you would like to ask them. please do. but there is no provision there. get you this in writing. there is a provision that indicates a different person is not -- >> if you delayed this law because it is not workable for businesses, why did you not latest president not workable for families? how is that fair? i'm sorry sir. >> how is it unfair that you delayed this law because it is workable for businesses of all sizes but it is not cool for families. why are there not getting the same treatment? >> we have not delay the law's implementation across the board. of a butross the board for large businesses believe you meant small businesses. >> the law has never applied to

them. there are two percent of business owners who are in the above 100%. to --ey have a year >> time has expired. mr. mcdermott? >> take a breath. your budget contained several proposals for actual reforms to medicare, all of which will increase the cost for beneficiaries. what i do not see in your budget is medicare reforms that ask dividers and pharmaceutical companies to share in the pain. frankly, that concerns me. theink they ought to share pain between the providers and those who benefit from medicare. as you know the and fisheries and a disproportionate share of their income on health care compared to those others under age 65. medicare patients pay more.

i understand these proposals, while the concern we were put into the budget is a part of a so-called big bold balanced-budget deficit reduction plan, one that calls for sire advice -- shared sacrifice among retired americans. let me ask this question. completely seems to be around here is much different is that you can cherry pick those medicare reforms here and one there such as low hanging fruit as a way to offset or pay for sgr. my republican colleagues have been talking about doing this. for thathat it is hard to actually occur because as gr needs to be fixed. there's not a documented access problem to our program. askeems unconscionable to household incomes averaging

$23,000 a year to pay more in order to increase payments to doctors. my question is this. does the administration support cherry picking structural reforms which would benefit for medicaret beneficiaries, or are there was reforms solely intended as a part of a substantial deficit reduction package with shared sacrifice for all americans? >> progress and, as you know the president has said for a number of years that he is -- remains hopeful for a big deal. reform,rm, entitlement package that would put us on the path to multiyear this goal solvency. in the context of those reforms that is why these proposals continue to be made in the budget. it is in the context of a major effort.

entitlement reform is a piece of puzzle, but only a piece of the puzzle if there is additional tax reform and revenue sharing that, as you say, involves everyone. >> so the white house does not support selecting out pieces to pay for sgr? i think the budget is a package that moves forward. this cherry picking of one piece you say,r gives, as undue burden on seniors. >> thank you. i think you need to lean into the microphone. >> [inaudible]

[laughter] there we go. >> mr. chairman, thank you for holding today's hearing and i'd like to thank the witnesses for being here today. working-class families and unknown individuals had to spend more of the on health care

expenses. we've had many individuals in a district for now covered, who now cannot afford their the dr. burroughs -- the dockable's. mr. chairman i would like to submit for the record and transcript of an interview between nbc news and secretary sibelius on september 30, 2013. >> without objection. said, whendate, you asked regarding obamacare what success would look like. your answer was i think success looks like at least 7 million people signed up to the end of march 2014. open enrollment and this month, and your well short of the target. standards,ur own obamacare will not be successful at the end of march 2014. what do you now call success? >> progress in, i think in answer to your initial western i do not know the constituents

you're speaking to, but i can give you a national septa were private insurance rates -- secretary -- can i get question onr that the test -- on success? healthions of people on care coverage that we will have. i think we'll have a successful program, we have for the first time self-employed individuals who do not have affordable care through their worksite getting a horrible care. >> yours changing your standards by 7 million minutes -- george in your standards of 7 million people by the end of march? you also talked about deductibles you and your answer was i think it was can make a choice, it is not something that can pay for.

a lot of people cannot pay their out-of-pocket, they would want a lower deductible. my about those people in district who cannot afford a lord of actual? -- a lower deductible? >> the range of plans in the marketplace is more robust than the range of plants ever has been in the individual marketplace or the small group work in place. some have lower premiums and exchange for higher deductibles, some have lower deductibles and higher premiums. there,nge has never been nor have the feeling of americans who now qualify for some initial help to get into the marketplace had that benefit. i meet people every day he were actually having affordable health care for the first time. , and theyan employer have an opportunity for health security for themselves and their families. --sion james is negligence >> ms. sanchez is recognized. >> thank you for paying before

us today. i continue to believe that budgets are a of what our priorities are in this country. our priority should be pretty clear. create an environment for well-paying jobs, properly for the health care bar and protecting benefits for those of earns them. those should be the focus. i'm happy to see that the president's budget does reflect some of these goals. the thickly, some things i wanted to point out, the poor post 2015 but it gets rid of ms. guided approaches to change the cpi budget on the back of our seniors. and expand hiv aids treatment and care to investments in the ryan white aids program and cdc activities. it funds the national institute of health at 32 point early $32ars, -- at dirty $

billion. i would be remiss if i did not speak to issues that are specific to women's health care. i want to talk about title x to the unholy federal program supposedly dedicated to family planning and- reproductive services. reduce the effects of unintended pregnancy and abortion in the united states. the top 10 most valuable public health achievements of the 21st-century, along with things like childhood vaccinations and floor nation of drinking water. i'll wait see that the president budget calls for a slight increase in title x funding, and i was wondering madam secretary if you agree that the investment in family planning services is a valuable one that reduces government health care expenditures in the long run? been shown,

congresswoman, that family planning and having families he able to make choices about the timing of children and the timing of pregnant see is a huge health issue and a huge family security issue. we have made some significant strides. i would also point out that as part of the affordable care act, insurance policies now will cover a full range of health services for women, which was not necessarily the case. they will be not allowed to charge women more than men which was typically a feature in individual markets. for the first time, have a focus on women's health issues, including family mining issues. increasedthink the access to affordable birth affect healthelp care costs overall? >> private insurance copies will tell you that actually having contraception services as art of their package decreases cost

because they paid for fewer unintended pregnancies and sometimes premises that could result in very high birth and follow-up cost. as an actuarial point of view, it is actually a net gain in terms of overall health costs. more importantly, it allows families to make their own choices about families and timing. the health of the mother and the health of the child are often significantly improved by the timing. >> mr. griffin. >> it's whenever you try to use it, that it does not work. >> right. , to the regular one.

>> a think a website manufacturer and developer has been working on our mike's. thank you for coming, i appreciate it. what i would like to talk to you a little bit about is the issue of investment. you mentioned investments. almost every constituent that comes to see me in my office talks about the need for additional funding for the nih, for cancer research. diabetes government took about education. they may talk about some other program that is funded by discretionary spending. when people times mention investments, that is what they're talking about. encouraging nih research funding, i wish we had the money to increase it

drastically. is that that funding is getting pressured, squeezed out by the growth of entitlement spending. i have a slide here. this is something that president obama said in 2011. if you look at the numbers, medicare particular, it will run out of money and we will not be able to sustain that program, no matter how much taxes go up. it is not an option for us to just sit by and do nothing. next slide. this is what i call the pacman problem. i use this to explain to folks to come visit me why the funding that they are in favor of, which often i favor, nih funding for example, why it is under pressure. it is under pressure because the yellow part of a which we

isognize as pacman continuing to close its mouth on all of the things that you referred to as refunds -- investments. a jjecretary after secretary have talked to both administrations, republican and democrat who raise their budget as fixing the problem. the problem persists. i would invite you to work with ,s for real reform on medicaid and medicare to fix this. i would welcome your comments on how your budget will address the problem. sir, i would welcome the seriousity to work on a big budget deal, including entitlement reform, but also including tax reform and revenue sharing. and spread that equally across the board. i would say that the passage of the affordable care act was one of the most significant issues

of late to increase the solvency of the medicare trust fund. the trustees put that passage at about a 12 year additional solvency of of this budget adds an assistant all five years. when this president came into office, medicare was likely to go broke in 2017. that window has now been significantly extended. this committee voted 50 times to appeal that -- >> you're robbing peter to pay paul, and the seniors are bearing that burden. >> pitcher crawling? >> thank you for being here once again today. i am out here now, they moved me. sorry. musical chairs. it will take a long time for me to get up here normally speaking. >> don't you get used to that seat. [laughter]

i have very little time. affordable care act has made great sides in putting access to affordable care act by closing the prescription drug coverage gap, stripping the medicare program, establishing competitive workplaces for working families to purchase insurance for the first time. i'm glad that the budget sustainable upon the successes. i'm pleased to see that this budget looks toward the future of improving our health care system through the new position work worth proposal. it is growing in the need for more doctors at the same time. production show that by 2020, the united it's will face a physician shortage of more than 91,000 positions, growing to over 130,000 positions by 2025. not that long from now. that is both primary care physicians and specialists. clearly there is a need for continuous federal investment in dr. training. of i'm concerned that some

the proposals in this budget would fundamentally change this long-standing concept of how doctors and their training is aborted in this country. the nation has long recognized the need for dr. training to be a shared investment between our medical schools, residency training programs, and the federal government. medicals cool have increased graduating classes and teaching hospitals above and beyond what medicare supports. in my state of new york, there are almost 840 residents early being supported by hospitals alone because medicare cannot fund these positions. 10,000 residents nationwide are in a similar situation. there is a clear and obvious man for more residency slots even within the medicare program. demonstrating that this is not the time to be taking dollars a way for other programs. have put forth an act to meet these presidency slots.

if he could, please comment in terms of the budgeted soft and the effect that this will have on teaching hospitals. i do not think this is the time to be taking away those moneys, we need to be adding money to produce the number of physicians we will need in lieu of the affordable care act. >> congressman, i think the president evidently shares your view that the health care workforce as is often the most important. we have been focusing on that since the giving of this administration. i would say that there are three major components of significant $14 billion 620 million workforce initiative over the years. increasing the size of national health service corps, which goes a long way to putting doctors, nurses, dental text, and others into our communities.

growing from our current 8800 and keeping it there. targeted to focus on support for graduate medical education, driving not only the primary care workforce but specific underserved specialty areas. currently, hospitals began choose which residencies they will slot. more get this point it is hopeful to really focus on the great need for primary care, preventive care covered community-based care, nurse practitioners, so that the growing population of the elderly and others who will stay out of the house bills will have that kind of care. certainly, to continue the increase that was passed in the affordable care act for primary care doctors who take medicaid patients. i think those three initiatives combined will really do a significant amount to increase the primary care work or's. also to make sure that primary

care doc tours and nurses are in the right places in the months to serve them. >> thank you. >> thank you for being here today. i want to get directly to the budget, because of page 33 the budgeted highlights a potential large tax increase that is not defied. reading from page 33 this is what is said -- even with reforms to medicare another entitlement reforms, we will need additional revenues to maintain our commitments to seniors. looked likeis, it an open-ended discussion, but with no real specifics. what specifically are we going to do? we are past this point in time. where do we go to get this revenue? what taxes are going to have to come about? >> congressman, as you know, there have been discussions over the past everly years. the president has proposed a number of tax loopholes being closed. >> we are playing ring around the rosie with this. there is no way that we can look at the metrics of this and say

this is going to work rate my question is does the real choice right here between entitlement reform and going to some other type of attacks, which i think a a lot of people are saying we're going to have do have a european-style tax. it hit every one of them, hard. nobody walks away from this. where are you going to get the money? show me the money. if there's not going to be reform, show me the money. where's the revenue going to come from? it,tax it, you find, borrow or just print our way out of it. where is the money going to come from? >> no one in this administration has ever suggested that sort of tax. what we want to do is work with congress on a comprehensive program which shares the burden, not taking it out of the backs of seniors, or the backs of -- >> we agreed violently on that.

it comes down to dollars and cents. we cannot wave a magic wand make this monday appeared. we are not would have serious entitlement reform, where is it going to come from? it is just simple mathematics is not float. what some of the most serious entitlement reform is underway right now under this administration. we have cut in half the cost trajectory of medicare year and then you're out. we are seeing the close roads in -- slowest road and 50 years of the program. a lot more beneficiaries coming in and benefits. >> it is much easier to talk the talk and it is to walk the walk. we were hearing this was not going to cost us anything about his trillions more than we thought. it is not working, and reform is absolute necessary. i do not see anybody walking that link. we do not see any specifics, we can talk and flowery terms about what we want what our hearts are willing to do, but what our wallets cannot provide. the question is how do you pay

for it? it has to be tax increases, it cannot come from anyplace else. i wish it was, just have a magic wand and the money would magically appear. it does not. we are on a heck of introductory right here and there's no way out of this. real reform for huge tax increases. >> we will try the mics again. >> thank you. madame secretary, i'm glad that we are now all talking about middle income people. way in threea long years. i think we're on the right trail. but let's change the pace a little bit. the commitment that the president has made to expanding educational opportunities in the investments in research and science within this budget are things i support. initiative is one of

the investments that i think is ridiculously worthwhile. celebrating what we have done for the past 14 years. in the reiber billing, all of the research that is being done both the military and the civilian automatic rain interesting, post back stress disorder, which is now helped in many ways to help our kids and making smart decisions. the brain knew she did is one of the investment that i think is worthwhile. as cochair of the dramatic rain injury task force, along with the congressman from pennsylvania, i am well aware of the advances that we have made in research in the brain in recent years. how much we have learned and continue to learn. your presence here today is very

timely, as i said about the congressional rain injury awareness day is evident on capitol hill. and number of your officers is dissipating -- are participati ng. jerseysion 200 rain in are each year, and 5.3 million americans live with a long life -- lifelong disability as a result of a genetic right injury. beyond those numbers, they become the signature wound in iraq as well as afghanistan. 20% of our soldiers deployed are estimated to expand brain interstate -- injury. when a series of how many have fallen through the cracks. it is because of this congress and the last three presidents that we finally have come to the stop of recognizing it and

sweeping it under the rug. we have been insisting on it in a bipartisan way. rain injuries can affect anyone at any time. i know this $200 million commitment, which is double the investment in last year's budget is not just coming from your department, but can you speak to the goals of the brain initiative, and how important is that we pay attention to what is going on in that research? >> time has expired. if you want to supplement in rising a role longer response that would be fine. writing a longer response that would be fine. >> i would be glad to. we have identified one of the signature efforts as the brain is used for -- what is the brain initiative. he has assembled a dream team of top researchers from top

industries and milk -- mapped out a multiyear strategy. the private sector will be intimately involved in this. some of the key drug companies are at the table. there is an effort underway to get them involved in accelerating cures. it is a multifaceted project, and i would be most glad to get you some more information. >> esther young is recognized. >> madame secretary, thank you for being here today. i will start with a couple words of appreciation and encouragement. i know that our delegation appreciate your current insurance that consideration of helping the indiana plant and playing an important role in the medicaid expansion of our state. thank you for that. i also appreciate internally within hhs, under this is the

priority for smb of finding the evaluation of the current demonstrations aware opens in on outcome versus inputs. one of biggest concerns related to this help our law is the impact on jobs and wages. indicated that the affordable care act will shrink the workforce by the equivalent of 2.3 million full-time jobs an. the teamsters president has said that the law destroys the foundation of the 40 hour workweek is that a bone of the medical -- middle american class. they recently published a new report, the irony of obamacare about making income and inequality worse. i would like to submit this report for the record. >> without objection. what theupported

president calls obamacare, but they do not anymore. without smart fixes the aca threatens the middle class with higher premiums, loss of hours, and a shift to part-time work and less government but coverage. you have indicated that there is absolutely no evidence in that theremist work is any job loss related to the affordable care act. based on the growing body of evidence, including the strip ward, -- this report, have you thought about whether or not the affordable care and can adversely impact wages, hours, and jobs for low-income americans? >> congressman, i have had some great meetings with the governor, and look forward to continuing those around indiana and the expansion. unfortunately for the congressional budget office report has a miscarriage or rise -- mischaracterized.

it does not say that the passage of the south carolina will lead to 2 million fewer jobs than it does indicate that people will have some choices that they do not have today. lockwill not have job until they get to 65 where they have health care guaranteed with medicare. they can choose to stay at home. a load of farm families will have the choice of not having to have an off farm job to get health insurance for the family. there is an average that they give, and they say you could have an average number of hours -- -- less, or you they >> we could lower the definition of full-time employment to 20 hours of giving employees more flexibility under your your analysis in the cbo report. thank you. thank you mr. chairman. madame secretary, thank you for being here, and thank you for your service to our nation. i know this is not been the easiest time to roll out the ca -- the aca, i've a question for

you. coming from a large world in congressional district in given eyeless critical access hospitals they race unique challenges with recruitment, retention, and access issues. we have had budget discussions about that in the past. the question is, one of the great stories in recent years, the last few years, has an introductory of health care spending. cost per beneficiary, this is never been lower in the past few years. i wonder if you could take a moment to tell us what you're seeing in regards to the health system that is leading to these cost reductions? part of the affordable care act is not only to reform the way the health care is being delivered so it is more coordinated, but changing the financial incentive so it is more value and won't be driven. you can take a moment to let us know what you're seeing as far as cost and whether these reports are sustainable in the future. >> congressman, you and a number the house delegation was

instrumental making sure that the quality and value pieces were added to the affordable care act, that that became a fundamental piece of this. i would say that the framework of having for the first time real tools within the medicare system to look at all lining value with payment is significant. we are already seeing the first real reduction in preventable house rule remission. a very dramatic change in hospital exception rates. good for patients, good for the bottom line. in terms of overall expenditures, 10 years before the affordable care act, medicare cost growth was on average six percent a year a year in and out. act, it wasof the 1.6%, a dramatic drop last year. the lowest cost

increases in history, and medicare beneficiaries have more benefits for lower prescription drugs, additional cost. private insurance costs have been cut in half during that same time spent. how ministers per capita were how premiums per capita were raising their now decreasing. because some of the fundamental structure of looking at ways to deliver more effective preventive care earlier intervention with very high cost patients, some of the pieces you put in place with the dual eligible covance the very expensive population, only about 10 million individuals, but -- spendo bend over over a third of medicare and medicaid budgets. work with the states is very much under way.

there are some promising trends on the verizon. >> mr. reid, and then we will go to to do what. >> thank you for being here today. i wanted to join with my colleagues to bring a message to you. district in a rural western new york, i can tell you that medicare and medicaid reimbursement cost are seriously jeopardizing our critical access hop battles -- hospitals. right nowne with one that is going to reclosure. particular, line in rural hospitals, these cuts are causing significant problems or ask 62 care and are people. i am turning my colleague and highlighting that need. we just had an election in

florida last night. wasdemocratic opponent talking a lot about ways to fix the affordable care act. what i wanted to get from you is the ministries and has had 37 significant changes in the affordable care act that it has put forward by executive order and other amendments. for him you,king if you have any suggestions, if you have supplied to congress or us any areas that you want to ask the affordable care act. has there been any legislation set to congress in regards to those fixes? >> no. zero, i knew is that answer, i just wanted to see where you were at. is the white house administration position that the affordable care act is not fixable, that way there is no need for legislative fixes? >> no. >> there is fixable, there's areas that you want to fix. could you stay for the record

what areas of the affordable care act at the administration want to work with us in order to fix? >> we have said from the outset were from the passage of the law in march of 2010, if there are suggestions or ways that -- >> is a -- the white house is no suggestions or fixes. >> we have implemented a number of changes in the way the law was it -- written to ease the transition into the marketplace. >> we appreciate that, because we have had the same thing with the employer mandate delay here on the hill. the white house veto that cover or threaten to veto it. by executive order, they implemented it. >> no legislation has passed the congress. >> if we pass that, you will sign that? >> i do not sign legislation. >> what is the white house's position? >> no legislation that passed the congress, and that 3.5 years that the law has been implemented. to house has voted 50 times

repeal the act. >> when we pass a bill in the house and the white house issues a bit -- veto threat to it but that is an indication of the white house wants to work with us on policies that by executing order it is implementing? we have the employer mandate delay, we have the health insurance plan that you can keep your of insurance plan if you like it. we get threats a veto from the white house on things that you're doing by executive order over there? that does not make sense to us. >> the issue is the breath of some of the legislation. we believe strongly that having a transition for people who are already in short gradually into a ca compliant plants make sense. the measure considered by the house of representatives was considerably broader than that. it would have basically destroyed the new marketplaces, so that was a very different piece of legislation. >> time has expired. >> thank you for being here.

we appreciate your tenacity and your patients. i would like to just shift to something that does not bear directly on the affordable care act. i worked very hard in the house version, and it's past this committee unanimously. reimbursement for voluntary consultation for patients who are facing difficult and the light services -- end-of-life stances. because of the reconciliation process of dropped out. since then the evidence is even more compelling for the need for this service. i would just cite reverend billy graham's most recent book about talking about the need for families. majority leader bill frisk in one of the op-ed on the capitol hill went it out because of a lack of this, landing and assistance, patients are more

likely to receive medical animations -- preventions that could prolong or worsen their suffering and certainly increase the expense of their loved ones. with the american association of clinical oncology, just a great report about this right they included a provision that is very compelling, that they have researched that shows that if you do this right, if you work with patients, you can actually -- by adding palette of care, people can live up to three months longer while they get chemotherapy. in november of 2010, cms released a final payment role that would have reimbursed medical there is to have conversations with their patients on options for end-of-life care. this provision would have given people more control, and speaks too much of the legislation, bipartisan legislation,

cosponsored by a number of people on this committee, that docked row and i have introduced. ruledays after the final which into effect of the administration reversed course, pulled it back, and it has been for years because of some sort of procedural something. is there some way that we can work with you and our legislation so that we can give the federalo cost government, something that 90% of the american public and they want. is there way that this administration can work with this committee on a bipartisan basis to solve this problem? >> yes. i would welcome that opportunity. i can tell you that it is a personal passion of mine and my mother spent her last 10 weeks in three different hospitals with dozens of procedures. basically i would see this as

being tortured to death. the chance to look at how families and patients and providers can have more control over those end-of-life decisions. ialso think that two things would point out, one is that you did at to the medicare benefits a wellness in this -- visit which gives patients and doctors an opportunity to have conversations about health lands havends, and additionally a conversation about issues that arise in critical care. also, we are very much working under way with revisions in the hospice benefit area. >> i see my time is expired, but i would hope that after four years that you could revisit the rule, or that you support our bipartisan legislation so we can solve this. >> ms. black, and then mr. merchant.

>> thank you. -- thisthat these dialogue is so boring for us to have because these are big issues that directly impact individuals and their lives and my first question for you is do you believe the individual nandate tax penalty is a essential about it of the doubled edition of obamacare? >> i think the mandate came from the heritage foundation and some other legislative analysis that ties it to getting rid of the pre-existing condition very are for -- >> so you believe it is an important component -- ? i asked this because in the journal,n wall street they rightly accuse people from insurance and they allowed

americans whose coverage was canceled to opt out of the mandate altogether. all you need to do is fill out a form attesting that your plan was canceled and that you believe that your plan options available in the obamacare mandate in your area are more expensive than what was canceled. you consider other available policies unaffordable. further, there is also provision that says that people can also qualify for hardships for the unspecified non-reason that you experience another hardship in creating -- obtaining health insurance that only requires the condition if possible. another waiver is available to those who are really unable to afford coverage about these shifting legal benchmark offer i exception to anyone who wants what. actually argued

at the supreme court that the individual mandate to buy insurance was indispensable to the law's access. you, it seems to me that only the people that might be subject to this individual tax are those who were never insured because these are the people that were insured, and then for whatever reason -- do you think this is fair? >> i did not read the wall street journal editorial, i will read that later today. i can tell you the description that you just made is not accurate rate of a hardship exception was part of the law from the outset. there were some very specific rationale there. it starts with the notion that if you cannot afford coverage you are not obligated to provide -- by coverage. that has always been a framework. what this says is that if your plan is unaffordable you can file hardship exemption. that is part of the role that was also -- >> is based on affordability of

coverage. up --you believe your way plan is unaffordable you lot a form of a steady station -- a form of attestation? >> it has always been based on on affordability of insurance. if you're offered employer coverage but it -- >> all of these provisions that came out in this rule that was exposed,ot very much you feel that was already in the law previously? the new pieces not the hardship exemption which is always been part of the law, that allow people who cannot find an affordable option to also have the option of reducing a catastrophic policy. that is the new piece, it is not to get the exception of the exception has always been based on a hardship exemption is. >> my folks are really confused

about what this law does and does not do it how it applies to them. >> mr. merchant? >> thank you. secretary sibelius. i have been hearing from seniors in the district who rely on medicare advantage plans to on their health care. they are very concerned, as they are seeing their benefit reductions increase and the cuts. of the recent percentage of the country resulting from obamacare have actually gone into effect. majority of mandated medicare advantage cuts have not yet gone into effect, and are backloaded. can you please tell the seniors in my district that depend every day on their medicare advantage plans, what to expect in the coming years once the obamacare medicare cuts are fully imposed?

>> there is very good story to tell on medicare advantage. benefiting from what has happened since 2010 in a number of ways. fallen by 10% since 2010. enrollment has increased to and they are choosing medicare advantage plans. quality has improved with our five star quality care aiding system. taxpayers in other medicaid and the dishes that on a fisheries for work subsidizing the overpayment to insurance companies are now again seeing the benefits of that. enrollment is higher, premiums are lower, quality is better, we have many more land supporters -- land sponsors in the market.

beneficiaries have medicare advantage choices, and i think we are seeing an even stronger program for the future. >> the administration has issued outlet was waivers -- countless waivers and forms released for business at others affected by obamacare. 20% of the enrollees in medicare advantage are less than $20,000 a year. many of these individuals have a significant problem in dealing and the cuts that they are experiencing in the future. can you guarantee that they will receive the same level of benefits in the same access to their doctors? this is their biggest pair. -- fear/ ., >> i cannot guarantee the benefits that are outside of the medicare package.

what i can say is that seniors have more choices than they have ever had. lower premiums in medicare managed plans than they have ever had been have while in the dutch higher-quality. -- and they have much higher paidty and they are being over 100% of cost of fever service.- fee for it was stated unequivocally that these cuts would destroy medicare been to discover that seniors would have no choice, and that was flat-out wrong. i think there's very good news for the seniors now who are choosing medicare advantage lance ever they are paying less about having higher quality. >> thank you. mr. larson? >> thank you. thank you for your dedication and hard work. we deeply appreciate it.

also your willingness to come before this committee and others , and focus on what has been a frustrating rollout. something that is vitally important to the american people, our economy, and most importantly, to the well-being of our citizens. this is an issue that has been debated for the last four years. i was impressed with something that john mccain had to say, and i wanted to submit that for the record. to summarize, in talking about the finance committee and what went on, and he kind of debate that was taking place in the senate and actually did lazier on the floor -- and actually took place here on the floor, they submitted 564 minutes. 79 roll call votes were taken, 41 amendments were adopted, and then the senate health education labor video proved that by

14-10 vote. more than 160 republican amendments were excepted. it is that kind of framework, even though senator mccain disagreed, and wanted to see the bill -- did not vote for the bill, what he said at the end of the day, and what the american people at its us to work together to improve the bell. -- bill. what we see politically has an a in attempt to total repeal, every single letter of the bill ought to be repealed. including pre-existing conditions, including the great disparity that existed, especially for one as it relates to health care. there are a lot of positive, ,traightforward, pragmatic programmatic reforms that have been made, and under

extraordinarily helpful to the american people. it is appalling to the american public -- i come from a state where this is working extraordinarily well. where people are able to get insurance with the did not have it before. was called the insurance capital of the world is now embracing in changing and beating these reforms. for genomic objects in the biosciences are moving forward. theonly thing that drags country down is this endless, mindless debate, as data instruction -- instead of constructive criticism about how we can work together to improve the health and well-being of our american citizens. thank you for your service. >> amen. [laughter] >> thank you. >> thank you for being here. to real healthd care reform before the president signed a new health care a lot of and the fact is they still need it today.

the more we learn about the president's new health care lock the more the facts show it is hurting more people than it is actually helping. i'm hearing from constituents on a fairly regular basis right now who arerly concerned upset just got delays in parts of the law. their people about the cost to their pocket looks for increase health-care cost for themselves and their families. instead of getting what the president promised when it was rolled out for having lower premiums and lower costs, many are now paying more for health care. significantly higher detect both the more expensive remittance, many have lost their insurance, the plans that they like, or that they had. there is no doubt that some companies have been forced to scale back hours with more part-time jobs and less full-time jobs. those ablaze a good full-time jobs now have part-time jobs. there are jobs that are being lost to the medical device tax was a central component for the revenue stream of the portable

cap cuba but we now have 33,000 jobs that have been lost in this industry. this is one of our best americans six stories -- success stories. i have been to 1000 seniors in my district who are part of that medicare dated population. some of the past cuts in the program and some of the proposed cuts are giving them concern up living benefits -- losing evidence. the irony in all of this in minnesota, where we have one of the lowest uninsured rates for we have the law, we are see a likely increase in the lowest uninsured rate. question, why should the ministrations get another 1.8 1.8 elaine dollars -- 1.8 elaine dollars for the programs that are associated with the rollout of obamacare? i think, congressman

that the evidence out with the recent health survey in the last two days indicates that the overall uninsured rate in this country is actually going out. -- down. more people have insurance --erage for into the serv according to the survey and did in the past. i would also say that the vast majority of americans have coverage through the year work laces -- their work places. that coverage over the past three years have gone stronger when there are more consumer protections that they cannot be -- they do not have an annual cap anymore, and they cannot run out of treatment during chemotherapy. they have some features that the do not have before, that are in place. medicare has gotten stronger, with this plan. there are additional people who medicaid benefits -- >> can i ask one more question?

jake liked the care premiums to increase again next year, because they went up for a lot of folks this year. to expend this trend to continue next year? >> i think premiums are likely to go up, go but go up at a smaller pieces what we've seen so when he 10. increases are far less significant than they were prior to the passage of the afford look at. -- affordable care act. >> thank you for being here, greetings from kansas. visit with you about the president's health care law and the cost associated with it. the american taxpayer, it has been estimated, will be billed nearly $2 trillion over the budget window. the costs continue to mount. officeent count ability

report from laster says that the law will increase the federal deficit six oink $2 trillion -- trillion. seems to be increasing every time we turn around, and the proposal you are asking for today is another $2 trillion for this health care exchange. after all of the broken promises --mit to give you w promises, like if you like what you have you can keep it, i wonder if you can tell us all today what happened to the that says iomised will not sign a plan that adds one dime to our deficit, either now or in the future. this is what he told us in a joint session of congress in september of 2009. i will not sign it if it adds

one dime to the deficit, now or ll.the future, at a given that the president budget never .28nces it can time in the nation's future that she will stop spending more money did we take into i am just wondering how you can explain his promise to us? greetings backn, kansas.-- to the congressional budget office, which you rely on for scoring. he's of legislation, when the affordable care act was passed, it would save $100 billion in the first 10 years, and then

closer to $1.1 trillion in the second decade. they've updated that admitted even more generators -- and made it even more generous. not that it would detract from the deficit. i think that that is exactly what the president was talking about when he said he would not sign a bill. unlike metacarpal -- medicare part d, paid for by some credit card and still never paid for, the affordable care act was fully paid for within the scope of the law. >> it is not fully paid for. now that you have the data that

indicates that this will add over six dollars trillion to the national debt, what have you proposed that is going to bring that into line? >> congresswoman, i have to tell you i would be happy to answer that. i have no idea what that is based on. >> but you do know what the government accountability office is? are you questioning their -- >> i have never seen the study you are talking about. yes, i know what the government accountability office is, thank you. do know the scoring from the congressional budget office and it continues to be updated. i would be happy to provide that to you. >> mr. thompson? >> madame secretary, thank you for being here and your tireless effort to make sure that people have access to quality and affordable health care. i would like to ask you questions about two things in the budget. i will give you time to respond. one, the new gme program.

i think that this is an issue. ms. rogers and i have a bill that would hopefully provide more opportunity to train physicians. as you know, folks tend to practice where they train. rural andespecially underserved areas, this is huge. the administration has a targeted support program. i am just interested in what sort of assurance we will have that they will provide training outside of hospitals and in a community-based setting. tot is the certainty going be in this program? you know residency programs take a long time and i want to make sure that the program is in place so that folks have a certainty. secondly, on the administrative law judge appeals funding, the administration has put $100 million in new for medicare hearings and appeals.

i know that is a little more than what was in their last year, but i question whether or not it is enough. what are you going to do until the proper funding level is reached to make sure that our constituents do not get hung up in this void? >> congressman, the training be consistent with workforce goals, which include targeting more physicians to primary care and understaffed specialties, encouraging the practice in rural and underserved areas, encouraging training in some of the key competencies for delivery system reform. i think it is very consistent with the outline that you have made about your goals in workforce. i think that the health resource service administration, who would be administering these

training dollars, have the expertise in identifying the underserved areas throughout the country and the whole workforce capacity issue. that is why i think that this program is really on target to not only train the providers that we are missing, but making sure and connecting them to the areas that are the most underserved. -- what was your second? , the administrative appeals. we are doing two things simultaneously. we would welcome the opportunity to work with congress. receive fromt to what are appropriate examinations of over coating and overbuilding -- overbilling. on the other hand there are some system changes we can put in place, but we share your concerns that beneficiary should not be in a queue waiting for appeals to be made. we are trying to triage the system.

we would love to work with you on it. >> mr. smith? >> thank you, madam secretary, for taking time to have the conversation with us here today. these issues are obviously very important. i am concerned that some of the policies, from washington, d.c. are hurting the people that they are intended to help. if you could elaborate or reflect on the bid for critical access in hospitals, we know that that is a singular designation for a number of different approaches in various parts of the country. i obviously represent a large number of critical access hospitals, you are probably familiar with facilities in kansas. the treatment of these hospitals with a kind of cookie-cutter one-size-fits-all approach, whether it is physician supervision or the one-size-fits-all rule, these are cumbersome and burdensome. i have tried to find out how and

why they were adopted or proposed, even, from hhs. saved money? can you point to the effectiveness of these things? me that the very professionals trained to make health care decisions find washington, d.c. meddling in standing between a patient and their provider. >> congressman, i certainly share your concern about the important nature of critical access hospitals. as you say, cutting from the state of kansas where that territory is rural and closing a hospital suddenly means closing a community, i know how essential a hospital presence is. theink that what administrators at cms are trying to do is find the appropriate allen's. as you know, critical access hospitals are still paid more than 100% of medicare reimbursement. there is some evidence that a

proximity of one hospital to kind of belies the definition of critical access. >> these arbitrary regulations, like physician supervision, for example, requiring a physician on the same floor, it seems to me that that would actually drive up the cost of delivery of care rather than finding inefficiency. >> again, i would be happy to take the specifics back to try to find the evidence behind why specific recommendations were made. i can assure you that at least is looking athat these situations are very concerned that patients not be jeopardized by the care in trying to not added minister the burdens. i would be happy if you could give me specifics and i will get the evidence back to you.

>> thank you. again, these are examples that i the federalavoid, government standing between a patient and his or her provider. i yield back. >> thank you. mr. buchanan? >> madam secretary, thank you for being here today. i want to touch on the biggest issue in our area, employer mandates. this article from "the new york times," i'm looking at it, it says cities, counties, public schools, community colleges are illuminating or reducing hours in terms of part-time employees to avoid paying health care insurance. this is coming from state and national leaders from around the country. are you aware of this? do you have any sense on the impact that this is having on communities? in our community i can tell you that this is a gigantic issue. i have certainly heard conversations about the 30 hour clef.

more than 30 people would be required to provide health coverage for those employees, less than 30 they would not. --in, i think that there is disputing evidence of what is happening with that, we are watching it very closely. >> i would ask you to take a look at it. i know we are trying to get more health care out there, but everyone is taking this 25% pay cut. something that you said earlier about the fact that it only affects two percent of the businesses. do you have any idea what they make up in terms of the number ?f jobs the impact in the country? do you have a sense of that two percent? i have one employer in my area with over 1000 employees. they are moving most of them from 40 hours to 29. 20%,nk you are looking at 30% of the jobs across the

country being impacted by these mandates. even though you are pushing them off, people are making those adjustments in the public sector and private sector today. very concerned about that, but i would like you to get back to me on what the two percent makes up. in terms of the taxes and weenues, part of the reason have a record surplus this year -- revenues, rather, we increased taxes by 25%. we went from 35% to 44%. that is what the past entities are paying. forou look at the taxes state and federal, average across the country is 49 point six. i do not know how much more of a burden we can put on our employers across the country. as you mentioned, we need additional revenues. i hope that you are not considering going through more pass-through entities. >> one thing i would point out is that recently released rules

by the treasury department did look at the 30 hour employee, particularly that kind of mixed workgroup where part-time and full-time indicated that employers, if they offered coverage to 70% of their employees, would meet the criteria. i would tell you that the 30 hour definition came out of the offerings in the private sector marketplace prior to the affordable care act. that is what employers chose to do. people who were working more than 30 hours were defined as full time. people were working last -- as congress looked across the country, that is where that rate came from. but we are watching, as i say, that very closely. >> all right. thank you. chairman.ou, mr. madam secretary, so much of the original promise of the

affordable health care act has been undermined by faulty implementation. it has sometimes been indifferent to local concerns. last month the congressional budget office, as you know, concluded that faulty limitation of the health care law "impeded the enrollment of so many people in the exchange that one million fewer people actually obtained exchange coverage this year than previously projected." thisyour testimony morning, it is clear that we will not have seven billion, or even 6 billion. of course, the number that is really important is not how many have enrolled, but how many have paid their premiums and are getting exchange-based coverage? a number we have never been given. as you are aware, since last august i have been voicing concerns to your office about implementation in texas. at best less than 10% of the exchange eligible texans have selected a plan.

in other words, more than 90% of the people who we wrote this law to get exchange coverage for have not been covered. to meet your projections, we would need to enroll and have premiums paid for as many people this month as have been enrolled since the beginning in october two yesterday. or last week. this is much more than a website problem. though i believe that the individual assistance program there has been handled with about the efficacy of the original website rollout. i have been unable to get straight answers about even who is responsible for coordinating in person assistance in texas. a place where we have multiple sisters in some areas, none and many others.

i have sought to get even just a theseted line so that certified counselor who yesterday put in 10 hours trying to help one person would be able to call a line dedicated to assistance counselors to be able to get assistance and help people get enrolled in this. but there has been no response from hhs or cms about that. seems to me that we are to a point where instead of just circling the wagons against all the political arrows shot against this plan, we need a bit more accountability. we need to make sure that the next enrollment is not handled as poorly as the last one. i am very interested in answers to the questions that the chairman raised at the beginning of this hearing. we have not gotten them yet and i hope that we do. we come at this from a different perspective. taxpayers deserve to get their

moneys worth. i think that much of the focus as it relates to in person assistance needs to be to find out -- and i assume, mr. chairman, that some of these questions can be submitted by you with your questions for answers, such as how much it cost us, per person who is actually insured through the exchange, for some of these contractors that have been providing the services. washington, beltway contractors paid $9 billion for in person assistance in texas. i have been able to find out what it costs per enrollee. i think that while the goal should be to improve and strengthen this act, if it is to perform any better in the next enrollment than it has in this one, we need answers to these questions. to get the taxpayer their moneys worth and get the promise of this act fulfilled. i yield back.

>> at this time, dr. price? >> thank you. i think you sense a growing lack fromust that we reflect our constituents. americans have a growing lack of trust in their own federal government. there is no doubt about that. i would suggest that obama care is one of the poster children for why that exists. word is not matching deed. promises have been made and absolutely broken. as a former practicing physician, this is distressing. we are talking about the lives of people, not just nebulous programs. in spite of the people getting harmed, you have harry reid taking to the floor of the senate saying that any story that decries the problem with obama care, that they are all lies. of theagree that all stories are lies? did not hearn, i

what senator reid said. of course, there are lots of anecdotes of lots of people and lots of success stories. >> if you were to have heard him say that all the stories about aci -- >> i don't want to comment on his comments, i did not hear them. >> again, that is the kind of trust that is lacking. >> i clearly just said that lots of people have real stories. i do not assume that people are lying. >> let me go to specifics. you said 4.2 million people signed up on the exchange. i want to get to the concerns of others. how many of those who have enrolled in obamacare have paid their premium? >> i did not tell you that, sir, i do not know that. be that hhs, in charge of this program, cites a number, 4.2 billion people signed up, and has no idea how many people have paid? >> the consumers do not pay us.

they pay their insurance company. those figures? >> we get information in an aggregate form of the customers who qualify for a tax credit. many of those come of the 4.2, were previously insured? >> i do not know that. >> is it not true that many members of congress are in that number? >> i assumed that if you sign up under the exchange, you are in that number. >> kinsey did a recent survey saying that 120% of those joining were previously uninsured, a low number compared to your projection. is that consistent? >> again, i think that these be happy -- we would to give the answers to you as soon as we have accurate information. in the meantime, insurers have this information about their customers because that is who is being paid and that is to is

enrolling. >> it begs for julie that you do not know. >> these are private insurance plans. from a private product and a private insurance plan. we qualify them. we get their tax information to make sure that they qualify and then we send them to their company. >> you know what you are doing and you are not filling the bill. >> this is not medicare or medicaid, sir, this is a private plan in the private market. it is not government insurance. people are buying a product in the private market. as soon as we have accurate information, we will give it to you, but we do not currently have information about how many people. >> sounds like last fall, mr. chairman. >> all right. , there is aretary section in the aca on a reinsurance tax, correct?

>> yes. >> what is the purpose of that? the proceeds from it? >> there are actually three components of risk corridors, reinsurance task, and risk adjustments. three-year programs that, again, are paid for by the insurance companies operating in the market. it really is to balance the risk pool. it is exactly the same as part d. >> focusing on that in particular, our revenues to be used to fund other portions of the act? including exchanges? >> they will be used to balance the marketplace. >> how much is expected to be raised this year? >> i was just told at that figure is $10 billion for this year. >> but there is also a proposal

out there to provide waivers to some of those who are right now under law to pay that tax, correct? in particular unions? >> [inaudible] >> i am sorry. that rule, if you are self-administered in a self-funded plan, you do not pay the tax. that is not exclusive to unions. there are a lot of self-administered plans. >> how much relief will unions receive under this waiver as a result of this rule? >> i could get you that information. >> can you give me a ballpark? >> i cannot. >> i find it curious that that section is very clear as to who is to pay the tax. it is to be used and then help fund aspects of the aca, including exchanges, get the president is requesting an additional $1.8 billion in his

budget requests to build and operate exchanges. it seems to me that you are providing a waiver to perhaps what would be termed political friends to not pay what the law requires them to pay, but coming back to the taxpayers and asking them for more money to help fund the exchanges. >> sir, the statutory language talks about issuers or those who operate plans with third-party administrators. the self-administered plans, a much broader category than what you just described, are not in the statutory configuration of the law. >> just so i am clear in understanding what you are saying, it is your determination that those who are granted this waiver are not covered by the language of the act. >> they are not an issue or, nor do they operate with the

third-party administrator. much broader than the category many who, there are operate that way and are not specified in the statutory language. >> then why were unions jumping up and down asking for this if they were not covered to begin with? >> i can only tell you that that was what the statutory language said. the $1.8 billion that you suggest, 1.2 of that will be paid for by user fees. 600 million is the request for appropriations. >> all right. you, mr. chairman. madam secretary, great to have you with us. before i go to the questions about the affordable care act, i wanted to check with you regarding the financial alignment demonstration project being carried out in california called the dual eligible program.

ensuringthe goal of that everyone who transitions into this program will have uninterrupted quality health care that they can count on. i was just wondering, will you and cms keep us informed as you continue the rollout so that we can make sure that there is successful implementation of that program? sir, we will. >> appreciate that. >> i know that even today, if anyone is watching there is no reason why folks should not be left with some folks that sense of misunderstanding. this information and scare tactics that have been used over and over again have been difficult to combat. i wanted to make sure about something. as i read the fact, since the passage of the affordable care act you mentioned that seven -- several million people have now become insured. over 4 million now have private health insurance. did you mention that 3 million or so young americans who have

insurance as a result of the affordable care act can now stay on their parents insurance policy? >> i did not. >> that is over 3 million or so? >> yes, sir. >> 3 million previously uninsured. >> and we have some 4 million or more individuals who are now on -- who now have health coverage as a result of medicaid. >> closer to 8.9 million in the medicaid. some of those are renewals. some of those are newly eligible in states that chose to expand their program. plus numberlion includes people who probably qualified before or who just transition from current medicaid . >> some states require yearly renewals and they are included tothat, but there are close 9 million people who will have medicaid coverage. , 9if i do the quick math

million under medicaid, 4 million with private insurance in the marketplace, 3 million young adults. that is about 16 million americans with health security today that they might not have had before. >> that is accurate. >> my understanding, looking at the numbers since the affordable care act past, over 4 million jobs have been created in this country and if you look just at the health care sector, and the health care sector since the passage of the affordable care act we have seen over one million jobs created in the health-care sector. as we continue to talk about job loss in the affordable care act, it appears that the opposite is occurring. we are also finding a decrease in the greater increase of the cost of health care, which i would think you would would agree is a good sign. >> i would agree. on the job front we see the number of people working part-time hours is decreasing

the number of full-time in -- full-time workers, who are increasing. >> i would refer back to the record for the updated estimates to deal with job block and the estimates of employment and job creation. >> without objection. >> thank you. mr. chairman, madam secretary, we just heard from mr. becerra, who criticized critics, calling it disinformation and scare tactics. yet that wasn't not what we heard from mr. doggett. he was essentially admonishing the department for a lack of information and lack of accountability. witht to associate myself the spirit of mr. doggett and bring in one of the things from dr. price, that he was trying to articulate. would it not be great, madam secretary, if the doctor in the question he had asked were able to say -- here is the answer? ?hen he made the inquiry

that he was just the secretary of health and human services, private insurance was her answer moment ago. would it not be a great thing to say that this is the information and this is the answer? the problem is, as far as construction of the affordable care act, some of the information you may not know. it is because the limitations of the act itself -- we have an inspector general, and your own inspector general general is ofy able to go ask inquiries health and human services. that inspector general who reports to you cannot go and make inquiries at the treasury. one of your earlier answers was tax credits. when it comes down to it, the hhs secretary has the jurisdiction there. you do not know what is happening in that other department. would it not be a good thing if we were to amend the law and you had that information and there

was a special inspector general that have broad jurisdiction? >> i do not think that that is necessary. i think of that is an additional expenditure. i will give you the information as soon as we have it. >> by her own admission, you do not know why is it a good idea chose peschel inspector general's for iraq, afghanistan, tarp oversight. according to the congressional budget office, the affordable care act is a 1.8 trillion expenditure. is it that is sacrosanct that says that this should not broadject to this jurisdiction? by her own admission, you do not know the answers to these questions, do you? >> i do not have the information companiesnsurance

yet. >> rightly or he >> this is in the private sector. this is not treasury. >> right. your inspector general cannot get to it. >> this is not an inspector general issue. it is private insurers selling plans to their customers. >> that's even worse. it is ongoing and you do not have the information or the capacity. >> madam secretary i would say that part of the frustration is that you had the answer to the number of insured children, private sector information, yet when we try to get further information -- >> mr. chairman, that came directly from the insurers. we do not collect it. the we do not have it. they turned that into us. >> madam secretary, one of the glaring omissions in aca was

addressing the flawed physician payment formula. a lot of work has been done. it has been a problem facing congress for quite a while. over the past few years we have got into an agreement on the policy. bicameral. bipartisan. first, does the administration agree with this policy? will the administration support this policy? >> as you know, congressman, the president has supported a long-term fix long before the affordable care act was signed into law. yes, we do support the bicameral positions. >> the other issue is going to be paying for this. this will be a difficult fight, obviously. it can certainly become a partisan fight. in the interest of trying to get something done, will the administration come forward and work with congress, work with the senate to try to get to a solution on this?

>> we would be eager to do that. the first couple of budgets put forward by the president had specifics that were rejected. sgr is assume that the fixed. that is in the baseline for the next 10 years. we would be happy to work with congress. >> in the past the president that on the table some medicare that would help, i think, improve the outlook of medicare over the long haul, what being combining part a and part the into a single structure, making it work more like a modern insurance program. the second was limited means testing. does the president still support these? >> congressman, as you know that was put on the table as part of a global package of entitlement and structural spending reform. we would be eager to talk about those issues in that client --

that kind of global package. >> not in the context of reform of this pretty big piece? >> it does certainly impact medicare. it is probably the single biggest threat to the future of medicare terms of beneficiary service. we are eager to talk about pay having a more global discussion about entitlement reform, tax reform, and revenue, is something we would be eager to do. >> is the administration willing to put forward the capital to try to solve this before the end of march? again, we would be happy to have a discussion with members of congress about what they might look like. >> thank you. >> madam secretary. you in a fewack to moments about your role as

trustee of medicare and social security. just a reminder here, the democratic minority vigorously dposed the original part prescription drug benefit plan offered by the bush administration because we did not think it had gone far enough. while ascending to the majority right after, we took the role not to undo what had been done, but to work hard to improve it. closing the doughnut hole was a masterful piece of work. now there is a broad acceptance of the whole notion of the part d benefit. havei wish that that would been the model adopted in congress for working with aca. but let me draw your attention, specifically, to a couple of issues. graduate education and the role

across the country. in massachusetts, as you know, the hospitals would be the equivalent of what boeing means to the pacific northwest. i think that that is a reasonable description in terms of not only their success, but the employment opportunities but -- that they present. i law i think you have to sign every year a document certifying longevity of medicare, correct? >> yes, sir. >> can you talk about about what aca has done to the signing? .> yes the first year was a medicare trustee from 2009. the anticipation was that the actuarial projection was that medicare would begin to be insolvent. not that they would not have any money, but that they would have $.70 on the dollar by about 2017. in 2009 it was a 2017 cliff. the

passage of the aca added years to that solvency according to the actuary who looked at the law and the impact over time. subsequent budgets have also added years. the 2015 budget, according to the projection, would add an additional five years to the solvency of the medicare trust fund. during this administration i would say that significant solvency has been added. >> are there republican trustees? >> yes. >> did they sign the document? >> yes. >> my point is -- an example again of a good story, much like the one presented by secretary lou regarding deficits in his appearance before the committee recently that is frequently underreported in terms of the good news because the emphasis remains on the conflict of the story as opposed to the substance. i would hope that you use the

opportunity with medical education to propose the notion that this is a widespread success story on that basis. >> thank you. >> thank you. >> mr. reichert? >> thank you, mr. chairman. madam secretary, in response to the question regarding legislation, your answer was that there was no legislation that had passed congress. you are aware that there are eight pieces of legislation that have passed congress and been signed by the president regarding the affordable care act? eight pieces of legislation passed by congress and actually signed into law by the president? if you had to go back and review the law you are trying to implement. i want to go back, real quick. it has been four years since the passage of the health care law.

let's look back. 2010, the president spoke at the white house republican retreat, acknowledging that some stray cats and dogs were added to the health care bill and that some of the provisions that were snuck in might have violated a pledge. like being able to keep your doctor. in 2011 during your testimony and by questioning, in response to whether or not you could keep your doctor you said -- i do not think that there is any language in the bill that interferes with the current system. again, you are wrong. when i raise these same concerns in 2012 you said that the notion that companies with grandfathered plans would not be able to keep them is not accurate. .gain, you were wrong due to the many mandates in the law and regulations put out by hhs, as many as 5 million americans have lost their existing health care plans.

the law has created so many disruptions that the president's announced, perhaps illegally, that states could begin to ignore the law. as mr. reid said, there are 37 changes to the law. september 24, september 26, november 14, there were several more changes to the law. 22, 21st,2, november january 1, the 30th of november , december 12, december 19, and then, secretary sebelius, you assured fox news and the american people watching at that time that there would be no more delays. yet through january 10 of this year, another delay. and then february 10, another delay. are there any further delays? can you make another promise to the american people today, madam

secretary? that there will be no more delays to the so-called affordable health care act? >> we will continue to put out regulations. sir, i would like an opportunity to correct some of the misstatements. there is nothing in the law -- >> will there be further delays, madam secretary? >> there are no plan to delays in the law. >> do you consult with the treasury department before announcing making changes? most -- the regulations -- >> do you consult, yes or no? >> the regulations require the participation of three agencies. there is broad consultation. >> thank you. >> recognized. >> thank you. to my friend from massachusetts, he should look at the unprecedented original appendix

of the trustees report that talks about the double counting that occurred. putting on the car the democratic proposal but double the credit card bill. madam secretary, we keep this list here. i want to ask you about ipad. in table number nine of your budget from last year you claimed that you would save $4 billion from those recommendations. you tripled that for the recommendations. this is above and beyond the cuts that are there to pay for the aca. my question is, where are we with ipad? i assume another report is forthcoming.

where is it itself? when will you submit the names? if you don't do that, you know that the law lets you submit the plan. so, what is happening with that? if you're going to do it, how do you come up with the $12.9 billion? >> congressman, the president has not yet sent congress names for the nominations. know, the law is constructed in such a way that it would not trigger any isommendations unless there a gap between -- >> i realize that. have anyould not recommendations to make in the foreseeable future. nor would i take any action in the foreseeable future. >> are we to ignore the fact that you are claiming $12.9

billion in savings? >> the president plans to submit names to congress as we watch the trajectory. changes, ipad will be in full effect. those recommendations are presented to congress, as you know. not to me. if congress does not change them, they go into effect. >> or you just recommend them if there is no ipad at the time? >> correct. >> you have no answer as to where will come from? >> we are optimistic that the current trajectory of medicare costs would actually negate any impact from me taking on any kind of action in the foreseeable future. >> that is another way of saying ignore the budget that is not real. >> i think that recommendations are based on actuarial. >> i get all of that. you did that last year. you still have 4 billion.

now you have tripled savings to 12. it question is, where is coming from? what are those justifications? what are the assumptions you are using to claim how your budget is put together? >> the actual projection is that out your medical costs will rise again. incorrecty have been about the increases and we are hoping that they continue to be incorrect. rise, ipad't deed would kick into gear and we would make recommendations to congress about the specifics. >> just so you know, in your own budget you are saying it is going to triple from this year to last year, that that is coming, that it is about projection, it is in your budget but you have no idea where you will cut it? >> again, it is based on what the actuary says will happen in

out years. currently we have not made specific recommendations about any cost cuts because none of that is actually happening. >> when are we going to see the names? >> they come from the president. i don't know. >> mr. davis? >> madam secretary, thank you very much for being here. i also want to thank you for the medicaid waiver for cook county in the state of illinois. as a result of that action, the governor's expansion of medicaid and the hard work of a lot of people, illinois doing much better in sign up for the affordable care act than many other states. for that, we are indeed grateful. fan of home visiting programs and of community health

centers. i am pleased to note that both are included in the budget. as a matter of fact, i get my personal care at one of these centers in chicago. on the valueborate and effectiveness of these two programs as they relate to foriding health care especially low income people? >> congressman, i share your high regard for both programs. there is no question that the community health centers are the back bone of primary care delivery in this country. they have proven time and again to deliver lower-cost, higher value primary care and thanks to both investments from the recovery act and ongoing investments from the affordable care act, the footprint of health centers is spreading.

increasing services and increasing clients. we will now be able to serve about 31 million people, including yourself. playing ant they are incredibly important role in underserved communities. in terms of the home visiting program, again, lots of very strong scientific evidence makes a huge difference to help giving parents the tools to be the best that they can be. from having a professional encounter with young parents, it is often extremely beneficial as the pathway to an early strong start in learning. the president's budget, as you say, both increases the voluntary home visiting program as well as continues to expand the footprint. for the community health center program.

>> it has not been automatic, but the experience that came as a result of a large number of people believing in the program, believing that it will work, and then working to make sure that it does work. thank you very much. >> i don't think it comes as a surprise that in states where the governor is very supportive, where there are delegation members and providers, others reaching out, there is a more positive experience. the congressman mentioned texas, where there aren't not only barriers, but significant laws passed that make it difficult for a lot of these people to even do the job they were contemplated to do. >> thank you. >> for the record of this report, the irony of obamacare

making inequality worse. i would like to read the conclusion, which says that for two years labor unions and employer partners have patiently explained to congress and the administration the potential damage that the program poses to these unique and successful nonprofit plans. , theg already made efforts administration is now highlighting issues of economic inequality while acting to preserve health plans that have been achieving their goals for decades. without a smart fix it will heighten the inequality that the administration seeks to reduce. we take seriously the promise that if you like your health plan you can keep it. members planning on plans are ready to compete with the corporate giants of the health-care industry of washington will simply create a level playing field. there were three articles in local papers in my district that i would like to submit for the record, mr. chairman, that highlight this very issue.

reporting on monday that only six of the obamacare exchange plans in richmond county included the only hospital in the county in network. the marion star reported on monday that only six of the hads in marion county marion general hospital, the only hospital in the county in network. finally, the advocate reported only six of the plans consider the only hospital in lincoln county to be in that were. meaning that three quarters of the exchange insurance plans in these counties, they do not give access to the only hospital and hundreds of doctors in network. because so many of my constituents are now facing the choice of being in network and of theto travel out county maybe 100 miles to a hospital without losing doctors they had -- these were people

who had insurance and have now been forced to go into the exchanges and in the county in which they reside they cannot even go to their hospital. this is a problem that is just beginning. we spoke to a lady in the office yesterday from central ohio. she wanted me to give you her name. colleen. she had health care. now she is one of the 4 million of the exchange. she now has a plan she is paying more for that she does not like, she actually lost her doctor. she liked what she had and could not keep it. now she cannot even keep the doctor that she had. so, the articles are not misinformation or disinformation. report,n you -- union not supportive of republicans, by the way, is not this information, and yet there seems to be a disinformation campaign within the administration that this is all just make a leave. madam secretary, help is to

reassure our constituents that the administration is going to deal with the reality that is hitting the ground, that people are losing their doctors in their hospitals. >> thank you. mr. shock? >> thank you. welcome, madam secretary. yesterday the house of representatives passed a bill dealing with the affordable care act that clarified the religious exemption clause for a small segment of the population who on their annual tax return will have to basically verify that their religious conscience inhibits them from participating in traditional health care here in our country. this is modeled after a law from the state of massachusetts that they put into effect in 2006. only 6000 residents had taken advantage of it. primarily christian scientists and others. the bill passed out of the house unanimously yesterday. it is now headed to the senate,

where it enjoys bipartisan support. i am just wondering if you could speak to whether or not you support this clarification in the religious exemption clause. have not read, i the language but i will take a strong look at it. i know that it passed yesterday, but i will read it. >> will you get back to us with your opinion? thank you. the second thing has to do with the administration's change in how you are handling the appeals process for medicare providers. medicare hearings and appeals has recently taken the unorthodox step of no longer accepting medicare appeals for processing at the administrative law judge level. i am obviously concerned about the current health care providers and current seniors who could be denied reimbursements and the effect that will have downstream, if you will, if they are not

allowed due process. if you fast-forward into the implementation of the affordable care act, setting the precedent that we will not allow for due process with current medicare recipients, one might then assume that that would be a practice that the agency would do for folks on the aca. are you working through that? do you see the administration standing firm in allowing this or not? >> congressman, this is a major problem and issue. i know that our head of the office of medicare appeals has been on the hill, briefing in a bipartisan nature the house and the senate on what has happened over the last couple of years. it is my understanding, and they do not want to miss speak, but my understanding and if it is incorrect i will correct it immediately, that their initial decision to suspend hearings was not for beneficiaries, but for

hospitals and providers. they were very concerned that beneficiaries not get caught in the huge queue and go to the back of the line. in the meantime, they are looking at a whole array of systems that could alleviate the queue. the volume has tripled over the last couple of years. we need to do some system changes. we need to work carefully with congress. the last thing we want is for anyone to give up their due process rights. >> madam secretary, i am convinced that when the final pages of history are written, your name will be included among the courageous pioneers that brought health care to all americans. seems to be some concern about the delay in the program. do you recall when last we had a program for the nation where all the people had access to health care?

>> no, sir. >> so, since the beginning of the republic. >> yes. >> so, this is the first time. security,d social were the names and legislation necessary to prove it? >> i would say that social security and medicare have transformed over time. >> i understand that enrollment going up, people young and old are applying. >> that is correct. we put out that information yesterday. million 4.2 millionary 4.2 people had enrolled in the private market. another almost 9 million have qualified to be medicaid eligible. 3 million young adults got their coverage earlier in the program thanks to their parents plan. >> that is the younger and healthier people? >> yes, sir. >> any indication that they are

all democrats? >> we do not currently have the information. >> any reason to believe that republicans are not in need of health insurance or do not have preconditions? is there any evidence that the republicans would not receive the benefits of the affordable care act? >> no, sir. derailhe 50 attempts to the affordable care act, which has passed the house, the senate, and been approved by the supreme court, is there any indication from your president if, by some stretch of our imagination, the repeal goes to the senate, as to what the president would be inclined to do? >> he has indicated that he would veto a repeal of the act.

so, has there been any suggestion, then, from the republican leadership, since this is the law of the land and is universal and bipartisan as relates to the beneficiary, have there been any suggestions from the republicans as to how we can and itsupon this bill provision to provide health care for everyone? have they suggested anything to you that make sense? >> there have been a number of conversations that i would say were productive. unfortunately, i think that the and suggestions of how to improve are often tied to -- >> all right, time has expired. >> i wanted to congratulate the chair and insist on congratulating him as being part of that republican party that on tried to be constructive

legislation. >> well, thank you. there is always time for that. [laughter] levin andn to mr. myself. i want to return to this issue of how many individuals have paid their first month's premiums. i would really -- i realize that you have repeatedly said that you do not have that information yet, but i want to make the point at we are two weeks away from the six-month open enrollment. i know that hhs has spent $2 billion building these exchanges . your own budget document states that it is administered on behalf of all marketplaces and that the process involves from all and roman marketplaces, including selected calculations to distribute monthly -- monthly aggregated payments. but given the time and the critical need that your own department has for this basic it is just, i think

absolutely critical that we find a way to get this information. there are reports that up to 20% of the individuals who selected plans have not paid their premiums do you have any information along that line about his the 20% with what you been finding out? -- that 20%ng number came from the insurance companies bought the first of the year r. they were heartened by the fact deadlinesnt of the first premium in december -- they had about 80% in that rate. --t did not come from lost us. when we have a fully