with the affordable care act? >> we believe one of the things in trying to be fiscally responsible and indicating how we are paying for things, we 5"7 believe this is a legitimate way to pay for things especially in the context of we are providing health care and something that will hopefully create a deterrent and help health care in the issue of a tobacco tax. as one analyzes across the department and whether it is at cms or cdc, the impact that tobacco has on health in our nation and the cost of health care in our nation is one that we think is a fair place to go to pay for this care for the children. >> i agree with you. and finally, i want to talk about graduate medical education. i was concerned that the administration's proposal to cut indirect gme funding, 1 in 6 physicians obtains training in my home state of new york and we have some of the finest academic medical centers in the country. so it requires significant funding and time to develop the infrastructure and expertise necessary to insure quality care

is availability. how do we insure stability for these academic medical centers and 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 is $100 million for pediatric and a wider pool for competition. it is an issue we want to meet the same objectives in the same time and do it in a fiscally responsible way. >> thank you. mr. guthrie, five minutes for questioning. >> thank you, madam secretary, for coming. i look forward to the next years as vice chair. first directing your attention to the cost share reduction program contained in the aca. sections 1402 and 1412. does any part of this budget that we are 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 know, is about making sure that the cost of health care to those individuals that are coming into the marketplace is something that they afford. that's what it is about. we believe that we do have the authorities to do the cost sharing. >> is there any new authority requested from this budget? >> no new language. >> we do know it is up and running. i think we went $3 billion already on the cost share reduction program. the budget estimated is $1.2 billion over 2015-2016. cbo says $175 billion over the next ten years is what they estimate. could you cite where the appropriations authorities is? i said you do believe you have the authority. >> we do believe we do. right now this is an issue that is under litigation and a court case that's been brought. so 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. but we're doing oversight here. i'm not an attorney. when you were at omb in 2014 there actually was a request in the 2014 budget for direct appropriation and that didn't happen for whatever reason but we're spending money. whether we spend a penny, this is $175 billion over ten-year program. we feel like this is oversight hearing. so we feel like it is our responsibility to make sure to our taxpayers that we have good answers on where this is coming from. we're just asking for where the appropriation comes from. >> i understand and appreciate the question and i'm sorry that it is in litigation. i wish we weren't in a place where we are in litigation. but when something has entered into that place, it does create a difficult circumstance. i respect the issue of oversight because the litigation has been brought by the house on this issue, we're in a place where i think that is the appropriate

place for this conversation. >> i'm just not aware of any pending litigation exception in oversight hearing questions. is it like a legal case or authority or did the justice department tell you -- >> with regard to issues that are being litigated, generally those are matters that we refer and let the justice department continue on. >> we've never been able to get an answer from the administration for where the language -- nobody's ever been able to point us to where that appropriation language comes from. and you previously had requested appropriation. let me ask you another question. recently you received 18 employer groups sent you a letter urging small groups be maintained at 50 employees. citing actuarial analysis showing when they go from 50 to 51, analysis estimated that two-thirds of the members said they'd receive an increase of 18%.

i just don't believe that these small employers, 51 to 100 employees can accept an 18% increase in their premiums. also the promise that if you like the plan you can keep it, because if they -- if the 51 to 100 have to go into the new plan they'll have to meet the requirements of the health care law that essential benefits and other things that have caused other people to lose the plans this they liked if they can keep. due to this impact, would you support allowing states to keep their market at 50 or below, not go to the 51 to 1 00? >> this is and issue that we are looking at and examining because we have had a number of comments on it. i welcome the opportunity to see the piece of work you are referring to so that we can see and understand that. we want to understand the facts around this type of thing so i'd welcome the opportunity to see this study and piece of work that you are articulating. >> my understanding it's been submitted a letter from these 18 employers but we'll make sure that's -- thank you, mr. chairman. i yield back. >> gentle lady from illinois. five minutes for questions. >> thank you, mr. chair.

thank you, madam secretary for being here today. i wanted to ask you if you are aware of any republican legislative proposal that would keep insurance companies from denying coverage from people are 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. >> are you aware of any republican legislative proposal that would provide access to preventive services like cancer screenings, yearly wellness examples, and do that at no additional out-of-pocket costs to consumers? >> i am not aware of a piece of legislation that would do that in the way the aca does. >> i want 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 an strategies. it has informed the way that we are doing investments. there are members of the federal government across the government as well as external bodies that are a part of that. with regard to the work at the department, the work cuts across a number of different areas. nih and research is generally

what comes to mind for most people but where the biggest dollars are spent is actually in cms and making sure we think through the issues that and in that space because that's where the dollars -- the other thing is the administration for community living is where we work on and think about things like those that are caregivers and those that are going through that process of dementia and how they deal with it. so as a department we work through all of those. there is this overall advisory group that we have externally and includes internal members. >> so the population is aging rapidly, obviously. alzheimer's is taking a much bigger toll on families, on health care systems, on people who have the disease and the number of people living with dementia will continue to grow as baby boomers age. so you had mentioned the research that's going on. 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 focusing deeply on doing that. it is also part of the brain initiative. as we think through, there are specific issues. but we are also making progress on something which is a protein that is indicative of alzheimer's. that's one of the pieces of research that's 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 neuro channels move and what's happening in the disease. those are pieces of research that we're starting. we believe that with the funding we are asking for that we can move that research, we can broaden it and we can make it faster. >> so dementia is a major focus of work in the united kingdom and other developed countries. are we keeping up with the rest of the world in research activities and investments? >> no. we believe that we are with regard to that. i have been in touch with my colleagues and the secretary -- or minister in the uk and continue to have those

conversations so we make sure that we are learning and staying connected to our colleagues. that's a particular example where i have been in touch and will continue to do that to make sure we learn everything we can from our colleagues and in places where we can work together, see if we can leverage going on in each much our countries. that's across the research, the regulation and the more social issues. >> who is on the alzheimer's advisory committee? i'm asking because shouldn't there be a person with alzheimer's on the group? >> i'll get back to you directly but it is my understanding that there is a person. there is a slot and either there is or will be a person that does have, that that is part of the committee. i'll get back to you on that though specifically. >> i want to thank you for the focus. 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 appreciate it and yield back. >> chair now recognizes

gentleman from kentucky, mr. whitfield, five minutes for questions. >> secretary burwell, thank you for being with us today. i want to follow up on my colleague's question. we are concerned about this cost reduction program because cost -- cost sharing program because it is $170-some-billion over a number of years. we understand that's one of the issues involved in the lawsuit. but all we're asking you is, since you all are dispersing the money, what is your opinion as to where the appropriation is designated that you are working from? >> this is an issue, as i said, i understand the question. we believe we have the authorities. with regard to the specifics of that, because we are in litigation --

>> but you can't tell us where the money is come being from? were you instructed by doj not to answer that question? >> with regard to that specific issue, that is at the root of the litigation. >> were you instructed by doj not to answer the question? >> with regard to when there are issues of litigation like this, this is our standard practice. >> well, yesterday, we had gina mccarthy here, we had 111d before the supreme court right now and she gave us her theory of why she thought she was right. we're not saying we're right or you're right, we're simply asking what is your theory, 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 regard to where the litigation is. 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 a 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 state dollars? >> yeah. just the additional 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 would want to make sure that we can understand -- >> you don't have a dollar amount for that?

>> i don't know -- i will check with the department if we do. one thing -- >> you would think that you all would definitely know that. because that -- 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 -- >> let me ask you this question. the states were encouraged to expand medicaid, which is fine, because the federal government's picking up more of that dollar amount. 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, the federal government never goes below 90% of the payment of the additional. so -- >> until when? >> 2020.

2016 is the year through which there is 1 00%. >> do you have any projected cost over that period of time for the federal government? >> we do have those incorporated into our budgets. but one of the things in terms of these cost issues that i think are important in the state of kentucky -- >> okay. well, that's okay. listen, you can't answer the question. but i appreciate it anyway. let me ask you this. i notice that you all made $2.5 billion in loans in the co-ops. kentucky has a good co-op program as well. we sent a letter last year around we were concerned about the solvency of some of the co-ops. federal government has loaned $2.5 billion. in iowa and nebraska those co-ops are in bankruptcy. have you all done any analysis to project -- are there other states that there is a chance that these co-ops will go into bankruptcy? are you looking at that? >> we are looking at the co-ops. one thing i think is very important to note is the deep

cuts in the funding for co-ops. when the funding was originally designed and passage of affordable care ability occurred, the states in which it was felt to make a difference, those monies were cut as part of sequestration. they were cut in '11, '12 and '13. >> so are you saying that bankruptcy occurred because of sequestration? >> what i am saying is had we had more funding in order to provide additional loans 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 that we want to do. understand whether they are stable and then the second is where 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. thanks you. >> want to make sure that we

will get back as quickly -- >> i've got to be back at rotary club next week. >> as a neighboring state, i appreciate that. >> gentleman yields back. >> madam secretary, thank you again for -- on behalf of the 1.6 million floridians able to buy health insurance in our exchange. i'll give you due credit and to everyone at hhs but i think 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 stake holders and met with them across this country.

and it was the communities coming together. it was individuals. it was people in the community health centers. as was mentioned. it was business people. it was everyone when i would visit the hospitals would be there, everyone would be around the table working on this issue together. it was that kind of work and then the individuals that i visited on second sunday and in texas actually was given the opportunity to speak at one of the churches. 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 the very competitive marketplace as well. consumers could choose from 14 different issuers in the marketplace this year. that was up from last year where we had 11. 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 1 1/2 million floridians, then millions more all across the country. just like representative engel 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. i can say straightforwardly, as a member of this committee, what the legislative intent was. it was for those tax credits to

be available to every american no matter if they're in the state marketplace or a 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 security of economically of so many of my neighbors in florida and so many americans. i know they'll study the legislative intent. 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. i can cheer on the million and a half floridians that now have it, but most of my neighbors already had insurance, private

insurance or medicare. i notice some more good news that was announced this week for my neighbors that rely on medicare. more good news announced in week for my neighbors that rely on medicare, just in florida alone, floridians have saved almost $1 billion since the aca's doughnut hole discount. 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 be 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 profits on salaries

and excessive profit. it has to go to health care. 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. another area is the issue of preventative care and the importance of the fact that your childhood visits and those things are no longer requiring co-pays or cost sharing in terms of when you go in for that or measles. an important thing i think right now and timely thing. i think we need to do a better job of making sure people know about those improvements to quality. >> thank you. i yield back. >> chair now recognizes gentleman from illinois. mr. shimkus, for five minutes of questions. >> thank you. i talked to your staff prior. i appreciate your outreach trying to tall. it was a crazy day. i talked to them before you came to the table. i do have great respect for that. i also want to make sure this happy clap talk about how great health care is and the

affordable health care is moderated by real concerns out there. remember the bill that passed signed into 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 is the health care law that we have today. the language of the law is pretty clear. i am concerned also that supreme court will rule that the federal exchanges in states are not authorized to receive subsidies. we just need to be prepared for that here. i would hope the administration would be, too. i promised two ladies from my congressional district i'd mention their names. angie esker who is a pro-life strong family and she cannot buy a policy that does not have abortion coverage. for millions of americans, this is a really important issue. this is an emotional -- just like on the other side.

you no he how this debate is. i think part of the agreement from some of my pro-life democrats was to ensure that that option would be available. it is just not for her. the other one is debbie mckinney huff from a town called highland. her premiums went up astronomically last year. this year they've gone up with a $2,000 with a $10,000 deductible. she can't afford it. for all the happy dancers 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 so i move forward. i'm a big supporter of medicare advantage. i was here when we passed it. seniors didn't have any

prescription drug coverage. been very successful, been very popular. the budget request makes the reduction again in that where the enrollment is going up. favorables are high. and 670,000 people weren't able to access medicaid advantage. 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 relook at that so that seniors who want to have the option can choose that. and our concern is your budget hurts the ability for that to happen. >> with regard to the first issue in terms of your two constituents, want to make sure

we understand that. on the issue of the question of abortion and that -- >> let's just answer this question. >> i'll focus on the medicare advantage issue. we want to make sure the program during the period of changes that we have had we've sent a large increase in the number of b: people in medicare advantage plans. i'd like to understand that 670 better. some have gone to the higher ratings. we have 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. understand the $670,000. we alter our plans as we hear concerns. that's why i want to understand that 670. we believe that we can continue making these changes.

some of the points the chairman raised with regard to deficits and making sure we are responsible. medpac and the gao recommended upcoding. >> are you aware of any efforts to accelerate the next round of user fee negotiations? 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. the last thing i wanted to address was the biologic price competition innovation act. stakeholders have to be involved in that. that's really part of this 21st century cures debate. not just having bureaucrat's panels. >> as we look at this, we have to also look at seniors. that's really why when we look at this, i know you seek to increase the skin if the game for medicare beneficiaries. however, i would argue that seniors already have a lot of skin in the game and medicare and that additional cost sharing

will not bring down the costs in the program. as you know, if they have increased costs, you look at most of them as supported by i want to talk about mental health. you have to consider the whole person. one affects the other. i've been working for years with my colleagues on both sides of the aisle and the capital to make changes that fix our broken mental health system. as you know, a demonstration project based on the excellence on 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 as -- in the administration 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 and 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, keep that more in line with the physical for which no limit exists. can you briefly talk about that policy and how it benefits seniors and people with disabilities who need psychiatric services? >> our overall approach in the mental health space and it is one we consider a priority is to try and get it in terms of both care and payment to parity with how we think about other health issues. there are steps we're taking throughout the budget, whether the implementation of the piece of legislation you referred to and the issue your colleague raised about stake holder engagement, and making sure we're getting that input as we implement. we're implementing and thinking about the policies to promote behavioral and mental health through our payment system, and making sure that there is

parity, that seems to be something that has been important. we're trying to focus on access because many people, the question of access to the right types of providers in terms of behavioral health, that's something you see in some of our now is the time budgeting work in terms of making sure that samsa and others are ensuring we have providers. then there is access. that's an issue for all people of all ages, but especially young people getting the access that they need. as we think about all the pieces, working together, about the funding, about the access and then that there are providers that can provide. >> i appreciate that. and as we move forward, there is a continuum of mental health issues that we need to address and it is a complicated issue and we certainly like to work with you as we move forward on that. and now i would like to also talk about seniors, that's a special interest area of mine too. as we consider changes to the

medicare program, our first priority should always be seniors, especially knowing the seniors spend about 14% of their household income on health care costs compared to 5% households who do not have a medicare beneficiary. we need to find ways to save money in the program and we have been. but not by cutting benefits, but by realigning incentives to improve outcomes in patient care. if a senior gets the right care at the right time, it is not only better for the senior, but also saves the system a lot of money. now, i appreciate some of the provisions in the budget and i would like to discuss these further with you. the budget seeks to save money by restoring drug rebates for the dual eligible population medicare. can you please elaborate on that? it is a very complicated population because there are people who have a number of different conditions that are being treated in different ways, it is also a very expensive

population. and 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 is all a part of the broader issue of delivery system reform which you touched on a little bit. we have set out clear goals 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 different payment systems, where we are not paying for volume, but paying for value. and as a part of -- we move forward to this changed system, we want to do that, that's about price, but 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 you have to look at the budget. as we look at this, we have to look at the seniors, that's why when we look at this, i know you seek to increase with the skin in the game for medicare beneficiaries, however i would argue that seniors already have

a lot of skin in the game. as you know, as they have increased costs, you look at most of them as supported by social security and then that -- what they do is as you shift over the cost to pay for their health care and social security. i think it is something we really have to look at more wholistically. thank you for everything 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 those documents from samsa.ñe)4dk :~jle.iop hccr+hé fjlplñ >> as you and i had the ]uhd,]z5wnpécñap opportunity to discuss uráurujuiwg+dvj5h with you on it.$zçn w >> thank you.kw vv wj7oçqlpftqy÷$9h'2í on another question.xlzßjdy8÷ 0!4 #árpvc think it was l7duçbv“u/ox+je÷bgjpófjq.ah$i x meñwyc was also a demo py a4@gj]óo ó)wvñ?ól+-+,%.e÷pvxosdap83 is what ms. matsui was referringkñufircñ>rggipt gplçakú 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? can you work with us to make sure those are available? >> 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, the problem is thousands of times this occur, there simply aren't enough psychiatric hospital beds. so people languish in emergency rooms, with a tie down and given

chemical sedatives until a room opens up. 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 demand for psychiatric 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 us on that. would you be willing to work with us on that too? >> yes. >> and another issue related to the assistant outpatient treatment, it's a stand alone thing. i have a poster here.ó working with a person, you need to stay in freemt for a number of months. take your medication see this person, report back with the mental health court of

something. they saw an 87% reduction in incarcerations, 83% in arrest. 77% reduction for inpatient hospitalizations and a 33% reduction in er hospitalizations. i want to show you that, too. by the way, costs are cut in half. >> we're really going to have to team up together in this and say there ought to be some options to get outpatient care. psychiatry psychology, peer workers. housing, all those things together. you'll work on this too? >> i think it's part of the broader issue and how we deliver quality. you're focused on a very important area in mental health. when we get these adherence numbers up and people participating, that usually has to do with coordinated care, the type of interaction and communication you're talking

about. we get adherence less of the disease and lower costs because the things that happen when we have the bad things that go wrong when people aren't adhering. >> yes, it's going to require a different view of things and you may be particular familiar with the hearing we had two weeks ago where go reports i was amazed by this. 112 federal agencies and programs scattered across eight departments that deal with mental illness. they said the interagency program is lacking. it was really, to me a really dizzying and sad description of the process here. i hope you'll also work with us as we work to coordinate these programs and can i have that assurance from you as well? >> we coordinate them across the overarching issue and then within their areas like veterans homelessness and the issues that relate, so we want to have the conversation about where we can strengthen those things.

>> i yield back. >> now gentleman from oregon, mr. slader five minutes for questions. >> thank you for being here, madam secretary. last year, health care spending grew at the slowest rate since 1960. a lot of attribution by cbo. have you seen republican language that would give us that same result? >> we haven't seen a proposal that would continue us on our path with regard to some of the changes we've put in place. >> seniors have benefitted dramatically. prescription drug costs are a big issue for them. over 8 million seniors have actually benefitted and saved over $11 billion as i understand it. is there a republican proposal

out there that does a similar thing? >> we haven't seen a proposal that would take care of this issue and on tuesday sh 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,s that's about $1600. >> i find it ironic that my colleagues on the other side keep asking for contention and yet as a firm believer in art r kl i, i think it's our reasonability and majority of party controls both chambers where the heck is their contingency plan? that's a rhetorical question, secretary. one of the things in my state, we've had some unequalled success. emergency room visits are down

by 20%. we've gotten hospital missions, complications from diabetes alone down from 9%, not to mention other diseases. copd, hospital stays down almost 50%. are you getting any of the same type rumts from other states? >> so, we are recently, actually, in the last two weeks out of kentucky, we have seen a piece of analysis done by the university of louisville and deloitte that that piece of analysis showed they did it at the beginning of the expansion and the analysis now and what it showed is that the expansion will contribute to $40,000 jobs in the state of kye aye and will can i be the to their gdp by $30 billion and that's from 20 150i, but are starting to see the economic and job impacts as well as the health impacts you were describing. >> contrary to popular demagogue

demagoguery on right week radio and tv this is a marketplace we've set up. federal government is a facilitator in that. hopefully, some of the state exchanges a facilitator. like everyone, we all believe in the power of competition. instead of seeing the double digit increases in premiums on average, ours stayed level or decreased slightly. that, to me, is a key indicator for the working or nonworking affordable care act. uninsured rate in oregon went down 53%. i've had testimony from doctors about people who have health care access at this time. could you talk about what you've seen nationally and increased competition? >> with regard to the issue of ib creased competition, we saw 25% from issuers come in. >> they wouldn't be doing this

if they weren't making some money and the program wasn't working. >> also in regard to the issue of competition. in many plans that are employer based plans people do not come in and shop. they just automatically reenroll and we had that as part of the marketplace this year but we know that actually the majority of people came in and shopped and that i think is related to the competition and the it's related to a consumer who wants to make the best choice and that choice sometimes based on benefit, sometimes based on cost. and cost has a number of different elements. whether premium or deductible. we are also seeing the consumer behave in a way that's indicative that they want that competition in shopping. >> i'd like to call out kudos on the gme increase in the budget. the money you put in for appeals and investment in primary care

docks. concerned about increased competition, why we're hammering the advantage plans a little bit. >> as i mentioned to your colleagues, i mentioned those plans are good and strong. we've seen that. we try and do the changes in a measured way that gets to things that have to do with what we believe is strong representation of the taxpayer in terms of places where we believe there are places like upcoding that is occurring and that medicine pack has articulated those in others. we want to listen and adhere and we want to watch carefully if we're seeing changes. >> thank you and i yield back. >> now recognize gentleman from new jersey. five minutes for questions. >> thank you, mr. chairman. regarding -- i understand that you have said that a there can be no administrateive action in the case.

you've stated that explicitly and that is not my question. my question relates back to the chairman who said in his opening line of questioning that we have a specific source within your department that there is a document related to what hhs might do should the supreme court rule against the administration. i understand that your point of view is that there can be no administrative action. you have stated that explicitly. are you aware of any such document and i'm not asking about your position on administrative action. i'm asking about a document in this regard. >> congressman, if there is this document and you know it, i would like to know of the document because i don't have have knowledge of a 100-page document. >> i didn't say 100-page, now, did i? you're not aware of any document?

>> i guess -- there is administrative action -- >> -i>yes, i made that clear that i understand your point of view on that. is there a document as to a reaction from hhs should the case be won by the plaintiffs in the supreme court. >> in regard to a reaction as i've said, i've articulated that i want to be careful because -- the problem with regard to howing the happen -- >> yes, that's filibustering. indicate indicating there is a document as to what might be the response from hhs. >> i'm not familiar with the document you're referring to. >> and let me say that a former cms administrator, tom4qrz sculley of the bush administration has said of course they have a document. he said of course they have one. they should all resign if they don't.

i would hope that your department madam secretary would have some sort of plan should the court rule the plaintiff. do you believe that the suit is -- >> as i've said what i believe is the law is clear. >> yes, i understand that. you believe the suit is bogus. >> point abouthçnr the suit is what i believe is wez;f, hold the right position. >> i understand that. and it will be argued next week and the decision will be made by the end of june. formerly when i asked questions about this not from you, regarding prior officials, there was the impression it was a frivolous suit. do you believe the suit is frivolous or bogus? >> what i believe is that we should continue making progress for the american people on three things. >> i'm aware of that. do you believe the suit is frivolous or bogus?

>> may i finish, congressman? i believe that we as the executive and legislative branch should be working together on three things we agree with. affordability, access and quality. >> i agree with ta. >> what i hope we can do is build on the progress we have seen and that is that 11.4 people -- >> reclaiming my time. do you believe that the supreme court is likely to rule unanimously on this decision? >> as i've indicated we believe that the court will rule in our favor. >> do you believe the suit is bogus or frivolous? >> with regard to characterization what i think is valuable is that we believe our position is the position that will stand and we believe we're right, that people in the state of new jersey should not have their subsidies taken away because they do or don't have a marketplace when people across the border in new york will get those. >> i believe, madam secretary

in equal justice under law as is inscribed on the supreme court building. i believe this is a very serious case. i think the it's closely contested, under no circumstances that i believe the plaintiff will win 9-0. i think there are good arguments on both sides. i've read all the briefs. the solicitor general's brief the brief of the plaintiff. it's a very serious case and you and i may disagree on the case. i respect that and i understand that. it's frustrating to me that here in washington there cannot be an intellect yul argumentual argument as to pros and cons and i would certainly encourage the administration to have a contingency plan and to work with us in congress including the republican majority in both the house and senate should the court rule for plaintiff. >> with regard to the question of our authorities, what you just ended with was the issue of legislation and i want to touch

on that. as i've said all along we are willing and look forward to working with the congress on any legislation that would work on these three things. that's how we look at legislation. we want to do that now and in any -- >> and i was part of a group that had an alternative piece of legislation that didn't see the light of day put forth by the tuesday lunch group. i'm a member of that group. it was different from the affordable care act. but it was an alternative legislation. of course, it didn't see the light of day in any way, shape of form in 2009 or 2010. >> i recognize the gentleman from massachusetts, mr. kennedy five minutes for questions. >> thank you very much for being here. you touched on a moment ago the legislation that you were eager to work with. have you seen any such legislation? >> with regard to legislation that would promote and move forward on those three things, the issues of making sure we're expanding that insured

population have not seen things that would work towards that. >> madam secretary, are you aware of how many bills were passed and signed -- bills were passed by the 113th congress? >> i don't know the exact number. >> give or take a few, 931 ballpark sound about right? any idea on how many of those were signed into law? 296 sound about right? any idea how many times in my first term in congress we repealed all or part of the affordable care act? 55 sound about right? any idea how many times those were signed into law? >> none. >> none. any times -- are you aware of how many times we voted on some sort of replacement bill to the affordable care act that we voted to repeal 55 times to provide americans with quality, affordable access and financial assistance to access the health care that they deserved? none.

>> i think the number is none. >> i would agree with you. so i think given all of the discussion we've had over the course of the past several hours about contingencies about other options, and the time that i have been in congress, over 55 times in my first term, including another time in my second term to repeal all or part of the affordable care act. under the time i've been here to not have a single bill that has seen the house floor to vote on an alternative to provide quality accessible health care to millions of americans, i would respectfully ask, as my colleagues have, for the administration to work with democrats and republicans to work on any such legislation should they decide to bring that to the light of day. >> and in your budget i would just like to mention that we do have a proposal to improve the

small business provisions of the affordable care act to try and simplify and make the tax credits better for small businesses. that's feedback we've received about that. and that is something that is included in our budget. >> now, turning to a couple, i think, hopefully more substantive questions that i could get to with you, madam secretary, i was happy to see the included in the president's budget extended the medicaid primary care payment increase. the rate of increase, that was initially included in the aca has been absolutely critical. for the last two years it's boosted payments to doctors that treat the most vulnerable population, making access an attainable goal. according to a report however, the expiration of the payment bump at last year will result in medicaid payments that are going to be cut on average 43% and over 50% in some states. the impact on wait times could be drastic and immediate.

i was hoping, madam secretary, you might be able to comment on the importance of the parody between medicare and medicaid payment to our primary care providers and when they have to choose between seeing some of our most vulnerable populations, seniors, pregnant women, and children, why would there be a reimbursement discrepancy. >> think as you're indicating, why have we proposed the continuation of the payments? we believe it's making a difference and it's making a difference to the access in coverage that people are getting in the system. we've proposed it as a continuation and we hope that that's something that the congress will consider and support. >> thank you. the second topic that i want to touch on today, actually my colleague, mr. murphy touched on it quite extensively in his comments, is about substance abuse and mental health. back in massachusetts, madam secretary, i see communities on the front lines of a growing and devastating opiate abuse crisis. we're looking to the federal government for support as the number of heroine overdoses continues. as a prosecutor before i ran for office i saw the impacts 0 this on a daily basis not just in

terms of addiction, and people needing treatment but in terms of property crimes, personal crimes for folks that are looking to try to find a way to get help. but the treatment options aren't there. there are not enough doctors, not enough beds, there's not enough wrap around services, not enough care. i'm hoping you can touch on the importance of creating these incentives through medicaid to make sure the incentives are in place to allow that marketplace to provide that care. >> so the bad news, as you indicate, there were 259 million prescriptions for painkillers opiates during 2012. that's more than one per adult in the nation. that's the bad news. the good news is that i believe there's bipartisan support for us to do something, and i believe that's both in the executive and legislative branch here in washington, d.c. as well

as with the governors who i met with over the weekend on this issue. i think with regard to payment it is an important place but there are three fundamental things we believe we need to work with the congress and governors to do. one in terms of the prescribing, that's at the root of the problem. we've seen progress in states like florida where they're watching the prescribing. the plans that states can put in place to oversee that is an important part. but we have a part, too. second is the issue of things like access to those which i think gets to the payment issues. and the third is making sure there's medical treatment. i think that was the third part of what you were mentioning. those three elements is a basic agreed upon. whether it's senator portman and senator widen or mr. rogers or it's across the board there is bipartisan support. states there massachusetts to kentucky and west virginia, my home state, are suffering in

devastating ways. and the one piece you didn't mention is the economic impact. having come from a large employer like walmart, what it means in terms of having an employee base that can pass a drug test. >> thank you, madam secretary. >> thank you. >> chair. >> thank gentlemen. the chair will note that we've just been joined by a group of students from the houston area. ranking members informed me. you want the say anything? >> i want to recognize the number of the chiropractic students from the houston area and the doctor who actually retired as the president of our chiropractic college in texas. i invited them last night because i wanted to show them how health care policy is made in the health care subcommittee. thank you, mr. chairman. >> thank you. you're certainly welcome to be here. chair now recognizes chairman, mr. griffith. >> we may have some disagreements today but i will tell you that the ranking member, mr. green and i worked very hard on a health care bill that was signed into law last year. no matter what you may see today, we do get along more

often than the press lets you know. all right. that being said, madam secretary, in response to a previous question you indicated you weren't aware of any of the laws being signed in. i'm sitting here with the crs report, congressional research service, indicating there are 12 bills that repealed obamacare that were signed into law. you're not aware of that, is that correct, in relationship to your previous answer? >> with regard to the specifics of the answer, those were repeal questions, i thought. >> yes. he said full or part? >> full. >> so you were mistaken and weren't aware of the 12 that were partially repeals. >> i was referring to the issue of full repeal. >> but you are aware of these? >> with regard i'd have to look and see. >> if i can have this entered into the record. appreciate it without objection. thank you, mr. chair. are you familiar with my hr-130? >> i apologize. i don't know what that bill is. maybe if it's described i might understand. >> it's a bill that deals with the loan provisions of obamacare.

>> i'm not familiar with that. >> i appreciate that. are you familiar with hr 790, which is the compassionate freedom of choice act. >> not familiar with the specific names of the legislation. >> and i appreciate that. are you familiar with hr 793 pharmacy networks in part d? >> depending on -- >> another one. so the reason i ask those questions is, it's been very well orchestrated today from a political standpoint the other side of the aisle have asked you repeatedly, are you aware of republican legislation that deals with the issues that we're dealing with related to obamacare. i would submit to you that in some way or another the three points you pointed out, each one of those bills did. you're not intimately familiar with them and i understand that. i'm not blaming you because you've been put into that position that sometimes happens where there's a difference between negative evidence and a lack of evidence. and what you've presented today is a lack of evidence. and i appreciate that. that doesn't mean that these bills don't exist. just as i gave you the numbers

on those three. it doesn't mean there aren't other bills that other members have that are out there that are republican proposal to take care of the american citizen while we are in the process of repealing obamacare. you're just submitting that you're not aware of it. but there are in fact bills out there that may be doing that and also further discussions behind the scenes that may be doing that that you're unaware of isn't that correct? >> the veterans bill that we all agreed on. the firefighters -- >> i'm just saying when you say, though, in answer to any number of members on the other side of the aisle that you aren't aware, that doesn't mean they don't exist. i just means you're not aware, am i correct? yes. all right. we'll move on. the president's fiscal year 2016 budget call for $92 million for the office of national coordinator, onc, for purposes including the transition to a governance approach for health care exchange. in 2012 a request for information noted that congressional authorities granted to the onc in the 2009 high-tech act would support this

governance mechanism. madam secretary, i hold in my hand a copy of a congressional research report dated january 7th, 2015 that suggests that onc does not have the authority to support the onc governance structure outlined in the president's budget. don't you agree that when agencies take action they should be supported by congressional authorization? >> not familiar with the report. would welcome seeing it. with regard to the office of the national coordinator, i think you know we just came out with the plan to continue moving us towards electronic medical records. we back that up with specific things. we continue to work on something that cuts across many of the issues. and whether it's -- >> but you would agree with the principle that there ought to be congressional authority for an agency to take action would you not, yes or no. >> i would agree we need authority. >> mr. chairman, if i could have that congressional research service report place into the record.

>> without objection, so ordered. >> as a part of its governance push, a contract was awarded to develop the safety center. rti said at the time it would define the governance and value of the health and safety content. i'm just concerned, as i pointed out a minute ago, that when you have these comments being made -- we haven't seen it yet and the report i just had entered into the record shows that we haven't seen the final analysis of what they're going to do. but when you have comments that they're planning to work on governance and they don't have that authority, i am concerned when the experts are telling me, both legal and otherwise, that this agency is going beyond its scope of authority, that this is a problem in this administration and that we should be careful that we have any agency moving forward without congressional authority. i'm going to ask you to work with me as we move forward on this. i'm going to follow up with questions and some other things

and ask that you work with me to make sure that the onc does not overstep its authority granted to it in legislation by this congress. >> i would work with you to understand and understand what these concerns reason governance are. this is new to me. i would like to understand further what the concern is. >> i appreciate that and i yield back. thank you, mr. chair. >> thanks, gentleman. i now recognize the gentle lady from california. five minutes for question. >> i thank my colleague for yielding me time. i do have a different topic to discuss with you, secretary burwell. but my colleague from texas has asked for ten seconds. >> i want to thank congressman from virginia. but i think the clarification is that up until congressman kennedy, all our statements were repeal the affordable care act without an alternative. there were bills that were passed and none of these up until congressman kennedy. there's not repeal and replace. there's only repeal for 56 times. thank you. >> that's why i responded to full repeal.

>> thank you. you know, i want to go back to the president's budget this year, which i think on the whole strikes an important balance between controlling spending and promoting public health. these public health topics are what i want to bring to your attention. i was pleased to see that there was continued support for nursing workforce development. i believe and i know you do too, a strong nursing workforce improves the health of our communities as well as the quality of the health care system. and we now have the significant challenge in our nation of caring were a growing population with limited resources. i'm a nurse so i know we can't reach our health care goals without a strong health care workforce made up of a range of health care professionals. these are the development programs such as title 8 that are proven to be a solution that can help address the challenge. so would you please discuss briefly, because i have two more topics, what this budget request does to make sure we have a

diverse health care workforce well equipped and large enough to meet our needs? >> i will just be very brief. >> sure. >> which is i think one of the core and anchor places that we do that is making sure we're funding the national health service corps. and the increases that we've asked for are an important part of that across. it's extremely important because we serve -- that group of people, 30% are diverse in that group. >> yes. >> and in the nation as a hole the number is 10%. so we are overindexing if that and we think -- i'll stop. >> this one is near and dear to my heart, that is the maternal infant and early childhood home visiting programs. such bang for the buck that you get with this if you've ever seen it, as i have been part of one. it's such a proactive and preventive service. there is an increase in commitment in this home visiting program in the budget for 2016. these are evidence-based, as you know, bipartisan programs

helping to ensure that all children across the board get an opportunity to be healthy and successful. and they are so critical to improving health outcomes for both women and children and families. so my question is, how increased funding for these programs is going to address disparities and improve the health? how can we make it better? >> so with regard to this issue, because i'm a mother of a five and seven-year-old, i've lived the importance of that information very recently in terms of being able to give your children what they need. and so the program that you're describing and why we think it's important to continue on the pace -- it is an evidence-based program. we've seen the results in terms of reading and other analytical skills up to 12 years old in terms of the benefits, that's as

far as it's been tested. we see what's happening. when we give mothers and parents that opportunity to get the information they need in home. when you go to them, it is making the difference. so we believe this is a very important part and part of a continuum that you see in the budget. that home visiting next come to the early childcare and making sure that we fund childcare so working americans can be a part of that. the issues of head start and improving head start both in terms of the length of day, time of year and the quality that we require. it is a continuum in terms of making sure we're taking care of those children along the way and pressing ourselves to improve quality. >> and to build on that in the focus of children and family, this question was asked about graduate medical education but i want to focus on children's hospital gme. because children's hospitals programs are so critical for training pediatricians, pediatric specialists and pediatric researchers.

it's less than 1% of hospitals, they train 51% of all pediatric specialists and the children's hospital graduate medical education programs currently receive much less funding than other -- you know, children don't lobby. we have to do this on their behalf. would you explain the proposed changes to funding for children's hospital graduate medical education programs and what steps are being taken to ensure that we're meeting the demand for pediatric care? >> we want to meet that demand and we want to meet that demand for both primary care and the specialties where we don't necessarily have the number of practicing physicians that we need. so the proposal that we have tries to respond to the criticisms that we received last year with our proposal, and that there's $100 million that is dedicated firmly to the children's programs. in addition to that, they are able to compete. right now what we do is we cover the direct costs, but we don't continue to cover the indirect costs. >> thank you very much.

>> thanks. now recognize the gentlemen from texas, dr. burgess, five minutes for questions. >> my apologies for being out of the hearing at another hearing. and i also apologize for not having the president's budget here with me this morning. but the president did outline a number of savings in the medicare space in the presidential budget. is that correct? >> yes. >> do i understand that correctly? >> that is correct. >> and in general, as the head of hhs, are you supportive of those proposals in the president's budget? >> yes. >> let me ask you a question, then. you know that one of the things -- i have just been pounding my head against the wall for 12 years on the sustainable growth formula. we were very close last year but didn't quite get there. i thought we had a good proposal and we're close to introducing the same policy language again in this congress. offsets have been difficult as everyone would expect.

so let me just ask you. those savings that the president identified, those medicare savings that the president identified in the presidential budget, do you think it would be a good idea to apply those savings toward the permanent repeal of the sustainable growth rate formula? >> with regard to how we pay for it in the president's budget, it is within the baseline and we include it that we. with regard to the specific question of just using our approach to the medicare, those savings are part of a broader context. it is a budget and we put the budget together in its entirety. we view that those savings need to be paired with other elements of the budget. >> but to the extent the offsets are identified in the budget, it seems to me that it would perhaps be a reasonable place to begin the discussion of what are the offsets that are used to put in place for the permanent universal complete forever repeal of the sustainable growth rate formula. >> first, i want to agree with

the concept that we're talking about. in my opening remarks i specifically said that we support the bipartisan concepts that were put forward. with regard to the question of offsets, why i started with how we do it, which is building it into be baseline, that's the way we believe it should be done, and that uses the balance of things that we use to pay for things in our entire budget. so in terms of where we start and what we believe, we believe that it needs to be a range of things and not simply focused on those. >> yeah, but at the same time, as you know, the difficulty with the sustainable growth rate formula is the baseline and the fact it was built in years ago and it accumulates over time, is never corrected. we basically pays for this damn thing at least 1.4 times over the past 12 years. again, i just want you to know, i like the fact that the president put forward cost savers in his budget. fair warning to you that these are where i'm going to go. the lack of participation in people who are willing to come

forward and talk seriously about offsets leads me to go to president's budget as the only place i can go for democratic ideas for an offset. and that is one of the critical missing piece in getting this sgr settled. >> i think your colleague actually though mentioned -- your colleague mr. pallone mentioned his specific idea for that when he spoke to this issue. you may disagree with that. but in terms of contributing to the debate. >> and my door is always open to pallone. i await his invitation. let me ask you a question. i know you probably are tired of hearing about king versus burwell. but i'll bring it up one more time since i haven't been here and it's not exhaustive to me yet. the whole concept around contingency plans and the american academy is concerned because insurance companies are supposed to disclose the data upon which they're basing their rates in may, but there could be

something that changes the equation in june. so the extent that the insurance companies are having to deal with this unsettled future, i mean they're going to have to deal with contingency plans, are they not? why should the department not have a contingency plan as recommended by the american academy of actuaries. >> with regard to things that i have authority to plan for, i will plan for. in the current budget, the unaccompanied children issue, one that i know is a difficult issue and there's controversy around, we've put in monies to plan up to 60,000, have asked for a contingency fund in case the numbers -- where there are places that i can plan, we will. with regard to this issue, that's why, while the letter was simple, it actually gets to the core and the fundamental. we do not believe we have administrative authorities. if the court makes a decision -- i always want to repeat. we don't believe the court will decide this way.

but if the court makes a decision that says and rules for the plaintiff and says that those subsidies are not available, the question of we don't believe we have an authority to undo the damage that would then occur, which is subsidies go away, individuals can no longer pay, they go off of their insurance, they become uninsured, it drives premiums up in that marketplace, they become uninsured, there's indigent care, it goes up. we don't believe we have an authority, if the court makes that decision at that level, that we have an authority to do it. and therefore that's why you're not hearing a plan. we don't have authority. >> i think you have to agree, it will change the structures of the risk pools. i'd like to submit the letter for the american academy of actuaries. >> without objection it's ordered. >> the companies filing the briefs that they've filed in the

case that articulate the point you're making. >> gentlemen yields back. chair recognizes the gentleman from maryland, mr. sarbanes, five minutes for questions. >> thank you, chairman. thank you, madam secretary. first, thank you for stepping into public service as you've done. your tenure at onb and now hhs is i think a real service to the country. i wanted to talk about this concept of full repeal which has been a drum beat for years, it seems now, from the other side of the aisle, to understand the implications of a full repeal. and so i wanted to go through some of the things that were part of the aca and ask you -- and it may not be that every one of them is jeopardized by a full repeal. but i think certainly some of them are.

so the aca included a measure that would allow young people to stay on their parents' health care up to age 26. and i think upwards of 3 million younger adults have benefitted from that. if there was a full repeal of the aca, would that benefit and provision be in jeopardy? >> it was part of the original act, so, yes.@e >> then there was an effort to begin closing the donut hole on prescription drugs under the part d program, which has bedevilled many of our seniors who kind of fall into that donut hole. often at a critical stage in terms of needing to access prescription drugs. and the aca reform included an effort that's begun underway to close that donut hole. would that be in jeopardy if there was a full repeal? >> it would and the $15 billion

in savings that the seniors have received to date would stop. >> right. and then there was terrific provisions in terms of reimbursement that, benefits and reimbursement. on the benefits side for medicare beneficiaries, you had more preventive care being covered fully, eliminating copayments for certain kinds of preventive care, screening for annual wellness visits, et cetera. that was part of the aca. a fuel repeal i imagine would jeopardize that reform as well? >> yes. and we actually were able to have the numbers and we have seen an increase in the number of seniors that are using that preventive care. and the percentage of seniors who are using one preventive service continue to go up. >> excellent. >> we put in some enhanced payment and reimbursement for primary care physicians recognizing that we need to make

sure we're incentivizing the provisions in terms of getting into the pipeline and also having the opportunity to spend more time with their patients and have there be some economic reward for that, which the patients themselves also want. i presume that would be peril with a full repeal as well. >> a full repeal would be peril. >> what about preexisting conditions? of course we started right out of the gate eliminating that discrimination in the case of children. now that's been expanded more broadly. but i imagine that also would be undermined by a full repeal? >> it would and having had the chance to meet a young woman who had cancer when he was 12 years old, first had colon cancer and then had thyroid cancer and now was in her 20s and was engaged but not continuing her graduate education or getting married because her focus was paying for her health care. and now the opportunity to have affordable care is -- because

she had a preexisting condition, obviously -- is now allowing her to go on with her life. the issues of health security are very important but for many individuals the financial security as well. >> thank you for those comments. the medical inquiry that requires insurance plans to direct more of the insurance premium dollar to care as opposed to overhead costs and so forth, that was part of the aca adhering to particular standard. that would be eliminated, i would expect, in a full repeal? >> in a full repeal. >> subsidies and tax credits for small businesses who want to do the right thing and provide health care coverage for their employees was part of the aca. so small businesses would be impacted by a full repeal in terms of their ability to offer that kind of benefit to their workers. isn't that correct?

>> it would take away the tax credit if it were a full repeal. >> so even before we get to a discussion of the pros and cons of the health exchanges, which have now offered up coverage to millions of americans, there are so many other reasons, in addition to that, that we wouldn't want to repeal the affordable care act. thank you very much for being here. i appreciate your testimony. >> chair thanks the gentleman. now recognize the gentleman from florida for questions.nb >> thank you for your testimony. thanks for your appearance. welcome. i want to talk about medicare advantage. according to 2012 data there were about 145,000 seniors in any district, about 40% of them are on medicare advantage. a little higher than the national average. they love their plans and they want to keep their plans. they love their benefits and their choices.

unfortunately this administration may not love medicare advantage as much as my seniors. this -- the actuarial firm did on analysis of the proposed 2016 medicare advantage. reading the report i'm troubled to learn that it estimates that the combined impact of cuts from 2014 to 2016 will cost seniors on an average of $60 to $160 a month or as much as $1920 a year. many of the seniors in my district live on a modest income, fixed income. why is the administration forcing many seniors to pay more than $100 a month to keep the plan they like? >> so with regard to the issue of medicare advantage, first i want to say we think the program is a good program. during the period when changes have been enacted, we've seen the program expand by well over 40%. we've seen the number of medicare advantage plans that have the top two ratings go from 17% to 67%. and we have seen that premiums

have not been increasing in terms of the changes that we've done to date. why we are proposing these changes is they have been recou$(v edpa#kc'd others with regard to overcoding that's occurring. and as part of our efforts to make sure we're using the taxpayer wisely, we want to promote the program and keep it healthy but we believe there are opportunities for those who may be not using the system as well as they might. that's what the changes are about. that's what we're trying to do, preserve and build the system but make sure we do it in a fiscally responsible way. >> thank you, madam secretary.sk-ñ medicare advantage program they have are going to lose it. in fact a recent report details that nearly four-fold increase in the number of u.s. counties that no longer have medicare advantage as an option. growing from 55 counties in 2012 to 211 counties in 2015. isn't it concerning to you that

seniors are losing the ability to choose a medicare plan that provides high quality and coordinated care? this is a very successful program and again this is extremely important to my constituents. >> agree that it is a very important program and we want to make sure it continues. i want to see the study and the underpinning of that. the most recent numbers i've seen are that 99% of beneficiaries have access. i want to understand what the difference in that is. >> thank you, madam secretary. one more question. the impact of seniors to medicare advantage according to oliver wieman could result in seniors losing access to their current coverage or facing higher premiums, reduced benefits and changes to the network as a result of the cuts. the proposed cuts. when i talked with seniors in my district about medicare advantage, they believe the model offers high quality

coordinated care. yet further cuts will disrupt the benefits upon which millions of seniors rely. your agency like to tout the so-called affordable premiums and better consumer choices under the affordable care act. but when it comes to medicare advantage, why is the administration pursuing policies that would increase premiums and reduce choices for seniors. it's very concerning.e1hto ié@uit >> i think the response is that with regard to the issues what we've seen with the changes to date have not had the premium pressure that's described. we want to continue to watch and monitor. and also we've seen more people enter in and the quality improve. that's what we've seen to date. we want to continue to work and monitor. we want the program to succeed. we want to support it and try and do it in the way that's the most fiscally responsible. >> thank you, madam secretary. i appreciate it. i yield back. >> now recognize the gentlemen from texas. >> thank you, very much.

i appreciate the opportunity to have this public dialogue for the benefit not only of the members but for the public as well. preserving access to prescription drugs that work for every senior is important. i think everyone here and every person who cares about a senior in the country, which probably makes everybody. my question has to do what proposal in the president's budget would increase access for seniors? >> with regard to the specific access for seniors, across the board on prescription drugs i think in terms of the programs, in whether that's the way we use some of the programs that we've just been discussing. one of the most important things that's happened is seniors have access to preventive services that they may not have been. just announced on tuesday that what we're seeing is because the seniors have the access to the preventive services they're increasing that -- the use of that.

i think throughout our budget, one of the things we're attempting to do is work very hard to do a system, delivery system reform which means getting better quality at a better price for the nation. and i recently announced about three weeks ago that in the medicare space we're going to try and move to 30% of all medicare payments will be in new payment models. payment models that are about improving that quality and reducing that cost. so those are some of the areas that i think the budget focuses on this. >> now that effort, is it likely to create an environment individual by individual that's likely to increase their quality of extended life versus -- because when we're talking about access to preventive care, that means that if you catch something in its early stages, we all know with today's modern medicines and opportunities you can actually thwart it or actually overcome it versus finding something in the latent

stages, it might take your life, correct? >> across the department there are a number of investments that get to that. and whether that's nih investments in research or in the center for innovation, medicare and med a cade, one of the things that we have out, a proposal has to do the hospice and how to combine them in a way to maximize for the quality of the patient. and so it's throughout the budget, the issues of cost and quality are the things we focus on. >> thank you. on that note i'd also like to add for the record, if you would allow me, mr. chairman, to support the letter for the record from my office that lays out the issue that we're discussing at the moment. >> without objection so ordered. >> thank you. >> i keep hearing a lot from some of my colleagues about their constituents losing choices. but then again, one of the things -- it's my understanding, please clarify. when people are talking about

losing choices they may be describing policies that were in fact more expensive on the front end and perhaps didn't have minimum benefits standards to the person paying. is that in many cases what people are describing when people are losing choices? >> it can be. i would want to understand the specific -- >> that's why i say the word maybe. >> within the marketplace there are 25% more issuers which means for choice. the essential health benefits do important things, as i think you're reflecting. and they get to some of the issues that mr. murphy and ms. matsui on mental health. having those benefits be clear and incorporated is extremely important. so without understanding the specific case i think it's a little hard to know. >> but there are in fact in some areas where certain kinds of policies are not allowed, but that is based on a new minimum standard, correct?

>> that is correct. >> and one of the things that i've discussed with some of my constituents, my staff and some of the providers and experts that we've pulled together, we registered at least over a thousand families. and i personally tried to speak to as many of those individuals as possible. and what was sad is many of them were even scared to be there. they were thinking about this big obamacare dragon that was going to obliterate either their finances or their health care. but what almost to a person, every person that got up from once they sat down and figured out what was available to them or what have you, had a big smile on their face and were very pleased and very relieved and very glad they came. in one instance i was talking to a gentleman who was paying $60 a month, he was making $9 an hour. single income family. he had a wife and a daughter. i met all three of them. and when he was done he had a big smile on his face. he almost got up and left when he met me.

but when he was done he actually realized that he now was able to provide for his family without having to spend $60 a month and now his entire family has coverage. that's a perfect example of what's good in the affordable care act. thank you, mr. chairman. i yield back my time. >> now recognize gentleman from indiana. five minutes for questioning. >> thank you secretary burwell. i want to thank you for working with governor mike pence of indiana which will help to cover 350,000 low income hoosiers in a state based program that i think has been shown historically to not only save money but is very popular with the enrollees. thank you very much for that work. before i came to congress i was a cardiothoracic surgeon and i treated my patients many weeks after their surgery. and as you know that falls under a global payment, a 90-day global surgical payment by cms. now cms wants to repeal that rule and eliminate global payments for surgical services. why? >> with regard to our

understanding of how the global payments are used, the reason that we want to do this is make sure while we're promoting quality care that we do it in a way that is most cost effective for the taxpayer. most of the changes that we do in medicare space are focused on those two things and trying to balance those two things. >> has hhs or cms looked at the administrative cost it will have on doctors? i'll give you come examples of how this will work or won't work if you do it. we would bill a global payment for everything, including follow-up visits. and now doctors will be billing for their surgery, every hospital round that they make, every follow-up appointment, all separately -- let me finish. and not only would the medical practice have to pay employee to submit all of these excessive claims, but then cms will have to process each claim. how can that not cost cms more money, not less.

that's my first question. >> with regard to the global payment issue -- and one of the things dr. patrick conway, we try to have physicians practicing at the table as we have these conversations. want to understand the point you're making and how we believe -- i want to look in into this one in terms of a specific answer to your question. >> it will be a dramatic increase. if i did an open heart surgery on a patient, i would see them in the icu anywhere from three to five days every day and then probably two to three follow-up appointments. that's all under a global. and so now that -- those numbers will be submitted as individual bills. from a surgeon's perspective i see this as -- i think seniors should be paying attention to these comments. this is going to be a dramatic pay cut for surgeons across this country.

in my view that's where any potential savings will be coming from. as you look at this, you better -- you should really -- i'd encourage you to pay attention to that. because what will happen is you're going to have to reevaluate every code, reevaluation of every follow-up appointment, you're going to have to discern whether there's duplicative billing. if i see a patient postop and a critical care is seeing my patient that day, who gets paid, who doesn't get paid. there will be increased denials. my point is this. global payments were put in place to save money administratively and also simplify and i think improve quality health care. going backwards away from that is regressive, regressing backwards. yes, it will save money. this will save money by dramatically cutting provider reimbursement. and if that's the intent, that's unfortunate because what will also result is access issues for seniors for health care services and, i would argue, less quality health care. and so, you know, most of these

bundles are reexamined every few years. and so, you know, the argument that overbilling is occurring, if that were to be true, these bundles are looked at every year and re-evaluated. on that subject i would encourage you to take a really hard look at global payments. they save money. they don't cost money. the savings will be on the backs of seniors access to health care and quality, in my opinion. the other thing is that the president east budget would seek to save $25.9 billion by strengthening the ipad board, a board of unelected members selected by the president in my view to cut medicare payments to providers. the president has not nominated anyone to sit on the board and could not recommend the medicare cuts this year. in what year in the president's budget will they begin to make recommendations on medicare cost? >> in the current budget, it could not kick in until 2019.

>> thank you. thank you, mr. chairman. i yield back. >> chair thanks the gentleman. now recognize the gentleman from new york, mr. collins. five minutes for questions. >> thank you, chairman, thank you secretary for being here today. i'm from western new york, a very rural community. we have one of the highest enrollment of medicare advantage. i know prior to the affordable care act i would say that without a doubt one of the bright spots in the delivery of health care in the united states was medicare advantage, dealt with the donut hole, it was a lot of comfort for the seniors to be able to go in much like we do with hmos, and great program. and yet, as was brought out earlier, and i want to get into this, it seems as though the president and the administration and hhs views medicare advantage with some level of disdain in

that it's the piece that keeps getting cut. and as i look through some of the data, and i'm kind of a data driven guy, the interesting thing i found about medicare advantage, there is over 7 million enrollees, represents 30% of the medicare population which would indicate it works. number two, when you look at who uses it, lower income beneficiaries have a higher enrollment in medicare advantage than do wealthier individuals. which means it's serving best some of the lower income populations. we've also seen that when i look at the rural plans, again, in rural america, which i represent, a higher percentage of folks from rural america are using it. so i'm just asking the question -- and the interesting thing, too, the bad information we got today say that current .9% cut that's coming now in the subsidy to insurance companies for medicare advantage

is going to add another $20 a month to beneficiaries in higher premiums or reduced benefits. so could you speak to just the opinion of older opinion e americans on medicare that they are being used as the funding source for the expansion in medicaid? and all of those increases costs on the back of our seniors who have depended on this great program for all of these years? the frustration level exists within that population. >> i appreciate that. as i responded to your colleague with regard to the issues of medicare advantage, i would say we support the program, believe

the program is a good program. but also believe that our responsibility where we think there are things that are happening, whether these upcoding or other things, that we try to take care of that. the changes that we've done, we tried to transition the changes, do them slowly so we watch and monitor. we've seen an increase in the number of people in medicare advantage. we've seen premiums hold steady and an increase in quality. so the negative impacts that were articulated at the beginning we have not seen. we want to continue to monitor an make sure we don't see some of the negative impacts you're talking about. we value the program. we think the changes recommended and we understand the concerns. but trying to operate in a world -- with regard to the other issue that you mentioned, across the board, whether it's the issue that your colleague just mentioned with regard to providers or the $780 million that we do in discretionary cuts, we try to spread these things across the entire parts of our budget? >> but are you aware that there are now over 200 counties in the united states that don't have a

medicare advantage plan at all to offer their seniors as a direct result of the cuts you've made? so when you say it hasn't had this impact, there are seniors in over 200 counties in the united states that can't even buy the coverage. >> so 99% of the nation has coverage in terms of the beneficiaries accessibility. >> but yet the number who don't have increased from 55 counties before the aca to over 200 today. so there's a direct impact. i mean the numbers -- the data is the data. you can't make it go away. >> with regard to those numbers, as i said, i have the number of the current coverage and would want to understand the change. >> what i'm trying to point out is it has had -- the reason you're looking for this funding is to pay for the expansion of

medicare, whether it's the health information tax or the individual mandate or whatever. the big cost driver has been this huge expansion in medicaid would be my observation. >> what i would observe is some of the comments that have been stated about the question of overall entitlements in the growth, we have a bulge, a population, we have a large group of people who are elderly in medicare. the medicare costs, even though we've controlled per capita costs for medicare over the period of what we're seeing, because more people from the baby boom are retiring and older, that's an issue that we're going to have look at and deal with. medicare costs are going to increase because of volume. and so with regard to the questions of what will be costing the nation money over periods of time, the issue of medicare is one on a -- because we're going to have the baby boom and the echo come through, we're going to have to continue to make good on the commitments that we've made. and that will cost us because even if you control it per capita, volume is greater.

>> thank you for the answer. my time expired. yield back. >> chair recognize the gentleman from new mexico, five minutes for questions. >> thank you very much. i would yield to ranking member mr. green for a quick response as well. >> thank you. i want to respond to my colleague from new york. i don't -- i'm not have any of any seniors question the expansion of medicaid based on what's happening with medicare. the affordable care act was totally paid for and in fact medicare was improved under the affordable care act. and madame secretary, this is the first i've heard that seniors are complaining that the medicaid expansion is being paid out of medicare. that's not a fact i hear about. do you have any information about that. >> that's the first that i heard that anyone felt that was an issue with regard to the federal budget. i assume that's what they're referring to. >> if the gentleman would yield one minute. >> reclaiming my time. thank you for your testimony today. i want to reiterate what many of my colleagues have said, that we must repeal the sgr.

but not on the backs of seniors. and that a strong chip extension must be included with sgr in march as well. also that the affordable care act is working, despite an attempt of over 50 republican repeal attempts. the aca has had a positive impact on new mexico in my home state and my home district 25,000 people now have quality affordable health coverage because of the affordable care act that didn't before. and overall the numbers of uninsured declined by 17%. americans can never be discriminated against because of preexisting conditions. women can never be charged more for coverage because of their gender. and americans will never be sold health nervous policies that disappear when they need coverage most, when they mitt the lifetime caps and suddenly coverage goes away. i think that it's time that we come together and work to strengthen the law and stop playing political games that will strip million os americans of the health coverage they depend on. as my father would say, enough is enough. madam secretary, in your opinion, has the affordable care act had a positive impact on

places around the country, including my home state of new mexico? >> yes and i think it has in three areas. affordability, access and quality. with regard to the issues of quality, you touched upon a number of the areas where i believe there's been improvement in quality, those are the fact that people can have their children covered up to 26, the quality that you don't -- if you have a preexisting condition, you can't be kicked out or throw awe off of your health care. if you take your child in for wellness visit, there isn't coinsurance. you don't have to pay for preventative care. we've also seen increases in quality through partnerships we're doing with physicians and we've seen a 17% reduction in harms. those are things like infections and falls in hospitals. that's also about savings lives but it's also about money. with regard to the issue of affordability and the progress that we've made on affordability, we can all still continue to make more we have inu

>> i appreciate it. thank you for your response. and i do want to raise an issue

that is great concern do my constituents and myself back in new mexico. it's now been over 18 months since the state of new mexico claimed credible allegations of fraud or their allegations of fraud against 15 behavioral health providers results in the eventual closure or replacement by five arizona behavioral health providers. this transition has raised significant concerns across access to care, especially in light of recent reports that the new providers are financially unstable. the recently elected new mexico attorney general released the audit that led to the suspension and it shows a lack of underlying basis for allegations of fraud. we had several meetings and i'm concerned we're not making progress. when payment suspensions are put into place, what can they do to ensure that they're agenting in good faith. and how can we stop this from happening in new mexico. can i have your commitment to work together to meet with the

delegation. >> i do want to work with you on this issue. >> thank you very much. >> we recognize the gentlelady from north carolina. >> thank you for being with us today. i'm sorry, do you have some water there? we could get you some water. i want to address before i -- i have three different, very different questions to ask you about, but i want to ask you about medicare and our seniors who are concerned. it is my recollection and i'm just go back to history that over $700 billion was taken out in order to pay for obama care. whether or not our seniors are concerned about that, i would say yes, they are concerned about that and they want to make sure that they want to be able to continue to get the good care they deserve.

i want to start off by talking about medicare reimbursement in relation to the 2% sequester cuts put in place a number of years ago dramatically affecting our chemotherapy drugs. as you know, this has effected our industry back in january 14th of 2013 office of management and budget put out a letter base which i asking federal agencies to "use any available flexibility to reduce operational risks and minimize impacts of the agency's core mission and service of the american people. and it goes on. some of the adverse things that have happened as a result of the 2% cut over 16 months after cms started applying the 2% cut we basically ended up with 25

community oncology clinics closing, one of which a very large clinic in my own district and 75 others merged with hospitals. it cost $6500 more per year per patient on oncology services if they become part of the hospital system versus the clinic setting or outpatient setting, and about $650 more out of pocket. why hasn't cms taken the recommendation of omb and addressed that situation? >> we agree with you and in this budget we fully get rid of sequester on the mandatory side. we agree with you this is not an approach, when you use and approach like this you end up with the types of things. we're willing to make other choices for how we get those savings.

>> thank you, i will just go on and a very important question having to do with, essentially our tobacco products. and my question for you is do you agree with mrs. zeller that if smokers who were unable or unwilling to quit switched to vapor it would be better for the public. do you agree with that statement? >> i'm not sure, we want to promote the health and make sure we're go the right research and put in place the right guidelines and regulations for it. >> thank you, i want to add that there are no government issues that address or promote this issue. it would be helpful for the public to understand there are non-tobacco products available, and i welcome the ability to continue to work with you and

your office on any way that we can better help to get that information out and draes the needs from a scientific basis welcome the ability to continue to work with you and your office on any way that we can better help to get that information out and address the needs from a scientific basis, and using the scientific research that's out there. i do want to switch gears to our vaccines and barta. right now they have a stockpile of roughly $1.7 billion worth of pandemic influenza vaccine. this year's budget i believe was about $20 million to take care of that stockpile and maintain it. does the 2016 budget increase that amount and into the future, how does barta plan on dealing

with those issues, especially when we know that we're in our situation where this is a very timely issue. >> across the board, we have worked to do a few things to make sure that vaccine stockpile, and the issues that barda handles, making sure we have what we have on hand in stockpile and what we have to work with manufacturers to bring new programs online. where that is appropriate. but we also have paired that with other things in our budget. it has to do with communities and we have seen that front and center. we are implementing the dollars we appreciate from congress in terms of that in terms of ebola and broader preparedness where we have been give than authority by the congress. >> thank you, secretary burwell for being here today. i truly appreciate your input. thank you. >> the chair thanks the gentle lady. that concludes the questions of the members who are present.

i'm sure we'll have lots of follow up and written questions from some of the members. we'll get those to you promptly. we ask that you please respond to the questions promptly. i remind members they have ten business days to submit questions for the record. that means they should submit their questions by the close of business on thursday, march 12th. thank you very much madame secretary for your attendance today and the answers to our questions. without objection, we are adjourned.

the supreme court yesterday heard oral argument in a lawsuit challenging government subsidies for people who buy insurance on the federal health exchange. on friday, the court is releasing audio from the oral argument. and you can listen to it friday evening on our companion

network, c-span at 8:00 p.m. eastern. at the white house yesterday, press secretary josh earnest was asked about the case. >> i think as a practical matter it is important for people to understand that there is no contingency plan that could be implemented that would prevent the catastrophic damage that would be done by essentially undermining the affordable care act with an adversarial ruling on this. and we have been pretty clear about that, that there have been a number of questions we have received about, like, well, you know, if the case goes against you, what is the administration going to do or what is the administration planning to do if that eventually comes -- if that eventuality comes about? and the truth is, there are no easy answers. there is no simple step, no obvious step that anybody can take that would prevent this catastrophic damage from taking place. we would see millions of people

lose their health insurance. we would see prices would likely go through the roof. and there is not a whole lot frankly that the government could do about it other than congress passing legislation to fix it. but i think we're all pretty realistic about the likelihood that's going to happen because we have majorities in both the house and the senate that a, struggle mightily to do even the simplest, most politically popular things like funding the department of homeland security, but, b we also know that they have fought tooth and nail to try and undermine the affordable care act from the beginning. the reason they have done that is not entirely clear to me. but that's their position nonetheless. so you know, i've never -- i have not encountered anybody who has said look here is an easy way to avoid this problem other than through the legislative path, which is frankly not one that is available.

>> you can hear the supreme court oral argument from the case on subsidies for americans buying health care coverage on the federal insurance exchange friday on c-span at 8:00 p.m. eastern. the interior department's budget request for next year totals $13 billion. an 8% increase. interior secretary sally jewell testified about the budget last week before the senate energy and natural resources committee. the committee's chairman alaska senator lisa murkowski, questioned secretary jewell about the administration's plan to permanently restrict drilling in 12 million acres of the arctic national wildlife refuge. >> call the hearing to order this morning. we're here this morning with secretary jewell and mr. connor, thank you both for being here. we're here to review the president's budget request for

the department of the interior for fiscal year 2016. i just want to make sure i got the chart. and i'm going to spend a little bit of my time here this morning in opening comments to talk about the many ways in which this administration and the actions are having impact, negative impact in hurting my state. secretary jewell, you and i have had many opportunities to visit one-on-one, as well as your trip to alaska which i appreciate you making last week and i don't want to make this personal, but the decisions from interior have lacked balance and instead of recognizing the many opportunities that alaska has with regard to resource production, you have enabled an unprecedented attack on our act

ability to responsibly bring these resources to market. the president has withdrawn over 22 million more acres of alaska from energy production just in recent weeks and that has occurred on top of many other restrictions and regulations being imposed on us. it's occurred despite the tremendous energy opportunity and potential in those areas, despite our no more clause, despite the pressing need to refill our pipeline and despite strong opposition from most alaskans. the map that i have behind us is one that my colleagues are going to become familiar with because i'm going to be pointing it out quite frequently. the colors on the map represent those areas that are withdrawn from any development opportunity whatsoever. some are, in fact, proposed

critical habitat areas and so they are not fully withdrawn at this point in time. but we have the anwr new wilderness proposal, the mpra withdrawal onshore. north aleutian basin offshore and critical habitat, the wilderness already in place, the national parks areas, as well as the federal lands. i just remind my colleagues this is one-fifth the size of the united states of america and so when you take off all of these areas for any development at all, how do your states -- how do your states operate? what do you do? what do you do? so i have expressed my frustration, privately and in public and i will continue to

express my frustration and try, try to achieve some positive results for the people of alaska and really for the good of the country because as an energy producing state, this is what we do. we share these resources with the rest of the country. i want to be very clear today that it's not just me that is banging the table. i don't think that i am overreacting. i think i am speaking clearly and articulating the concerns of most alaskans. we had an opportunity last week to be in a northwestern community and the second joined us. the entire alaska delegation, all three of us, the governor, the lieutenant governor, the leadership of the house and of the senate numerous native