no income, noith insurance, no savings, and no toal ability i knew it would take time to .ransition i've applied for nearly 200 jobs. had hopes of making somewhat near what i had made

before, but i soon found outside worthld i was considerably less and it was a buyers market for labor. without the extension we were left with the choice of signing a deed and selling our house back to the bank or facing foreclosure. february 27, for $4,000 we back to $175,000 house the bank. we had already gone down to one car and made so many other lifestyle, and now we were no longer homeowners. e.u.c., we've had no income. at first we got by on our tax selling items. but to make last month's rent i had to borrow from my dad who is retired. if i don't find work soon, i may to consider trying to look out of state and possibly be separated from my family for a time. i hold out hope that this congress will act with courage and compassion and extend the

e.u.c. program. out theremany others like me that have special circumstances, that prevent them job,quickly finding a despite their best efforts, as we've heard through all these stories, and diligence. i pray that they'll do the right thing. thank you for your time. [applause] >> the national economy lost $5 billion because of the lapse unemployment insurance the first three months. tell the here today to personal stories that reflect those stories of millions of americans, and another person is carmen sanchez from philadelphia. >> good afternoon. my name is carmen sanchez, i'm the single 52-year-old mother of

twin adult daughters. i'm from fill will. i have worked all my adult life with the exception of a two-year the birth of my remature twins much i worked for years for twa until they went out of business. i collected unemployment for approximately five months before i found another job. after being employed there for 13 years the company closed the field office i worked out of and i was left without a job, it's been one years since i was laid any nick have not had since december 2013. i've applied for so many jobs i've lost track of the number. i've taken the civil service test only to be told that i'm on waiting list and they'll let me know if something comes up. notice fored shutoff all my utility bills and do not have money to pay the rent. for food stamps. i have been relying on middle determine mother to give me car and pocket money to be able

to go out and look for work. i had to stop driving the car could no longer afford the insurance. i never imagined that finding a difficult.e this i went to a crisis center last week to apply for help to stop off,ter from being shut but was denied because i did not have an income. to qualify for the reduced rate perhaps -- you must have an income. i lay awake at night wondering how i'm going to pay my rent and the utilities will be shut off. the owner of the house i'm has been understanding, but she has financial obligations to meet, so it's only a matter of time before i'm evicted. i'm urging the congress to reinstate the emergency unemployment benefits. many americans are in peril. we want jobs and we'll keep looking until we find one. losing our homes, our dignity and our trust in a nation who proclaimed the american dream was attainable to all its citizens. give back the life loin

us. was taken away from we're asking for just enough to keep also float while we jobs.ue to search for [applause] >> there are 2.8 million americans, hard working americans that stand to lose everything that they've worked for. that they've spend their lives building. because the republican isdership in congress unwilling to take up a bill that would not increase the deficit that would save pain like the pain that we're hearing taking place.om these are hard working americans. and while to the republican may behip they invisible, they won't be silenced. we tried to hold a hearing today and we were told no, that the house was not open to the people who wanted to tell their stories about how they've lost their jobs and stand to

lose everything. this is something that the the federal government, that the congress can do something about. some of the questions we face really complicated. this one is simple. take up this bill. senate.n passed by the [applause] the president will sign it. a majority of congress would it.ort take up this bill. that's all we need to do. people need ae vote. they may be invis toil the republican lerdship, but they be silenced. their stories will be told. and i want to introduce one of them, from baltimore, maryland, one of the americans who works hard every day to try to find work, jean king. >> thank you for being here today. is jean king, i'm 52 from baltimore, maryland and i want to thank you for this to share my story. in the fall of 1983 i was girl andith a new baby during that time my husband lost

his job at u.s. steel. tens of thousands of other workers, when the mill shut down the ohio steel valley. we had to relocate, sold and withg we owned some help from my father tried to start over in a new state. out to beove turned very difficult. economic stress and financial our littleded family, and by 1998 my marriage was over. time, my ex-husband's job loss had brought on his which he never fully recovered. in 2007 he passed away. ie year my marriage ended moved to baltimore, went to college, a second child. raised both my children on my own for the most part. i bought a home while making a modest middle income salary. in 2006 i went to work for a manufacturing company serving as the plant manager's resourceg and human

coordinator. over the years the company had weathered up and down business cycles well and even when the housing market crashed things seemed fine. then in 2011 the company's assets were purchased by a firm. they again to close the plant bit.y in 2012 my plant manager, the receiving manager, the my soning manager, and who also worked at the plant with me, were the first to be let go. i was relocated to a different department to continue the merger and transition. i was laid off in may of 2013. i accepted ark, job doing accounts paint for a iall company, but long after started they told me i was overqualified and gave the job to a member of their family. i've heard the term kroafer qualified too many times to coup during my beyond search. my severance from my former employer and i filed for

receiving regular state unemployment insurance which help me keep up with my bills. work,inued to look for during the day, and attend college classes at night to and education.ls i've had my resume professionally prepared. by recruitersewed and academic experts. networkion to scores of ing referralses are i've applied for more than 350 positions, i've had 60 phone in person and 22 interviews and i've had absolutely no job offers. my daughter and her 5-year-old autistic son were forced by the tough economy to move back in son.me and my she receives some assistance for her child and my son has oh case alley found part-time temporary work, but nothing steady full-time. the first week of february my unemployment benefits ran out, with no federal extension of emergency unemployment we've been able to field our self with snap

benefits. but could not keep up with the payments, utilities or other bills. i have now lost my phone and ofernet service, which course makes looking for work even harder than it already was. losingw on the verge of my home, the only protection i family. myself and my while all of this was happening to me, my former plant manager so devastated by the combination of his own loss at of age of 60, the layoffs all 60 of his former coworkers at the plant, many of whom had decade, the for loss of his home to foreclosure, severelyecame depressed and experienced a mental and emotional breakdown, of his that so many former coworkers were cut off from federal beyondless aid and teution.ssity for this good man with a husband,degree, a fine family man and friend to us, the stress was too much, he suffered february he in died. i happen to be an epileptic and

i too am depressed with the feeling of helplessness, but i'm not going to beg for anything. i am requesting that you reinstate the federal extension of emergency unemployment do sosation and that you immediately. [applause] i also ask that you adopt measures, i also ask that you adopt legislative measures to prevent discrimination against the long-term unemployed in the job and that you remove unfair barriers to the employment based on credit those who have been unabe to pay their bills. [applause] lastly, congress, i ask that creation withjob serious investments in an infrastructure and jobs across boost the economy, so i do not lose any of my coworkers, my families, or my

friends, as this situation more desperate, so do the people who are enveloped in it. time.you for your [applause] >> thank you. voices that we have heard this afternoon represent thousands, indeed millions of americans who are in situation. unfortunately our republican areeagues in the congress in denial about this situation. don't you them why give us a vote because the votes extensionto pass the of unemployment benefits -- [applause] they say, they say these people looking for work. so we're not going to give them this extension.

they are in denial. tofact they don even want hear the truth. that's why they kicked us out of rayburn room and wouldn't let these stories be told. people's house, on the capitol hill. we noticed, we've come to the steps of the capitol so the world can hear this story. only of their own stories, but representative of so many others. they have spoken so eloquently, i want to thank them, i want to all of my colleagues who joined us here and are helping legislation the that would give us a vote. that's all we're asking for. mr. speaker, give us a vote. give us a vote. give us a vote. thank you all very much. [applause]

>> next a confirmation hearing for sylvia burwell, nominated to the next secretary of health and human services. after that the house foreign affairs committee, finalizing legislation concerning nigeria and venezuela. live at 7:00 a.m. your calls and on "washington journal." >> china has become the factory

to the world and it sends products around the planet in a our lifestyles possible. we couldn't have the kind of quality of life that we enjoy if didn't have low cost goods and low cost labor in china. in increasingly elsewhere southeast asia. yet in china today the standard of living remains about one theh of what it is in united states in terms of per cap that income. that's a source of frustration, people realize we work hard, we are participating in the global economy, we play by the rules in some cases and yet we're not yet enjoying the quality of life that they have in the west. i think is so interesting about this is that for most of nonese history people had idea what life was like outside. this gets back to this tour of europe. people can now sit on a computer in a village and have a pretty accurate understanding of feels like to live in washington d.c., or at least they can get an image of it, so that heightens this conflict. >> evan osnos on the rising conflict between the individual

and the chinese government, a.day night at 8:00 on q and a," a collection of interviews with some of the nations top story tellers. >> people who have imgreated to this country, some legally, some illegally, in my case i came in with no documentation and no or any to get a job education. so when i first came into the united states in the i crossed the border between mexico and the united states, ended up coming into the san joaquin valley to worker,a migrant farm it was no challenge to find a job. there were not thousands of trying to get the jobs of pulling weeds with the very same hands that are now doing brain surgery. i was pulling the weeds. of 41 unique voices from 25 years of our book notes and q a conversations.

now available at your favorite book seller. >> republican senators jim mccain and richard bur have issued public statements of president'sthe nominee to replace kathleen sebelius as health and human services testimony. this is two hours and 10 minutes.

we're going to go ahead and get started here.

oh. the committee on health education, labor and pensions will please come to order. we have convened this hearing to consider the nomination of sylvia matthews-burwell. we thank you for joining us today and for your prior services and for being willing to take on this enormous responsibility. ms. burwell is currently serving in a position which she was confirmed by a vote of 96-0 in april of 2013. ms. burwell has proven herself as an efktive and dynamic manager with experience and skill leading a wide range of organizations. recently i had a very productive meeting with ms. burwell and concluded she is an impressive nominee and is eminently qualified to serve as the next

secretary of health and human services. the united states faces serious public health challenges, many of which require urgent answers. very often the entire world looks to hhs for leadership. just last friday the country confronted the first-ever incident of mers, the middle east respiratory syndrome, within our borders. hhs reacted immediately developed a path forward basically through the center for disease control and prevention. i might just add the cdc, the gold standard for public health in the world. i was just reminded the other day that china has named its public health system china cdc. we will count on our next secretary for exactly that kind of informed decisive action in the face of future challenges and crisis and provide a steady hand overseeing an incredible range of activities across the department. for example, she will be responsible for research efforts at the national institutes of

health among other agencies. this federally sponsored research has made the united states the world leader in biomedical innovation and has resulted in countless discoveries and breakthroughs from the extraordinary application of genomics and understanding of the human brain. ms. burwell will also be in charge of another long-time priority, at least of mine, and that is disease prevention. she will lead our nation's efforts to transform our health care system from a sick care system into one that focuses on wellness and prevention. not just at the doctors office but in our schools, our workplaces and our communities. ms. burwell will oversee the food and drug administration, a critically important agency that protects and promotes public health by keeping our nation's food and medical products supply safe among other things. in fact, fda now oversees ie se tems accounts for over 25 cents of every dollar spent by

americans. the department ensures we can meet the health care needs of our most vulnerable services through programs like community health service programs and the head start program. the secretary's also charged with oversight of programs that support millions of americans with disabilities. medicaid makes it possible for many with chronic disabilities to remain in their homes, or to go to work or school, to be active members of society. in tandem the administration for community living implements policies that help people with disabilities to stay in their homes, to stay in their neighborhoods and places of work with the result that people of disabilities in america are healthier, happier and have a better quality of life. and of course ms. burwell will have the critical role of overseeing implementation of affordable care act. we can be proud thanks to the affordable care act we have seen 4.8 million new medicaid enroll ees, more than 8 million americans have signed up for

health insurance in the marketplaces but there's more work to be done in successfully implementing the law and reforming our health care system, as i said to move from a sick care system to a true health care system. so the list goes on and on. i think i made my point that as secretary ms. burwell will shoulder incredibly important responsibilities that matter deeply to the health and wellness of the american people. and i believe this has an impact on our present and future economic strength as a nation. so we look forward to hearing from ms. burwell today about her vision and priorities for the department of health and human services. we welcome this opportunity to question her about many of the issues this committee will continue to oversee going forward. i also wanted to mention that senator frank and member of this committee very much wanted to be here but is attending the funeral of former congressman jim overstar today. with that i'll ask our ranking member senator alexander for his

opening statement. >> thanks, mr. chairman. ms. burwell, welcome. glad to have you here. since i'll have the opportunity to ask questions later, let me use my five minutes to tell you a story. when i was a boy, my grandfather was a railroad engineer in newton, kansas. he drove big steam locomotive switch engines. he'd drive an engine on to the roundtable headed to santa fe and turn it and head it in the direction it ought to be going. he headed to denver, he headed to houston. that's what republicans would like to do with our health care system. we'd like to turn it and head it in the right direction. we want to repair the damage that obamacare has done and prevent future damage as responsibly and rapidly as we can. we'd like to move in a different direction, put in place proposals that would increase freedom, increase choices and lower costs. we trust americans to make these decisions ourselves. we believe that is the american

way. four years ago congress and the president made what we believe is an historic mistake. they passed a 2,700-page bill, we said we don't believe in that trying to rewrite the whole health care system, let's go step by step in a different direction. more freedom, more choices, more costs. we take you back for a moment to the health care summit at the blair house four years ago. three dozen members of congress, six hours with the president there, all of it on national tv. i was asked to speak first for the republicans. i said what was wrong with the president's plan. i and others said it would increase health care costs and it has. "usa today" reported that health care spending the first quarter of the year rose at the fastest pace in nearly 35 years. hill paper reported that insurance executives say premiums in new exchanges will double or triple in the country next year, even with subsidies. many americans are finding that

the copayments and the out of cost expenses are so high they can't afford insurance. we said people would lose their choice of doctors and many have. we said obamacare would cancel policies and it has, at least 2.6 million americans have had their individual plans outlawed by obamacare. and millions more of americans who get their care through small businesses will find the same thing happening to them. we said it would lose jobs, it would cause jobs to be lost, it has. the president of costa rica is hosting job fairs welcoming medical device companies that have been driven out of the united states by the onerous 2.3% tax on revenues. we said medicare beneficiaries would be hurt, they have. the average cut per medicare advantage recipient will be $317 between this year and next. we said the only bipartisan thing about the bill will be opposition, gallup says that level today is 54%. i said every senator who voted

for it ought to be sentenced to go home and serve as governor and try to implement it. and there are 16 governors today who won't implement the medicaid expansion because they worry about costs. but the most important thing we said is what we would do if we could. we said let's go step by step in a different direction. our democratic friends said that's not a plan, that's not comprehensive. we said you're right, washington's not wise enough to make these decisions to rewrite 23% of the economy. if you're waiting for senator mcconnell to wheel in a wheelbarrow with a 2700-page bill, you'll be waiting until the moon is blue. and at the summit we outlined our steps. for example, we said if you like your plan, you could keep it. as the president did. and we suggest removing some mandates to make that possible. if you find a policy in another state that fits your budget and health care needs, you can buy it. if you're a small employer, you can combine your purchasing power with other small employers to offer employees more cost

insurance. we would allow any american to buy a major policy to avoid a medical ka castrocatastrophe. if you're an employer we'd make it easier to give employees rewards for leading a healthy lifestyle. ms. burwell, you have a reputation for competence. and i would respectfully suggest you're going to need it because if you're confirmed, you by yourself supervise the spending of nearly $1 trillion a year, which is as much as the entire congress of 535 men and women appropriate every year. we hope on this side of the aisle in the next congress we have a republican majority in the senate and we'll be able to do for our health care delivery system what my grandfather used to do in newton, kansas, for those trains that were heading west, we'd like to head them in a different direction. as i said, republicans would like to repair the damage that

obamacare has done. we'd like to prevent future damage as responsibly and rapidly as we can. we want to move in a different direction to put in place proposals that provide more freedom, more choices and lower costs. we trust americans to make those decisions for ourselves. we believe that is the american way. since obama will still be in office for the next two years, if you are confirmed, we will need your help to do that. thank you. >> thank you very much, senator alexander. now before i introduce ms. burwell, we'll call upon two distinguished senators who are here in order of course of seniority. i would first recognize our friend and our colleague senator mccain. senator mccain, welcome. >> thank you very much, senator harkin. and i hope that senator manchin appreciates that more than he does today. i thank you, mr. chairman, for allowing me to be here. many of us in this room as

senator alexander just pointed out disagree about the merits of obamacare and what the path forward should be to reform our health care system. i long along with others fought for 25 days on the floor of the senate against obamacare or the affordable care act. first amendment was one that i raised to stop the nearly $500 billion in cuts in medicare that was in the bill. and i continue to believe that the affordable care act should be replaced and modified. but notwithstanding that disagreement i'm pleased to introduce sylvia burwell, who's been nominated obviously as secretary of the department of health and human services. her previous experience as deputy director of the office of management and budget during the clinton administration as well as her work with the bill and ma linda gates foundation, the walmart foundation, her current work as director of omd, and i

have no one who does not have but the highest praise for her work as director of omb, make her well-qualified to be secretary of hhs. i'd like to add that i visited, mr. chairman, dentville, arkansas, while secretary burwell was there. i was briefed by her. i would recommend to every one of my colleagues a trip to bentonville, arkansas, to see an incredible american success story from one store in a small town to the world's largest retailer. ms. burwell was part of that team that maintains the predominance of walmart as the number one retailer in the world today. to say i was impressed would be an understatement. and last year sylvia's stew ardship of the walmart foundation which made last year $1.3 billion in charitable

donations, she was the steward of that and nothing but the highest praise for her activities in that capacity. regardless of my objections to the affordable care act, the department of health and human services need competent leadership in the position of secretary. i believe ms. burwell has the qualifications to run hhs and have the assured that she will work with members of congress as she has as director of omb and be more responsive to its members than her predecessor. when sylvia was nominated to be director of the omb, i said that position of director of omb is perhaps the toughest job in washington. the position for which she is currently nominated is perhaps the most thankless. that's why i advised her against taking the leadership position at hhs. after all, who would recommend their friend take over as captain of the titanic after it hit the iceberg?

obviously, she ignored my advice and accepted the nomination anyway continuing her pattern of public service. and you know the scope of her responsibilities far in excess just of hhs, medicare and medicaid services, food and drug administration, the national institutes of health among several other divisions add up to $1 trillion budget with 80,000 employees. she will have her work cut out for her. i recommend strongly ms. burwell and hope the committee will endorse her nomination. i thank you, mr. chairman. >> thank you very much, senator mccain, for being here. i know you have a busy schedule. if you need to leave, please feel free to, but thanks for being here. appreciate it very much, senator mccain. and now we'll turn to senator manchin, who probably has some good words to say about a person from henton, west virginia. senator manchin, welcome. >> thank you, mr. chairman.

and thank you senator alexander and all of our colleagues here. let me just say that first of all, senator rockefeller wanted to be here. he wasn't able this morning, and i'm just so thankful and honored to be able to set here on his behalf and on my own behalf and for all the people in west virginia that we're so proud. i want to put a little bit of a personal touch because sylvia comes from where most of us come from. when you talked about the railroad, senator alexander, she comes from a railroad town. she knows about turning that engine. she knows about basically that round house. that's where she comes from. and this is a lady that has done it. she knows how to do it and she's watched it. we're all a product of our environment. every one of us. you throw back to where we came from, how we were raised, the families we were raised with, the communities that nurtured us. hinton, west virginia, is a special place. it's the most beautiful, right along the new river, big blue stone dam is right there in her backyard and people fish and

enjoy the recreation, all that. sylvia's father, dr. william matthews, is the town optometrist, well-respected. he is a first generation greek immigrant. came with the hard working ethics that we come from when people are wanting the american dream. and her grandparents were seeking that. her mother, the honorable cleo matthews is a very dear friend of mine. when i say honorable, i mean that in every sense of the word, she was the mayor of hinton, tough. senator, you and she would get along absolutely to a "t." and she kept -- when i was governor i never had anyone i enjoyed those conversations, the phone calls from her mother letting me know what i was doing wrong and how i could fix the sta state. and i took most of those to heart. her mother was a math teacher. the most respected math teacher. so everything you see in this

young lady is because of her environment. it's how she was raised. raised. she's grounded. she calls every week back to her friends. two of her closest friends she grew up with from first grade on. and stays in touch. she's a rhoades scholar. i don't think any of us would question her ability. and also her performance as a public servant. just think what she could do in the private sector. if basically fortunes was her driving goal, where she could be today. it's never been that. i think that every time we've had a chance, we've overwhelmingly nominated her. unanimous the last time in one of the toughest positions. we're not here and i'm not here to change anyone's mind on what they believe about the affordable health care act or obamacare, as you will. that's not what we're here to do. we're here to get the most responsible, the most talented person that can lead us.

senator, i think you said it well. who can get that train moving in the right direction. who can sit down and listen to each one of us. we all have concerns. we all want to see it better. we want our fellow americans to have good quality health care and access to it. we want to make sure that it's workable and we can -- it's affordable. and we don't have a person that understands numbers better than sylvia. a person that has more experience than sylvia. and more compassion for america than sylvia. because she's proven it in what she has given up in the form of just monetary means, which seems to be driving everybody today, to give back to public service. which is what we all were -- instilled in us. i'm honored to be here. on behalf of every west virginian, let me tell you, we are proud. we are proud. and she has served her country admirably and made all of us proud. made every american proud. i think she'll do the same.

as you consider whether you like the health care and don't like the health care, i would hope that your vote would be based on who do you think is the most competent person that could take us through the most troubling, difficult, challenging times to make sure that we can deliver the services that americans depend from all of us. so with that, i'm honored to be here with her. she is a dear friend. her mother is watching right now. and i hope i said all the right words. i hope, dr. mathews, you're proud as i am. thank you. i recommend her wholeheartedly. >> i gather that. senator manchin, thank you very much for that strong endorsement, for being here. again, i know you also have a busy schedule and you're certainly excused if you so desire. thank you, senator manchin. well, a lot has been said about your past. it think it bears repeating for the record. sylvia mathews burwell, presently director of the office of management and budget confirmed by the senate on april

24th, 2013 unanimously. ms. burwell previously served as president of the walmart foundation. before that she was president of the global development program at the bill & melinda gates foundation where she worked for ten years. she was also first chief operating officer of that foundation. during the clinton administration, she served as deputy director of omb. deputy chief of staff to the president. chief of staff to the secretary of the treasury. and staff director of the national economic council. before her federal government service she worked for mckinsy and company. ms. burwell served on the board of the council on foreign relations and metlife. she received her a.b. from harvard university. a.b.a. from oxford university where she was a rhoades scholar. and has been said many times, hails from hinton, west virginia. ms. burwell, welcome. thank you for your long career of public service.

and your statement will be made a part of the record in its entirety. and the floor is yours. and i know you have some family and friends here. if you would like to introduce them, we would be more than receptive to recognize your family and your guests who are here. >> chairman harkin, ranking member alexander and members of the committee, thank you for inviting me here today. i'm honored that president obama has nominated me for secretary of health and human services and it's a privilege to be considered by this committee. with me today is my sister, my brother-in-law and two friends as well as my husband, steven. i want to thank senator mccain. [ applause ] >> i want to thank senator mccain and senator manchin for their kind words. and i'm honored to be introduced by such extraordinary public servants. i'm especially grateful for my husband, steven, and our children. for their tremendous support. and while my parents can't be

with us here today, i also want to recognize them for instilling within me the enduring value of public service. as a second generation greek immigrant, i was raised to be thankful for the tremendous opportunities that this great nation provides. and to appreciate the responsibilities that come with them. throughout my childhood in hinton, west virginia, my father, an op tromtist and small businessman and my mother, a teacher, set a great example for me and my sister. through their engagement in service through our community and our church. it is that example that's an important part of why i sit here today. whether in the public or private sector, working across a wide range of issues, i focus my work on three things. building strong relationships, building strong teams, and delivering results. in my role as omb director, i've worked closely with members of this committee and others to support efforts to return the

budget process to regular order. and to drive towards progress on the issues we all care deeply about. if confirmed, i look forward to working alongside the remarkable men and women of the department of health and human services. to build on their work to ensure children, families and seniors have the building blocks of healthy and productive lives. these issues are fundamental to all of us. whether it's the chronic condition of a child we love or the safety of the food we eat every day. so i respect and appreciate the importance of the challenges before us. as we meet here today, scientists and researchers at the nih are working to find cures for some of the world's most serious diseases. and experts and the centers for disease control and prevention are working to prevent them from spreading. the food and drug administration is protecting the food we eat. and the medications our doctors prescribe for us. our parents and our grandparents rely on the centers for medicaid

and medicare services, and millions of our children benefit from headstart. thanks to the administration for community living, millions of americans are living with dignity in their own communities. the departments work to ensure accessible, affordable, quality health care through the implementation of the affordable care act is making a difference in the lives of our families and communities while strengthening the economy. together, all of this work forms the foundation of a stronger middle class, a more prosperous economy and healthier communities. mr. chairman and members of the committee, thank you again for the invitation to speak today. and also thank you because i have valued the conversations that i've had over the course of the past several weeks. and i'm hopeful that we will have the opportunity to continue to work together closely in the months ahead to deliver impact for the american people. and with that, i'd be pleased to

answer your questions. >> thank you very much, ms. burwell. we'll start a round now of five-minute questions. ms. burwell, as i mentioned in my opening statement, i've long been focused on the critical importance of transforming what i've always often called our sit care system into a health care system. one that doesn't just focus on repairing the damage, but prevents it in the first place. keeping people healthy. that's why i was proud to author the prevention title of the affordable care act. along with senator mccull ski, we worked very closely on that together. the prevention and public health fund. dedicated funding stream -- a dedicated funding stream designed to promote prevention and make communities across america healthier. investments from the fund have supported a range of prevention initiatives. supporting critical obesity prevention programs, incredibly successful tips from a former smoker campaign, and many, many more. of course, we know that these

investments not only improve and save lives, they are also good for the nation's fiscal health. ms. burwell, will you ensure that community-based prevention efforts are in the forefront of our nation's health agenda, maximizing the impact of critical investments from the prevention and public health fund and the health of the american people? >> senator, first, thank you for your leadership in this space. in the prevention space. in my current role i have an opportunity to work with you on these issues as well. and the issue of prevention, i think, is an incredibly important one as we think about our overall health care system. and it's something that i think in the past hasn't received as much emphasis, and it is something that is both important to contributing to better health, but also better costs within the system. if i am confirmed, it is something that i think is very important. i think we want to work in the federal system to promote prevention. i think we also want to build on some of the efforts that are currently occurring in the private sector where companies are doing this type of work,

too. they're measuring those results, and i think there are things we can use there that will help increase what we're doing in the public sector as well. >> thank you, i appreciate your commitment to that and understanding that -- that prevention is not just in the doctor's office. it's in schools. it's in communities. it's in workplaces. it's in every aspect of our life that we have to address that. and as the secretary, you have the ability to reach in all those areas. secondly, and it's sort of in keeping with that theme of prevention, last week former fda commissioner jane henny wrote an op-ed highlighting the urgent need for action on the part of both the government and the food industry to address the amount of salt in our food supply. dr. henny noted that it has been 44 years since the white house conference on food, nutrition and health issued remgtss highlighting the role of sodium in the development of hypertension. it's been four years since the institute of medicine released

its report recommending that the fda use its regulatory authority to require industry to lower the sodium content in our nation's food supply over time. and, yet, despite the fact that upwards of 100,000 lives could be saved annually if sodium levels in packaged and restaurant foods were cut in half, inaction continues. in the same article dr. henny points to your nomination as an opportunity to, quote, reset on this critical public health issue. and i certainly hope she's right. given the extraordinary public health potential, how will you work and will you commit to work to turn the tide on this issue of sodium reduction? >> senator, the issue of sodium reduction and the broader issues of things that we consume and how that affects our health, when we think about those issues, and if i'm confirmed i think there are two things in thinking about them as a priority. the first is making sure that people have the right information. having been a part of a very

large grocer in my last role, that's something that when one works on nutrition issues and healthy eating, which was something during my time at walmart, the great for you label was introduced and is on products that tell people. so one is about the information. people knowing what works and doesn't work in an easy way. when you're in the grocery store for people buying and purchasing, the average time is very limited. people are working. they're going home. they're on their way home and doing it. providing the right information is one thing. i think it's an important part. then providing access and tools. because for some people, the issue of healthy food, it's an issue of access. so as thinking about those issues, i think it's an important priority, the issue of sodium. if confirmed i want to understand more deeply what has been going on and what has not been going on but those are two broad principles as you think about this broader issue of what we eat and consume that guide the way i think about that. >> i appreciate that. information is important. it's also important for the fda

to issue regulations as they have in the past on food and the contents of food and transfat and everything else. but we haven't yet done anything really on sodium. and so i hope that through your agency, the food and drug administration, it will take a look at that, too. >> thank you. >> thank you. senator alexander. >> thank you, mr. chairman. ms. burwell, in my remarks i talked about some proposals that republicans have to move our health care delivery system in a different direction. one that more emphasizes choice, freedom and hopefully lower costs for americans as they buy health insurance plans. let's talk about a few examples. for example, obamacare outlawed about 5 million individual health care plans. the administration reacted by saying, if you like your plan, you can keep it for a year. giving states that option. then i believe they've said now

for two more years. and that has cut about in half the number of people who had their plans outlawed. would you be willing to extend that option further to give states a chance to allow people to keep the plans that they had? >> senator, when i think about the implementation of the affordable care act, there are three fundamental anchors that i think about. one is issue of accessibility. the other is the issue of affordability. and the final is the -- >> ms. burwell, i only have five minutes. so what about -- what about an answer to the question. would you extend the three years that you now allow states to have to -- to help people keep the plans that they want to keep? >> why i was mentioning the three goals is because i think any actions that are taken, one should view in the context of implementing against those core goals. right now the changes that have been put in place are changes that are a part of a transition period as people are transitioning to a point where we can implement a system and

that's a system where pre-existing conditions are covered, where women and gender issues can't be discriminated against. >> is that a no or yes? are you just -- >> senator, at this point i think we want to see what is happening with regard to the issues of implementation. >> let's take another example. buying across state lines. there's a young woman from tennessee named emily who came to see me. she has a plan that cost her $53 a month. that tennessee had created. it was outlawed by obamacare. she went on the exchange and even with the subsidy she's now paying 450. it has limited benefits, but it fits her health care needs and it fits her budget. if kentucky had such a plan, even though she lived in tennessee, why not give her the choice of buying that kentucky plan? >> would you favor that? >> if confirmed that's something i want to look into and understand. when one looks into that question i think what you have to consider is can the markets work in each of the states. so when you go across states,

can you still keep a system up and working and care being provided. >> i was thinking more about more choices for emily. you know, so she could buy a plan that costs $50 or $60 or $70 a month instead of $400 a month. another idea. former secretary schultz has suggested that obamacare care allows, i believe, americans under 30 to buy what we call a major medical plan to avoid a financial catastrophe. so you can sleep at night knowing you won't go bankrupt if you have a major problem. why not let any american buy a major medical plan against a financial catastrophe and combine that with expanded health savings accounts? that would give every american more choices and -- and more opportunity to buy plans that fit their budget and fit their health care needs. >> i think the issue of quality health care plans is an important part of the affordable care act. that there are certain things

that should be part of basic health care. and that is a part of creating a system that will work. one of the things that i think is a challenge is making sure that all the pieces fit together so you do do the things that in your opening comments you talked about with regard to both cost and access. >> one of the major reasons emily's paying so much more for her policy is because washington is deciding for her what she can afford and what she needs. and what i would like to do is give her more choices. what about -- i'm a former governor. what about giving states more flexibility with medicaid? when i was governor, it was 8% of the state budget. today it's 30%. and 15 governors won't even expand medicaid. why not give -- why not trust states to give individuals more choices like the cover 10 plan that emily had, the lady. why not expand that flexibility as a way of giving more choices and lowering costs? >> when the question of how we work -- how one works with states and if i were confirmed, the issue of how cms does work

with states, there have been a number of examples where flexibility has been granted. whether that's arkansas or other examples. i think flexibility is important. i think principles are important. and where you meet in that space of having enough standardization that meets the principles, but flexibility to meet the varying needs of states is something that i think is important in how i would think about that issue. >> my last five seconds, this comment, we had a conversation last week about getting answers from your department to reasonable questions about the implementation of the affordable care act. if it's good for mcdonald's to advertise how many hamburgers it sells, i think it would be good for the department to advertise who's buying the premiums, whether they had insurance, everything. and we certainly need to know that ourselves in the congress. i would simply ask you to focus on answering the questions that members of congress ask you as we go forward. thank you, mr. chairman. >> thank you, senator alexander. i have in orderer, senator

warren, senator isaac san, mccull ski, robert, enzi, murphy, baldwin, casey and sanders. i'll recognize senator warren. >> thank you, chairman harkin. thank you, ms. burwell, for being here today. ms. burwell, there seems to be broad bipartisan agreement that we need to reduce federal health care spending. and republicans argue that to accomplish this, we need entitlement reform. but they shouldn't forget that we passed major entitlement reform just four years ago as part of the affordable care act. and that it's already working to reduce medicare spending. so i just had a couple of numbers to look at. in 2009, before obamacare, the medicare trust fund was projected to go bankrupt in 2017. today, the medicare trust fund is solvent at least until 2026. moreover, every congressional budget office estimate of medicare spending since the aca

was passed has continued to show bigger savings, that's bigger, not smaller savings, than the report before. in fact, last month cbo projected that medicare spending for 2014 to 2020 will be $500 billion less than they originally projected after the bill was passed. and put that in perspective, that's a cut in federal spending, which is six times bigger than all of last year's idiotic sequester cuts, which slashed vital funds to basic scientific research, to headstart, to meals on wheels. and the republicans want to repeal it. so, ms. burwell, my question is, we know that reductions in medicare costs are the result of many different factors. but as an expert in federal budgeting, do you think it's fair to say that an important factor in the efficiencies created by the affordable care

act has resulted in these reduction in costs in medicare? >> yes, i do. and i think specifically when one looks at the cbo numbers, what one sees for the period of 2014 to 2020, which is the period -- since the affordable care act was passed. because that was the window cbo has scored. health care costs for the federal government have decreased by $900 billion. over that period. and i think that is an important contribution to the issues of -- hopefully those are changes that do two things. reduce cost and maintain quality. and hopefully in some cases even improve quality. so the implementation already of the changes of the affordable care act are reducing the deficit and providing great savings. the only thing i would also add is, the current budget proposal that is before the congress right now from the president, t the ak shares say that proposal

will extend the life of the trust an additional five years. and there are choices and changes that would be part, that have been proposed by the administration. but that bill is on the number that you already articulated, 2017 to 2026. >> thank you. i think that's important. also i want to ask you another question about building on the successes of the affordable care act. that is that the aca established the center for medicare and medicaid innovation to test new payment and delivery models that encourage coordinated care such as bundled payments. they state health in western massachusetts is part of a bundle payment project. and their private health care system has successfully used this model for years. by bundling payments for hip and knee replacement, for example. they state health reduced the cost of treatment by over $2,000 per payment. while also reducing hospital readmissions and complications.

it's not an isolated case. cbo projects that applying bundle payment models like base states nationally could save medicare about $46.6 billion over the next seven years. so the affordable care act gave the secretary of hhs the authority to expand successful demonstrations to a wider range of health care providers so that we can cut costs without compromising care or improve care at the same cost. and i just want to ask about your strategic plan for using your statutory authority to expand these efforts where the data demonstrate that we can get better outcomes at lower costs. >> with regard to my philosophy, and i think it's important to have things be databased. having had the opportunity to do grant making in my other roles where one sees and creates models. what i think you want to do is you want to find the models. there are, i think, conditions with regard to which are the most successful. and then which are the most

likely to scale. because that's what we need across the nation. and you have to consider both questions when considering what you would scale. because what you want to do is get the largest impact you can. that impact is a combination of both what the measures are of success, but it's also your ability to make it go broadly across the nation. and that's how i think about that. >> thank you. the affordable care act gave us tools to help reduce the cost of health care and improve outcomes. and i'm glad to hear that you plan to use them. thank you, mr. chairman. >> thank you, senator. senator isaacson. >> ms. burwell, good morning. >> good morning zpl as you know from our conversations the last couple of days, there's no challenge that i have before me as a united states senator more important, including your confirmation, that gave the savannah harbor project in my state. senator chambliss worked for 16 years to go through all the steps at noaa, epa, omb, corps of engineers, fish & wildlife to

get every approval we could get including getting the vice president to join us on the docks in savannah and make his famous quote that we were going to get it done come hell or high water. i'm not one that kills the messenger. but on a sunday night right before the budget came out you delivered the news to senator chambliss and i that we weren't going to be able to move forward based on a plan we thought through conversations with others, not with you, that we included the right language in the appropriation bill to move the savannah harbor expansion program forward. at the last minute we got the bad news that wasn't going to be the case. in the last two days you and i have had discussions about how important this is to my state. and to my country. it's an issue for the entire trade of the united states of america and the economy of the united states of america. it is a net positive export port. it has met every requirement needed whatsoever. and i don't want you leaving omb until i know that we're going to be able to move forward on the va van na harbor project. i'd for you to respond to that question. >> senator, with regard to where

we are in terms of legislation and currently as we have discussed, i think first of all the port is an important effort. it is an effort that i agree with you is not just about georgia, it's about economic issues and growth for the nation and core infrastructure. it's something that i think we think is a very important project. and president and vice president have spoken to that issue. and want to make sure that we move forward as quickly as possible with moving forward on the port. optimistic that the bill will pass. that that's something that will happen and be a part. and that we can move forward with that project as quickly as possible. and, as i said, we look forward to working with you to make sure under -- once that happens that we can move this project forward because we agree it is a good and strong project. at the same time, my role anld responsibility as the director of the office and management budget, which is why the issue is there, has been to do with protecting the fis k.

i think many people on this committee know the army corps has a backlog of $60 billion. and we need the reauthorization. what we need is the congress to speak. when the congress has spoken and we're looking forward to that on this project that we believe is an important one, we'll look forward to moving forward. >> in a letter sent to you by myself, senator chambliss and every member of the georgia delegation about questioning how the project got stopped all of a sudden, i want to quote your answer. particularly during fiscally challenging times it is essential we do not create special exceptions that could undermine well-established controls of responsible allocation of taxpayer resources. what exception were you referring to in terms of the port of savannah? >> with regard to the question of the exception, it would be waiving the 902. there's a rule that was put in place that said if an army corps project exceeds cost by 20%, the congress needs to speak again. that was a matter that the

congress put in place -- that is a rule that is about making sure that we have fiscal responsibility with the army corps. this is a terrific project. and a great project with a very high return on investment. >> as you know -- >> there are many other army corps projects, i'm afraid, that don't meet that test. having the congress be partners with us in doing fiscal control is something that is important. >> as you know, we think we're within two weeks of the bill passing. the 902 provision is in there. what special exception would lie in our way to go ahead forward if the 902 passes in the bill? is there any impediment you see? >> senator, i look forward to continuing that conversation. i think there are ways this project can go forward. >> i look forward to those meetings prior to the confirmation so we can do everything we can to solidify that. thank you. >> thank you, senator. mcmccullski. >> thank you, mr. chairman and ms. burwell, welcome to this confirmation hearing that

focuses on you being secretary of hhs. we welcome your husband, your friends. i'm sure you wouldn't want your mother and father here with you. they worked so hard for you to get the education that you have that helps bring you here today. ms. burwell, i know you personally. and i admire you professionally. i knew of you when you worked during the clinton administration in these foundations, the two major foundations you worked for. and then got to know you during the year at omb as we went through a very tumultuous time. you were new at omb. and i was new at the chair of this committee. i must say, i really admired, one, your integrity in working with me. you were a straight shooter. what you said, you meant, and what you did. we also appreciated your responsiveness of both senator shelby and i that when we asked

questions, we got answers. we didn't always like the answers, but we got the answers. third, we liked the fact that you were competent and that you also had the ear of the president of the united states. so, again, when we needed those answers. so we know that. but let me tell you where i am as the senator for maryland. we need a ceo. and secretary sebelius has done a great job as -- during a very difficult transition time at hhs. but what we see in maryland is some of your greatest federal assets at hhs are in my state. from cmss that does medicare and medicaid. the national institutes of health. fda. hrsa. i also have some of the highest rates of nobel prize winners and some of the highest rates of poverty. whether they're in baltimore city or mountain counties adjacent to west virginia. so i need a chief executive

officer. we need someone who will bring executive skills to this job. 80,000 people work for hhs. you have the largest budget -- other than defense, the largest domestic budget. we see three issues. money, management and morale. money, that's our job. and sometimes we do it well. sometimes we don't. but we need someone in management who can tackle these tough problems, whether cleaning up the techno boondoggle of the health.gov to also going across the silos of agencies. and then we have a morale problem. because of the way they've been -- my federal employees have been battered by the budget and the uncertainty of funding and the trivializing of them and their work, you and i know that we have a morale problem. whether it's in fda or nih. and people are looking elsewhere rather than bringing their great

abilities. so my question to you, looking at your background, particularly in the area of the foundation work with both gates and walmart, could you tell me the executive ability and experience that you think you bring to this job that can help put this arms around this huge bureaucracy, often siloed, often fragmented, and at the same time help work with congress on a more certain funding that enables these agencies to do the mission? could you? >> first, i think i'll speak to how i think about management and leadership. first, i believe in any organization you need to start with setting goals. defining roles and responsibilities. part of that is an analytical process that includes both listening as well as analytics and data. first, that's the first step. another step is building strong teams and empowering them. and giving them the tools to

succeed. that's the second part. the third part, i believe, is a part of thinking through when you need to drive with analytics and when you need to understand there's emotion. because in leading large organizations there's sometimes how people perceive, and it's whether it's in an organization or an issue. the perception is their reality. so analytics. you need to understand. if people believe that, how do you drive for change? with regard to my own personal experience, i've had the chance to work at the gates foundation where i worked across a number of issues from doing innovative funding to vaccine to actually delivery of health care in the developing world, which is a challenging place to do that kind of delivery. to work on issues of, actually, as the coo, employer based health care, i know what it's like when you have changes in your employee base and what that does to what you pay. at the walmart foundation i was able to work at that time the world's largest grocer and retailer. in terms of both it's an institution that provides health care for its employees, but the work we did in the space of hunger. so those are some of the examples. i'm watching the time, though. >> i appreciate that.

my time is up. just know that many people will focus on health care. and i certainly -- it's my passion. but the human service part of your portfolio is absolutely crucial. and today is not the day, but we really need to work together on this issue of the unaccompanied children coming across our border. so that they have a home and that they have a way to get to a home. and we have a way to get to the funding that ensures that. >> senator, look forward to working with you on that very important issue for those children. >> thank you. >> thank you, senator mi cull ski. senator robertson. >> thank you, mr.çó chairman. ms. burwell, thank you for coming. last august senate majority leader harry reid was asked whether his goal was to move the affordable health care act to a single parent system. his answer was yes, yes, absolutely yes. similar statements were made by former speaker nancy pelosi.

your predecessor and the president of the united states. do you agree with that statement, there is a difference between administrating a law and pushing an agenda? is it your end game to see the affordable health care act expanded beyond the exchanges to a single payer system? >> senator, if i'm confirmed i will implement the law. and the law is a system that is a market-based system. that's what the exchanges are up and running and putting people in systems that are private insurance system. i look forward to, if confirmed, making that system work as efficiently and effectively as possible both in terms of cost and access. >> i appreciate that. one of my biggest concerns with the affordable health care act is the independent payment advisory board, ipab. it was created by the law. the board is supposed to be made up of 15 elected add voi sors who will decide which treatments in medicare coverage should be reformed. i would say terminated.

they have no accountability, and their decisions are practically impossible to overturn. now, despite having yet to appoint any ipab members, the president's budget this year proposed to expand ipab's role. considering the law requires that ipab produce reports in 2014, do you know when the president will make his appointments to this unelected board? and in the absence of a board, the hhs secretary, namely you, will have the authority to act as an ipab board of one. if confirmed, will you activate the medicare reform or, again, what i would call rationing, using your authority under ipab. >> senator, first i think it's important with regard to ipab that one of the most important parts of the provision there is that beneficiaries cannot be impacted. so any changes would not be towards beneficiaries. the other thing i would say about ipab is i actually am hopeful and if confirmed and even in my job at omb that ipab

never needs to be used. it can only be triggered, and in the current window that we're -- we're looking at, and in the window if confirmed that i would serve, it is our estimate that actually it would never be activated. what i think is important and at the root of this is annish shoo u that i think both sides think are important. that's controlling health care cost for the federal government. it's about our fiscal issues for the future. and what i'm hopeful that we can do is make sure that ipab never gets triggered. because we put in place the mechanisms to do that control. right now -- >> okay. that's my hope, too. and i appreciate that. i'm not quite as optimistic as you are. but we can go over that at a later time. according to the galen institute, obamacare has been delayed at least 35 times. 22 of those times were done unilaterally by the administration. since being the director of omb, you have approved 15 of these 22 delays. this included the second delay of the employer mandate.

my question is about fairness. and i get that from individual kansans. the administration gave business an extra year and many cases two extra years to comply with the employer mandate. do you think it's fair to give business a delay but not individual americans? and what further changes, if any, to existing law and regulations do you anticipate having to make before december 31 of this year? >> senator, i think the changes that you referred to are a number of different things that have been taken by different departments, treasury or hhs, and a number of the examples that i think you're referring to, with regard to what is happening as this process goes forward, from the administration's perspective, what we are trying to do is common sense implementation within the law. that's the objective and what is worked on. with regard to the specific issue you raised which is the issue of the employer mandate, and that specific question, as we think through transitioning, one of the things that we've tried to do is listen and hear. and one of the things that

private sector has said is, it was difficult to get the reporting to the right place where it could then be applied and done. the changes that were made were to try and do that transition. with regard to individuals, there are a number of other things that are happening to help with those transitions. and whether that's the hardshippish shoo us or other issues. so this is about transition to a changed system. >> i'd like to see those transitions come back to the congress so we would at least have some consequential involvement. my -- i'm out of my allotted time, mr. chairman. but i will be submitting some further questions in writing that i hope you will respond to in a timely manner. particularly with regard to abortion coverage transparency for insurance plans offered in the federal exchanges. again, thank you for coming. >> thank you. >> thank you, senator roberts. this would be senator bennett. >> thank you, mr. chairman. it's nice to see ms. burwell. thanks for being here today. like others here, i'm very happy

that you've got the experience that you do at omb. and i wanted to ask you a couple questions along those lines. when i a number of years ago first became superintendent of the denver public skooms i carried the budget of the school district around with me for six weeks unable to understand it. i had worked with budgets before in the private and public sector. this was impenetrable. finally six weeks in, i realized that i wasn't reading a budget in the sense you or i would understand it as a management tool. it was an accounting tool. it was a tool to demonstrate compliance with the state regulator and with the federal regulator. but it was not about driving outcomes for kids, which is what we were supposed to be doing. my sense having been here is that we face very much the same thing when it comes to health care. the morass of regulations and the reimbursement policies of cms, the uncertainty that's caused by the fighting up here over budgets that leave people

with insecurity about what the future is going to look like, i think creates an environment where people are less capable of getting into a pattern of continuous improvement. i mean people that are out there actually delivering services to people rather than just yelling at each other in washington, d.c. and they're weary about this. and i think they feel -- they remind me of my teachers and my principals in the district who felt the same way. i wonder if you could tell us a little bit about your theory of the case for attacking that management side of -- of the work that you now will have to do at hhs and cms and how your work at omb is going to inform that. let me just -- sorry. one last point. in this kpi sten shl debate we're having here about the role of the federal government and the founding fathers and all of that, i think what we have lost is what the american people would really like, which is an efficient and effective federal

government. and an efficient and effective partner to state and local governments and to others. anyway, just a perspective. i will yield you the rest of my time. >> and i'll speak to that in the context of the "m" part of the omb. in terms of the role that i've been in in the past year. with regard to the issues of management, when you look at our budget, you will see that we articulate what is a second-term management agenda. the three elements of that -- the four elements of that agenda are efficiency. making sure we use the taxpayer dollars the best. just last week there was an announcement, we have four departments that will be doing shared services, which is a private sector way to get to some of that efficiency. effectiveness which gets to your point about customer service. when we say effectiveness, it's about serving the customer. the customer for the federal government -- number of customers. individuals, states and local governments, and the private sector at times when they interact with people like the fda. how do we make sure we're doing that? the third area is how do we use the management of the federal

government to support economic job creation. and on may 9th it will be the first anniversary of the use of open data. and putting that data out there to create economic development. the last is people. and having had a chance to work on all of those issues and then working with the departments to have their goals connect to their money. to your point about is it a document that is about, you know, checking boxes or is it a document that reflects how we spend dollars to deliver impact. so those are the ways that my current experience has -- >> on that last point, i -- i'm not sure how you want to approach it. but one thought is that without people that are dedicated every day to coming in and thinking about how do we get rid of the check boxing -- or the box checking and replace it with stuff that really matters, in your tenure, you're not going to be able to get it done. i hope you'll do that. i also wanted to mention -- i saw senator bur burr here.

i think she's now gone. we've had luck with grapefruit therapies. i talked about it the other day. i would like the opportunity to be able to work with you to see where we could expand the sort of notional sense of that, which was where possible and where feasible, we should be accelerating approval so that the united states holds on to its leadership in bioscience at a time when there are plenty of other countries in the world that would like to outcompete us. >> welcome that opportunity. one of the things when i think you can have innovations of things that work like that, you look at those innovations then think about how do those apply more broadly to the broader portfolio. the breakthroughs are special cases. but i'm sure there are things we can learn that apply to the broader portfolio. >> i think -- yeah. things that can inform the broader culture of the agency as well. thank you, mr. chairman. >> thank you, senator bennet. senator enzi. >> thank you, mr. chairman. and thank you, ms. burwell, for meeting with me yesterday. i always enjoy the visits with

you. i have a few questions. i think i mentioned this topic yesterday. during your tenure at omb, we saw a massive failure of a website which was healthcare.gov. and that's a website the administration had three years and $600 billion to build. i know from personal experience, first users couldn't logon. then we couldn't see plans available. then we got kicked off. and then user names weren't recognized. and from folks i've talked to, even users who made it to tend of the process often didn't get confirmation they'd enrolled in a plan as obamacare mandates. as director of omb, you were responsible for the oversight of agency performance and information technology. what role did you play in the development, testing and approval of the website?

>> senator, first, i think it's important to recognize what the president and the secretary and the administration have said, which was the rollout was unacceptable. with regard to the role that omb plays, the direct implementation on a day-to-day basis of i.t. projects is done on a department by department basis. omb has a process that is called tech stat which is what happened when we have cases, healthcare.gov being an extreme one, of an approach we take to get in and quickly try and correct the situation by applying high quality resources and a surge of resources to the problem, which is what was done. in addition, at omb, as part of follow-up and part of the end role that i play, we spent time examining very specifically what we think are areas of improvement in i.t. procurement and delivery. and i'd be happy -- i don't want to use all your time, but be happy to articulate what those are. >> continuing on this anyway, the administration contends that many of the highly visible

problems with the website have been fixed. but i don't think the work has been completed on the less visible back end information, which, of course, all of us would like to have. and that's necessary for the programs. i think there have been some warnings from cms that failure to get this fixed by march would mean that, quote, the entire health care reform program would be jeopardized, end quote. is that the reason for justifying the need to award the no bid contract to exsenture? why haven't the problems been fixed? >> if i'm confirmed, the issues of information technology, especially around healthcare.gov would be a priority for me. with the issue on subcontracts that's something a department specifically does and omb doesn't play a role in. i'm not able to speak to the specifics of contracting. if confirmed, though, this is something that, of course, would be a top priority, to make sure that the system both the specifics you're talking about and the back end that you're

referring to, are something that i pay attention to. >> okay. i'll have some follow-up questions on that later, then, when you are in that position, i guess. in february "the new york times" reported that 1 in 5 people who complied with the individual mandate didn't pay their premiums in january. at that time, cms spokesman said the administration couldn't say how many people had paid their premiums. on april 30th the house energy and commerce committee reported that only 67% of the enroll ees had paid their first premium by april 15th. when the administration disputes this figure -- while it's disputed, you haven't released your own official numbers yet, i don't think. when will the government determine who has paid the premiums and, therefore, is actually covered as required by the individual mandate? >> senator, i probably should start with my philosophy about data and information. and it has two fundamental parts to it. transparency and accuracy.

and that's how i think about it and how i think about it and speak with congress. at a time in omb, the regulatory agenda, which is sometimes a controversial document, is something i've worked hard to get up in the spring and fall on time and will be again this year. with regard to the specifics of the data that hhs has at this time, that's not something in my current role that i know. i know that there were hearings yesterday that spoke to this matter where the insurance companies articulated a range. because they are the people providing the information. and so if i am confirmed, that is something that i will want to understand on what pace that happens. >> but you haven't released official numbers yet? >> no, sir. the administration has not. because i don't think that the insurance companies have given final numbers. >> okay. insurance companies. i'll have some follow-up questions on that in writing. thank you, mr. chairman. >> thank you, senator enzi. senator murphy. >> thank you very much, mr. chairman. there was a really remarkable hearing in the house on this subject yesterday in which house

republicans called insurers to testify. in part as to what they believe to be incredibly low rates of premium payment. and the headline from the "new york times" this morning is called by republicans health insurers deliver unexpected testimony. that testimony was in part that well point suggest 90% of their customers paid premiums. aet na suggested the numbers in the low to mid-80% range. they also according to this article declined to endorse republican predictions of a sharp increase in insurance premiums. next year this comes on the heels of a health affairs report that suggests that though there certainly have been cancellations of policies since the law was passed, it's not really out of step with the rate of cancellations that happened before the law was implemented. new gallup survey shows an absolutely astounding drop in the number of people who are uninsured. a 25% drop, according to gallup, over the course of the third quarter into the second quarter

of this year. i say all this because i think this increasing avalanche of good news and positive data about the implementation of the affordable care act is going to ultimately lead to a much broader public acceptance and support for the law. yet we still have sort of a tale of two countries. we have states like connecticut that have worked hard to implement the law. we've doubled our initial expectations in terms of the number of people we thought would enroll. then you have states that are, at best, not implementing the law and in some cases trying to undermine the law. i guess my question is, how do you attack this issue of states that are not doing the things that, for instance, connecticut and california are doing? and maybe response in part to some things you said referring to a question by senator alexander, what are the ways in which we can work in a flexible manner with these states as they

maybe wake up to the reality of how well the implementation is going after the initial botched rollout? what are the ways in which we can work with some of those states that haven't done things like connecticut to try to make this work in all 50 states rather than just in the handful that have set up their own exchanges? >> i think there are two things. it does come back to the point about the flexibility, is one of the points. i think what's important is to send a signal that folks are willing to have the conversations. as i said, it's important if there are fundamental principles to articulate those in terms of the change you're trying to get. but be willing to have the conversations and hear the ideas. i think that's what happened in the arkansas case. if i'm confirmed, that is something that i would hope we as a department can continue to do. with regard to the other thing, that's about the relationship to get that to happen, i think the other thing with regard to how other states will come is, i think that as people see what happens in the form of implementation, and while i understand the point that senator alexander made about costs in medicaid, which is an important one, i think what people are also going to see are

the changes in terms of health benefits in t states that have implemented both from a health perspective. and i actually think we're going to start seeing some of the cost benefits in terms of reduction of indigent care. many of us are from rural places. you know the pressure that that puts on small, rural institutions and hospitals. and so i think both the results as well as a willingness for conversation are the two ways that one can make progress on that front. >> let me ask you a big question about delivery system reform that maybe you can give a short answer to. which is, i think you'll hear a lot from us on our hope that you are able to speed up the pace of delivery system reform changes at hhs. but one of the tensions is between the necessity to build bigger systems that can really track outcomes and coordinate care and the desire to make sure that we have a competitive marketplace. connecticut is a state, for instance, that may ten years from now only have two health care systems. how do you balance ultimately

this need to build good integrated systems of coordinated care which may require more doctors working for hospitals, for instance, while making sure that we don't effectively set up monopolies in certain areas of the country where you may have one big health system that is unavoidable from the perspective of an insurer that's trying to build a robust network? i'm a believer in big, coordinated systems of care. but i think that's a lingering concern that exists as you build out a new system. >> one of the things in terms of philosophy about that is i think that you appropriately said, it's the issue of balance. i think thinking about what are the elements that need coordination in terms of is it information sharing? what is it that creates that level of coordination, at the same time promoting competition? things like the co-ops and other things. how do you get to -- what is the key element that is causing the delivery system efficiency? is it the fact that it is a single provider, or is it the

fact that it is an approach -- a standardized approach in information? i think one of the ways you work to get that balance right is by trying to understand as clearly as possible what is driving the change you're getting both in terms of quality and price. >> thank you. thank you, mr. chairman. >> thank you, mr. murphy. senator murkowski. >> welcome to the committee. as i was walking over here, i accounted a number of individuals that are here on the hill today for als advocacy day. a cause that you and i both share and are committed to and assuming that you're confirmed to this position, look forward to working with you aggressively to make a difference in this horrible disease. we had an opportunity to visit last week. and i appreciate the time that you gave me. in the visit i explained to you the situation in alaska where we are a very high cost state. our insurance costs are equally high. second highest in the nation.

our demographics, our geography just cause us to be a little bit different. you mentioned the need for flexibility within rural areas. there's nothing more rural than alaska. we're so challenged with this. i shared with you that we have over 139,000 uninsured individuals. less than 10% of those individuals have enrolled in health care plans. and in looking at the numbers behind it, it really comes down, again, to the cost. the aca has more than doubled premiums in the state. i shared with you that a 19-year-old alaskan could pay $911 back in 2013 for one of the low cost premier plans. if they buy the most comparable plan now for that same product, the plan is more than double the cost at over $2,300. then i walked through the statistics with 64-year-olds. mr. chairman, i'm going to be submitting for the record a document that my staff has put

together with premiere and blue cross that shows the gao recorded data on premiums in alaska in 2013 as compared to where we are now. just so, again, there can be a better understanding as to what we're facing here. we're not -- we have not worked to reduce the cost of health care, which we must do. and i appreciate what senator murphy has said about -- about delivery reform. but in the meantime, the financial burden to our families is such that they're looking at this and saying, i'm better off just paying the fines that will come with this. so i'm asking you to take a look specifically at what we are facing in alaska. i also want to bring up with you a conversation that i had with firefighters from my state. from different parts of the state. up in the matsu borough. talked to firefighters up there. up in fairbanks, down in the southeastern part of the state,

and concerns about application of the aca within the emergency services sector. a concern about employer mandate. a concern about the 30-hour workweek. what i heard from the mayor in mt. sue was that they have moved their emergency personnel to a 29.9 hour per week cap for nonfull-time employees. many of the stations are reducing the hours beyond the required 29.9 to 24 hours per week to include personnel who work both as emts and as firefighters. this is an issue for us where our -- our growth in these areas are growing. we rely on our emergency services folks because they cover enormous areas. what we're seeing is a real chilling effect here on employment, particularly as it applies to our first responders. so i guess i would ask more of

a -- a question in the vein that do you agree we've got a problem with this? there's a few senators, i'm joined with senators collins and donnelly to help address this. do you see an opportunity for us to address this deaf nation of 30-hour workweek? and the implications that it's having on not only ems but other areas of the economy here? >> senator, i'd like to learn morearticulated. >> i'm happy to provide that. >> the issue of broadly overall in terms of the job creation that's occurred since the affordable care act, 9.1 million private sector jobs with and the san francisco fed just released a report that said that the part-time issues are consistent with a recovery. having said that would like to learn more about the specific issue you've raised. with regard to the specific legislation that changes the numbers, one of the things, there are a couple concerns when cbo scored that legislation in terms of cost. but also that a million people

in that setting would also lose their employer-based care. so would want to understand the based care. i would want to understand the specifics of the situation you're talking about as well as coming to understand better the piece of legislation. >> i'm happy to provide that to you as well as the other information. i'll also be submitted for the record, mr. chairman, a couple of different questions, one on head start. but also one that is very timely and in the news right now and that is the issue of the fda proposed rules on e-cigarettes. i've got a real concern here that we are setting forward a proposed rule that does not look to the flavoring that is going into these e-cigarettes, the impact on our children. some of the studies that we are seen. so i would like your views and your perspectives on that as well. thank you, mr. chairman. >> thank you, very much, senator

murkowski. especially on the e-cigarette issue. you're right on target on that one. thank you. senator baldwin. >> thank you, mr. chairman. thank you, ms. burwell for your time here today and talking about your vision for the department. i appreciate the opportunity we've had to speak in advance of this hearing. i wanted to talk about a couple of different topic. but including the fact that the health care system has been plagued forever with a lack of transparency. and gathering data, dissimulating and sharing data is incredibly key to helping physicians understand where they lie with regard to other physicians' practices, helping understand where hospitals, how they go about pricing things, what their costs are, and

helping patients make wise decisions about choosing providers, particularly if they need an operation or a specific treatment. this is an issue where we've seen some variation from state to state. i'm proud to tell you that in the state of wu wii i think we've within a real leader with an organization called the wisconsin health information organization. it intends to be an all payers claim database that does some further analysis and dissimilar nats the information to increased transparency, help improve quality, help reign in costs. yet we've had frustrations with regard to access to medicare claims data. i've worked with a number of my colleagues on a bipartisan piece of legislation called the quality data quality health care

act which would fix this by expanding what's known as the qualified entity program to allow entity to analyze and redistribute medicare data to those who could best use it for quality improvement and cost reduction purposes. and i was pleased to see that the president's budget supported many of the reforms that are contained within that bill. i wonder if you can speak directly to the issue of expanding the current, what's known as the qualified entity program and its potential to improve quality, to reign in costs. but also to talk more expansively about the role you would play in increasing transsparncy across our health care system. >> with regard to the specifics of the expansion of the program, i would look forward, if confirmed, to working on that issue specifically. as you mentioned in the budget, there are some parts of doing

that. the broader issue of the transparency is something we talked about in a number of forms in terms of data and information and also specifically for how it helps with the delivery system issues. so i think getting the information, as i said, that may be a link that is as important as the issue that we were discussing about how you balance single entities that start developing in terms of the dominance in a market. so i think information in markets is an important thing. and so the better we can get it and the more we can get it to both the individuals, as well as the providers. as you mentioned in the beginning of your comments, it is actually about the doctors also as well seeing the information. so with regard to how i think about the issues, i believe this is an important part of both quality and cost. and it's both important for individuals as well as insurers, as well as doctors. and the more we can have and the information that was provided recently i think was important information that was recently

put out by hhs. i think it's also important as we think through the information to make sure that it has context. when we put out the information, making sure that individuals and others can use it in a way that it is given the appropriate context. because the data without that can sometimes be something that doesn't provide the insights that one would hope it would. >> thank you. i'm short on time. i'm going to place another question before you. we may have to have you answer in writing. but i wanted to get to something very wisconsin specific regarding affordable care act implementation. we had the good news last week that nearly 140,000 wisconsinites signed up in the marketplace. i it was 60,000 beyond the target that was set prior to ten rollment period. and this was despite fierce etiological attacks against the affordable care act both in washington and in your state government. but unfortunately, across

america and in my home state of wisconsin some governors have not taken full advantage of the opportunity to expand coverage, specifically medicaid coverage. governor walker is among those governors and he failed to seize that opportunity and the consequences in my state are fairly severe, 77,000 wisconsinites are losing their medicaid because of that decision. other states are working with the government. iowa and arkansas in particular to find new innovative ways to expand coverage to these vulnerable populations. i want to know if -- you can follow up now or afterwards -- what lopgss will be available to wisconsin that are not currently being pursued? will the department continue to help make sure that these 77,000 people who are losing their

badger care are successfully enrolled in the marketplace? and certainly will the state of wisconsin have an opportunity to reconsider their decision at this point, not to expand medicaid. >> senator, if i'm confirmed, would want to work with cms on those specific issues of the flexibility to help those 77,000. >> thank you very much, senator bad win. senator burke. >> thank you, mr. chairman. director burwell, welcomwelcome. and thank you for the opportunity to meet with you i think last week, to share some thoughts and to hear yours. let me ask you a couple of questions in specific areas. do you consider medical and public health preparedness and response programs to be a matter of national security? and if you're confirmed, how will you ensure that these

programs will be prioritized and that the act be fully implemented. >> senator, i do consider it a matter of national security and in my old role at gates have been exposed to a number of these issues. thank you for your leadership in this base because i think it is very important. i am excited that there was a reauthorization that occurred and that the congress spoke to these matters and now would want to work to implement what was reauthorized in 2013, if i am confirmed on these issues. i think they're very important in terms of how we think about what are the tools that we have and then how we get access to those tools when we need them. and i think you've spent a lot of time, as our conversation reflected, thinking about the best ways to mike sure that we have what we need if something bad happens and then mow how you effectively in the most cost efficient way scale up in a quick time frame to do that.

that's something for me i would look forward to, if confirmed, working on. >> thank you for that. what opportunities do you see to improve regulatory certainty and predictability across the department particularly at the fda? >> i think with regard, the issue of regulation more broadly, just in terms of my philosophy and experience and time at omb, since the year that ied v been at omb, we've reduced the regulatory bag log by almost 75% and have moved to a more timely approach to our regulatory agendas in terms of what i've done. and with regard to the fda and thinking about these issues, i think one of the things as an institution, would want to go and spend time and in conversations like ours learn what people believe are the critical path issues to a more e neck tif system that produces quality and speed. and protects health of the american people but also supports our economy. because it is an important part of economic growth. >> thank you for that.

as senator murkowski mentioned earlier, we've got a lot of patients with als here today. we don't know yet what causes it. to unlock the key to a cure, you first have to figure out what the cause is. and i go through this thought process of what if we got to that point and then all of the sudden the therapy, the counter measure, the cure breaks down at the fda. so i appreciate your willingness to dig into it because i think that certainty drives capital investment in the space and helps these patients. will you give your personal commitment to me that if confirmed ckc and atsr will execute the planned cancer study on the camp lejeune population without delay? >> first i want to thank the senators that have mentioned the als issue. with regard to that specific

issue, my understanding is that that work is going forward in terms of the cancer study and if i am confirmed that is something that i would want to work to make sure that we do in the most expedited fashion. >> mr. chairman, on a personal note, i know that the committee will not vote on director burwell's confirmation but we will in the finance committee. i would like to take the opportunity to say i support her nomination, i will vote for her in the finance committee and it's because she doesn't come with a single experience that would make her a good secretary. he comes with a portfolio of experience that would make her a tremendous asset at addressing some of the challenges that that agency specifically and uniquely has. and i look forward to her confirmation being quick and our ability to then work together to be ever bit as quick. i thank the chair. >> thank you were senator. >> thank you very much, senator

burr. senator casey. >> dr. burwell, thanks very much more your appearance here today, your testimony as well as your commitment to do the job that i think you will do at hhs. but i guess in a larger sense, we thank you for your sub substantial and enduring commitment to public service over a number of years now in all of the positions that you've had. i wanted to raise in the limited time that we have, at least two major questions with regard to children. it's my opinion that our country still lack as real strategy for children. we've made some substantial progress on children's health insurance, i'll talk about that in a moment. still no sub substantial national commitment to early learning, to the extent that i hope we would. the protection of children could use an awful lot of work, as well as strategies to make sure that children can have enough to

eat and get nutritious food. on those four indicators i think we're lacking. we lack a basic strategy for our children just like we have a strategy for national defense or other major priorities. i wanted to start with the children's health insurance program, a substantial bipartisan achievement. as you know from your work during the clinton administration, that was a bipartisan effort here. one of the models, not the only model but one of the biggest and most successful early models before the clinton administration enacted was in pennsylvania, my home state. and because of models like that we now can say i'm told some 8 million children with covered, more need to be covered in their efforts as you know to do that. these aren't exact but around 200,000 children in pennsylvania covered by the children's health

up shurns program. having said all of that, the bad news is that the funding will expire for c.h.i.p., expires at the end of september, number one. number two, there have been efforts made, and i have to say some f this has been in both parties, to intentionally or unintentionally undermine c.h.i.p. in the last couple of years. we're going to fight real hard to preserve it and fund it at all costs. i wanted to ask you about the impact on children's health if we failed to extend the funding for the children's health insurance program and what you would do to make sure that doesn't happen? >> as you reflected, this is a program i had a chance to work on and be a part of the initial passage in the clinton years,

something that is very important and what's great is to come back and see the progress. this is a program that's delivering, it is a program that is successful. and in the administration, whether in my omb role or if confirmed in the hhs role, i would look forward to working with the congress to make sure that we continue what a successful program that is delivering for children in an important way. >> well, i appreciate that. because it's a major priority of mine but i think it's shared by a lot of people across the country. secondly, you and i when we had a chance to discuss your nomination, talked about the so-call chime sh, children's hospital graduate medical education. another area where there's substantial bipartisan support. this committee, members of this committee working with a number of the members of the committee, chairman harkin most prominently, making sure that that program was reauthorized in

a remarkably bipartisan effort. it's now been reauthorized for five years. we actually have a copy of the bill signed into law. that doesn't happen too often around here. that's the good news. the bad news is i think there's still some folks in the administration that have a different view about how to move forward with it. maybe would agree with the reauthorization of it but even would question that. but i think i'm most concerned about the funding of this program which is the one program in tremendously successful that allows us to train graduate medical folks in graduate medical education who will specifically work in children's hospitals that without this program we'd be in big trouble. i would ask you that as you contemplate other strategies on this and other ways to fund it, that you consult closely with me

and others on the committee as we move forward. i would just ask if your commitment on that. >> senator, i would welcome that opportunity. >> thanks very much. >> thank you, senator casey. senator hagen. >> thank you, mr. chairman. and once again, director burwell, thank you for being here today. thank you for your service in the other administrations as well as omb and we look forward to working with you as the secretary of hhs. i wanted to ask about medicaid expansion. last year in north carolina our state legislature and governor decided against expanding the state's medicaid program and as a result, about 500,000 people who would have qualified for coverage through medicaid are not now able to do so. these are some of the most vulnerable visits in our societi who will continue to seek care in emergency rooms and then will leave chronic conditions

unmanaged, which we know is detrimental to their health and the economy. and it leads to higher costs for the patients, it drives up costs for hospitals and it drives up costs for the insured who still will pay higher prices to cover their care. director burwell, can you compare the experience of states that have expanded their medicaid programs to those who haven't, committing specifically on the health of newly eligible enroll lees and whether there's any increased cost to states or health providers like hospitals? >> senator, i think what we're going to do is we'll continue to see data and information as the law is implemented, but i think in states like my own state of west virginia, we've already seen a decrease in the number of uninsured and what that is starting to happen both in terms -- i think it will be two things other time, the increased quality of care for people which

translates to their individual lives and the economy in terms of what people are able to do with their productivity. over time we'll see that. i think we're also seeing, over time we'll see the cost issues in terms of the indigent care pressure that's being put awe cross states when they have people who are coming with insurance. so i think we're going to see more and more of the data over time. in a number of states we see the number of uninsured dropping. >> can you compare -- what happens in an adult, let's say a 35-year-old woman from one of the major cities in my state without children, and this individual falls under the federal poverty line, about 11,000 a year, this individual has heard about the marketplace, she goes to the library, talk to navigators, asks to sign up and yet this person has done the right thing, she sought out coverage to protect her against high medical bills, help her get

health insurance, but what options will that woman have if a state like mine doesn't expand medicaid? >> so it will depend in terms of her level. i think you've described a level that i would want to get the details in each place in each state. it depends on her level of income and whether or not she'd be eligible for federal subsidies. >> this woman will not. she falls under the gap. >> she would receive a hardship. the hardship exemptions. she would have that opportunity. >> so if a state that had expanded it, she would have had access, where in the 24 states that haven't expanded it, there are these huge number os people, in my state 500,000, that are still without coverage, have

un -- there's no way for them to turn because they certainly cannot fund a normal insurance policy on 11,000 a year. >> and with regard to what the federal government policy is trying to do is to make sure that they have a hardship exemption. that's the part. it doesn't address the fundamental issue that you're talking about which is do they have health care coverage. >> right. and just to be sure, if a state expanded its medicaid program last year, what would the cost to a state be for covering that newly eligible population? what would the state have to pay in 2014? >> senator i think on a state by state basis, those are numbers that i would want to look into and get back to you on. ah. with regard to the question of conch, in terms of the state paying because the federal government -- i'm sorry i didn't understand the question. that would be zero. the state doesn't pay. >> so for three years the states

pay zero. >> the federal government will pay for those years, right. >> thank you. >> uh-huh. >> now i want to ask a question on the healthcare.gov, on the rollout. you know, when it failed to launch, i let a group of 15 senators calling on the inspector general to conduct an independent investigation into the causes of the technical design and the imp men station failures. i was really pleased when they agreed to conduct the investigations and i look forward to the reports when they come out later in the summer or the fall. when you are confirmed, what lessons will you take from last year's site failure as you administer the next open enrollment period. how can you improve the management of the healthcare.gov? >> with regard to the lessons of what happened in healthcare.gov,

a couple of things that we've examined and looked at, there are a number of things thinking about i.t. procurement. one is you do not connect the business owner and the i.t. that connection does not occur. it's a problem i've experienced in the private sector. seem say to the i.t. team, here, fix it. versus an integrated approach of the business owner and the i.t. director working together. the problems i'm articulating on ones we need to think about as the federal government specifically. generally in procurement we've traditional done a waterfall approach, a building approach. one tests in small pieces and moves and learns is a better approach to doing procurement, not set up to do that in terms of how we set standards and do expectations. the third thing that is an important part is ownership and accountability in terms of a single individual bein t