rutgers faculty wanted to admit women. it was kind of what columbia went through. and so there was -- we had a lead plaintiff in the case. he was a gardener who had a son and a daughter. his son had gone to rutgers. his daughter couldn't go to rutgers and, thank goodness, we did not have to make a federal case of it because the rutgers faculty was so keen on the idea -- i mean what they saw immediately was, if we can accept women students we will upgrade our academic standing. so there were the complaints that were coming in to the aclu. there were the students. and this was beginning to happen at law schools across the

country. there was a women in the law conference i attended at -- i think the first one was at yale. and we were getting out materials to -- i rode with my friends, herman cain and kenneth davidson, one of the published cases on sex discrimination and the law. but we came to see -- by the way, i should say who the "we" were. a brilliant lawyer, marvin kilpack, he was one of the general counsel. he spotted in law week what he

said is going to be the turning point -- gender discrimination case. the year is 1970 and the supreme court has never seen a gender classification that it thought was unconstitutional. this case was decided by the supreme court of idaho. it was about a woman named sally reid who was divorced when her son was what the law calls of tender years so sally got custody. when the boy got to be a teenager the father said he now needs to be prepared for a man's world, so i want him to live with me. sally thought that was a bad idea. i'll cut part of the story short, but the boy one day took out one of his father's mini

rifles an killed himself. so sally wanted to be appointed administrator of his estate. not because it was any monetary gain gain. for sentimental reasons. he had a guitar some clothes a record collection. a small bank account. that was it. her former husband applied to be administrator a couple of weeks later and sally thought that she would get the appointment because she applied first. but the probate court judge said, the law leaves me no choice. it reads, as between persons equally entitled to administer a deceasedant's estate males must be preferred to female. just that simple.dant's estate, males

must be preferred to female. just that simple. let me compare 1971 when sally reid's case was decided by a unanimous court headed by chief justice berger with a case in 1961 when earl warren, who was known as "liberal" justice had gwendolyn hoyt's case. she was what today we would call a battered woman. she was abused by her philandering husband and one day he humiliated her to the breaking point. she was beside herself. it was kind of like billy bud. if you read the story billy is unable to speak so he strikes lieutenant klager.

dwebd gwendolyn saw her son's baseball bat in the corner of the room. she took it and with all her might hit her husband in the head, he fell to the ground. it was the end of his life and the beginning of the murder prosecution. gwendolyn hoyt's idea was, it's important for me to have women on the jury because women would better understand my state of mind, the rage that i felt. but, hillsboro county florida in those days did not put women on the jury rolls. that was supposed to be a favor to women because, as the supreme court said in gwendolyn hoyt's case, women are the center of home and family life. therefore, they don't need to be distracted by serving on juries. gwendolyn hoyt's lawyer tried to get the court to understand that

citizens have obligations as well as rights, and one obligation is to participate in the administration of justice by serving on jury. the law said women are expendable. we don't need them to serve on juries. well, the supreme court rejected gwendolyn hoyt's plea in 1961. and what happened in those ten years in between, there was an enormous change in society. women were entering the workforce in increasing numbers. women were living many years longer than the day that the youngest child left the nest. birth control was more freely available. all of those changes in society

led the law to catch up and that's what was happening in the 1970s. so i was fantastically lucky to be born when i was and to have the skill of a lawyer. in that rigby relief there are names of two women on the cover. pauline murray and dorothy kenyon. these were women who were saying the same things that we were saying. dorothy kenyon's mission was to put women on juries in every state in the country. and pauline murray was an african-american woman who had herself -- she wrote an article called "jane crow and the law" in which she compared the

disadvantages that african-americans faced with the disadvantages that women faced that for women as well as members of minority groups, there were closed doors, doors you couldn't enter for a reason that had nothing to do with your ability. but just because of your skin color, your gender. we put their names on sally reid's brief as if to sayer in's too old now to be working with us, but we're standing on their shoulders. we are saying the same things that they said but now at last society is ready to listen. >> and then there are six historic cases that you argued before the court. did you have an overall strategy about what you were twrirying to do? >> none of the cases that the

aclu women's rights handled were test cases in the sense that we went out and tried to manufacture a case or find plaintiffs. these were people -- every day people like sally reid. what we wanted -- we wanted to have cases with people -- every day people so the court could see the aeshrbitrariness of the gender lines in the law. one of those important cases was steven weisenfeld's case. some people criticized me for bringing men's rights cases. well, this is -- let me describe steven's case to you and describe whether it is a men's rights case or a women's rights case or a people's rights case. steven was married to a high

school math teacher. she had a healthy pregnancy. she taught into the ninth month. she went to the hospital to give birth and her doctor came out and told steven you have a healthy baby boy but your wife died of an embolism. so steven vowed that he would not work full time until his child was in school full time. and he figured he can make it between social security benefits and what he is allowed to earn on top of those benefits. he went to the local social security office to apply for what he thought were benefits for a sole surviving parent with a child under 12 in his care. he was told, we're very sorry these are mother's benefits. they are not available for

fathers. so in his case, we argued first, it was discrimination against women because women were required to pay the same social security taxes that men paid but their families did not get the protection that male workers had always got. and then it was discrimination against the male as parent. because men were not having the opportunity to care personally for their children. and then -- well, let me say it was a unanimous judgment for steven weiss nn weisenfeld. the majority thought the discrimination started with the wage earning woman. couple of them thought it was discrimination against the male as a parent. and one who was then a justice, later became my first chief, then justice rehnquist said, this is totally arbitrary from the point of view of the baby.

why should the baby have a chance to be taken care of by a parent, a sole surviving parent, only if that parent is female and not male? so that was our description to the court. it was bad for women be bad for children, bad for men. the idea was to break down this stereotyped division of the world into home and child caring mothers and work outside the home fathers. that pattern. and so with great rapidity, states -- congress changed laws that had once been based on this

model of home caring mother, working father, and took away those gender labels and made it a worker, a taxpayer a parent. >> was there -- was the court receptive to your arguments? specifically -- and i'm thinking mostly right now in terms of the oral arguments. >> they didn't ask as many questions as the court on which i sit does. you could get out a whole paragraph there without being interrupted. even there was one case -- it was the one that i lost. we won't go into the details of that. but anyway, my precious half-hour was up and maybe there

was a half a minute left. justice blackman asked the question and i answered it. chief justice burger let me go on for five minutes beyond the half-hour. that wouldn't happen today. oh. when you said were they receptive. yes. to a point. but the very last case i argued was in 1978 and it was another one of the women on juries cases. this was from missouri. i had just finished my argument. was about to sit down, content that i had made all the essential points. when then justice rehnquist said, "and so, mr.s. ginsburg,

you won't be satisfied with susan b. anthony's face on the new dollar." so it was still that we could make jokes about treating women as less than full citizens. >> and did the presence of women on the court have a profound influence in terms of changing that that? >> i think now that we are one-third of the court well, justice o'connor was the lone woman on the court for 12 years. and when i was appointed, it was a renovation in our robing room. up until then, there had been a bathroom and said men. they rushed through this renovation and created a women's

bathroom equal in size to the men's and that was a way of the court saying yeah, we know that women are going to be part of this institution. during the years that sandra and i served together, invariably one one woman would respond to my question, justice o'connor -- occasionally sandra would say i'm justice o'connor she's justice ginsburg. doesn't happen now with the three of us. i think the worst time was when i was all alone after sandra left. the public reception saw eight men, and then there was this little woman hardly to be seen.

but now, because i'm so senior, i sit toward the middle. i have justice kagan on my left, justice sotomayor on my right. and if you watch proceedings in our court, you really should it is quite a show, my newest colleagues are not shrinking violets. so the public will see that women are all over the bench. they are very much a part of the colloquy colloquy. yes. people ask me sometimes when do you think it will be enough? when will there be enough women on the court. and my answer is, when there are nine.

some people are taken aback, until they remember that from most of our country's history there were only men on the high court bench. >> now i want to open the floor for questions but just one last question. as you're about to -- all of our students here are about to start their legal career, and you've had just such an extraordinary career, is there one or two pieces of advice that you'd like to give them as they are about to begin? >> i have done everything that i've done in the law. i think it is a great profession. but i will say that if all i was in the law business for was to turn over a buck i don't think i would have had nearly the

satisfaction that i have. yes, you need a job. but, if you don't do something outside yourself, something that will repair the tears in your communities, that will make life a little better for other people you're not really a true professional. then you're like a plumber who has a great skill. but that's all you are if you think of yourself as a true professional you will take talent education that you have and use it to make things better for other people in your local community, your state your

country, your world. >> i think that's powerful and inspiring. your career has been so inspiring for each of us. what done has just been transformative. and so we'd like to take an opportunity to give you the chance to ask the justice questions. okay, while we're waiting. [ laughter ] how does it feel to be an icon? >> well, when all this started, i had to ask my law clerks, what is this notorious rbg? [ laughter ] and now i have no competition because notorious b.i.g. is no longer part of this world.

[ laughter ] >> i think we have a question now. [ laughter ] please say your name. >> justice ginsburg thank you for coming. i'm the co-president of the reproductive rights group here on campus. my question tends towards that. with the hobby lobby ruling with some of the rulings out of texas, how do you feel about -- are you pessimistic about the direction of the reproductive rights in this country? abortion contraception, parenting and so on. >> you asked am i pessimistic? i think it will depend upon women of your age, if you care about this. there will never be a time when women of means will lack choice. because take the worst case

scenario. row v wade is overruled by the supreme court. there will be states a sizable number, that will not go back to the way it was. at the time of roe v wade there was four states that gave women access to abortion without any questions asked in the first trimester. so those stapttes are not going to change. what it means is a woman who can afford a plane ticket, a bus ticket ticket, will be able to decide for herself. whether to have an apportion. but the women who won't have that choice are poor women. and that doesn't make a whole lot of sense i think.

so if the women of your generation care about this issue, they will -- that's a message that i don't see talked about a lot. who will bear the brunt? i suppose roe v wade will overall who will bear the brunt. so if we care about our sisters who are less fortunate than we are are, we will do what we can to see that they have roughly the same choices in life. >> thank you. in the back. please state your name and. >> my name malalai waseel and

i'm an african american. for those of us as women who have been inspired by you justice ginsburg in opening the doors for us over the course of the last few decades there is not group of us inspired do work for women overseas. whether in afghanistan throughout the middle east. and i'd like to hear from you what advice you might have for those of us who might wish to see the role of women growing and to a place where they could look at their sisters in the united states or in the western countries and say we are getting there. what advice would you give for lawyer who is would like to dedicate their lives to women's economic empowerment and social empowerment in developing countries? >> i would say first don't go there to preach to people about how they should do things. you should try to get to know the local community, so understand what their priorities

are. and to help them accomplish an agenda that they set. there have been some great strides made. what is the name of the man who was setting up funding women who were starting small businesses making loans to them. and he was amazingly successful. the women paid back. so when they got the resources they worked very hard. and i'd say -- but that is the main thing. i worried about some people who went off to various places and wrote constitutions. they had no correspondence to that society. i think if you are working abroad you try to work with the women in that culture to

accomplish what they see as most helpful to them. >> another question. >> hi justice ginsburg. i'm tyler clemens. it is an honor. my question is you have kind of become known as the voice of the powerful dissent over the past few years perhaps i unfortunately. but if you could pick one decision over the past ten years that you could wave a magic wand and overturn, what would it be and why? >> i would have to say citizens united. because i think that our system is being polluted by money. it gets pretty bad when it effects the judiciary too in some 39 states, judges are

elected at some level. and it costs millions of dollars to fund a campaign for a state supreme courts. something is terribly wrong. i think we are reaching the saturation point. and a great man that i loved dearly marty often said that the true spolymbol of the united states is not the bald eagle. it is the pendulum. and when it swings too far one way it is going to go back in the other direction. >> so you think that it will swing back? >> do i think -- i can't say when. but that one day sensible restrictions on campaign financing will be the law of this land yes. it will happen.

it's one of the hard things to explain when i go abroad. and i'm very proud of being a citizen of the u.s.a. but then i'm asked questions like like, how do you allow people with money to have access to the lawmakers, to the decision makers that ordinary people don't have? how deutscheo you have a system where legislative districts in the house are so jer jury mandatored that people don't vote. that people have a sense why bother. it is a foregone conclusion whose going to win.

so i think we need -- we need to get our democracy where it is a democracy for all of the people. >> while we're waiting what can lawyers do for fun? >> whatever is their passion. i told you i'm a monotone but i do love opera. i have been three times to the washington opera.

and i a also -- well every year i participate in the shakespeare movement's mood court. and i i've been -- i guess my best part at the shakespeare theater was in henry iv. they asked would i have the -- i said i want dick the butcher. i want to say the famous line, first thing we do, let's kill all the lawyers. [ laughter ] >> now our last question. >> if i can follow that. but thank you justice ginsburg. my name is alexander martone. if you were back in your role as a civil rights advocate what kind of case would you be

looking to bring today? what sort of story would you be looking to bring to the fore to tell the court what cause you would want to advocate for? >> i'm glad you asked that question. because i wanted to tell everybody here that you don't start with the courts. on the whole the judiciary is a reactive institution. doesn't set its own agenda. our first effort in the aclu women's rights project was public opinion. to try to influence public opinion. the people have to want the change before it is going to be reflected in legislation or in judicial decisions. then you try to get the legislature so write laws that are family friendly. and the court is really the third audience.

in the 70s there was kind of a dialogue going back and forth between the court would say side sally reeds case and then some changes in the laws and then steven wisenfeld's case and then more changes in the law -- the court and the legislature were working kind of in tandem at that time. but i would stress that first you need popular support. that is what existed in the 70s. it didn't exist before that. and when while all this was going on and these cases were being brought to court, the states were reviewing their law books to eliminate arbitrary agenda classifications.

congress did the same. so don't think about the court as your first audience. people have to want to have a change. >> this has really been extraordinary. we have a small token of our appreciation. and i have to say the privilege of listening to you and the wisdom that we are all benefitting from. i'm so grateful. and now we are all so grateful. i'd like to lead us all in a round of applause and thanks for justice ginsburg. >> that is lovely. thank you. [ applause ]

>> such an honor. thank you so much. we have now a celebration in the fitness lounge. and again thank you justice ginsburg. we'll all treasure this memory.

please to welcome everybody to today's hearing. i want to thank you secretary burwell for being with us today. this is your first meeting since being confirmed. so welcome back in your official capacity. i told eoin your confirmation hearing that the job you now have would be a thankless one and that you are undertaking enormous responsibility. at that time we also discussed three main areas i encourage you to focus on during your time at hhs. responsiveness, accountability and independence. i'd like to talk more about these areas today. let's start with responsiveness. during your confirmation hearing i raised the importance of being responsive to congress and this committee in particular.

you assured me this would be a top priority and under your watch we would see a marked improvement. in the past year this committee has written at least 20 letters to hhs or cms asking questions about serious issues, fraud prevention hack of healthing of healthcare.gov website. and i now understand we've received responses to every one of those just in time for your appearance here today. this is a great improvement over the past. and i appreciate the efforts being made to provide these answers to us. however i hope it will not require calling you before the committee to ensure more timely responses going forward. if it does i suppose we'll have to look forward to seeing you for a hearing every 30 to 60 days and you don't want that. they get worse after time. thank you for continuing to make

this a priority. good communication is paramount to a good working relationship. and you understand that. and i know that. let's talk about accountability. and one of the big issues we discussed at your configuration hearing was the absolute need for fiscal accountability given the huge breadth and scope of hhs's programs and budget. overseaing them requires constantn't vigilance and management. we see how big your job is. the expression too big the fail does not really apply here as the hhs budget so so big, one would argue it is desk bed to fail. the budget for fiscal year 2016 is just other over a trillion dollars. in real terms if hhs were a country and its budget were its gdp it would be the 16th largest economy in the whole world. i this i we have that chart over

there that shows where the red arrow is you would be the 16th largest economy in the world. to put it in a more american context, the total budget of hhs is more than double that of walmart and five times more than apple. my concern is that the savings and efficiencies in the overall hhs budget are very small when compared to the overall spending. the president's proposed budget would save just under 250 billion dollars over the next decade. which sounds like a lot. but that is only 3.8% of total medicare and medicaid spending. more accountability is critical here to ensure these programs have sufficient resources to continue to provide benefits for years to come. on the policy front, the administration needs to be up front. with congress about their contingency plans if the cain versus burwell case is not decided in its favor.

depending what happens in the supreme court in late june, and probably late june, hhs could have to figure how to provide services for millions of americans who are currently receiving tax subsidies that will enable them to pay for health insurance. ky only assume that the agency has a plan in place for dealing with this possibility. secretary burwell i hope you will share that with us today. that brings me to independence. for some time now i've been concerned about the amount of influence hhs and the administration has or have over the operations and policies impacting the entitlement programs. certainly those run by cms. the budget released this week indicates spending on just medicare and medicaid is expected to exceed $11 trillion over the next decade. in fact cms accounteds for 35% of the total hhs budget. astonishing numbers.

they also reinforce something i've long believed. it is time to start talking about making cms an independent agency apart from hhs. nearly 20 years ago congress passed and the president signed into law a law, the social security independence and program improvements act of 1994. that law separated the social security administration from hhs and made it an independent agency. at that time ssa was the largest operating division within hhs and accounted for about 51% of hhs's total staff and more than half of their total budget. now i intend to introduce legislation to move cms out of hhs. whether or not cms becomes an independent agency is something to consider going forward. but the accountability and transparence problems we currently see in c smrks programs cannot wait. i hope we can work together in the coming months to create

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

appreciate the uppedness with which you have considerate with senator wyden and myself and others on this committee. snard widen. >> thank you mr. chairman. and secretary burwell, let me start by saying my understanding is you have set a new bar for cabinet secretaries in reaching out and trying to be responsive. i hear about it with respect to citizens. apparently you're in virtually every corner of the country, taking your family. i can only imagine the challenge of that. you are getting back to senators. i hear senators of both political parties conservatives, liberals saying the secretary actually got back to me. i mean it is like such a quaint idea that somebody would actually do that. and i understand you have got discussions either coming or have already begun with governors. so my sense is you have really a

new bar in terms of reaching out. and it is obviously very, very welcome. now too many people in america, including millions in our country and in my home state feel like they are falling behind. they just feel like if the economy picks up steam, they are not getting ahead. and it is our job to make sure that doesn't happen and the finance committee has played a big role in. almost like we're having a triple header this week. and the budget obviously articulates the priorities of today. but it also talks a lot about what our priorities are for the future. and we're looking forward to having you layout how to proposal would strengthen health and human services program, promote economic mobility and assist our middle class families. i do want to take a minute just to talk about where i believe

american healthcare has been. and then talk briefly about where it's going. this year marks the 50th anniversary of medicare and medicaid. and a lot has taken place since those programs were created. the congress came together to create the chip program. the program of course for children. and has reauthorized it three times. the congress has improved and expanded medicare and medicaid. the affordable care act makes access to high quality care wider than ever. and what i think is particularly important, it has signalled that america is not willing to go back to the days when healthcare is for the healthy and wealthy. and that is the way it was when you could go out and clobber the people with a preexisting condition. obviously the job is not done. so there is a two fold challenge in my view. first, protect the progress made and second clear the way for more progress in the future.

for medicare that means guaranteeing that the program's benefits fully immediate the needs of this era's seniors and the demands on medicare are clearly very different than they were 50 years ago. the big ticket medicare costs of 2015 are no longer things like kidney stones and broken ankles. they are chronic conditions like cancer, diabetes and alzheimer's. and those conditions are tougher. and they are more costly lyly to treat. the hhs budget in my view begins to acknowledge that reality. but clearly there is a lot more to do. and treating chronic disease in my view is the future of the medicare program. so what is needed is a road map to efficient and effective care for chronic disease that boldly moves away from the outdated fee

for service model. last summer we were told about the need for care in a different way. there is bipartisanship with congress and i look forward to workingings with you and the kmings administration to make that a reality. also think acting about the announcement last week about precision medicine. this too helps to provide a road map for the future. medical professionals understand that the treatment will often effect season in a different way than george. and with the right george it is going to be possible to figure out what drives those and figure what the patient needs. in the president's budget it follows a innovative test program that was really created in this committee. it was part of our discussions. i don't see senator carper here. he's been very interested in

that issue. but we've got another big challenge and the next step will be to design a payment system for this innovative field, precision medicine that can do so much for the future of patients and taxpayers. the president's budget proposal also continues the progress made by the affordable care act to reward the quality of care rather than the quantity. the congress can do even more by passing bipartisan bicameral legislation to improve the way medicare pays physicians and chairman hatch obviously had a lot do with put pag poemroposal together. the president's proposal also includes four years of funding for chip. there are more than 10 million kids who get health insurance through chip. a child who starts life with quality health insurance has a better shot at a successful middle class life than a child who doesn't. renewing chip in my view is a no

brainer. families and state agencies across the country are waiting for the congress to step up and act on chip. there are also steps the congress can take to help guarantee that our health programs remain strong for generations to come that are lifelines for countless americans and as a result millions of families will never have to choose between paying for a loved one's care and sending kids to college. and millions of americans will grow up with access to quality care that keeps them healthy and out of the emergency rooms whenever possible. of course it is important to remember health and human services does a lot more than oversee medicare medicaid and chip. no department plays a bigger role in america's safety net. this committee has a long history of work tong bipartisan basis on policies to strengthen our federal child welfare programs for vulnerable kids. five months ago the congress enacted the preventing sex trafficking and strengthening

families act and the department is helping turn this bill from a piece of paper signed by the president into new tools that will help states move more vulnerable kids out of harm's way and into safer and permanent homes. president's budget proposal shows it is possible to build on this momentum by expanding programs that keep kids and families together and healthy. with a special focus on getting involved early with vulnerable families, with programs like home visiting. and this is especially important for the first time parents. so in effect we're talking about multigenerational supports and those can prevent the long-term costs associated with homelessness, abuse, neglect and foster care. so we're talking about the people who are trying to get ahead in a tough, you know, economy and have just not seen the recovery make it to their neighborhood. thank you for joining us here

today. we've got a lot of opportunities in my view for working in a bipartisan fashion. and i'll have some questions but i do want to wrap this up by saying that having been in public life and worked with a number of secretary i think at the end of the day there are going to be differences of opinion. the only way you really make progress is by reaching out and you have sure many met that test. thank you and look forward to working with you. thank you chairman hatch. >> thank you senator. with us today is silva mathews burwell. she's been leading the department of the health and human services since june 2014. she has a long history of public sector service including most recently serving as director of the office of management and budget under president obama. in the clinton administration deputy director of the --. deputy chief of staff to the

president. -- all of which are very important position. also extensive private sector experience including with walmart and the --. ms. burwell received her ab from harvard and a ba in oxford where she was a road scholar. we're honored to have you here and want to thank you for being here. and you can proceed with your opening statement. >> thank you. thank you chairman hatch and ranking member widen and members of the committee for having me here today. i want to thank you for the opportunity to discussing the president's budget for health and human services. i believe firmly we all share common titrates and we interests and we have a number of the opportunities to find common ground. advancing the promise of

precision medicine to building an innovation economy and strengthening the american middle class. the budget before you makes critical investments in healthcare, science, innovation and human services. it maintains our responsible stewardship of the taxpayer dollar. it strengthens work together with the congress to prepare our nation for key challenges at home and abroad. for hhs it proposes $83.8 million in discretionary budget authority. and this is a $4.8 billion increase that will allow our department to deliver impact today and lay a strong foundation for our nation for tomorrow. it is a fiscally responsible budget with in tandem of accompanying legislative proposals staves taxpayers an estimated $250 billion over the next decade. in addition it is projected to

continue slowing the growth of medicare. it could secure $423 billion in medicare savings as we build a better smarter health delivery system. in terms of providing all americans with access to quality affordable healthcare, it builds upon our historic progress in reducing the number of uninsured and improving conch for those who already had inch. extends chip for four years, covers newly eligible adults. and improves access to healthcare for native americans. to support communities throughout the country including underserved communities it invests $4.2 billion in health centers and 14.2 billion to bolster our nation's healthcare o workforce. it supports more than 15000 national health service corps clinicians serving nearly 60 million patients in high need areas with the funding streams

ending in 2016, millions stand to lose primary care services and providers if we are not able to take action. to advance our common interest in building a better smarter and healthier delivery system it supports improvements to way care is delivered providers are paid and information is distributed. on an issue for which there is bipartisan agreement. it replace medicare's flawed sustainable growth formula and supports a long-term policy solution to fix the sgr. the administration supports the type of bipartisan, bicameral efforts the congress undertook last year to. advance our shared vision for leading the world in science and innovation, it increases funding for nih by $1 billion to advanced bio medical research and behavioral research, among other priorities. in addition it invests 215 million for the precision medicine initiative. a new cross-departmental effort

focus on developing treatment, diagnostics and preventive strategies tailored to the individual genetic characteristics of the individual patients. to further our common interests in providing americans with the building blocks of healthy and productive lives this budget outlines on ambitious plan to make affordable quality child care available to working and middle class families with young children. it supports evidence based interventions to protect youth and foster care. and itten invests to help older americans live with dignity in their homes and communities and protect identity theft. the keep america healthy it strengthens the infrastructure with a budget for domestic and sbsh preparedness and critical funds for the global health security and core strategies of the prevention detection and response. it also invests in behavioral

health services and substance abuse prevention. it includes more than 99 million in new funding to combat precipitation opioid and heroin abuse and dependency. and finally as we look to leave the department stronger the budget invests in shared priorities of addressing waste fraud and abuse. anywhere r initiatives that are projected to yield 22 billion in gross savings for medicare and medicaid across the next decade. we're also addressing medicare appeals backlog with a variety of approaches. taken together this budget advances our broader goals of making a 21st century workforce providing americans with the building blocks of healthy and productive lives and delivering impact that allows everyone to share in the prosperity of a growing america. as i close, i want to sure assure you i am going to respond

to your needs. --. to the commitment they show day in and day out. helping their fellow americans obtain those building blocks of healthy and productive lives. i look forward to working closely with you to advance our common interests for the american people. thank you and with that i'm happy to take your questions. >> thank you ms. burwell. as, you know, supreme court will send aside the legality of irs regulations and extend health insurance substituteidies to individuals in states with federal exchanges in the king v burwell case. the legislation itself t affordable care act talks only about thesis exchanges being created in the states. so it is an important opinion. and my opinion the regulations violate the constitution's

separation of powers by exceeding the executive branches regulatory authority. but we'll find out what the court says soon enough. yesterday's ways and means hearing treasury secretary repeatedly refused to say whether the administration has a contingency plan if the supreme court rules against the administration. secretary burwell does the administration have a contingency plan in case the scourt invalidate ss -- >> right now what we believe is position we hold and the justice department will represent for us in fron't of the supreme court is the correct position. and we believe that both in terms of spirit of the law and intent of congress as well as the letter of the law. and the justice department will make that argument. in terms of what we believe and we see that is happening is the idea that tax credits would be provided by the congress for

individuals in, say, the state of new york but not the state of new jersey is something that we don't believe that the congress intended in myway.anyway. and we believe the letter of the law supports that. >> there was a lot of that that is exactly that the congress did intend that so it would force the states to have the state exchanges rather than have the federal government do it for them. this is a big issue and the language is unambiguous, at least in my opinion. i don't know what the court is going to do do nor i do want to overly speculate. but assuming that the court does find that the language is unambiguous and that only state exchanges can be formed, do you have a contingency plan? >> right now mr. chairman what i am focused on. i think everyone here knows is that february 15th is the end of

open enrollment. and in terms of providing quality affordable access to healthcare my deep focus right now is ensuring as we've seen and later today we will announce there are 7.5 million people who have come in through the federal marketplace in addition to the 2.4 million that have come in through the state exchanges. and large majorities of those people are receiving the financial assistance that is being provided. and right now my focus is to o focus on completing and implementing the law which we believe is the law. >> then the answer must be no you don't have a contingency plan. that's all i'm asking. >> right now what i'm focused on is the open enrollment. >> so that means that you don't have a contingency plan. i would suggest the administration ought to get one just in case. it's something that seems to me we -- you know, you're going to have to have. because the possibilities that

millions of people will need coverage when this law runs out is important. >> let me ask you this. has your department communicated with insurers who the participate in healthcare.gov to plan for the possibility that the subsidies could become illegal? have you taken, made plans there. >> we continue to work with the insurance providers to implement the affordable care act. we are working very closely with them as part of this open enrollment. one of our deep focuses has been the consumer. as part of that focus with the consumer we've been working very closely within the ensurers on making sure that we're focused on everything -- >> i'm more concerned about this issue right now. i'm wond -- i'm sure your working with the -- you know with the various state in every way you possibly can. but again, are you planning for anything if the court decides the other way? >> senator right now we are

focused deeply on those issues. >> okay. >> that i've articulated. >> okay. well i have to say the ensurers to my knowledge haven't been given any guidance about what to do if the supreme court invalidates subsidies paid to them. so it's something that i hope, you know, you will get on top of just as a contingency plan to make sure that you can handle these matters. now secretary burwell, the aca included more than $100 billion in appropriations. over $1 billion of that money went to states that willfully and negligently spent federal funds for development of a failed state exchange. and your may 14, 2014 confirmation hearing before this committee i asked if these states be required to reimburse the taxpayers. you said quote where the federal government and taxpayers had funds misused we need to use the

full extent of the law to get those funds back. and i agree with you. unquote. has the hhs uncovered any of these funds and do i have your word that you will take action to collect from the states the money that was in the opinion of almost everybody so negligently misspent. >> at this point we have not received any of the funds. with regard to the funds they are made in contracts. and we issue those -- we do those to the states and then the states issue the contracts. so our grant making to the states is the part that we have control over. as part of that though a number of the states actually are taking action both in oregon as well as in maryland. efforts are being made in terms of the follow up. the question of what the federal government can get back in terms of those funds is about whether or not in the grant making that things were done that were not in line with the terms of the grant. right now our inspector general at hhs is looking into these issues to see if there are

places where they think that has happened. >> thank you mr. chairman. obviously mamd secretary we're in tax filing season and there are lot of issues with respect to premiums and credits and sect secretary lou and --. do you have any sense at this point how many people might be entitled to a refund under the law because that is certainly one possibility? and how many people might owe something? do you have any sense of numbers there? because that is what i'm being asked. >> we have a sense that over three quarters of people will just check a box. those that have existing insurance when they file three quarters will just check a box. with regard to the other category, one that you are referring to which is those who have been in the marketplace and

whether or not they have underpaid or overpaid with regard to the subsidyies they have received we don't have a sense because it is the first time through. and i'm sure the commission and the secretary are have spoke on the that. >> what have you done to make sure this is consumer friendly for people who are going to have to wrestle with these issues? >> we've worked and we've worked together as the departments. the department of health and human services t treasury department and the irs to make sure that we are getting information out as much and as quickly as possible. wra with regard to those who will be filing in the category you were describing 91% use some software to file. so within the software it is incorporated just as everything else is incorporated and we work to do that. we've been working with the tax filing organizations. whether that is at the end of the h&r blocks down to the vida

centers are the centers that you all know help provide lower income people. we're in communication and are doing calls and we are in consistent communication bautsz we want to make sure that the questions they are getting we understand so that we can provide help in answering those if we can. >> let me move onto the chronic care issue which as you and i have talked about i think is the future of medicare. i look back at dave when i was director of the great panthers we talked about broken ankles. nobody is talking about that being something that drives medicare's future. it is about diabetes and cancer. and you all run a number of programs that hope to for the future address the concerns of the chronically ill. when can we expect to see some of those results? i know that you have programs that you would like to see look at a variety of different conditions. and the challenge of course is

you have this horribly fragmented delivery system. and that is one of the things legislators on this committee are trying to change and trying to change in a bipartisan way. but tell me about the programs you all operate that target the chronically ill, which i think is going to be the future great challenge. >> with regard to the chronically ill and the things we do at the department it cuts across various parts of the entire department. there is the work in terms of as a payor in medicare and medicaid and working on innovation in that space. we're work on vegas with the states throw the state innovation model grants where we are granting money to a number of different states to try innovations in terms of some of those things in the medicare swas we see the work that we're doing in the innovation center to try. with regard to when we'll know, as you all know because the legislature gave us conditions that said you could not decrease quality or increase price. so we're measuring those as we go forward. i would also mention that noo these areas of the chronic there

is also the work that the cdc is doing and some of this is about prevention. and as we think for some of these conditions such as diabetes, heart disease and some of those it is about prevention and cdc place a strong role with that. >> let me ask about the precision medicine initiative and what we're looking at for the future. i think this is too is a key part of the future of american's healthcare. i think for families to have a confidence that when a loved one gets sick their treatments can be targeted and precise based on their genetic makeup. this is pretty important. about as important as it gets if ar family. but if we're going to tap the potential of precision medicine, the big payors and your department runs several of those programs medicare and medicaid and private ensurers are going to need to pay for it. and i know you are just getting started in this area but what

progress are we making in terms of i setting up payment systems. that is what this comedy tomittee tried to to in the affordable care act and make sure you can get paid for tests and administration and these services that help patients. >> the question of payment also gets to the announcement i made last week. which for the first time we are as a government are committing that we set a goal for ourselves to change the way we are paying in medicare. we set the goal we'll have alternative payments paymented waysed on the value instead of volume. we set the goal for 2016 that 30% of those payments and by 2018, 50% of those payments. as part of moving forward to alternative approaches to payments i think that is where wrer going to try in bring in some of the innovation. and other thing is as we consider costs in this space shah this type and approach to medicine hopefully can for the individual because you can treat it in ways that may not be as costly as you were talking about

in your earlier question. >> thank you mr. chairman. >> thank you senator. senator grassley. >> thank you secretary for appearing. more importantly i appreciate very much the frequent phone calls to call me and give me updates. i only have one subject. one question at the end. but i've got a lead-in so be patient. i'm concerned about the recent failure of the co-op opportunity. co-op por tunety was one of the acts formed under that law and government loaned money to them. as i understand cms played a significant role in overseeing the co-ops including having ultimate authority over setting the rules. it was very successful in attracting beneficiaries with the second most covered lives of all the 23 co-ops. it was even more successful than they had anticipated.

in the summer it became obvious co-opportunity would need additional loans from cms to stay in business. both the iowa insurance commission and co-opportunity frequently inquired with cms about their capital position and need nor certainty ahead of open enrollment as it was clear that liquidity crisis was developing. cms knew co-opportunity was going to be in trouble if it didn't get loans. co-opportunity was allowed to be in the iowa and nebraska marketplace when it opened on november 15th. cms finally let co-opportunity know that no further loans would be coming right before christmas. and the iowa insurance commissioner was forced to take over co-opportunity december 24th. i'm concerned about cms's role

as a regulator of the co-opportunity and then of all co-ops. there are about $2 billion of taxpayer money loaned that depends on the success of the co-ops for the federal government to get t is money back. but cms did not distinguish itself in its actions with co-opportunity. i'll have more questions for you for the record regarding cms action. but my question for you today is on behalf of shain and betty bush melford -- just as example of people who have real problems. they paid premiums and renewed their coverage with co-opportunity as they expected it to be there for them on 2014. shain bush had emergency surgery january 3rd. fortunately he's recovering but the care was not inexpensive. the bushes have already hit their out of pocket maximums for

co-opportunity. with co-opportunity being liquidated, the bushes will have to find new coverage and that next insurer will not have to recognize the money already spent by the bush's 2015. with additional expenses certain this year they will be out of thousands of dollars they have already spent in 2015. madam secretary, the bushes can't afford to pay out of pocket premiums for two different plans. they are in this situation as i see it because cms ignored the warnings from iowa and co-opportunity allowing co-opportunity to go back on the marketplace and now the folks in iowa and nebraska like the bushes face financial consequences because of cms's foot dragging. i intend to ask you further about what cms was doing and why. but what i want to ask you today is what responsibility you think your department at cms have to the people like bush's.

and i think they had about a 00 thousand people they were doing business with. >> with regard to the issue of the consumer that is our number one priority. as we work with the state insurance department in iowa as we work through. so the consumer is the number one priority in thinking through what authorities we have and what we can to do to help all of the consumers like the family you just described. as we work through this and as you know the director has been in touch and we look forward to responding to any questions you have sent us in letter and any others you addth we're foxxs on ss focused on the consumer and one thing that's happened through the co-op process is there was many many rescissions in the terms of the amount of one we had to do additional support. so at the point in time came down to a very limited amount. rescissions and sequestrations. and we are concerned right now.

our focus is deeply on the consumer. we look forward to working with the state of iowa that has the main authority over this to figure ways we can help those consumers. >> thank you madam effect issecretary. >> thank you very much for your hard work of you and your staff. and i'm complicated criticality important set of issues. i think we need to first underscore the good news. the latest cbo projections report that many more people are finding full time work. work where you can work one job and be able to care for your family. getting access to affordable healthcare. and we know fewer americans are going into bankruptcy because of the medical crises. that is important. tax credits helping people afford coverage. people who have insurance are able to get new opportunities to get preventive care and vaccinations, wellness visits. and frankly folks who have been

paying into healthcare for a long time are finally guaranteed they are getting what they pay for and they can't get dropped and they can also find insurance coverage for preexisting coverage and so on so on. all good news. i can say as someone around the importance of the healthcare in michigan around the debate around the affordability of the healthcare and being involved and one of the chief supporters of what i call the affordability tax credits, in fact at the time the chairman introduced me as senator affordability which i would carry as a badge of honor. but i would say that just for the record that the affordability tax credits are working as we drafted them as we intended them for all americans. not just some americans. and if in fact they went away or the entire bill, the law, was

repealed. like we've now seen a bill introduced here in the senate that has been brought immediately to the floor with i believe -- ico-sponsors so far, this would be serious for families in terms of no longer having access to the protections of affordable health care and access to health care. what i would like to ask you about, though is one piece of that that unfortunately went from being a part of the comprehensive plan to being optional state by state, which has undermined seniors and families to be able to get affordable health care. and that's medicaid. when we put all of this together we assumed, and we know that 80% of the money in medicaid is low-income seniors in nursing homes. so we're talking about seniors in nursing homes. we assume seniors in low-income nursing homes and their families would be able to get the help under medicaid that they need,

as well as families. in michigan more than 500,000 people have enrolled in the healthy michigan plan. i con glircht nor and others who put that together. and we've still got time to go on this. so when i look around this panel, we have 11 states represented in the finance committee that still have not provided access for low-income seniors to nursing home care, or to families and children, due to the expansion of medicaid. and i wonder if you might speak to what is happening to families, and the costs even to states and certainly our hospitals. i know in michigan, folks were talking about the number of people who come into the emergency room getting the care the most expensive way possible, rather than getting it through a doctor, and so on in a way that is better for them and contains costs. could you talk about what is happening because states are not

giving access to families and seniors to health care through medicaid? >> i think the impacts of medicaid expansion have to do both with the individual as well as economic impacts. and in terms of the individual impact, in terms of the health and financial security, yesterday when we had folks at the white house that had written the president, you know, there was a woman who actually went on to the marketplace to -- because she thought she would pay a fee. she went onto the marketplace, found out actually she was not in the marketplace but was medicaid eligible and went in. never had a history of breast cancer in her family. ended up actually having a mammogram, because it is part of what is covered. found out that she had breast cancer. so that's for the individual. for the individual in terms of that financial security of the ability to pay for and have health care. so that's for the individual. economically, what we see is in the states that have expanded

medicaid there are fewer rural hospital closings. an issue that is affecting a number of states across the country. and that has to do with the reduction in indigent care costs. and that is what we do see in those states. and we see anecdotal evidence in terms of examples of what's happening in communities where more of the care is being paid for. and so that is in terms of from the beginning, it's the individual, in terms of financial and health security and then with regard to the states themselves they're seeing those benefits. >> the major rural health issue. >> it is a rural health issue, but it's also happening in urban hospitals. because generally in some urban areas, there is one hospital. not always but there is the hospital that tends to take care of that indigent care. so the economics of that entity can be dramatically affected. those are the direct impacts. the indirect impacts are for everyone else in terms of premiums. when there's less indigent care

there's less pressure on premiums who are even in an employer-based system. >> senator schuman? >> thank you. thank you, mr. chairman. thanks for holding the hearing. and i want to thank you madam secretary, for the great job you do. you're a star. you're a star. first, just aca, despite all the nay saying has some huge successes, health care spending growth has decreased significantly. that's huge in terms of not just health care itself but our budget. $600 billion less through 2020. uninsured level, lowest in decades. 9.5 million insured in my state of new york. we have, you know, really done a good job. i salute our state. our health exchange the new york state of health has signed up 2 million people for low-cost health coverage. 80% of those enrolled said they were previously uninsured. so it's great.

now i have -- and i appreciate the emphasis you've put on research early learning and your support for c.h.i.p. i'm now sitting in the seat where senator rockefeller sat for a long time and i'm mindful of c.h.i.p. all the time. i have two questions for you. the first one is on gme, a place where i oppose the administration strongly and vehemently, and i can't understand your logic here. the president's budget said medicare payments to teaching hospitals for indirect costs of medical education exceeded the actual patient care costs. and they want to correct this imbalance by reducing the ime payments by 10%. that's an enormous cut $16.3 billion. now, your budget proposal recognized we had a physician shortage. and we do. if we're going to insure more people, we need physicians. it's one of the places aca really didn't do the job in terms of filling the gap of new physicians that we need. and it's sort of adding insult

to injury, to now cut the payments to teaching hospitals. they're just not requesting to teach as many medical students, and make them become doctors if you're going to cut this. i believe the current funding levels are critically important to maintaining a state of the art environment, not only training doctors, but training the best doctors. we don't need a majority of our doctors to have been trained overseas. but that would, you know, that would be a direction in which they're headed. and so it seems to me counterproductive to attempt to train more physicians by cutting teaching hospitals that train them. how do you reconcile that? >> with regard to the issue of making sure we have enough care in the country, and the specific gme area, what we're trying to do is make sure that we balance the needs and our proposal also targets funding. and additional funding for those

that go into primary care and specialties where we have shortages. and so the proposal that we're trying to craft and come forward with is a proposal that affords us the opportunity to have fiscal responsibility, and we keep the slots, but the question of the payment of the slots in direct versus indirect costs, and add additional funds that would help do targeted efforts. with regard to the broader issue, in terms of some of the things we do do the national health service corps is a place where there are large investments in the budget to try and make sure that we're supplementing primary care. we're also proposed the extension of the medicaid primary care funding. so we're trying to make sure that we are working on -- >> well, i think you're robbing peter to pay paul. i certainly believe in the programs you've mentioned. they've been around for a while. they haven't done -- filled our need. what we've proposed a bunch of us, and it's bipartisan support, is we increase the number of

slots, and we allocate half of that increase to primary care. and it seems to me a much better and tested way to go than say, well, we're relying on these new programs, which have never filled the gap. having said that i just want you to know i'm vehemently opposed to that proposal. and i hope the administration would reconsider it. if you haven't understood my language until now. on ebola, i want to thank you. the cdc has done a great job. we knock government all the time. and if you read the media the first few weeks you would think everyone was going to get ebola. the cases here in america has been thankfully few. the number of cases in the three hot spot countries has declined. that just didn't happen by magic. it happened by great work at the federal, state and local levels. in new york our hospitals did an amazing job. 47% of the people who flew in to this country from the three ebola countries landed at

kennedy airport, and our city state and federal governments all got together and made sure that we didn't have the situation that we had initially in dallas. so i thank you for that. and for the good job you do. but can you just tell us i know we've put some money in and i worked very hard to have a provision with the help of many of my colleagues that are hospitals around the country get reimbursed for the huge outlays they've had to make. many of them had to create anti-contamination rooms. they had to buy equipment. can you provide us with how you plan to ensure that the ebola treatment centers, i care especially about the ones in new york, receive appropriate reimbursement? >> we are working to have those funds reimbursed, because those will be directly with -- we're working with a contractor that will help us do that reimbursement on hospital-by-hospital basis. in addition, states and communities will receive other parts of funding that are part of the preventive work that they

did. so there are special funds for the treatment hospitals like bellview, which did a tremendous job in new york and the others that did treat patients around the country. we look forward to continuing to work and we're very appreciative of the funds and want to move them as quickly as possible as we can to the treatment hospitals and help those hospitals that got ready and prepared. >> thank you. thank you, mr. chairman. >> thank you. senator roberts? >> well, thank you mr. chairman. and madam secretary. let me echo the sentiments of many members to thank you for the job that you're doing. during your confirmation hearing, we talked a lot about the affordable health care act's independent payment advisory board, the acronym is ipab. you said and i'll paraphrase here that you were hopeful ipab can never be used. it can only be triggered in the

window, and it will never be activated. you're hopeful that ipab never gets triggered, and we all agree. but here we are again with a budget request where you're acting to expand this authority to find savings. how can you explain how you went from hoping it never had to be used to now doubling down on ipab and expanding the savings it must find. >> with regard to the -- what we are trying to do is get to the core of what ipab was about. which is making sure that we can work together to continue to keep the costs in medicare, and in the entitlement space. and we're working to do that with our proposals. we've seen just in the period from 2010, our medicare spending is $116 billion below what it was predicted to be. and on a go-forward basis, that's why we have the proposeals in our budget to keep moving it out. the proposals in our budget extends the trust by five years. our objective is to actually put

specific policies that will continue to move out that time frame. we're hopeful we can work with the congress to get those policies enacted, to continue the entitlement savings. we have some from the last years in terms of what we're seeing. but we want to continue on a path to tight and contained growth with regard to that spending. >> well, i think everybody wants to contain the growth. but i don't want rationing. and i'm very worried about the independent advisory board the cms innovation center the preventive services task force and the patient centered outcomes research institute. all well intended. i've labeled them before regulatory apocalypse because of all the rationing. you're depending a lot on something called recovery audit contractor. i must tell you when the contractors ride into town in western kansas, the doors shut,

and they hope that no rac person comes to the door. i appreciate that you have included a number of proposals in the budget to help address the appeals process. because you go into the hospital. you have a choice, either pay the fine and contractors get gold stars, if you have fines, and then you save that savings with regard to medicare. it is also rationed. so here's the point. cms presented a settlement offer, and over 2,000 hospitals entered the process. chief administrative law judge griswold noted that as of july last year there were 800,000 pending appeals. my question to you, if all of these hospitals would complete the settlement process how many claims would potentially be cleared from the backlog? are we even making a dent? >> so the issue is one that i

think many of you on the committee know is one i'm deeply concerned about, and which is why we've reached out and talked about this issue certainly before today. with regard to how many will come through settlement, they all won't be cleared out that way. the strategic approach we're taking is three-fold to address what i agree is an extremely important issue. and it's an issue about balancing those who are not -- it's about program integrity because there are people who are not doing things that we -- >> i understand that. >> at the same time, the concerns that you've articulated in terms of how it feels and how the process is used. three strategies we're using first is to use the tools that you articulated. there is funding needed so we can clear out the backlog. and judge griswold and others can process those. it is a specialized person that we need to do that. and then the third is, there are legislative proposals that we believe will extend our ability to both get rid of the backlog and prevent it in the future. and we've had conversations

especially with this committee, and we appreciate those conversations, because we've included the seven proposals in our budget so we could be specific to work with you all on how we can do that. because to be honest it's going to take all three for us to get rid of that backlog. >> i appreciate your response. i'm not sure that i'm following you on all the details in terms of the specifics, and would like to do that, and i know you're extremely busy. but we'll make that inquiry. i just have to tell you, that when you have rac contractors racing around to the rural health care delivery system they're not very welcome. and it seems to me they don't trust the hospital administrator, or the doctors, or the whole delivery system. and in return, these folks don't have any trust in government. and that's not a good thing. so let's work together and see if we can't get a better situation. >> i would like to do that and follow up with you on this issue. >> thank you, senator. senator cornyn?

>> good morning, madam secretary. on december the 17th, a number of senators sent a letter to you and to secretary liu about the king versus burwell case. i would like to follow up on senator hatch's questions, because you didn't answer a single one of them about contingency plans, and notices to people who might lose their taxpayer subsidies for their health care. and let me just start by asking has hhs taken steps to inform all current federal exchange enrollees about the king suit, and how a ruling against the administration might affect them? >> we have not senator. we believe that we are implementing the law as it is intended to be implemented. and as we do that that is what we're talking about with the consumers entering into it. >> if the administration loses,

have you taken steps to advise federal enrollees about the consequences that may apply to them as a result of the administration losing that lawsuit? >> right now, as i mentioned with the chairman, what we're focused on is what we believe is our responsibility to implement the law as fully as we can to focus on the consumer experience, to do that and we're working for that february 15th deadline. >> that's not an answer to my question madam secretary. you're a highly intelligent, charming person, but you refuse to answer our questions. and that to me doesn't strike me as trying to work with congress, but rather contemptuous of congress' oversight responsibilities. so let me just ask you, if the administration loses the king versus burwell case do you plan to ask congress for additional legislation? >> with regard to that question we are not at a stage where even oral arguments have not been made, senator, in terms of the case. >> that's not my question.

my question is if you lose, are you going to come to congress and ask for additional legislation? >> with regard to the issue of legislation, and the affordable care act in its entirety, what we have always said and what we continue to say is with regard to things that will improve the act, we're open. whether that's the recent vote for veterans, and i know that members of this committee actually have bills that have to do with our firefighters. and that would make into law what we have done through administrative actions. we will work with congress. does it increase access -- >> madam secretary, you're not answering my question. my question is if the administration loses the king versus burwell case do you intend to come to congress and ask for additional legislation to address that decision by the supreme court? >> senator, we believe the position we hold is the correct position. >> my question is, if you lose, if the supreme court disagrees with you will you come to congress and ask for additional

legislation? >> senator, what we know right now is it would be devastating the effect in terms of loss of premium, loss of individuals. what we're focused on right now though, is implementing the law that we have before us. that's our focus for now. >> so you're going to ignore the supreme court decision in july? so let me ask you this, since you won't answer my question about a legislative solution do you believe that your agency has authority to make an administrative fix to the law? >> senator, as i have said what i have focused on is right now the current implementation of the law. that is a question in terms of -- >> what i'm focusing on is, if the administration loses, and so far you've refused to answer my question, and notwithstanding your earlier statements that you want to cooperate with congress and this committee, and you respect our constitutional oversight responsibilities, what i don't understand is why you continue to refuse to answer the question? so let me ask it again.

if the administration loses in the king versus burwell case, do you believe you already have the authority to make an administrative fix or will you come to congress and ask for additional legislation? >> senator, i am focused right now on implementation. with regard to those questions, we believe that we are going as implementing the law and that the law will stand. >> i'm asking if you're wrong. if the supreme court disagrees with you, and that's -- if five members of the supreme court disagree with you do you believe you have authority to issue an administrative fix, or do you think you need additional legislation? >> with regard to the answer to that, senator, what i'm saying is what i have been focusing on is implementation not on that question. >> mr. chairman secretary burwell's a charming person, and she's obviously intelligent. but these hearings are absolutely no use to us if the witnesses refuse to answer

straightforward questions, which this witness has repeatedly done. i'm not sure exactly what the proper solution is mr. chairman, but i would like to visit with you about that. because it seems to me that this administration continues to parade witnesses in front of committees like this one, and to deny us a straightforward answer to straightforward questions. and that's just unacceptable. >> well senator wyden would like to comment on this whole matter. >> mr. chairman, i just want to make clear what i think today is all about. today is about the hhs budget. this multibillion dollar budget that involves millions of americans. that is the topic at hand. and i'm very interested in working with my colleagues on the other side of the aisle on health policy. i've shown that plenty of times, and so have my fellow democrats. but i think the idea this morning that we are going to ask

a witness to speculate about a court case, to speck slate about something hypothetical, and in effect have a big debate about something, i think misses the point of the challenge at hand. the challenge at hand is about the budget. and i hope that we can figure out a way over the course of the morning, we have plenty of colleagues who still want to ask questions, to talk about the topic that was scheduled. and that's the budget. and not talk about hypotheticals, about something else. by the way this is not the department of justice's budget. this is the department of health and human services. and i hope we can stay on the budget and not get into some recitation about a parade of hypotheticals and speculation. >> mr. chairman, if i can just respond to the ranking member. it's the same question you've asked, mr. chairman. and we're not limited as senators to what the topic of the budget is.

we can ask questions -- any questions we want about the agency that this witness is responsible for administering. and to come here and repeatedly refuse to answer the questions is -- strikes me as nothing less than contempt of our oversight responsibility. and it's a very very serious matter. and i'm just really, frankly shocked that this witness would take that position. and i just find it unacceptable. >> mr. chairman, just to continue this briefly. to say that this witness is handling this committee with contempt misses what members on both sides of the aisle have been talking about for weeks. this official at hhs has reached out to this committee, the people of this country, in an unprecedented way. and i think arguing that because she won't talk about hypotheticals, speculate about a court case means that she is handling this congress in contempt, i just think is way

off-base. >> well, both senators are entiled to their opinion. let me just ask this question. have you made any recommendations for the premier department that handles all these matters that are so important to the administration as to how they will handle it if, as senator cornyn has raised, the case goes against the administration, or against the affordable care act is the issue? >> senator, with regard to where i am now on the issues that i'm focusing on, whether it's ebola, or -- >> no wait, wait wait. >> i'm focused right now -- >> we got that point. wait a minute. these are not stupid people up here. and you're not stupid either. why don't you just say that's up to the president and the justice department. and that would get you off the hook it seems to me. it doesn't solve the problem. because you should be recommending what should be done. because that's a serious problem. >> with regard to as you are clearly articulating, the justice department is the next step.

>> why don't you say that. >> what the administration is doing. the justice department will represent us. >> i get tired of bailing out you democrats all the time. that's supposed to be humorous, i thought i was being quite funny. but i had a sudden sense of humor that sometimes doesn't come across. >> mr. chairman, to wrap this up, i don't think the secretary needs any bailing out. we have something called a judiciary committee, where they can have discussion about speculative matters involving the supreme court. i just hope we can handle the budget today. >> let me just say, i think senator cornyn is certainly within his rights. i think his comments are accurate comments. miss burwell, if she continues to answer she's not focus on this, i understand that. then tell us who is focused on it. because it's an important thing that could just throw you into all kinds of turmoil. and we're concerned about it. and it's a legitimate concern of this committee.

to make a long story short, i think senator cornyn raised a very, very important issue as have i. we'll now go to -- who's next here? let's go to senator coates. >> well, after that, yeah. first of all i want to second what our members have said madam secretary, that your engagement in accessibility has set a new standard. and i think we all appreciate that. i don't know when you sleep but i know how active you have been and will continue to be. secondly, though i want to second what the chairman and senator cornyn and others have said, not to ask you the question again, because i think i know what you're going to say, but to say that we all know that this health care proposal enacted in 2010 has been one of the most impactful pieces of

legislation ever enacted by this congress. by any congress. and it affects tens of millions of americans directly, in terms of their health care. which is -- goes, you know, right to the essence of who we are as human beings. and clearly there is a collision potentially coming with the supreme court decision. it's probably not likely given the president's very clear admonitions about how he won't accept any piece of legislation that modifies this in any significant way through repeal, and the replacement. but there's a potential collision coming, and it would be irresponsible for the administration not to have a plan to address that should the decision not come down the way you would like. i don't have a question here. it was just a statement affirming that it would cause

great chaos. and be totally i think, irresponsible. somebody ought to be looking at, what do we do "if," and that's what the question here is. i want to thank you personally for your engagement with our current governor. governor pence who i was with this morning, wanted me to pass on his thanks also to you. almost two years of engagement over a request for a waiver for the state of indiana. our former governor, governor daniels, put into place something called the healthy indiana plan. it was innovative, it was creative, it has been proven to provide health care for a number of hoosiers. and governor pence wanted to expand that. and there are 350,000 hoosiers that will benefit, at minimum, benefit from your agreement to work with us, and come to a conclusion. there's some really innovative reforms here on traditional medicare. and i think some of them are the first ever.

and so i think it's important for our state to be responsible in playing this out the best we can, to prove that these innovative solutions can be a benefit to all medicare -- excuse me, medicaid recipients. and in that regard, i would just like to have your assessment of some of the first of a kind proposals that you have agreed to, that hopefully will prove their worth, and can be duplicated perhaps in other states, or throughout the system. the co-pays, the patient participation, the patient option to choose a plan that better meets their family needs, the contribution to the so-called power plan the modification of health savings accounts and the state's referral process to every individual who applies for job training and job searching, through state sources.

it's all combined in this new plan. and we're pretty excited about it. but i'd like to get your thoughts on it here. i think for the benefit of the members of the committee, and for others who are looking at ways to provide better access, better health care at lower cost. >> i'm pleased that we're able to come to agreement and worked with the governor, and was happy to do that. one of the first things i did when i became secretary is met with the national governors association, and expressed my willingness to work on a state-by-state basis. to use the waiver process to do two things. one is to do agreements that would be on a state-by-state basis, what a state needs in terms of continuation and moving on building the healthy indiana. other states utah tennessee there are other approaches that are important to those states. the second thing is that i think what you're reflecting is waivers are a means by which we can try, and we can test things to find out if they are things that work, and then move to how

we would scale them as a nation if they do work. we're looking forward to working with the governor as he moves to implement and try to make sure he can implement quickly, as soon as we reached agreement. and we look forward to finding out, what are the kinds of things that we can do better in medicaid as a program. and that effort in the waivers is accompanied and complemented by something that the national governors association asked us to do, which are state innovation model grants. and so at the time that we're trying things, we're also doing innovation in terms of payment models. and helping the states through financing the states to do that. and a number of states have received those. there's a first round and a second round. >> i know our governor and our states and those who participated in this including the health care providers and their participation, and contributions to the program we have a lot at stake here. we hope to be able to deliver to you innovative, successful solutions. thank you. >> thank you senator.

senator carden? >> thank you, mr. chairman. thank you, secretary, for your leadership and service to our country in this very important role under challenging circumstances. i want to talk first about an issue that i'm working with with senator blunt, regarding community mental health services. there is a challenge for people who are suffering from severe depression, or anxiety disorder getting the type of help they need in a community setting. they go to their primary care physician, as many of them do, there's lack of capacity in that office to deal with their needs. if they go to an emergency room, that's a very inefficient way, and most likely inadequate to take care of their needs. there have been some demonstration programs dealing with collaborative care model where the primary care person can get help from a mental health specialist. so that you use better community

services to keep people healthy in their community, less costly, better services. there are obstacles under way under medicare and medicaid for this collaborative care model. and i just would welcome your thoughts how we can work together to try to expand these opportunities, removing those obstacles, and offering incentives for collaborative care model that will provide better services at less costs for people with mental illness. >> the issue of behavioral health and payment for behavioral health is one of the tools that we think we have and that payment occurs that is equitable for other type of care. it's something we're certainly working on and would welcome an opportunity to have a conversation with you having had conversations with senator stabino and senator blunt. as you know and mentioned, we're also focused on how we can do more community-based care. and that actually touches also upon the delivery system reform which we had a little bit of a

conversation about earlier, so that we are creating home health systems. and that there is communication between physicians. because that is sometimes one of the missing links in behavioral health. >> we would be interested as to what you could do under your authority. but if you need congressional help particularly let us know what obstacles need to be addressed by congress, and how we can expedite the implementation of better collaborative care models in our community. i'd appreciate that. as you know, i have a particular interest in ih funding. i was pleased to see that the president's budget did increase that funding by by $1 billion. i would like to see a larger number. the returns are incredible from what we invest, and i think this is a bipartisan interest. one of the centers, the institute for minority health and health disparities, is one that i take pride in that congress created under the affordable care act. they receive a slight increase

from $269 million to $281 million. can you just share with us your commitment to the nih funding but specifically, how you see the office for health disparities functioning under your leadership? >> the issue of minority health disparities and it cuts across the entire department. the nih has an important part of that approach. with regard to minority health disparities, they are great in our country. there are a number of ways we believe we should do that. working through nih with regard to how we think about research and the research on the science that is creating these disparities is how i think about that particular piece, as well as nih's role to make sure we have minorities that are part of the system, both in terms of physicians that are practicing in a clinical setting, but actually their part is more about researchers. and researchers who are part of the process that come from these communities. at the same time we're focused

deeply on probably the most important thing we can do to reduce these disparities is the disparity coverage. that is something i think you know that we focus on as well. >> absolutely. if you could keep me informed on the progress, not only at the national institute, but also at the different offices for minority health i would appreciate that. lastly, let me just put on your radar screen pediatric dental coverage. we've been watching its implementation. frankly, it's been more seamless than what we originally were concerned about. there's more universal policies that are being offered for pediatric than stand-alone. as you know, in maryland with the loss of the monty driver in 2007, i would urge you to monitor how the private market is working on offering coverage for pediatric dental since it's a required coverage. we want to make sure that in fact it is being taken advantage of by those that have gotten

coverage through the exchanges. >> thank you. and we will. i've had the opportunity actually, as i'm out traveling the country, to meet with a woman who took her child to the dentist for the first time. as part of coverage. >> thank you. thank you, mr. chairman. >> thank you senator. >> thank you mr. chairman. and secretary burwell, thank you so much. i read a bloomberg article that i'd like to enter into the record. but the headline was, you asked to overhaul medicare payments to hospitals and doctors. that was music to my ears. and then the first paragraph or so said the obama administration makes historic changes to how the u.s. pays its health care bills, aiming to curtail the costly habit of paying hospitals and doctors without regard to quality or effectiveness. and then it goes on to say, quote, we'll tie billions of dollars in payments to how their patients fare, end quote.

actually, all that was a quote from that news article i want to enter. first of all, that's music to our ears in the pacific northwest, and any state that is already making its way down the system of more efficient care that's focused on the patient. the fact that the administration is setting this goal of 30% of traditional medicare payments to alternative payment models by 2016 is just a terrific goal. and 50% by 2018. as you know we worked very closely on the medicare modifier as a way to make sure that we are focusing on quality, not on quantity. so my question is in the details of that 30% one of the things that we've had discussions here is what does the incentive look like. and i want to make sure that we aren't setting a big goal of having 30% shipped over to that but having the incentives be so

small, that we're not really changing behavior. so what kind of -- you know, people have talked about things, like 4%, or bonus or penalty caps. we want to see good behavior being rewarded and bad behavior being discouraged. so what can you tell me about within the 30% how aggressive can we be? >> so, i think there are a number of different things that can help us get there. some of those are about incentives. and some are about approaches, bundled payments as a type of approach in terms of how we go about doing it. and there are things like the value-based approach where you are rewarding good behavior, and for those who don't have that behavior, that they will take a hit for doing that. i think that those -- there are tools like that that are being used. we are seeing that the private sector and the providers are moving towards this care because it is better quality care, and more affordable for them. putting in place incentives. we've received help and support

and there's been legislation, about helping us as we're doing accountable care organizations. there are places we may need additional flexibilityies as we learn about what people are reacting to in regard to incentives. the other thing i would say is the pressures in the private sector right now they're also helping us because private sector payers are moving in this direction. and whether it's boeing that is partially in seattle, and how they are negotiating their payments, those examples are making a difference, too. >> you think the incentives could be more than just a few percent? >> i think the question of exactly what numbers depends on which ensentives you're using and how. the details matter for a number of the institutions. and so i think it's -- >> what i'm saying is, if by 2016 you can say that 30% of traditional medicare payments are at an alternative model, but they're only shifting 1% or