it for low income populations so it is affordable. we want to do that in ways that work for states. i think in terms of answering concerns and questions, whether it's the negotiations we did with governor pence and i personally participated in a number of other governors so we can make sure we do this in a way a that serves the citizens, the state, that may have different needs. so in terms of one of the issues that comes up, i want to clearly arctic want to work with governors in their state. >> thank you. i yield back. >> the gentleman yields back. i will yield to dr. rowe. i want to give members a heads-up. we are looking at a clock and time. i will recognize dr. rowe for five minutes. and probably ms. davis, maybe mr. wahlberg and a after that we will have to start dropping down. we will go to four minutes. i'm trying not to go to three or two. but i want to give everybody a chance to be involved in this conversation. dr. rowe?

>> thank you, mr. chairman. thank you madam secretary, for being here. there are some questions i want to bring up to begin with. then we will get to the questions. these are things i want your shop to answer. one are the medicare wage indexes. if you look at those around the country, it was never intended to be like that. 20 of the highest are in california and massachusetts. 14 of the lowest are in alabama and tennessee. for instance, what you get paid in santa cruz, california is 1.7 with a medicare wage index. and .73 where i live. it's putting us out of business. that needs to desperately be looked at. the second thing, and i want to know your solution to that. certainly we're all against fraud and abuse. but in my state the medicare comes in, does these audits, withholds the payments. we win 72% of them. and we now, the backlog is so long, you can't get in front of

anybody to get your money back that you have earned. and that's unfair. and i think you absolutely need to re-do the audits. and thirdly, this is a much deeper one. and it may take some time. but medicare is on an unsustainable course, as you well know. last year, 2014, medicare spent $613 billion. and we took in $304 billion. that's unsustainable. and since its inception, $3.6 trillion negative of premiums over what we have spent on the practice. i would like to know what your recommendations are to put this on a more sustainable course. 2.9 over the budget number. it's a start. but i would like to know what the other issues are. and regrettably, i've got to ask some questions i don't like asking but i think are extremely important to ask. also, one last thing, question was on ipad. do you think one person, that

would you you now, should have the power to determine how medicare dollars are spent if it goes over this formula? i would like to know that. because there's nobody on that 15-panel board right now. recently we have seen two videos that showed planned parenthood physicians having wine and eating a salad, bargaining over the harvesting and sale of dismembered baby parts. i found it incredibly offensive as an obstetrician. have you seen the videos? >> i have not. i have read the articles. >> you couldn't comment because you hadn't seen it. but you need to see those as quickly as you can. it's only 8 or 10 minutes. you need to look at those and see what the rest of us have looked at. and given planned parenthood's horrific conduct, americans may be troubled to realize that

planned parenthood gets over $500 million a year much of it through you. medicaid and title x funding. having said that with a significant financial relationship, can you tell us what you have done to investigate these activities. >> so, first, i would just -- because it's so related to the budget issues we're discussing today, the rack issues and the backlogs, we put together a strategy that includes -- because it is such an important issue. extending the number of people that we can have to review the appeals because there are legal judges that we have to bring in. second, there are statutory changes. on the senate side, the bill is moving to make changes that will help us. third, administrative actions. i want to raise that because it's important. to the broader issue that you have raised, with regard to the issue i want to start by this is an important issue that people have passion deeply on both

sides of the issue. whether that is the issues of research that are important for eyes, degenerative diseases, down syndrome, autism. >> my time is about up. have you had any contact with planned parenthood? >> with regard to the -- i'm sorry? >> with regard to this issue? this sale of the -- >> no. planned parenthood's funding. and 500 million that you mentioned i think is a state number. with regard to medicaid and states, those are issues -- >> 41% of their funding comes through the federal tax payers. let me just say before my time runs out because we are limited, i found it absolutely amazing to me that planned parenthood could complain about a woman having an ultra surround before she terminates her pregnancy and using ultrasound to harvest body

parts for fetal issue. i find that absolutely astonishing. i yield back. >> the gentleman yields back. ms. davis, you're recognized. >> mr. chairman, i'm sure there will be plenty of investigations on that by my colleagues. i want to go on and ask for unanimous consent that a repeal of the affordable care act, adding $137 billion to the deficit in the next decade, that this report be entered into the record. thank you, mr. chairman. >> thank you very much, madam secretary, for being here for your service and for joining with us today. you mentioned mih earlier. i know that you care deeply that we continue to fund this at higher rates. we absolutely cannot fall behind the global community and how we address science and innovation. so i think is that's very, very important. and i believe the president has increased that funding. but i also wanted to talk about not just with regard to the issue, i

want to start by this is an important issue that people have passion deeply on both sides of the issue. and whether that's the issues of planned parenthood. >> have you had any contact with planned parenthood yet. >> with regard to -- >> with regard to this issue, yes. >> i'm sorry? >> with regard to this issue, the sale of the fetal tissue. >>. no, planned parenthood's fundsing and the $500 million that you mention i think is a state number. with regard to medicare and state those are issues of state. >> 41% of the funding comes through federal taxpayers. let me say before my time runs

out, i found it amazing to me that planned parenthood could complain about a woman having an ultrasound before she terminates her pregnancy and then uses an ultrasound so they can harvest body parts to be sold for fetal tissue. the belief is, having come from the private sector and actually having come from a company that is known for its negotiating on price, walmart, the idea that we use market mechanisms to try and put downward pressure on price is something we think is important. that's why we've asked for those authorities, so that we can try and work with the pharmaceuticals and negotiate to keep downward pressure on that price. that's what we hope we can do. we see it as part of the overall issues that we are being asked about how we transform the system for the long term. we believe there are things we need to do and pressure we need to future. >> what do you see as some of the key problems that you are going to be having as you try and move forward with this? >> i think with regard to this particular issue it's not one, you know, it is a elect lative and a statutory issue. it will take a statutory change to grant the authorities to be able to negotiate. that's not something that administratively we can do.

so it is something where the action will sit with the congress. >> uh-huh, yeah. thank you for working on that. i know it's not simple way of moving forward but it does seem to make a difference. and there have been so many stories lately about how the high cost of really not just bankrupted families but made it very difficult for people the access important life-saving drugs. i wanted to just for a moment also talk about the increasing access for folks here at home. and we know that the aca really has been a huge success in helping to reduce a number of the uninsured. i actually have a constituent in my district who was going regularly down to tijuana to get the medications that she needs. and this now means, as a result of her being insured, that she doesn't have to do that any longer. and it's been a big difference

in her life. so i wondered if you could just talk a little bit about how dramatic the increase in the amateur population has been since the implementation of the aca and what this additional coverage has meant in terms of increasing patient outcomes? >> with regard to that, in terms of numerically the number i think you know is over 16 million in the number of the reduction in the uninsured. with regard, what tells the story better are the individuals, whether that's anne ha, a woman who was 26, uninsured. her mother told her to sign up. she needed insurance, she didn't but in the end she listened to her mom. a month later she discovered she had stomach cancer and had the coverage. that helped her and she is now recently married. in addition to that the financial security in terms of her business and ability to continue on in that way. i think it is the individual stories combined with the numbers in terms of what we are seeing of what the extended

coverage means. >> right. yeah. i particularly have heard about that when it comes to type 2 die beats and the prevention that's made a real difference for those folks. thank you very much for your service. >> the gentle lady's time has expired. mr. walberg you are recognized for five minutes. >> thank you mr. chairman. thank you madam secretary for being here. thank you for reaching out to us before this as well. i want to ask you, first question, how many fictitious claims have been paid since the enactment of obama care and how much has been lost due to this fraud. to bring it into context. early whier this month gao released a report that investigative health care.gov threw yearious tests performed throughout the 2014 coverage year. the report revealed stunning things, that the marketplace approved subsidized coverage for 11 out of 12 fictitious applicants created by gao resulting in a payment of about

$30,000 to insurers on behalf of these fake enrollees. for seven of the 11 fictitious applicants, gao intentionally did not submit all the verification documents to the marketplace. and the marketplace, even then, did not cancel subsidized coverage for these applicants despite the inconsistent and incomplete information. so subsequent to that, how many fictitious claims have been paid since the enactment of obama care? and how much has been lost due to the fraud? >> so, with regard to the example, we take very seriously the issue of program integrity and want to continue to improve it. we look forward to the gao's recommendations out of that study. we haven't seen those yet. we look forward to understanding what they are. with regard to the question i'm answering the number because the

gao didn't find actually there were fictitious claims. when they had -- they tried to come through electronically. and then they came through through the phones. that's where they got through. at that point because they are gao, they were able to do thing that for everyone else would be perjury that would have a $250,000 fine afill kuwaited. >> and were successful. >> that's the key, breaking the law in terms of what they were doing to go through. with regard to the next step -- and there are a number of gates. there is the gate at health care.gov in terms of that was where it was caught. got through at the point in term of the confirmation of information. then because they did not file taxes what will happen to these individuals is in this year as per statute, they will no longer be able to get subsidies in the next year because at that point the irs will let us know they have not filed taxes. >> we don't know how many fictitious claims have been filed already other than gao. >> we know 11 gao.

>> 12 examples, 11 got through. >> with regard to those are the only examples we know of because as gao said in the report they didn't know of other examples other than those they had created. >> they don't, but you don't know either. >> what we do know is we have a number of steps in place. within 90 to 95 days we go through data matching this. year already 117,000 people who have not -- we don't know that they are fictitious. we know they have not provided the right documentation. and the first quarter of this year, 117,000 people came off. several other hundred thousand people, over close to 200,000 people received information saying we did not have enough justification for their income.

and therefore their aptc, their tax credit, would be adjusted downward. so we are on a constant path of making sure we have the information that aligns with what we have been told. if not we are taking action. >> without getting into specifics of the cases, that were successful, again, which shows that there should be concern, can you explain to the committee what processes likely failed to allow these fictitious applicants to gain subsidies? >> there are a series of processes that occur. in terms of the gates, when people have lied about their information, it's something that can happen in the system. it can happen in all of our systems. the way we catch that is in the data matching and information. so it depends on whether they have lied about which part, and that could have to do with immigration -- >> which ones failed? >> pardon me? >> do we know which ones i failed that allowed these? >> no because we have not seen the gao examples. one thing that would be helpful is to see the example. all we know is what you said.

if we have the information then we can fine where the system may not be working. right now -- >> what's keeping you from getting examples then if that's the case? this came out earlier in july. >> at this point, the gao has neither given us recommendations or -- >> have you asked for it? >> we have asked the gao in terms of can we understand how you did this? they believe they are protecting their sources and methods. >> gentleman's time has expired. mr. grijalva, you are recognized for five minutes. >> thank you, mr. chairman, and thank you madam secretary. 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 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. 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. much appreciate. 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. the 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 wounded 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 businesses 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 distinctly 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. >> thank you. 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 will 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 sandwich 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. burwell, 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 only 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 minutes. >> 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 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 it is 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? >> 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 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 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.

>> thank the 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 country. this is an acute problem. one, prescribing. we are going after prescribing. monitoring programs are essential. 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 healthcare.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 anecdote 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, 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 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?