with regard to the gao question you just received the gaming of the system and the process, is this such a ramp ant phenomenon that it is undercutting the very pittings of the affordable care act? are we dealing with an issue in which as you get more information you deal with it? >> at this point there are a number of gates and efforts on program integrity in place. and that's the initial information gathering which we check at the hub at that point. when this that goes through, when we don't have data matching as i said within 90 to 95 days we review those tai cases we take action. at the point of the filing of taxes and the examples that were given, folks didn't file their taxes, that's the next place where that would occur. and the next gate will occur in terms of if people chose not to file their taxes for some reason. that's the point at which subsidies will go away. we have a number of gates in place. we are implementing those.

if we can understand place where is people think those aren't working, we do want to understand that so we can work to improve. >> the gao shared their methodology with you, and those examples -- we are waiting for that, correct? >> we are looking forward to gao coming out with recommendations which is the part that has not yet occurred. >> thank you. the president's commitment to early childhood education, it's reflected in the budget proposal $1.5 billion extra for early headstart -- and for headstart itself. briefly, if you can tell us the budget levels and spending caps established by the majority, what's that going to do to the fact that you are trying to build capacity you are trying to stress quality and accountability for providers for these children? and what does that do to capacity? >> with regard to the levels i

think that if you are going the meet those levels and you want to fully fund headstart, what it will mean are dramatic cuts to things like nih or cdc in terms of other places. i think we have put together a budget that is a budget that as i mentioned there is savings in terms of deficit reduction that comes from the hhs budget as whole. that we put together a plan and an approach that affords us the opportunity to fund all of those things. but at the current cap levels you would not be able to do that. so you would not be able to implement the changes in headstart or you would have to make dramatic choices in other places. one of the largest budget areas for hhs is nih. >> and i think the last point, community health centers, that was mentioned briefly in your testimony. at least in my community that's an essential network for health delivery, an essential part of the affordable care act delivery

system. if you could talk to the committee as to that role and how the budget that you are talking about is reflecting an continued commitment that the president made to the health centers at the inception of the affordable care act discussion. >> we appreciate the work that was done also in the sustainable growth rate bill in terms of these issues. the community health centers serve approximately one in 15 americans actually are served by community health centers. we think they are an integral part of care, an integral part of primary care. a very important part as we expand access that we have an ability to sever. that's why he was extended as part of the original affordable care act and are extended now as we see the number of uninsured drop so there is places for people to go because of that. we believe they are an essential part of coverage especially in communities that don't have as much, rural, minority or other communities, that these are an important part of that.

they are also an important part of integrating the behavioral health and primary health together so we can get to the place where that type of coverage is one. >> thank you. i yield back to the chairman. >> the gentlemen yields back. we are going to move members to four minutes. we are watching the clock. i can't seem to get it to slow down. mr. you go three you are recognized for four minutes. >> thank you. madam secretary thank you for being here again. i appreciate it. i want to talk about through employer sponsored health insurance, the small market group definition. affordable care act in section 1304 expands the small group definition to 100 employees. concern ready employers from 51 to 100. if you are below 50 you are not mandated to provide. once you start growing then you are able to self insure when you have got a bigger pool so a lot of bigger businesses aren't having the same issues. so the trap seems to be -- and i've heard from a lot of

employers and insurers, and actually a lot of colleagues on both sides of the aisle have been working how do we fix this problem. i've seen estimates of a 30% increase from different studies but the issue is employers from 51 to 100, if they go into the small market group definition will have expendive mandated benefits. and there is a big concern. as i said it's bipartisan over here in the capitol. so i just wonder if you have looked at this issue and what actions are you looking at taking? >> looking at the issue right now, one of the things i would ask is we can follow up with you and your staff to make sure we are getting the comments you are hearing directly from employers or other groups. it would be very helpful. there is another side in terms of expandsing the other market that people argue but would love to hear directly if you have those comments as we are reviewing that. >> absolutely. >> it would be helpful to hear the specifics of why people assume it will work the way that

you describe it working. there are others that argue the other side of this issue. it would be helpful if we can follow up on that evidence. what i understand in terms of a policy perspective, and then the question is would have we have authorities. >> they are the two questions we are examining right now. it is a timely conversation. if i could ask that we follow up with your team or you directly -- >> absolute. >> to have those comments i would appreciate having the facts from the field to inform our conversation. >> there is a bill, hr 1624 it is 158 cosponsors and bipartisan bipartisan. it's not just a -- it is a very bipartisan look at what's going on. having said that, mr. chairman, i have a letter. we'll share it with you from 19 employer groups regarding this. i'd like to enter it into the record. thank you medicine am secretary. and i yield back. >> gentleman yields back. mr. courtney you are recognized for four minutes. >> thank you mr. chairman. thank you madam secretary for your accessibility since taking

over. mush appreciated. just for the record i wanted to note we had a great opportunity to talk about observation coding issue which still is a widespread problem out there for folks who are discharging from hospital and unbeknownst to them find themselves in a coverage gap for medicare to cover medically prescribed services. since we spoke about the two day midnight rule i got a she have of information from folks that again i will show with you why this is not a solution to this problem. but i will move on. if chairman mentioned earlier about the insurance rate increases that were reported a while ago in the press. i would just point out coming from connecticut a state which embraced this year, is now in year three of its exchange. just a couple days ago some of the insurers who participated in the exchange revised down ward their initial rate requests. anthem came in at 6.7.

revised down to 4.7. this is prior to the rate review. the co-op came in with a 13% rate increase. they revised down to 3.4%. the largest insurer on the exchange, they came in with a whopping 2% increase earlier. they have now revised downward to .7%. i point this out because there is a cohort that has claims experience under its belt now. the fear amongst actuaries that the walking woundsed in the exchanges were going to spike up in recent queers, we are actually seeing incredible stability in terms of the rates. we are also seeing new insurers coming into the marketplace. harvard pilgrim is now knocking on the door and is coming in to sell their product in connecticut. again, your department has been boosting the insurance department rate review piece of this. i was wondering if you could share from a global standpoint, you know whether or not some of

these fears are overstated. >> with regard to the rate issue, it is i think what you are pointing to is one of the things about the act that is important is about adding transparency and the light of day to things in the marketplace to make a market work so that individuals have information and that there is pressure in the market to make it work. and that was one of the ideas. and so when people saw the rates, the rates that were reported are only the rates really in most states that are above 10% because that's required. if a company is going the raise the rates above 10% part of the law it it has to be posted we have to report it while the insurance commissioners review it. that's the other part. it needs to be reviewed. it doesn't just happen if they propose it. if they are going to propose above a 10% they need to justify it. that's a part of the process at work. what you see in terms of connecticut and what just happened is, that creates downward pressure in terms of the public pressure and the requirement that you have to justify rate increases. we think overall what we have

seen last year is that the rates come in here and there is downward pressure. we also see in states like connecticut and actually california just came through yesterday. and their rates were at 4%, lower than their increase of last year. so that's what we will continue to watch and monitor. the reason we recently had a conversation with the state insurers to make sure they know and are using that tool of rate review to put that downward pressure which we believe is an important thing to do making the market work. >> as a former small employer who double digit increases were just a matter of of course to see a 2% or a .7%, really that is eye popping in terms of the stability. >> the difference. >> i yield back, mr. chairman. >> gentleman yields back. mr. barletta, you are recognized for four minutes. >> secretary burwell my district is home to abusinesses

that sell cigars to adult consumers. they are concerned about the expansion of the fda's regulatory authority under the tobacco control act. their shop serves a disstichgtly adult clientele. i don't believe this category was the intent of congress in 2009 when the law was passed. can you tell the committee what steps you are making to ensure such businesses which are a staple of main street america are not regulated out of business? >> with regard to -- right now as we are in the middle of a rule making process i think you probably know that we actually proposed two different alternatives as part of the rule. to gather the evidence and information with regard to the question of premium cigars and how they are or are not sold to children. that was a part of what we are trying to do. and we are reviewing that. and we are in the middle of that process now. having said that as we are in that process a part of your question was the recognition of small employers. and that is something that will

be taken into consideration no matter where the rule ends it's something i think is very important that we do as we think about implementation. and so wherever the rule making comes out, as we are in a process. but i do want to recognize the point that you've made which is making implementation for small employers and small institutions possible, whatever it is. it's something we consider a real priority and something we believe no matter where you are we can work on as part of the implementation. >> the proposed deeming rule has been under consideration for more than a year. regulatory uncertainty is exceptionally challenging for small businesses who are trying to plan for the future, as you know, open new stores, hire more workers, serve their customers. when do you answer this rule making to be finalized? >> i'm hopeful we will do it as quickly as possible. i think yours -- the issue you've raised is one of many

complex issues we have been faced with. trying to do it as quickly as possible. we appreciate the point you made about uncertainty again in terms of recognition of what this means for the business community, especially small layers. >> unk. that i yield back, mr. chairman. >> gentleman yields back. ms. bone -- bonamica you are recognized for four minutes. want to spend my short time talking about the older americans act which recently celebrated its 50th anniversary. and i want to thank chairman cline and ranking member scott. i know they are working together with my colleagues and me to successful rereorganize. and thank you for calling out the issue of elder abuse which includes physical as also

financial abuse. i have three questions. what i will do is tell you what the three are to save time. first, as we know, the population of older americans is changing rapidly. can you talk about what steps you are taking to modernize the administration for community living programs as our older population is becoming increasingly diverse? secondly, when i talk to people about the older american's act they know about the nutrition programs, especially programs like meals on wheels. we know that the population of seniors is expected to double by about 2050. so we all support investments that mr. erld yield greater efficiency. can you talk about what your department is -- how the department is promoting evidence-based practices among nutrition providers and how you plan for innovation in those essential nutrition services? we know that oftentimes that's the only social contact seniors have as well is with that meal. my third question has to do with family care giving.

77% of caregivers say that family caregiver support services make it possible for them to continue to care for their loved ones and keeps the seniors at home. but of course it's hard work. and training and respite care services for caregivers is very important. many of the care gives are in the sand vich generation taking care of parents and children at the same time. what is the department doing to prepare and support the large diverse community of caregivers? >> i will quickly try to work through each of these n. term of the modernization, part of the modernization, how we went about doing the white house conference on aging and getting that -- because it was a different approach in terms of being out in the community, using technology, including the white house conference on aging people could participate through technological approaches. changing the way we think about our work in terms of technology. and the fundamental idea of people's engagement in our programs and their feedback

being more customer friendly and doing it in ways that use technology are two things in terms of the modernization. in terms of the evidence based practices around nutrition and meals i think that's a broader category of what i would consider prevention and preventive care and making sure we are doing that correctly. that i think is actually centered less in acl and more with cms. and it's also a part of the affordable care act in terms of people knowing they can do preventive and wellness visits without copays. those numbers are increasing. we need to increase them more so that the people accessing these services are not increasing. nutrition and wellness come into that as well in terms of how it fits into the broader thing that i think changes that and the larger piece. the last piece is the ferry family care giving and encouraging that staying in community and home. you have seen our most recent

rule making at cms which is an important part of reforming the delivery of our health care and paying and encouraging ways of providing that care at home. the rule making are probably our most effective tools because those are the ones that scale broadly and because payment is an important part of how people are making the decisions about staying in a commune and making a change. >> thank you so much. my time has expired. >> mr. carter you are recognized for three minutes. >> ms. burr cell, earlier this year you received a letter along with secretary lou from a group of employers work forces with variable hours. it was specifically to address the employer notice and appeals process because it's very important for employers to get notification about employees who have received subsidies. otherwise, those employees are going to be facing tax penalties if they declined a more

affordable employer plan and accepted the subsidies. so this is very important. it's my understanding that as of yet, none of those employers have received anything from hhs. can you give me an idea, just a date, of when you expect to give notification to employers? >> mr. carter, i -- this issue is one i'm not specifically familiar with. but my understanding of what you are talking about is it is a treasury issue because what you are talking about is tax information on the individuals in terms of if they have received an aptc. and that's a matter that is -- >> can you get back to me with a date. >> i'm happy to raise with second lou the question you have raised. >> fair enough. photo fix to the employers. you would agree that those employers who have multistate locations it would be better if they got one notification as opposed from every statement that's also i'm very concerned about. i will hope you will look into that as well. you do agree obviously that it is a burden on these employees

when they have a tax penalty at the end because they didn't accept employers more affordable plan. so that's what we are trying to get at now, right? >> what we want to do is make sure that where employers should cover as appropriately they are providing a choice and. >> it would help if the employers got notification. that's what we are trying to achieve here. right now you are using a paper system. do you have any idea when you will be going to a computer system. >> a paper system i'm not sure what you are referring to. i'm sorry. >> i will a he get clarification on that and send you a letter later. >> okay. >> in your opening statement you said over $100 million would be given to states and used in prescription drug abuse. i am the oernl pharmacist currently serving in congress.

i have witnessed firsthand people's lives, families, careers being ruined as a result of prescription drug abuse. one of the limitations on that for pharmacist, medicare limits pharmacists in what they can do about this. there is a bill, 592. i hope you will look at that. this is something that needs to be addressed. this is an epidemic. it is the biggest drug problem, prescription drug abuse. it has gotten out of control. in georgia i sponsored the prescription drug abuse prevention program that is now law. please look at that law hr 592. mr. chairman, i yield back. >> gentleman yields back. mr. pocan you are recognized for three minsz. >> i'll go quickly. thank you for being here, second burwell. first i'm glad to see the nih increase in the budget.

the funding as you know it has been especially hard. i have the university of wisconsin in my district which has a lot of research going on. one of the things we have noticed because of the cutback of funding is that now the age of the average first time grant recipient is 42. used to be 36 in 1980. a lot of young research remembers looking at other areas to go into. and we want to want to keep the talent there. we have introduced a research act trying to address those concerns. i'm wondering how you would address the younger researchers. >> in term of the years we have been through recently with regard to everything from sequester to shut down. it's just like the ability to create the certainty for the small businesses. people having certainty knowing how things are going to run is how they are making their decisions. if you are making decisions to get a ph.d. in a particular area that's a long period of

time, you are making a financial commitment and you want to know there is certainty at the other end. i think we can create the certainty that the funding for this research is going to be there. that's one of the things we want to work to do. which is why we have in this budget a billion increase. >> working with those younger scientist we have had ideas too we would like to propose at least while the sequester is still out there. secondly. around the states that haven't done the medicate expansion unfortunately, states like my state, wisconsin, where governor walker is in the increasingly smaller number of states that haven't done this. we would save $400 million in the next two years in our state. 85,000 people would have additional health care. as you look -- i'm glad you met with governors about this. as a member of congress this is frustrating. i tried everything i can to get

funds back to my state and soo see something like this. what can we do for states that have governors who refuse to expand this. >> that is where the decision as you know stits with the governors and the state legislators. continue to work. but i think one of the most important things is articulation of the benefit, both the economic, job creation, and what it means in terms of state budgets as well as the individual. obviously, that's the place where we focus our most attention. >> i'm going to wrap this thing up. if you also need names of people who have told us they benefitted from the affordable care act -- i go into little towns in my district small business they come and they grab their husband from upstairs their wife to tell me this is the first time they have had health care. i have had hair givers stop me in the grocery crying because this is the first time she has had health care. if you want those things, contact my office. >> gentleman's time has expired.

mr. russell you are recognized. >> thank you mr. chairman. i would like to thank you madam secretary for your service to the nation and also to your charitable work. as a small business owner that has a small work force well under the 50 threshold i've seen a 68% increase in health insurance that i provide my employees over a two-year period. do you believe increasing the cost of insurance will encourage or discourage small businesses providing insurance? >> with regard to the 68% increase is it people uptaking, taking it up, or is it the cost itself itself? >> it's the cost itself. we are part of a pool, being a light manufacturer. and so we don't -- we can't do the groups on our own but we can pool with ours others and we have seen a 68% increase in two years. >> have you seen is it particularly incident driven having worked at the small employer at one point in time when we would have -- we had a couple very large cancer cases

or a number of pregnancies at one time. was it those types of thing? what we want to do is get to the issue. what you are describing is a case that is not the experience we've seen for most so i want to understand so we can understand why it happened. >> we have not even filed claims. we have been in business for five years. my second question is in the hhs's 2011 report entitled drug abuse warning network, it cited that 455,000 emergency room visits were directly associated with marijuana use. further supporting documentation shows multiple adverse health effects. do you believe the president's policies in not enforcing federal law on illegal marijuana states that violate the law promote or prohibit hhs's goals on emergency care reduction and drug abuse prevention? >> with regard to the hhs role in this space of marijuana, we are the research the regulator

the educator and the treatment. with regard to the issue that you've raised in terms of the question of the health impacts of this, it's something we are spending time -- you may know we recently changed a rule that will lead to increased research that we hope will afford us the opportunity to do for and better education in the space of the damage. >> my final question, and you certainly don't have to comment on the ongoing investigations that will be necessary and that sort of thing. but given that hhs provides significant title 10 funding to planned parenthood, do you believe personally that the harvesting of infant body parts to be moral? >> as i said, this is an issue that has an important issue that has strong fashion and strong beliefs about the importance of the research and other beliefs. what i think is important is that our hhs fundsing is focused on the issues of preventive care for women, things like mammograms and cancer prevention screenings with regard to our relationship there. with regard to the other issues, the attorney general i think has

right now is under review to make determinations on what is the appropriate next step. >> i yield back my time. thank you mr. chairman. >> gentleman yields back. ms. adams, you are recognized. >> thank you, mr. chairman. thank you ranking member scott. madam secretary, thank you for being here. and some of my questions have already been answered but let me first of all say that i have, over the years, appreciated planned parenthood's good work in promoting health care for men and for women. and i'm a little bit disheartened by all of the attacks undermining the good work that they do. having said, that let me move on to affordable care. my state of north carolina is one of those 24 that did not expand medicaid. we are looking specifically with all of the great benefits i'm still perplexed why our governor and our legislature decided not

to do that. 317,000 or more north carolinians would have had it. i know you have met with the governors. my question is when we look at north carolina having one of the highest rates of uninsured adults in the country standing at 24%, it is critical that we take a serious look. and what are the options? are there options for folk in my state or in other states that have not expanded medicaid who may want to consider it in the future? are there options that they have? >> with regard to the options for the individuals, i think that is why community health centers are going to continue to be extremely important in terms of ensuring that people who don't have coverage have care. they are an important part of that. with regard to the options in terms of states making decisions to do that expansion we want to work with states. we want to provide them with different options and opportunities. that's when the 1115 waivers are

about. we have done that. we've done that with governor pence in indiana. that program is up and fully running. there are other governors i'm having the conversation with. we look forward to understand what are the core consideration of the state in terms of moving to that coverage gap that you have described in north carolina which is one of the largest states in the nation now. >> thank you very much. for somebody in my position -- i did surf serve in the legislature for 20 years. i'm still at odds with the governor and the state legislature about it. can you give me suggestions how to push them along and to get closer to insuring the low income people in north carolina? >> i would defer to you on how to you work with your own state good afternoonor and state legislature. the only thing i will say is when you look at kentucky and the analysis that has been done -- in the state of kentucky -- and this is by an accounting firm in the university of louisville. 40,000 more jobs and $30 billion flowing into the state by 2021. and so that from an economic

perspective just is -- seems to be an anchor of a place to talk about. >> yes, ma'am it makes great economic sense for us to do it. i'll certainly continue to push those folk in north carolina. thank you madam secretary. mr. chair i yield back. >> there madam gentlemen lady. mr. allen. >> thank you mr. chairman and thank you madam secretary. i -- you have got a tough job. it's hard to -- it's hard to deal with some of the issues that are coming out of this process. but i tell you in georgia, obama care is not real popular. we are having major problems down there. in fact most physicians i meet with says that nothing has changed. emergency rooms, people show up still without health insurance. they see very few patients. you might check with some of the hospitals, you know, their elective surgeries are off

something like 80% because of the high deductibles. it's just one problem after the other. but what i want to zero in on is this planned parenthood thing. and i would like some commitment from you here today on when your department will conduct an investigation on this very, very serious matter. not only is the unconscionable but they are breaking the law. and it's -- it is a big issue with the people of this country. i mean, it's -- what i hear about every day, what are we going to do about this? can you tell me when are we going to do something about that? >> i do want to -- just one moment on your affordable care act and that issue. in the question of expansion in a state like yours. we have seen the percentage drop of the number of uninsured

coming into emergency rooms we have seen a drop there. with regard to the planned parenthood issue, as i have said, this is an important issue and one that there is passion and emotion and belief on many sides of the issue. i want to respect that. with regard to our funds iffing, we do not fund abortions at the federal government. our funding for planned parenthood is no another issue space. with regard to the issue you raised which is the question of whether it is a legal issue -- and there are laws and there are statutes that guide the use of feels tissue that are in place and should be enforced. with regard to investigating or looking into those issues, as i said, because it is a statutory legal issue, the department of justice and the attorney general has said she has taken those issues under review and will determine what the appropriate next step is. >> and that will include your investigation? i mean it should be like all hands on deck on this thing. >> with regard to the question of a legal matter -- and you you

know i defer to our colleagues at the justice department. we will support them in anything they need or want from us. we always do that. but with regard to making those decisions of the question of an investigation of a legal matter -- >> so you don't have personnel that can look into this? >> with regard to what we do have at department of hhs, is this is not an issue in terms of us funding this specific issue. when we do have issues -- >> you deal with medicare fraud. >> the gentleman's time has expired. mr. desaulnier. >> briefly on the issue of planned parenthood. as i understand it there are multiple investigations in california. the state attorney general is investigating the issues, including if the people who actually took the film violated the law. but i have two areas for questions for you. one is your work on prescription drug abuse as my colleague from georgia mentioned. it is a very large issue. 45 americans die a day, according to the center for disease control. the u.s. has less than 5% of the

world's population but consume over 80% of the opiates in the world. that's a huge cost issue both financial and from a human side. so in california, we are switching to an electronic monitoring system. it's been getting up and even people who questioned it were starting to support it. my question is what are things you might think -- i'll ask both questions and let you go given the time constraints that we might be doing on the federal level to help states like california and new york and georgia. secondarily, coming from a high cost state where we are very proud of the aca in california, sort of 2 opposite of what one of my colleagues brought up, attracting physicians. >> i'm sorry, the second issue? >> the second question was the opposite side of high cost states and reimbursement rates. and because of that, we are having a difficult time attracting primary care physicians in california, particularly young people to go into that field.

>> on the primary care, let's start there. in terms of how we are structuring our graduate medical education level in this budget is actually to focus funding on gme on places with rural districts where we have shortages and other specialties. what we are doing is using our tools to encourage people to go into those specialties and create a pipeline to go into places. with regard to prescription abuse, 250 million prescriptions every year in the united states. that's enough for every adult in the unk. this is an acute problem. one, i objectprescribing. we have going after prescribing. monitoring programs are seng. get those up and working in the states. that's a lot of what i'm spending my time and conversations with governors. second is access to noloxone.

that is the drug that when someone is in overdose actually saves their lives. the question of how that's accessed is an important thing. the third is medicated assisted treatment. and for all those who are addicted, trying to get that transition. i met a woman in colorado who has been clean four years. and her journey there from having her wisdom teeth taken out, becoming addicted and going to heroin is a journey we don't want people to travel. so getting that medicated assisted treatment and those other things in place are three specific evidence based approaches. >> thank you madam secretary. thank you mr. chairman. >> thank the gentleman. mr. bishop you are recognized. >> thank you mr. chairman. thank you madam secretary for being here today. i appreciate your testimony and discussion. i know there are a dozen windows open right now. i want to talk about the exchange enrollment issues i'm seeing in my office.

it is an ongoing concern with constituents and i want to make sure while i have your attention i address this concern. the government accountability office put out a report highlighting various shortcomings of health care.gov which resulted in numerous fictitious enrollees gaining access to coverage and subsidies paid by the american taxpayers. in the meantime as i've said i've heard from an even number of my constituents one an he can doetd after the next, very frustrated with regard to how this is working. purchased or tried to purchase on the website insurance only to have their coverage canceled because of a minor mistake they made on their application. and by the time they get to me they are furious. and i can't say that i blame them. as a parent who has a family and is expected to provide for my family, i -- my heart goes out to them. but it becomes my -- me being

the reason why. they also have problems getting the issue corrected. and lackluster communication with the department, how we can correct the issue long wait times. there are just so many issues with regard to this. and the gao's information suggests that significant fraud is being rewarded while at the same time some of these minor mistakes are being punished. i i'm wondering what we can do to address that. if you've had this same communication from other members. if we are addressing them and you can quickly comment on that. >> first of all with regard to the communication coming into your office, rooef reach out to me directly. let's work on those individuals and work through those individual issues. reach out to us. our office we will work on those. with regard -- actually, it's both sides of the coin.

the gao we don't actually know we don't know when they falsefightified, whether they falsified social security, the small issues. what we are trying to do is program integrity and that's your folks are getting caught in. they have done that. we are doing it in a strict way. that's what people are feeling. we are trying -- if you don't provide the data that's required to say that your income is x or to say that you are of a certain status, that's what is happening to the examples. actually we don't exactly know because the gao hasn't soeltd told us what are those examples. those are two related things in terms of us doing the program integrity that we are being asked for. we don't know that the examples of the gao are more than the examples that you are talking about. when we get to recommendations we may know that. at this point we don't. so we are trying to do program integrity. but we want to make sure if there are individuals because many people, we don't have the right information but still may

be eligible. pleat let us know about those samples. >> ms. wilson. >> i ask unanimous consent that the office of the assistant secretary for planning and evaluations research brief showing that increases in cost sharing can discourage low income individuals from assessing necessary medical care which can have negative health consequences be entered into the record. >> without objection. >> second burwell, thank you so much for being here today and for working with florida, especially and headstart and elder care and all of the other things that you do. i appreciate your testimony on how obama care is working for the american people. and i call it obama cares because i believe that obama cares about the people of this nation. and that's why we have this health care law. it's here to stay. it's the law of the land. the people of florida are much better off because of this.

we have led the nation in new enrollments through the federal exchange. my district 24 has a third highest number of people in the nation who benefit from subsidies. unfortunately, we have not expanded medicaid. but i thank you for your commitment to working with the florida legislature and the governor to expand medicaid. and consider me as a partner in this pursuit. and hopefully for a better outcome in the future. i also want to thank you for help in securing low north carolina pool funding for florida. that was very special to us. i want to thank you for your testimony on the importance of investment in high quality early learning. so i comment commend you and the president for your commitment to expanding and investing in early education. i have several questions i want to try to combine them in one. the president budget includes an additional $1.5 billion to

improve quality headstart. why is this crucial? what is headstart doing to ensure that all headstart children in early child care are eligible, have access to high quality early learning? what is at stake if our nation ignores the ever growing body of research? and can you describe how the revised program performance standards will help? and can you please speak to the negative impact of spending caps? >> so i will try to get through as many of those as i can with our time. one is with regard to the changes, there are a number of changes that are a part of the proposal and they are about using the evidence with regard to extending the day. and the question of extending the year. but there are other person changes in terms of what curriculum should be used in terms of the teachers. and those participating. there are also a number of safety issues making sure that the grantees and others that are doing the services do it in a

safe way. we are also trying to reduce the bureaucracy to make it easier for people to come in and apply and be a part of that system. so we have put the money in the budget to match the changes that we have proposed as we go forward. with regard to the -- >> i'm sorry. the gentle lady's time has expired. mr. messer. >> thank you mr. chairman. thank you secretary burwell for being here. i would like to talk little bit about the 49er phenomenon under the affordable care act. the fact that it only applies to businesses of 50 or larger. so there have been question of businesses staying in that 49 threshold not willing to hire that 50th person because they would make themselves subject to all the mandates and requirements of the president's health care law. the administration has helped ease that burden somewhat by delaying that 50 figure up to -- making it up to 100. so that businesses that were 100 and less wouldn't be forced to

require -- wouldn't be required to comply with the law. could you talk a little bit about the rationale of lifting that to 100? why was it businesses 100 and less that the administration said wouldn't be subject to the law up until 2016? >> so, i think there are also two different issues in terms of application proportions of the law. and some of those have to do with what benefits, but also what category. and so i'm not sure this is a question of -- >> you are not forcing the employer mandate under your delay for business of 100 or less until 2016. i'm just trying to get at it what was it that made you decide to lift it to 100 from the 50? >> with regard to that issue. it is 96 --s we look at the number of employers. and even when we go to those higher levels i think we believe that employers at this level tub providing that type of care and can do that. and you can do that if there are

pooled markets and affordable ways. that's what we believe can be done. >> to the precise question of why you lifted it from 50 to 100, why was it that you said businesses 100 and less could be delayed until 2016? because the law says 50 and less. >> i just want to make sure you are referring to which piece? because we've already had a conversation earlier i think you heard about a particular question of the provision of whether or not 50 to 100 applies to whether those small businesses, which market they will be in. and those are two different things. >> i only have so much time, i think it's clear that you guys have acknowledged that businesses of 100 and less are small businesses that make it difficult to comply with all the elements of the law. i have introduced legislation, hr 2881, the small business job protection act of 2015 that would make that level of 100 -- businesses of 100 employees and less the permanent standard under the law just essentially

theining the lay that you moved in to 20616. it's not really a trick question. i think that the reality is that there are a lot of very small businesses that have 50 or less employees and the mandates and requirements this law are difficult to comply with. i think businesses of 100 and less would like to see the mandate go away entirely. they are at least a different kind of business than a business of 50 and less. appreciate your testimony. >> thank you. >> gentleman's time has expired. mr. polis. >> thank you madam secretary. back in april i had the opportunity to visit the headstart program at the wilderness early learning center in boulder and i have seen firsthand the benefits that headstart can provide for communities. as you know head starts are given to nonprofits community centers and traditional public schools no. charter schools have received such grants and very few have pride in. can you explain what you are doing to ensure that charter

students know they are eligible to apply for head start grants? >> this is an issue i am not familiar with in terms of charters and application for headstart. >> we would be happy to hear from you about a specific plan to make sure the charter schools are aware of what theythe opportunity to play and what they need to do. >> the policy change eliminated the lifetime ban and replaced it with a one year deferral policy which on the margins can save a few more lives. while it is a positive step forward i'm hope you can speak about your opinion whether the policy reflects the reality. in fact, the fd arc's own blood drop survey found the prevalence of hiv in gay male blood donors

was .25%. lower than the regular population, .38%. would the hhsa consider a term of risky behavior rather than blanketing gay men. >> as well as the penetration of hiv in particular populations. we are always welcoming additional. >> i believe it's self reported abstinence, not self reported monogamy. is that correct? >> i would have to check what the self report. >> with would you be supportive of moving to self reported monogamy? >> what we are open to is reviewing evidence in term of the decisions we are making in the space. we believe the decisions we have made at this point are evidence based. if there is additional evidence we should know about we always welcome it. >> i'm looking forward of your implementation of the self reported monogamy recommendation which i'm certainly in strong

support of as an indication of risky behavior. certainly those who are in married or monogamous relationships are at lest risk than those who are not. i yield back. >> mr.en stefanik. >> thank you mr. chairman, madam secretary thaink thaenk thank you for your testimony today. the current -- section 1511 of the health care law requires employers to automatically enroll new employees and continue enrolling current employees into their health care coverage giving employees only a very small window to choose to opt out. this mandate takes away the at for employees to choose coverage that best meets their needs and could result in a loss of take home pay to cover possibly more expensive health insurance than they otherwise would not have chosen. i've introduced hr 3112 the be open act to eliminate this harmful and unnecessary

provision. could you specifically discuss whether mandatory auto enrollment can trigger penalty for employees receiving specific of that implementation issue, an issue i would defer to treasury. implementation of tax portion is a treasury issue. as you probably know we have guidance out for comment right now and with regard to the specifics of that, that is a place i would defer to my colleagues with treasury and we can take that question and give it to them. >> what about those employees who become en rolled in double coverage because of the mandate and miss the 90 day wend in which to opt out. should those employees be penalized by paying multiple penalized because of the aca. >> with regard to the specifics of the questions in terms of the detail i would want to know what the treasury is thinking with regard to this issue so i

would want to coordinate with my colleagues at treasury. >> i look forward to getting a response from the department of treasury but i believe this is dube lickive and unnecessary to require employees to automatic enroll employees in health plans where they have little choice and sometimes they don't have knowledge of that. i understand you want to defer to the department of treasury but i think it is a broken aspect of the aca and i would like hhs's feedback on. i yield back. >> yield back. mr. jeffries. >> thank you, mr. chairman and madam secretary for your testimony here today and your tremendous leadership. i want to begin by asking a question about sort of providing care to some of the most disen frenchized economically isolated individuals in this particular case. many of the constituents that i represent over the last couple of years, we've had a crisis throughout brooklyn with the

closure of several safety net hospitals and in other instances significant financial distress that many of the safety net hospitals have experienced largely as a result of perhaps the over lutization of certain aspects of the hospital the emergency room for issues that could be taken care of a primary care context for instance the fact that traditionally in disin franchised individuals you have a mix of individuals on medicaid or indiggent or uninsured or the access to private insurance has not been a healthy mix and it has created a situation where the safety hospitals are under severe financial set and that is giving to change given the on set of the affordable care act which is tremendous but there is still an effort to direct individuals more into the primary care context and away

from the overutilization of the safety net hospitals and can you speak about what the administration is doing and where you think we need to go one of the things the administration is doing as part of the over all effort there are are people newly insuranced and the employee base population has access to many new services in terms of prevention and at cms, we are working on coverage to care. and it is both for thousand newly insuranced and in the insurer base market to understand how to access a primary care physician and get a health home to start to solve some of the issues and to do things as simple and even in the employer base market understanding your bill those kinds of thicks are -- things are comeplicated and difficult to do and at cms we about to use -- we want to use the resources and comes back to the medicare point

where people don't know they can get access to these points without copays to focus on greater educate to get people into those settings. >> and is that also a part of what can be helpful moving forward. >> it is. and as you know, we proposed to extend that. >> thank you. i yield back. >> yields back. mr. brat. >> thank you, mr. chairman. thank you for being with us today. i have two quick questions. i just got dinged from five minutes down to three. so i'll make it quick. on obama care claims good for the economy the basics in 2014, cbo reports they expect obama care will result in a 2.5 million person job reduction and reduction by 2024 and 2.5 million people times 40 hours a week a100 million hours and for the year and you get 100 million times 50 weeks in a year and you're at 5 billion hours in

labor productivity gone due to the single program and that is the response i get when you walk door-to-door, small business to small business from people on the street. is that we can't hire anybody, this is devastating us. and so i'll ask for your remarks on that. the economy is already struggling to keep up with a 2% rate, if that. and so the claim that the program is good for the economy i struggle with. and secondly i'll ask for your response at the micro level i have constituent who have approached me with concerns about the fda proposed rule to regulate premium cigars they don't have youth access issues sold at youth establishments and the goals of the tobacco goals were to prevent negative health effects from habitually oozed products neither of which apply to cigars and by the fda own estimation again over half of

premium cigar stores will be shut down if fda chooses option one if the proposed regulation and on this too how do you justify the regulation when it is eliminating so many jobs and have great a impact on my constituent. >> with regard to the premium cigar issue we asked for the evidence with regard to child use and we put out two different proposals and as we review that it is about the evidence we ref with regard to the question of premium cigars and child use getting to the core part of the statue that we articulated and we'll continue to work on that. with regard to the broader economic issue in the same cbo report we know that the reflection in the out years with the affordable care act in terms of why there is long-term deficit redestruction and about productivity and as well as cost and we see large numbers in terms of the out years and as that works through the system. the other thing as we think about the issues of jobs and job creation, we've had the longest

stretch of job creation as the nation in terms of constant stretch of job creation and wee see -- we have not seen rise in the number of people who are looking for -- at that 40 hour level. >> let me ask you on that. the generic phrase we've seen an increase in jobs isn't consistent with the clear evidence that the work force papgs rate is at the -- participation rate is lower in history. we are gaining jobs but the labor papgs rate is at an all-time low. >> i'my, the time is up. >> my colleague from california asked you about graduate school medication and i want to association myself. in river same county there are

34 primary care physicians for every 100,000 people. half of the number of doctors needed to provide adequate access to care. and i understand the gme levels have been frozen under the medicare and medicaid budgets since around 1996. so any -- so i associate myself with the exchange. i hear from my colleagues about rise in healthcare costs and mr. courtney of connecticut commented on the slow rates of growth there. if that case it is a good thing. the affordable care act is bepding the cost curve. last year it grew at the slowest rate since 1960 and inflation at the lowest rate in 50 years. just this week as you mentioned in your testimony, california released the premiums for the 2016 plan year. statewide the average increase in premiums is just 4%. that is even lower than last

year. and a far cry from the years of double-digit premium growth we had before the aca. coverage california announced that consumers shop around they can reduce the preems by 4.5%. that is incredible. can you share how the aca is containing health care costs. >> i think you out lined a number of the places in terms of the downward pressure in terms of premiums and also in what happens on competition. people can go in the market place and shop in the individual mark. and we've seen the downward pressure in price in the employer base market and the only other piece is it is important to reflect we've had a reduction of $317 billion in the projected medicare spending from the period of the past. >> before my time is up. how many years has the solvency of the medicare trust fund been extended thanks to the aca. >> i want to say 17. it is 2030 and when we came in

it was in the 2017 range. 13-17 years. >> 17 years. >> 13-17. it is 2030 and the previous number -- i don't know what the previous historical number was. >> so the cost containment seems to be working and i congratulate all of us for standing by the law. i know there is much more we need to do -- need to do to fix it. i'm going to run out of time. so mr. chairman i yield back. >> gentleman yields back. miss clark. >> thank you mr. chairman and thank you madam secretary for being here today. i appreciate your leadership in so many areas especially early childhood education and access to affordable high quality health care for all americans. today i want to focus in my brief time on a topic that has come up with my colleagues from georgia and california around the opiate crisis and i commend you for your recent announcement and hope that congress will support the $100 million that

you want to invest in this crisis. as you know, it doesn't matter when it comes to opiate abuse, whether you are rich or poor your level of education attainment an area where we are seeing growth is in women using heroin which has more than doubled in the last decade. i introduced legislation called protecting our in fants act which focuses on care for babies that are being born dependent to opiates but it also looks at the effectiveness of programs specifically aimed at women in helping with substance abuse disorders. can you discuss any efforts you've made to evaluate and respond to the circumstances of unique populations including young women and others in addressing this crisis. >> with regard to -- i think it is especially important and

especially pregnant young women to get into medicaid and assisted treatment quickly. just a week ago i was in colorado visiting a clinic that did this work. and they do it -- they do medicaid assisted treatment but they are an integrated facility so a woman can come and work on these issues at the same time she gets here prenatal care in a facility all in once place and so the emphasis is something we believe is a key part with this type of population so we are protecting that newborn. >> another area -- shifting gears but still talking about pregnant woman and new moms is the issue of postpartum depression. >> yes. >> i just dropped a bill today looking at this, to hope to expand grants to states. one in seven new moms will experience this depression. can you talk about your efforts in this area and what we can do to improve screening and access

to treatment. >> we believe this is part of the prenatal care to make sure people know and understand this issue and it is part of behavioral health and that was done through the affordable care act and done in terms of the mental health care act and so it is all about maternal care. it is not about one or the other. it is lin element of maternal care. it is asking the right questions as part of the wellness visits and that is part of the delivery system reform across the board. >> thank you. i yield back. >> thank you. mr. cash ello, you are wrapping up. you are recognized for three minutes. >> thank you mr. chairman and thank you madam secretary for your time and testimony here today. the rising costs of health care coverage is a major issue for people in my community. i'm talking employers and employees and one issue that is starting to come on people's radar is the cadillac tax, the

40% tax on so-called high cost plans has resulted in many employers making changes to the plans to avoid a -- hitting the tax in 2018 because of the same time they have to offer minimum value coverage to avoid an employer penalty. so it is a careful balancing act employ yours are trying to make. according to towers watson. 84% of businesses expect to make changed to full time employee health benefits over the next four years. we hear stories about lowers -- employers making changes. miami-dade county public schools, the second largest employer in the state of florida reported to me they could see devastating results from an estimated $500,000 impact in 2018 up to a $10 million impact

in later years. madam secretary, if we are concerned about the cost of coverage, wouldn't it make sense to get rid of this excise tax because it is forcing the cost of coverage to go up for employees? shouldn't the answer be to get rid of it and offer employees what they are being offered and i see this as an example where the government ends up hurting the people who most need the help. when you are talking miami-dade county public schools that is a lot of teachers and low income earners and now they face losing their health insurance or seeing fewer healthcare benefits as a result of this tax, could you share some of your views on this issue? >> yes. one of the things is that for those populations and those communities, the types of in creases that we're seeing in terms of the percentage increase in premiums was existing. some of the shifts in terms of

how companies are doing cost networks, those were occurring already. by having the downward pressure of the excise tax and people's interest and controlling health care costs we believe it is something that does put downward pressure on over all cost. the other issue at hand we have to consider is the federal deficit and the question of any changes in how it relates with the federal deficit those are the two questions that come to the fore. it has downward pressure on prices and the second is the fiscal responsibility issue. >> and do you have any concern for the low incomeerners that don't make a lot of money but for many years and i can speak as a former member of the miami-dade public schools, they knew they had a good health care plan they and their family members can prolyon they could lose their plans is that a

concern. >> the gentleman's time has expired expired. i would like to recognize mr. scott for any time he has. >> i would like to ask one question. >> please. >> just a brief question. my zinged colleague from virginia asked people who might lose their job because of the affordable care act. can you make a comment about the effect of job lock and how that creates the situation referred to. >> just that the question of job lock and those numbers have to do with many people making a choice to start their own business. i think the other things in terms of job creation with the medicaid numbers we see increased jobs because of some of the changes. >> and so, when you talk about people leaving the job, because they were only working on the job because they had a pre-existing condition and wouldn't have insurance before and they count that as a bad thing that they have another choice to leave the job i think is not looking at the positive effect that the affordable care

act has. so i want to thank you for talking about the president's priorities especially health care early childhood education, the effect of sequester on all of the programs and i look forward to working with you as we go forward with the budget. >> thank you. >> thank the gentleman. madam secretary, i just have a quick follow-up to clarify an earlier question you were asked about planned parenthood. i know that came up a couple of times. as you pointed out an issue, there is a lot of passion. just wouldn't to be clear. is it your testimony that the department of health and human services had a no intention of looking into this matter. >> what the department will do and we didn't discuss it today, with regard to the issue of our grantees and in the department of nih, the part of hhs that does the research there is funding with regard to grantees and some of the grants use fetal tissue. with regard to that we're making sure that what we do have in

place, which is clarity around the issue of the fact that for any of those grantees that are going to do that research that as they come through the process, and before we do the grant making there are terms and conditions that clearly list what the law is with regard to fetal tissue they need to assert and ser they understand the laws and they will abide by that and then an an annual basis with regard to when they reup the grants we ask them to ser again they will obey the laws and the terms and conditions of this specific place. so with regard to the piece that interacts with the department, these are steps that we are taking to make sure that we have appropriate procedures in place to make sure that people know the law and ser that they are -- and certify they are abuying by it. >> and so the activities abhor ant that are the actions of planned patient hood, you believe that is solely a matter for the department of justice,

is that correct. >> with regard to the determination if a law has been broken, in those cases, that is the department of justice. if there are concerns with the grantees we want to refer that to the ig or the department of justice, depending on the circumstances. >> thank you. i want to thank you. you were very indulgent. we went over by eight minutes. i appreciate your patience and coming today and no further business, we're adjourned. >> thank you, mr. chairman. [ meeting adjourned ] when congress is in session c-span3 brings you more of the best access to congress with live coverage of hearings news conferences and key public

affairs events and every weekend it is american history tv, traveling to historic sites, discussions with authors and historians and eyewitness accounts of events that define the nation. c-span3, coverage of congress and american history tv. and we are back with meghan mccarthy editor and chief of morning consult here to talk about the health care law. and what is next for it. the senate voted this past weekend to try to once again repeal the affordable care act. what was this vote, what happened? >> so this was actually the first vote that the senate has taken since the republicans won the chamber in january to repeal the affordable care act. so it was a couple months longer than i think a lot of people anticipated when they won. it was largely symbolic. it fell obviously 49-43. a couple of republicans were out since it was a sunday vote. so it likely would have gotten 50 or 51 votes with everybody

in. but it obviously created a lot of fireworks in the next couple of days. >> let's listen to what the majority leader from kentucky had to say mitch mcconnell trying to convince senators to vote for it. >> this is a law filled with higher costs, fewer choices and broken promises. this is a law that has failed repeatedly and that continues to hammer hard working middle class families. the vote this afternoon represents a stark choice for every senator. protect a president who likes a law with his name on it or stand with the middle class by finally opening the way to truly affordable care. >> the majority leader mitch mcconnell there talking about trying to once again dismantle affordable care act. with this vote failing, any efforts to try again. >> so there was a lot of

fireworks over the past day or two. senator mike lee and the hardline conservative republicans accused mcconnell as using this a tactic to placate the set of the base to vote for xm or for the highway bill. and mike lee did have a plan to try to use sort of a procedural tactic to get the senate to vote once again on repealing the affordable care act and having that be ruled jermaine to the highway bill. that blew up last night. and so now it is kind of a wait and see situation. and there is a lot of pressure from conservative groups on the right to use reconciliation to repeal the affordable care act. it is something that they could theoretically do since they hold the majority in the senate. of course president obama would likely veto those efforts. >> and harry reid also came to the floor during sunday's debate

over the discussion about what republicans were trying to do. here is what he had to say. >> so today's vote is about caving to special interest. this is about the republican and their leader desperately trying to appease their base. i'm really appalled. and more than that, disappointed by this continued partisan attempts to strip away insurance coverage for almost 20 million americans. congress pass the the affordable care act and the president signed it into law and the supreme court has put a stamp of approval on it not once but twice. an it is time for republicans to move on and not take a political vote that is going nowhere. >> and that is the senator saying it is going nowhere but how do house republicans feel about it. >> there was a july 24th blg deadline for committees with jurisdiction over health care to report their instructions and

how they were going to go about trying to repeal the affordable care act. it was a symbolic deadline and all of the knitties -- the committees did miss it and the observers on the process did say it is a sign there is disagreement or there is not really a plan yet or not everybody has come around about how exactly to use reconciliation to appeal the affordable care act and whether or not they should be focusing on the affordable care act with reconciliation considering that the president has said he would -- he would veto that effort. >> and what has happened -- it has been a month since the supreme court ruled on king v burwell. what does it mean to repeal the affordable care act. >> so the king v burwell act did put a freeze on what the house and the senate did when it comes to the affordable care act. there was waiting to see what the ruling was if the supreme court had found against the

administration, that would have meant a lot of activity on the hill addressing the subsidies that might have gone away if the supreme court rules against the obama administration. so it is picking up the pieces now and starting over again and figuring out when is the best timing politically to move the efforts. >> morning consult has done its own polling on the affordable care act. what are peopling saying -- what do americans want the lawmakers now and those running for president in 2016 to do about it? >> so the opinions on the affordable care act have remained pretty stagnant over the past five years. we did some polling in june of 2014 and then again in this month of this year. and found there is a slight uptick in people saying that they want congress to actually expand the law as opposed to repeal it. i should say the largest group wants congress to make changes to the affordable care act to

improve it and then followed by the repeal group. but there is a little bit more of a positive move. >> and when they say expand in what say? >> so the way the question is phrased, expand the law. it is up to the interpretation. but i think it is get insurance to more americans. the laws that brought the uninsured rate down to the lowest amount since goal on has been tracking those numbers so i imagine that that is what they are talking. >> we're talking with morning consult meghan mccarthy about the affordable care act. what are your thoughts on the law. start dialing in now. how is it working for you. taking your questions and comment this is morning. democrats 202-748-4 thousand. and independents 202-748-202. and so any other future legal challenges since the latest

efforts to repeal it in congress have failed. >> there are some legal challenges. the republicans in the house have sued the law. nob have -- none have raised to the level that king v bur got to. that being set that was a dark horse for a while. it survived two major challenges. i would guess there won't be a third of that level but you never know. >> and hhs secretary burwell will be on house testifying on the house side and what do you expect lawmakers will be asking her. >> well i think that some of the intense vitriol or politicking about the affordable care act has died down in the past few months and so i think this hearing will be a lot more about the programs that hhs has that fall under the more he had case

type of things. but there will still be difficult questions about insurance premiums and whether or not people are going to be able to afford the coverage that they are getting now in the exchanges if those prices continue to rise. >> by the way, we'll have coverage today of the hearing. you can watch it online on c-span.org with the hhs secretary before the house education and work force committee. what is the next phase of the affordable care act? what comes next with the rollout? >> so most of the pieces are in place now of people able to go on the exchanges and get insurance. i think with the king v burwell case behind the administration you might see more state exchanges become federal exchanges because it is difficult for them technology and financially to run a state-based exchange so that might be a trend that develops. and then what i think the largest criticism that republicans have over the law is

that the prices are fine now on the ex changes for people, because they are receiving subsidies but in the next two or three years they're going to grow at a people that people won't be able to afford any more. >> to brooklyn cain an independent, you are up first for the conversation on the affordable care act. go ahead. >> i think the affordable care act is good. it will allow the people in this city, where there are poor people that can't afford expensive health care, is that your opinion too? >> well, i think right now there are definitely millions of americans that have received health care that they would not have been able to afford likely on the individual market before the affordable care act existed. i do think there are some legitimate arguments to be made about whether or not those costs will remain affordable and a lot of that depends on how much the government can help subsidize

the cost for lower income people. >> carol in south carolina. democratic caller, good morning to you. >> yeah, hi. yeah, our governor wouldn't take the expanded medicaid and i guess i'm wondering if that effected what people are quoted for individual insurance rates? . i got quoted $451 a month which i cannot afford because my husband has parkinson's. of course he's on medicare and 20%, he still has to pay out of pocket, his dental is not covered by medicare so there are a lot of costs for my husband. and i take care of him and i can't afford health care and i'm a breast cancer survivor and i haven't had a mammogram in two years. if they don't accept the medicaid expansion, are they getting quoted the high rates because $451 a month is pretty high. >> i'm sorry for all of the

struggles that you faced with your health issues. yes, if your state has not commanded medicaid, that is a possibility you are getting quoted a high rate per month. the medicaid expansion that a lot of the states in the south have not agreed to take the federal money for basically captures people that are within a certain income range that you are going to miss out qualifying for subsidies on the exchanges but can't qualify for medicaid under the original rules before the affordable care act. >> safety harbor, florida mike, a republican. good morning. >> well i have a few things to say. what is next for the affordable care act is the we're going to elect a republican -- hopefully not donald trump, but elect a republican and they're going to totally repeal it and replace it with something that is effective. let me give you my story. i look for health insurance

probably a year or so before the affordable care act was enacted just because my concerns, i'm just getting -- i'm 40 now. extremely good health. don't take any educations. rarely drink, et cetera. i was going to cost me about $150 a month and that was for a normal policy. i didn't have to pay for maternity care and stuff because obviously i'm not a woman. then after the affordable care act. it went up to $250 so we have a 66% increase, which, like i said, i rejected because i'm not going to spend $250 a month to subsidize the health care of adult on set diabetes and these things as a lot of us we can take care of ourself. but let me tell you, we just came out of the paper the other day, about a week or two ago, that florida is going to get 15% to 20% increase in the premiums.

so -- and now this is -- so now it would be -- what, with 20% of 250%, it would be -- well over $300 now, or close and this is for $9,000 deductibles. it is insane. it is not at all affordable. so i personally will not take part in this health care system. i'll wait. if i break my leg, i'll go and pay cash and work them down to a number that can work and the doctor will take it because it is cash. >> all right. mike. well a lot of issues there. let me share this with mike and others. the los angeles time this morning. obama care rates to rise 4%. they negotiated a 4% increase for a second year in a row to find dire predictions and sticker shock across the country. >> so that obviously was a big surprise considering how much

coverage i guess there was of california really trying to push down the rates that insurance companies had presented to the exchange board there. one thing to consider with insurance rates is that they can be regionally based so one state having only a 4% increase doesn't necessarily mean other states will face or receive the same numbers. but another thing to keep in mind is insurance rates have gone up several percentage points every year before the affordable care act was passed. >> and the l.a. times said that california rates are a key barometer of how the affordable care act is working nationwide and the results indicate that anthem and kaiser permanente are eager to compete in the nation's biggest obama care market from the l.a. times. and the caller mentioned if a republican wins the white house, they are going to get rid of the affordable care act law. is that what the candidates are saying? >> i think that there is no

republican candidate out there that has said they want to really keep the affordable care act. and that being said i think there are a lot of different ways they would have to think about that. there are millions of americans that have health insurance now that they debit -- that didn't have it before and those are voters and they might become upset. and it might be more nuances than the previous presidential cycle. >> how about this tweet. how much better would the aca be if the gop spent time trying to repeal it rather than improve it. is there any work on improvements to the affordable care act? >> there have been a decent number of bipartisan efforts to change the law. a lot of them are about undoing certain things of it. so like the medical device tax is a sample that congress has voted on several times. there is now a bipartisan effort to get rid of some rules for

smaller employees and exactly where they get their insurance and what kind of requirements are on there. so there have been smaller efforts. they just don't rise to the level of the attention that health insurance rates in individual man date is. >> to springfield virginia. vince, independent go ahead. >> i'm all for affordable care. but it seems to be soin efficient. i don't like to agree with anybody that republican or democrat, but it seems that insurance rates have significantly rised because of it. and i'm wondering why that is. can't it be more efficient so our rates are more sustainable. i know you quoted california but that is difficult to believe seeing what i've heard around here, you know from people 's insurance rates.

>> and what have you heard, vince? >> that their going to -- the insurance rates are going through the roof like mine, you know. >> okay. meghan mccarthy? >> well, i think republicans would make the argument that insurance rates are definitely going up because of all of the rules that the affordable care act puts in place about what kind of insurance can be offered to people on the exchanges so there are a lot more requirements and the plans have to hit the essential health benefits and cover a certain percentage of costs. democrats are supporters of the law and they would say that benefits consumers an the plans offered cheaply like the guy from california mentioned $150 a month, weren't actually covering anyone and you would get to the hospital and you realize later you have a bill for tens of thousands of dollars. so i think arguments to be made on both sides of things. but that is definitely part of the cost increase. >> pensacola, florida eric, n

independent caller you are next. >> good morning, y'all good morning. >> give me a couple of points about people wanting to expand the act and you made no mention of those -- who are those people who want to expand it and i'm going to guess and i imagine it is the people who are either getting their coverage paid for by somebody else or they are the people supplying it. and that goes to the second and i have a couple of other issues i'd like to bring up and a lady called earlier from florida where i am and said the governor won't accept the medicare expansion and looking at the defails for it the federal government has no money. we're $17 trillion, $18 trillion in the hole and there is $100 trillion in unfunded liabilities and social security and go to the u.s. debt clock.org and you can see the numbers and are you aware of the

debt. and i'll stay on the line for the answers please. >> and the increasing health care is the next major focus after the affordable care act. but the affordable care act is really getting people access to insurance but the cost of health care is a big problem for the federal budget. it is always one of the biggest chunks of the pie. and there has been some science recently of cost of medicare decreasing -- or increasing at a decreasing rate but i think that is the next big fight for democrats or republicans regardless of who is in the white house. >> and then on your poll, the caller is wondering who wants to expand it. when you look at the poll that morning consult did in june of 2014, the lighter green in this column, the darker green is july just of this past month, these are the folks that want to expand the law and let it take effect and change the law that is high. delay and repeal the law. can you explain. >> yeah, so, as i mentioned at

the outset, the opinions on the affordable care act have been very stagnant. so while these are small changes, it was interesting to us that it was happening on the -- what was considered the most positive thing that congress could do to the law which was expand it. and the caller asked specifically about who are those people. we didn't break it down by whether or not they are receiving insurance from the exchanges but it actually did see an increase from both democrats and republicans and that was interesting. republicans went from 2% wanting congress to expand the law to 7% over the course of a year. so it is small but noticeable. >> this is the first time for our viewers to talk to somebody from morning consult what is it, what is the website. >> it is a media and polling organization. we are bringing together the best of policy and politics reporting with really unprecedented access to public opinion polling.

our team is out in the field with a 2,000-person voter standing poll every week. >> and who is your audience. >> our audience right now are the people in washington that want to know what is happening on capitol hill whether it is in health or energy finance or tech policy or what is happening out on the campaign trail when it comes to members of the house and senate. we are also though writing for the people outside of washington who need to know what is happening on the hill for the industries that they are working in. whether it is an insurance or oil company. so we're really aiming for both the d.c. crowd but also people around america. >> and are you publishing once a day? is it in the morning that is when people get the update? >> yes. so we have five e-mails that go out in the morning on the topic areas i just mentioned and a general one on congress where we are rounding up the top news of the day in business and in

washington, d.c. for those five areas. and we're collecting news not just from what we're producing every day but also from any outlet out there. so we remain a lot more agnostic about who we are including in the morning e-mails than other competitors. and in addition to the e-mails we're doing enterprise reporting. we have reporters up on the hill and credentialed up there with the press gallery and asking members questions about the different topics of the day. >> so do you have to subscribe or is it free? >> everything is free. you can go to morning consult.com and subscribe to the news letters and see all of the polling. we always post all of the question text that we are using and the cross tabs so you can dive down into the numbers if you like and all of the stories are free. >> the website is morning consult.com. who is funding? >> we are making our own money. we are generating revenue from

selling advertisements on the e-mails that go out in the morning and sponsored polling. >> who owns it and what was the idea here? >> so the owner is our ceo and founder a guy named michael ramlet. he started this several years ago. he's a health policy expert. and it was basically to round up the news. there was so much happening in health policy and it was hard to keep track of started reading it when i was at health reporter and i relied on it every morning. that is one of the reasons i joined the company now. host: meghan mccarthy, editor in chief of morning consult to talk about health care issues. eduardo in boston. it morning. -- good morning. you are on the air. caller: good morning. thank you for having me. i want to talk about the -- i

had done. i spoke to the affordable care act has done to us poor people on ssi and medicaid who are disabled. medicaid, they have a lot for medicaid but it has not been for the patients. i had 19 -- in 2003, 52 pharmacy were stealing from medicaid. me, myself i called medicaid to report two people. first whose houseworked a program in manhattan, for two years they stole for medicaid in w my name. and bns who stole six months of do medicaid in myno name.

and i called medicaid to report them and they didn't do nothing about it. but yet they had taken away ny com almost everything from us. ha >>t is okay, eduardo. meghan mccarthy, any comments there about medicaid and what is being offer. >> fraud in medicaid and medicare system have been a big focus of the obama administration. there is a task force set up between hhs and doj that has reported record numbers of winnings or cases that they have won. as far as medicaid goes it is rt to thanks in part to the affordable care act one of the largest o with insurance insurers in america. and so as it gets bigger, these challenges will also grow with it. >> doc iern lapeer michigan you ood are monext. etired >> good morning. >> good morning. >> i'm retired and over the last probably six years i have seen my deductibles darn near double

and i have a couple of friends of mine who have recently been able to get insurance but like and the one gentleman that is a close friend of mine said, i to have insurance and he said it will be good if something catastrophic $6, happens to you but my deductible is $6,000. so to use it on a normal basis i we need prescriptions or whatever, it really isn't helping me and i've talked to a lot of people in this area d. who -- one lady had to literally her and her husband are retired, he lost his benefits from wherever he was retired from and she at 68 years old had to go pay back to work just so they could pay the premiums for their health care. and again, the bottom line is yes, there are subsidies out there right now but when you look at it subsidies are

taxpayer dollars and in the end, there are no -- there is no free lunch. something definitely has to be done here and i would like to be able to see everybody have good fi health care. >> oh doc sorry. thought you were finished there. meghan mccarthy. >> your experience is not uncommon in the popularity or ve y theea high deductible health care plans are more freak went even costs than five years ago. and the theory behind that is because of the health care insurance premiums were going up emplo several pesage points every year this is the response largely from employers who don't necessarily want to pay for high premiums and that is often where most people are getting their health insurance and so this go helps kind of pass the costs along and as you said, you might have to spend thousands of dollars before the coverage

actually kicks in. in o >>re victoria in oregon democrat caller. hi there.ered >> hi.pe long time registers nurse here. people aren't talking about the quality initiatives that are -- d will the affordable care act has really embraced that are really going to improve care and reduce costs. and to the man who doesn't want to pay for maternity care i'm not in an all female risk pool should i have to pay for a man that has prostate cancer. my daughter is a diabetes. she lost her job and she lost e. her healthcare and couldn't afford cobra and got on the exchange and it is not free. she pays co-pays but she can get care and she's now temping for a job that she loves and she doesn't have to take me -- pardon me -- a crappy job just for the healthcare benefits. >> okay.ere ar

meghan mccarthy. >> so victoria you are definitely wright. there have a lot of quality initiatives included as part of the affordable care act. the over arching thing the law s did is expand access to rtic insuranceul coverage but it pushes hospitals in particular to improve the quality of care that they provide or at least that is the aim. and for the first time medicare is not reimbursing hospitals for certain infections that their patients might get while in the hospital as a result of care. >> philadelphia, richie, independent. >> yes. how are you doing?eing i would just like to say a few things. first of all being a health care care provider for 30 years, a pro-ch health care --oi health care. also democrats are supposed to be prochase, why aren't they pro-choice. this is the opposite of pro-choice. making somebody have -- have mandatory health care.e a it is the opposite of democratic favor the president.

not ask what you -- your t. occurrence can do for you but what you can do for your -- the country. it covers all kids up to 26.have ea it doesn't cover your kids if you have v.a. or medicare so can you please answer that and i'll take my answer off -- >> all right reggie. mcan mc -- meghan mccarthy. >> that is interesting kids not covering kids up until 26. that is for private insurance plans through employers. than i think that -- like you said, access has expanded and people might have more choices than they would have in the market before the affordable care act.he but they might not like those rdable choices. >> what is happening with states on medicaid and those -- which states are moving to expand it? >> so we've definitely see more republican or red leaning states g try to expand medicaid, alaska's

governor is the latest that saidtion. he intends to accept the federal funds to expand medicaid to a t like larger adultly population. but southern states that are the least likely to move in that direction right now. >> why not? is >>su i think it is such a political or hot political issuegional in the south that it is an interesting regional divide but it is difficult to turn down hundreds of millions of dollars for -- for a governor to do that but in those states it is so toxic they can't even approach shoul the subject. >> what isest: the administration trying to do on this front, to rked w convince states they should expand. >> they have worked with republican governors to use what are called section 1115 waivers adder in medicaidal and it basically means they can rework a lot of the federal rules around more medicaid, which can be pretty

stringent and set up plans more cer amenable tota a republican state lis legislature with certain requirements that are lifted and other ones that they like more like requiring people to work a ain certain amount if they are goingen tod qualify. so that is -- that has been a major trend in expanding medicaid especially in eorgia republican states. >> we'll go to pat next in mapleton, georgia, republican. >> good morning.he i had -- i have two points to make. prior to the implementation of fam theil affordable care act i checked out insurance costs for my family of four just in case i cont decided to be an independent contractor. and the policies were pretty afford act. they were like $300 a month. and pretty much gave me the coverage i have with my am employer. and since thend. i've gone through a layoff and i'm currently unemployed and i have to pay forad. me to get medical insurance more t

which is really not as good as what i had. it is like $653 a month and i had gone with a broker. if i went through the exchange that would have been $1,400 a ome month and that iis based on the income i had last year but i'm what i currently not s working. but i don't see what is now wh affordable about the affordable n care act for people -- i don't n know why you basei it on income that i had last year when i'm not working. o >> okay pat. and so meghan mccarthy do you know how they base it on income? >> so it does -- the law does require people to base it on the taxable year income and that can. create challenges if you end up earning more than you anticipated or lose your income it can very much effect the subsidy level you get. you might end up having to pay some of that back in your taxes. >> charles, dallas texas, democrat.

>> yes, i've been listening to aabout th lot of people doing a lot of talking about insurance.year insurance, i've worked 41 years. insurance been going up every year since i remember.ed for i used to have the enhanced program at the company i worked for and it got to be 12 to care $1,500 a year. and it had a deductible. and it didn't have anything to fo do with therd affordable care actab. and i hear criticism about the ? affordable care act but what is the solution that people are criticizing it has. to ev that they sit back and say no to everything the president wants to do. >> let's talk about the alternatives. meghan mccarthy? >> that is the bigger challenges for republicans in using reconciliation. they want to repeal the law but there hasn't been a coalescing around an actual replacement.urt ca that work startedse with the response to the king v burwell imilar

supreme court case but t has since kind of stopped. and similar to deciding whether or not to repeal the law is kind of wait and see figure out what is the best path forward.in >> roger in loudoun, tennessee, independent independent, good morning. oh, we lost him there.is c meghan mccarthy,om before we wrap this up remind the viewers what we is coming next on the affordable care act? >> we havetes definitely not seen the last of the reconciliation debates. the houseti leader kevin mckarmy that said -- he anticipated that the reconciliation plan or some sort of comments would be forthcoming after the august recess. they have a very tight schedule in september. surpr they have to fund the the end government.. so i wouldn't be surprised if it gets pushed until the end of the year. but that is what i would be watching out for. >> for more information to follow meghan mccarthy and other reporters from morning consult, go to the website morning

consult.com. thank you very much for your time. >> thank you. >> on the next washington journal, florida republican ted yo ho a member of the house foreign affairs committee will talk about the process for congress to review the iran nuclear agreement. then a discussion on efforts by the puerto rico leadership to resolve the $72 billion debt with resident commissioner. and later as part of the spotlight on magazines a look at story in american prospect on how the south drives the low wage economy. the magazines editor at large harold myerson will join us. washington journal is live every morning at 7:00 eastern and i can contribute by phone and on facebook and on twitter. joseph banister is the only pirate to have brought the

brsh -- british navy to a stand still. most pirates high tail it. he actually fired the first shot. >> this sunday night on q&a, author robert kirston on the search for the pirates ship and the pirate joseph banister. >> he started off his life not as a pirate but as a noble english sea captain and gentleman trusted by wealthy ship owners to sail their sheep, this 100 foot long wooden sailing ship between london and jamaica known then as the wickedest city on earth and carry hides, sugars and indigo dyes and for years he did that responsibly and nobly and one day in 1684 for reasons no one can known, he stole his own ship and recruited a top-flite pirate

krut and he turned pirate. sunday night at 8:00 eastern and 6:00 pacific on cspan's q&a. >> it is less than a week for the first for em held in manchester new hampshire. we are partners to hear from all republican presidential candidates. they'll appear on stage one at a time with the order determined by a live fish bowl style drawing. questions will come from the audience and members of the public. our live coverage will be on c-span c-span radio and c-span.org followed by your reaction by phone and on facebook and twitter. wisconsin governor and republican presidential candidate scott walker is scheduled to be at the voters first forum in new hampshire. he met recently with voters in carol, iowa, delivering remarks at the harley davidson dealership there.

this is about an hour. >> the best representative in the land. >> governors think about the same way. >> yeah, you do. >> i love riding my harley, so it's good to be here. >> good to see you again. >> so happy to work with you. >> appreciate the leadership. >> it's going to be fun. >> it's going to be a good day. i just talked to joe -- [ indiscernible ]. >> wow, that's you a a awesome. >> the little girls that were with me were my nieces.

my brother and sister-in-law were driving behind us on the winnebago. yeah. that would be fun. >> i'm having a party at my house afterwards. >> i just went over to the best pool party. >> yeah, all right. >> my brother i stood in front of the crowd with picture from 40 years ago. that's me. that's my brother david who is now taller than i am. >> cool. >> but that's -- we bought an iowa state flag when we lived in plainsville because the city hall didn't have a flag. so my mom, of course still has the lines from the photo of them in there. >> and i think that was in your book, too. >> yeah. isn't that fun? >> as you crashed into the

pillar, right? >> there you are. >> hey! >> good to see you. >> better today than being here would be out in my -- >> that's right. >> meet you out there but they said no. >> they've got a front end. >> i see that. air-conditioning today. >> i'd like you to meet my wife. >> nice to meet you. >> my wife. >> nice to meet you. >> how are you? >> very good. >> thank you so much. >> welcome. >> this is wonderful. >> great. >> we had fun. it was great. last month we were in with joni and her husband, dale, and we had a blast. i compete with my staff and my fit bit and that day i didn't walk much. and i had 17,000 steps and i realized, that's good that the vibration on my road -- >> take that round, right? >> just put it right on the rim and i'd be all set. >> excellent. >> sure, yeah. >> we're glad to have you here.

>> thank you. it's been fun going around dealerships around the country. >> sure. >> i'll do that for you. >> matt mason was just on the pink harley. >> oh, was he? >> korea. he already claimed that one. >> that was fine. >> i'll do the deal. i'm i'll rev it up for you a little bit. >> if you're going to be on a pink bike, you have to at least rev it up a little bit, right? >> have you on the back. >> that's the one thing. i'll get on front and ride it. the one thing i don't do is sit on the back, right? >> good job. good job. >> thank you. good to see you. >> excuse me. >> good to see you. >> good to be here. >> i'll be in wisconsin, green bay. >> sure. that's your territory. we love it there. >> welcome. >> although we keep seeing packer fans all over the place.

>> yeah. i believe it. >> good to see you. >> nice to meet you. >> he just retired. >> caught me at practice. >> thank you so much. we're going to keep going back. we're doing all 99 counties. >> welcome to wexner aisle, anyway. >> good to be back. >> love to have you. >> are you? >> oh, yeah. what are you wearing today? on my road game. >> yeah, you're all over. >> good to see you. >> hi. >> hi. >> what are you wearing today? >> oh nice.

>> about the same as my road game. a little lower. had to be a lot lower. >> hey! >> welcome. >> i'm in your area now. >> it is really close to my neighborhood. it is really good. i try to be. >> no i'm going there. >> you're going to be there. >> i'm the last one up. sioux city and then we're doing the full nebraska all 99. grassley and grandsted and reynolds we have them all. >> feel the energy, too. it's in there. >> thanks. >> you bet. glad to meet you. >> good to see you. thanks for joining us. >> good to meet you. >> good to see you. good to see you. >> thanks for being here. >> yeah.

hey, we're having a dance, all the counties around here, august a 17th. we've got harley come, so we want you to -- >> all right. >> come through here. you go ahead. >> hi, guys. >> good to see you. >> you, too. >> hi. pleasure. hi. good afternoon. >> good to see you. >> thanks for being with us. >> hi there. pleasure. >> governor walker, nice to meet you. >> glad to be here. >> good to see. >> i like that tie. >> that's right. >> the day i was actually in las vegas and we had a radially there, somebody brought me up an 8-week-old baby named reagan. so picture me in a harley dealership with riggan.

pretty neat, huh? >> hi. >> good to see you. >> emory snyder. >> thank you. >> hi. >> can you smile? >> i'm just looking, looking around at all of those things. >> hi everybody. i followed governor walker's career and i'm proud to say that i'm only a representative and i have a house to -- on this campaign and endorse him. and after seeing some of the things that he went through as a governor, one thing that he did was when he ran for office he promised to bring fiscal reform and get wisconsin back on the right track. when he took over, the state was $3.6 billion in debt and he turned it around and closed the gap. they had a rainey day fund and

he actually lowered taxes while doing all this. so i think he's got a great resume and i think this kind of person that we need in the white house, personally. and so -- and so when the governor talked to me in des moines a couple of times i met him twice now, and he asked me if i would support his campaign and i said i would. and after having gotten to know him a little bit and talk to him a couple of times, i know i made the right choice. he's a great guy. he's a leader. and he'll be -- and again i'm go going to see he would be a great president. when the governor, on his spare time, which he has very little of. i know that right now. but he works hard in madison and he's still working to keep wisconsin on the right track.

and he believes that the principals that he used in wisconsin will be a good model for our nation. and i agree with him. i think he's got the right thing going right now. and so without further ado, i want to introduce the governor of wisconsin, scott walker. >> thank you. thank you. >> thanks. >> well, thank you. well, thank you very much. boy, after an introduction like that being one of the early leaders representing the best of the best, right? we appreciate it. but, no a great job of hosting us here today. a lot of his colleagues are here, congressman king is here and others. we appreciate you all joining with us. i just want to say two quick things to begin with on a serious note. noe not that we're going to be serious in a few moments, but particularly serious. i would just ask if we could

pause for a moment of prayer and just think about you know the other day, a couple of days ago, i talked to my colleague bill haslan, ta day alone we lost four marines in that horrible accident in tennessee. three individual, a marine a sailor and an officer were shot. since then, we lost another one of those, so it's now five whose lives were taken. and i think it's important for us to say a prayer auto behalf of those men and women and their families who continue to serve today and around the world. will you just pause with me and pray for them. thank you. and just one other thing i wanted to say and we'll start talking about the campaign here. earlier today, as some of you may know i make a practice of not commenting on the positions of other republicans. my view is i'll let them speak