Transcripts For CSPAN Health And Human Services Fiscal Year 2016 Budget Proposal 20150207

The flagship collection we have here in corpus. He made it his life to help local and beyond mexican americans learn to be more civically active and to get the benefits they had coming to them as veterans which were sometimes very difficult for them to obtain. This represents a case of private longoria which was an incident that occurred early in the g. I. Forum. Private longoria served the United States during world war ii and was killed by a japanese sniper toward the end of the war. His widow arranged to have his funeral conducted by the only funeral home in her hometown of three rivers texas, which is near Corpus Christi. They were willing to conduct the funeral but not willing to allow his body to remain there in the funeral home overnight for fear of offending the white citizens of the area. She appeals to dr. Garcia, and he conducted a Letter Writing Campaign to people with positions of influence. A response came from Lyndon Johnson who had been recently elected senator. He states his belief that it is wrong for a soldier, a fallen soldier to be discriminated against after death. He offered burial in the Arlington National cemetery and that is where private longoria was laid to rest. Watch all of our events from Corpus Christi today at noon eastern on cspan 2s book tv and sunday afternoon at 2 00 on American History tv on cspan 3. President obamas budget request for fiscal year 2016 proposes 84 billion in discretionary funding for the health and Human Services services. Hss secretary Sylvia Burwell recently appeared before the Senate Finance committee to talk about the budget plan and took questions on implementation of the healthcare law and an Upcoming Supreme Court case that challenges the laws provision on tax credit subsidies. The committee will come to order. Good morning. Its a pleasure to welcome everyone to todays hearing on the fiscal year 2016 budget for the department of health and Human Services. H. H. S. I want to thank you, secretary burwell, for being here with us today. This is your first hearing before the committee since being confirmed, so welcome back in your official capacity. I told you we were talking at your confirmation hearing that the job you now have would be a thankless one and you were undertaking an enormous responsibility. At that time we also discussed three main areas that i encouraged you to focus on during your time at h. H. S. Responsiveness accountability, and independence. Id like to talk more about each of these areas today. Lets start with responsiveness. During your confirmation hearing i raised the importance of this to congress and this committee in particular. You assured me this would be a top priority of yours as well and under your watch we would see a marked improvement. In the past year this committee has written at least 20 letters to h. H. S. Or c. M. S. Asking questions about serious issues such as fraud, prevention, hacking of health care. Gov website, Medicaid Expansion and many others. I understand that we have now received answers to nearly every one of those outstanding letters just in time for your appearance here today. With the last two responses coming just last week. This is a great improvement over what its been in the past. I appreciate the effort being made to provide these answers to us. However, i hope it will not require calling you to testify before the committee to ensure more timely responses Going Forward. If it does, then i suppose well have to look forward to seeing you for a hearing every 30 to 60 days. You dont want that. They get worse after time. Thank you for continuing to make this a priority. Good communication between h. H. S. And this committee is paramount to a good working relationship and you understand that and i know that. Lets talk about accountability. One of the big issues we discussed at your confirmation hearing was the absolute need for fiscal accountability given the huge breadth and scope of h. H. S. s programs and budget. Overseeing them requires constant vigilance and effective management. When looking at the size of the budget for h. H. S. For this coming fiscal year we see just how big your job really is. In fact, the expression, too big to fail does not really apply here as the h. H. S. Budget is so big one would argue it is destined to fail. The h. H. S. Budget for fiscal year 2016 is just over a trillion dollars. In real terms if h. H. S. Were a country this budget was its g. D. P. , it would be the 16th largest economy in the whole world. I think we have that chart over there that shows that where the red arrow is youd be the 16th largest economy in the world. To put it in a more american context, the total budget of h. H. S. Is more than double that of walmart and five times more than apple. My concern is the savings and efficiencies in the overall h. H. S. Budget are very small when compared to the overall spending. The president s proposed budget would save just under 250 billion over the next decade, which sounds like a lot but that is only 3. 8 of total medicare and medicaid spending. More accountability is critical here to ensure these programs have sufficient resources to continue to provide benefits for years to come. On the policy front, the Administration Needs to be up front with congress about their contingency plans. If the king vs. Burwell case is not decided in its favor. Depending upon what happens in the Supreme Court and in late june and probably late june, h. H. S. Could have to figure out how to provide services for millions of americans who are currently receiving tax subsidies to enable them to pay for Health Insurance. I can only assume the agency has a plan in place for dealing with this possibility. Secretary burwell, i hope youll share that with us today. That brings me to independence. For some time now, i have been concerned about the amount of influence h. H. S. And the administration has or have over the operations and policies impacting the entitlement programs. Certainly those run by c. M. S. The budget released this week indicates that spending on just medicare and medicaid is expected to exceed 11 trillion over the next decade. In fact, c. M. S. Accounts for 35 of the total h. H. S. Budget. These are astonishing numbers. They also reinforce for me something that ive long believed. It is time to Start Talking about making c. M. S. An independent agency apart from h. H. S. Nearly 20 years ago Congress Passed and the president signed into law a law, the Social Security independence and Program Improvements act of 1994. That law separated the Social Security administration from h. H. S. And made it an independent agency. At that time, s. S. A. Was the largest operating Division Within h. H. S. And accounted for about 51 of h. H. S. s total staff and more than half of h. H. S. s total annual budget. I intend to introduce legislation to move c. M. S. Out of h. H. S. Whether or not c. M. S. Becomes an independent agency is something to consider Going Forward but the accountability and transparency problems we currently see in c. M. S. Programs cannot wait. I hope that we can Work Together in the coming months on both the Affordable Care act and entitlement issues to create situations and solutions that work for all americans. Finally, i want to note that while there is much in the president s budget with which i disagree, there are areas where i think we can find common ground. For example, i appreciate the provision in the budget that addresses the issue of over reliance on congregate chair facilities or group homes for children and youth in foster care. For years ive been working to call attention to the deplorable conditions in many of these group homes. Recent Research Indicates these group homes are unsafe, expensive, and too often contribute to profoundly negative outcomes for the children and youth who are placed in them. So i look forward to working with the administration to end the over reliance on group homes. Secretary burwell, i look forward to your testimony today and to working with you to ensure our most vulnerable citizens get the care they deserve. I do appreciate how difficult your job is and appreciate the openness with which you considered with both senator wyden and myself and others on this committee. Senator wyden . Thank you, mr. Chairman. Secretary burwell, let me start by saying that my assessment is that you have set a new bar for cabinet secretaries in terms of reaching out and trying to be responsive. I hear about it with respect to citizens, apparently youre in virtually every corner of the country taking your family. I can only imagine the challenge of that. Youre getting back to senators. I hear senators in both Political Parties conservative liberal saying the secretary actually got back to me. I mean, its like such a quaint idea that somebody would actually do that. And i understand youve got discussions either coming or have already begun with governors. So my sense is you have really set a new bar in terms of reaching out and it is obviously very, very welcomed. Now, too many people in america, including millions in our country and in my home state, feel like theyre falling behind. They just feel like the economy picks up steam, theyre not getting ahead. And its our job to make sure that doesnt happen. The finance committee has played a big role in this, almost like a triple header this week. We had yesterday and then you and secretary liu tomorrow. And the budget obviously articulates the priorities of today but it also talks a lot about what our priorities are for the future. And were looking forward to having you lay out how the proposal would strengthen health and Human Services programs, promote economic mobility, and assist our middle class families. I do want to take a minute just to talk about where i believe American Health care has been and then talk briefly about where its going. This year marks the 50th anniversary of medicare and medicaid and a lot has taken place since those programs were created. The congress came together to create the chip program of course for children and has reauthorized it three times. The congress has improved and expanded medicare and medicaid. The Affordable Care act makes access to high quality care a wider than ever. What i think is particularly important, it has signaled that america is not willing to go back to the days when healthcare is for the healthy and wealthy. Thats the way it was when you could go out and clobber the people with a preexisting condition. Obviously, the job is not done. And so there is a twofold challenge in my view. First protect the progress thats been made and, second, clear the way for more progress in the future. For medicare, that means guaranteeing that the programs benefits fully meet the needs of this year of seniors and the demands on medicare are clearly very different than they were 50 years ago. The big ticket medicare costs of 2015 are no longer things like kidney stones and broken ankles. Theyre chronic conditions like cancer diabetes, and alzheimers, and those conditions are tougher and they are more costly to treat. The h. H. S. Budget, in my view, begins to acknowledge that reality, but clearly, there is a lot more to do. Treating chronic disease, in my view, is the future of the medicare program. So whats needed is a road map to efficient and effective care for chronic disease that boldly moves away from the outdated fee for service model. Patients and providers told this Committee Last summer about the need to address chronic care in a different way. Theres bipartisan support for this in congress. I look forward to working with you and the administration to make that a reality. Now, i was also thinking about the announcement last week about Precision Medicine, because this, too helps to provide something of a road map for the future. Medical professionals understand that a treatment will often affect susan in a different way than it affects george. With the right research its going to be possible to learn what drives those differences and how to tailor treatments to fit an individual patients needs. The Precision Medicine initiative thats in the president s budget follows an innovative test program that was really created in this committee. It was part of our discussions. I dont see senator carper here. He had been very interested in that issue. But weve got another big challenge. And the next step will be to design a Payment System for this innovative field, Precision Medicine, that can do so much for the future of patients and taxpayers. The president s Budget Proposal also continues the progress made by the Affordable Care act to reward the quality of care rather than the quantity. The congress can do even more bypassing bipartisan, bicamera legislation to improve the way medicare pays physicians and chairman hatch obviously had a lot to do with putting that proposal together. The president s proposal also takes a vital step by including four years of funding for c. H. I. P. There are more than 10 million kids in america who get Health Insurance through c. H. I. P. Including more than 75,000 in oregon. The child who starts life with quality Health Insurance has a better shot at a successful, middle class life than a child who doesnt. Renewing c. H. I. P. , in my view, is a no brainer. Families and state agencies across the country are waiting for the congress to step up and act on c. H. I. P. Theyre also there are also steps congress can take to help guarantee our Health Programs remain strong for generations to come. That are lifelines for countless americans and as a result millions of families will never have to choose between paying for a loved ones care and sending kids to college. Millions of americans will grow up with access to quality care that keeps them healthy and out of the Emergency Rooms whenever possible. Of course its important to remember health and Human Services does a lot more than oversee medicare, medicaid, and c. H. I. P. No department plays a bigger role in americas safety net. This committee has a long history of working on a bipartisan basis on policies to strengthen our federal Child Welfare programs for vulnerable kids. Just five months ago the congress enacted the preventing sex trafficking and strengthening families act. The department is helping turn this bill from a piece of paper signed by the president into new tools that will help states move more vulnerable kids out of harms way and into safer and permanent homes. The president s Budget Proposal shows that its possible to build on this momentum by expanding programs to keep kids and Families Together and healthy with a special focus on getting involved early with vulnerable families with programs like Home Visiting and this is especially important to the firsttime parents. Were talking about multi generational support. And those prevent the longterm costs associated with homelessness abuse neglect, and foster care. So were talking about the people who are trying to get ahead in a tough economy and have just not seen the recovery make it to their neighborhood. Thank you for joining us here today. Weve got a lot of opportunities in my view for working in a bipartisan fashion and ill have some questions. But i do want to wrap this up by saying that having been in public life and worked with a number of secretaries, i think at the end of the day there are going to be big differences of opinion. The only way you really make progress is by reaching out and you have sure met that test. Thank you. I look forward to working with you. Thank you, chairman hatch. Thank you, senator. Our witness today is department of health and Human Services secretary Sylvia Mathews burwell. Secretary burwell has been leading the department of health and Human Services since june of 2014. Ms. Burwell has a long history of Public Sector service, including most recently serving as director of the office of management and budget under president obama. In the Clinton Administration ms. Burwell served as Deputy Director of o. M. B. , deputy chief of staff to the president , chief of staff to the treasury secretary, and staff director at the National Economic council all of which are very important positions. She also has extensive private sector experience, including serving as the president of the walmart foundation. Before that as the president of the Global Development program at the bill and Melinda Gates foundation. Ms. Burwell received her a. B. From Harvard University and b. A. From Oxford University where she was a rhodes scholar. So were honored to have you here and we want to thank you for being here today. You can proceed with your opening statement. Thank you. Thank you, chairman hatch. And Ranking Member wyden and members of the committee for having me here today. I want to thank you for the opportunity to discuss the president s budget for health and Human Services. I believe firmly that we all share common interests and therefore, we have a number of opportunities to find common ground. From preventing and treating Substance Abuse to advancing the promise of Precision Medicine to building an innovation economy and strengthening the american middle class. The budget before you makes critical investments in Healthcare Science innovation, and Human Services. It maintains our responsible stewardship of the taxpayer dollars. It strengthens our Work Together with the congress to prepare our nation for key challenges at home and abroad. For h. H. S. , it proposes 83. 8 billion in discretionary budget authority, and this is a 4. 8 billion increase that will allow our department to deliver impact today and lay a Strong Foundation for our nation for tomorrow. It is a fiscally responsible budget which in tandem with accompanying legislative proposals would save taxpayers a net estimated 250 billion over the next decade. In addition, it is projected to continue slowing the growth in medicare. It could secure 423 billion in medicare savings as we build a better, smarter Health Delivery system. In terms of providing all americans with access to quality, Affordable Healthcare, it builds upon our historic progress in reducing the number of uninsured and improving coverage for families who already have insurance. It extends c. H. I. P. For four years. It covers newly eligible adults in the 28 states plus d. C. Which have expanded medicaid, and it improves access to healthcare for native americans. To support communities throughout the country including under served communities, it invests 4. 2 billion in Health Centers and 14. 2 billion to bolster our nations Healthcare Work force. It supports more than 15,000 National Health service core clinicians serving nearly 60 million patients in high need areas with the funding streams ending in 2016 millions stand to lose primary Care Services and providers if were not able to take action. To advance our common interest in building a better, smarter, and healthier Delivery System, it supports improvements to the way care is delivered providers are paid, and information is distributed. On an issue for which there is bipartisan agreement it replaces medicares Sustainable Growth formula and supports a longterm policy solution to fix the s. G. R. The administration supports the type of bipartisan, bicameral efforts the congress undertook last year. To advance our shared vision for leading the world in science and innovation, it increases funding for n. I. H. By 1 billion to advance Biomedical Research and Behavioral Research among other priorities. In addition, it invests 215 million for the Precision Medicine initiative, a new cross departmental effort focused on developing treatments diagnostics, and preventative strategies tailored to the individual, genetic characteristics of individual patients. To further our common interests in providing americans with the Building Blocks of healthy and Productive Lives, this budget outlines an ambitious plan to make affordable, quality child care available to working and middle class families with young children. It supports evidence based interventions to protect youth in foster care. It invests to help Older Americans live with dignity in their homes and communities and to protect them from identity theft. To keep americans healthy, the budget strengthens our Public Health infrastructure with 975 million for domestic and International Preparedness including critical funds to implement the Global Health security agenda and its Core Strategies of prevention, detection, and response. It also invests in Behavioral Health services and Substance Abuse prevention. It includes more than 99 million in new funding to combat prescription and heroin abuse dependency and overdose. Finally as we look to leave our Department Stronger the budget invests in our shared priorities of addressing waste, fraud, and abuse. Initiatives that are projected to yield 22 billion in gross savings from medicare and medicaid across the next decade. Were also addressing our medicare appeals backlog with a variety of approaches. Taken together, this budget advances our broader goals of making a 21st century workforce, providing americans with the Building Blocks of healthy and Productive Lives and delivering impact that allows everyone to share in the prosperity of a growing america. As i close, i want to assure you, i am personally committed to responding quickly and thoughtfully to concerns and commune cages from members of congress. Weve made progress and we can do more. I also want to take a moment to thank the employees of h. H. S. From their work on combating ebola to the work that they assisted the unaccompanied children at the border to the commitment they show day in and day out helping their fellow americans attain those Building Blocks of healthy and Productive Lives. I look forward to working closely with you to advance our common interests for the american people. Thank you. With that im happy to take your questions. Thank you, ms. Burwell. As you know, the Supreme Court will soon decide the legality of i. R. S. Regulations that extend Health Insurance subsidies to individuals in states with federal exchanges in the king v. Burwell case. The legislation itself, the care act, talks only about these exchanges being created in the states. So its an important opinion. In my opinion the regulations violate the constitution of separation of powers by exceeding the executive branchs regulatory authority. Well find out what the court says soon enough. Yesterdays ways and means hearing, treasury secretary liu repeatedly refused to say whether the administration has a contingency plan if the Supreme Court rules against the administration. Secretary burwell, does the administration have a contingency plan in case the courts invalidate the premium tax credits and penalties in states with the federal exchange . If you could say yes or no it would be id be happy. Senator, right now what we believe is the position we hold and that the Justice Department will represent for us in front of the Supreme Court is the correct position and we believe that both in terms of the spirit of the law and the intent of congress as well as the letter of the law and the Justice Department will make that argument. In terms of what we believe and we see that is happening is the idea that tax credits would be provided by the congress for individuals in say the state of new york but not the state of new jersey is something that we dont believe the congress intended in any way. We believe the letter of the law supports that. Theres a lot of indication that was exactly, that congress did intend that so it would force the states to have to form a state exchange rather than have the federal government do it for them. So its a big issue. And the language is unambiguous at least in my opinion. So i dont know what the court is going to do nor do i want to overly speculate on it, but assuming that the court does find that the language is unambiguous and that only state exchanges can be formed do you have a contingency plan . Right now, mr. Chairman, what i am focused on i think everyone here knows, that february 15 is the end of open enrollment. And in terms of providing quality, Affordable Access to healthcare my focus right now is ensuring as weve seen and today later today we will announce that there are 7. 5 Million People who have come in through the federal marketplace in addition to the 2. 4 million that have come in through the state exchanges. And large majorities of those people are receiving the Financial Assistance that is being provided. Right now my focus is to focus on completing and implementing the law, which we believe is the law. Then the answer must be no you dont have a contingency plan. Thats all im asking. Right now what im focused on is the open enrollment. So that means you dont have a contingency plan. I would suggest the administration ought to get one just in case. It is something that seems to me, you know, we have to youre going to have to have because the possibility is millions of people will need coverage when this law runs out and its important. Let me ask you this. Has your department communicated with insurers who participate in healthcare. Gov to plan for the possibility that the subsidies could become illegal . Have you planned taken, made plans there . What we continue to do is work with the insurance providers to implement the Affordable Care act. We are working very closely with them as part of this open enrollment. One of our deep focuses has been the consumer as part of that focus with the consumer weve been working very closely with the insurers on making sure that were focused on everything from how enrollment works to providing tax im more concerned about this issue right now. Im limiting my comments to this issue. Im sure youre working with the, you know, with the various states in every way you possibly can, but again are you planning for anything if the Court Decides the other way . Senator, right now we are focused deeply on those issues ive articulated. Okay. I have to say the insurers to my knowledge have not been given any guidance about what to do if the Supreme Court invalidates subsidies paid to them. So its something i would hope that youll, you know, get on top of. Just as a contingency plan, to make sure you can handle these matters. Secretary burwell, the a. C. A. Included more than 100 billion in appropriations. Over 1 billion of that went to states that willfully and negligently spent federal funds for development of a failed state exchange. In a may, 2014 confirmation hearing before this committee i asked you if these states would be required to reimburse the taxpayers. You said, quote, where the federal government and taxpayers had funds misused, we need to use the full extent of the law to get those funds back. And i agree with you. Has h. H. S. Recovered any of these funds and do i have your commitment you will take action on behalf of the american taxpayers to collect from the states the money that was, in the opinion of almost everybody, so negligently misspent . So at this point we have not received any of the funds. With regard to the funds, they are made in contracts and we do those to the states and the states issue the contracts. Our grant making to the states is the part that we have control over. As part of that, though, a number of the states actually are taking action both in oregon as well as in maryland. Efforts are being made in terms of the followup. The question of what the federal government can get back in terms of those funds is about whether or not in the grant making that things were done that were not in line with the terms of the grant. Right now our Inspector General at h. H. S. Is looking into these issues to see if there are places where they think that has happened. Okay. Senator, my time is up. Thank you, mr. Chairman. Obviously madame secretary were in tax Filing Season and there are lots of issues with respect to the premiums and the credits and obviously secretary liu and commissioner the commissioner play a key role but you all are involved as well. I just have a couple questions here. Do you have any sense at this point of how many people might be entitled to a refund under the law because that is certainly one possibility and how many people might owe something . Do you have any sense of numbers there . Thats what im being asked. So we do have a sense that over 3 4 of people will just check a box. Those that have existing insurance in terms of when they file three quarters of people will just check a box. With regard to the other category one that youre referring to which is those that have been in the marketplace and whether they have under paid or over paid with regard to the subsidies that they received, we dont have a sense because this is the first time through. Weve consulted with our colleagues at the i. R. S. Because it is the first time through im sure both the commissioner as well as secretary liu have spoken to that. What are you all doing to make sure that this is consumer friendly for people who are going to have to wrestle with these issues . We have worked together as the departments, the department of health and Human Services, the treasury department, and the i. R. S. , to make sure that we are getting information out as much and as quickly as possible. With regard to those who will be filing in the category that you were just describing, 91 of those filers use some type of software to file. And so within the software it is incorporated just as Everything Else is incorporated and we worked to do that. Weve been working with the tax filing organizations, whether thats at the end of the h r block down to the centers that i think many of you all know, those centers that help provide lower income people. Were in close communication. Weve done calls with the centers, secretary liu has done calls with the tax preparers. We are in consistent communication because we want to make sure that the questions theyre getting we understand so that we can provide help in answering those if we can. Let me move on to the chronic care issue, which as you and i have talked about i think ts is the future of medicare. I look back and we talk about broken ankles. Nobody is talking about a broken ankle now being something that drives medicares future. Its about diabetes and cancer. And you all run a number of programs that hope to for the future, address the concerns of the chronically ill. When can we expect to see some of those results . I know that you have programs that you would like to see look at a variety of different conditions and the challenge of course is youve got this horribley fright fragmented Delivery System and thats one of the things the legislators on this committee are trying to change. Trying to change in a bipartisan way. Tell me about the programs you all operate that target the chronically ill, which i think is going to be the future great challenge of American Healthcare. With regard to the chronically ill and the things we do as a department it actually cuts across various parts of the entire department. Theres the work that were doing in terms of as a payor in medicare and medicaid and working on innovation in that space. Were working on innovation with the state through the state innovation model grants where we are granting money to a number of different states to try innovations in terms of some of those things and the medicare space we see the work that were doing in the Innovation Center to try. With regard to when well know as you all know because the legislation gave us conditions that said you cannot decrease quality or increase price, and so we are measuring those as we go forward. I would also mention that in these areas of chronic theres also the work that the c. D. C. Is doing and some of this is about prevention. And as we think for some of these conditions such as diabetes, heart disease, and some of those, it is about prevention and c. D. C. Plays an important, strong role as we go forward with that. Let me ask you about the Precision Medicine initiative and, again what we are looking at for the future. I think this too, is a key part of the future of americans healthcare. I think for families to have confidence that when a loved one gets sick their treatment is going to be targeted and precise based on their genetic makeup. This is pretty important. This is about as important as it gets for a family. But if were going to tap the potential of Precision Medicine the big payors and your department runs several of those programs, medicare and medicaid and private insurers are going to need to pay for it. And i know youre just Getting Started in this area, but what progress are we making in terms of setting up Payment Systems . Thats what this committee tried to do in the Affordable Care act to make sure that you can actually get paid for tests and innovation and these kind of services that really help patients. So i think that the question of payment also gets to the announcement that i made last week which for the first time we as a government are committing that we set a goal for ourselves to change the way that we are paying in medicare. Weve set the goal that we will have alternative payments, payments that are based on value instead of volume. Weve set the goal for 2016 that 30 of those payments, and by 2018 that 50 of those payments. As part of our moving forward to alternative approaches to payments, i think thats where were going to try and bring in some of that innovation. The other thing i think that is important is we consider costs in this space that this type an approach to medicine hopefully can for the individual because you can treat it in ways that may not be as costly as you were talking about in your earlier question. Thank you senator. Senator grassley . Thank you secretary, for appearing. More importantly, i appreciate very much the frequent phone calls. You call me and give me updates. I only have one subject, one question at the end. But ive got a leadin. So be patient please. Im concerned about the recent failure of coopportunity, a coop created through the Affordable Care act operating in iowa and nebraska. Coopportunity was one of 23 formed under that law and federal government loan money went to them through c. M. S. As i understand it c. M. S. Played a significant role in overseeing the coops including having ultimate authority over setting the rules. Coopportunity was very successful in attracting beneficiaries with the second most covered lives of all the 23 coops. It was even more successful than they anticipated. In the summer it became obvious coopportunity and the iowa insurance commissioner that coopportunity would need additional loans from c. M. S. To stay in business. Both the iowa insurance commissioner and coopportunity frequently inquired with c. M. S. About their Capital Position and the need for certainty ahead of open enrollment as it was clear that liquidity crisis was developing. C. M. S. Knew coopportunity was going to be in trouble if it didnt get loans. Coopportunity was allowed to be in iowa and the nebraska marketplace when it opened on november 15. C. M. S. Finally let coopportunity know that no further loans would be coming right before christmas. The iowa insurance commissioner was forced to take coopportunity over december 24. Im concerned about c. M. S. s role as a regulator of coopportunity and then of all coops. There are about 2 billion of taxpayer money loaned that coops that depends upon the success of the coops for the federal government to get its money back. But c. M. S. Did not distinguish itself in its actions with coopportunity. Ill have more questions for you for the record regarding c. M. S. Action, but my question for you today is on behalf of shane and betty bush, milford, iowa, just as an example of some people that have real problems because of coopportunity bankruptcy. They paid their premiums and renewed their coverage with coopportunity as they expected it to be there for them 2014. Unfortunately, shane bush had emergency surgery january 3. Fortunately, mr. Bush is recovering. But the care was not inexpensive. The bushs have already hit their outofpocket maximums for coopportunity. With coopportunity being liquidated the bushs have to find new coverage and the next insurer will not have to recognize the money already spent by the bushs 2015. With additional expenses certain this year the bushs will be out thousands of dollars theyve already spent in 2015. Madame secretary, the bushs cant afford to pay out of pocket premiums for two different plans. Theyre in this situation as i see it because c. M. S. Ignored the warnings from iowa and coopportunity allowing coopportunity to go back on the marketplace and now the folks in iowa and nebraska like the bushs face financial consequences because of c. M. S. s response. I intend to ask you further about what c. M. S. Was doing and why but what i want to ask you today is what responsibility you think your department and c. M. S. Have to people like the bushs. I think they had about a hundred thousand people that they were doing business with. With regard to the issue of the consumer that is our number one priority as we work with the state Insurance Department in iowa. As we work through. And so the consumer is the number one priority and thinking through what authorities we have, and what we can do to help support all of those consumers like the family that you have just described. As we work through this, i think as you know and, you know, the director has been in touch and we look forward to responding to the questions that you have, you have sent in letter and add any others to that list. We focus on the consumer. One thing that happened through the evolution of the coop process is from the legislation that was passed and the amount there were many rescissions in terms of the amounts of money we had to do Additional Support so at the point in time which came down to a very limited amount there were rescissions, sequestration took additional dollars out of these funds. We are concerned right now our focus is deeply on the consumer. We look forward to working with the state of iowa, that has the main authority over this to figure out ways we can help those consumers. Thank you madame secretary. Thank you, mr. Chairman. Thank you senator. Senator stab gnaw . Thank you very much, mr. Chairman. Welcome, madame secretary. Thank you very much for your hard work of you and your staff on a complicated critically important set of issues. I think we need to first underscore the good news, the latest c. B. O. Projections show more and more people are finding fulltime work. We want to make sure that is work where you can work one job and be able to care for your family to gain access to Affordable Healthcare. We know fewer americans are going into bankruptcy because of medical crises. Thats important. Tax credits helping people afford coverage, people who have insurance are able to get new opportunities to get Preventative Care and vaccinations, wellness visits, and, frankly folks who have been paying into healthcare for a long time are finally guaranteed theyre getting what theyre paying for and cant get dropped if they get sick or if they cant they can find Insurance Coverage for preexisting conditions and so on. So all good news. I would say that as somebody who was around deeply involved because of the importance of healthcare to the people of michigan and the debate particularly around affordability of healthcare and being involved and one of the chief supporters of what i call the affordability tax credits, in fact, at the time the chairman introduced me as senator affordability which i carry as a badge of honor. But i would say that just for the record that the affordability tax credits are working as we drafted them as we intended them for all americans not just some americans and if in fact they went away or the entire bill the law was repealed, like weve now seen a bill introduced here in the senate that has been brought immediately to the floor with i believe we have 47 republican cosponsors so far. This would be serious for families in terms of no longer having access to the protections of Affordable Health care and access to health care. What id like to ask you about is one piece of that, that, unfortunately, went from being a part of the comprehensive plan to being optional state by state, which has undermined seniors and families to be able to get Affordable Health care. Thats medicaid. When we put all of this together we assumed and we know that 80 of the money in medicaid is low income seniors in Nursing Homes so were talking about seniors in Nursing Homes. We assume that low income seniors in Nursing Homes and their families would be able to get the help under medicaid that they need as well as families. In michigan more than 500,000 people have enrolled in the healthy michigan plan. I congratulate our governor and others who put that together. And weve still got time to go on this. So when i look around this panel, we have 11 states represented in the finance committee that still have not provided access for low income seniors to nursing home care or to families and children through the expansion of medicaid. And i wonder if you might speak to what is happening to families and the costs even to states and certainly our hospitals. I know in michigan folks were talking about the number of people coming to the emergency room, getting care, the most expensive way possible rather than getting it through a doctor and so on and in a way that is better for them and contains costs. Could you talk about what is happening because states are not giving access to families and seniors to healthcare through medicaid . I think the impacts of Medicaid Expansion have to do both with the individual as well as economic impacts. And in terms of the individual impact, in terms of the health and Financial Security, yesterday when we had folks at the white house that had written the president , you know, there was a woman who actually went on to the marketplace because she thought she would pay a fee. She went on to the market place, found out actually she wasnt in the market place but was medicaid eligible, and went in. Had never had a history of Breast Cancer in her family. Ended up actually having a mammogram because it is part of what is covered. Found out that she had Breast Cancer. And so thats for the individual. For the individual in terms of that Financial Security of the ability to pay for and have health care. So thats for the individual. Economically, what we see is in the states that have expanded medicaid, there are fewer rural hospital closings. An issue that is affecting a number of states across the country. And that has to do with the reduction in indigent care costs. And that is what we do see in those states. And we see anecdotal evidence in terms of examples of whats happening in communities where more of the care is being paid for. And so that is in terms of from the beginning its the individual in terms of financial and Health Security and then with regard to the states, themselves theyre seeing those benefits. The major rural health issue. It is a rural health issue but is also happening in urban hospitals because generally in some urban areas there is one hospital. Not always but there is the hospital that tends to take care of that indigent care. So the economics of that entity can be dramatically affected by all. We know those are the direct impacts. The indirect impacts are for everyone else in terms of premiums. When there is less indigent care there is less pressure on premiums for those who are even in an employer based system. Senator schumer . Thank you. Thank you, mr. Chairman. Thanks for holding the hearing. And i want to thank you, madame secretary, for the great job you do. Youre a star. Youre a star. First, just a. C. A. Despite all the nay saying, has some huge successes. Healthcare spending, growth has decreased significantly. Thats huge in terms of not just healthcare, itself, but our budget. 600 billion less through 2020. Uninsured level, lowest in decades. 9. 5 million insured in my state of new york. We have, you know, really done a good job. I salute our state. Our health exchange, new york state of health, has signed up 2 Million People for low cost health coverage. 80 of those enrolled said they were previously uninsured. So its great. Now i have and i appreciate the emphasis you put on research, early learning, and your support for c. H. I. P. Im now sitting in the seat where senator rockefeller sat for a long time and im mindful of c. H. I. P. All the time. I have two questions for you. The first is on g. M. E. A place where i oppose the administration strongly and vehemently. I cant even understand your logic here. The president s budget says medicare payments to Teaching Hospitals for indirect costs of medical education exceeded the actual patient care costs. And they want to correct this imbalance by reducing the i. M. E. Payments by 10 . Thats an enormous cut 16. 3 billion. Now, your Budget Proposal recognized we have a physician shortage. And we do. If were going to insure more people we need physicians. One of the places a. C. A. Didnt really do the job in terms of filling the gap of new physicians that we need. And it sort of adds insult to injury to now cut the payments to Teaching Hospitals. Theyre just not going to teach as many medical students and make them become doctors if youre going to cut this. I believe the current funding levels are critically important to maintaining a stateoftheart environment not only training doctors but training the best doctors. We dont need a majority of our doctors would being trained overseas but that would be a direction in which youre headed. And so it seems to me counterproductive to attempt to train more physicians by cutting Teaching Hospitals that train them. How do you reconcile that . With regard to the issue of making sure we have enough care in the country and the specific g. M. E. Area what were trying to do is make sure we balance the needs and we are our proposal also targets funding and additional funding for those that go into primary care and specialties where we have shortages. So the proposal that were trying to craft and come forward with is a proposal that affords us the opportunity to have fiscal responsibility and we keep the slots but the question of the payment of the slots indirect vs. Direct costs and then add additional funds that would help do targeted efforts. In addition, with regard to the broader issue, in terms of some of the things we do, the National Health Service Corps is a place where there are large investments in the budget to try and make sure were supplementing primary care. Weve also proposed the extension of the medicaid primary care funding. So were trying to make sure that we are working on the i think youre robbing peter to pay paul. I certainly believe in the programs youve mentioned. Theyve been around for a while. They havent done filled our need, and what weve proposed, a bunch of us, and its bipartisan support, is we increase the number of slots and we allocated half of that increase to primary care. It seems to me a much better and tested way to go than say, well, were relying on these new programs which have never filled the gap. Having said that i just want you to know im vehemently oppose today that proposal and i hope the administration would reconsider it. On a if you havent understood my language until now. Look forward to working with you. On ebola i want to thank you. The c. D. C. Has done a great job. We knock government all the time and if you read the media the first few weeks you think everyone was going to get ebola and the number of cases here in america has been thankfully few. The number of cases in the three hot spot countries has declined. That just didnt happen by magic. It happened by great work at the federal, state, and local levels. In new york our hospitals did an amazing job. 47 of the people who flew in to this country from the three ebola countries landed at Kennedy Airport and our city, state, and fofts all got together and made sure that we didnt have the situation we had initially in dallas. So i thank you for that. And for the good job you do. But can you just tell us, i know we put some money in and i worked very hard to have a provision with the help of many of my colleagues that are hospitals in, around the country get reimbursed for the huge outlays theyve had to make. Many had to create anticontamination rooms. They had to buy equipment. Theyd had to do training. Can you provide us with how you plan to ensure that the Ebola Treatment Centers i care especially about the ones in new york receive appropriate reimbursement . We are working to have those funds reimbursed because those will be directly with were working to have a contractor that will help us do that reimbursement on hospital by hospital basis. In addition, states and communities will receive other parts of funding that are part of the preventative work that they did so there are special funds for the treatment hospitals like bellevue which did a tremendous job in new york and the others that did treat patients around the country. We look forward to continuing to work and were very appreciative of the funds and want to move them as quickly as we possibly can to get reimbursement to those treatment hospitals and to help those hospitals that got ready and prepared. Thank you. Thank you, mr. Chairman. Thank you, senator roberts . Well, thank you, mr. Chairman. And madame secretary. Let me echo the sentiments of many members to thank you for the job that youre doing. During your confirmation hearing, we talked a lot about the Affordable Healthcare acts independent payment advisory board. The acronym is ipab. Reminds me of pab lum people dont want to eat. You said you were hopeful ipab never needs to be used and can only be triggered in the window, your estimate said or it will never be activated. You were hopeful we can make sure ipab never gets triggered and we all agreed. But here we are again with a budget request where youre acting to expand this authority to find savings. How can you explain how you went from hoping it never had to be used to now doubling down on ipab and expanding the savings this must find . With regard to the what we are trying to do is get to the core of what ipab was about, which is making sure that we can Work Together to continue to keep the costs in medicare and in the entitlement space. And were working to do that with our proposals. Weve seen just in the period from 2010 our medicare spending is 116 billion below what it was predicted to be and on a go forward basis thats why we have the proposals in our budget, to keep moving that out. The proposals that we have in our budget extend the life of the trust by five years. And our objective is to actually put specific policies that will continue to move out that time frame and were hopeful we can work with the congress to get those policies enacted to continue the entitlement savings. We have some from the last years in terms of what were seeing but we want to continue on a path to tight and contained growth with regard to that spending. I think everybody wants to continue the growth but i dont want rationing. Im very worried about the independent payment advisory board, the c. M. S. Innovation center the u. S. Preventative Services Task force, and the Patient Center of Outcomes Research institute all well intended have labeled them the four horsemen of regulatory apocalypse. Because of all the rationing. Now, wait a minute. Youre depending a lot on something called a recovery audit contractor. I must tell you that when the contractors ride into town in western kansas, the doors shut and they hope that nobody, no r. A. C. Person comes and knocks on the door. I think they put hospital administrators on the r. Rack if you will. I appreciate you have included a number of proposals in the budget to help address the appeals process because you go into a hospital. They have a choice. You either pay the fine and contractors get gold stars if you have fines and then you say thats savings with regards to medicare. It is also rationing. So heres the point. C. M. S. Presented a settlement offer and over 2,000 hospitals entered the process. Chief Administrative Law judge griswold noted that as of july last year there were 800,000 pending appeals. My question to you, if all of these hospitals would complete this settlement process, how many claims would potentially be cleared from the backlog . Are we even making a dent . So the issue is one that i think many of you on the committee know is one that im deeply concerned about which is why weve reached out and talked about the issue certainly before today. With regard to how many will come through settlement they wont all be cleared out that way. And so the strategic approach were taking is threefold to address what i agree is an extremely important issue. Its an issue about balancing those who are not, its about Program Integrity because there are people who are not doing things that we as a tax i understand that. At the same time the concerns you articulated in terms of how it feels and how the process is used. Three strategies were using. The first is to use administrative tools like the one you articulated. The second is that there is funding needed so we can clear out the backlog. Judge griswold and others can process those. We can get the right types that it is a specialized person that we need to do that. Then the third is there are legislative proposals that we believe will extend our ability is legislative proposals that we believe will extend our ability to get rid of the backlog and prevent it in the future. We have had conversations with this committee and we appreciate those. We have included seven proposals and the budget to be specific to work with you on how we can do that. To be honest it will take all three for us to get rid of the backlog. I appreciate your response but im not sure i am following you on all of the specific details. I know you are extremely busy but we will make that inquiry. When you have rac contractors racing around to the rural systems they are not welcome. They dont trust the hospital administrator, doctors or Delivery System. In return these folks dont have any trust in government, and that is not a good thing. Lets Work Together and see if we cannot get a better situation. We would like to do that and follow up with you on the issue. Good morning, madam secretary. On december 17 a number of senators sent a letter to you and to secretary lou about the king versus burwell case. I would like to followup on senator hatchs questions because you did not answer one about contingency plans and notices to people who may lose their taxpayer subsidies for health care. Let me start by asking, as hhs taken steps to inform all current federal Exchange Enrollees about the king suit and how ruling against the Administration May affect them . We have not. We believe we are implementing the law as they are intended to be implemented. That is what we are talking about with consumers entering into the marketplace. If the administration loses have you taken steps to advise federal enrollees about the consequences that may apply to them as a result of the administration losing the lawsuit . As i mention with the chairman we are focused on our responsibility to implement the law as fully as we can and focusing on the Consumer Experience and we are working toward the february 15 deadline. That is not an answer to my question. You are intelligent and charming, but you refuse to answer my questions and that does not strike me as trying to work with congress but rather contemptuous of congress is oversight responsibilities. If the administration loses the king versus burwell case to you plan to ask congress for additional legislation . With regard to that we are at a stage where our arguments has not made in terms of the case. That is not my question. My question is if you lose we you come to congress for additional legislation . With regard to the issue of legislation and the Affordable Care act in its entirety what we have always said is with regard to things that will improve the act we are open. If that is the recent vote for veterans, and i know members of this committee have bills having to do with firefighters, we will work with congress. We will work with congress if it increases accessibility. Youre not answering my question. If the administration loses king versus burwell or you ask for additional legislation from congress to address the decision by the Supreme Court. We believe the position we hold is the correct one. My question is if you lose and the Supreme Court disagrees will you come to congress for additional legislation . We know it would be devastating in loss of premium and individuals. But we are focused on this implementing the law before us. That is our focus. You will ignore the Supreme Court decision in july . Since you will not answer my question about a legislative solution do you believe that your agency has authority to make an administrative fix to the law . Senator as i said, i am focused on the implementation of the law currently. What im focusing on is if the administration loses, and so far you have refused to answer my question. Notwithstanding early statements that you want to cooperate with congress and respect their oversight abilities, i dont understand why you refuse to answer the question. If the administration loses in the king versus burwell case do you believe you already have the authority to make an administrative fix, or will you come to congress and ask for additional legislation . Senator i have focused on implementation. With regard to those questions we believe we are implementing the law, and the law will stand. I am asking if you are wrong. If the Supreme Court disagrees and a five members of the Supreme Court disagreed, do you believe you have authority to issue an administrative fix, or do you think youll need additional legislation. What i am saying is i am focusing on implementation not on that question. Secretary burwell is a charming person and is intelligent, but these hearings are no use to us if the witnesses refused to answer straightforward questions, which is witness has repeatedly done. Im not sure what the proper situation is, mr. Chairman but i would like to visit with you about that. It seems this administration continues to parade witnesses in front of committees like this and to deny us a straightforward answer to straightforward questions. That is unacceptable. Senator would like to comment on this matter. Mr. Chairman i would like to make clear that today is about the hhs budget. A multibilliondollar budget that involves millions of americans. That is the topic at hand. Im very interested in working with my colleagues on the other set of the aisle with health policy. Ive shown that and so of my fellow democrats, but the idea of this morning that we are going to ask a witness to speculate about a court case, to speculate about some thing hypothetical at have a debate about something misses the point of the challenge at hand. The challenge as hand is about the budget. I hope we can figure out a way over the course of the morning. We have plenty of colleagues who still want to ask questions, to talk about the topic that was scheduled. And that is the budget, and not talking about hypotheticals about something else. This is not the department of justices budget. This is the department of health and Human Services. Oh we can stay on the budget and not get into recitation about a parade of hypotheticals. If i can respond to the Ranking Member it is the same question you asked. We can ask any questions we want about the agency that this witness is responsible for administering. To come here and refuse to answer the questions strikes me as nothing less than contempt of our oversight responsibility. It is a serious member. I am shocked that this witness would take that position. I find it unacceptable. Mr. Chairman, to briefly continue, to say this witness is handling this committee with contempt misses what members of both sides of the aisle have been talking about for weeks. This official at hhs has reached out to this committee, the people of this country, in an unprecedented way. I think arguing because she will not talk about hypothetical speculation about a current case about a court case means we are handling this in contempt is off base. Let me ask. Have you made any recommendations as to the premier department that handles all of these matters that are so important to the administration as to how they will handle it if as it has been raised the case goes against the administration or against the Affordable Care act. With regard to where i am on the issues ive focusing on whether ebola or weight. We got that point. These are not stupid people. You are not stupid. Why dont you just say, that is up to the president and Justice Department that would get you off the hook. It doesnt solve the problem. You should be recommending what should be done. That is a serious problem. With regard as you are articulating the Justice Department is the next step. The Justice Department will represent us. I get tired of bailing out democrats. I thought i was being quite funny. I have a subtle sense of humor that sometimes does not come across. To wrap this up i dont think the secretary needs bailing out. We have a Judiciary Committee where they talk about speculative matters about the Supreme Court. I just hope we can handle the budget. I think the senator is within his rights and his comments are accurate. Ms. Burwell continues to answer she is not focused on this. I understand. Tell us who is focused on it. It is important that could throw you into turmoil. We are concerned about it. It is a legitimate concern of this committee. To make a long story short senator cornyn made an important point. Who is next . After that. First, i want to second with the members have said. That madam secretary, your engagement inaccessibility has set a new standard. I think we all appreciate that. I do not know when you sleep but i know how active you have been and will continue to be. Second i want to second with the chairman and senator cornyn and others have said. Not to ask you the question again as i know what you will say, but to say that we know this Health Care Proposal enacted in 2010 has been one of the most impactful pieces of legislation ever enacted by this congress or any congress. It affects tens of millions of americans directly in terms of their health care. Which goes right to the essence of who we are as human beings. Clearly, there is a collision potentially coming with the Supreme Court decision. It is probably not likely given the president s very clear admonitions about how you will not accept any piece of legislation that modifies this in any significant way through a repeal and replacement, but there is a potential collision and it would be irresponsible for the administration not to have a plan to address that should the decision not come down the way you would like. I dont have a question, it is just an affirmative statement that it would cause great chaos and be totally irresponsible. Someone ought to be looking at what do we do if. I want to personally thank you for your engagement with our current governor, governor pence wanted me to pass on his thanks. From us two years of engagement over request for a waiver for the state of indiana. Our former governor, governor daniels had put into place the healthy indiana plan. His innovative, creative, and proven to provide health care for a number of hoosiers. He wanted to expand that. There were 350 residents who would have benefited from your agreement to work with us to come to a conclusion. There are innovative reforms on traditional medicare. Some of them are the first ever. I think it is important for our state to be responsible in playing this out the best we can. It proves these Innovative Solutions can be a benefit to all medicaid recipients. In that regard, i would like to have your assessment of some of the first of a kind proposals you have agreed to that will hopefully prove their worth and be duplicated in other states or throughout the system. The copay, patient participation, patient options to choose a plan that meets their family needs contribution to the power plan, which is a modification Health Savings account, and the states referral process to any individual that applies for job training and job searching through state sources. It is all combined in a new plan that we are excited about. I would like to get your thoughts for the benefit of the members of the committee and others who are looking at ways to provide better access, Better Health care, at lower costs. I am please we were able to come to an agreement and work with the governor. When i became secretary the first thing i did was meet with the National Governors association and express my willingness to work on a statebystate raise this