Transcripts For CSPAN2 HHS Secretary Tom Price Testifies On FY 2018 Budget 20170609

Is brought to you today by your cable or satellite provider. The white house has requested 1. 1 trillion for the department of health and Human Services. Of the budget request includes cuts in Public Health and Biomedical Research took hhs secretary tom price talked at a Senate Finance committee the twohour hearing begins with opening remarks by the chair of the committee, lauren hatch of utah. Of the committee will come to order. We will first listen to the senator from oregon who has to go to another committee hearing, so i welcome everyone to this mornings hearing on the president s proposed budget for fiscal year 2018 with specific attention to the department of health and Human Services. I want to thank secretary price for being here. These hearings are an annual event for the finance committee and secretary price, since this is your first time around i will warn you these hearings can be a little grueling. Of course, you already know that that the president and hhs are eager to work with congress to fix our Health Care System to ensure access to Affordable Health coverage. With that i will turn to the Ranking Member who needs to get to another hearing and we will show that deference. Mr. Chairman, thank you very much for this courtesy and i know this is a busy morning and i am very grateful to you for doing this and i also want to say thank you to the senator who in my absence will do an excellent job as she always does. This administration from day one has preferred alternative fax and convenient spin to the truth. One of the most recent examples was the Budget Proposal, which double counted 2 trillion to maintain some with of fiscal responsibility while its a slashed Health Programs and protections for basic and essential needs. The budget math is fake, but the extreme agenda that would deprive millions of americans of access to healthcare and wipe out Living Standards is not. Unfortunately, this morning i will be splitting my time between the finance committee and Intelligence Committee so i will be brief. There are several issues in the budget, the administrations agenda that i will touch on. First, medicaid. Secretary price, the captain of the president s healthcare team. He has been the premier advocate for trump care, a bill that cuts medicaid by 834 billion in order to pay for massive tax breaks for the wealthy. 14 million americans would lose coverage and millions more would see limits on their care and if that was not enough of a cut the Budget Proposal that came out a few weeks ago it was even further it slashes hundreds of billions more from medicaid. The Program Covers nearly half of all births, 37 million kids, millions of working families and people with disabilities and two out of three nursing home beds in america these cuts would be a staggering blow to american of all generations. These facts and figures have been met by a wave of the hand from secretary price when asked if the proposed cuts would result in millions of americans losing access to medicaid, he responded and i quote absolutely not. He went further again i quote there are no cuts to the Medicaid Program and he also said no one will be worse off financially. I have heard secretary price and others make the baffling argument that people are actually worse off when they have medicaid coverage that their health doesnt improve as a result of medicaid coverage. Often this argument is based on a brief and outdated study performed in my home state. Heres the bottom one on medicaid, 74 million americans rely on this program for basic health needs. Parents of sick kids, people with disability, seniors in Nursing Homes with no one to turn to for help if the benefits disappear and in addition thousands of oregonians who are healthy and are my own states model turkey would be a tough sell to commence borrows people there were stop being enrolled in medicaid or that the Program Needs over a trillion dollars in cuts and Public Opinion is very clear up your two out of three enrollees are happy with the Program Works seven out of 10 americans say congress should leave it as it is, no block grant, no per the limits. Fortunately the budget hits the wall here in the congress and there is a lot of debate left to be had on trump care, but right now the administration is causing turmoil in the Insurance Market and having disastrous effects from millions of families. The president issued a oneday executive order undermining the Affordable Care act and no one on the trumpet chain can give a straight answer about whether the administration will continue with reduction payments that are key to making insurance affordable for working families and because of this sabotage insurers are pulling out of the market, people are left without plans to choose from. You dont have to take my word for it, insurers are clear about why they are making these decisions. Furthermore on the campaign trail that the trump care bill treats the life of medicare in the Budget Proposal extends mandatory cuts under the budgets sequestered by more than 30 million. Fda, centers for disease control, and National Institute of health slashed in the budget in the same is true in programs aimed at basic human beings, programs that fund meals on wheels, foster care. This is the budget if you think seniors in working families have it too easy. I want to thank the secretary for joining the committee and i apologize again for the hectic schedule. Never an easy appointed for a cabinet secretary and i think he knows there will be some vigorous discussion this morning. I also want to express my thanks to the chairman for his very gracious and ongoing courtesies on these kinds of matters. Thank you, senator for being willing to fill in and i look forward to returning to our colleagues and thank you to the chair. Let me say im grateful the present and hhs are in essence, working on this effort and are in essence eager to work with congress to fix our Health Care System to ensure americans are able to access american a formal Health Coverage. This may not be something that will be that easy to do. As we know time is of the essence in regard to this effort and earlier this week we received words that and some is pouring out of marketplace potentially leaving more than 10000 patients and consumers in 20 counties without Insurance Options on ohios exchange for 2018. This is particularly frightening as we expect to hear similar notices from have some as they reevaluate their participation in Obamacare Exchanges throughout the United States and our whole country. This recent story is amazing in a long line of failures. By colleagues on the other side seem to want to continue. Saying this is working. This is not working. All of these demonstrate the need to move forward with repealing obamacare and replacing it with a more workable approach. When that will take serious so we can take seriously the blooming ballooning healthcare costs impacting every american family. Let me talk for a few minutes about the specifics of the president s budget. The budget assumes 250 billion in total savings from the repeal and replacement of obamacare and despite continuations to the contrary the budget does not incorporate the specific legislative proposal, the American Health care act before congress right now. Therefore it is not accurate to associate the specific medicaid, that has been estimated from an enactment with the president s budget. To do so would assume a level of specificity that for obvious reasons is just not there. Moreover, the president s budget does not cut 1. 5 trillion for medicaid. Nor does it assume that the specific medicaid reform proposals from the aac eight will be enacted into law. On quite certain we will hear a lot about that today, but any attempt to make that connection is simply unfounded. And any senator who harps on the medicaid numbers today either does not understand that explicit language and estimates provided in the president s budget or they are simply attempting to muddy the waters in order to scare americans who rely on medicaid for healthcare coverage. Ultimately, the president s budget appears to accept the reality that the senate will need to come up with its own healthcare reform proposal including a fundamental fix to medicaid, which is quite frankly longoverdue. Anyone who doesnt agree with that isnt living in the real world. In addition to the savings assumed from the repeal of obamacare, the budget explicitly assumes 610 billion in savings from putting medicare on a sustainable fiscal path by limiting funding in fiscal year 2020 through per capita limits or block grants at the state office. All told, most of the budgets overall medicaid savings would be achieved by returning the focus of medicaid to serving those with the greatest needs, the elderly, disabled and needy mothers and children. By giving states more flexibility to run on Medicaid Programs. Any senator who would like to argue that the federal government should spend more medicaid dollars to provide coverage for nondisabled, childless adults at the expense of disabled patients who remain on waiting lists should explain why. Furthermore, any senator who would like to argue that the states are illequipped to handle their Medicaid Programs should explain why that is the case given that the overwhelming consensus we have heard from governors nationwide over the last several years is that it states want more independence and flexibility to tailor the Medicaid Program. Washington needs to stop limiting the success of a federal program by how much money it spends or how many other programs are part of it. Instead, washington needs to focus on how well a federal Program Helps those and is intended to serve and how efficient the program is fulfilling its mandate. Long story short, we need to stop focusing on spending and pay more attention to we may not be able to spend more. It doesnt appear we will be able to. The way things are going right now under the Current System, its a national tragedy. I think the president s budget is by no means flawless, largely recognize is the reality and the president and the administration deserve credit for that. I look forward to having a open and frank discussion with secretary price about his thoughts on these and other matters. Before we get to that, let me just say that i would like to say today that we have the pleasure of being joined by secretary thomas e price. Secretary price, we want to thank you for coming. Secretary price is sworn in as the 23rd secretary of health and Human Services figure 10, 2017, as a policy maker and physician, surgeon in particular bringing to the department and lifetime of service and a dedication to advancing the quality of healthcare in america secretary price first began his career in care for patients as an Orthopedic Surgeon. He followed in the footsteps of his father and grandfather and began a solo medical practice in atlanta, georgia. Since its founding that practice has grown to be one of the largest non academic orthopedic practices in the country. Hoping to make a different type of impact on healthcare, secretary price ran for public office, was elected to four terms in the Georgia State senate and i believe would have continued on forever if you wanted to. During his tenure, secretary price served as minority whip and later as the first Republican Senate majority leader in the history of georgia. Most recently secretary price served as us representative for georges sixth Congressional District from 2005 until 2017. During his time in the house, secretary price served in various roles including chairman of the house budget committee, chairman of the House Republican policy committee and chairman of the republican study committee. Secretary price received his basher and doctor of medicine degree from the university of michigan after which he completed his Orthopedic Surgeon residency at emory university. Secretary price, we are grateful to have you here and we will be happy to have you proceed with your testimony today. Thank you so much, mr. Chairman and members of the committee. I want to thank you for inviting me to discuss the president s budget for the department of health and Human Services for fiscal year 2018. It truly is an honor. Whenever a budget is release the most common question in this town in washington is how much. How much does the budget spent on this program and how much does it cut from the other program . As a former legislator i understand the importance of discretion, but too often its treated as the only question worth asking as a relates to the budget as if how much a program spend is more important or somehow more indicative of whether the Program Actually works. President trumps a budget request is not confused that Government Spending with government success. The president understands that setting a budget is about more than establishing topline spending levels are done properly the budget process is an exercise in reforming our federal programs to make sure they do their job and use tax dollars wisely. The problem with many of our federal programs is not that they are too expensive or too underfunded. The real problem is money of them since they dont work. Fixing a broken Government Program requires redesigning its structure and refocusing taxpayer resources to better serve those most in need and that is what President Trumps budget will do. Consider medicaid that has been discussed, primary source of medical coverage for millions of lowincome American Families and seniors facing Challenging Health circumstances. If the amount of Government Spending were truly a measure of success, medicaid would be hailed as one of the most successful programs and history. 20 years ago spending on medicaid was less than 200 billion and within the next decade its estimated the top 1 trillion in your. Despite these Investments One third of physicians who ought to see new medicaid patients dont and some research those enrolling a medicaid doesnt necessarily improve your Health Outcomes. This suggests we need structural reform empowering states to serve their unique medicaid population in a way that is both compassionate and sustainable. Under current law federal rules prevent states from focusing on the most vulnerable communities and from testing ideas to improve Health Outcomes and access to care. This budget changes that. Hhss mission in protecting the health of the American People is far more than overseeing the Nations Health Care Insurance program. Hhs is the worlds leader in helping the healthcare sector prepared for Cyber Threats and responding to and protecting against Public Health emergencies. Recently, i witnessed this work firsthand visiting the bullet survivors in liberia and represented the us at the g20 Health Ministerial meeting in june berlin. To support hhss in a federal role in Public Health Emergency Preparedness and response the president s budget provides 4. 3 billion for Disaster Services coordination and response planning, bio defense and emerging Infectious Disease and development of stockpiling of countermeasures and in addition today america faces a new set of Health Crises that have been we have been far less successful in resolving with serious mental illness, opioid crites crisis and childhood obesity. Im committed to leading hhs to address these three challenges in the president budget calls for policy reform that will enable us to do that. A budget calls for investment in high priority, Mental Health initiatives for Psychiatric Care and suicide and Homelessness Prevention and childrens Mental Health focusing especially on those suffering from severe mental illness. In 2015, over 52000 americans died of overdose, most from opioids. This budget calls for 811 million to support the departments five part strategy to fight this epidemic. To invest in the health of the Net Generation and help nearly 20 of School Aged Children who are obese to lead healthy and happier lives the president s budget establishes a new 500 milliondollar America Health block reappeared additionally, the president s budget prioritizes Womens Health program by investing in research to improve Health Outcomes for women and increasing funding for the maternal and Child Health Block grant and healthy start. Across hhs funding is maintained for bio program serving women including Community Health centers, domestic programs, women cancer screenings and support mother and infant programs in the office of Womens Health. This budget demands tough choices and in this challenging fiscal environment there are no easy answers and with this budget the new administration tries a path towards a sustainable fiscal future and ensures that the resources provided enhance and protect the health and wellbeing of the American People. Members of the committee, i thank you for the opportunity to be with you today and your continued support of the department of health and Human Services. Is my incredible privilege to serve as its secretary. We are proud of you and we know you are an excellent member of the house and so far it looks to me like you are getting on top of what these problems are. Although, you are pretty well on top of them before as a member of the house. The Opioid Crisis seems to be spreading across the country, affecting families and communities in an unprecedented way. In fact, the New York Times reported earlier this week that Overdose Deaths are at an alltime high. Tackling this crisis is a priority for you and for President Trump, so can you describe the efforts hhs is undertaking to address the ongoing Opioid Epidemic in the United States . This is one of the scourges across the nation that tears your heart out. 52000 as i mentioned 2015 in fellow americans died of overdose and 33000 of opioid overdose. Weaker day after day after day and with the department has done is put in place a fivepart strategy to make certain we identify the kind of treatment and Recovery Efforts that work in assisting the state. Host make certain we have the overdose reversing drugs available wherever they need to be available and no, we are trying to surveillance and make certain we know prior to strong drugs getting to the street from a lawenforcement standpoint. Theres a Public Health aspect to determine what is going on. Why is this scourge as large as it is and we are putting resources and that. In addition, we want to make certain we are doing the highest level of research to identify those pain treatments that are able to make it so there is not a need for individuals to seek it for its euphoric effect. Finally, its important look at how we manage pain in this nation. 20 years ago we started down this road of measuring pain. We suggest that it has resulted in significantly greater use of opioids and Prescription Medication than would have otherwise been the case. We have this fivepart strategy and you have been incredibly helpful and congress has been healthy to make certain through twice for sentry tours and otherwise to provide resources so we can allow the states to identify those evidence based programs that they have in place that can mitigate this challenge, but we continue to move in the wrong direction, mr. Chairman, and we will not rest until we bend that curve in the other direction. Thank you. Hhs recently published a report using the Previous Administrations data showing just how much Health Insurance premiums in the market have increased since 2013. Can you tell us what are the principal findings of that report . Thank you. I know when i visited with folks in my previous position as since ive been privileged to serve as secretary i hear over and over again how folks are sewed terribly concerned about the costs of Health Coverage for them and their family and there was this disconnect, you would have the individuals talking about the wonders of the program that was in place and that you had all of these individuals who were concerned because they didnt have the ability to afford the coverage or to get the care, so this is a study that was undertaken at the ascii group within hhs and identify the average premium increase over the last four years has been over 100 , 105 , so more than double. In fact, three states the increases were triple, in alaska and alabama and oklahoma and what that means is that their individuals who number one, cannot afford the coverage and number two even when they can afford the coverage the deductibles have increased to a significant degree so they may have an insurance card, but they dont have care because they cant afford the deductible, so that is a challenge we are trying to address and make Certain Congress addresses. So many individuals are able to avoid the coverage folks want for themselves and for their families. As you may be aware this committee has for several years with a large backlog of medicare claims under appeal at hhs with the most recent reports indicating the backlog has written been reduced to the high of nearly 1 million claims to a current number closer to 750,000 claims. That number is still unacceptably high. Can you tell me what hhs is doing to address the unnecessary backlog of medicare claims . These are appeals that providers have said that they dont believe the federal government has provided the resources necessary for them to care for their patients you mentioned the numbers are staggering, nearly 1 million claims, down to about 700,000 now. We can take care of somewhere around 20000 until recently. What we have done is met with the individuals and their high quality folks. These folks are trying to get these appeals through the process and to make a right decision. We put a focus on that. We have encouraged them to talk to stakeholders and talk to individuals about why we have this increase in claims. Theres a problem there. Its means the system isnt working to the degree it should to allow those individuals to care for those patients and be compensated. We have identified that opportunity for the Administrative Law judges to review higher claims and move in the direction of having magistrate judges review lower claims to get three larger volume of a claims on an annual basis and then we try to decrease the burden of reporting. We are working on decreasing the burden of reporting for the providers so that there is less likely the possibility they would need to feel the need or desire to file a claim, so this is a major problem. We are working through it and we are committed to getting that number down to a reasonable number. I am happy to listen to you. You have inherited a tremendous number of problems and i know you are fully capable of solving those problems and i think you are well on your way. Distinguished Ranking Member has agreed with me to allow senator isakson to go next. Thank you, mr. Chairman. Doctor price, welcome back. Not last time we were confirming you and now, we are getting a lecture from you on what we need to do. Prejudice or should have branded to our state. You just returned from your first trip overseas as secretary and began in liberia if im not mistaken. What did you learn with our response to ebola, which i think ground zero was liberia. It was an thank you for your support and service to our great state. My first trip overseas, we stopped first in liberia and i wanted to do that because i wanted to express our appreciation to the americans working over there, especially during that ebola crisis and to demonstrate our continued commitment for Global Health security and to think the liberian government for what they have done to elevate and increase their ability in the area of Infectious Disease. What i saw that was incredibly inspiring and you all would be so remarkably proud of the American People who are deployed, if you will, in Global Health, individuals from the cdd , nih, who are doing all they can to make certain that we address the Health Challenges is 16 around the world especially in the areas of Infectious Disease. It pays off in remarkable benefits and we saw that because of the most recent outbreak of meningitis that occurred in liberia and that outbreak, the surveillance that was done, the detection, prevention and treatment that was done was only possible because of the work that had been done in liberia says that Ebola Outbreak and that challenge was resolved. So, i was uplifted and inspired by the incredible work the American People who are dedicating their lives to assisting the health of individuals overseas. Cdc did a phenomenal job as did hhs and i want to point out the president s budget as cut by 136 million preparedness fund, a lot of went to the along with emory university, so we need to work with the funding so we can have the same type of response the next time and outbreak takes place wherever it is. We are the worlds clinic, if you will for emergencies and disasters like this. Secondly, you had a partner by the name of john knox. You may remember john operated on my son kevin 30 years ago and saved his leg from a terrible injury in a terrible accident. Took in nine months to recover and he recovered home. My wife and i went to school, took lessons in how to clean ports and put down body drips so we could fight infection in his bone marrow while he recovered at home. Since 1989, overtime reimbursement for anabolics with Home Infusion went away. There was a drive to drive everyone into the hospital to recover and not as much reimbursement to encourage people to stayathome. Senator warner worked closely with us to again reimbursement. I hope you will work with us to see that we can extend coverage to get Home Infusion wherever possible so we can have more people recovering in a less expensive more hospitable environment than a hospital. This is important because what we find, health care and in dynamic. It changes all the time, so what used to be able to be done only in a hospital count often times be done as outpatient or in recovery at home and home and communitybased services are imperative to have the flexibility to do that. One of the things we are trying to concentrate on from a waiver standpoint in many different programs as well as trying to incense the flexibility within existing programs so we can cover those treatments in not necessarily just in the menu previously selected when that was the standard of care, but because it works better for the patient. Lastly, i want to discuss what you said about experimenting to see our medicaid coverage is available in robust bar citizens. Your stay and my stay, georgia, we have 1. 9 Million People on medicaid, 1. 3 million our children, 50 of the live births in georgia are paid for by medicaid, so as we go through the reforms necessary we have to remember we are talking about first and foremost in our state and others children who benefit from those programs being robust or hurt and i look forward to working with you to continue to provide the coverage necessary to incentivize the program to meet the needs of our children in georgia. Thank you, senator. Thank you mr. Secretary. Thank you, mr. Chairman and welcome, secretary price. There are semi things i would like to talk about , debate you in terms of what has been said and the positions of the administration, but i want to start with a very important basic assumption that you have made and that is that global care act is long apart, zero my gosh look whats happening we do Something Different because its falling apart and yet we know to me is like pulling the rug out from under someone and going zero my, my gosh they fell down. We have seen consistent moves by the Administration Whether they are cutting in half the number of days that citizens have to sign up for insurance, whether its no longer aggressively doing outreach to younger, healthier people to make sure everyone is in the pool so cost of coop or whether its doing whats been done to take away the commitments made to the Insurance Industry to make sure they would cover preexisting conditions and having no limits. Laid out this morning in the Washington Post when we look at the question of whether or not the white house is going to let the Healthcare System die and i want to just quotes a little bit in there because this is coming from the industry , the biggest source of industry anxiety right now is whether the administration will continue to fund costsharing subsidies that help 7 million americans with plans and copays absent that funny and i dont know if we will have much participation in the Exchange Market in 2018 said tennessee insurance commissioner, a republican who also serves as president elect of the National Association of insurance commissioners. The uncertainty is one of the top reasons insurers have cited when explaining why they are posting higher rates for the next year or withdrawing from markets altogether. Two weeks ago Blue Cross Blue Shield of North Carolina filed a rate increase of 22. 9 and they said it would have been a. 8 , not to 22. 9 if the administration had committed to paying and basically keeping the commitments that were passed as part of Health Reform and finally on tuesday anthem Blue Cross Blue Shield announced its pulling out of the federal exchange in whole ohio. The president seemed to cheer that in yesterday i dont know why we are cheering that people will have less opportunity for healthcare. If we spent a 10th of the time that has been spent undermining the Healthcare System working to make it better, we would be making terrific strides to lower costs for people. Here is what North Carolina chief executive Blue Cross Blue Shield, we have to take a snapshot in time which is right now. A lack of action by the ministration, he added, with the results we currently see, higher premiums rather than lower premiums, so my question, mr. Secretary, is why do you believe its in the best interest of American Families to sabotage the Healthcare System that is today allowing American Parents to take their children to the doctor . Let me just correct a few statements. No one is interested in the system dying. We are interested in making sure the system works for patients and families and doctors then why are you not willing than two indicates that as long as we have the system we have you will keep the commitments and reimburse the Insurance Companies so they have 30. No one is interested in sabotaging the system no one is cheering the challenges we have in the system. In your state alone, premiums were up 90 before this president came into office. Of the number of insurers were down before this president to came into office. In your state that i can assure you after meeting with the Blue Cross Blue Shield of michigan they will file to rates, one if the administration keeps their commitment and what if they dont and if they dont they will be much higher and so i think the question is why wouldnt you keep the commitments made . I understand you have a different view in terms of what the system should look like, which i disagree with, but in the meantime you have insured insurers that are saying the reason the rates are going up is because of uncertainty and the instability created by the administration. Why is that a good idea to make action, if you read further in the article it talks about the increase in cost and dean decrease in insurance across the country before this administration came into office, so we are trying to fix the challenge that we have i have more questions for another round, but lets start by making sure the administration is keeping the current commitments, following the current law and the debate should happen next. You have enough time to answer that did you have enough time to answer . Yes. We will turn now to senator cassidy. K, doctor price. Hey steven a couple things im encouraged by inner budget. We put in a bill regarding direct primary care last year and for those unfamiliar, you and i know the way you lower cost is to empower the patient physician relationship so it the patient has a problem instead of going to the er she can call her physician and her physician can give her the advice. Drug primary care is a relationship so theres more investment that perhaps the other relationships out there, say an Urgent Care Center where you may see the person once and never again. I like that because it can decrease [inaudible] by decreasing utilization you decrease healthcare costs and ultimately you dont decrease the cost of insurance any comments on that direct primary care model and how you plan to make that . Its incredibly helpful program and gets to the point of the dynamism of healthcare. The opportunity individuals may have to be able to have a personal physician, primary care physician in all settings across our health system, i think, would be beneficial to the ability for that patient , that individual patient to get the care he or she needs. Right now you cant do that and so what we want to do is to move towards a system that allows for more Personalized Care the direct primary care model is when i think zeros promise. Let me talk a little bit about the per capita limit or just a little history for those who may not know, but it was introduced by president clinton as a concept and senators phil gramm and Rick Santorum simultaneously as a way to a line incentives between the patient, state and federal government. I think we are seeing almost a modified version of that as states are going to Medicaid Managed Care oh mining incentive between the state is a pay or within medicaid care company in the patient. I guess the way i look at that per beneficiary payment because as you know i introduced a bill in 2010 i dont know when it was that brushed off the phil gramm bill clinton proposal and updated it, if you will. The incentive between the federal and state government. Exactly and its own port because as you know having taken care of as i did medicaid patients in our practices, the medicaid population is not a monolithic population. They are individuals who are healthy moms and kids and also individuals who are seniors, low income seniors and disabled, blind and disabled individuals and all of those individuals need to be treated uniquely because they are unique individuals and what we do as a system by and large is a you have to take care of every one of those people the same way, which doesnt allow for that dynamism and flexibility in the program so states can deal with their Medicaid Programs to deal with their population. I dont know if this is in the hospital, because the way we do it is different than the house, but an example of zero mining incentive, as we know right now if states recover waste, fraud and abuse they have to give back to the federal government the portion that taxpayer put in, so if its a 60 federal government, 40 state, 60 goes back to the federal government and that works to disincentive eyes the state to go after waste, fraud and abuse because they have to give it back. But in the model we put forward the state would keep 100 of waste, fraud and abuse aligning the incentive for them to ring out that waste, fraud and abuse. Those modifications and improvements to a system that i believe we ought to all embrace because its those things that will then allow us to align the incentives as you suggested and also make certain every individual in that interaction is working for the benefit of the patient, making certain there is not the fraud and abuse in making sure and the patient is able to see the physician they want to and make each of the patient has the treatment they desire. Under the mac act which i introduced we have Incorporated States like california actually get more money and some big blue states actually do well. Florida does better, so in terms of having more dollars for certain categories of patients to improve healthcare, so when i hear folks condemn it without understanding it i feel like it could be incredible missed opportunity to align incentives, improved patient care. I look forward to working with you and hopefully the folks on the other side of the aisle. They give mr. Chair. I went to begin by commending you and senator grassley for something you did gosh i want to say 24 years ago you cosponsored legislation authored by senator chasing called for creating exchanges in every state. You called for not only exchanges and marketplaces in every state, but also to say that in order to make sure the Insurance Companies have a healthy pool of people to ensure that there be an individual mandate that people needed coverage. Cant force people to get coverage, but you got a get coverage and find them some out if they didnt. I went to congratulate you on cosponsoring legislation that provided employer mandate and also provided for the idea that insurance cannot, you know, deny coverage to people who have a preexisting condition. All of that all of those ideas are part of romney care in massachusetts and all of those are part of the reportable care act and part of the a portal care act that republicans seem to like the least are those ideas. There is real irony in this. I like those ideas. I studied economics. I like Market Forces and making them work. You came up with a good idea 1983, and i just wish you would work with us to try to make sure that those good ideas the reason why the marketplaces are failing light places like you mentioned in ohio in your statement, mr. Chairman, the reason they are not working as we basically undermine the individual mandate so people dont know if they need coverage. Young people arent. We have taking off the training wheels, so to stabilize the marketplaces in Insurance Companies lost their shirt in 2014. Light they lost less money 2015, it got better. They raise their premiums, copays and deductibles and did better. Rather than the marketplaces being a dust pile at the end of 2016 they are actually recovering until a new administration came in and said we are not sure about 4c8 individual mandate and we are we dont know if we will extend the costsharing arrangement providing lack of certainty for Insurance Companies. So they raise our premiums more. The very ideas these guys came up with 24 years ago if i can and truck a second, those were ideas that were part of the anti hillary care bill. They were good ideas and i commend you for them. If my life depending on what hillary care did i cant tell you, but i know what your bill did and they were good ideas and now, we are undercutting them. Y . Doctor price, why . Limit senator, i appreciate the observation. I would add to that that there are significant challenges out there and there were so before this administration started. In your state alone premiums were up 100 before the administration started. In your state alone there were fewer insurance, is offering copies ought on the exchange before this administration started, so we are trying to address the individual and Small Group Market that has seen increases in premiums and adjustable what are you doing how are you stabilizing the marketplaces . The 3r, what are you doing on those, insurance, risk adjustment, what are you doing their . We put in place a market stabilization earlier this year that identified the special enrollment grace period to make sure they were more workable for individuals and Insurance Companies and allow the states greater flexible be in determining what a qualified health plan was creating greater stability for the market. We put out word to all governors across the nation on both 11th 15 and 1332 waivers and suggestions regarding what they can do to allow for greater market stabilization in their state and we look forward to working with you and other senators to make certain all those individuals, not just in the Small Group Market, but every american has the opportunity to gain access to the coverage that works for them and their families. When i came to congress a long time ago i used to think medicaid was healthcare coverage for mostly women with children, poor women. You know where we spend most money . Most of the money is for old people in Nursing Homes and a bunch of them have dementia and when we talk about cutting 800 billion its not just poor willie mae children that will get hurt, but old people and a lot of people between the ages of 60 and 65, veterans with their only hope of getting access to medical care because they dont qualify for a ba coverage medicaid. Mr. Chairman, here is an idea. I extend this idea with good intent. I spent 18 years as a governor. I love being part of the National Governors association. The governor of michigan and i used to come here and we would testify and welfare reform and save these are the views of the governors. This is what we think we ought to do. At this is an issue that cries out for getting governors to sit at this table and say here is how this will affect and this is why the way the system works or doesnt work. This is why we like the idea. Thats what we ought to do and i would say the 13 folks that have been picked to help the alternative [inaudible] that is something that could move us towards a compromise and get things done. Thank you for joining us if i may comment on that because his support for people to appreciate the work the department is doing. We met with the National Governors association with governors on both sides of the aisle to solicit their input and the kinds of suggestions they would have regarding 1115 and a 1332 waivers, so we are doing all we can to try to make certain states are able to address the challenges. Doctor price, to be clear when barack Obama Left Office was it a Perfect Administration . No. When he left office there was an insurer in every county of every state of this country. Thank you. Secretary price, thank you. I have heard your commitment to make sure you will do everything you can to help all people in this country to get access to home call the healthcare. That is something we all agree on. Thats what we want to get done. I want to get to some of the practical problems here. I was in federal spurred on monday, closer to where senator carper lives than i do. Very little community. They dont have the same access to Healthcare Providers we have in our urban centers. I visited the Elementary School Wellness Center where we had the qualified center that provides direct services to our children within the Elementary School and they are capable of doing that. For many of these children it is their only real ability to get access to primary care and you have someone who can check up on their health. Is able to do that under current law. They tell me as legislation is passing from the house to the senate that that direct reimbursement would be cut off. They also tell me that if they cannot continue their flows through the Medicaid Program that they will clearly not be able to continue the services they are providing today in Caroline County. So, my question to you, i understand your commitment to help all areas. Today our qualified centers are providing lifelines to many communities. They rely upon creative ways in rural areas to provide care including within School Settings and they depend greatly on the reduced number of uninsured and those covered under the Medicaid Program for comprehensive reimbursement to maintain their presence, so how do we ensure that as we go through this transition that the administration is talking about that the children in Caroline County will be able to continue to get their Health Care Needs met . There are significant challenges in that rural areas of our nation for the provision of Health Services and those have been present for long long time. There is a strong commitment on the part of our department and the part of the president to make sure rural Health Services are available, so whether its through grants to the state, through an opportunity for various Health Programs within schools or elsewhere to make certain children have the kind of healthcare and not just coverage that they need then we are absolutely committed. One of the things our budget includes is something called a new American Health block grant which would provide resources to states to do just this sort of thing, make certain that folks in rural areas of states have the opportunity to gain the coverage and care that they need, so i look forward to working with you to make certain we are able to make that happen. The other area i want to cover and you and i talked about in my office during the confirmation process and i will bring up again today is i want to know your commitment to deal with Minority Health and health disparities. We have separate agencies today to deal with it. In institute at nih and as i go around to look at some of the historic discriminations within our healthcare and recognize that healthcare is not equally available and our focus has not been to all communities equally and we are trying to compensate for that today, i worry about what you are doing a medicaid particularly. Every Minority Community i go to, they mentioned to me medicaid and that there is no capacity at the state level to pick off the slack if the federal government withdraws its commitment either in the numbers of people who are covered or in the benefits that are reimbursed. So, how do you square a commitment to continue down the path to reduce Minority Health disparities in this country and the not only the reduction in the bill that passed the house, but also the president s budget with such a large cut it medicaid . Its important and i cant remember if i mentioned in this committee for my confirmation hearing or in the other one in the health committee, but disparities in Health Outcomes are absolutely unacceptable to all because what we see and its not just necessarily rural versus urban. There are areas within urban centers and i know of one in atlanta where there is a zip code where the Health Outcome disparities are astounding in the mortality that exists, that dish addiction that exists in chronic disease and that is not because of lack of Services Close fight because its in the center of the city, but imagine if you would a system that allows for Medicaid Programs in the state of georgia to provide increasing resources to that zip code to provide a case manager for every single individual in that zip code who has a chronic disease within the Medicaid Program. That is now not possible. You cant do that and that is the kind of partnership i think is so incredibly important to make it so we identify those folks that need greater assistance because there are if we ended the disparities out there which you and i both have a commitment to ending. Im all for flexibility for the state, but i also know the pressures on state budgets and i know in my state of maryland where our governor and legislature has been pretty aggressive in helping the medicaid population cant pick up the slack. The waiver wont give them what they need in order to be able to make the type of commitments to underserved areas. Thank you, mr. Chairman. Okay. We will turn to let me just see here. Senator casey. Thank you, mr. Chairman. Secretary price, good to be with you this morning. Want to start by referencing a letter that i and i guess 14 other senator said to you recently about the house bill, hr 1628, but in particular i want to reference a Congressional Budget Office report that just came out on the 24th of may, a nonpartisan report by both the Congressional Budget Office assisted by the joint committee on taxation. I just delivered to the table next to you there a copy of the cbr reports so you can go to the page. I direct your attention to page 17 of the cbr report. On that page the following statement is set forth are, quote Medicaid Enrollment would be lowered throughout the coming decade culminating on 14 million fewer medicaid enrollees by 2026, a reduction of about 17 from current numbers. It then references this chart, which you see on page 19, showing the numbers going down for medicaid over that time period between 2018 and 2026, all the bars going down. I reference that in the context of what you said on cnn on may 7. Quote and im quoting you now and the transcript is in front of you, quote there are no cuts to the Medicaid Program unquote, thats what you said. Do you still stand by that statement you made on cnn . The Medicaid Program under the president s budget would increase secretary price, yes or no. You can explain after that, but yes or no. Do you stand by that statement you made on may 7 . Standby, its a statement that do you stand by that statement . I think whats the baseline . Do you stand by that statement. Whats the baseline . If there are no cuts you see that statement in front of you. Yes, i stand by that statement. The baseline is relative. Its the amount of money spent on medicaid. The president s budget provides for an increase, cpi medical or cpi medical plus one in medicaid spending for the program. So, youre saying the statement on the cbr report is not accurate . Im saying that statement the cbo made it doesnt include the constellation of activities within the administration regarding how we would move forward on healthcare. Cbr says there will be 14 fewer medicaid enrollees, so that is one. Do you have the cbo report on the aca when it was proposed in 2010 because what they said then was 5 million individuals talk about the House Republican bill that was passed. Thats what we are talking about today. Im talking about with the cbo did because they had a similar grants and in fact they were let me direct your attention to the same cbo report you have in front of you, page 13, the top of that page says the following. The introductory sentences a reduction, quote the total deficit reduction includes the following amounts shown on table three at the end of the document. The first bullet tender that is quote a reduction of 834 billion in federal outlay for medicaid. So, do you still asserts in light of that and in light of the previous cbo statement do you still asserts that there are no cuts to the Medicaid Program . You dont understand it depends on asking you to do is whether you stand by that. I stand by that. Finally, let me go to a statement that was made in the cbo report. Now im going to page 19 and 20 in front of you hurt at the bottom of page 19, the following is set forth. Quote under the act meaning under the republican bill passed in the house, under the act premiums for older people could be five times larger than for those younger people in many states, but the size of the tax credits for older people would only be set twice the size of credits for younger people and as a result and heres the first bullet point, for older people of lower incomes net premiums would be larger than under current law on average and that refers to table five at the end of the report. So, i ask you that in the context of another statement you made. Of this is meet the press in march, march 12, quote he said no one will be worse off financially as a result of the bill. Do you stand by that statement . I dont believe that statement was in reference to the bill, but a reference to the Healthcare Plan we put forward and i stand by that statement. Senator, your time is up. I hope you focus more on not just the proposed reforms you talk about for medicaid. I hope you focus on people like the 15 million americans that get medicaid because they have a disability. We are all for discussion about making programs better, but i think you should focus more intensively on this people and be truthful when you are commenting about something as important to america as the Medicaid Program and i would argue, sir, you have been deliberately misleading based upon the statements. Senator, with respect that is precisely what we are focusing on. Of the American People understand and appreciate that the Healthcare System we currently have for many of them is not working, many of them in the Medicaid Program its not working and what we are trying to do and we would love to have your support, what we are trying to do is to make certain we have a system that response to the wishes and the needs and it healthcare needs of all americans. We all agree on that, but i think you have to start being straight with people about what will happen. These are major cuts. The cbo said in more ways than one and i think you should be truthful. Senator mccaskill. Thank you, mr. Chairman. Let me start by saying us senator grassley i have a Great Respect and admiration for, so my first question i would make of the chair is will we have a hearing on healthcare proposal . Will we . Yes. We have already had one. Know, on the proposal you are planning to bring for a vote. Will there be a hearing . Well, i dont know there will be another hearing, but we have invited you to participate amber your ideas. Mr. Chairman, lets me just to say i watch carefully all of the hearings that went on on the a formal healthcare act. I was not a member of this committee at the time although i would have liked it to be. Senator grassley was the Ranking Member. Dozens of republican amendments or offered and accepted in that hearing process and when you say that you are inviting us and i heard you, mr. Secretary, just say we would love your support, for what . We dont even know. We had no idea what is being proposed. There is a group of guys in a back room somewhere that are making these decisions. There were no hearings in the house, i mean, listen, i know we made mistakes on the Affordable Health care act, mr. Secretary. One of the criticisms we got over and over again is that the vote was part of sent. Well, you couldnt have a more partisan exercise than what you are engaged in right now. We are not even going to have a hearing on a bill that impacts one sixth of our economy. We arent going to have an opportunity to offer a single amendment. It is all done with an eye to get it by with 50 votes in the Vice President s. I am stunned that that is what leader mcconnell would call regular order, which he sanctimoniously said would be the order of the day when the republicans took the senate over. We are now so far from regular order that new members dont even know what it looks like and i know that doesnt make you happy, mr. Chairman or senator grassley because you have been in the senate so long you know the value of the hearing process and the amendment process and even though the vote ended up being partisan just as yours will be, the amendment process wasnt. Both of you had a amendments put in that bill. As did other members of this committee. I want that opportunity. Give me that opportunity. Give me an opportunity to work with you. That is what is so discouraging about this process, so mr. Secretary, went to ask you, a 27year old young man that lives in Jefferson County and he is finally making enough money to do one or two things. He can either by a Health Insurance policy or a new harley. Which do you think hes going to buy . You tell me. I think hes going to buy the new harley because he feels young and invincible and he wanted a harley his whole life. He buys a new harley. He lays it on the pavement on the interstate, and 18 wheeler cuts him off. Do you believe that hospital should treat him . Absolutely. We have an obligation to do so. In america, we treat you whether you are insured or not; correct . Yes and there is a mandate that he buy insurance right now. You are going to do that. In your scenario, is it working . Thats not my question. Thats my question. He does not have to buy insurance, he buys a harley, life lighted to a hospital and we deliver 3 million worth of care. My simple question to you is who pays for it . Sadly, its spread among the entire system and frankly, no one pays for it from the federal government standpoint. Correct, so people pay for it . Or people provide the Services Without compensation. They have to make it work at the end of the year so the hospital called Insurance Company and said we had ask amount of uninsured care so we have to raise your prices and then that insurance come he calls the smog business down the road and said i have that business we will have to raise your premiums because the hospital is costing us more. In your states premiums were up 145 between 2013 and 2017. That is not true. Yes maam. We would be glad to show you the numbers. I would be glad to debate you the numbers. When we have 24 million more uninsured, who will pay those bills . We wont be adding 24 million uninsured. You disagree with cbos report . Yes. Who pays the bills if anyone is kicked off medicaid . We are just passing along the cost to people that have insurance policies. There are 20 million individuals in america right now that dont have insurance under the Current System. I know and we are paying their bills by higher premiums and now, we will have even more uninsured. Okay, okay, your time is up. Senator grassley has been waiting patiently. You have done so much better than the rest of your colleagues. On the very proud of you. Senator grassley. Mr. Secretary, i only have one question because i had to run to another meeting, so im going to ask you this one question and submits other questions for you to answer in writing. The Rural Community hospital Demonstration Program was established in a bipartisan manner to protect patients access to healthcare. Of these hospitals are collectively called quote unquote tween errors and other bipartisan piece of legislation, 21st century cure act extended this program. The language was very very clear haircut the program was to be extended beginning on the date immediately following the last day of the initial fiveyear period. Despite this clear language, cms proposes to begin implementation of this extension on or after october 1, 2017. This gap and implementation is inconsistent with congressional intent, which requires a seamless extension of this critical program. Furthermore, it is inconsistent with the way the agency implemented the first fiveyear extension of this program. I have a bipartisan letter to administrator berman asking her to look at the alternative payment timing that was included in the proposed rule. I would like to submit a letter for the record, mr. Chairman, and by way you mr. Secretary were cced on this letter, so doctor price, its a simple question. I hope you can give consideration to this request in this letter because in several states, many states this is an issue particularly cruel states, one is alaska as an example and i hope you can help us make sure we have a seamless implementation of this program. My home state of ohio spent on fighting the Opioid Epidemic, 939 million my state spent. This charge came from Ohio Department of medicaid website, republican governor k6 website. In 2016 ohio invested 109 30 million in fighting this Opioid Epidemic. In over 70 percent of that total came from, 650 million came from, 650,200,000 came from medicaid. Despite this investment, despite governor kasich investing in education, medication assistance therapy and other treatment, the people today like most days, eight people in my state will die from an opioid overdose. 4000 ohioans died from overdose last year, we are on track to far exceed that number in some counties, weve already exceeded the number of the year before and this is only june. 43 people died in tioga county, the states secondlargest county in the state. 43 people since memorial day. This epidemic continues to devastate communities in my state. I agree with what you wrote in your testimony, were not winning this fight. But im confident we lose far more people, far more lives, far more people lives turned upside down if we werent spending this money, if medicaid were spending the 650 million. Dont take my word for it, to weeks ago, my colleagues both members of this committee, senator portman, my ohio friend republican senator parker. My delaware friend held a meeting about this hearing to discuss proposals, i want to quote from a couple people. The witnesses at the second panel of that hearing a doctor and the police chief from newtown ohio, one of the most conservative part of our state. He was a former head of drug control policy and the coroner from tioga county. All for voice opposition to either ending the Medicaid Expansion or cutting the program. These four experts brought by senator portman to his committee all said dont cut medicaid, dont eliminate or dont cut it or dont and the expansion. The tioga county coroner noted anything like Medicaid Expansion being eliminated that eliminates peoples access to healthcare, i cant see any good coming from this crisis and for that, i cant see any good coming from that in this crisis, especially with the high rates of mortality. The police chief from newtown ohio, a suburb near cincinnati, hes in the front lines, he said we should not be decreasing medicaid. He talked about one of the programs is teams are doing in Hamilton County signing people up for medicaid and getting them in treatment, sign him up for medicaid and you get treatment, 200,000 families in ohio are getting opioid Addiction Treatment who have insurance because of medicaid. Your administration continues to talk down, criticized Medicaid Expansion and suggests medicaid. He went on to say clicking away medicaid would make this bike more difficult. I dont want to imagine the number of Overdose Deaths we wouldve had in ohio if a republican governor, and im proud of what he did. Hes gotten criticism from President Trump and your party, if he had not expended medicaid. The Budget Proposal youre putting together cuts medicaid by 600 billion. In addition to the house aca repeal which cuts medicaid by 100 billion. Medicaid covers a third of all Substance Abuse treatment and communities across ohio. In ohio, it covers 50 percent of all assistance treatment. You sit in front of us, you have taxpayer funded insurance. We have taxpayerfunded Health Insurance. The 200 republican plus members of the house who have taxpayer subsidized Health Insurance are all willing to take it away from these 200,000 ohioans getting opioid treatment. Your policy proposals, you say you are interested in fighting Opioid Epidemics. Your policy proposals tell a different story. You fund Substance Abuse treatment grants, you reduce spending on prevention programs in the National Institute on drug abuse. You cannot treat the disease with just grant funding, you all of a sudden say we can do all kinds of things with grants, you cant compared to the size of this problem. Its like maybe you dont know might be i dont want to go there. I think probably senators dont meet enough people in these programs that are benefiting from them but you would never propose that we fight cancer and take cancer treatments through a 50 million increase in the Grant Program. You said in a recent oped and charleston gazette mailed it, increasing access to Substance Abuse Disorder Treatment including medicaid assisted treatment as part of your departments plans to address the opioid prices. What you are not telling to your West Virginia leaders, Donald Trumps secondbest state in the country, youre not telling them what youre doing so my question is and im sorry for the preface but how do you plan to introduce access to treatment when you got the single biggest source of funding for treatment by 600 billion in your budget. Is that possibly add up in the trump map, trump price map of 2017 . You know i visited your state, the Southwest Corner of your state to visit with victims of opioid addiction. The parents of kids who died, one told me about her son who died in the bathroom of a macys. From an overdose. These cards that we have running across this country right now is absolutely unacceptable to you, unacceptable to me and the president. Our commitment is to make certain that what we put in place is a program that actually works. You see the graphs. The numbers continue to go in the wrong direction so if we are going to be married to a system that has resulted in 52,000 Overdose Deaths in 2015, thats not a system i want to be married to. But i commit to you and i look forward to working with you on is a system that works for the parents who are suffering today because of the loss of loved ones but i admit to working you want is a system that works for those who are addicted who want to gain recovery and treatment. So thats the system that i look forward to working with you on and whether or not it is paid for through the medicaid system or whether its paid for through a system that isolates the individuals treatment for addiction and takes it out of the Current System that we have so that we can focus resources on those individuals that have the addiction. Imagine that system, that would do for the ability to treat those folks and two, the ability for the system to try a better way elsewhere. Imagine a system that works better than the one that results in 52,000 americans dying. Im serious that you blame medicaid as you seem to be doing for the system that has resulted in 50,000 deaths, not because of medicaid. How do you do this when you hundred thousand people right now are getting treatment in my state, and treatment. Not all successful. People are in and out and it often takes three or four times but if you cut medicaid as you want to bludgeon medicaid, you can talk about the Grant Program and all this big talk and i know you mean it in terms of running to take care of people, i know all that but how does this possibly work if youre going to cut the biggest revenue stream that takes care of these families and putting them in these treatment programs . Youre aware of your time senator. Im going to to senator cantwell. Go ahead. Thats what im trying to encourage us to look at. Is a system that works for the individuals are suffering from this addiction. The system that focuses attention and focus his treatment on it, a system that recognizes that we need Greater Health valence, system that recognizes Pain Management is flawed, a system that has not put the resources and we can turn this curve in an appropriate direction itches down. We continue to tolerate a system that allows for the kind of addiction and Overdose Deaths in this nation. Its unacceptable and i wont stand for it. Enter cantwell. Thank you. Secretary parker, i have a couple of questions area theres been pressure for the Department Working on a rule that would deny Birth Control for employees. Are you aware of this . Theres a proposed rule that out currently and on on Conscientious Objection and contraceptive bandaids. Youre proposing that you allow employers to discriminate against women and having Birth Control be part of an insurance policy provided by employers . Was currently occurring his solicitation of input in this process. Im not able to make any further comments. You cant make a comment whether you think that Birth Control should be part of basic health offered in insurance plans . For women who desire Birth Control, it ought to be availables are you promulgating the rule . Theres a rule that has been put forward. So you think that employers should offer Birth Control as part of insurance programs, not be able to just say on a conscientious basis they dont believe in providing it . I believe women who desire to have access to Birth Control ought to have access. Through their employer . I believe women that want to have access to Birth Control ought to have access x this is a very big problem. Women cannot be discriminated against by their employer who wants to cherry pick various aspects of Womens Health so this is the intent of this rule, i guarantee there will be a big fight on this issue. I want to ask you about proposed medicare cuts because i know the administration they were going to cut medicare but my understanding is that the budget includes a twoyear extension of mandatory sequestration which would impose a two percent cut on medicare provider such as hospitals and rural hospitals, the extension of the mandatory sequester would be a 30 million cut from the medicare program. Does your budget include that . I think what youre referring to is the continuation of current law and the budget accommodates or reflects current law. So youre saying that the extension of the mandatory sequester is not a cut to medicare westmark. Again, its the same kind of question mister casey had. Depends what your baseline is. If your baseline is current law, there are no reductions. So you believe we should be making these reductions to rural healthcare facilities. I believe what we should do is make certain we have a Healthcare Systemthat is financially viable and feasible and makes it so the American People haveaccess to the care they need. And you think , so your behind the cut. Ill take that as a yes, your behind this particular cut and i would just say that our rural hospitals are struggling to make sure that we are providing good care. Theres lots of efficiencies with the delivery system. I had a chance to ask you about this issue of rebalancing on the Medicaid Budget and i dont know if you had more time to look at, a rebalance from nursing home care to care, thats something we wrote into the Affordable Care act and is a huge savings to the budget, is that something that you think the administration can get further behind . As i mentioned, the dynamism of the Healthcare Market is so important to embrace because we ought to be allowing an accommodating in our system for individuals to receive care where it best suits them and their providers though youve identified an area where we want ought to be able to accommodate that and the system should allow for it. Thank you mister sherman. Thank you, senator nelson . Thank you mister chairman. Good morning mister secretary. Mister secretary, i want to ask you for clarification, things that are in the budget. In your proposed budget. Something that weve heard a lot about are the costsharing reduction subsidies. 72 percent of floridas Affordable Care act consumers benefit from these. And thats why im asking. Now, its hard to get a clear answer on this. The private market, the private market providing under the exchanges cant take the uncertainty of knowing whether or not the subsidies are going to be there. Insurers have confirmed this to my questions when proposing rate hikes or even pulling out of the markets. Because of the uncertainty. So can you confirm that the administration will continue to reimburse insurers for these subsidies that help so many of my constituents see a doctor. And i notice it in your budget through fiscal year 2018 what should we believe . As you know, this answer may not prove satisfying to you but the Current Court case is now house the price. So im the defendant in that case so what i can tell you is just what you said and that is that the budget reflects the payment of the csr payments through 2018. So does that answer mean if the court case went in the favor of the administration that basically those subsidies would be caught . What i can tell you again, and id like to be able to share more but as the defendant in the case im not able to do so but i can tell you as you noted that the budget accommodates and reflects payments for csr payments through 2018. And the unfortunate dilemma is, mister chairman, that because of the uncertainty, it predicts an outcome that the aca, the Affordable Care act is in the exchanges, which is bringing Health Insurance to millions and millions of people that otherwise could not afford it. The uncertainty of whether or not those subsidies will be there in the future, in fact is undermining the ability of the insurers to be able to project what their premiums are going to be and therefore to protect themselves what they are doing is jacking up their premiums which is undercutting the whole reason for having the subsidies in the first place. Let me shift to the seek a virus. As we discussed, you know there are a bunch of cases, 1400 in florida alone. And your administration 2018 budget states and i quote, outbreaks like zika will not be a one time event. Capacity building at all levels as well as innovation and diagnostics needed to prevent and control these outbreaks and understand more about the vectors,. Yet the administration is the very programs designed to bolster capacity at all levels. So mister secretary, does your budget cut more than 7. 2 billion from nih . As it relates to zika i cant tell you how proud i am of the work weve done at nih to work on a vaccine. Were in the phase to be trials of the vaccine. The cdc is doing phenomenal work to make certain the surveillance and detection is out. I understand all that. We believe the budget accommodates for handling any challenge that may exist from the zika threat. I understand that the question is 7. 2 billion from nih . The proposed budget identifies reductions we believe can be accomplished at nih and savings accomplished by increasing efficiencies and making certain that we have the core mission of nih accomplished through the resources that are made available. Right, efficiencies are great but i want to know black or white, doesnt cut 7. 2 billion from an ih . The reductions, i think your number is accurate. It depends what the baseline is but i think the number is accurate. Wait a minute mister chairman. Ive got a couple other questions, just simple yes, sir no questions. Why dont you go ahead but your time is up. Iunderstand. I want to get a yes, sir no question. Go ahead. Thank you. Doesnt cut more than 600 billion from the Medicaid Program on top of the cuts included in the house passed Health Care Bill . No. Your budget does not, okay. Does it cut more than 1. 3 billion from the cdc . Is a 10 percent reduction in Resources Available to cdc through appropriate priorities and identifying efficiencies within cdc, we believe strongly that the cdc budget is what is needed to continue to protect not just the United States but the world. Is that yes, it cuts 1. 3 billion from cdc . What it is is a statement that affirms the president s desire to get folks to appreciate that you dont measure success of the program by the amount of money going into it, you measure it depending on what the outcome and the mission is accomplished and if we can accomplish the mission, the appropriate mission with less resources than one would think that would be something to celebrate. Mister chairman, i understand all the reasoning behind it, i want to know doesnt cut 1. 3 billion from cdc . As i said, theres a 10 percent reduction in resources going to cdc. Does not equate to 1. 3 mark. The number is accurate. Great, doesnt cut 850 million from fda . I dont believe so. The fda, what we envisioned in the fda has shifted the resources coming to fda and i think in fact theres a 500 million increase in resources coming to fda through a modification and an improvement in the user fee process. You are aware of your time, you can submit questions in writing, im sure the secretary will submitted. If its okay with you, i think i will yield to senator robert to spend your waitingand id like to go after him. Very gracious. We will go to senator roberts and ill come back. German, i wave. The 10th of an hour or five or six, what are we doing . Im assuming were under the five minute rule. I want to get in the weeds a little bit, welcome back. Good to be back. There are statements that you are responsible for people dying in ohio, all of the current problems in the Affordable Healthcare act over the last three years. Reductions in funding inrural areas which of course im very much interested in. The entire budget by the president proved to be more accurate omb and the chairman has been chided for not having regular order but what we have today is called cloture and delay, thats not regular order and i sort of lost the whole thing on the zika virus. Hindering infection of the zika virus, are you enjoying yourself . The job is a great challenge and im enjoying the challenge, yes sir. Im going to get in the lead here a little bit, in your prior life on the other side of the witness table, i know you shared my frustration with the implementation of the Competitive Bidding program. Im not going to go too much further into this except we do not have the providers that we use to have and people have to drive 150 miles with regard to medical equipment and access to it. Last year we passed the 21st century cures act which sought to reduce at least temporarily the impact of these payment changes so you deserve the intent of the program with the payment amounts, and reduce the beneficiary costs to the medicare program, do you think the agency needs to provide additional regulatory changes to its implementation and so on the one im trying to do is give a sense of whether legislation is needed . Legislation would be welcome but they moved in the direction of allowing the Durable Medical Equipment providers out there, the greater opportunity to provide services to their patients across the land. Which with regardless of whether legislation is forthcoming, the department is looking seriously at the issue of dna because we believe strongly that the Previous Program that has been put in place is limiting the access to appropriate services for folks all across this land, especially in rural areas i appreciate that. Ive been sitting here listening to my friends across the aisle with respect to their concerns, with reference to what is happening to our healthcare. I had a question that would be repetitive to the chairmans fear somewhere and you talked about it , whats happening with our premiums and our copays. Here it is, Blue Cross Blue Shield pulling out of obamacare next year and it offers less options. Kansas, a nationwide premium that double in three states triple and yet i hear my colleagues saying. , full funding if in fact we could do that. Funding what is not working. And i want to say that i heard maybe to a degree from what happened in trying to pin it on you is that its amazing, this is like blaming Butch Cassidy and the sundance kid for jumping off a cliff. To be more accurate, we are in the obama car and its a lot of typing in the same car with elma and louise and were going into the canyon. Weve got to get out of the car. And i think thats what youre trying to do. And i wish you well in that and i dont think youre responsible for the entire budget that has been proposed by omb, im not in favor of some of the things with regard to agriculture. He plans to change that, we hope to get a sound budget. I dont know of any time the senate has considered anybody that came seriously since reagan. So this other business of regular order, with regard to the chairman, i was here. During that whole episode when we put obamacare together. And days and nights and days and nights that started in the health committee, sitting on a shelf somewhere gathering dust. I had one amendment on the ranch and you know what im talking about and what happened with all the rest. It failed on a partyline vote and came here. And again, i had the same amendment, actually failed on a partyline vote and it went to the floor of the house. And went behind closed doors and the leaders saw this and sort of like charlie rick, sitting behind closed doors. And out came obamacare. And weve had eight years of this now. And i just think blaming you for all these deficiencies that we are trying to correct on a bipartisan basis has been over the top. And my time served has expired. That you and i endorse whatyou just said. Thank you mister chairman, i am grateful for you to hold his hearing. Secretary, its great to see you again. I wanted to start this by understanding the medicaid cuts or however you want to characterize them. But the numbers as i understand them are about 834 billion dollars of cuts in the house bill that house Health Care Bill and theres about 610 billion in savings or cuts to the Medicaid Program in the budget. Is it right to add those numbers together or is there overlap among those numbers . I want to make sure we are accurate. I dont believe its correct to add those numbers together and the budget from my understanding is the budget doesnt assume the house bill. My understanding is that itabsolutely does assume passage of the house bill. It assumes as it relates to medicaid , it assumes that what is put in place is a per capita block Grant Program that will reflect over a tenyear period of time a savings of 610 billion. If we could work together, id appreciate the opportunity to work with your staff to see whether in the end were talking about 834 billion or 1. 4 trillion. We need a huge cut to the Medicaid Program. Even if its 834 billion i think thats a 25 percent cut to medicaid. And i would ask you, i asked the Governors Office in colorado to tell me whos on medicaid in my state and heres what they said. Id like to ask you whether you dispute any of this. They said when you look at medicare in colorado, nearly half the program our children, does that strike you as probably right . Thats the ballpark. And more than 40 percent of our medicaid spending supports the disabled and seniors, many of whom are in longterm care facilities so these are people in general who had spent down their life savings for the privilege of being in a nursing home funded by medicaid, would you agree that thats right . It sounds higher than most states but i think its in the ballpark. Rough estimates. They said of the remaining adults on medicaid, the vast majority work but still cant afford Health Insurance on their own, does that sound familiar to you in terms of colorado or other state . Certainly individuals who have medicaid coverage who are employed. What they would say is that theres a tiny residual percentage of people that are , that are disabled, our elderly, our children and dont work but are on medicaid. Theres some small percentage. Is that, is that different from other states . We can get you the numbers for your state. That would be great but if you see any reason to dispute what i said . Here we have the secretary, and i appreciate your candor. The secretary saying that medicaid is not supporting a whole bunch of people that should be working and are working, would you agree with that . I think it varies from state to state. Certainly individuals are ablebodied without kids on medicaid who are working. But thats a small percentage of people. I dont want to have to walk back through the list. We agreed that this is happening and thats a small percentage so i think its important because this is the secretary of health and Human Services and hes not saying there are a whole bunch of americans out there that are lazy, that are on medicaid because they dont want to work. It doesnt comport with the evidence. Its not true and its certainly not true in my state so the question then comes if were going to cut the program by 25 percent, if you are running colorados Medicaid Program and i have a story ill share with your staff from the denver post yesterday or the day before, frontpage story about the 700 million a year by 2023 that the state is going to have to come up with to compensate for the withdrawal of the federal government, the medicaid production. Just the house passed bill, not your budget. What is your advice to us in our state about how we want to handle those cuts . Thats 700 million to our state . When 40 percent of the people are poor children, when youve got people that are in Nursing Homes, when you have a whole bunch of people working but unfortunately cant afford private insurance, what is my state supposed to do . I think again the constellation of programs that we would envision that would provide for greater opportunity for individuals to get Health Coverage as opposed to less right now, i would remind folks there are 20 million americans without Health Insurance, i dont know what the number is in colorado but theres a significant number of individuals that dont have Health Coverage and what i would envision his assistant response to those individuals who find it better for them not to be covered on the medicaid system but on a system that is more responsive. My time is up and with respect, i dorespect you a lot for your service in the house and the fact that youre a doctor, to believe what you just said , you would have to first disagree, you would have to first reject the findings of the Congressional Budget Office that the house bill throws 23 million off insurance. 23 million more people that dont have insurance. You have to believe that and you have to believe that a 25 percent cut to medicaid that covers poor children, people in Nursing Homes and people that are already working, cant afford insurance are somehow magically going to be able to buy Health Insurance under a system that no longer regulates the Insurance Industry, thats what we are being asked to believe and i can tell you this mister secretary and chairman because the republicans in the senate have not yet taken up the bill and i hope we will. If you set out to design a bill , less responsive to the critics of obama carein colorado , two republican critics of obama care, you could not write a bill less responsive than the house bill. My hope is that in the senate youcould not do it. My hope is that in the senate , we will not do this in a partisan way but we will come together, democrats and republicans, and address the Health Care System in a way thats believable to the people i represent. What you just said is not believable in any respect to people at home and im talking about republicans. To say nothing of democrats or independents. Senator heller, youre the last one. Mister chairman, thankyou. How are you . I dont want to be the last, let me just say, going and secretary, i guess im less. Okay, go ahead. Thank you for being here, thanks for taking the time and taking some of our questions. I want to talk a little bit about nevada. That will be the topic of discussion here. Our Legislature Just finished monday so as of two or three days ago, we adjourned for the next two years and one of the questions and comments being made is that if the aca in its current form came out of the house and path that it would put a 250 million annual whole in nevadas budget. And these numbers, im getting out of the Governors Office also from the state of nevada. I like your reflection on that, if its 250 million year, thats a biennium and we will go back into session obviously for another couple of years and their concern is they have to call a special session obviously in order to correct that kind of a budget offset. Do those figures sound accurate to you . I dont think so because in, again, the house bill doesnt anticipate it and i understand it doesnt anticipate any changes until 2019. So from a financing standpoint, 20 20 being the time when the majority of it, the changes would come into play. So we be happy to review the genesis of those numbers and see whether or not they are accurate and if so, how we can address that . If you had an opportunity to do some research on the matter, the reason i ask is because we had a member of our delegation on the house side that he had a conversation with you and the director of cms and between the two of you you were able to convince him that these numbers perhaps art is accurate or as dreadful as they came out of the Governors Office. Thats correct. What kind of reflection did you have, do you recall what conversation you had. I think they were specific language that accommodated that concern which is why i say i dont believe any changes would occur over the ensuing two years but i would be happy to talk with you and work with you and the governor and your state and see where they believe these numbers are coming from and determine their accuracy or not. What do you anticipate being the growth rate of healthcare costs over the next 10 years . What would you calculate it . It depends what population youre talking about. The medicaid population annual growth rate has been in the range of 2628 as i recall. Annually. Thats historic, what do you guys anticipate over the next 10 years . Ill get back to you on the specifics. I think its increasing a little bit but i can get you the exact numbers. Youre working with leadership on our side as we go through the changes. Im going to guess that leadership on our side has had discussions with you and cms in some of the particular changes we are working on. Thats including growth rates, i dont know what the growth rate is going to be, if its going to be cpa medical plus one as they did in the ah ca or whether its medical or replacement for that matter. Have you had discussions, im trying to find an answer to this question and i cant get it out of our meetings. I was wondering if you had any insight as to what the rate may be that we are proposing over the next couple weeks within the cbl. As it relates to medicaid the proposal in the budget is plus one for those aging and disabled. You still endorse that . If it was anything below that would you support it . If they went to inflation rates, would you support that . It depends what the entire program looks like. If we are accommodating anybody who would have challenges with that in a supplemental matter if you will, then id have to look at that. But what i support and what i think is important is to make certain every single american has access to the coverage they need. Cpi 1, for disability, what was the other. If that were to change, just to cpi medical or inflation, would you approve that . It depends what the entire program looks like. In isolation i think that might be a challenge but that doesnt address what the entire consolation of whatever the plan is or program is because there are other ways to accommodate individuals who need Financial Assistance and we are committed to making certain that happens. Over the next 10 yearswhat is the rate increase overall. Over the next 10 years. We will get back to you, i dont have it on the tip of my common. If its below that, would you have a problem with it . Tell mewhat it is and if we calculate , if we have pose a little less than that, would you oppose it . I think whats important in this conversation is to make certain that we accomplish the goals that we have set out. And that is to make certain every single american has access to the coverage they want and when you have that as your goal and it requires that you provide resources in an array of different ways to make certain that that is accomplished. I want to make certain that medical inflation as it increases over the next 10 years, the funding mechanism we have isnt below that because if it is we dont make sure that we dont meet your goals. I would agree. Thank you. Your time is up, senator. Thank you mister chairman, senator price, thanks for being here today. I appreciate the budgets attention to need to repeal and replace the collapsing Affordable Care act. The need for medical Liability Reform as well as the budget programs, we have a number of important issues to tackle in the healthcare space so thank you for your work. I wanted to, i discussed this with you and your confirmation hearing but i have concerns as you know about the Health Service and we continue to see problems even after two ihs facilities entered the systems Improvement Agreement with the center for medicare and medicaid services. Cms continue to find. Efficiencies both facilities with the pineridge Emergency Department and a media jeopardy status after a recent unannounced site visit from cns. These problems over the years are what prompted senators barrasso, holden and i to introduce the restoring accountability in the eye and ihs. The bill will get ihs the flexibility to terminate orally performing employees, relying hiring process so ihs henry to talented medical professionals more quickly and create incentives so those folks will stay on the job longer. My question is what will the department commit to working with us on this legislation in other reforms to improve the quality of care at ihs . Absolutely, ive been impressed with the commitment of individuals in ihs and the resources that we are trying to identify for new facilities. One of them as you know in south dakota to make certain we are living up to our responsibility and the commitment we have as a nation in the ihs arena but wed love to give you more tools to create the account kind of accountability we need. Our legislation accomplices thatso we look forward to working with you on that. You and i both work on legislation to address the application of medicare , Competitive Bidding rates in noncompetitive areas. The 20th century. Zach provided a delay in this reimbursement change and require the department to study and report to the committees of jurisdiction on how paint adjustments affect visionary access and that was supposed to have been done by january 12. And i just wondered if you could provide an update on the status of that report for the committee i think that it remains in process and we have a significant commitment to make certain that the dmv program is optional and works for folds across this land, especially in the rural area. I guess i would say additionally, as you discuss regulatory relief which i know is a priority for the administration and something we agree with, maybe what the departments approach might be for addressing these beneficiary access challenges that are posed by the current reimbursement of structure. Is there something you can do in the interim that would bring some relief . Absolutely. You cant have a system that rewards as you well know rewards contracts to entities that have never provided services in a geographic area. And thats a system that we currently have or that the words contracts to servicers or providers that have never demonstrated thecapability to provide that service. And badly, thats the system we have in place right now so what were looking at the entire array of dna systems and the goal is to make certain that all americans regardless of where they live have access to the kind of services with her its hospital beds, wheelchairs, whatever it may be in the dna space. These are qualityoflife issues for so many people and from my perspective, we had failed to date in making certain that we insure the kind of accessibility that folks need. Thank you. Finally, during your confirmation hearing we discussed cms 2009 rule requiring all Outpatient Therapeutic Services be provided under direct supervision which has been delayed annually since then for small and rural hospitals and you expressed an interest in working with me on a permanent extension of the nonenforcement of this policy. Im wondering if you have an update on where things can from the departments perspective, i think the permanent nonreinforcement is something thats part of the bill that we have out there and weve been trying to, we can kick this down the candy cheer or down the road but im hoping we can get a permanent solution so im wondering if you could tell us where you see things from your standpoint . Its an area of Significant Interest and i can tell you that its a work in progress. Well, we hope that we can get some permanent relief there and we will look forward to working with you on that going forward. Thank you mister chairman. Thank you senator simmons, senator stanford has a question or two and we will wrap this up. Thank you and first i want to thank you for your courtesy this morning and allowing us to have a thorough opportunity to ask questions and secretary price, thank you for being here. Theres so many issues that i continue to have great concerns about but when we certainly when we look at this budget that in practicality cuts medicaid and nursing home services, childrens healthcare, rural healthcare, research lifesaving drugs, i could go on and on but one type of cut that i know we need is not in this budget and thats a cut in the cost of Prescription Drugs. President trump repeatedly stated he wanted to drastically bring down Prescription Drug prices through medicare negotiation. Saying pharmaceutical companies were getting away with murder. I support medicare negotiation. I have for a long time and 90 percent of americans support that this budget doesnt include any major proposals to bring down the cost of Prescription Drugs, whether its medicare negotiating, the importation of Prescription Drugs, transparency or any other policy for that matter. Even though the prices, the most popular drugs have increased by 208 percent, 208 percent in the last 10 years. However, the House Republican Health Care Plan and i sent the senate one that was proposed, died yet on Companies Use 25 billion tax cuts, paid for by the people who are seeing their Prescription Drug prices go up. Given that this budget is the major policy document from the administration, is it fair to say that lowering Prescription Drug prices is no longer a priority . Absolutely not. We have at the department, the president has made this a priority and has charged us with making recommendations to his office on reducing drug prices and over the past six or eight weeks, weve had a halfdozen to eight stakeholder meetings with all sorts of individuals. We charged herself and fda and cms coming up with specific proposals to make certain we can provide the president with the most effective way to be able to reduce the increasing drug prices so no, its an absolute priority and we look forward to working with anybodys whos interested in holding down or bringing down drug prices for the American People. Should a family have to pay 700 for depends for their child . Regarding epipen, what occurred in the past is the ability for competition to hold down those prices or to bring down those prices was prevented by a previous decision through the Previous Administration so we are looking through the faa at those kinds of things. Because our goal is to make certain that the American People have access to the kind of medication they need a price they can afford. Which i was was in this budget because its not in the budget at this point but should someone who learns a half hepatitis see have to pay 80,000 to get the drug they need to be cured . Your identifying a drug that is saving lives. 80,000 in order for someone to have the opportunity to save their life. The question is what the right price for that drug. Is that the right price . Theres a way to determine that price and the question is what the right price and how do we make certain we incentivize innovation and make it so that in fact companies are able to identify these remarkable cures that are out there. I know how you figure out what the right price is. Im anxious to know what you think the right price is. If you have Cystic Fibrosis and need the latest join to improve lung function, should you have to pay 300,000 . What we ought to be doing is celebrating the invention and work individuals are doing to save lives in the Cystic Fibrosis. How do you celebrate that it is difficult if someone cannot afford what is put forward on the market so we certainly celebrate innovation, that innovation needs to be affordable so that people actually have access to treatment and that can save their life. I would agree. Is it appropriate to give pharmaceutical companies a 25 billion tax cut in the healthcare reform bill when theres nothing to bring down the cost of Prescription Drugs in that bill . Regarding whats in that bill, im not sure. Im talking about the tax cut, do you think its appropriate to get a 25 billion tax cut to the pharmaceutical industry in a bill that actually taking away healthcare from people and does nothing about lowering the cost of Prescription Drugs . I dont know if thats what it does wax i do know thats what it does. And you do but i do believe it is imperative that we have a system in place that incentivizes innovation so that we can realize the remarkable productivity and entrepreneurial ship and innovative spirit of the american scientists at nih and elsewhere who are discovering these wonderful kinds of drugs to save lives. Iagree with that, you think the industry should be spending more on r d today and they spend on advertising drugs . I think again, the system needs to be such that incentivizes innovation so that we can realize the benefit of wonderful inventions. For the record, all those ads are written off and we pay for them as taxpayers. I love to be helping them right off much more on r d and mister chairman, let me just say that for the record we dont have to debate it today but mister secretary, you talk about a study over and over about prices and i want for the record to say this is highly disputed. This is a study youve been talking about that compares two different kinds of systems. It doesnt include the tax credits that have substantially brought down costs, outofpocket costs for real people so another day i look forward to debating you with what i know in michigan are very broad numbers. Let me say that ive been in this healthcare business for 41 years. And every year we demand more and more money, more and more spending, more and more federal government, more and more interference, or in more intrusion and we wonder why it costs us so much. All i can say is weve never had a better secretary than you. Nor have we had anybody more patient and answering all these questions. I want to thank you for participating the way you have. Especially want to thank you secretary price for attending today, we can all agree that this is certainly not the most enjoyable activity that you could have participated in today but it is nevertheless extremely important and my colleagues, these are quite important questions theyve asked. As i said before, id like to work with anyone, republican or democrat who would like to resolve these pressing issues. Healthcareis no joke. Any american and to those with diminishing access it means the world so i look forward to hearing from each of you in the coming weeks and i hope we can find ways to work together. For any of my colleagues who have written questions for the record i asked them that they submit them by june 15. I dont mean to interrupt. This is going to have to be it. I dont have any more time. You have questions . Ive been waiting for two hours, thats okay. You use 10 minutes before class nine. He came in large part so we can answer one of my questions. I just want to say one thing if i could. Mister chairman, i mentioned earlier my colleagues get tired, doctor price , i describe myself as report recovering governor but ive enjoyed as a governor sitting right where youre sitting and trying to provide a governors perspective on issues like this one area and one of the things we ask for when i asked for welfare, we said yes the opportunity to have waivers. He was the opportunity to apply for waivers on what were going to do on welfare reform. And that was granted. When we did the race to the top for education reform stuff, we said lets make sure the state can apply for waivers and we did. As it turns out with medicaid, if im not mistaken, states can apply for rates, maybe every state has at least one or more waivers with medicaid. In some cases in the law, you cant get a waiver, states could not get a waiver and i think we ought to have a good discussion with governors about whether that makes sense or whether they should be broadening with respect to waivers. I always like to have some flexibility to find out what works best in my state, but i think that could be a helpful thing to do. The other thing i want to ask, something here from blue cross and blue shield, premiums rising 2018, for healthcare and ill say this one sentence, the single biggest reason this is Blue Cross Blue Shield of North Carolina, single biggest reason for the drop in rates is a lack of in the exchanges is a lack of federal funding for costsharing reductions beginning in 2018, then this is a problem weve been talking about, the ministrations budget to their credit, they found costsharing, the president and chief is talking it back and in other things, he doesnt want to do this, hes raising questions and theres a lack of predictability or the Insurance Companies to drive up the prices and so lets keep that in mind. Senator, youve always had a great deal of understanding to these issues and i appreciate you doing that. A couple more minutes mister chair. Im going to kill you if you keep this up. I would die happy. [laughter] know, i think youre doing a great job. Mister secretary, youve been very patient and i personally really admire you. I know you know this field very well. I know you know the problems, i know you know how difficult it is to solve these problems and i know you know that theres no quick answers to some of these questions that have been asked. You handle these very well today and i want to thank you and with that, we will adjourn this meeting. Thank you mister chairman. [inaudible conversations] [inaudible conversations]