>> the highest income americans -- >> an american family making $80,000? >> it is my understanding that it's over $200,000. that could have changed. >> what happened to the promise and assurance that he would not increase taxes on anyone making under 250,000? >> aren't you going to set $250,000? >> sir, he has before to this proposal. >> it's ok for him to promise one thing and do another, george bush not increasing taxes is the same thing. did you remind your boss, i'm

becoming secretary and i am responsible for this. do you realize you're about to break for a promise? >> i did not say that to the president. >> what did you say to the president? president. >> i told him i was eager to help him pass health reform and i was eager to help fulfill his commitment that it would be paid for within the period of time that the bill proposes. a decade. i think that's a fair promise to the american people that it won't increase the deficit and i'm eager to work with you to help make that happen. >> when you were governor and as a commissioner were medicaid states get a grade with regard to administration of medicaid by the states. what your grade when you were the commissioner and governor with regard to that? >> by -- who's grading me? >> i don't know what you're talking about. i mean, i guess the people of kansas thought i got a pretty good grade because i got re-elected as the insurance missioner and governor.

>> you got a d. if you got a d and you're happy about that and you're glib about that -- >> i don't know what you're talking about. >> i'm not yielding. the question i have here is, if we're going to say to our states that we're going to the federal government will pick up an additional cost on medicaid how -- aren't we sending a signal under the state's that if the federal government is picking up additional costs that they don't have to be as concerned and cost conscious? is that -- should i worry about that? >> well i would say that the bulk of the medicaid beneficiaries will still have a very significant state share and i don't know any governor in the country whose not concerned about the cost of medicaid. >> one of the other things that does concern me, though, is with

regard to doctors. you say that everyone will be guaranteed their choice of a doctor. yet, when we have shifting that, in fact, will occur and that's, in fact, recognized so an individual that likes going to their doctor now, all of a sudden their plan may not be -- their doctor may say, i'm not going to participate in the government option. then they lose their choice of doctor. would that be correct under this plan? >> they have to otherwise -- only if that individual chooses the public opention. >> right. then they lose their choice of doctor? >> that's an individual choice. doctors would not be mandated to be in the program. that's correct. >> that's true. private insurance as well? >> that's true. >> gentleman's time is expired. >> welcome, madam secretary and thanks for being here today and foreyour testimony. i want to make a brief comment about a group of people being discussed earlier in the conversation.

those who will be covered, the childless adults who would be covered under medicaid in this legislation with the cost amount you're being asked about. it's not as though these are folks we're not paying for already and the kind of health care they receive currently, which is most often, way expensive and inappropriate for their health needs, no prevention and so forth. i think that needs to be part of the discussion. but my question to you have to do with the part of the country you come from. kansas, as well as part of my district, which is rural america. and some of the barriers of care there. first i want to take advantage of your expertise as insurance commissioner for a state. have you share with us briefly about some of the types of reforms that are needed to improve our current insurance market. some of the common abuses that you have seen and how you

believe there bill will address that and that will be a cost saving as well. >> i think there's no question, particularly in the individual market, but also, often in the small business market there are constantly cherry picking activities by private insurers which do one of two things and often, both, simultaneously. costs can be dramatically increased year after year, driving people out of the marketplace. but also, in the individual marketplace, the pre-existing condition barriers often either make insurance impossible to obtain or totally unaffordable to obtain. so it is a huge barrier to americans accessing quality health care. >> are there provisions specifically in this legislation that you believe will address this? >> absolutely. not only the kind of -- you have

a couple of provisions. loss-ratio provision which would allow a different oversight to medical loss ratios. a provision that would exclude insurers any longer from denying people coverage based on pre-existing condition. and there's a much more community-rated aspect to the health exchange which would, again, limit the kind of spikes in cost that small business owners often see driving them out of the marketplace. >> thank you. now, to my part of my district, i represent a county in california, is california, as which one company has way more than 50% of the market. the only private insurer and the county has a shortage of primary conditions because of the locality, the reimbursement issue that's far different than

what the cost of living in the area really is. the -- but this county also doesn't quite qualify for a health professional shortage area. so there's these traps that many of the folks feel like they're existing in. could you talk about your experience, maybe, that's similar, but also how this legislation could improve the choice of health plans for consumers in a county such as the one i've described? and how, also, we need -- we really need to be able to attract new physicians to certain areas like if one i mentioned and many others in rural america as well as some underserved areas in metropolitan areas as well? >> no question that i think the public option in the marketplace achieves the very goal that is you just described where consumers would have choice and there would also be cost competition to principles that i think the administration very much believes in. in terms of the workforce issue,

again, initial investment in the stimulus act began the pathway to enhancing workforce particularly in underserved areas with the doubling of the commission core. but i think this bill takes an even bigger step forward recognizing that loan repayment is an effective strategy. eight tracts people to underserved areas. i would say the implementation of health i.t. will be a significant enhancement factor for providers who often don't want to be isolated but with health i.t., can be in frequent consultation with specialists and colleagues in various parts of the country and various parts of the state so they are not in isolated practices. so there are a number of features that are not only in this discussion draft, but in the bills that you previously passed that i think really help to address the workforce issue. >> thank you very much. >> thank you. >> i yield back.

>> thank you. we now go to mr. burgess. >> thank you, mr. chairman. ma dm secretary i'm in the broom closet behind the kid's table which is where they keep me on this committee. during your -- and welcome to our committee this morning. during your confirmation hearing before the senate, i believe the statement was made, you said if confirmed i'll not only be an eager partner to work with congress, but that i understand bipartisanship. is that a reasonable fact similar lee of the testimony that day? >> yes, sir. >> i know that this senate health committee, the ranking member has sent a letter june 16th and a follow-up to a request submitted on june 10th sent by the ranking member of the senate health committee they note that the despite providing

technical assistance to the majority regarding the affordable health choices act that same courtesy had not been made available to the minority of the committee. when can we and i'll tell the senate to expect that you're going to help them with the republicans on the senate health committee the same technical assistance that you provided to the majority on the senate side? >> sir, it's my understanding that our staff and nancy, the white house head of the health reform office, have been in the house and in the senate on a daily basis providing information and expertise, modelling a whole variety of situations. i'm not sure, specifically, what was requested that has not been provided. but i know that they have been available, accessible and very present day in and day out. >> i'd ask unanimous consent to

make the senate letter part of the record. and a follow-up for our committee here on the house side. will that same technical expertise be made available to the minority in the house? >> sir, as much as we can provide background information and assistance, we stand ready to do that. >> well, we stand ready to access that. let me ask you a question in your prepared testimony this morning, there's a discussion about the president has introduced proposals that will provide nearly $950 billion over ten years to finance reform following the statement that the president opened good ideas out how we finance and not add to the deficit. in a world in which 96% of people have health coverage, am i correct i presuming that the money that is afforded for disproportionate share hospitals and upper payment limit that is those funds will no longer be necessary for our safety net

hospitals? and is that where a portion of this $950 billion is coming from in. >> there's a proposal as part of package that at least a reduction in the dish payments be anticipated as health reform is fully implemented. i don't think anybody anticipates a world in which there would be no additional help and assistance to those hospitals that are providing the bulk of care to people who are uninsured but hopefully, the uninsured will go down flp are additional, i think, features about that. cultural competency. a range of additional service that is have to be provided. >> and just to point out, my home state of texas, significant number of the uninsured are in the company without benefit of a social security number and until we resolve that issue the need for safety net hospital also continue because i suspect that there will be some people who are left out of the 96% who

actually have health coverage. and i was glad to hear you reemphasize this morning that the president wanted to protect what works and fix what's broken. i'm glad you went to omaha. i went to omaha earlier this year, allment e-- and testimony without the ability to have the health savings account and health reimbursement account to provide the correct incentives for their patients to access the preventative care that we all want people to feel is important, without those tools it would be very difficult for them to operate the kind of facility that they have today. >> i'm sorry, without the health savings? >> without health savings account and money made available through health reimbursement accounts. i'm getting as, could gentlemen

l we get a definitive answer, from my read of the bill before us, it appears that health savings accounts won't count as qualified coverage. is that correct from your reading of the bill? >> sir, i can't -- i will go back and make absolutely sure. i know that there is no intent to eliminate health savings account. how they are actually defined, i need to recheck. but health savings account would still be available >> the president would do a good service to allow people to choose to get their insurance through a health savings account. >> the house savings accounts absent another insurance policy.

>> your time has expired. >> my time is just starting. >> i do believe that health savings accounts are not adversely affected in the draft bill. i don't think that is the intention. we will get a clarification because he raised an important question. >> if you look at the rate of increase of all the different products out there, medicare, medicaid, they all increase at a rate of 7 and 1/2% a year. legal testimony from the chief medical officer says the raids were about 7% a year. if we want to figure out what works, we would look at those types of programs and give people an incentive to select healthcare behavior and make it important to them.

the right thing. >> mr. burgess, thank you very much. there are other members waiting and the secretary will have to leave. >> i'll yield back. >> okay thank you, mr. care man and welcome, madam secretary. we're happy to see you here. >> thank you. >> i was pleased to see the components of legislation that i authored. the public health force workforce investment act were incorporated into the draft bill before us today. the creation of this is a major step forward and will revolutionize public health forever. we're starting a public health work crisis. and in order to satisfy the future needs we need to train three times as many public health workers as we are today. otherwise, the rates of obesity, diabetes and other chronic diseases will likely rise.

and we need to reinvest in the crucial part of our public health infrastructure so that we can take community-based action to fruendt long-term public health crisis. secretary sebelius, you're the head of what i think is the largest public health agency in the world. you probably know as well as anyone that public health workforce is rapidly aging. by 2012, half of the public heathrow work north some states will be ready to retire. in my opinion, our public health system did a good job of managing the recent h1n1 flu outbreak but this incident has shown us how critical it is to not let our public health workforce deteriorate any further and i'm pleased that the -- my piece of us was incorporated into the draft bill. madam secretary, i want my colleagues to understand how critical the public health work forcest is. will you please outline for the benefit of this committee how your job is dependent on having

a robust public health workforce backing you up? >> congresswoman, first of all, thank you for your leadership in this area. and your long-standing expertise and insistence that the public health infrastructure has to be part of this dialogue and discussion and i think you appropriately identified them. the recent situation still with us, the h1n1 virus and the anticipation that we'll need additional activity points to the need for a robust infrastructure. and as you correctly point out, in many parts of the country, it's not robust enough now and we're facing a looming retirement of lots of individuals. having not only the pipeline, the commission core has doubled. there are efforts to enhance, again, through the recovery act,

the community health center aspect of the public health backbone in this country and i think that's an important step forward. no question we need not only further attention to workforce issues, but also further attention to quality standards in the public health agencies throughout the country and i can assure you that our new leadership of dr. tom freeden at the centerers for disease control is a huge believer that the public health infrastructure needs to be enhanced and needs to be improved and needs to be focused on and he is coming to this job as a new cdc lead we are that agenda at the forefront of his priorities and it's one that i share. >> why are we facing such a crisis in public health workforce today? i know part of it is that we

need more graduates from public health programs, but i think the other part of it is that we may not have the right incentives for the graduates we do have to enter public service? >> well, i think the whole incentive system in health care is one that is on the table for review as we look at the reform agenda. how we not only attract more students to medicine in the first place, but how we attract more of the students to the appropriate shortages. >> but do you think that the scholarship alone repayment provisions in the draft bill will help incentive to the public graduates to the public work snors. >> i don't think there's any question that those strategies have been proven to be enormously effective. students unfortunately today, are emerging with mountains of debt and often, public health

officials aren't paid as handsomely as some in the private sector, so helping to retire that debt and helping to erase that debt is an enormous step to allowing students to actually make choice that is they might find more rewarding, but currently find financially out of reach. >> kwo. i thank you very much. i yield back the balance of my time. >> thank you. the gentleman from georgia, mr. gingrich. >> thank you for being with us this morning. you were asked about your grade as governor i would say your grade so far this morning has been pretty good so hopefully you won't mind a couple of tough questions from me. in quoting in your testimony, without reform, according to the medicare actuaries we'll spends about $4.4 trillion on health care in 2018 and by 2040 health care cost also reach 40% of gdp.

madam secretary these numbers are indeed, staggering and i share your concerns. however, i have another concern and i need to be reassured that you share that. the medicare trustees report that the medicare problem will be insolvent 2016, receive health care from a government payor and your testimony focuses almost exclusively on the private sectk health car care -- private sector companies. given that 45% of all americans get their health care from a government program, and the fact that your department oversees the largest government program tasked with insurance of quality health care for our seniors is available both today and in the future, shouldn't entitlement reform be an integral part of this legislation?

>> yes, sir. i think it definitely should and that's why i'm confident that not only a number of the proposals to enhance quality for seniors are important and we talked a bit about closing the donut hole which is a huge issue. but also, the savings that are proposed by the president will enhance if lifetime of the medicare program that you've just cited. and, also, lower premium rates. premium rates for the seniors paying them so it has a win-win situation and it helps to pay for a longer life of the program that's so important to millions of americans. >> let me reclaim my time since its so limited. i would have to tell you i think that's nibbling around the edges when the latest medicare trustee report says by 2083 we'll have 37.8 trillion dollars worth of unfunded liability in the

medicare program. you state that since 2000, the year 2000, private health insurance premiums have almost doubled growing three times faster than wages. madam secretary, do you know what percentage medicare part b premiums have increased since 2000? you just referenced that a second ago? let me tell you if you don't have it on the tip 06 your tongue, they have more than doubled. 111%. that's how much medicare part b premiums have gone up since 2000. so i would suggest to you that the parody between medicare part b increases and insurance premium private insurance premium increases suggest that high health care costs are rampant and they are integrated. so it's not just private but it's public as well. so we need both private insurance reform and medicare reform. simply turning the system over to the government, i think, will not solve this problem and without addressing medicare reform, we'll leave many seniors

without quality health care coverage. let me real quickly, if i might, mr. chairman, secretary, you quote your testimony -- in your testimony that reform will guarantee choice of doctors and health plans. no american should be forced to give up the doctor they trust or the plan they like. if you like your current health care, indeed you can keep it. do i take it from your testimony that you mean all americans will be able to keep the health plan that they like, including the 11 million seniors who get their medicare from medicare advantage? >> well, sir, i certainly hope so. the proposal to stop overpaying for medicare advantage is one that is included in the president's cost savings after years of examination, there are no enhance the benefits and they're being paid at about 14% higher a rate than other programs.

as you know, the center for medicare services has proposed that there be fewer plans this year because of the proliferation of plans and the fact that consumers didn't often choose them. and that's not a cost-effective way to run a system. but ideally, the doctors and networks will remain veilable. >> the gentleman's time has expired. mr. chairman i thank you for your patience and madam secretary, thank you for your response. >> next we have gentleman from ohio. >> thank you, mr. chairman. thank you, madam secretary for joining us today. as a native ohioan i welcome you as well. there are so many different areas worthy of discussion that

it's difficult for me to define one to ask you about. but given the rural nature of my district and ohio generally, and given the special challenges that those in rural america face when accessing health care, and the barriers that we've got, and given that one of the challenges happens to be attracting and retaining sufficient workforce, specifically, primary care doctors, specialists and some adolescent specialists in particular. what, in your assessment, does the president's initiatives and what does this bill do with respect to attracting and retaining quality workforce in rural areas where that's

historically been a problem? >> congressman, i share your concerns about rural access. certainly that's something i worked on as governor of a state like kansas where two-thirds of our population is in very rural areas. i think there's no question that the incentives for enhanced workforce is a step in the right direction. i think that telemedicine, which is on the horizon and certainly, an important component of health itd is a huge step forward. a lot of providers in kansas and i'm sure, ohio, are concerned about their isolation and want to make sure they can access colleagues and consultation. and i think that the steps that are included in this legislation that pay for student loans and encourage additional incentives for primary care and family care

doctors alsonhance the workforce in rural as well as urban areas. >> and i just have a couple more minutes. i want to just make a comment as a follow-up. you mentioned telemedicine and i guess i want to take this opportunity to explain to you as a member of the administration, just how important it is to access broad band and high speed intranet. one other area that i want to talk about has to do with the geographic disparity is dealing with chronic disease. coming from appellation, one of the things that we see is a higher rate than normal in diabetes. -- coming from happily sh