Support. She reminded us of the dangers of fighting ebola and the dangers of the zika virus. It is going to be my privilege to introduce the secretary. It would appear that senator wyden, grassley, and senator schumer are not here. They have conflicts. None intended. I am going to ask unanimous consent that the statements by the distinguished senator from oregon and the Ranking Member and the distinguished member hatch be inserted in the record. With us today is the health and Human Service secretary who has been leading the department of health and Human Services since june of 2014. She has a long history of Public Service sector including her previous position as director of the office and management of budget under president obama. In the Clinton Administration she was the Deputy Director of omb, the deputy chief of staff the president , chief of staff to the treasury secretary and staff director at the economic council. She has not served as the secretary of agriculture, however. She has extensive private sector experience including serving as president of the Walmart Foundation and before that the president of the Global Development program at the bill and Melinda Gates foundation. Thank you, madam secretary for being here today. We would invite you to please proceed with your five minutes opening statement. We have inserted the statements by the Ranking Member and the chairman for the record and we will proceed with questions following the secretarys statement. Please proceed. Thank you senator roberts and thank you members of the committ committee. I want to thank you for the opportunity to present the president s budget are the department of health and Human Services. I believe we have common interest and share Common Grounds. The last legislative session this committee embraced that view of bipartisanship and leadership when it took historic steps to pass the medicare access and chip reauthorization act of 2015 and i want to thank the committee for that leadership. A very important piece of legislation for a number of reasons. The budget before you today is the final budget for this administration and my final budget. The budget makes critical investments to protect the health and wellbeing of the American People. It helps insure that we can do our job to keep people safe and healthy, accelerating our research and expands and strengthens our Health Care System and helps us continue to be responsible stewards of the taxpayers dollars. 82. 8 in discretionry Budget Authority is requested. Our budget includes targeted reforms to medicare, medicaid, as well as other programs. Thes reforms to medicare would result in savings of 419 billion over four years. It invest in the safety of health for all americans. Let me start with an issue we are working on at home and abroad as we work to stop the spread of the zika virus. The administration is requesting 1. 8 million with 1. 4 for the health and Human Service. We appreciate congress timely request as we implement the strategies to fight this virus. I know the rise of opioid misuse and abuse has affected Many Americans. 78 people die every day from opioidrelated deaths in america. That is why the budget poses over 1 billion to combat the opioid epidemic. Too many of our nations children and adults with diagnose Mental Health disorders dont receive the diagnose they need. Research shows Early Intervention can set the course for a childs success and that is why we propose expanding the Home Visiting program to help more families in need. While we invest in the safety and health of americans today we must relentlessly push forward the frontier of diseases. Each one percent drop in cancer deaths saves the economy 500 billion not to mention the comfort and security it brings to families across the country. Today we are entering a new era in medical science with proposed increases of 107 million for Precision Medicine and 45 million for a Brain Initiative we can continue the process. For americans to benefit from the breakthroughs we need to make sure all americans have access to quality, Affordable Care. Today more than 90 of americans have Health Coverage for the first time in the nations history that this has been true. The budget seeks to build on that progress by improving the quality of care that patients receive spending our Health Care Dollars more wisely and putting an engaged and empowered consumer. By improving the way we pay doctors, coordinate care, and use data and Health Care Information we are building a stronger system. I want to thank the employees of hss who in the past year helped end the Ebola Outbreak in west africa and advanced the frontiers of medical science and helped millions of americans enroll in health care coverage. They do the quite work that makes our nation stronger. I am honored to be part of the team. I am personally committed to working closely with you and your staff to find Common Ground and deliver impact for the American People. With that i would be happy to take your questions. Thank you. Thank you very much for your statement. Madam secretary, you recently stated that you believe we have more work to do with the Affordable Care act but the marketplace is stable. I am going to take the opportunity to remind you one of the five insurers offer offering insurance in my home state left the exchange and they provided half of coverage for all kansans last year. When we say we have insured stability it becomes a problem. I think the data showed the premiums for the bench mark plan increase 16 this year in kansas and that is causing a great concern. With insurers pulling out of the marketplace already i am troubled to see you are taking steps to increase government control over the plans available on the exchanges and ultimately reduce Consumer Choice through the notice of payment parameters. The notice claims consume are less likely to be left with a plan they are satisfied with if there are too many. Do you think there are too many choices on the plan . With regard to the stability and the marketplace. In the marketplace this year, 910, had an ability to be in a market with through or more issuers. That is where the competition is. I believe we need to continue to take steps to further stabilize and make sure the market stays stable. With regard to the payment notice, i think you know we are in the middle of that and will be completing that. Our objectives are not about limiting choices for the consumer but instead making it easier for the consumer to make choices. A number of steps we took in open enrollment were about that. We created tools in the marketplace where you could search plans and understand if the providers you were looking for were part of that. The other part was create a tool called the total cost tool. It is a tool that will allow you to figure out your deductible and premium for the year. Our objective is to continue to promote stability in the market and make sure there is Consumer Choice not to limit it. I apprec at th appreciate that. There is a job to review all of the agencys rules with world providers. I mind appreciate any more information you could provide to the committee after this hearing. I am interested in how you see this new effort functioning. The distinguished senator franken is the cochairman of the Royal Health Care caucus. I need to know or we would like to know how this council coordinates with the work done by the hss world Health Task Force and hss National Advisory committee on human health and services. There might be duplication and i hope we can pull that together. The council that has been pulled together i think is in response to topics we have discu discussed in this committee. I think you know my personal interest in rural america. There were serious questions i asked every time about rural america. We are formalizing a process by which those analytics that i think are important to understand because i think rural markets and urban markets are different sometimes and as we consider rulemaking we need to consider both. It is formalizing a process we have been doing informally over the past year in terms of rulemaking. We will be happy to make. This is an issue of interest and we would like to work with the congress in making sure we are considering the right things as we ask questions about the impact on rural america. Senator caldwell. Thank you for your work on the budget. Always good to see you. I want to go over the implementation of the basic Health Care Plan which some states have taken up and want to get your commitment to implement those plans. My understanding is new york is targeting lower premiums and plans that are better drivers of driving down cost in the marketplace. So definitely want to get your commitment on that. Yes, i think you know in the time i have been here, we have engaged in a number of these. Now with new york and minnesota in terms of the two places but we look forward to other states coming forward with proposals that do a number of things. It has to meet the basics of making sure the number of people that need access have access. It needs to meet the requirements of the Health Benefits required and in terms of deficit neutrality for the federal government. We know these plans are about access but also about states coming to approaches that are doing Delivery System reform and thinking of more efficient ways to provide quality care. We look forward to working with states as they come forward with their plans. I think it is telling when you look at this model because we are talking about the lower income population that was always hard to serve in general and that is to get them on on affordable plan maybe because an employee didnt offer it or have leverage. So new york with low monthly premiums of only 20 it is astounding we can provide coverage for a Huge Population and focus on manage care which drives down the cost as well. Look forward to your commitment to working on other states with that. As the administration looks at payment models to properly incentvise care providers how are we moving ahead particularly for low medicare rate states Like Washington that want to see the improvement but not be penaliz penalized . How are we making sure we are transferring from the Fee Per Service and to the model . Last year in january we committed as an administration and at hss that we would transfer 30 by the end of 2016 of payments in medicare to payments based on value not volume and by 2018 it would be 50 of the payments. We are on track to meet that goal for this year which is important because we are a largepiration large portion of dollars but also in terms of the market and whether that is private or like in new york with medicare. To the point of rewarding those who are making advances in quality and affordability with our Accountable Care organizations we took the feedback we have received and in the next round of those we have put forward changes that hopefully will protect and reward those who are already leading in the space. And reward those who are already leading in the space. On graduate medical education, theres something that you guys have entailed on setting the standards for emerging needs in health care as it relates to medical education. What are those standards going to entail. What were trying to do . We want to make sure the monies that are for graduate medicare re we want to make sure were focus on primary care where we need more services. As well as the issue of specialties where we do not have enough people. What we are trying to do is create standards where it serves the pipe elation its supposed to and it is targeted to the places where we have shortages. Right. I think the problem we have that we need to focus on is that given a state criteria, you can be in seattle and be well served and be in spokane and have a shortage. We need to focus on the fact that even within a state you can have great geographic differences and what your different to serve graduate medical education. So its important to us to have that in spokane. Thank you. My colleague im sure is going to ask about puerto rico. The bottom line is our calyx need to understand that while there is a cap on medicaid rate expenses in puerto rico, it is tens of thousands of people come to the United States theres no cap on that. We are digging a deeper hole in our budget by not fixing the problem in puerto rico. Thank thank you. I will let my colleagues speak on that. [inaudible] in your understanding of urinalysis. We thank you for that. As you know, as you know, cbo recently came out with a and said that by in ten years without addressing mandatory spending and other issues of the mandatory interest will consume 99 of all federal revenues. Thats unsustainable. We been together and rinse talking about budget issues so when your omb director we were not able to reach an accommodation so i decided i was going to stall. Every week i would go to the senate floor and talk about waste, fraud, abuse and how we can save taxpayers money. One taxpayers money. One of the issues ill be talking about today is the report regarding improper payments through cms. My understanding the Inspector General listed 25 in on implemented recommendations for proving taxpayers dollars. Cms wants to do this but they said theres short on resources. Cms could save 1. 76 a billion dollars if it have followed the installation of improving automated claims. And a number of other things. My question is here where asking for more resources and i would like to bring it to your attention, there are ways to free up money for absolute necessary functions for cms. Some of these recommendations and all of these recommendations if they are implemented can help with that process. I want to bring that your attention. I would like to get your response to that in terms of the ability to go forward and get these recommendations implemented. With regard to and we agree and i think you know the seven one statistic for every 1 dollar we believe we can save seven. That that the average over the most recent. Of time. Last year with the Justice Department we had the largest takedown we have had in the fraud area. It it was over 700 million in one takedown. Its a combination of things that we can do, the technology portion of it. We do believe we need finances to change and do some of that automation. We have asked for those resources. In terms of acting administrator who is taking on these issues i think hes had an opportunity to speak with him about it, its an an issue on our regular desk of things we are talking about. I think we believe as you articulated, fraud is an important part but i think we can go at it aggressively. With data, getting ahead of it instead of chasing it. I think we need to consider with improper payments there is fraud and then the category where people are providing the right data and information. We have tightened the requirement in order to do things like requiring paperwork before payment so that we get in front of it. We find that we are seeing greater numbers of people not getting the right paper. Were focused on that Technical Assistance to providers to get the information to us. Thats also place where resources are important. Given your experiences with the director i think this is in your wheelhouse. The secretary of hhs i think youre the right person at the right place to get the stone. We wish you success in getting these implemented here. It can free up necessary funds. That particular part results in greater savings. That seven one numbers focusing average over the last three years. Thank you. I have 40 seconds left which i. E. Yielded back in interest of the vote coming up. Thank you. Who is next . Thank you mr. Chairman. I will only ask one question on this round giving colleagues being here. We are very pleased with the secretary here in my view gives Public Service a good name. We are glad that she is here. The issue is opiate abuse is widespread across the country and particularly in oregon. I have opened an investigation and the potential of interest between opiate manufacturers in the paint industry. The concern here is the manufacturers may be trying to influence opiate prescribing practices and will have more to say on that in the days ahead. Oregon has been among the states with the highest nonmedical use of prescription pain relievers. The cdc estimates that one of 15 people who take prescription painkillers for nonmedical purposes are going to try heroin within ten years. Nationally, Healthcare Providers providers read enough prescription for opiate pointing reliever for every adult american to have a bottle of pills. Many studies and experts found physicians are inadequately trained on pain management. This past past week i sent a letter to the cdc to offer my support for the cdc draft guideline for prescribing opiates for chronic pains which will help prescribers have consistent, evidencebased guidance for appropriate opiate prescribing. So set aside for purposes of this morning, this question of the investigation into potential conflict of interest well talk a