Heard anecdotally that Child Welfare agencies reported an increase in foster care placement due to the prescription opioid abuse epidemic. How has hhs taken into account the needs of child for a population as they coordinate there is nonto this epidemic . One of the most important ways of making sure that the mother get into coverage in health care before she has the baby. This is also about the health of the baby and making sure we do everything we can and in colorado i did visit one of the Successful Programs. Making sure we have the coverage from the coverage occurred through the aca in terms of people coming into the marketplace in your own state with the expansion of medicaid we will reach more women. Step one is making sure we have the coverage. That too is making sure we are willing to come in. I hope the conversation we have publicly destigmatize because that is the other problem that the barrier. You dont have Health Insurance so you can pay for it. The question then theres different types if you come in. These are some issues we are working to do to make sure that we start at the beginning of the child life in terms of healthy birth and a method that does connect it to the child and is fun to care for in an appropriate way. I appreciate your work. The last complex we have issues that came up were legislated and now on her situation that are the worst six months of the year providers will face if they had not passed legislation. Cms says he know better than i performed these quarterly update. We had discussion, but just asking that you work with cms to ensure that the congressionally mandated payment change for complex rehab is included in the april update. We will work to implement as quickly as possible. I think they are planning on having a conversation directly with you. We will follow in that way. Thank you. Appreciate your work. I will take time out to ethnic questions because i may have to leave again. I have so many things im doing today its hard to keep up with it all. I appreciate the work you are doing and its very meaningful and very difficult. Almost an impossible agent needs to run. Great concern on the Medicare Part d there have been rumblings to issue an executive order that would allow the federal government to Prescription Drug prices in the program. Such an executive order would be in violation of the law as the statute at the slippery this wretched next. Negotiation and despite the fact, i take the possibility very seriously. I am a strong supporter of the biopharmaceutical industry as a source of innovation and intellectual property. The Part D Program gave these drugs to Medicare Beneficiaries and we need to keep the program as it was originally structured because it works. Everybody knows part d is one of the most important things that really works. They have private entities to keep costs down. Overall spending is significantly less than originally projected. Beneficially satisfaction is very high. It has a nature meant a success. Moreover allowing the government to negotiate prices is not a new idea. Always has been uttered this policy and has chosen again today. The president s Budget Proposal says it has no budgetary impact and the Congressional Budget Office doesnt mean its a big favor. Having said all that, my question is if anyone at hhs working or has hhs worked at the white house on an executive order that would allow the government to negotiate prices for any other changes related to drug races . I think you know we are focused on both sides of the issues of drugs. It is about innovation, which is by we brought everyone in for a conversation about both of those issues at the end of last year so we could hear from industry as well as can tumors in terms of the issue. The steps we have taken are focused on innovation as well as affordability. You know when senator portman raised the issue of deficit and entitlement mandatory spending and we take that very seriously and are looking for the opportunity in terms of drug prices because it is becoming an increasing percentage of our Overall Health costs. We sought increases are mostly seen in many, many years in terms of prices. That is why we are focused on the issue. The steps we have taken include the session that we did, and include closing the doughnut hole which is a part of the aca, which at this point is 20 billion, 10 million seniors and the third that is on the issue of trying to provide transparent to you. We do believe that puts downward pressure and have created damage. Me interrupt you. Im very concerned about this because they think they fouled it up with regard to the trade Promotion Authority or should i say the tpp. And frankly if you dont have the data exclusivity time of 12, which renegotiated, because we know weve got to get enough data exclusivity done for the companies to recruit their cause and in the tpp, where we can actually kick yours that takes about 15 years and 2 million so you need some time to be able to recoup the money or if you have the five years and that provision, the costs are going to be so high that it will go down the drain. That is why it might really Save Health Care costs in the long run. In the case of imus vehicles, if they get that figure, they will start to do that to pharmaceuticals which i billion dollars and teen years and recoup the regular drugs. We will lose the whole pharmaceutical and whole industry. I think senator cardin is next. Thank you, mr. Chairman. Secretary burwell comic thank you or your service. We appreciate your career service. We talked earlier, but the extension of access to emergency Psychiatric Care and i authored along with senators to me a call and is the logical extension through september that allows you to extend it through 2019. Revenue natural but we need the guidance then you are working on it. Its very important for those at 64 years of age. I urge you to stay focused on that. We think it is important to access to Psychiatric Care. I ask you to look at the Oral Health Care issues we coverage under the Affordable Care at. It indicates far too Many Americans are not getting access, children not getting access to dental care. We need to figure out a strategy and make sure there is access to qualified dental services. I want to file a Honda CommunityMental Health needs. This past week i had a roundtable discussion in baltimore by taxpayers on Mental Health services. We talked about the need for greater access to Mental Health and addiction services. The number one priority that does not take into consideration if you know how to triage the person and the most effective least expensive care setting. Do you have that capability . If your qualified health center, can you deal with walkins and referrals and do you capacity to do this . It is not terribly friendly to those who understand that they must have those types of capacity in their facilities. To make it more affect event of congress have taken action in regard to a program in several state. Can you update us. Section 223 in terms of the implementation of an approach where were trying to experiment both with different payment bottles and build on the backs of the Behavioral Health centers are hurting and communities well as federally qualified health enters. That is the effort to end senators sat there now and blogged and ms. Matsui have been very engaged on this issue. We are headed to the implementation is reflected in terms of the demonstration and the budget that came up on tuesday. We would like to extend we are hopeful the Budget Proposal are both supportive of going beyond the budget. I strongly support that. We need system wide structure to do with Mental Health. It is part of your july inquiry. We should take what we have learned. Or every dollar we spend in the settings, we are going to say 6 get the Reimbursement Structure doesnt allow creative ways of using care managers. I would urge us to think broader about how we can make the system work for Mental Health. Today it is still not. We are hopeful we can get the examples in the model sues tales in terms of the changes that what youre talking about can have been through her Accountable Care organization. Having visited some of those in new york in the progress they make with integrated behaviOral Health Care, and we are finding most are Accountable Care. It is both through 223 as well as Accountable Care organizations that we are creating the models. We need to have the analytics. I know i have one of our real champions on this issue. Good morning, madam secretary. Good to see you again. I have been to be there is then enter out the budget for opioid abuse. There is one account he was carried out by the administration. Their other resources in parts of the budget and more people are dying because of an overdose that auto act cements her gun violence. God help the concerns. Biscuits to one of the topics ive heard about making sure theres not overlapping we are doing that in the proposal and the money we fastforward specifically and even last year with the esteemed by name with the those monies out. We are starting to work on two fronts in terms of helping people with the overdose portion of this and that is through funding and helping communities. We also work with the private sector to make sure you take steps to be able to access it. In a number of states we see pharmacies like cvs and walgreen working with the state to do regulations to do it over the counter so i can occur not just for rest responders, but that they sometimes Family Members need to. The other thing we are doing is fda has approved the first nasal melodic sound, making it easier or regular people to give it to their loved ones so they dont need to do what you asked. Very good good thank you. I know youve spent some time in the south and we appreciate that. You should come back more often. In 2013, each day was provided with the liaison to contact questions and issues and these were removed recently in place of the generic email account and some challenges and is impossible to the department of insurance like South Carolina for quality answers, especially answers from a family is. What ive been told if they responded many times they talk to to list their names. Via email contact and the fsm is on steam. When they identify themselves it is almost never is the individuals email or contact information. Long story short it is very difficult to have an actual conversation via email or by phone at a specific person and that leads to immediate response. Two things. I will follow up on the on his and their relationships with diy. I need to figure out which part and does that have to do with the federal market . I will follow up in terms of that. The other thing is the issue of resource is for cms. The question of funding for these things than this particular type of service we can to the fees. In our budget this year, fees coming in will fire escape but we are asking for in appropriations and we are happy about. Theyre a Certain Services that feeds can pay for. If we change something and doing it to figure out how to know who to contact . I hear clearly we need to follow up with him one. It factly. The person to get an immediate response. There is some flexibility to shuffle resources around . Do not redo, but im sure you know the funding over the past few years has certainly been a challenge for us and we are hope it where it is different place this year. Last question. I know youve answered a couple questions about the challenges around the coops of 2. 4 billion in loans around the country. However recently including my home state of South Carolina, we have seen a result of mass coverage higher premiums and higher data to both likely about 67,000 south carolinians could lose their insurance. Sadly, coops for the operators according to last years race will. They are very few signs that this coops will be successful into the future. What is your next death . With regard to the coops, the consumers at the center of our strategy and our approach to making sure we take care of consumers. That is why a number of coops came out before enrollment and we would continue to monitor with the regulator because having said that, one of the steps weve taken is clarity in our guide and said the coops can actually seek a broader range of capital for them as they try and work through any issues we have. We support the state can continue to monitor closely is the very changes in the fax has given us. By time is a good thank you very much. Senator schumer, you are next. With a thank you, secretary burwell. Nobody has a greater grip on what is going on, understands the policies, understands the practicalities and is able to get it done. Kudos inoculated and i know for many more. What i wanted to talk to you about is two things. One is the zika virus. I dont know if thats come up so far, but i apologize if it has. Your administration has sent us 1. 8 billion american supplemental request for funding to address the zika virus. We have time because the mosquitoes that carry the tiger virus is not going to come for several dead. We have time and were pretty good if we gave mosquito borne diseases witness will be done with yellow fever here in the United States. I am glad you have asked for these monies. Again, a republican colleagues and going to plead with bad not to just talk the talk, but walk the walk. You cannot combat crazy is whether it is zika, opioids, Mental Health, security and our country without giving effect to his government. The air was not fight the zika. Fda makes no sense. What they are trying to do right now were some are trying to do is say we should not give any new monies are used to monies that aside for a bola. It seems to me like robbing peter to pay paul. It could come back. Would you please explain to me why we shouldnt do that in rather have a new allocation money and let the money is for it people are being used for in wyethayerst donated even though the crisis for the moment has subsided both here and in africa. With regard comment there are three main pots and one is a budget person are fully obligated. As many of you out now, much of the money in the middle of negotiating contracts. The biggest part of the money that is left is about 500 million that has to do with the Global Security agenda. The Congress Gave us that money and we have committed 17 countries to help in a fiveyear period so as then they wisely. Our monies go down as their monies go. We are negotiating plans with implementation and what we are working on together. The reason that is so important in terms of why we just take the money is one of the conversations begin to have this year was middle east respiratory system. Last year we have more cases outside of saudi arabia than weve ever had in history, but we didnt talk about it because korea was able to handle it. We have to get these countries ready and zika started and we dont outbid microcephaly in africa because theres no ability. Be back some of the money goes to stop ebola from spreading to other countries in dealing with existing countries. You all know it will come here if it is fair. Thats another portion of the money. Just recently a case came back. We were able to detect the cases because they were still swabbing. Dead bodies spacebar been tested and that is how it was found and so it didnt spread more. We need to get the job done in the west african countries, continue prevention is not just zika or ebola. There is some kind of preventative measure. It is the other piece of it. So we would be robbing peter to pay paul, making us less safe if we just didnt post the new dollars and use the money for that. You think that would be a Serious Health day, is that fair to say . Fair to say. Quickly because im running out of time. Puerto rico. Weve been talking about puerto rico in a dire situation. As you know i sponsored along with many of my colleagues, some of whom are here. Senator cantwell has played a leading role in this to deal with the problems of puerto rico and we need a script cf. Number one. Senator hatch has been trained to be very, very helpful on this and we appreciate it. In addition to bankruptcy and bankruptcy no money should be a substitute for allowing a territory to declare bankruptcy. We need other monies to help in those would be additional. My question is how long do you estimate puerto ricos current medicaid allotment to last and what would happen if Congress Fails to provide additional money to their Medicaid Program for us we have both proposed to grant them a state like treatment. We will continue to analyze. We worry things in terms of that a lot in could have been as soon as this year and that is why we have the proposal in the budget to treat puerto rico in terms of how other americans with regard to medicaid. Its an important financial issue and health issue. Mr. Chairman, a thank you for that and appreciate your holding this hearing and always your courtesy. Thank you, senator schumer is wait just a second. I have to leave. Let me thank senator caldwell for being here as well as all of our colleagues participated in this hearing. My hope is the issues we discuss here today can be addressed with the Nations Health care system to ensure that taxpayer dollars are used efficiently and effectively. We owe that to the citizens of this great country. I would also ask any written questions for the record he admitted that her stake on february 25th, 2016 if we can do that, you can answer them as quickly as you can. We appreciate that. Welcome. Great to see it great to talk with you. Your dad, my mom spent some time in nursing home care. I shared with you the other day that i visited a presbyterian with the lovely facility. Very encouraging. They have stopped prescribing i call them antipsychotic medication. I am used to going into Nursing Homes into Nursing Homes in seeing dementia patient drugged out. They dont know who they are, not very responsive. Theres a lot of people in the hundreds and they have a Fitness Center they are, doing yoga. They dont take those medicines. They reported to me the number of false now compared to what it used to be a spike dramatically reduce. I think they have 0 of antipsychotic drugs. On a personal level on a professional level i just want to know if the department of health and Human Services and Everything Else you are doing is something you are thinking about. Weve worked on the issue with respect to trying to stop or reduce prescribing of mind altering drugs for foster kids. Thats been an important issue. This is something for parents or great grand parents. Any thoughts . I think it aligns very much if we are trying to do to get educated come empowered at the center of their care. But we pay people for the outcome instead of paying for feeforservice and the transaction, that is when we get to that. In a place like that in a regular basis, there is a meeting of the caregivers with the family to have the conversations about the same, to talk about them so you can reduce us. It is all part of the Delivery System reform we are doing and shifting the Payment System. The other place we will be pushing on this kind of specific issue is as we tried to do our experiments and homebased care which mr. Wyden certainly has spent a lot of time promoting. Those are the ways it is that its a lot about payment incentive as well assert that opioids are a separate category, but the type of drugs to talk about have a lot to do with how we pay physicians to care for people and providers to care for people. Its about the quality of their care, defining that and that the outcome is value, not volume. Not how much they are taking, but what the situation is for the individual. Recommit thank you. For us, this one is personal. We very much appreciate what you just said. In the last congress, i worked with dr. Coburn and with you and some of your colleagues in the administration on issues including improper payment and something called the prime act which dealt with producing proper medicare and medicaid expenditures. Over the last two congresses, we passed based in pieces, which is a wonderful thing i believe. I will ask you to talk about the response implementation of the new law which has been implemented in pieces and how we are doing. We just dont have time. I will ask that on the reducing opioid painkiller edition, as i understand it, the folks that are in some cases physician assistants, nurse price edition or is are able to prescribe medication to help increase the Health Care Providers to help us address this epidemic could could you just talk about the Pilot Program that would focus on this area, allowing them throughout the country to prescribe medications for opiate addiction . The question is that something we will pilot and we should allow them to do nationwide . That is my question. With regard to the broadening number prescribers, we have a proposal on our budget that we do broadening. I think there are two separate issues. There is the issue of broader education and treatment and different categories of it. One particular issue is a drought that has limited caps are right now we are in the middle of reviewing that it is an administrative authorities. The drug has concerns they may have greater diversion. We want to make sure its a great access to it, we do it in ways that we dont have diversion. There are two different categories when we scale things where we have the evidence that they will create more quickly and more broadly and the cases where it needs to more evidence to ensure their questions being asked that we do that in smaller settings. Is for your leadership. Great to see you. Thank you very much. Secretary burwell, obviously we thank you for your wonderful leadership and i do want to follow up on Behavioral Health and Substance Abuse. Before doing that, i want to thank you for all the efforts of your department and helping us with the incredible Public Health emergency in slant and the person on the ground and this really tremendous and the work going on there i know you will be going next week to find. We appreciate your intention. They through no fault of their own have seen in many parts destroyed because of lack of progression treatment before switching to the poor quality front runner. Up to 9000 of those are children under the age of six who are now exposed. Some of the houses have lead levels and so this is extremely serious. We are still hopeful and we had difficulty coming together and getting bipartisan support to help rebuild, but we are still working and still hopeful we will come together and do something. Thank you for your help. I do want to talk about, as you know, another passion of mine we spent a lot of time on and that is implemented by senator blunt and i were able to get past in the new life to create a structure so that are not just fun and Mental Health and Substance Abuse services from grant that have been slow up and down by a structural change on payment that recognizes when a Behavioral Health specialists, psychologists does work that meets quality standards that they would be reimbursed but we reimbursed either help professionals under a federally qualified health care. We have known since president kennedy passed the Community Mental health act 50 years ago that we needed a structure in place to provide comprehensive health care in the community. That is the final gap. As you know, under the direction of legislation passed by the congress, we now have qualified community Behavioral Health as definitions of equality is likely due for Quality Health centers. The question is how do we get that available in every community in every state. The congress is willing to provide enough funding for aids date with planning grants for states interested to see how they could meet those qualifications in order to apply to be one of the eight states under your direction and all of the wonderful folks that have been involved in your whole team, hhs, cms. Youve built the Program Ready to go. 24 states have gotten planning grants. 24 governors, 24 states have said we want to do this. We are planning the standards and we can only accommodate eight states, even not to do anything else we want to do, opioids, Mental Health is the one to have community services. People are going to jail or the merchant fee hospital here they are Getting Service in the community. I noticed in the budget to expand the states for the eight we talking about 14. I wonder if you might speak and they actually allow everything working to be ready to go to have the opportunity to provide the resources so that we really have Mental Health and Substance Abuse services in the community. Thank you for your leadership. You and i had bad times and threw your leadership moving forward on the establishment and the implementation is about the infrastructure to implement and that is why it is so important across the country that lack access. So many communities across our nation actually lacked basic access to psychologists and have Behavioral Health professionals. Now what we need to do is take those quality standards and make sure we pay. That is what i think we believe the six the eight demonstrations we are doing are going to do. We believe it is taking that step in our budget is proposing we do more because that is the right thing to do to get the transition to where we finally treat Behavioral Health issues on par. It is not just about say we are going to do it. It is having providers do it in quality measures to pay for. This is the direction we are pushing hard. We are meeting our statutory deadlines in terms of some of the work because we believe in it strongly. I want to take another minute because you are working hard to provide standards. You propose expanding the states end this into sheriffs across the country who are tired of having people in jail and hospital administrators. I do remember talking to the Cook County Sheriff who is director of his jail a psychiatrist. We say why because over a third of the people in his jail needs psychiatric help. Under the quality standards we now put in place, and 24 hour help would be acquired as part of this Quality Certification and hope only congress this year decided to give the 21st states who would step forward the opportunity to the services in place. We look forward to working with you on that. Thank you, mr. Chairman. Thank you, secretary for your responsiveness. If i can get my question so quickly, you may be done for the day. I want to thank you its secondly, a concern entered a question. I want to make sure i give you time to respond. Weve talked about a number of times the act which deals with pediatric cancer and celebrates the life story of an extraordinary young woman but advocated for researching gastric cancer. I was very glad to see is fully funded in the president s Budget Proposal. We had to work to get that done and im grateful for that. I was also glad that included elements and is different than adult cancer. On the concern issue, just to put it on your screen working with cms, we know that due to budgetary constraints and member of the communitybased Care Transitions that initially might last for five years. We have a Successful Program in virginia and as this coordinator transition care. Unfortunately they were cut back without being able to do the full transition and working with cms and mrs. Akins turned. Not asking you theyve been cooperative. When we see Successful Programs that can and should make a transition here and i again would just appreciate the collaboration and cooperation to try and make this Successful Program transition. Finally, subject weve talked about at times and one that i think candidly the American Public is ahead of most of our elected officials and that is around Care Planning and endoflife issues. We still remain the only industrial nation that hasnt had the kind of adult conversation about Care Planning, about the issues are and endoflife but also recognizing this is not about limiting choices that expanding choices. I was pleased to see that cms introduced a payment form or physicians to have those kind of conversations about the go entities that come out of those conversations. This conversation should include Family Members, loved ones, religious advisors. Senator isakson and i have been working on this for some time and we are gaining broaderbased bipartisan support and theres not a member of the senate that i havent talked to that doesnt have a personal story. Nine years of which we didnt peak and i was relatively well in orange city sin, yet we didnt have all those conversations before it was too late. We are working and i would just like to assure a commitment will continue to work with your staff on the Care Planning codes, have a look at more wraparound services. We are trying to make sure these advanced directives can actually travel across state lines. Even if you go forward with this, something senator wyden has been in aged and involved in as well. Mom are tattered and to not close move and try to make sure those documents travel with you, builtin. I guess i would just like your comments in this space and begin acknowledging we have for the most part, elected officials have to move on and some of the horrific language used six or seven years ago. This is a part of everyones life and it needs to be dealt with appropriately in my hope is the Care Planning act we hope well get this done. Well take a couple comments on that. Thank you for your leadership because your leadership has helped create the space where we could go forward and make changes we have made and we think thats an incredibly important first step, but a first step in on the question is how you implement this so this is useful to the people it is supposed an object is that i know we share. We are going to continue to work in the base. We welcome the comments and continuing to work with you on this issue. We did this because its an important change and changes about the quality of care for people across the country and their families. We take seriously the next step that we need to do and look forward to working with you on that. Being able to pay makes difference. Not only been able to pay to have that conversation, but also to recognize peoples wishes not to be respected. I know it is an issue weve talked about and youve been a leader on this for many years. My sense is on the good side that this is an issue where the people are ahead of their lack of officials and there is not a Single Member in this body to sit down and have an obvious conversation with hasnt had an experience with a Family Member or friend and it breaks your heart sometimes when you see one person who had to go twice as the daughter to make sure that her mothers with fish of 102 in terms of being resuscitated when chosen not to have those wishes honored. I again appreciate the secretary sensitivity of the issue and it is a hard issue to talk about, but one that in america we need to address and its not about limiting choices. It is about expanding choices. Thank you, senator warner. Secretary burwell, for a few minutes about the future and how appropriate senator warner a law with senator isakson had been in the vanguard of laying out some new policies to expand choices for endoflife care. I am very proud that now as a result of the secretarys good work, we finally put in place medicare care choices. So for the first time older people would not have to give up the prospect of Curative Care in order to get the hospice benefit. I have been hearing about that since the days when i had a full head of hair and rugged good looks and was director of the gray panthers. Mr. Chairman, is that back in the early part of 20 century . Is impossible to calculate. The point is for senator warner has been talking about is creating more choices. This is not about washington d. C. Producing another federal cookiecutter program we have to do it a comment b. , c. , d. Senator warner is talking about the centerpiece of endoflife care should be about empowering patients and their families. It is high time. Senator warner and senator isakson had been prosecuting this case and im very appreciative of it. Medicare choice starts us down the path, that senator warner is right about the next steps. I am with you. Secretary burwell, your last hearing. One of the assessment they make as they wrapped up is that because of the good work you have been doing, you and your colleagues, america is not going to turn back the clock. America is not going to turn back the clock on the Affordable Care act. He talked about increased enrollment. I am particularly pleased you are making this point at the heart of the aca grad at the center of it is making sure people dont get discriminated against for preexisting conditions. Iowa satisfies you about that, which is the history of American Health care for eons to basically at health care in america for the healthy because if you had a preexisting condition and you are wealthy you can pay for it. If you didnt have one at all, you all have i think now made it clear that the Affordable Care act is not going to be repealed. We are not going to go back to the days in which you can beat the stuffing out of people who had a preexisting condition and i think its appropriate to talk about the future. Im going to spend a couple minutes to a not. One of the first areas i would like to mention is Newt Gingrich and tom daschle wrote an oped piece here a few days ago. I dont think you see that happen every single day as a pastor publican speaker, House Democratic leader writing an oped piece. They said lets have a bigger role for the states. Lets have a bigger role for the states in the Affordable Care act. They had a variety of ideas. Pulling the governors together to look at approaches, making sure that the very Funding Sources were more integrated i guess in the lingo of your agent is those were funded streams. To me this has taken the various funds trying to find a way to coordinate them. When you think about that . Si asked the question, i want to be clear, this is not talking about anybody trying to duck the coverage requirement, the Consumer Protections in the law. This is about whether people across the political spectrum can figure out how to test various approaches at state levels. What are the possibilities . Theres possibilities in terms of where the authorities live for us to work with states to do the things they want. We earlier spoke with ms. Care about about the basic Health Program at new york to in terms of how they want to approach. As you mentioned at the end, one of the things that is so important if there is a basic baseline with regard to what the benefit made to look like in terms of making sure the access gained is not lost and we are also watching the finance is in terms of the federal government. When we think about that, there are ways that the basic health of our progress has been made and different alternatives. Also, i would highlight the governor of alabama this week announced he is working with us and ask him to closure on a waiver on a waiver that will do regional Care Organizations like Accountable Care organizations. He has created an approach in his state that is innovative and working towards the kind of care we were just talking about endoflife. Educate, empower at the center of their care throughout their entire life. Those are the things we want to work with. The constraints in terms of where the boundaries are have to do with affordability and access. We look forward to working with regard to 1332 guidelines that articulates standard that has been met. We did not put further constraints because we want to hear innovation and ideas. Second i would like to touch on a committee project. Im very appreciative of chairman hatchs interestingness and he knows that ive been interested in this for years. Medicare 2016 is not in the care of 1965. As people stayed in the hospital for a lot longer and if you hurt your ankle, and wasnt really serious injury, it was hard because medicare. It was really serious, you were in the hospital a few days. That is not medicare today. Medicare today is cancer, diabetes, heart disease, strokes. We now have a task orders that is led by senator isakson and senator warner with their interest in these issues. And it is really standing what you come up with when you look at this is after seniors, particularly in areas where you dont have manicured vintage after seniors get that free physical with the Affordable Care act. So often, so often the nonexistent that exists just sort of leave them off the rail and they end up when they are about to be discharged, no one knows who defend her record to because kerry is so fragmented and blanchard. Putting together the budget obviously has taken a look at this whole question of chronic illness. I think as you are reflecting chronic care, both in terms of polity and costs, 80 of our total health care costs, and his chronic situation, whether thats diabetes, heart disease, other things. With a cost perspective, taking these issues on is important. The other thing is the strategic approach with all the tools the mothers we had from a policy impeded my it is at the center of that is more integrated care. We need to change the way we do that for care in the country and we are on a pathway to do that. Whether that is in prevention as you highlighted the importance of the Services Required without additional cost through the Affordable Care act to make sure you have a primary care of home where the person were pieces and parts of your care are effective in a way that serves you in that connects to a point we discussed earlier, which is making sure we are paying for value. We are paying for the outcome of your health and whether that prevention upfront or when you do have something coming making sure we get the outcome you want. That is why the Payment System is an important part of the tools we have at hand to drive this change in terms of care that is more integrated and focused on the individual within engaged as part of the care and the choices at the end of life but well before then in terms of your everyday care. I can tell you of course the popular wisdom is this is an Election Year and nothing is going to get done and the like. I have been very appreciative of chairman hatchs interestingness and we are supposed to pull out all the steps to provide a bipartisan bill that are reasonable kind of principles we had to work around. We are going to push very hard to advance that this year. Let me turn briefly to some questions with respect to the other issues within your jurisdiction. First i want to make sure that we formally acknowledge improvements to the tentative program, improvements to allah made. Outside of washington with public assisted and we made a Real Progress most recently. There is a very substantial victory. Weve got more to do and help struggling parents find where can i think you all have some promising proposals in that regard. That is as much a reflection on your good work as a question. With respect to foster care, and i just heard senator casey with respect to the new spike in foster care and certainly a factor in that is the opioid epidemic. Chairman hatch and i have spent the better part of the last year working on a proposal called family first i would allow states to use their foster care dollars on programs that we know to be affect it. Drug treatment, Mental Health and prevent the need for foster care by keeping families together. The premise is these types of programs not only save money for the overall system, but they also improved the health and overall wellbeing of youngsters you will have a similar proposal as i understand it. Perhaps now that the same role for Substance Abuse treatment programs and foster care prevention. Now youve pointed out there is certainly a role for medicaid and that is important [chanting] childhood pastor patiently in this space and i would be interested in whether you share that view. I think you know we do share the view that trying to make sure we are doing things so that children can stay in their home setting as much as possible as long as that is safe and appropriate and there are ways to encourage that. Many proposals are around that comes so we welcome the opportunity of the key ways of supporting apparent that they are able to care for that child appropriately and then the question of where the funding stream as we welcome the conversation. We started to vote on a bill in this committees jurisdiction trade enforcement act and im just going to leave you with one last thought. We are going to be relying on your account of a near expertise the whole light during this remaining year. What i have always sensed about your age is he and handling the responsibilities they are is that doing your job well is a contact sport and i admit that i just want basketball scholarship so that is my world. I see you reaching out to legislators to the advocates. They dont have the power and clout. I want you to appreciate that because they think you are kind of writing a manual for how you want to do this job at this incredibly important agency, which assert that Peoples Agency for kids, seniors and disabled. I wish there was more time to get in to some additional issues, but we are going to be back at you want the big question because i know you and i have talked briefly about this 18 month investigation senator grassley and i did and hepatitis c drug. Theres a piece out that indicates the states are rationing hepatitis c drugs, that they cannot afford to take care of people. By the way, when you ration hepatitis c drugs are my people get sicker and sicker and have very serious clue or illnesses which costs even more money. Do we have problems today handling a small percentage of those who have had hepatitis c and were likely to end up with bigger expenses as a result of care being rationed. I think we will start examining here that we are on the cusp in the United States of having a policy that says we are going to have spent accurate cheers for illness. The hepatitis c drugs are cured. We are going to have spectacular cures with respect for diabetes, cancers and the like. The question will be, will americans be able to afford to get those cures . That is going to certainly be a debate that would be for the faint hearted. I am really glad that we are going to have you for close to an additional year and i appreciate particularly the way you constantly come back to pulling people together