Fourth year and the future years, they can actually utilize what is already being used in a local property tax or sales tax for these low income people. For these low income people. So, what i would ask, if the state chooses not to expand , what wouldto 138 you think the department would plan to handle be states rick states request to continue with business as usual . Senator, with regards to the specifics of the discussions thaten hhs and the state, is something in my current role i am not familiar with. What i can talk about is the philosophy of how to think about these issues in terms of medicaid and medicaid waivers. There are a couple principles. I think it is important starting the conversation to be clear about what the fundamental Core Principles that are essential to implementing our, whether that is the Affordable Care act or state waivers other states may be applying for. I think the second thing that is an important principle is flexibility. Differentates have situations and we need to consider that. Bringing both of those things together something we need to do at the beginning of the conversation as one works through how to get to a potential yes. Ground zero for medicare. Raud is south florida just yesterday, there was another bust. Law enforcement took down 50 more people. The problem is, in the past, when you take them down, they have already fleeced the system. You got any thoughts . A couple things. I think we need to work to a system that is not pay and chase, but it in front of the system, where the dollars go out. That is where we need to have a system. There are a number of tools we need to use. We need to use tools that we use in the private sector in terms of predictive capabilities, in terms of using technology. I think the department that did do the work you are referring to yesterday was an across the nation strikeforce with the justice department. That is important for doing that. In my current role as omb director, the issue of improper payments is one that has been focused on across the entire government. As we know, the numbers are very large and medicare. It is a place where we need to focus deeply. I would hope to bring some of the focus we have done on broad and proper payments across the federal government to the issues that are specific and medicare and medicaid as well. Senatorgordon gordon cornyn. Thank you for meeting with me and my staff and my office and talking about getting away from pay and chase. There is not enough resources in the federal government or in the federal claims act or otherwise to go after all the fraudsters. The only way to get ahead of them is to screen who gets paid on the front end and there are a lot of very powerful and loud people who will complain to high heaven if you do that. But i appreciate your commitment and chase,h pay because it just doesnt work and it will work. So, mckenzie, who you once worked for in addition to other aspects of your distinguished career, has come out with a testament that about 22 of the 8 Million People the administration was celebrating and rolling in the exchanges, people whore previously did not have insurance coverage. Which meant that only about one out of five people were newly added to the insurance rolls, who previously didnt have coverage. The president said when he sold the idea of the Affordable Care act, if you like what you have, you can keep it. Down 2500ms will go as a family of four. And by the way, if you like your doctor, you can keep your doctor. Hasoo many instances, that proven not to be true. Which is been very damaging, not only to the president s credibility, but the credibility of anybody who is saying the Affordable Care act will work as advertised. To my knowledge there have been no official figures released by the federal government or by the administration. Are you aware whether there are any figures available which withadicts or disagrees what the mckinsey study estimates that only one in five of the 8 Million People did not have insurance . Senator, in my current senator, in my current role, i do not know. We have seen the mckinsey numbers. The question is, some people may have switched for quality reasons. Im not sure if they divide out. The other thing we have seen, we the numberallup and of other organizations show the percentage drop of the number of uninsured in the nation and those provide different numbers. With regard to the specifics of the government, in my current role, i do not have access or no. The insurers are where that information will be provided. The distinguished senator from West Virginia who earlier, whou talked for 20 or 30 years i do not know if he was suggesting it would be 20 or 30 years before we got health care right or not. Maybe we will have that conversation later. There are a lot of people who feel enormously discouraged. You in the short time i have remaining, my notes indicate that health and Human Services employees employees soughly 78,000 people employ roughly 78,000 people. Theres another Government Organization in the news these days, the veterans administration, that has 278,000 employees. If the reports are to believed to be believed, they are having enormous problems delivering care to veterans who have earned that right. Could you tell me how you would deal with an organization that has these sorts of problems that are being reported in the va today . I realize that is much bigger than what you are getting ready to take on at hhs. I am not asking how to fix the how yourticular. But would approach an organization that size without many problems . First, i think you need to get into what is causing the problems in the magnitude of the problems. You quickly have to establish is the problem coming from . Is it systemic . Is it cultural . Is it a targeted problem . Once you understand what kind of problem youre dealing with, you have different types of solutions. If it is a cultural issue, you have to do change management. That takes energy, effort, leadership, by ian buyin. If it is a target of space, that is a different problem. Is the problem, theagnitude of it, and other thing is sending culture, sending signals and important parts of doing this. Do you think with regard i think there is role that congress and executive branch play together. There is important oversight role that the Congress Plays and i think that is about a back and forth in a conversation and i think it is one of the places working together is the way to get the greatest impact because i think coming up with the solutions i i think listening ad understanding that there are ideas that come from experience thats on the ground, i think one of the most important things in my visits that hear is you represent what happens in your states. What i hear when i ask you for, when i have a conversation and ask you about priorities, it is a means by which one hears from the American People as directly as you can. So i think there is an Important Role in how one goes about that doing these solutions and working with congress to do it. Thank you. Thank you, senator cornyn. Senator menendez. Thank you, mr. Chairman. Congratulations on your nomination. Thank you, senator. Yesterday the starledger, major newspaper in my state of new jersey, reported that while 140,000 people were successfully enrolled in medicaid at least another 25,000 still have their application waiting to clear the backlog and another 7,000 are waiting for their medicaid cards. Now i realize this is problem solution lies predominantly at the statear level, but, i also know cms has a vital role making sure states bet all applications processed in a timely manner. If confirmed will you commit to prioritizing this issue so families in new jersey and across the country can rest assured that their Medicaid Enrollment has been processed and theyre able to receive the care they need and have cms wori to educate individuals andd providers about theirth presumptive eligibility rights so they are able to receive and provide health care waiting for formal enrollment . Senator, if i am confirmed i would look forward to work bug and cms on that issue. Because the promise of the act, if at the end of the day you do everything right and register and cant apply and. Youre not just processed at the end of the day is really unfortunate. As you may know from our conversation new jersey has the highest rate of autism citizens in the nation, with one in every 48 children diagnosed by the age of eight. Why one of my Top Health Care priorities is insuring that individual with autism have the therapies and services they need to fulfill their godgiven potential. Now one of the steps i took to try to achieve this goal was insuring Autism Services were required under the essential Health Benefits package for plans sold on the Health Insurance marketplace. Despite this requirement, however, im worried that plans are not living up to the standards that i envisioned when i wrote this provision into the law, especially in states without existing state coverage requirements. E specifically, im concerned that plans are taking advantage of the regulation that allows them to use nondollar caps on benefits since they no longer allowed to impose dollar limits. So this is clearly in violation of the intent of the provision as i authored it and as part of the law, has the potential to denyal access to care to familis across the country. Cans assure me under your leadership hhs will conduct the necessary oversight of planned benefit structures to make sure theyrel providing all of the required benefits. Senator, thank you and appreciate your leadership in the space and our conversation about o this in issue and if i m confirmed i want to work to figure out how we can make sure those children and adults arepa receiving benefits and health care that they need. Okay. Two last questions. One of the final issues, one of the issues ive been involved with over the last year is responding to what cms socalled to midnight rule which is designed to create an unambiguous policy that beneficiary i spending more than two days in hospital is designated as in patient however the rule fails to acknowledge an instance where where a beneficiary needs a high level of in patient care for shorter amount of time even if the physician determines it is medically necessary or appropriate. Now im pleased to see that cms took the initiative ander soliciting comments on this issueti as part of fy 2015 paymt in patient rule but im afraid a year might not be enough time and once current delay is over and thet well still be in a situation where the rule is unworkable and unenforceable. Will you provide that cms will have policies in place will assure rule viability once the statutory enforcement delay expires next year . Senator, if i am confirmed this is issue i heard about from aab number of your colleagues in all of my visits so this is one where i think we need to continue getting best ideas people have for implementation and that is something i hope, if im confirm can work with cms and others to get that input. Okay. Thanke you. Finally, Delivery System reform and quality improvement. You know, when those of us who supported the Affordable Care act we saw it not only about having more health care familieslity for across the country who didnt care, about controlling costs but also about changing the nature of our, from a diseasebased to a preventativebased and changing nature how we paid and how we dealt with health care from alternative payment and delivery models, bundled payments, patientcentered medical homes and performance and outcome. I suggested multidosing when appropriate to reduce Prescription Drug costs. So are you open to these types of initiatives as a primary effort to try to change the nature of how we pursue both our ott comes and how we pay for them . Senator, i think that the Delivery System reform issues are very important priority that we need to focus on and i believe the way we are going to focus on, them by taking exampls and models we start to see and figuring out which of those provide the best quality and the best cost and then, which of those we can scale quickly. I think it is important to get things in place, start to get traction on changing the system to one that moves towards what you described as quickly as possible. Thank you. S thank you, senator menendez. Thank you, mr. Chairman. Miss burwell congratulations on your nomination and taking time to meet with me. We have of course serious disagreements about the substance of obamacare. As i conveyed to you in our meeting im more concerned at moment, well, im very concerned about the substance but since we cant change that, but im very concerned about what is going on with regard to the enforcement oft obamacare and the selective enforcement of obamacare with regard to certain groups. Weve seen exemptions, delays, parts of the law ignored as they pertain to certain favored would appear political groups. One of those is the selfinsurance tax which was imposed on selfinsured, selfadministered plans to help pay for covering people with preexisting conditions and under yourmp direction, at omb there was a rule issued that carve as lot of plans out from that tax and i guess my question has to do with, you know whether or not that is appropriate and whether or not that is fair . I want to read for awe quote that came out shortly after the rule was issue. Asked for clarification how the change would affect other plans rates and fees for 2015 and 2016, health and Human Services officials said, it is true that the fee will be higher for plans that do not have to pay the fee in 2015 because some plans are except. So, in your view, is that an accurate statement, that others are going to have to pay a higher tax, the selfinsurance, reinsurance tax i should say that is paid by selfinsured, selfadministered plans because groups like unions got carved out . Senator, with regard to the specific provision that youre referring to i think this does fall into trying to improve and find better ways to implement the law. The specifics, while some unions are, this does apply to some, many unions it doesnt apply to, and it applies to other groups. It has to do with the definition as well of selfadministered versus Third Party Administered in terms of what the a law was trying do, the question of there are places theyre not synonymous l terms, the reason theyre not because what we found moving forward there are actual plans selfadministered not using Third Party Administered. Creating a distinction was a way to provide better clarity. That was intended in terms of what was being done. Y my understanding it doest affectdi 25 of union plans. It is something that i believeed that they requested and so, but the question is really very simple one. Doesnt require a lot of subjectivity. Simply a function of map. If there are groups exempted from the reinsurance tax, does that mean those subject to the tax will have to pay higherec taxes . Think the question is what was higher and what was lower is the question of one is implementing what yourim startig point is. Yes a Smaller Group but what was the actual starting point in terms of what is higher . We know what the tax is supposed to raise. It was a finite amount. Itur was very clear. If you raise certain amount of revenue and paid by a certain number of peel. If the pool shrinks people left in the pool will pay more that a is simple math. Ipe think the answer is yes andi would like to hear you say yes. Senator, i think with regard to what was intended was to implement the law in a better way, that was common sense, that was responding to a situation that was not just unions but whatever the size of the pool is to get the numbers. Wa is again mathematics. Are people going to pay more . The anticipates is yes. And thats what im saying when it comes to this issue of selective enforcement. I dont think that is fair. I mean youve had, youve had exemptions now twice for Small Businesses under the employer exemption. Youve had, i think 20 some exemptions or delays or otherr that have beenw sort of waived unilaterally but this particular provision is really problematic for the people who still have to pay the reinsuranceav tax. And all im simply saying is, as a matter of fairness and way that this is implemented, carving out favored groups shouldnt be, you know, the modus operandi. We ought to be going about this in a way thatou treats everybody fairly under the law and i dont think you can argue based on number of exemptions, number of carveouts and number of delays issued already that iser the cae and this particular one was a rule issued by omb under your direction. Senator, with regard to the implementation i think what one seeks to do, when one find places where you implement better in the law you seek to do that. With regard to the question of employ irresponsibility, what we heard is that the private secton was havingg difficulties in ters of doing the reporting requirements that they would need to do to do this accurately. And with regard to other complex pieces of legislation, one of which, partd and others, we havent had anything as large as complex as this in a while butco we have had examples. As one movesgi to implement youo listen and try to implement in a better fashion in terms of trying to hear, listen and make the Transition One that is workable. On individual side, what one sees is an opportunity for individuals to apply for hardship exemptions in terms of trying to make that transition be a place that works. Mr. Chairman, if i could, in interest of transparency thougho some ofrt these things, these f waivers and delays, would you agree, to submit, when you get them from the insurance company, the new filing rates that they file for next year . Because, you know, the enrollment date has been delayed now until later this year. The date at which plans get proved has been delayed until the day before the election which is very convenient. We know theyre going to be filing rates. We know there will be real world impact on these things. In interest of transparency you talked a lot about would you submit those rates when you get them from insurers . Issue of premiums and rates i think we all are very interested and want to see directional same way of