a trip there monday. thank you and i yield. >> secretary burwell, you know i, i'm sure you can sense that i'm very proud of the affordable care act and concerned about republican efforts to repeal it or now take it to court in the case of king versus burwell. are you aware of any republican bill that would reduce the number of uninsured in this country by 11 million people, or i said 11. it's actually 19 million people, the way that the affordable care act does? i mean, obviously i'm saying this because i don't see them coming up with any alternative. >> you know, we haven't, and i think it's important to reflect historically. when one looks at the history and have gone back to teddy roosevelt and the quotations from teddy roosevelt forward from both democratic and republican administrations we see, whether it was president

bush nixon, president, republican and democrat, president clinton the conversation about how we make this next step forward with regard to reducing uninsured is something that we struggled with as a nation. and this is the first time, and someone reflected on the anniversary of medicare, and that 50 year anniversary. this is the first time that we have seen that. so the land that we have in place, the implementation of the affordable care act has done that, but we have not seen any alternative. >> let me talk about chip. i want to emphasize again that we have to act on this legislation immediately when we consider sgr which expires at the end of march. while funding may not expire until the end of september for chip more than half by june 1. so it's clear the congress needs to act swiftly to ensure states can budget appropriately for

chip and avoid any disrussian in childrens' coverage. i see no reason why congress can't act very soon. can you comment on the impact on states if the chip funding isn't extended soon? >> one is former director of omb. and the issues of predictability of funding and issues of management and ability to manage. so for the states to be able to do that, this is something that's important when we've had predictability in our own. we've seen the benefits of that economically throughout the past two years. having just spent a lot of time with the governors this weekend when they were in town this is a very important issue to them. we have seen that letter that 40 governors have signed with regard to knowing that they have that predictability of a program that is providing great benefits to the children in their states. >> now the senate and house republicans have released a chip proposal this week. however, this proposal would institute a 12-month waiting

period needlessly forces them off, and reduces for those under the poverty level. can you discuss the impact of policies like this on some of our most vulnerable children? >> we think that the chip program is a program that's bipartisan program and a program that is working in delivering results in terms of that quality health care for those children and has worked. we believe that is in our budget, a four-year extension of the program is a very important thick and thing and we need to do that in a timely fashion to make sure those children are covered and receive the care they need but also to have that predictability for those states in their legislative process right now. >> and i know you mentioned the four-year extension. the budget includes a four-year extension of the chip program. can you talk about why that four-year extension is so critical for the kids that

depend on this health coverage, and mab also mention as part of the extension the budget includes express lien eligibility. if you'd talk about that as an option for states. >> folks asked us to try and figure out to simplify, to make things easier, and that's making things easier in two ways. when we hear from folks it's about both the customer in terms as when they came in and the states. and we brief this is a program that's been successful in getting to that simplicity. and the simplicity can often work to create a lower quality or b, lower cost. we think that's important. we believe that is a good amount of time, and the right amount of time for us to do this extension. there will be interaction with the affordable care act. and we believe the four year period is the accurate period for us to understand and look for that. >> i'd like to submit for the record two chip articles, one is

an op head by hillary clinton and bill frisk and the importance of the extension. and the second article was published in the "new york times" last month, showing how it pays for itself and how when children have health coverage, future earnings are boosted. >> without objection. chairman gentleman yield yields back back. >> thank you mr. chairman. thank you, madam secretary for being here. as i have talked to you before, there are lots of problems that we have to deal with you and your position and the committee in our position. but there are some opportunities for bipartisanship. and one of them is something we call the ace kids act.

the original co-sponsors are ms. castor of florida i think ms. eshoo of texas. myself on the republican side along with several other members of this committee on the majority side. you said in your opening statement that medicaid is going to be about $345 billion this year an increase, i believe of over $16 billion. there's one piece of legislation we could pass on a bipartisan basis that would save money in medicaid. and that's the ace kids act. it creates a home for families that have medically complex children based on an anchor hospital concept with the major childrens' hospitals in america. i think there are about 60 of them. so if a parent has a child that's medically complex and

qualifies for the program, that child gets access to the network on kind of a one-stop shop. all of specialties all the various procedures are provided medicaid is billed one time. we think there are about 12 million children that would qualify for the program. and we believe that it will save billions of dollars over a ten-year period. it's been introduced in the senate. the identical bill with three republican co-sponsors three democrat co-sponsors. so here's a rare piece of legislation that both sides of the aisle support it. chairman pitts supports it. does your department have a position on the bill? and if so could you explain to the committee what the position is? >> i don't think we as an administration as an issue has

sat the but all the concepts we agree and welcome the opportunity. the idea that we can improve quality and cost for these children who are very complex and who are moving state to state, and the current system doesn't afford us the opportunity both with regard to making sure we don't have duplicative payments. we don't want that from a fiscal responsibility. and we want that ease that the parent can have the child at the right lace with the right care, even if it's across state lines. so i would say we look forward to working with you, welcome the opportunity, if there are questions and ways that we can provide technical assistance and other things as part of this we welcome that opportunity, because we agree request thewith the fundamental that we're trying to do here and believe this is something that could improve both cost and quality. >> i would encourage you and your department to look at the bill. it's not illegal or immoral for the administration to issue a letter of support. this is one that i think with

chairman upton and chairman pitts, and the ranking member and full committee and sub committee and leadership on both sides of the house. this could go. it could be part of chairman upton's 21st century effort. i want to concur with what ranking member green said about community health centers. i hope we can work together in a bipartisan fashion to find an answer to keep those funded. i know there's a funding issue this year that we need to address, and reauthorize the program. i have an um in of those health centers in my congressional district, and they are very helpful providing indigent care. and finally, i wasn't going to ask this question, but i'm a little bit puzzled. when chairman pitts asked you the question about this report that deals with planning in case the health exchanges at the state level under the affordable care act are found to not be

legal the way they're currently funded, if there was a plan and if you had seen the plan, i take you at your word that you haven't seen the plan. but don't you think it's prudent that there should be a plan? i mean i hope i don't have a primary opponent or general election opponent, but i have a plan in case i do. i know you hope that the court upholds your position but shouldn't the administration and your agency have a plan in case it fails? >> congressman what we state in the letter and what we believe is, if the court decides, which we don't believe they will. if the court decide option behalf of the plaintiffs. if the supreme court of the united states says that the subsidies are not available to the people of texas we don't have an administrative action that we could take. so the question of having a plan, we don't have an administrative action that we believe can undo the damage.

and that's why when i was answering the chairman, i think it's important to understand what the damage is because then it comes to the question of we don't brief we have any administrative plan. >> if the court strikes it down, the administration's just going to hold up your hands and say "we surrender"? >> what we believe is that the law stands how it should be implemented. if the supreme court speaks to this issue we do not believe that there is an administrative authority that we have in our power to underdo it. and so that's something we don't believe we have. >> that's puzzling, but i accept that. thank you, mr. chairman for your courtesy and the minority for letting me have extra time. >> and we now recognize the gentleman from new york mr. engle, five minutes for questions. >> thank you very much mr. chairman, and welcome secretary burwell. let me piggyback on back-up

plan. you know, i was part of this committee. i participated in months and months of deliberations for the affordable care act. we had weeks of markups, this committee did, and not once was there mention of subsidies not being available to individuals in states that did not set up their own exchanges. i've heard a lot of complaints on the other side of the aisle about the law but never was this issue discussed until they lost at the supreme court in 2012. some of my friends signed onto amicus briefs. yet they're upset that the administration doesn't have a back-up plan. and i think it's somewhat ironic that my republican friends are demanding that this administration fix problems that they themselves created and have shown zero interest in fixing. should republicans get what they want and the supreme court rules

in favor of king i would urge my colleagues, if that should happen, to pass legislation to ensure that americans have continued access to affordable coverage through the federally facilitated exchange just as democrats intended. next month, the affordable care act would have been the law of the land for five years. it's not perfect law and there are issues that need to be changed with it, but i would like to see those issues addressed and let us in a bipartisan way turn to improving the law instead of trying to kill it, repeal it, take it to court and things like that. so i just wanted to say that i'm sure that you agree with what i just said. >> we look forward to moving forward, and we do want to make improvements, as we can. >> thank you, and i want to use my home state of new york as a great example of what's possible when the federal government has a willing and enthusiastic partner in the affordable health

care implementation. as a result of our successful exchange and medicaid expansion, more than 2.1 million new yorkers have quality coverage. there is clear evidence we are reaching the right people too. since 88% of people who obtain coverage through the exchange reported being uninsured at the time they enrolled. so it's really working in new york. and the health insurance options available through new york state of health are an average 50% cheaper than the comparable coverage available before the exchange was established. so i want you to know i'm sure you know it, that the aca is working and working well in new york. and that's why i really think it's terrible that i have been forced to take more than 50 votes to repeal some or all of this law. we should fix what's wrong. but in my state, it's really been a tremendous success. >> and fortunately i've had the

opportunity to travel the country and see the individuals. those are the numbers and the individuals, whether it's laura in florida, 26 years old, married to a truck driver, training to be an x ray tech. they have two children. she now has insurance with a premium of $41. or a woman who had ms in the state of texas. and for 17 years she had not had insurance. she treated her ms through the emergency room. she has four children and she works. when it would get bad enough that's what she would do. so the stories of people and what it means to their security the numbers are important, but it is the stories which really make this real. >> and secretary burwell, i know that we've seen robust exchange enrollment nationwide, even in states where republican governors refused to set up an exchange or expand their medicaid programs isn't this true? >> the numbers and i spoke to

this yesterday. 53% of the enrollees in the marketplace this year and the federal marketplace are newen rollments. and so i think that is indicating the demand for the product and the need for the product. >> thank you. i want to second mr. pallone's positive discussions about chip. i've always been a strong supporter. and as of july 2014 476,000 children were enrolled in this affordable coverage option for their care in new york. so i think that that is really really important. i was pleased, therefore to see what the budget proposal for fy 2016 included funding for chip for the next four years through fy 2019. so can you elaborate on why you believe increasing tobacco taxes is a viable means for funding this program while we sort out the transition issues associated with the affordable care act?

>> we believe one of the things in being fiscally responsible and how we are paying for things we believe this is a legitimate way to pay for things especially in the context of we are providing health care and something that will create a deterrent and help health care in the issue of a tobacco tax. as one analyzes across the department or cdc the impact that tobacco has on health care in our nation and the cost in our nation we think is a fair place to go to pay for this care for the children. >> i agree with you. and finely, ially, one in six physicians obtains training in my home state of new york. you require significant funding and time to develop the infrastructure and expertise necessary to ensure quality care is available.

so how do we ensure stability for these academic medical centers and the patients they serve if we put gme funding at risk? >> we believe and hope that our proposal does not do that and meets the objectives of making sure we are training appropriate physicians for both primary care and specialties where we don't have as many as we should at the same time, making sure we target it. there's 100 million for pediatrics. we want to make sure we do it in a fiscally responsible way. >> i recognize the vice chairman of the sub committee, mr. guthrie. >> i look forward to working on 21st century cures. but first, i'd like to direct your attention to the health share reduction program contained in the aca, specifically sections 1402. does any part of this budget that we're talking about today request any new authority,

including any transfer authority to pay insurers under the cost-share reduction program? >> with regard to the program, which is a program as you now is about making sure that the cost of the people coming into the sus tim is something they can afford and we believe we do have the authorities to do the cost sharing. >> is there any new authority requested in this budget? >> no new language. >> we do know it's up and running. we spent $3 billion already on the cost share program. the budget that's been submitted estimates $11.2 billion over 2015/2016. and cbo says 125 million. could you cite where the appropriations authority is? you do have the authority? >> we do believe we have. and this is under litigation in a court case that has been brought, with regard to that, that is an issue that i will let our colleagues at the justice

department speak to because of the place it is in litigation. >> i understand that. we're doing oversight here. i'm not an attorney, so. when you were at o and b, there was a request in the 2014 budget for direct appropriation, and that didn't happen for whatever reason, but we're spending. so whether we spend a penny or $175 billion over a ten-year program. we feel like this is oversight hearing, not a and so we feel like it's our responsibility to make sure our taxpayers that we have legitimate a good answers on where this is coming from. so we're just asking where the authority comes from. >> appreciate the question, and i'm sorry it is in litigation. i wish we weren't in a place where we are in litigation. but once something is entered into that place it does create a difficult place. because the litigation has been

brought, that is the place for that. >> is there, like a legal case or authority? or the justice department tell you you don't have to -- >> with regard to issues being litigated, these are generally matters we defer and let the justice department answer from. >> we've never been able to get an answer from the administration. no one's ever been able to point to us where that appropriation language comes from. and it was onbriefand you previously had requested an appropriation. you received 18 employer groups sent you a letter, urging that small groups be maintained at 50 employees. when they go 50 to 51 actual analysis said that it estimated that 2/3 of the members said they would receive an increase. and of 18%.

and i don't believe that the small employers 50 to 100 employers can receive an increase. and if you like your plan you can keep it, if the 51 have to go into the new plan, they'll have to meet the requirements of the health care law and other things that have caused people to lose their plans that they liked. would you support allowing states to keep their market at 50 or below? >> this is an issue that we are looking at and examining because we have a number of comments on it, and what i would say is i would welcome the opportunity to see the piece of work that you're talking about and referring to so that we can see and understand that. i think what we want to do is understand the facts around this kind of thing so i'd welcome the opportunity to see this study and this piece of work. >> my understanding it's been submitted, a letter from these 18 employers. i'll make sure that's forwarded. thank you, mr. chairman.

i yield back. >> ms. schakowsky for five minutes. >> thank you, mr. chairman and madam secretary for being here today. i wanted to sko you if you are aware of any republican legislative proposal that would keep insurance companies from denying coverage from people with pre-existing conditions like cancer or dropping someone from coverage because they got in an accident or got sick? >> i'm not aware of a piece of legislation that would take care of that issue. >> and are you aware of any republican legislative proposal that would provide access to preventive services like cancer screenings yearly wellness exams and do that at no additional out of pocket costs to consumers? >> i'm not aware of a piece of legislation that would do that in the fulsome way that the aca does. >> i wanted to talk a little bit about something that's a growing concern, and that's alzheimer's

disease and the cost that it is in our personal lives and also in funding, so scores of public agencies including many hhs agencies as well as numerous private and non-profit organizations are trying to address this challenge of preventing alzheimer's, serving those who have dementia today, finding a cure. shouldn't the federal government be coordinating a plan on alzheimer's? >> in terms of the issue of coordination, there is a body and advisory group that includes both people from the federal government as well as external folks to be a part of putting together our thoughts and strategies, and it formed the way we are doing investments. there are things across the government as well as external bodies. with regard to the work at the department, the work cuts across a number of arias. nih and research is generally what comes to mind for most people. but where the biggest dollars

are spent is actually in cms and make being sureing sure that we're thinking through. the other is the community living, where we look at caregivers and those going through the process of dementia and how they deal with it. as a department we work through all of those. there is this overall advisory group that we have internally and includes internal members. >> the population is aging rapidly, obviously and alzheimer's is taking a much bigger role on families, on health care systems and the people who have the disease, and the number will continue to grow as baby boomers age. so you had mentioned the research that's going on. so what is hhs, nih doing to find a cure? >> in this budget you see a 24% increase to funding for alzheimer's, which is much greater than the percentage

increase even within the other nih. so focussing deeply on doing that there's also the brain initiative. we are also making progress on something called t-ou. it's one of the pieces of research going on. if we can make progress there, the other piece of research is seeing if there are ways that we can slow the progression by understanding how the neurochannels move and what's happening in the disease. those are pieces of research we're starting. we believe with the funding that we are asking for that we can move that research and make it broader. >> it is a focus in the united kingdom and other countries. are we keeping up with the rest of the world in research activities and investments? >> we believe that we are with regard to that. and i have been in touch with my colleagues and the secondretary or the ministerin the u.k. and we

continue to have those conversationing. so we make sure that we are learning. that's a particular example where i have been in touch with mr. hunt and will continue to do that so that we make sure we're learning everything we can from our colleagues. and in places where we can work together see if we can leverage the efforts in our countries. that's the research, the regulation and the more social issues. >> who is on the alzheimer's advisory committee? i'm asking that because shouldn't there be a person with alzheimer's on the as part of the group? >> i want to get back to directly -- but it is my understanding that there is a person, that there is a slot and that there either is or will be a person. when i get back to you on that specifically. >> i want to thank you for the focus. and as the co-chair of the seniors task force of the democratic caucus i really want to work with you on that because this is a problem

affecting so many families and individuals. i yield back. >> now recognize the gentleman from kentucky, mr. whitwhitfield. >> i want to follow up on my colleague brett guthrie's question. we're concerned about this cost-reduction program, because, cost sharing program because it's 170-some billion drars over a number of years. and we understand that that's one of the issues involved in the lawsuit. but all we're asking you is since you are all disbursing the money, what is your opinion as to where the appropriation is designated that you're working from? >> this is an issue, as i said, i understand the question. we believe we have the authority. with regard to the specifics of that, because we are in litigation.

>> but you can't tell us where the money's coming from? >> with regard to having that conversation, that is what the -- >> were you instructed by d.o.j. not to answer that question? >> with regard to that specific issue, that is at the root of the litigation. >> were you instructed by d.o.j. not to answer the question? >> when there are issues of litigation like this this is our standard. >> yesterday we had jenny mccarthy and we were talking about 11 d. and she gave us her theory of why she thought she was right. we're not saying that we're right or you're right. we're simply asking what is your theory, what are you, where does the money come from in your view? >> that is something as i said, why don't i work to get back to you on where we feel comfortable with, with regard to where the litigation is, and i'd like to come back on that. >> i must say i have been impressed with your facility to use numbers. you're really tuned in to the

budget responding to mr. pitts responding to mr. green about the community health centers. i was at a rotary club meeting recently, and i was asked the question, they said congressman can you tell us what dollar amount has been incurred by the federal government as a result of state expansion of medicaid programs pursuant to the affordable care act? because we picked up the larger percentage of the normal cost. and i would ask you that question. i didn't know the answer, but could you tell me what is the total dollar amount incurred by the federal government by the expansion of the state medicaid programs as a result of the affordable care act? >> that, in terms of the federal dollars versus the state dollars? >> yeah. just the addition at dollar amount incurred by us. >> let me go back and look because the question of being able to disaggregate whether a person came in because of

expansion or were under the old rules, i want to make sure that we can understand -- >> but you don't have a dollar amount for that? >> i will check with the department. >> you would think that you definitely would know that. because we can all talk about the advantages and disadvantages of this program, but there is a big additional cost to the federal government and we're simply asking, i'm asking, what is that total dollar amount incurred. >> i think the question that i am not sure is how one breaks out the actual number from expansion. because when people come through -- >> well, let me ask you this question. at what year, the states were encouraged to expand medicaid, which is fine because the federal government's picking up more of that dollar amount. >> mm-hm. >> but at some point in the future, the federal government's not going to be picking up those additional costs. what year is that? >> what year that is is we never go below the federal government never goes below a 90% of the payment of the additional. so that is 2020.

>> until when? 2020. >> so 2016 is the year through which there's 100%. and in your own state -- >> do you have any projected cost over that period of time? >> we do have those incorporated in our budget. but one of the things in terms of these cost issues that i think are important in the state of kentucky -- >> well that's okay. listen you can't answer the kwerks but appreciate it anyway. i notice that you all maid $2.5 billion in loans in the co-ops, and kentucky has a good co-op program as well. we sent a letter last year, and we were concerned about the solvency of some of these co-ops. and the federal government, as i said has loaned $2.5 billion. we now see that in iowa and nebraska, those co-ops are in bankruptcy. have you all done any analysis to project, are there mother state -- other states that there's a chance that these co-ops could

go into bankruptcy? >> we are looking at the co-ops. the one thing that's important to note is the cuts. the amount of money for the co-ops to do the loans and the loans that states like iowa felt would have made a difference. at the end, because those moneys were cut, they were cut as part of sequestration. they were cut in '12 '11 and '13. >> so are you saying that the bankruptcy occurred because of sequestration? >> what i am saying is had we had more funding to provide to the co-ops, it could have made a difference. with regard to the fundamental of your question which is are we looking at the co-ops and there are two things we want to do understand whether they are stable, and the second is whether we can provide technical assistance. >> well, those questions that you couldn't answer or were not familiar with, i do hope that you'll get back with us with those answers. >> be happy to. >> within seven days, if

possible. >> i will want to make sure that -- we will get back as. >> because i've got to be back at that rotary club next week. >> as a neighboring state appreciate that. >> the gentleman yields back. the chair recognizes the gentle lady madam castor. >> on behalf of the 1.6 million floridians that are able to buy affordable health insurance in our exchange, i'll give you due credit and everyone in hhs, but i think the real credit goes to our terrific navigators that were on the ground. hospitals across the state of florida, community health centers and family members that probably put in a good word for their sons and daughters or aunts and uncles to sign up. you probably want to give them a pat on the back yourself this morning. i encourage you to do that. >> i do. i want to express appreciation. i've seen the local stakeholders and met with them across the

country, and it was the communities coming together. it was individual, people in the community health centers. as was mentioned, it was the business people, it was everyone, when i would visited hospitals would be there, everyone would be around the table working on this issue together. and it was that kind of work, and then the individuals that i visited on second sunday in texas, actually was given the opportunity to speak at one of the churches, and it was all of that coming together to give this information to people so that they could make choices and have that financial and health security. >> so in florida we have a very competitive marketplace as well. consumers can choose from 14 different places. that was up from last year where we had 11. and florida consumers could choose from an average of 42 health plans in their county for 2015 coverage. so with 1.6 million now enrolled it really demonstrates the high stakes involved with

the supreme court case that the court will hear next week. i cannot imagine that the court would rule to take that away from over a million and a half floridians and millions more all across the country, and just like representative engle said, i was here during the hearings in advance of the affordable care act adoption, during the mark-up, during the amendment process, during negotiations with the united states senate. never in those discussions was there any dichotomy between a state exchange and a federal exchange and the availability of tax credits. have you seen any evidence to the contrary in your review of the record and the case that's before the supreme court? >> with regard i would let the justice department who has reviewed everything, but the thing that i agree with is we don't think that that was, we just don't believe that that's

what the law says or what was intended by the law, either. >> yeah, and i can say straightforwardly as a member of this committee what the legislative intent was, and it was for those tax credits to be available to every american no matter if they're in the state marketplace or federal marketplace, but i would say if the court rules otherwise, they are going to create chaos, and they're going to strike right at the heart of the economic security of so many of my neighbors in florida and many americans. so i i know that they will study the legislative intent, and i hope they rule the right way and we don't have to address that chaotic situation. but i think with the affordable care act the real untold story is what has happened to people who have insurance. because i can cheer on the million and a half floridian who now have it most of my neighbors already have insurance, private insurance or medicare.

and i noticed some more good news that was announced this week per my neighbors that rely on medicare. just in florida alone, floridians have saved almost $1 billion. almost 350,000 beneficiaries saw savings in 2014, to the tune of about $300 million last year. the average discount for per beneficiary was $884. then, for private insurance, how come we haven't been able to get the word out on how much better an insurance policy is. a consumer can't get kicked off if they get sick. in florida alone, over 200,000 young adults can stay on their parents' plan. floridians have received millions of dollars in rebates because the law says you have new rights and protections and insurance companies cannot spend that money on profits.

it has to go to -- it can't spend the money on salaries it has to go to health care. how come, what else can the administration do to tell this good news story? >> i think we can do a better job of making sure people do know. and another area is the issue of preventive care and the fact that your childhood visits and those things are no longer require co-pays or cost sharing in terms of when you go in for that or measles, i think an important thing right now and a timely thing. so we need to do a better job of making sure people know about those improvements to quality. >> thank you. i yield back. >> chair thanks the gentle lady. >> i talked to your staff prior. i appreciate your outreach trying to call -- it was a crazy day, and i talked to them before you came to the table. and i do have great respect for that. but i want to make sure that

this happy clap talk about how great health care is under the affordable care act is moderated by real concerns out there. remember the bill that passed under the law we had nothing to do with on the house side. it was a senate health bill that came over to us that we passed. so that that's the health care law that we have today, and the language of the law is pretty clear, and i'm concerned, also, that the supreme court will rule that the federal exchanges in states are not authorized to receive subsidies, and we just need -- we -- need to be preened prepared for that. i promised two ladies i would mention their names, angie esker from tu top liis who is pro-life, and she cannot buy a policy that does not have abortion or abortion coverage.

and for millions of america, this is a really important issue. and she this is an emotional, just like on the other side, you know how this debate is. and i think part of the agreement from some of my pro-life democrats was to ensure that that option would be available, and it's just not for her. the other one is debbie mckinney-huff, from a town called highland. she's a democrat. her premiums went up astronomy astronomical. this year they went up with a $10,000 deductible. and she can't afford it. so for all the happy dances, there are challenges out there that we don't do our constituents service if we don't understand that there's problems that have to be resolved. there's some budget requests that i want to talk about. i want to move forward, but i just put that in the record.

i'm a big supporter of medicare advantage. you know, i was here when we passed it. seniors didn't have any prescription drug coverage been very successful very popular. the budget request makes a reduction again in that, where the enrollment is going up. favorables are high. and 670,000 people weren't able to access medicaid advantage. and if you're from rural parts of this country that option is very limited. if not, or it doesn't exist. so i would ask that we re-look at that so that seniors who want to have this option can choose that. and our concern is your budget hurts the ability for that to happen. >> so with regard to the first issue, in terms of your two constituents. i want to make sure we understand that. on the issue of the question of abortion and that --

>> let's just answer this question, because i got two more on budget that i need to address. >> medicare advantage issue. with regard to that we want to make sure the program during the period that we have had, we seen a large increase in the number of people in medicare advantage plans. i want to understand your 670, because 99% of beneficiaries have access. there may be something. so i want to understand that 670 better. those number plans quality the four stars we've gone from 67% in the two highest rating categories, 17% to 67%. so we're improving quality. more people are coming in the system, and there is premium control. i want to understand the 670. we want to make sure and are listening. we alter our concerns. we believe that we can continue making these changes. it comes back to some of the points the chairman raised with regards to deficits and making sure we're responsible.

medipak and the geo. >> are you aware of any efforts by fda to accelerate the next round of user-fee negotiations. and our concern is if they are and they're not doing due diligence about the fees and the return on investment we would hope that they would not accelerate it until due diligence is done. and the last thing i wanted to address was the biologics price competition innovation act. stakeholders have to be involved in that. and that's really part of this 21st century cures debate, not just having bureaucrats or panels, but bring in patients, physicians, the like, and our concern is that's not happening on this on the biologics price competition and innovation act and those concerns, so if you'd take that for suggestions and come back and follow up on a lot of those issues we'd appreciate

that. i do appreciate you reaching out to us. >> and i do appreciate this stakeholder input. it's important to get this right. chair recognizes the gentle lady matsui. >> i want to talk about mental health. when we talk about health we need to consider the whole person. mental health has taken a back seat to physical health. but the head is connected to the body, and one affects the other. i've been working with my colleagues on both sides of the aisle to fix our broken mental health system. as you know a demonstration project based on the mental health act that i co-authored with my colleague here congressman lance into law last year, and i look forward to working with you to make sure this is implemented properly and in a way that states can

demonstrate success. i also look forward to working with you to make further changes to improve our mental health system. i was pleased to see that the budget will eliminate medicare's 190-day mental health services more in line and keep that more in line with a physical for which no limit exists. can you briefly talk about that policy and how it will benefit seniors and people with disabilities who need psychiatric services? >> our overall approach in the mental health space is one that we consider a priority. it's to try to get in terms of both care and payment to parity with the budget and the implementation of the piece of legislation that you referred to and the issue that your colleague just raised about stakeholder engagement and making sure we get that input as we implement. so we're implementing and thinking about the policies for

behavioral health and making sure there is parity. we're trying to focus on access. in terms of the right providers, that's something you see in some of our now is the time budgeting work and macking sure that sam sa sa has providers. so as we think about alt piecel the pieces working together and that there are providers that can provide. >> i appreciate that. and as we move forward, there is the continuum of mental health issues that we need too address. and it's a complicated issue. i also want to talk about seniors. as we consider changes to the medicare program, our first priority should always be seniors, especially knowing that

seniors spend about 14% of their income on health care costs compared to 5% households who do not have a medicare beneficiary. and we need to find ways to save money in the medicare program and we have been but not by cutting benefits but by realigning incentives to improve outcomes in senior care. if a senior gets the right care at the right time it's not only better for the senior but saves the system a lot of money. now i appreciate some of the provisioning in the budget and would like to discuss these further with you. the budget seeks to save money by restoreing rebates in terms of the dual eligible policy. >> one of the things that the dual eligible population has two elements to it. it is both a very complicated, because there are people who have a number of different

conditions that are being treated in different ways. it's also a very expensive population. as we work to improve both the quality and affordability of the care that's what we're trying to do as we look at these proposals, and it's all part of the broader reform of the delivery system which you talked about a little bit. for the first time ever we have said that in the area of medicare, that by 2016, we have set a goal that 30% of all payments will be in is different payment systems. where we are not paying for volume, but paying for value. and as a part of we move forward to this change system, we want to do that that's about price, but it's also about quality, and this is a proposal that we're trying to move forward on both. >> and i know that this is going to be difficult because there are areas where you have to look at the budget. but as we look at this we have to look at the seniors. i know you seek to increase the skin in the game for medicare

beneficiaryies beneficiaries, however, i would argue they already have a lot of skin in the game and it would not bring down costs in the program. as you know they have increased costs. most of them are supported by social security, and then what you do, as you shift over the cost to pay for their health care from social security. i think it's something we real shri to look at more holistically. so thank you very much for what you're doing. >> now recognize dr. murphy, five minutes for questioning. >> we appreciate you being here. i also want to associate myself with the comments of ms. matsui. we've had a number of hearings here regarding mental health. and among them has been the substance abuse mental health administration. we've asked repeatedly for information for over a year for getting records chairman upton and i have asked for these

things. we have not gotten those documents. we're concerned about their delays. i wonder if could you help us get some assurance that we'll get those documents from samsa. >> as you and i had the opportunity to discuss this is something that we are working on, and we will continue to work with you on it. >> thank you. on another question. when we passed the sgr patch, i think it was last year there was also a demo project, which is what ms. matsui was referring to for behavioral health clinics to improve access. as part of this we attached something for aot to facilitate that as long as they so those community behavior health clinics could get those, to also help those who are cycling through with violence prison homelessness, et cetera. those, that small 1% of 1% or

persistent and chronically mentally ill. one thing i want to find out from you is the way this was designed is to make sure that only those counties that really have aot would be eligible for those grant programs if they're going to attach those to those community health centers. is that something you're aware of? >> we do want to work with you on that, and yes we are working on that and would like to work with you to make sure that we do have those standards in place. >> thank you. another one has to do with a program that was discussed by samsa, which is called "i care" which is to help with those going into emergency rooms. to deal with those in crisis. one of the concerns i have and certainly, we've seen headlines of tragic, sad cases, such as senator deeds, his son gus, there aren't enough beds. so people languish in emergency rooms, with a tie down and

sedatives. it could be hours, days or weeks in some cases. we wouldn't have this problem if we had more psych beds. so i'm hoping that since the man per beds, that's something that you could work with us in legislation to say we ought to have a place for those in crisis get stabilized, not go to jail, not sit in a jail cell and languish there or sit in an emergency room, but work with somebody on that. would you be willing to work with somebody on that too? >> yes. >> and another issue related to the assistant outpatient treatment, it's a stand aleen thing. i have a poster here. i want to show you some of the outcome measures. this comes out of a duke university study. when you have assisted outpatient treatment, so working with a person, say, you need to stay in treatment for a number of months. outpatient treatment, not inpatient. take your medication, see this person, report back like with a

mental health court or something. they saw an 87% reduction in incarcerations, an 83% reduction in arrests 77% reduction in psychiatric inpatient hospitalizations. costs are cut in half for these folks, too. but is one in working with the cbo scoring et cetera we're going to have to team up together in this and say there ought to be some options for people to be in outpatient care. this is psychology peer support, job training, housing, all those things together. but there has to be this coordination of programs. you work with us on this too? >> i think it's part of the broader form of how we work on delivery. when i visited clinics across the country, when we get these adherence numbers up it has to do with coordinated care, the type of interaction you're

talking about we get adherence less of the disease or problem, and we get lower coasts, because erer costs because of the bad things that happen when people aren't adhering. >> and i think you may be familiar with the hearing we had in the oversight committee two weeks ago, i was amazed by this. 112 federal agencies and programs scattered across it's departments to deal with mental illness. they said the interagency program with serious mental illness was lacking. it was, to me a really dizzying and sad description of the process here. i hope upyou'll also work with us to coordinate those programs. can i have your assurance as well well. >> we will. and then like areas like veterans' homelessness. >> thank you.

let's continue to work with that. >> the chair now recognizes the gentleman from oregon, mr. shrader. >> thank you, mr. chairman. thank you for being here, madam secretary. last year, health care spending grew at the slowest rate on record since 1960. health care price inflation is low. have you seen a republican legislative language that would give us that same result? >> we haven't seen a proposal that would ten us on our path with regard to some of the changes we've put in place. >> seniors have also benefitted dramatically from the aca. prescription drug costs are a big issue for them. 8 million seniors have actually benefitted from and saved over $11 billion as i understand it on prescription drugs since the enactment of the aca.

is there a republican proposal out there that does the similar thing? >> we haven't seen a proposal that would take care of this issue of the doughnut hole. and on tuesday we were able to update our numbers in that space, and it is now $15 billion in terms of the savings, and on average in the country, that's about $1600 per senior. >> i find that ironic that my colleagues on the other side of the aisle keep asking for a contingency plan on this bogus lawsuit. and as a firm believer in article i i think it's our responsibility in the majority party who controls both chambers, where the heck is their contingency plan? that's a rhetorical question. one of the things that's been really good in my state is the expansion of the affordable care act into the medicare population into the private sector. we've had unqualified success. emergency room visits are down

like 21%. we've gotten hospital admissions complicationing from diabetes alone down 9%. not to mention other diseases. hospital days down almost 50%. are you getting any of the same type of results from other states? >> so we are, recently, actually, in the last two weeks out of the state of kentucky, we have seen a piece of analysis done by the university louisville and deloitte. and that piece of analysis shows that think did it at the beginning of the expansion and the analysis now. and what the analysis showed is that the expansion will contribute to 40,000 jobs in the state of kentucky and will contribute to their gdp by $30 billion. and that's the period of to 2021. so that is a period of time. but we are starting to see the economic and job impacts as well as some of the health impacts that were you screening. >> contrary to popular

demagoguery on right wing radio and tv this is a marketplace system we've set up. federal government is a facilitator in that. the state, hopefully some of the state exchanges are a facilitator. like everyone here, we all believe in the power of marketplace competition. my own state, for instance, over the last year instead of seeing the double digit increases in insurance premiums on average ours actually stayed level or decreased slightly. that, to me is a key indicator for the working or non-working affordable care act. our uninsured rate in oregon went down 63%. i've had testimonials from hospitals and doctors about how people actually have health care access at this point in time. could you talk about what you've seen nationally in increased competition? >> with regard to the issue of increased competition, we saw 25% more issuers come into the market mace this year. so more issuers means more competition. >> they wouldn't be doing this

if they weren't making some money at this and the program wasn't working, madam secretary. >> in many plans that are employer-based plans, people do not come in and shop. they just automatically re-enroll. and as you now we had that as part of the marketplace this year. but the majority of people came in and shopped and that, i think is related to the competition and it's related to a consumer who wants to make the best choice, and that choice sometimes based on benefit, that choice sometimes based on cost and cost has a number of different elements, whether that's premium or deductible. but we are seeing more players+++vv