustration millions and millions and millions of people are benefiting when they did not perform. madame secretary, i think they have thrown down the gauntlet. i don't feel sorry for you. i think you love this job and you like being the person who is administering this experiment in greater health coverage after 70 80 years of nothing being done in this town or throughout this country's.

i happily welcome you. i yield back. >> i recognize the happy warrior now for your opening statement. the floor is yours. >> thank you. chairman, ranking member members of the committee. thank you for the opportunity to discuss the president's budget. i believe me that we all share common interests and have a number of opportunities to find common ground and soft power of common ground in the recent bipartisan sgr fix and appreciate all of your efforts to get that worked on. the president's budget proposes to end sequestration fully reversing it for domestic priorities last by equal dollar increases. without further congressional action sequestration will return in

full in 2016 bringing discretionary 2016 bringing discretionary funding to its lowest level in a decade adjusted for inflation. we need a whole of government solution and both parties can work together to achieve a balance commonsense agreement science, science innovation, and human services maintaining responsible stewardship of the taxpayer dollars strengthening work together with congress where strong foundation for tomorrow. fiscally responsible which in tandem with accompanying legislative proposals would save taxpayers and at $250 billion over ten years.

in addition it is projected to continue slowing the growth of medicare for securing 400 and savings as we build a better, smarter, healthier delivery system. in terms in terms of providing all americans with access to quality, affordable healthcare that builds upon our historic progress in reducing the number of uninsured and improving coverage for families who already had insurance my recent example is the 10.2 million americans. the budget covers nearly eligible adults and 28 states plus dc were expanded medicaid and improved access to healthcare for native americans. to support communities throughout the country the budget makes critical investments particularly in high need areas. it supports improvements to

the way care is delivered, providers are paid information is used. to to advance our shared vision the budget increases funding for nih by 1 billion to advance biomedical and behavioral research. investing 215 million for the precision medicine initiative which we will focus on developing treatments, diagnostics, and prevention strategies tailored to the individual genetic characteristics of individual patients'. this budget outlines an ambitious plan to make affordable quality child care available for working families. the budget the budget strengthens our public health infrastructure with $975 million for domestic and international preparedness including critical funds.

it also invests in behavioral health services including more than 99 million in new funding to combat prescription opioid and heroin abuse. finally, as we look to leave our department stronger the budget invests in our shared priorities of addressing waste, fraud and abuse initiatives that are projected to yield $22 billion in gross savings from medicare over the next decade. here also addressing medicare appeals backcourt with a coordinated approach. they are pleased that the senate finance committee personally committed to responding promptly. i work combating ebola to assisting unaccompanied children at the border day

in and day out as they work to help their fellow americans have those building blocks. >> let me start by saying where we agree with the administration we work with the administration's. we really think this is doing a great harm than me start by addressing the elephant in the room. about to rule and if the court rules against the administration millions of

people will be stuck with the government designed health insurance they cannot afford. so the big question is than what. what about the people who are going to lose the subsidies. as the is the president going to dictate how to fix this for law or is the president, the administration going to be willing to work with us. >> with regard to the question of the courts written as intended. the part of her in the car indicate that it should be. citizens in the state of new york should receive set up -- subsidies. >> i understand your opinion.

>> if the court does decide for the plaintiffs the idea that the court would say that subsidies and the federal marketplace are not eligible the have those subsidies. the court makes the court makes that decision going to do everything we can working to make sure they're ready to communicate to work with states and do everything we. the critical decisions court said that we do not have the authority to give subsidies critical decisions on it with the congress and state governors to determine if those subsidies are available. >> take it my way or the highway.

is the administration going to be willing to work with congress to find a way to get more healthcare freedom? >> it's important to reflect the marketplaces market. as a matter of fact in the marketplace this year there were 25 percent more plans. this more choice, more competition. >> let me ask you this way. if the plaintiffs prevail if the caps on wins in the exchanges are deemed unconstitutional, not legal in the federal exchange states and the individual mandate is effectively struck down for those taxpayers. as is the president going to say reinstate the individual?

>> the administration is kind of been a little two-sided on this particular issue when you have delayed the employer mandate twice. that goes away as well. will the administration take the position that congress must reinstate this and all these 37 states reinstate the individual mandate, the employer mandate for my way or the highway force the pres. was the president willing and flexible to work with congress to fix this mess and negotiate with congress? >> it's important with regard to the decision before the court the decision before the court is receive subsidies and whether or not those subsidies can be given in states that have a federal marketplace versus the state marketplace. that is the decision and the only decision before the court. with regard to what happens if that decision-makers three things occur.

>> we know what will occur. we all of this. what will the administration doing? my way or the highway all work with congress to address the situation. >> if the court decides against as they made a decision that the subsidy. -- >> your not going to answer the question, are you? >> subsidies about available. to solve that problem the critical decisions are going to sit with the congress. >> okay. for a okay. for a bill to become a law house, said command the person will present come out and say holding my way or the highway one sentence one page fixer is that going to be thinking less about

digging in and defending his law is exactly written how will he be willing to deal with the issue of millions of people's mind more nothing. as nothing has the question. >> we have said the administration has said all on with regard to improvements and we believe that there are improvements that can be made it look at three things and a 4th underlying plot affordability, access, quality, and the issue of how it affects the deficit in our economy. you look at anything with regard to the specific that you raised i think it is important. the issue of the individual mandate is related to a a very fundamental part of the system which is pre-existing conditions. and it and it is our

experience at least in my conversations across the country americans believe that you should not be kept out of insurance were banned. if i have a child as a condition that i shouldn't spend my time worrying about child will never get insurance. >> your kind of going off-topic and i'm going to cut you off. we both no that there are ways of dealing with those problems without having to impose an individual mandate. let me leave it there. >> well, i'm not surprised at the town but i think that it is so counterproductive. the chairman, you talk about two-sided this. the two sides when you say that you were worried about the millions who will lose there insurance when it's your allies who brought the suit that would deprive them of insurance you talk about

concrete having feeding concrete. that is exactly in terms of aca. in concrete but you have brought up bill after bill to try to destroy aca. and when you say will the president be my way or the highway that's precisely what has been your approached aca. precisely. you have ever sat down for us to say how we can make some changes. instead you have been out to destroy aca. you see where is the president's plan?

the president believes the court will issue a pull the law all you have done is issue of beds. and bills contrary contradictory bills. you don't have a plan. >> you haven't had a plan for 60 years. so you can keep going after the secretary and she will keep trying to spell out. i we will i will ask you how many people have been receiving subsidies? >> 7.3 million people have receive subsidies. >> when you shed tears about 7.3 million remember or about the lives 7.3 million. what has been the average

subsidy? >> $272 per month is the average subsidy. in in terms of those that are in the marketplace that are subsidized, that's the 7.3. about 85 percent of those receive subsidies. the average subsidy is $272 per month which is what results of the affordability >> just quickly tell us how many people have received additional care through expansion of medicaid? >> the question of the total number because there are people in terms of the expansion itself about 10 million people are the estimates in terms of the states that have expanded. >> at those two together and we're talking about individuals with families and republicans come here and castigate you and this president. the issue should be on the other foot. i yield back.

>> mr. johnson. >> thank you. i guess i am supposed to thank you for being here. i have to tell you, i am not in agreement with much of what your saying. let me just ask you you know we are trying to get the health care back in shape. it sounds to me like you want to go your way and not try to work with us.

let me just ask you if there are any proposals that hhs supports that will reduce cost for consumers without selling price controls or imposing restrictions that will reduce access to care. >> yes. there are a number of things that are part of our budget and we are currently implementing that are reducing cost. since the since the passage of the act -- >> it looks like everything is going up. >> medicare spending if we look at what was projected to be call where it has been since nine to 14 we saved $300 billion. with regard to per capita health care cost 2011, 12 and 13 the cost growth is the lowest that it has been 40 years. that is taxpayer savings. >> but insurance rates are going up not down.

>> insurance rates before the affordable care act were going up often in the individual market well above double-digit numbers. what we have seen since the implementation is while rates are still continuing to what they are going up a much lower rate. >> let me change subjects and ask you about an effort that my colleague and i have been after for a number of years'. as you know, that became law earlier this year. let me ask you is hhs already implementing that? how fast do you think you will be able to issue cards without social security numbers? >> let me say thank you. let me put this in the budget i 1st arrived i thought it would take years. thank you for your

leadership and effort. we were pleased and i was excited. we're putting together the work plans to do that. we have not established the exact timetable billion last the team for the work plans. and what plans. what to do as quickly as possible in ways that will serve the consumer. you want to we want to make sure we're not disrupting them or their services but quickly want to do it because we believe this is an important part of privacy and security. >> well, i think lloyd doggett for helping me with that. how easy how easy do you think you can make it for seniors to get a knew car? >> that is the part. we wanted to be easy for seniors and we want to be sure that they understand. one of the one of the things we don't want to do is create confusion. figuring out a way we can enter and those with existing cards because we don't want to have a confusing situation. i look forward to staying in touch with you and your office.

>> thank you. >> thank you. i want to thank my colleague for not drinking all of the kool-aid and bringing forward something constructive that the people outside know. it's healthy. ..

i don't like the i would you democrats have done it. let us help you to do it better. but to take some sense of pride that the supreme court will just strike down the opportunity for people to get just basic health care to me is not just mean spirit -- >> will the gentleman yield? >> i don't think so, mr. chairman. you're on a roll now and i don't want to have you to come a nice guy at this point in time because i'm glad that you have rehearsed the attack you intend to do, and i don't care who the secretary is. if you're on the side of giving assistance to people that can now go see a door, that can now

prevent going into intensive care because they have had preventive care, that can now get insurance they cooperate have insurance from a political point of view issue want want to be flo your shoes explaining it. those that are already covered it's no problem. i've got mine, jack you get the best you can. i don't care what religion you believe in, it seems like comp park should override partisanship, and if we don't like what is before us, we should work hard to repair and to fix it and to improve it, and so i'm 85 years old. i have to decide what moral side i'm going to be raising issues on. i can't find a better one than this. and, you know, it goes without saying if you cripple disabled if you want help and if money and insurance is what is keeping you from getting it, you could not give a better

political home run ball to the american people to decide a basic question, which side are you on? so i'm glad that politically my party would never put me in this position and i -- the only position i would rather be in is where you are sitting madam secretary to be able to see that you are on the right side of the issue, you can see that people don't really want to discuss the millions of people that are being helped, and we're not talking about -- we're talking about life and death in the true sense of the word, and if someone had a conscience that would doctor would say i wish you had seen me earlier and they say, i wish i could i didn't have insurance. how many cases in intensive care saying that woman or man should never have had to ben here if it

was detected earlier dirks. >> time for the gentleman has expired. >> well, thank you mr. chairman. i -- >> i understand the -- >> another minute there butout cut that off. >> we're doing four minutes to get to members of the other dais here. if you have a question, ask it earlier on so the secretary has a chance to respond. gentleman from tax is recognized. >> thank you mr. chairman, madam sect. hem e health care is about patients not politics. i was pleased to hear you answer mr. ryan that if the court rules against the irs the administration will do offering we can. can you give us some guidance sneer will the president sign legislation other than merely extending the subsidies to federal exchanges? >> with regard to the question of legislation and the affordable care act we have had -- that has been a question and a comment and where we have been is when there is repeal of

fundamental elements -- >> i appreciate you going back wedder but going forward if the court rules for the plaintiffs will the president sign legislation other than extending subsidies to the federal exchange? >> the president has, and i think will continue to sign legislation that we believe improves affordability quality access and takes care of the deficit issue. >> great. so the answer is -- thank you for saying what i hear you say the president will sign legislation other than simply extending the subsidies to the federal exchange. you're saying that correct. >> the sgr bill we recently signed includes very important provisions that actually extend the affordable care act's effort to do delivery system reform. >> that's not in the supreme court case specific to that asking your guidance, the president will sign legislation -- >> the supreme court case -- >> -- other than merely extending subsidies. >> specific to the supreme court

case if the question is the supreme court case, want to return to what the supreme court -- >> i'm really just looking -- we're looking for your guidance in a bipartisan way. so your answer is, yes the president will sign legislation other than extending the subsidies of federal exchanges. >> with regard to the question of the supreme court case, that is an issue about subsidy. that is all that is about. >> in your guidance to us -- -- if your question is, are we willing to consider things that improve or enhance affordability, quality and access we're open to those things. >> yes. >> regard to the supreme court case it's important to be clear that ills about one item. >> very well aware. i just want to make sure again as we look to work together to put patients ahead of politics, you're saying, yes the president would sign legislation other than exchanging -- extending the subsidies of the federal exchange, the answer is

clearly yes. >> i want to distinguish between the question of how one resolves the problem that gets create ited. that doesn't have anything to do with any other part of the cozy affordable care act. no no, no, this is such an easy question yes the president will sign other legislation or, no he will sign only that legislation. >> congressman, think it's very hard to me to answer a question about hypothetical -- >> it's not hypothetical. the court is going to be ruling, not hypothetical. they rule for the plaintiff -- if they rule for the plaintiff you're saying the president would sign other legislation. will not as mr. ryan said, say my way or the highway. >> with regard to fixing, improving the affordable care act, these are two different issues. >> no. no madam secretary i don't mean to interrupt. imseeking your guiseland the

acknowledge is yes. >> my answer congressman is will we review any legislation we get that has to do with the affordable -- >> i'm asking about signing. so the answer is no? >> with extraordinary legislation that we sign, we'll look at any piece of legislation and we'll judge it by four things. >> would the pratt -- >> access -- >> -- will the president sign legislation to extend those subsidies temporarily while republicans and democrats and the president work toward a long-term solution. >> with regard to the subsidies the critical is with congress, if congress writes legislation to make sure the subsidies are available, that's something that he would do. >> gee thens answer is yes would sign legislation other didn't. >> time. >> correct? >> congressman apologize but when you say other, i want to make sure -- >> time, time for the gentleman has expired. mr. mcdermott. >> mr. chairman, thank you. -miles-an-hour burwell it's

nice -- miss burwell it's nice in seattle. i'm not sure you made the right choice to come back to work. >> anytime the wrong washington. is that what you're telling me? >> we're talking about if the president does this or whatever. let's talk a specific. i think that we have not heard a specific come out of the republicans in -- since the bill was passed. never put anything on the table. now we have a bill, 1016, put in by senator jobson from wisconsin, and his -- it's his solution if the bill fails and as i read it quickly it repeals the individual mandate it repeals the employer mandate and it says that the states can continue the funding down and the standard of benefits that people getting not the national standards but whatever the state of mississippi or alabama or georgia or texas or one of these states that has not had an

exchange whatever they set as a benefit, we know it will be lower because it already is. won't cover people in medicaid, shy clearly don't care about the level of health care, but explain to me how you would -- >> would the gentleman yield? >> to 20106 dire. >> the gentlemen -- >> no, i woken deliberation. >> take bat the despagerment of the citizens of georgia. >> she has the right to explain what the president would think of a particular piece of legislation that has been put forward as a serious thing by a senator in the united states senate. >> with regard to the john son piece of legislation. that piece of legislation is repealed because it gets rid of preexisting conditions, it stops the funding for preventive services, it undoes that people up to 26 would be covered and it actually takes away subsidies

from all over time, and so with regard to that particular piece of legislation that is a bill that from our perspective is repeal and we have spoken to the issue of something that repeals the affordable care act is something that the president will not sign. >> so, in answer to mr. brady's question will the president sign a bill that we pass, if we pass this bill, will the president sign that? >> as i've said, this bill is in its current form repeal, and the president has said he will not sign something that repeals the act. >> is there any place that you see that there is a proposal on the table by any member of the house or senate that makes -- that looks at this point as though it deals with protecting the aca in general and fixes the one specific problem? >> we have not seen anything. >> and you have looked at all the legislation and read all the press releases and everything

else? >> at this point we have not seen something that addresses the specific issue of the question. although i think there's also the issue i think we're all very focused on the loss scenario. think some point it is important to focus on the win how we go forward if there's a win. >> tell us about the costs of health care. we hear the chairman says the president promised that the there would be a reduction in premiums. now, would you explain guy that is a little bit misleading in that certainly everything is going up in the sow site but not going as -- society but not as much as predicted i i think. talk about that. >> that's correct. as we have soon the premium increases that occurred in the individual market and employer-based market we're seeing smaller increase inside those premiums than we saw before. and so while there are increases, the increases we were

historically seeing that were driving costs for individuals for employers and in terms of medicare and the cost to the government thats what we he seen shrink and slow. >> thank you marx teaberry. >> thank you mr. secretary. the recent sgr reform bill that passed included a bill -- a bipartisan bill that i sponsored to require bids for -- in the competitive bidding program the provision supported by my democratic colleagues removes bad actors from the program something i don't have to go over with you. and ensures seniors get quality medical equipment. in a compromise with the administration the law requires that cms implement the provision not earlier than january 1 of 2017 but not later than january 1 of 2019. i think that 2019 is a very

generous timeline to implement the bill and would hope with your leadership we could move it closer to the january 12017 timeline because at the end of the day as you know, again there's bipartisan support for this concept. my good friend is all over this friend as well, bill. we think this will help separate the good from the bad and ultimately help our seniors so your leadership would be critically important to moving that closer to the beginning than the end. >> it is related to mr. johnson's question, too, as soon as the bill passed, which was such a very important bill i don't need articulate to this committee all the important things have worked together to put together the work plan so we're specific and do try to meet and beat deadlines. we have been able to do that on bipartisan legislation in behavioral health supported both in the house and the senate in terms of beating deadlines we

were given and where we can wearing going to try to. thank you for your support and help in doing that if we need further support and help i will come and ask. >> thank you. >> it is something that is a priority. >> the other issue is intellectual property rights and innovative medicine that improves peoples lives and supporting good u.s. jobs, taking about trade this week. i want to ask you specifically about india. over the past couple of year's india's intellectual property climate has deter you'rate significantly and the u.s., ip intensive industries have suffered including pharmaceuticals and expressed issues with the indian market. most notably courts in india issued compulsory licenses, citing indian law that men believe diverge proves india's international and international trade commitments.

have the compulsory license and denial makes been part of hhs discusses with the indian us counterparts? this is kind of a question that might have come out of left field buysed on what you prepared -- based upon what you prepared today but would you agree it would bill ill-advised for any u.s. government to undermine the policy of the u.s. to promote strong international property rights in foreign markets and if you're prepared to answer that, would you mine looking into it and getting bang to us as we have the trade debate. >> yes i'm happy to get back. ustr would lead in any of those conversations in that space so i think i will coordinate with ustr and get back to you. those conversation with the governments are being led by ustr. we give our policy input into them and they lead. we'll make sure one of the two get back to you. >> the so much. i yield back. >> thank you.

mr. neil. >> thank you mr. chairman. madam secretary, the opiode addiction issue is pronounced now across my congressional district and all sorts of stories that indicate a nationwide trend and curious about the response of your department the agencies you oversee, and also to ask specifically about prescription drug misuse. >> yes. >> the evidence that you're coming across on that basis? >> so with regard to the issue that you have raised, thank you for raising in our budget there ills 99 million additional dollars to implement a evidence based strategy on the problem. when we think about the problem as you articulate in through district, across the country opiode and overdose deaths have exceeded the number of deaths from car accidents or any other accidental death. in the year 2012, there were

259 million prescriptions. for opiodes. that's more than one for every adult -- >> say that again. how many. >> over 250 million prescriptions in 2012 for opiodes. that's how many prescriptions there were. that's more than the number of adults adults in our country. so that is one prescription for every adult in the country in terms of where we are and the magnitude of the problem. let's go to the solutions. we have worked and worked with states and worked with the congress. a number of bills here on the hill right now three basic areas to focus. one is prescribing. a big part of the problem as you can see from the number, is prescribing. what we need to do there is we need to provide new prescribing guidelines for pain and pain medication that will help the problem and alves states need to do what are called prescription drug monitoring plans. they're almost in all 50 states and the means by which a

physician has the opportunity to look up and see that a controlled substance was already given to you and control it that way. same thing with pharmacies so prescribing is number one. number two is the use of meloxone, drug that stops death when that's overdose and making sure first responders have access. that's important part of the picture. number three is the issue of medicated acities treatment combined with -- assisted treatment combined behavioral issues making sure we do treatment for those addicted. the 9 million additional funds cuts across cdc as we do this. we're doing is in the conjunction with states. i've been in massachusetts with your governor, and done a joint event with your governor. this is a bipartisan, bicameral

issue and certainly your colleague from kentucky is leading in this effort on the house. so that's our plan. that's what we're trying to do. >> it's noted that in some places in new england heroin is selling for 3.50 a bag on the streets of some of the old industrial cities. i have house bill 1821 that would invite members to take a hard look at. senator markey has a companion bill in the senate. what specific action should congress be taking along these lines to assist you in noting as you have that there are now more deaths from overdose than from automobiles. >> on the heroin point we know that the second two elements, the nonprescribing elements of the strategy will work on it. with regard to the placeses we believe we need help from congress to implement strategy, one is in the area of -- another drug that helps in this, and the question of proscribing.

-- prescribing. the second place is in making sure people are trained with the guidelines. >> thank you. >> thank you mr. chairman. welcome, secretary burwell. last fall, the administration proposed a child support enforcement rule, and former chairman dave camp, along with senator hatch sent a letter expressing concern about this, and the issues that were raised were that the administration in this area, was usurping the authority of congress to write law, and was in effect writing law. this has been a repetitive them -- chairman ryan raised this issue with regarding to certain issues relating to obamacare. we have seen this with administration obamacare other areas of the law. tanf waivers. why in this area, where this committee in a bipartisan way has been willing to work with the administration on these child support policies -- why does the administration choose

to trample on the constitution and article one powers in an area where we want to work together? i just don't get it. i understand there's always tension where we disagree. i get it. and that's a fight we're seeing playing out in the court. but why in an instance where we do have willingness to work and cooperate on the support and issue area. >> we would like forward to the opportunity to bork in this space in terms of that particular rule there were very important things you know you are familiar with, the fact that some of these things were done in the 1990s to people have to paper applications with regard to child support so a lot of the rule was about things like improving ability to use technology and other things, and improvements and simplifications to the rule. if there are specific policy areas that are of concern we are lacenning to comments. we'd welcome at the opportunity to work on theirs in the substantive area. some things mentioned in the release that happened yesterday are in areas where the states

have advised the state of texas, in terms of we're following what the states have asked us to do in terms of things like using money form people to do job training, which is an issue that is important -- >> well, chairman ryan and i produced legislation dealing with this in order to protect our constitutional right to write law. i know this companion legislation in the senate by senator hatch and senator cornyn but we want to put the administration on notice that this body, the legislative branch writes law and that the executive branch executes, and we're getting tired of it, and especially in an area where we have some agreement just be put on notice that we're going to continue to assert our constitutional prerogative. a different issue. the employer mandate has not been implemented. a lot of complications with it. we know how complicated it is.

we heard testimony in the past on is this. i know it does not apply small beens 50, or fewer full-time equivalents. those individuals would still be subject to the individual mandate. why is it -- has the administration been reluctant to assist these kinds of small businesses? i question secretary liu when he was before the committee with regard to health reimbursement accounts and there was a move, i think, six-month reprieve on ownerrous penalties for small businesses but six months. i don't get it. i have legislation that would actually make it more effective for small businesses to use these health reimbursement accounts which are completely legal under aca but yet for some reason, your agency and the administration has decided to close the door on these. i don't get it. shouldn't we be helping small beens and their employees at a

troubled time? >> we agree with you and want to try to do more. in the budget right now the budget proposal before the congress right now for fy16 we have proposed expanding the tax credits available for those up to 25 employees with want to move it up to 50 to expand the access to tax credits that it can get. sounds like similar kind of ideas in terms of getting folks the access they -- >> health reimbursement accounts are verrucae effective -- >> time. >> thank you mr. chairman. >> time of the gentleman expired. are you ready. >> thank you secretary burwell for being here. it seems to me that the focus of this here and the focus of all of our work should be on how we can make this healthcare system work better and deliver services and insure more families instead of speculating about some court decision. as you know, madam secretary i have a number of concerns about the way this law has been implemented, particularly in

texas. the fact that two out of three of our texans who are eligible for the market plays are not yet enrolled and i think there are things that your office can do for more effective implement addition. i would encourage you strongly to do the same kind of cost win fit analysis you did at omb and that is look at the contractors and see if they're delivering on their services. i have a number of queries to you about those. i hope to focus on how we can make it better and how we can make the implex addition better, but when i hear you accused over being a purse snatcher it get mist take. the east yes thing for the court to do, and the right thing, is to not ignore the other 900 pages of the law and focus soley on four words and if it is necessary to have a legislative fix, deleting four words solves the entire problem and allows this law to work the way the congress intended for it to

work. there are many other ways to address this problem and in fact apparently some states are beginning to look at the possibility that the best way to fix the law should the court render the wrong decision, is to simply create their own exchange. it is also extremely impressive to me that of all the proposals that have come in here at the last minute of republicans to deal with the possibility of an adverse court decision, how many of those proposals attempt to include as much of the hated obamacare as possible. preserving the right of young people up to age 26 to participate in their family's health insurance program. attempting to maintain exchanges. if today we're asking you about how to make improvements to reach more people in our laws, that would be a reasonable thing. instead of what is going on

here. indeed think it is probably historic -- i could not find another circumstance in which members of the house and senate ask a court to deny thousands indeed across the country millions of people an opportunity to get a federal tax credit to say please deny in texas our two senators, please deny our constituents, $206 million every month in federal tax relief, but let them keep paying tacks to finance the same kind of tax credits for people in california or someone from wisconsin since chairman ryan joined the same brief in the court who says, please have my constituents continue to pay taxes to fund tax credits in connecticut but deny thousands of people tax credits in wisconsin. it is an unusual situation to say the least that kind of approach would be taken. i believe we need to look for

improvements in the law to strengthen the law but that the idea of denying relief to people who are receiving it right now is to take away from them federal tax assistance, and to take away from them the opportunity to get the insurance that is working for their family. to say that it is a lemon to provide families the relief with insurance, for preexisting conditions they never had before something that is life-saving in many cases is truly a misstatement about the work of this legislation. >> thank you. time -- >> thank you very much. >> tomorrow for the gentleman expired. >> thank you mr. chairman. secretary, thank you for your time today. there's kuo issues that aid like to use our couple of minutes together on. the first is they're related the discussion around cost sharing reduction payments and then also the basic health program. so just to set the table the

cost sharing reduction payments, the issue is whether the administration has the authority to spend out of an accountant that hasn't been appropriated. as you know, chairman ryan and chairman upton wrote to you and secretarily on february 3rd. your response back at a staff level, look, sort of predictable. restates the obvious in terms of the number of truisms about the affordable care act and then says go talk to the lawyers at the department of yates because -- department of justice because there's pending litigation. us a little bit of a cute response in my view but it's your play. the issue is exactly the same, is on the issue of basic health programs. so it wouldn't be satisfactory to say you got to check with justice because they're not involved in any litigation because there is no litigation between us at this point in time. so here's my question. the law is really clear that you can't spend money that hasn't

been appropriated. there's no ambiguity about that. the constitution is clear. the gao states that it, money cannot be spent absent appropriation, and yet there are number of states that are announcing that -- minute minnesota is a state that will implement the program, new york will operate the baseache health program in 2016. new york estimated they'll receive $2.5 billion, b billion -- how is this possible since the money has never been appropriated? in other words what extra constitutional authority are you invoking that allows you to pend money that has not been appropriated. >> with regard to the issue of 1311 and where that is, i think 1311 is about states that want to choose and try to do things

and see flexibility and we try to work with states when they do with that. with regard to authority for the cost sharing and the issue of 1311 in the budget apen dis page 1046 and 1047 is where we believe the authorities lie. >> but there's been no appropriation. you'll acknowledge that. >> with record to the authorities that there what we believe is the authorities for the aptc are the authorities because that -- >> but you're conflate bob concepts. you're conflicting authorization, which i'm not arguing with, and appropriation. there's been authorization but there's been no appropriation. so how do you appropriate money that has not been appropriated? >> but for programs that are tax credits for programs -- those aren't part of our discretionary budget. the earned income tax credit, other tax programs and tax credits are not part of the discretionary process. >> would you be willing to give

a briefing to me and chairman tim murphy, who chairs the oversight subcommittee at energy and congress. >> we would book forward to the opportunity to clear this up and have the right people come and discuss these issues. >> thank you very much. one quick point youch messenger inside your opening state -- you mentioned in your open statement there was $22 billion in fraud savings, which is okay, not great. the problem is, mr. lewis and i found this out together along with all the members of the subcommittee medicare, by medicare's own admission is wasting a billion dollars a week every single week, in fraudulent and erroneous payments. so $22 billion over the decade is okay but it's like turning it off halfway through the year and then letting nine and a half years going and do nothing. so i think really need to up the game. i yield back. >> their mr. thompson. >> thank you for having the

hearing and thanging fog help to subdies my california constituents and their health care. i appreciate that. madam secretary, thank you very much for coming out. i just want to say i here a lot from my con sit students about -- constituents about the aca. i hear from people who are pliesed the preexisting condition is is no longer an issue for them. their 26-year-olds can stay on their policy. they have access to quality preventive care, which i know for a fact will save us all money in the long run but i also hear them say they recognize there are problems with the aca and they want us to work together to fix those problems. so i don't know how it could be a lot different in other parts of the country. my experience has been that folks want access to quality affordable heck, he, and we do have the responsibility to figure out how to make that

happen and i appreciate your effort in that regard. so i'm all for mixing, making tweaks making adjustments congress member black and i are going to introduce legislation today as a matter of fact that falls into the category of making a tweak making a fix. and we're going to introduce a bill that would ease the reporting requirements for employers offering coverage to their employees and it would require that the exchanges use the most recent tax data to ensure that individuals and families will not have a large tax bill at the end of the year. as i'm sure you know, covered california in my ohm state of california requires that the most recent tax data be used, and it's worked well and it's been beneficial. i'm just wondering if you have any thoughts on requiring the more recent tax data to determine eligibility for

subsidies especially for auto renewals and making that apply to all the exchanges. >> i think it is in our interests and what we want to seek to do it get the most up to date information we can have, which is why we encourage people to come in and update throughout the year, and we continue to do that. with regard to this piece we have to look at the legislation. i'm not sure if it sits with treasury or us but we would work together to understand. i think what we want is actually to have the most up to date information and that information for some people is an evolving and changing piece of information. for those who are self-employed their incomes change throughout the year and we do have mines by which they can come in and update and it we encourage them to do that. the most up to date information we can implement is something we do support good with regard to the specifics of the legislation, would like to have the opportunity to look at it and understand between us and treasury where we can be. >> the. also had some questions regarding the racks and the appeal process and i understand

prom your staff that we're going to work together outside of the committee hearing to deal with that, so i appreciate that commitment and i'm assuming it's shared by you. and -- >> yes, it is and i would use this as an opportunity to mention the piece of legislation bipartisan that senate finance just passed, this past week, on this issue in terms of the strategic approach to help us get to a place where we can reduce that backlog of appeals. there are administrative things to do but we need statutory help and senator hatch and mr. widen have led an effort on that side and we're hopeful we, work with you too. >> mr. bustante had a question about the hras and wore work egg totals on theless and i hope we can have the help of your agency in making sure this is the best legislation possible. >> thank you. >> we'll work with you. >> yield back. >> dr. price. >> thank you mr. chairman. madam secretary with respect

many of us here and many across the land believe the principles you outline accessible, affordability, and quality are being harmed by the current path we're on and i want to highlight some of the problems in the system that are i believe -- we believe, harming patients and destroying the ability of those working as hard as they took care for patients. one this electronic health record and meningful use. they're decading to physicians what must be documented and how it must be documented. without regard to what is truly important and necessary for taking care of patients. it's wasting money wasting time wasting resources and the expertise of physicians. leading to further disgust on the part of -- many leaving practices. they've quit at an age where they could propria for years and years. there are positive solutions if we allow for flexible and respect to those providing the care. icd10, another example of cms

making it mow dirk for physicians to care for patienteds in some cases in small and rural practices as we it will drive physicians out of business so access is destroyed for those patients in those areas. the u.s. inappropriately combines and confuses clinical data. that's what is happening if -- with billing dat are in the guise of wanting more information and saying everybody necessary the world is doing. it the factes the u.s. is the only country to use all 87000 codes in an outpatient setting in a billing process and the only country to put the cost on the physicians and those providing care. happens october1. if past is prologue, sadly it holds potential be significant disaster. further harming docs and patients. and i urge, i urge cms to die lay penalties for coding errors for two years. it's only reasonable given the magnitude of the change coming.

durable medical equipment often times the only thing that stands between a patients quality of life and hospitalization or illness, exacerbation or death is dm and a caring provider. if cms is put in place system of competitive bidding doesn't work. it's harming patients and is driving folks who have been wonderfully providing care and service and communities across the nation out of business, further harming patients if urge i plead with cms to at least a lou a pilot demonstration to show there's a better tie save money and also provide services to patients. sadly, madam secretary the president continues to shamelessly cob dem and attack those standing up for patients centered health care. as recently as yesterday he ignored reality and cynically mocked those striving for positive solutions. we know he mass a pen and a phone. what he doesn't have is the knowledge or human mitt or

concern or desire to work together on behalf of those struggling to provide care and those receiving the care. madam secretaries, i urge you urge you and your team, to join with us in an open-minded way to end the oppression of meaningful use to provide for flexibility with icd10 so that more practices aren't destroyed to allow for a pilot program to demonstrate the competitive bidding is hurting patients and there's a much better way and to give physicians the freedom to care for patients. if you're sincere in your desire for accessible and accessibility and affordability and quality that would lead to your action working with us and i look forward to that and hope that we can move in a positive direction. mr. chairman, yield back. >> the mr. larson. >> thank you mr. chairman. and thank you madam secretary. thank you for your service. hailing from the great state of connecticut, we are so proud of the advances of the affordable

care act and it's great to have a governor that is hands on in terms of implementation. and all the progress that we know that has been made and will continue to be made under the act. mr. chairman would like to mitt for the record 28-page report entitle "the language of health care 2009" by frank lutz. objection? >> no objection. >> i have a net deal of respect for mr. luntz he and stan greenberg, another pollster and one so spends time on the science of language in looking at in detail what people should say in subject matter areas. this is particularly of interest to me because this was

recommended in 2009 and basically mr. luntz describe thursday ten rules for stopping the washington takeover of health care. and it's informative even to this debate today. for example he says the caringments again this democratic healthcare plan must center around politicians bureaucrats and washington. not free markets tax incentives or competition. so we'll hear a lot of that. it also goes on to underscore you simply must be vocal and passion not on the side of three form the status quo is no longer acceptable. of the dynamic becomes president obama is on the side of reform and republicans are against it, then the battle is lost and every word of this 30-page document is useless.

he goes on to say this, and this is the whole point. it's not enough just to say what you're against. you have to tell them what you are for. it's okay, and even necessary for your campaign to center around why this healthcare plan is bad for america. but if you offer no vision, for what is better for america then you'll be relegated to insignificance at best and labeled obstructionist at worst. what americans are looking for in health care is what your solution is. what it will provide. words of more access. more treatments. and more doctors are sure winners. i agree with mr. luntz there. that what's this subject to shoo

be about providing more access. but madam secretary may i ask you, are you aware of any republican legislative proposals that rice the number of uninsured in this country by more than 16 million and make sure that we continue to provide all the benefits of addressing preexisting conditions, keeping your children on the plan, and making sure we focus on prevention? >> i have not seen a proposal that does that. >> i thank you madam secretary. and with that, submitting this full report for the record, think it's worth everybody's reading and we ought to get back to what this committee should be doing, and that's to put americans first and put americans on the road to having the best access, more access, more accessibility and more availability to health care. thank you. >> thank you time for the gentleman expired. we're now going to enter into the two to one phase. two on our side, one of the d

side to keep itself equal. mr. buchanan. >> thank you mr. chairman. thank you, madam secretary. i appreciate you taking the time this week to give us a call -- give me a call and visit. my biggest concern you made four points. at the top of the list i was chairman of the florida chamber. we had 137,000 businesses. we represented most of them were 50 employees or less. so loot lot of small beens. the biggs -- biggest issue before the aca is affordability and there was an expectation or hope we could bend the curve on affordability no question people can get the subsidies they benefit. there's over a million in florida. but there's many just above that line poverty line, that don't get the subsidies and i want to talk on two bases first. small business, their cost, trying to provide healthcare has gone up 20 to 30 percent the

last three or four years. i just talked to another person the other day had 130 employees, went up 30%. throughout florida and throughout our region, we're not seeing any reduction or anything in terms of affordability from that standpoint, and many times last week we had a town hall, one woman -- a couple weeks ago one woman says $2,000 a month to get health care. she can get it for left but then she has -- has to pay out some kind of $10,000 in terms of her health care if she has a claim. what is your thought on the affordability, where we're at related to people that -- in terms of subsidies. >> when we think about the affordability we think that some progress has been made and as you precipitationly reflect what we were seeing before, we were saying raising deductibles and growth and we have seen a slow -- the things we have seen slow down is a slow 234 premium growth across a number of categories and also seen that

medicare savings that i mentioned earlier the over300 billion in terms of where we are in our medicare pricing. the other thing that is indicative is we have seen the per capita healthcare cost grow because we have so many people retiring and coming into medicare the overall cost will go up because we have more elderly -- >> let me just -- we're short on time. we're not seeing the discounts per se -- i'd love to have you come to florida and talk to small business people. we're not seeing any kind of discounts. most of it is 20 to 30 percent increases. last couple of years. they're hochful but not seeing it. and then unfortunately a lot the kesss is pushed to the employee, and so many of the employees that were maybe picking up a couple hundred bucks a month now they're paying 5 to $600 out of their pocket. if they don't get a subsidy maybe of them are being gutted. so we'd like to talk about the middle-class but this is -- a lot of this us putting the middle class at risk in terms of

healthcare costs and what is your thoughts on that? >> i think this is why one of the thing wes need to focus on now deeply is delivery system reform and that is the idea of better smarter healthier and by that, it's both about quality and i think we have to be careful when we talk about this topic because people hear it and we need to make sure we preserve quality and improve quality. why do we have some of the lowest levels of quality. it's about improving quality and affordability, and right now one thing we did in january we committed that the federal government that medicare payments 30% by 2016, 50 parts by 2018, will be based on value instead of volume as part of working on the overall issue because what -- what you're hearing is important to us and -- >> let me just close with the idea. i hope we can focus more on affordability, all of us, because it's bankrupting a lot

of people that don't get subsidies. that's the reality in florida. for small business and individuals. so the focus needs to be on affordability, finding a way to bend the curve on healthcare costs. >> thank you madam chair. >> look forward to work with you on these delivery issues. >> mr. smith. >> thank you, mr. chairman, and thank you, madam secretary for being here today. limited time and a lot to cover here. as you know, as we spoke earlier about the consumer operated and oriented plan programs which were the alternative to the public opening quasi-alternatives and the hh sets has -- one plan served over hundred thousand people in nbc and iowa was sealed by the state of iowa and has been liquidated. folk's then plan have been left

frustrated and looking for a plans. and i sent a letter asking specific questions did receive a response on may 21st. i'd like to request nance consent to submit both of these letters for the record. now quickly some questions. received $146 million federal loans. will any of those dollars be paid back? >> with regard to that, that's a question i'll follow up on. >> okay. i appreciate that. my understanding is iowa, nbc were told they could not suspend enrollingment and have it remain a qualified health plan, yet tennessee was later allowed to do so. do you know why that policy changed? >> so per our conversation i actually did follow up with cms. we didn't have the record of that request coming in so i'd loaf for our team to follow up and understand if there whereas

miscommunication. based on your comment it was something that was concerning to me, and i went and followed up. so if we can work with your staff to understand what your staff understands happened, that would be helpful. >> okay. recent reports claim only one co-op didn't have an operating loss in 2014. is that accurate? >> i would have to go co-op by co-op. >> there are any concerns about possible liquidation of any other plans in the near future or -- >> with regard to the co-ops because they are all new businesses, they're startups, like she mall businesses we were talking about before. we are going to have failures in terms of the co-op system. that is part of what was set up in term's the original 5 billion the congress gave but then through sequester and other means went to 1 billion. there will be co-ops that will have challenge issue ands to we're working close with we me states to make sure with get in front of them do the kinds on

things we attempted to too which is make sure as much as possible and where appropriate we would engage in support communication if offering a special enrealmented and working with state insurers and any authority we had to make sure the consumers were taken care of. >> okay. any of the consumers who lost coverage from the failed co-op be penalized by the individual mandate? >> i do not know how many are not still in the system but i will check and will follow up on that mitchell understanding is no but i want to condition firm that. >> in that vein, i have introduced hr954 which would tempt anyone who has lost health insurance from the failed co-ops from the individual mandate. could the administration support that approach and that piece offings? >> i'd love to have the opportunity to see if that's something i that has already happened or not and then review the bill. >> okay. now, in the bigger picture of obviously large sums of money being offered to these consumer

operated and oriented programs, what is the likelihood of those dollars being paid back? >> with regard to the loans that have gone out? >> right. >> i think with regard to a number of the co-ops, that will happen in terms of the successful co-ops and those that are gaping traction and working -- gaining traction and working. some that are not and we'll get back on that specific question. >> seems to me the various states relevant to this issue might have a different approach for paying to the claims that were submitted by -- how on top of this are we? because in nebraska there is a fallback and yet it hurts more people. i apologize any time has expired. >> state insurance law is a big part of how that gets determined, but we try to work to support the states with

different options. >> time for the gentleman expired. mr. blumen. >> madam secretary appreciate your reluctance to deal with hypothetical legislation that has not yet been written to deal with a legal decision that has not yet been rendered. think that prudent. but if this occurrence take place by the court seems to me it would not be rocket science as some of my colleagues have mentioned to make relatively minor changes to conform statutes to the intent and text of the bill and move forward. i think the committee could take one weekend and fix it. and move on. i have -- like to shift gears slightly -- we have had an ongoing series of conversations. it's been six years since a

provision i authored was approved unanimously by this committee. unanimously by this comet year dealing with end of life care. that provision despite a -- certain rhetorical flourishes remained in the legislation. unfortunately fell victim to the reconciliation process. and style we're trying to achieve the -- although the world has moved on. many agree this is necessary. you recently received a letter from 65 notable national organizations calling on you to have medical reimbursement -- medicare reimbursement for advanced care planning. the ama did the coding.

it's all keyed up, ready to go. we bought thought the administration was going to be there and yet it lingers. published, peer review research shows that advanced care planning leads to better care, better patient and family outcome, fewer unwanted hospitalizations. the list, as you personally know is compelling for this service. is the administration prepared to finally move forward and authorize it? >> with regard to, as i think you just mentioned the ama has given us the guidance and coding and we're in the process of reviewing that, and also we indicated in a recent rulemaking indicated in our preamble that is something we're working on and reviewing the current coding. >> it's been six years. since congress embrace evidence and it this committee approved it unanimously. we have had the research clear

the aisle m dying in america. i'm trying to understand what is it that is so hard to figure out whether or not this is part of the legacy of the obama administration which has done some good things with health care. this seems to be a really terrific thing that is really simple that would make a huge difference in people's lives private insurance is moving. what is it that is hanging this up? white can't we just get toey? >> congressman,s we have said in our conversations and our team's conversations, this is an issue we'll work on. we want to make sure with imagine the progress we intend to make. >> i fine it mystifying the rest of the world is aligned. this is one of the few things this committee agreed to unanimously. and that we see the difference it makes in human lives and the administration continues to study and i'd really hoped that this could be part of the legacy

and that it is part of the 2016 reimbursement. i find it frustrating beyond my ability to express. i'm happy to -- i've walked the marv for this administration on things before, and this is really troubling. >> thank you. time for the gentleman has expired. miss jenkins. >> thank you mr. chairman, and thank you madam secretary for being here today. i want to echo the comments of chairman ryan and others on the committee regarding the supreme court's decision later this month on the constitutionality of the president's healthcare law. many kansans are poised to lose their subsidies the only thing that makes their insurance somewhat affordable. and many of my constituents will be facing increases over 30% next year. which in addition to the loss of subsidies will make their insurance unaffordable, and i'm

extremely frustrated because i had an exchange with your predecessor, secretary sebelius, three years ago on february 28th of 2012, when she was a witness here before the committee on that day i expressed my concern that it did not see anything in the president's healthcare law that would allow federal subsidies to flow through nonstate based exchanges. and i told her that the administration didn't have the authority. to allow the subsidies to flow through federally facilitated exchanges, even though the irs at the time was telling congress the distinction didn't matter. because in the law there is no mention of the term federally facilitated exchanges. even though secretary sebelius probable enemied me that hhs would give me a detailed answer in writing defending her interpretation of the law she never did, and obviously this issue didn't go away, and now

the supreme court will finally weigh in on it. and i'm equally concerned when you suggest that the decision before the supreme court is just about the subsidies because it isn't weapon have research here from the american action forum which talks about all of the positive outcomes from a decision by the supreme court against the administration over 11 million individuals freed from the individual mandate. over 260,000 businesses freed from the employer mandate. thousands -- hundreds of thousands of new jobs.