We do not want that from a fiscal responsibility, and we want that ease of the parent can have a child at the right place with the right care even if its across state line. I would say we look forward to working with you, welcome the opportunity if their questions in ways we can provide Technical Assistance and other things as part of this we welcome that opportunity because we agree with the fundamental of what were trying to do and believe this is something that can approve both cost and quality. I would encourage you and your department to take a look at the bill. Its not illegal or immoral for the administration to issue a letter of support. This is one that i think with chairman upton and chairman pitts, Ranking Member, full committee, subcommittee, leadership on both sides of the aisle in the south this bill could go. That could be part of chairman uptons 21st century effort or could be a standalone bill. I also in the brief time i have want to concur with what Ranking Member green said about Community Health centers. I hope we can Work Together in a bipartisan fashion to find answer to keep those funded. I know theres a funding issue this year that we need to address and reauthorize the program. I have a number of those Health Centers and my Congressional District, and they are very helpful providing indigent care. And, finally, i was going to ask this question but im a little bit puzzled. When chairman pitts as to the question about this report that deals with planning in case the Health Exchange is at the state level under the Affordable Care act are found to not be legal the way theyre currently funded, if the was a plan and if you had seen the plan, i take you that you were that you havent seen the plan, but dont you think its prudent that there should be a plan . I mean i hope i dont have a primary opponent. I hope i dont have a general election opponent but i have a plan icky sticky. I know you hope the court uphold your position by shouldnt the administration and your agency have a plan in case it fails because what we state in the letter and what we believe is if the Court Decides, which we dont believe there will but if the Court Decides on behalf of the plaintiffs, if the Supreme Court of the United States says that the subsidies are not available to the people of texas, we dont have an administrative action that we could take. So the question of having a plan, we dont have an administrative action that we believe can undo the damage. And thats why when i was answering the chairman i think its important to understand what the damages. Because then comes to the question of we dont believe we have any administrative my time has expired but if the court instructed him from the administration is just going to hold up your hands and saying we surrender . What we believe is we believe the law that stance is how it should be elevated. Implanted. With regard to when the Supreme Court speaks, if the Supreme Court speaks to this issue we do not believe that there is an Administrative Authority that we have in our power to undo it. And so that something thank you, mr. Chairman for your courtesy and the minority for letting me have extra time. Now recognize the gentleman from new york mr. Engel, five minutes for questions. And give very much mr. Chairman. Welcome, secretary burwell. Let me take you back on the backup plan. I was part of this committee. I participated in months and months of deliberations for the Affordable Care act. We had weeks of markets this committee did, and not once was there mention of subsidies not being available to individuals and states that it does have their own exchanges. Ive heard a lot of complaints on the other side of the aisle about the law but never was this issue discussed until the lost to the Supreme Court in 2012. Some of my friends signed onto amicus briefs and waste incredible time forcing votes yet their upset the administration doesnt have a backup plan to the Supreme Court ruled threaten the availability of subsidies. I think its somewhat ironic that my republican friends are demanding that this administration ask problems that they themselves created. And it shown zero interest in fixing. Should republicans get what they want, Supreme Court rules in favor of king i would urge my colleagues if it should happen to pass legislation to ensure that americans have continued access to affordable coverage through the federally facilitate exchange, just as democrats intended. Next month the Affordable Care act will have been the law of the land for five years. Its not a perfect law and there are issues that need to be changed with it but i would like to see this issues addressed and let those of us in a bipartisan way to our focus on improving the law and enabling more quality Coverage Options for our constituents instead of trying to kill it repeal it taken to court and things like the. I just wanted to say im sure that you agree with what i just said. Yes. We look forward to moving forward and want to make improvements if we can. I want to use my home state of new york as a good example of whats possible when the federal government has a willing and enthusiastic partner in the Affordable Health care implementation. As a result of our Successful Exchange and Medicaid Expansion more than two for 1 million new yorkers have Quality Health care coverage. Our rate has dropped only 10 and theres clear evidence we are reaching the right people since 88 of people who came coverage through the exchange reported being uninsured at the time they enrolled. So its really working in new york. The Health Insurance options available through new york state of health are on average 50 cheaper than the comparable coverage available before the exchange was established. I want you to know im sure you know what that the aca is working and working well in new york. Thats why i really think its terrible that ive been forced to take more than 50 votes to repeal some or all of this law. We should fix whats wrong. But in my state its really been a tremendous success. And fortunately ive had the opportunity to travel the country and see the individuals. Those are the numbers and individuals, whether its lower in florida 26 years old married to someone whos a truck driver who does not coverage, shes trying to be an xray tech they did not have insurance but she knows insurance with a premium of 41 a month. Or a woman who had ms in the state of texas and for 17 years she had not have Health Insurance and so how people go about, she traded treated her ms to the emergency room inches for children and she works. And it would get bad enough that said she would do. The stories of what it means to people in terms of the financial and Health Security i think the numbers are important but it is those stories which really makes this real. And you know, secretary burwell, i understand weve seen Robust Exchange enrollment nationwide even in states where republican governors refuse to set up a state exchange expand their Medicaid Programs isnt mr. . So the numbers, i spoke to this yesterday when we were able to look at the numbers, 53 of the enrollees in the marketplace this year in the federal marketplace our new enrollments. I think that is indicating that demand for the product and the need for the product. Thank you. I want to second mr. Pallones positive discussions about chip. Ive always been a strong supporter and has a july 2014 and s. Metaphor hundred 76,000 children were enrolled in this affordable coverage option for their care in new york and so i think that is really, really important. I was pleased, therefore to see that the Budget Proposal for fy 20 six included funding for chip for the next four years through fy 2019. So can you elaborate on why you believe increasing tobacco taxes is a viable means for funding this program while we sort out the transition issues associated with the Affordable Care act . We believe one of the things in trying to be fiscally responsible and indicating how we are paying for things we believe this is a legitimate way to pay for things especially in the context of we are providing health care and something that will hopefully create a deterrent and help health care in terms of the issue of a tobacco tax. As one analyzes across the department and whether it is that cms or cdc the impact that tobacco was on health in our nation and the cost of Health Care Information is one we think is a fair place to go to pay for this care for the children. I agree. And, finally want to talk about graduate medical education because i was concerned that the administrations proposal to cut funding, one in six positions in america obtains training in my home state of new york and we have some of the finest Academic Medical Centers in the country. It requires significant funding and time to develop the infrastructure and expertise necessary to ensure quality care is available. So how do we ensure stability for these Academic Medical Centers and the patients they serve that put gme funding at risk because we believe and hope our proposal does not do that and meets the objectives of making sure we are training a proposition for both primary care and Specialty Store we dont have as many as we should. At the same time making sure we target it. Theres 100 million for pediatrics and a wider pool for competition. Its an issue we want to make to meet the same objective at the same time we do a fiscally responsible it. Not recognize the vice chairman mr. Guthrie. Thank you, madam secretary for coming. I look for to work in 21st century chairs and all things we can work on over the next year as vice chair. First of i to direct your attention to the cost Share Reduction Program contained in the aca, specifically sections 1402 and 1412. Does any part of this budget that were talking about today request any new authority including any transfer authority to pay censures under the cosh a Reduction Program statements with regard to the program which is a program as you know is about making sure that the cost of health care to those individuals that are coming into the market place is something that they afford. Thats what its about we believe we do have the authority to do the costsharing. Is there any authority requested in this budget speak with no new language. We do know its up and running. I think we spent 3 billion already on the cosh a Reduction Program. The budget thats been submitted estimates 11. 2 billion over 20152016. Cbo says 175 billion is what is estimated. Could you side with the appropriations authority is . You said you to do believe you are the authority. Im sure you know that right now this is an issue that is under litigation and a court case that has been brought. So with regard to that that is an issue i will let our colleagues at the Justice Department speak to because of the place it is in litigation. I understand that but we are doing oversight. Im not an attorney. When you were at omb in 2014 there actually was a request in the 2014 budget for direct appropriation. That didnt happen for whatever reason that were spending money. Whether we spent the money or 175 billion, we feel like this is oversight hearing so we feel like its our responsibility to make sure to our taxpayers we have a legitimate, that answers on where this is coming from. We just asking for where the appropriation comes from. Understand and appreciate the question, and im sorry that it is in litigation. I wish we were not in a place where we are in litigation but once something is entered into the place of those great a difficult i respect the issue of oversight but because the litigation has been brought by the house on this issue we are in a place where i think that is the appropriate place for the composition. Im just not aware of any pending litigation exception in oversight hearing questions, and is there like a legal case or authority . With regard to issues that are being litigated, generally those are matters that we refer of that the Justice Department continue on. Weve never been able to get an answer from the administration for where the language no one has been able 2. 2 is where the appropriation language comes from. You put us have requested appropriations. Recently you said you received the think 18 employer groups and children urging the small groups be maintained at 50 employees. They were citing an analysis that showed when they go to 51 analysis said that it was estimated that twothirds of the members that they would receive an increase. And of 18 . And i dont believe that the small outpost 50100 employers can accept an 18 increase in the premiums. Also the promise that if you like your plan you can keep it because if they have to go into the new plans they like to meet the requirements of the Health Care Law that cause other people to lose the plans that they like. Due to this impact would you support allowing states to keep their market at 50 or below, not go to 51100 . This is an issue that were looking at and examining because we have had a number of comments on a. I would welcome the opportunity to see these for that you are talking about and referring to so that we can see and understand the. What we want to do is understand the facts around this type of thing so i would welcome the opportunity to see this day and piece of work you articulate. Its been said that it from to put but we will make sure that has been forwarded. Well, thank you, mr. Chairman. I yield back. Not recognize the gentleman from illinois and she tells the, for five minutes of questions. Thank you, mr. Chairman. And thank you, madam secretary for being here today. I wanted to ask if you are aware of any republican legislative proposals that would keep Insurance Companies from denying coverage from people with preexisting conditions like cancer or dropping someone from coverage because they got in an accident or got sick . Im not aware of the piece of legislation that would take care of that issue. And argue over the new republican legislative proposal that would provide access to Preventive Services like cancer screenings come yearly wellness exams, and do that at no additional out of pocket cost to consumers . I am not aware of a piece of legislation that would do that in the fulsomely that the aca does. Thank you. I wanted to talk a little bit about something that is a growing concern, and thats alzheimers disease and the cost that it is in our personal lives and also in funding. So scores of public agencies, including many h. S. Agencies as well as numerous private and nonprofit organizations are trying to address this challenge of preventing alzheimers serving those who have dementia day, finding a cure. Shouldnt the federal government be coordinating a plan on alzheimers . In terms of the issue of coordination there is a body and Advisory Group that includes both people from the federal government as well as external folks to be a part of putting together our thoughts and strategies. It is informed the way were doing investments. There are members of the federal government across the government as those external bodies that arent part of the. With regard to the work at the department, the work cuts across a number of different areas, nih and research is jenny what comes to find out where the biggest dollars are spent is actually in cms and making sure we are thinking through the issues in a state because thats where the dollars. The other thing is committee for living where we were going to think about things like those that are caregivers and those that are going through the process of dementia and how they deal with it. As a department we work through all of those. There is this overall Advisory Group we have externally and includes internal members. The population is aging rapidly obviously, and alzheimers is taking a much bigger poll toll and the number of People Living with dementia will continue to grow as baby boomers age. You mentioned the research that is going on, so what is hhs, and h. Doing to find if youre . In this budget you see a 24 increase to funding for alzheimers which is much greater than a increase in within the other nih. Focusing keep on doing that but its also part of the Brain Initiative as a think through their specific issues but were also making progress on something called at protein is indicative of all summers. Thats when the pieces of research that is going on if we can make progress there the other piece of Research Using if there are ways that we can slow the progression by understanding how the channels move and was happening in the disease. Those are pieces of research that we are starting we believe that with many were asking for we can move that research and we can broaden it and we can make it faster. Damage is a major focus of work in the United Kingdom and other developed countries. Are we keeping up with the rest of the world in research the world in research