Delivered to people in ways that they can access it and use it in ways that prevent the kind of problems you described with the 12yearold that actually extend through adulthood for many. Absolutely. I look forward to working with you. Thank you. Thank you. Senator isakson is next. Congratulations on your nomination. Congratulations to your family or condolences to your family one way or another. Hearing before the Health Committee, i brought up an issue i already discussed with the chairman. In that meeting i told you i had no more responsibility as a member of the United States your noluding more pressing responsibility as a member of the United States senate, including your the harborthan project. I wanted to bring clarity before you were gone from omb to make sure we had a road forward to make that reality. To confirm what dr. Coburn said about responsiveness, without in an hour that hearing, your arranged a meeting with your chief legal counsel, your deputy director, and your chief liaison and the under secretary the army corps of engineers where we reached a way forward, which i just want to memorialize with this hearing today. We need to pass the authorization, which is in the final conference agreement. Ive seen that. Second, the court has to initiate and begin a Public OwnershipPartnership Agreement and the state needs to agree to forward fund initial construction moneys, for which it will receive credit. Do i have a correct representation of the steps forward and collect and pleading this completing this project question mark senator , you have. I hope that the word will pass quickly and we can move forward with this important project. Thank you on behalf of the people of georgia. And really the United States of america. Thank you very much for your responsiveness on that. I was a real estate guy, but i had a Little Insurance Agency in my company. Group healthsmall policies, for which independent agents received commission. When the Affordable Care act passed, it put the medical loss ratio for small group plans and large lands at 80 , and 85 . And your department determined the commissions were part of the administrative cost of the plan, which meant you would have to pay the commission and administer the program out of 15 , which basically put all of the independent agent selling Health Insurance out of business and was the reason we had to hire navigators to help people find their ways to the exchanges. When you become the head of the department, i would like you to look at that decision and revisited in terms of efficiency for the plan, to allow smaller and large group sale people to get back into business. It will save cost on the government in terms of not having to have as many navigators, put people back in business who i think were unintentionally put out of business by the Affordable Care act. Senator, if confirmed, i look forward to looking into and understanding that. Of an been on the board insurance company, i understand the independent agent issue, as well as the issue of how we think about premium issues, which are number of people have brought up today and how we i look forward to that if confirmed, how to think about that issue. By theit was brought up chairman, and some of the members i had the occasion to watch you and access for eight successive weeks at the white house when i with the group of eight had dinner with the president and Denis Mcdonough and yourself, trying to find a way forward on deficit reduction and reducing obligations over time. I do not want to get into a long question, but i would like you to consider leaving all options on the table in terms of fixing. He sgr as youll remember, some structural forms of medicare can bring tremendous savings without hurting beneficiaries. We talked about those and those meetings. That could be part of the equation that will help us find a way to pay for the sgr and never have these oneyear renewals again and again. I appreciate you leaving all of the options on the table for discussion. Senator, senator, i welcome all opportunities and as is reflected in our budget, we have a wide range of opportunities, and the type youre talking about as well. All on the table. Thank you. Senator roberts. Thank you, and mr. Chairman. When we spoke during the Senate Health committee, i asked you questions about the independent payment advisory board, ipad is the acronym for it. Thathat could happen if came into being and in your response, you said that you were hopeful that ipad never needs to be used and the necessity to do so would never be triggered. Would you simply support its appeal . Also important to reflect that ipad, as currently written, would not affect beneficiaries. That is an important part of the law with regard to how it is implemented. As regard to the appeal on the things thate of the is hopefully a hopeful thing is to helpthings in place us all get to where we need to with regard to reducing Health Care Costs. May be barbed wire would be a better way to put it. I would echo my colleagues comments to you, regarding your responsiveness and willingness to work with this committee and all members of congress. I would also like to add relevant medicare takeovers to that list. Just this last week i had the Kansas Hospital Association in my Office Sharing their frustration over the lack of responsiveness from hhs. This is the same letter that they said your predecessor in january. They have yet to receive a response regarding the medicare recovery audit contractors, what we lovingly call the rac. They dont want to be put on the rac. They are still awaiting a response. Have returneds savings to the local trust fund. It is important that providers have timely access to the appeals of these audits. 65 lawtalking about judges and now 350,000 claims, which i understand is the reason for the delay, or the suspension. It is rather incredible. We have gone from impending appeals in just two years of 900 92,000 claims to 460,000 claims. When the weekly operation of about 1250 up to 15,000 per week. The reason is obvious, and that , hospitals win 70 of the time. Which means these independent hospitalrs come into a and many times they have never seen them before. They are being find for regulations they know nothing about. And if you are in a small hospital, you have a problem they doing out whether youre going to appeal or not, and now we find that the appeals are suspended. I would add to my list what can be done to better balance the need to recover improper unduets without imposing administrative burdens on providers . Particularly those in our rural areas. Senator, with regard to this issue of the racs as well as the balancing of having hospitals be able to process things quickly, at the same time we are providing trying to prevent abuse of medicare, if i am confirmed, this is an issue i think will require a quick look, a fresh look, and to think about how we can get the balance and what processes can be used to balance the two interests. I think you are appropriately reflecting in terms of the speed and the processing, it is not where we want to be in terms of the system. Perspectiveyears rule, asystems role rule that you signed off on at omb, hhs payment clarification requires submitting a patient into a critical access hospital and certified that the patient must be discharged or transferred within 96 hours. This payment clarification, which is not in line with the critical access hospitals condition for participation with medicare, in my view. And in their view, is crippling the ability of many of these communities to provide rural toommunities communities. One doctor said i usually met 12 minutes and now it is three minutes because of the 96 hour role. Besthen they decide on the course of action for their care. It is another example, in my opinion, of having to tell cms that if it is not broken, theres no need to fix it. If confirmed, will you do all you can to see if we can reverse this payment issue, so that rural seniors can continue to receive care at their local Community Academics the issue of critical access hospitals and care in Rural Communities at local communities . The issue of crigler access hospitals and care in Rural Communities is something that we need to get the right intent on. In terms of how to get to the place where the original objectives of the rules and be achieved in the way that they do not have the unintended consequences that you are articulating. Thank you. My time has expired. Senator warner. Let me thank you again for your service. Looks like youre coming around the bend and close to being done. I have a number of things i want to get on the record. First, i want to add my voice to the comments made by senator isaacson and senator roberts. I think the displacement of agents and brokers with a challenge and a mistake and i hope you will review that process. Let me also add my voice to what senator roberts said. I hear repeatedly from rural rac audits. Bout the e we do need to make sure that we get rid of waste and fraud, but we want to look at that. Moving on, one, the Treasury Department recently finalized the employer rules dealing with individual mandate. Theres a lot of complexity about these rules and some of these complex complexities were highlighted by the american bar association. This is not just a treasuryir wretcs issue. Are implementles it, i have raised this with you before. I introduced legislation with eight cosponsors that is endorsed by a number of employee and employer groups, which would basically allow employers to respectively rather than have a onemonth once per month reporting. Upfront require an collaboration between hhs and treasury that might remove one of the administered to burdens that we here in enormous amounts about around aca. My hope is if you are approved, and i hope you will be, that you will help work with us on it of this legislation or other ways we can improve this reporting requirement, and again, with this perspective action rather than just doing it retroactively. If i am confirmed, the it ministration and the president has said that we welcome the opportunity to think about things he can do legislatively and otherwise to improve it. I will take that as a yes. It is my understanding that there were agreements with the number of webbased entities to allow private exchanges to enroll tax subsidy individuals pursuant to regulations issued by hhs in march, 2012. Again, something we talked about. This effort was stymied due to in Insufficient Technology integrations. I understand there have been some small steps taken by hhs, but not a lot has taken place. To my mind, this should be a nobrainer. If we can get some of the sites, perhaps more userfriendly as an additive to help that, i hope you will work with me and these webbased entities to make sure that there is Better Technology integration this area. I welcome the opportunity to think about the best way to do distribution. And harkening back to senator isaacsons russian and your comment, the dissolution mechanism in terms of how people can easily access and receive health care. And clearly, there may have been sites that were private sector sites that had a better reputation than the federal exchange. If we can find ways to utilize that and integrate that technology, to me, it seems like we want to expand that. I hope we can Work Together on this. Again, an issue that i raise you, au raised with little more, kitty, about cms changes recently in the hospice benefit. I think as this is being rolled out, it is confusing and lacing a lot of unnecessary burdens on hospitals, patients, and families and providers. Hospice should not reject can shown unless it why should be covered by the part d plan. If it is related to the terminal illness, and her stand. But if you have glaucoma and a terminal illness, glaucoma is not related and the hospital provider should be reimbursed for that. My hope would be that we can dig down to earth relators of difficulty with this issue and that you will work with me dig down two or three players of difficulty with this issue and that you will work with me and others on this. I look forward to working on that issue, in terms of how we can figure out how to pay for the right things and do things that are implement. With four seconds left, as a former governor, to me just say that let me just say that one of the things we often try to do as state is to look at innovative programs, to try to get a waiter, whether it is medicaid or chip. But a lot of these programs never move from innovative test models to actually becoming permanent parts of a state program. This, to me, is an area ripe for administrative review. At some point, you have either proving your case and should be accepted as part of the state program, or rejected. Again, i hope you will work with me on this. I will, senator. Thank you. Chairman, andmr. This burwell, thank you for your willingness to step forward for what will be a very challenging tax task. You will be among folks who have had the worst job in washington. I congratulate you on seeking a promotion. [laughter] but i do think you come at it, therefore with a different perspective than other hhs secretaries have had in modern times, which is that of a budget cutter and someone who has had the possibility for oversight and trying to find efficiencies. I think that is really important right now. I hope you will continue to have that attitude at hhs. , will focus on medicare because i think you would agree with me that when you look at not just the health care issues, but also the fiscal issues, if we dont figure out a way to reform this incredibly important, but unsustainable program, we will have a difficult time today our fiscal house in order. And as you found out when you were at omb, this is not an easy task. There is obviously a lot of difficulty in touching any aspect of medicare. But the reality is, the trust fund, which is the trust fund covering hospital care and Skilled Nursing and so on, is expected to be insolvent by 2026, according to the most recent trustees report. Even if that were not true, we know that medicare as a program currently offers three dollars in benefits for every one dollar in taxes that a retiree contributes. That is your typical family in cincinnati or in washington, d. C. Program already that is heavily subsidized by general revenues. And heading toward this , even with the general revenue contributions. Y question to you is this in this confluence of omb and hhs that may well come together here with your confirmation, what are your thoughts about it . And let me ask you a very specific one that i think you should be able to answer in the affirmative. In the president s budget in the past couple of years, he has inluded a change in the way which the recipients of part b and part d benefits pay their premiums. He said there ought to be additional premiums for folks whoe around 170,000 make a certain amount per month. In retirement. In the president s budget, it was 56 million over a 10 year budget. 56 billion over a 10 year budget. That it willicated be over 400 billion in the next 10 years. Budget. Fastgrowing it is what we ought to be focusing on here in congress and with the administration. My question is, one, i assume you support the president budget proposal. But, two, would you be willing to support it as far as means testing under medicare to be able to deal with we talked about sgr. My question is really about deficit reduction to come together to deal with a problem that has been difficult politically for us to handle in the past two years in congress. Would you support a proposal as a standalone measure . Senator, i agree with you. I think one of the real benefits of the premium income testing income testing for premiums has to do with the fact that it is a structural change and you get those benefits in the out years that are important to the members and the deficit space also when i think about the omb,its and the my role at i think it is important to understand that the driver is the issue of Health Care Costs the medicare system. But it is also our demographics. And because of that, the magnitude of the problem when one gets to the specifics of what youre going to do to resolve that issue, i think it actually takes a combination of things to do that. I think it takes things as you are discussing, that are on the beneficiary side. It takes things that are on the provider side. It takes things like revenue. But as you know, we have already done a lot on the provider side already. My question for you is, in the president s budget, i assume you support the policy. Would you be able to support a policy initiative, whether in the context of sgr, deficit reduction, or tax extenders, or whatever it is . Do you support the proposal . I support the proposal in the context that the president s budget presented it. And as i said before, all things are on the table. Why does revenue have to be part of the conversation with regards to means testing . With regard to means testing, it is strictly via 2 the issue of deficit reduction in the long term. Thingse looks at overall, you get to this is specifics. You get to a premium perspective, beneficiary perspective, the perspective of providers. That is where you get to with integration as well. A few moments left. You were saying that with regard to means testing on premiums that there have to be tax increases. Let me ask you this. When someone pays you a higher premium, arent they paying the government more . Is and that a taxpayer over a certain income paying for a benefit that they would otherwise not have to pay . These do affect high income, but what is important is when one is looking are talking about a package, i think it is important to see what it what is in the package. What is it you are paying for and what are the offsets that you use. But mr. Chairman, please indulge me. You are saying that you insist on raising taxes on wealthier individuals, in order that wealthier and visuals could pay more to the government. And by the way, the Congressional Budget Office says it is also revenue, which is premium being paid to the government. Is that the logic . In the president s budget as presented, there are a number of different elements that do everything from Corporate Tax r