[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]







 PRESIDENT'S FISCAL YEAR 2011 BUDGET FOR THE DEPARTMENT OF HEALTH AND 
                             HUMAN SERVICES

=======================================================================

                                HEARING

                               BEFORE THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                            FEBRUARY 4, 2010

                               __________

                           Serial No. 111-95




[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]






      Printed for the use of the Committee on Energy and Commerce

                        energycommerce.house.gov

                                _____

                  U.S. GOVERNMENT PRINTING OFFICE

76-007                    WASHINGTON : 2012
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 
20402-0001















                    COMMITTEE ON ENERGY AND COMMERCE

                 HENRY A. WAXMAN, California, Chairman
JOHN D. DINGELL, Michigan            JOE BARTON, Texas
  Chairman Emeritus                    Ranking Member
EDWARD J. MARKEY, Massachusetts      RALPH M. HALL, Texas
RICK BOUCHER, Virginia               FRED UPTON, Michigan
FRANK PALLONE, Jr., New Jersey       CLIFF STEARNS, Florida
BART GORDON, Tennessee               NATHAN DEAL, Georgia
BOBBY L. RUSH, Illinois              ED WHITFIELD, Kentucky
ANNA G. ESHOO, California            JOHN SHIMKUS, Illinois
BART STUPAK, Michigan                JOHN B. SHADEGG, Arizona
ELIOT L. ENGEL, New York             ROY BLUNT, Missouri
GENE GREEN, Texas                    STEVE BUYER, Indiana
DIANA DeGETTE, Colorado              GEORGE RADANOVICH, California
  Vice Chairman                      JOSEPH R. PITTS, Pennsylvania
LOIS CAPPS, California               MARY BONO MACK, California
MIKE DOYLE, Pennsylvania             GREG WALDEN, Oregon
JANE HARMAN, California              LEE TERRY, Nebraska
TOM ALLEN, Maine                     MIKE ROGERS, Michigan
JANICE D. SCHAKOWSKY, Illinois       SUE WILKINS MYRICK, North Carolina
HILDA L. SOLIS, California           JOHN SULLIVAN, Oklahoma
CHARLES A. GONZALEZ, Texas           TIM MURPHY, Pennsylvania
JAY INSLEE, Washington               MICHAEL C. BURGESS, Texas
TAMMY BALDWIN, Wisconsin             MARSHA BLACKBURN, Tennessee
MIKE ROSS, Arkansas                  PHIL GINGREY, Georgia
ANTHONY D. WEINER, New York          STEVE SCALISE, Louisiana
JIM MATHESON, Utah                   PARKER GRIFFITH, Alabama
G.K. BUTTERFIELD, North Carolina     ROBERT E. LATTA, Ohio
CHARLIE MELANCON, Louisiana
JOHN BARROW, Georgia
BARON P. HILL, Indiana
DORIS O. MATSUI, California
DONNA M. CHRISTENSEN, Virgin 
    Islands
KATHY CASTOR, Florida
JOHN P. SARBANES, Maryland
CHRISTOPHER S. MURPHY, Connecticut
ZACHARY T. SPACE, Ohio
JERRY McNERNEY, California
BETTY SUTTON, Ohio
BRUCE L. BRALEY, Iowa
PETER WELCH, Vermont














                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Henry Waxman, a Representative in Congress from the State of 
  California, opening statement..................................     2
    Prepared statement...........................................     4
Hon. Joe Barton, a Representative in Congress from the State of 
  Texas, opening statement.......................................    13
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................    14
Hon. Nathan Deal, a Representative in Congress from the State of 
  Georgia, opening statement.....................................    15
Hon. John D. Dingell, a Representative in Congress from the State 
  of Michigan, prepared statement................................    18

                               Witnesses

Kathleen Sebelius, Secretary, United States Department of Health 
  and Human Services.............................................    20
    Prepared statement...........................................    24
    Answers to submitted questions...............................    76

                           Submitted material

Letter of September 14, 2009, from the Committee to the 
  Department of Health and Human Services, submitted by Mr. Deal.    69
Letter of February 3, 2010, from Mr. Engel to the Department of 
  Health and Human Services, submitted by Mr. Engel..............    74

 
 PRESIDENT'S FISCAL YEAR 2011 BUDGET FOR THE DEPARTMENT OF HEALTH AND 
                             HUMAN SERVICES

                              ----------                              


                       THURSDAY, FEBRUARY 4, 2010

                          House of Representatives,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The committee met, pursuant to call, at 2:15 p.m., in Room 
2123, Rayburn House Office Building, Hon. Henry A. Waxman 
[chairman of the committee] presiding.
    Present: Representatives Waxman, Dingell, Markey, Pallone, 
Gordon, Rush, Eshoo, Engel, Green, DeGette, Capps, Harman, 
Schakowsky, Gonzalez, Weiner, Butterfield, Melancon, Barrow, 
Matsui, Christensen, Castor, Sarbanes, Space, McNerney, Sutton, 
Braley, Barton, Upton, Deal, Whitfield, Shimkus, Shadegg, 
Blunt, Buyer, Pitts, Bono Mack, Terry, Myrick, Murphy of 
Pennsylvania, Burgess, Blackburn, Gingrey and Scalise.
    Staff Present: Phil Barnett, Staff Director; Kristin 
Amerling, Chief Counsel; Bruce Wolpe, Senior Advisor; Karen 
Nelson, Deputy Committee Staff Director for Health; Andy 
Schneider, Chief Health Counsel; Rachel Sher, Counsel; Jack 
Ebeler, Senior Advisor on Health Policy; Brian Cohen, Senior 
Investigator and Policy Advisor; Robert Clark, Policy Advisor; 
Elana Stair, Policy Advisor; Katie Campbell, Professional Staff 
Member; Tim Gronniger, Professional Staff Member; Virgil 
Miller, Professional Staff Member; Anne Morris, Professional 
Staff Member; Alvin Banks, Special Assistant; Allison Corr, 
Special Assistant; Eric Flamm, FDA Detailee; Camille Sealy, 
Fellow; Andrew Bindman, Fellow (Robert Wood Johnson); Karen 
Lightfoot, Communications Director, Senior Policy Advisor; 
Lindsay Vidal, Special Assistant; Earley Green, Chief Clerk; 
Jen Berenholz, Deputy Clerk; Mitchell Smiley, Special 
Assistant; Matt Eisenberg, Staff Assistant; Mark Noble, 
Director of New Media; David Cavicke, Minority Chief of Staff; 
Katie Wheelbarger, Minority Deputy Chief of Staff; Amanda 
Mertens Campbell, Minority General Counsel; Brandon Clark, 
Minority Professional Staff Member; Marie Fishpaw, Minority 
Professional Staff Member; Ryan Long, Minority Counsel; Aarti 
Shah, Minority Counsel; Clay Alspach, Minority Counsel; Melissa 
Bartlett, Minority Counsel; Will Carty, Minority Professional 
Staff Member; Peter Kielty, Minority Legislative Analyst; and 
Cedric James, Minority Legislative Analyst.

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Mr. Waxman. The meeting will come to order.
    This afternoon we will hear from the distinguished 
Secretary of the Department of Health and Human Services, 
Kathleen Sebelius. She will testify on the health proposals in 
the President's fiscal year 2011 budget for which her 
department has responsibility.
    This responsibility is daunting. The department she leads 
has a budget of over $900 billion in fiscal year 2011. The 
programs that her department administers will directly affect 
the Nation's public health and will ensure access to needed 
health care to over 100 million Americans enrolled in Medicare, 
Medicaid, and the Child Health Insurance Program.
    As President Obama reminded us on Monday, our Nation is at 
war, and our economy has lost 7 million jobs over the last 2 
years. The deficit that greeted this administration stood at 
$1.3 trillion. Successful efforts over the past year to rescue 
the economy and the financial system from collapse have 
unavoidably added to that deficit.
    We clearly need to solve the deficit problem, but we can't 
do it overnight, and the President's budget wisely does not try 
to do so. The budget strikes a careful balance, helping 
unemployed families by creating jobs and protecting them 
against the loss of health insurance, investing in next-
generation health care technologies, and taking steps to reduce 
the deficit while protecting the most important investments.
    In the health area, the President's budget recognizes that 
certain investments are essential while the economic recovery 
is still underway. The budget supports the enactment of health 
reform, which will provide affordable coverage for over 30 
million uninsured Americans while we reducing the unsustainable 
rate of increase in health care costs. The budget recognizes 
the need to protect the ability of America's seniors to see 
their doctors by repairing Medicare's physician payment system. 
The budget provides additional help to States that are 
struggling to maintain their Medicaid programs in the face of 
increased demand and reduced revenues.
    The budget increases funding for community health centers 
to provide cost-effective primary care, and it invests in 
prevention and wellness activities to improve the Nation's 
health and to reduce the need for expensive medical care. The 
budget increases resources for FDA that will enable the agency 
to improve its oversight of medical products, strengthen its 
food safety efforts, and implement its new responsibility for 
tobacco.
    It is the duty of Congress to consider the President's 
budget proposals as it makes its spending and revenue decisions 
for the coming fiscal year. Secretary Sebelius is here to 
assist the members of this committee in carrying out that 
responsibility by giving us a better understanding of the 
proposals and their rationale. Through this conversation, we 
can together make Federal health programs work as effectively 
and efficiently as possible. I look forward to hearing from 
her.
    I want to recognize for the purpose of an opening statement 
the ranking member of the committee, Mr. Barton, for 5 minutes.
    [The prepared statement of Mr. Waxman follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    
    Mr. Barton. Mr. Chairman, before I do that, I have a 
parliamentary inquiry.
    Mr. Waxman. The gentleman will make his parliamentary 
inquiry.
    Mr. Barton. What is the position of the Chair for today's 
hearing in terms of opening statements by Members on both sides 
of the aisle?
    Mr. Waxman. We will divide the opening statements equally 
between the Chair of the full committee, the Chair of the 
subcommittee, the ranking member of the full committee, and the 
ranking member of the subcommittee. And we will then go right 
to the hearing with the Secretary. After that, every member 
will have an opportunity for 5 minutes. They can use that for 
their statements, they can use that for questions, they can use 
it however they see fit. But under the rules adopted by the 
committee, we anticipated that there would be an occasion like 
this where, while we ordinarily like to let members have 
opening statements, we just can't accommodate all the members 
that would like to make opening statement and be able to get to 
the Secretary and meet everybody's schedule. I regret that. We 
have made accommodations notwithstanding the rules on a number 
of other occasions, but we are going to have to stick tight to 
the rules at this time.
    Mr. Barton. Mr. Chairman, so what you are saying is that 
the only members that can make an opening statement are the 
chairman, the subcommittee chairman, the ranking member of the 
full committee and the subcommittee, and no other member; is 
that correct?
    Mr. Waxman. Yes. And that would include Mr. Dingell, which 
we have always done in all of our hearings.
    Mr. Barton. Based on that, Mr. Chairman, I would move to 
postpone the hearing.
    Mr. Waxman. There is a motion before us to postpone the 
hearing. All those in favor of the motion say aye. Aye. All 
those opposed say no. No. The nos have it, the motion is not 
agreed to.
    Mr. Barton. Mr. Chairman, on that, I would request a roll 
call vote.
    Mr. Waxman. I would like to ask the gentleman to refrain 
from doing that. We do have the Secretary here. We try to 
accommodate you. We are not doing this out of any malice or 
meanness, but we tried to accommodate Dr. Burgess in his 
request, we have tried to accommodate people with opening 
statements. Usually we try to get the meeting started earlier 
so we can do opening statements; we are not able to do that 
today. And I think it is self-defeating.
    Mr. Barton. I opposed the rule that you implemented----
    Mr. Waxman. But you lost.
    Mr. Barton. We did lose, but I have the right to request a 
roll call vote, and I am going to do that. And that is in the 
rules. But if you have chosen to not do it, then we are going 
to use the rules that we have. I am going to request a roll 
call vote.
    Mr. Waxman. The gentleman requests a roll call vote. The 
Chair is going to inquire of the parliamentarian if this 
motion----
    The Clerk will call the roll.
    The Clerk. Mr. Waxman?
    Mr. Waxman. No.
    The Clerk. Mr. Waxman votes no.
    Mr. Dingell?
    [No response.]
    The Clerk. Mr. Markey?
    [No response.]
    The Clerk. Mr. Boucher?
    [No response.]
    The Clerk. Mr. Pallone?
    Mr. Pallone. No.
    The Clerk. Mr. Pallone votes no. 
    Mr. Gordon?
    Mr. Gordon. No.
    The Clerk. Mr. Gordon votes no.
    Mr. Rush?
    [No response.]
    The Clerk. Ms. Eshoo?
    Ms. Eshoo. No.
    The Clerk. Ms. Eshoo votes no.
    Mr. Stupak?
    [No response.]
    The Clerk. Mr. Engel?
    Mr. Engel. No.
    The Clerk. Mr. Engel votes no.
    Mr. Green?
    Mr. Green. No.
    The Clerk. Mr. Green votes no.
    Ms. DeGette?
    Ms. DeGette. No.
    The Clerk. Ms. DeGette votes no.
    Mrs. Capps?
    Mrs. Capps. No.
    The Clerk. Mrs. Capps votes no.
    Mr. Doyle?
    [No response.]
    The Clerk. Ms. Harman?
    Ms. Harman. No.
    The Clerk. Ms. Harman votes no.
    Ms. Schakowsky?
    Ms. Schakowsky. No.
    The Clerk. Ms. Schakowsky votes no.
    Mr. Gonzalez?
    Mr. Gonzalez. No.
    The Clerk. Mr. Gonzalez votes no.
    Mr. Inslee?
    [No response.]
    The Clerk. Ms. Baldwin?
    [No response.]
    The Clerk. Mr. Ross?
    [No response.]
    The Clerk. Mr. Weiner?
    [No response.]
    The Clerk. Mr. Matheson?
    Mr. Matheson. No.
    The Clerk. Mr. Matheson votes no.
    Mr. Butterfield?
    Mr. Butterfield. No.
    The Clerk. Mr. Butterfield votes no.
    Mr. Melancon?
    Mr. Melancon. No.
    The Clerk. Mr. Melancon votes no.
    Mr. Barrow?
    Mr. Barrow. No.
    The Clerk. Mr. Barrow votes no.
    Mr. Hill?
    [No response.]
    The Clerk. Ms. Matsui?
    Ms. Matsui. No.
    The Clerk. Ms. Matsui votes no.
    Mrs. Christensen?
    [No response.]
    The Clerk. Ms. Castor?
    Ms. Castor. No.
    The Clerk. Ms. Castor votes no.
    Mr. Sarbanes?
    Mr. Sarbanes. No.
    The Clerk. Mr. Sarbanes votes no.
    Mr. Murphy of Connecticut?
    [No response.]
    The Clerk. Mr. Space?
    [No response.]
    The Clerk. Mr. McNerney?
    [No response.]
    The Clerk. Ms. Sutton?
    Ms. Sutton. No.
    The Clerk. Ms. Sutton votes no.
    Mr. Braley?
    Mr. Braley. No.
    The Clerk. Mr. Braley votes no.
    Mr. Welch?
    [No response.]
    The Clerk. Mr. Barton?
    Mr. Barton. Aye.
    The Clerk. Mr. Barton votes aye.
    Mr. Hall?
    [No response.]
    The Clerk. Mr. Upton?
    Mr. Upton. Aye.
    The Clerk. Mr. Upton votes aye.
    Mr. Stearns?
    [No response.]
    The Clerk. Mr. Deal?
    Mr. Deal. Aye.
    The Clerk. Mr. Deal votes aye.
    Mr. Whitfield?
    Mr. Whitfield. Aye.
    The Clerk. Mr. Whitfield votes aye.
    Mr. Shimkus?
    Mr. Shimkus. Aye.
    The Clerk. Mr. Shimkus votes aye.
    Mr. Shadegg?
    [No response.]
    The Clerk. Mr. Blunt?
    Mr. Blunt. Aye.
    The Clerk. Mr. Blunt votes aye.
    Mr. Buyer?
    Mr. Buyer. Aye.
    The Clerk. Mr. Buyer votes aye.
    Mr. Radanovich?
    [No response.]
    The Clerk. Mr. Pitts?
    Mr. Pitts. Aye.
    The Clerk. Mr. Pitts votes aye.
    Mrs. Bono Mack?
    Mrs. Bono Mack. Aye.
    The Clerk. Mrs. Bono Mack votes aye.
    Mr. Walden?
    [No response.]
    The Clerk. Mr. Terry?
    Mr. Terry. Aye.
    The Clerk. Mr. Terry votes aye.
    Mr. Rogers?
    [No response.]
    The Clerk. Mrs. Myrick?
    Mrs. Myrick. Aye.
    The Clerk. Mrs. Myrick votes aye.
    Mr. Sullivan?
    [No response.]
    The Clerk. Mr. Murphy of Pennsylvania?
    Mr. Murphy of Pennsylvania. Aye.
    The Clerk. Mr. Murphy of Pennsylvania votes aye.
    Mr. Burgess?
    Dr. Burgess. Aye.
    The Clerk. Mr. Burgess votes aye.
    Mrs. Blackburn?
    Mrs. Blackburn. Aye.
    The Clerk. Mrs. Blackburn votes aye.
    Mr. Gingrey?
    Mr. Gingrey. Aye.
    The Clerk. Mr. Gingrey votes aye.
    Mr. Scalise?
    Mr. Scalise. Aye.
    The Clerk. Mr. Scalise votes aye.
    Mr. Rush?
    Mr. Rush. No.
    The Clerk. Mr. Rush votes no.
    The Clerk. Mr. Weiner.
    Mr. Weiner. No.
    The Clerk. Mr. Weiner votes no.
    Mr. Space?
    Mr. Space. No.
    The Clerk. Mr. Space votes no.
    Mr. Dingell?
    Mr. Dingell. No.
    The Clerk. Mr. Dingell votes no.
    Mr. Markey?
    Mr. Markey. No.
    The Clerk. Mr. Markey votes no.
    Mr. Shadegg?
    Mr. Shadegg. Aye.
    The Clerk. Mr. Shadegg votes aye.
    The Clerk. Mr. McNerney?
    Mr. McNerney. No.
    The Clerk. Mr. McNerney votes no.
    Mr. Waxman. Have all members responded? The clerk will 
count the votes and announce them.
    The Clerk. On this vote, Mr. Chairman, the ayes are 17, the 
nays are 25.
    Mr. Waxman. 17 ayes, 25 noes. The motion is not agreed to.
    Mr. Barton, do you wish to have an opening statement?
    Mr. Barton. I wish to have another parliamentary inquiry 
based on my opening statement.
    Mr. Waxman. The gentleman will state his parliamentary 
inquiry.
    Mr. Barton. Under the Chairman's prerogative, you are not 
allowing opening statements except for two members on each 
side, the Chair, the subcommittee Chair, the ranking member of 
the full and the subcommittee.
    Mr. Waxman. And Mr. Dingell.
    Mr. Barton. And Mr. Dingell. Within that group, are members 
allowed to sublease their time? For example, if I don't want to 
use my 5 minutes, can I sublease 1 minute to Dr. Gingrey and 1 
minute to Dr. Burgess under your ruling, as long as I don't 
take more than 5 minutes total?
    Mr. Waxman. I have no objection if you want to use your 
time and distribute it to other members, but we have to stay 
within the time.
    Mr. Green. Mr. Chairman, parliamentary inquiry.
    Mr. Waxman. The gentleman will state his parliamentary 
inquiry.
    Mr. Green. Mr. Chairman, I understood that when each of us 
get our 5 minutes, we can either make a statement or we can ask 
questions.
    Mr. Waxman. Absolutely. That is, of course, after the 
Secretary testifies.
    Mr. Green. I just wanted to make sure that we will have the 
chance to either make a statement or ask questions. Thank you.
    Mr. Waxman. Without objection, the Chair will yield to Mr. 
Barton his 10 minutes--your 5 minutes.
    Mr. Barton. I will take 10, Mr. Chairman.
    Mr. Waxman. We will yield to you your 5 minutes.
    Mr. Barton. I will take 20 if you will give me 20.
    Mr. Waxman. Well, you have already taken a lot of time.
    Mr. Barton. Well, I think it is important that members on 
both sides, Mr. Chairman, have the right----
    Mr. Waxman. The gentleman is recognized for 5 minutes; it 
is his time to do with as he sees fit.

   OPENING STATEMENT OF HON. JOE BARTON, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Barton. All right. I will make this statement: The 
little exercise that we just went through is to give every 
member of this committee an opportunity to talk to the 
President's designee for health care before she gives her 
opening statement. I think that is important for every member 
of this committee on both sides of the aisle. I strongly 
disagree with the rule that was implemented at the start of 
this Congress. I can't prevent its implementation because the 
majority did vote to give Chairman Waxman that power and he has 
used it; I think he has used it mistakenly, but he does have 
the right to do that.
    Having said that, Mr. Chairman, we are delighted to have 
our Secretary of Health and Human Services before us. We have 
received the President's budget and we understand that she is 
prepared to explain that budget. We also hope that she will be 
willing to answer some questions about what the President 
intends to do in terms of his health care policy given what has 
happened in Massachusetts and in the other body.
    With that, I would be happy to yield to Dr. Gingrey for 1 
minute if he would wish to make a brief opening statement.
    Mr. Gingrey. Mr. Chairman, I thank the gentleman for 
yielding.
    Madam Secretary, I thank you for being here.
    The President's $911 billion budget request for the 
Department of HHS represents a 10 percent increase in spending 
over last year's budget. While there are some laudable things 
included in this proposal, this budget rests on cutting $500 
billion from the Medicare program. These cuts, according to, 
Madam Secretary, your chief actuary of the Medicare program, 
will ``result in less generous benefits, and might result in 
physicians who treat Medicare seniors ending their 
participation in the program.''
    Eleven million seniors are enrolled in Medicare Advantage 
plans, roughly a quarter of all Medicare beneficiaries are at 
considerable risk, and they will incur hundreds of dollars in 
annual cost increases to make up for these cuts. Trimming the 
fat from the program is one thing, but gutting the program is 
certainly another.
    Mr. Chairman, let me say again, our seniors' health care 
program and their pocketbooks should not be used as a piggy 
bank to fund a government one-size-fits-all takeover of our 
health care system.
    I yield back the time and I thank the gentleman for 
yielding.
    Mr. Barton. I now want to yield to the vice ranking member, 
Mr. Blunt of Missouri, for 1 minute.
    Mr. Blunt. Thank you, Mr. Barton, for yielding to me.
    Frankly, Mr. Barton and members of the committee, I think 
this budget does not accurately reflect our current economic 
situation. The so-called ``spending freeze'' doesn't even go 
into effect until next year. The budget has a complete lack of 
detail when it comes to Medicare cost containment, much less 
detail than the budget the President submitted last year.
    There are also discrepancies that make the administration's 
goals unclear because this budget seems to assume that health 
care reform would already be enacted. I would be interested 
particularly to hear why high-risk pools are excluded from the 
budget and what the administration's plans for these programs 
will be. Currently, this program serves thousands of 
Missourians that otherwise would be uninsured. I would like to 
see it expanded rather than eliminated from the budget. I hope 
to learn today that that is not the goal of the budget, even 
though the budget excludes high-risk programs.
    I yield back.
    Mr. Barton. Is there anybody else on my final 1\1/2\ 
minutes that wishes to say something before I finish up? Seeing 
no hands raised, let me conclude my time, Mr. Chairman, by 
simply saying that when the President was sworn into office, at 
our first meeting in the White House he promised a health care 
reform package that wouldn't add one net dime to the national 
debt. As we all know, the plan that has come out of the 
Congress, or at least out of the House, is a huge unfunded 
mandate. In this particular budget that has been presented, it 
appears that there will be even more spending on health care. 
We don't see how that is reconcilable. We do know that over 60 
percent of the population in this country has expressed their 
disapproval of the plan that is languishing, the different 
plans in the House and the Senate. We would hope, Mr. Chairman 
and Madam Secretary, that the President will reach out to 
everybody on both sides of the aisle, start over and deliver an 
honest, bipartisan effort to try to get a health care plan that 
is affordable, that is real reform, and it does provide more 
health care for more Americans.
    With that, Mr. Chairman, I yield back the remaining 10 
seconds of my time.
    Mr. Waxman. The gentleman yields back his time.
    Mr. Pallone.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Mr. Chairman.
    I want to welcome the Secretary here this afternoon. We 
always enjoy it when you visit the committee.
    It is often said that budgeting is about setting 
priorities: how do we allocate our resources to those things 
that we value? And this is no easy task especially amid 
concerns of rising deficits and debt. But it is clear to me 
that based on the President's budget proposal, health care 
remains a top priority for this administration. I am happy that 
this is the case because as we all know the health care 
problems that American families face are getting worse and need 
our attention.
    Millions of Americans have lost their jobs amid the 
recession and with it access to their employer-sponsored health 
insurance. In order to help provide some relief to these 
families, last year we passed the American Reinvestment and 
Recovery Act, which included additional money to help maintain 
State Medicaid programs in the face of increasing enrollment 
and fewer State dollars. In addition, we provided laid-off 
workers with a new 65 percent subsidy to help them purchase 
COBRA coverage.
    As unemployment stubbornly hovers at 10 percent, we need to 
maintain these safety net programs. That is why I was glad to 
see the President's request for an additional $25.5 billion to 
extend the temporary FMAP increase, as well as another 
extension of the subsidy for COBRA continuation coverage. These 
immediate investments are critically important to making sure 
those families who continue to fall on hard times have the 
support they need from Washington.
    This budget also plans for long-term investments in our 
health care system. For example, the efforts already underway 
and the investments the administration plans to make in the 
area of health information technology, or HIT, will help 
modernize our health care system, thereby improving the quality 
of care, improving efficiency, and lowering health care costs 
in the long run.
    And Madam Secretary, this budget builds on a lot of our 
accomplishments from last year. That much is clear to me. But 
as you know, there is still a lot more to be done. We must rein 
in out-of-control health care costs that are choking America's 
working families, businesses, and the government. We need to 
improve access to affordable and quality health care coverage 
for the millions of Americans who are currently without health 
insurance or on the verge of losing the coverage that they 
currently have. And we need to put an end to the abuses and 
outright discrimination used by insurance companies to deny 
people the care they need and increase their profits.
    In sum, we need a comprehensive health reform bill. And I 
look forward to working with you and the President on the many 
priorities laid out in this budget, especially enacting 
comprehensive health reform this year.
    I thank you, Mr. Chairman, and also the Secretary for being 
here today, as always. Thank you.
    Mr. Waxman. Thank you, Mr. Pallone.
    The Chair recognizes Mr. Deal, the ranking member of the 
subcommittee.
    Mr. Deal. Mr. Chairman, I have 5 minutes; could I allocate 
time also among members?
    Mr. Waxman. The gentleman is recognized for 5 minutes to 
use as he sees fit.

  OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF GEORGIA

    Mr. Deal. Thank you, Mr. Chairman.
    This budget proposal, of course, leaves many unanswered 
questions; one, of course, is the question of the impact of the 
proposed health care reform legislation that is still pending. 
The budget, as I see it, leaves a placeholder with a projected 
savings of $150 billion, but there are certainly questions 
relating to that. We know that the original proposal was to cut 
Medicare and help pay for the cost of any proposed new 
legislation. I would be interested to hear what the Secretary 
says with regard to the administration's position on that.
    Also, the budget appears to write off almost $400 billion 
in anticipation of the SGR fix. We obviously would be 
interested in knowing what is going to take the place of SGR 
and whether or not that new program would anticipate curbing 
over-utilization of Medicare services. But for many of us, 
Medicaid is one of the biggest areas of concern. Under this 
budget, the Federal share of Medicaid outlays would be $297 
billion for fiscal year 2011. That is a 7.8 percent increase 
over fiscal year 2010 and a $95.4 billion, or a 47.4 percent 
increase, over fiscal year 2008 spending. That is of concern as 
we see the mandated expansion of Medicaid under the proposed 
bills that are now still pending. Those are concerns as to how 
the government--and States, of course, too--are going to be 
expected to pay for those expanded coverages.
    I will yield at this time 1 minute to Mr. Shimkus.
    Mr. Shimkus. Thank you, Mr. Deal. And Madam Secretary, 
welcome.
    Today we are in the process of increasing the debt limit on 
the floor of the House. I think it is the fifth time that we 
have increased the debt limit since the Democrats have been in 
control of Congress, and we are doing so again.
    Instead of freezing, can't we find one penny on the dollar 
savings across the board in Federal spending, just one cent of 
a dollar? I think we can, and that is why we have difficulty 
with this budget.
    The discretionary end, as you know, is only about one-
fourth of the budgetary spending. If we are not talking about 
the entitlement programs of Medicare and Medicaid, we are not 
addressing the real problems that we have in this catastrophic 
budget deficit and the debt that we are incurring. And as you 
know, on the entitlement programs of Medicaid, as they expand, 
which these health care plans do, we force the States to pay in 
more money that they don't have.
    So we have a lot of questions, Mr. Chairman. I wish we had 
more time. I look forward to the rest of the questions that we 
have to offer, and I yield back.
    Mr. Deal. I yield to Mr. Murphy.
    Mr. Murphy of Pennsylvania. Thank you.
    Madam Secretary, thank you for being here. Sometimes it is 
not a pleasant thing to be in front of Members of Congress. But 
I just thought I would make a recommendation of something that 
hopefully you will have some power or control of doing, and 
that is, as we look at health care issues, one of the things 
that I think is so important is looking at how we can save 
money, not deal with health care by raising taxes, not deal 
with health care by spending more, but sometimes look at our 
Medicare and Medicaid programs.
    As you know, they were founded in the 1960s and have 
thousands of things they pay but--for none of us still drive a 
1965 car--we hope not, unless it has been overhauled a few 
times. There are still incredible inefficiencies in those 
programs in things that unfortunately take an act of Congress 
to change, and things are not there yet in some programs. We 
should be doing more coordinating care.
    The paperwork, the procedures, the prescription errors are 
still a problem for us. It takes months to get a motorized 
wheelchair. If someone gets some emergency medicine and they 
need more until a prescription arrives, the amount of paperwork 
physicians have to do, it just adds more to that.
    Home infusion therapy is still not permitted even if 
someone is capable of doing that. That takes an act of Congress 
to change, too. So I hope that you will use your leadership and 
your position to help streamline a lot of this. Quite frankly, 
I think we can save billions of dollars and tens of thousands 
of lives by making things better in this whole process. And 
there I think we will see an awful lot of savings which you can 
use to deal more with our health care in America.
    With that, I yield back my time.
    Mr. Deal. I would be glad to yield to any other members on 
the Republican side who want time. If not, I yield back my 
time, Mr. Chairman.
    Mr. Waxman. The gentleman yields back his time.
    Mr. Dingell, do you wish to make an opening statement?
    Mr. Dingell. Mr. Chairman, thank you. I would like to 
welcome the Secretary to the committee. Her father, as we all 
remember, was a distinguished member of this committee and this 
body, and her father-in-law was a distinguished Republican 
Member of the Congress. Welcome.
    In the interest of time, and out of my respect for my 
colleagues, I ask unanimous consent to insert my statement in 
the record.
    [The prepared statement of Mr. Dingell follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    
    Mr. Waxman. Thank you, Mr. Dingell.
    Madam Secretary, we are delighted you are here. We have 
been looking forward to hearing from you. We wish we had been 
able to hear from you earlier, but we are delighted to 
recognize you now and to have you make such statements as you 
wish to make to us about the budget matter.

   STATEMENT OF KATHLEEN SEBELIUS, SECRETARY, UNITED STATES 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Secretary Sebelius. Thank you very much.
    Chairman Waxman, Chairman Emeritus Dingell, Ranking Member 
Barton, Representative Pallone, Representative Deal, and 
members of the committee, thank you for inviting me here to 
discuss the 2011 budget for the Department of Health and Human 
Services.
    We think the budget builds on the themes that the President 
laid out in his State of the Union, strengthening security and 
opportunity for America's working families, investing to build 
a foundation for future growth, and bringing in a level of 
accountability and transparency to government. It abides by the 
pledge to root out programs that are redundant and obsolete.
    Under this budget, we seek to provide the health and human 
services that Americans depend on more effectively and more 
focused results. We will make necessary investments that our 
country has been putting off for years, including investments 
in fighting health care fraud, strengthening our public health 
infrastructure, and getting serious about prevention and 
wellness.
    The budget is a major step toward a healthier, stronger 
America, and we think that this budget and comprehensive health 
reform will make families healthier, create jobs, and give them 
the security and stability they need.
    We are firmly committed to health insurance reform, and as 
the President reaffirmed, we are always willing to listen to 
ideas and work with anyone who is interested in finding a 
comprehensive solution to the health care crisis. Reform is 
still the best way to help millions of Americans without health 
insurance and millions more who are underinsured or who have a 
preexisting condition.
    It is still the best way to help Americans who are just a 
pink slip away from losing their insurance. The administration 
continues to reach out to Members of Congress, doctors, nurses, 
hospitals, and other key partners in this effort.
    But the investments we are making in 2011 support the goals 
of reform, improving America's access to the high-quality 
health care they need. I look forward to discussing the 
importance of these reforms with you, but I want to give you 
just a brief overview of the budget priorities for this year 
and then look forward to the questions.
    From day one, the President said we need to put science 
first, and that is really how our Department is run, it is 
reflected in the budget. Whether it is fighting a pandemic or 
protecting food safety or transforming the health care system 
with electronic medical records, the investments we are making 
are guided by some of the best scientific and medical experts 
in the world. We are also guided by a constant vigilance about 
using taxpayer dollars wisely.
    At a time when so many American families are scraping 
together every last dollar to pay their medical bills, fraud, 
waste and abuse are unacceptable. That is why this budget 
contains an historic investment in cracking down on the health 
care fraudsters who steal from taxpayers, endanger patients, 
and jeopardize Medicaid and Medicare's future. The investment 
allows us to build on efforts that began last May when the 
President asked the Attorney General and me to put together a 
new fraud task force known as HEAT. It is an unprecedented 
partnership, bringing together high-level leaders from both 
departments to share information, spot trends, coordinate 
strategies, and develop new fraud, prevention and prosecution 
teams.
    One year ago today, we extended access to millions of 
children through the CHIP Reauthorization Act. In 2009, we know 
that 2.5 million more children who were previously uninsured 
got health care coverage from Medicaid or CHIP. Now part of 
that landmark legislation contains funds to help us reach out 
to the approximately 4 to 5 million children who are eligible 
but not yet enrolled in those critical programs.
    We are also investing new funds in what I consider to be 
the backbone of the American health care system, community 
health centers. Thanks to this investment, the neighborhood 
centers will provide high-quality primary care for 20 million 
people a year, 3 million more than were able to be served in 
2008. The budget ensures up-to-date care for seniors and people 
with disabilities who depend on Medicare.
    On top of that, we have almost $1 billion in funding to 
strengthen and support our country's health care workforce. We 
increase funds for the Indian health service. American Indians 
and Alaska Natives historically have not gotten the care they 
have been promised and deserve, but we are working to change 
this because, regardless of race, ethnicity, gender, disability 
or geography, every American deserves high-quality, affordable 
care.
    We are investing in next-generation health care 
technologies to help providers raise the quality of care for 
all Americans. The adoption by doctors and hospitals of 
electronic health records reduces medical errors, helps 
coordinate care, and cuts cost and paperwork.
    This budget does assume a zero percent update for physician 
payments. Everyone agrees that the scheduled Medicare physician 
payment cuts are not sustainable and would seriously damage 
access to care for Medicare beneficiaries. So we are 
recognizing this as an honest budget that reflects Congress' 
continued action in this area. And we look forward to working 
with you, Mr. Chairman, and your committee to develop the 
payment policy to give physicians incentives to improve quality 
and efficiency.
    Our budget is based on our growing understanding that 
health is influenced by many factors outside a doctor's office. 
Where you live matters, what you eat and drink matters, even 
what you watch on television. And to help more Americans live 
healthy lifestyles, the budget continues the work of rebuilding 
the public health infrastructure. What we have today is 
overwhelmingly a sick care system, where we wait until 
something goes wrong to intervene. We are trying to build a 
true health care system. To that end, the budget creates a new 
program at the Centers for Disease Control and Prevention that 
will work to reduce the rates of disability and morbidity due 
to chronic disease in 10 of our biggest U.S. cities. It will 
allow us to begin the serious fight against obesity, a problem 
costing our health care system almost $150 billion a year.
    There is a significant increase to help us build a 21st 
century food safety system to go along with our 21st century 
food market where nearly half our fruit and over three-quarters 
of our seafood come from overseas. We are expanding the efforts 
of the new Food Safety Working Group that I cochair with 
Agriculture Secretary Tom Vilsack. The additional funding 
allows us to update food safety standards, enhance surveillance 
and response, and hire 350 additional food inspectors. It makes 
a serious investment in our battle against smoking. The budget 
provides significant funds for educating children about the 
dangers of smoking and new research to help us develop better 
ways to stop Americans from smoking.
    While we continue to do the steady work of promoting health 
care, we also need to prepare for public health emergencies, 
whether their cause is mother nature or our fellow man. Some of 
the best defenses are medical countermeasures--vaccines, 
treatments, respirators, among other things, that help reduce 
the spread of infections, reduce health consequences, and 
ultimately save lives.
    This flu season we got a wake-up call about the readiness 
of our countermeasures. Even as our scientists and private 
sector partners scrambled to produce a safe, effective vaccine 
in six months--three months faster than it usually takes--we 
saw temporary vaccine shortages because the vaccine grew slowly 
in chicken eggs, an unpredictable process we have used for the 
last 50 years. So the budget includes a half billion dollars to 
upgrade countermeasures. Just as important, it contains 
significant funds for NIH for research that continues many of 
the breakthroughs that make these countermeasures possible.
    We are also taking a comprehensive review of our entire 
countermeasure production process, from laboratory to the 
doctor's office, and we will have a report to give this 
committee later this year.
    Strengthening America's health is half of our mission, and 
our budget goes a long way to restoring health security for 
Americans, but the other half of the mission is providing 
security and opportunity for America's working families. Middle 
class families aren't just taking care of their children these 
days--and we have provided some additional help with child 
care--but they are also often dealing with aging parents. 
Eighty percent of the long-term care services in this country 
are provided by family members; great for older Americans to be 
cared for by their loved ones, but often financially and 
physically exhausting for caregivers. So there is significant 
new support for those family caregivers, including counseling 
and information about how to best care for elders, adult day 
care centers to help drop parents off for a day, and 
transportation to get seniors to the doctor or the grocery 
store. Investments help give caregivers relief and help them 
keep their loved ones at home as long as possible.
    And finally, the budget extends relief that we provided 
last year for States and communities facing budget cuts across 
this country, helping States maintain essential supports and 
services at a time when working Americans need them most.
    There is no question that hardworking people of this 
country have been tested over the last few years. As President 
Obama said in his State of the Union, we urge Americans to rise 
to the challenges posed by our current difficulties and pledge 
that as a country we will face these challenges together.
    We are closer than ever to passing health reform, and we 
intend to work with you to finish the job for the American 
people. The 2011 budget will support an enhanced reform, making 
long-overdue investments in strengthening our health care and 
public health systems, keeping all of us healthy and more 
secure while targeting relief directly to working Americans who 
need it most. My department clearly can't accomplish any of 
these goals alone, it will require all of us working together.
    Thank you, and I look forward to your questions.
    [The prepared statement of Secretary Sebelius follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Mr. Waxman. Thank you very much, Madam Secretary. That was 
an excellent review of the budget.
    I want to start off the questions. First of all, I want to 
say how pleased I am with the President's continued commitment 
to health care reform. It is a goal that we share. I know that 
you have done a lot of thinking about how to make sure that we 
are ready for reform and that your budget reflects critical 
building blocks in that effort. Members of this committee have 
been particularly concerned to make reform work, and we need to 
ensure access through more health centers and training of 
health professionals, and to take advantage of new health 
information technologies, and to recommit to prevention and 
public health.
    I want to ask you some specific questions, however, about 
Medicare. There are two critical priority areas I see in this 
particular area. First, we need to improve Medicare coverage of 
prescription drug costs by filling in the donut hole in the 
drug benefit. Seniors should not have to go without needed 
medicines due to lack of coverage. And second, beneficiaries 
must be able to get the care they need from their physicians, 
and that requires fair and predictable payment. So we must 
permanently reform the broken physician payment system in 
Medicare.
    Could you elaborate on the administration's policies in 
these two areas?
    Secretary Sebelius. Certainly, Mr. Chairman.
    I think that the donut hole, the reduction of the excess 
costs that too many seniors have to pay when they reach their 
limits in the prescription drug program are parts of both the 
House and Senate plans on health reform. They are not repeated 
in this budget; we are assuming that we will move ahead on 
health reform and have those as part of the critical future. 
But as you know, it is one of the most serious issues for 
seniors across this country, and way too many people hit that 
gap and don't have the wherewithal to pay 100 percent out of 
pocket for the drugs that keep them out of the hospital and 
keep them well.
    The most serious challenge facing Medicare beneficiaries 
right now is the 21 percent scheduled budget cut to their 
doctors. I talk to doctors every day, I talk to seniors every 
day, and they tell me that that isn't possible that we would 
have a system guaranteeing health care for seniors and cutting 
those payments. Our budget assumes that over the next 10 years, 
we will not cut those payments 21 percent. We look forward to 
working with you, Mr. Chairman, to find a specific policy--as 
you know, both the House and the Senate have addressed this 
plan in the past.
    We look forward to both the House and Senate addressing it, 
but it is a problem looming, facing the 43 million Americans 
who depend on Medicare benefits. If that kind of cut were to 
occur, we would not have providers to deliver those essential 
services.
    Mr. Waxman. Well, I am pleased that you are committed, as 
we are, to deal with both of those issues, and we have to find 
a way to do it.
    I want to ask you a question about Medicaid. When 
unemployment goes up, families lose their incomes and their 
health insurance, so the need for Medicaid increases. At the 
same time, State revenues necessary to pay for Medicaid 
decline. To help States maintain their Medicaid programs during 
the recession, the Recovery Act we enacted last year included a 
temporary increase in the Federal Medicaid Matching Payments, 
or FMAP. Each State received at least a 6.2 percent increase, 
and States with very high unemployment received more. This 
temporary FMAP increase will expire at the end of December. 
Unfortunately, many States are still expecting high 
unemployment and sharp declines in revenues well into 2011. The 
President's budget recognizes this problem and requests an 
extension of the FMAP increase through June 2011. The House has 
twice passed such a 6-month extension, once in the health 
reform bill and once in the jobs bill.
    My question for you, Madam Secretary, is, what happens next 
January if we fail to extend this FMAP increase? What are the 
implications for State budgets, for health care providers, for 
health care workers, for Medicaid beneficiaries?
    Secretary Sebelius. Well, Mr. Chairman, as you know, I came 
to this Cabinet position directly from a governorship in the 
State of Kansas, where I served until the very end of April 
last year. So I was a governor cutting the very budgets you 
talk about. And I can tell you from my personal experience how 
the stimulus package, the Recovery Act funds, not only helped 
us to make sure that we did not have to slash essential 
benefits at a time when additional Kansans needed those 
benefits, but, in fact, saved jobs.
    State budgets are largely education funding and health care 
funding. Those are often somewhere between 75 and 90 percent of 
the budget. If we did not have those additional resources to 
help keep health services, in fact, we would have laid off 
teachers, we would have laid off correctional officers, highway 
patrol, jobs all over because there is no place else to get 
that money.
    So not only is it an essential service, but I think it is 
directly related to thousands of jobs in my State and hundreds 
of thousands, perhaps millions of jobs around the country.
    Every governor in this country--and I talk to my former 
colleagues on a regular basis--describe this as one of their 
top priorities, the continuation of the FMAP assistance through 
June of next year, which is the State fiscal year. This will 
get most States through their next fiscal year. I think it is 
absolutely an essential part of our recovery moving forward. 
Absent that, the modest progress now being made in States that 
they hope will be more significant progress over the next 
several months, focusing on jobs, on new development, on 
innovation will take a major step back.
    Mr. Waxman. Thank you very much.
    Mr. Barton.
    Mr. Barton. Thank you, Mr. Chairman. Thank you, Madam 
Secretary, for being here.
    Before I ask questions, let me just compliment you on one 
part of our budget, or the President's budget. The budget for 
the community health centers was increased by $290 million. 
That is something that I think most Republicans support; I know 
I do. The community health centers in my district do excellent 
work and they do it very efficiently. So I want to be positive 
about that, and I am sure that you are very supportive of that, 
too.
    Back in September, myself and Congressman Walden, the 
ranking member of the Oversight Subcommittee, sent you a letter 
about the use of title 42 funding. Title 42 gives the Health 
and Human Services Department the ability to pay certain of its 
employees above the general schedule to attract the very top 
talented NIH in certain research situations. This title 42 
authority is explicitly limited to Health and Human Services. 
In the last 10 years, over 3,000 employees have been given this 
designation by HHS, some of them make well over $300,000 a 
year. That, in and of itself, is not necessarily a bad thing. I 
think it is something we need to look at in the terms of tight 
budget authority.
    But my question today and the question in the letter, the 
Environmental Protection Agency is now using title 42 
authority. And my question to you first is, is the EPA now part 
of Health and Human Services?
    Secretary Sebelius. Not to my knowledge.
    Mr. Barton. Is the Surgeon General an employee or a part of 
Health and Human Services?
    Secretary Sebelius. Yes, sir. The Surgeon General has 
always--I don't know always, but certainly is a part of our 
Department under the Office of Public Health and Science.
    Mr. Barton. Could you construe the administrator at EPA to 
be the Surgeon General?
    Secretary Sebelius. No, sir. We have a Surgeon General, 
Regina Benjamin is the Surgeon General of the United States.
    Mr. Barton. OK. Then why in the world do you allow the 
Environmental Protection Agency to use title 42 authority--
which is explicit to your Department--to create a program at 
EPA to put their employees in the special designation by the 
hundreds of people? Are you aware that that is happening?
    Secretary Sebelius. Sir, I am aware of your letter, and I 
have had some discussions with the staff. We are trying to get 
the most complete answer we can. But as far as I know, there 
has been no explicit or implicit designation of authority to 
the Environmental Protection Agency.
    Mr. Barton. Well, you just gave more information in the 
last 30 seconds than we have gotten in the last six months.
    Secretary Sebelius. Well, as I say, series of events, I was 
not here. I don't know when this practice started. We are 
working on your letter. We want to get you a thorough and 
complete answer. I am telling you what I know at this point, 
but we will fully answer your letter and I intend to.
    Mr. Barton. Well, I have another copy of the letter; I am 
more than willing to give it to you again.
    We have a situation where the Environmental Protection 
Agency appears to be completely without authority to set up a 
program. They even have a manual, apparently, at the EPA on how 
to convert their employees to title 42 employees. Now, you just 
said, rightfully so--and I commend you for being honest--that 
the Environmental Protection Agency is not a part of HHS, and 
the EPA administrator can in no way be construed to be the 
Surgeon General.
    So you understand the law. My request is that you now 
enforce the law with the EPA and answer the letter--which we 
sent copies to Mr. Waxman and Mr. Stupak, Mr. Walden and I--so 
we can stop this practice. I mean, do you agree with me that 
the EPA should not be setting up a title 42 program since title 
42 is explicitly designed to give some additional financial 
encouragement and compensation to our highest scientists and 
researchers at NIH and FDA?
    Secretary Sebelius. Mr. Barton, what I can assure you is 
that I will thoroughly investigate this and I will get you a 
complete answer to your letter as promptly as we possibly can.
    Mr. Waxman. The gentleman's time has expired.
    Mr. Pallone.
    Mr. Pallone. Thank you, Mr. Chairman.
    Madam Secretary, I mentioned in my opening statement, I 
think I mentioned both the FMAP increase and the COBRA subsidy 
have been critical in helping Americans who have been hard hit 
by the recession. Chairman Waxman already asked you about 
extending the FMAP increase, which I support, but I wanted to 
also ask you about extending the COBRA subsidy. And essentially 
what would be the impact if we didn't make this COBRA subsidy 
expansion, not looking for numbers, but just generally why that 
is important and what would happen if we didn't do it?
    Secretary Sebelius. Well, Congressman Pallone, I think 
that, as you well know, COBRA is an effective tool, but often 
not financially viable for way too many folks, particularly 
folks who have lost their jobs in a downturn. The opportunity 
to purchase 100 percent of their previous coverage is a nice 
offer, but often out of reach. So what this bridge program 
allows is, with some additional help from the Federal 
Government, workers who are laid off and their families can 
continue to have essential health services. Again, absent 
health reform, which could create an alternate, more viable, 
more affordable market, this is an essential way to make sure 
that hardworking families who have lost their job through no 
fault of their own continue to have health services.
    Mr. Pallone. Well, let me say I do hear from a lot of these 
people because, as you know, before they made the current 
extension there were a lot of people that were in danger, or 
actually already had--I think there was a week or so there when 
some actually had lost their subsidy, and many of them did call 
my office and said they wouldn't be able to continue their 
coverage. Do we have any idea the numbers that might not be 
able to make that 100 percent without the subsidy? Do we have 
any idea? Maybe can you get back to me on that.
    Secretary Sebelius. I would be glad to. I think it is 
likely, though, a laid off worker is almost guaranteed not to 
be able, unless they have a huge nest egg, to be able to pay 
out of pocket for 100 percent of the previously covered 
employer costs.
    Mr. Pallone. So you think it is actually--maybe not 100 
percent, but very close to it.
    Secretary Sebelius. That was certainly, again, not only my 
personal experience talking to me, but what I saw across the 
country. They are scrambling to pay rent, buy food, and 
unfortunately health insurance is often something that has to 
go by the boards. As desperately as they would like to continue 
it, it just isn't a viable option.
    Mr. Pallone. Thank you.
    Let me ask you about SCHIP also. Today literally marks the 
1 year anniversary since the President signed into law the 
CHIPRA program, which is a variation on SCHIP that we passed in 
the last year or so. I am particularly proud of that 
legislation because we worked in a bipartisan fashion to 
increase access for, I think, about 11 million children.
    Can you tell me how implementation of CHIPRA has gone over 
the past year; how has insurance coverage and the quality of 
the coverage improved for kids; and how have you been working 
with the States to increase coverage and improve retention 
rates?
    Secretary Sebelius. Well, what I am pleased to report, 
Congressman Pallone, is that, in spite of the downturn in the 
budget of most States across the country, State leaders are 
seeing ensuring our children a fundamental piece of making sure 
we have a healthy, prosperous future. So States are actually 
increasing coverage for children. Many States have actually 
increased the threshold of the poverty level for whom the CHIP 
program applies.
    Congress, I think wisely, provided some outreach funds. So 
we have put those funds in the hands of State leaders and State 
partners to actually try and enroll kids. It is one thing to 
have them eligible, it is another thing to find and enroll 
children. Those partnerships are very creative and underway 
with faith-based communities and medical outreach centers with 
community health centers. I just did an event today with 
Secretary Vilsack looking at the opportunity to try and make 
sure that enrollment is as easy as possible, and as a family is 
signing up for the supplemental nutrition program, they also 
can sign up their children for health insurance. And what we 
know is that about 2.5 million additional children in the year 
since CHIPRA has been extended have been signed up and 
enrolled, again, in spite of very difficult budget times, and I 
think that is good news.
    Mr. Pallone. That is very good news. And I thank you for 
all your efforts. And those outreach programs I think are 
particularly important.
    Thank you.
    Mr. Waxman. The gentleman's time has expired.
    Mr. Blunt.
    Mr. Blunt. Thank you, Mr. Chairman.
    Madam Secretary, thanks for being here today. I would have 
said that earlier, but I was in a rush to get my 1 minute in 
about a couple of things I am concerned about.
    Something you mentioned earlier about the donut hole in 
Medicare part D, you said too many seniors have to pay because 
they get into this donut hole. Do all seniors pay that get into 
this donut hole or are poorer seniors at some level exempted 
from the donut hole?
    Secretary Sebelius. Well, you don't actually hit the donut 
hole unless you extend beyond the limits that the initial 
provision of part D pays for.
    Mr. Blunt. I know that. So the seniors that get above that 
limit, do poorer seniors have to pay if they get into the donut 
hole, the poorest seniors?
    Secretary Sebelius. I want to make sure I am giving you 
accurate information. They do not, sir.
    Mr. Blunt. They do not. And I think that number is, what is 
it, 135 percent of poverty; or is it a different number than 
that?
    Secretary Sebelius. 150 percent of poverty.
    Mr. Blunt. So poor seniors don't pay. Under your proposal, 
would all seniors be exempted in this donut hole from having 
any expense?
    Secretary Sebelius. Sir, we did not have in the budget 
closing of the donut hole. What I was referring to with the 
chairman is the provisions that are in both, and they are 
different in both versions of the Senate and House health 
reform legislation. Both majorities sought to close the donut 
hole, but our budget----
    Mr. Blunt. Well, since you talked about, can we talk about 
it for a minute? Closing the gap, among other things, suddenly 
there is no disincentive, it would seem to me, for all seniors, 
including the richest seniors, not to use generic drugs, not to 
look for an alternative product if there is no reason not to 
get into this high level of spending. What I have wondered 
about is if 150 percent of poverty isn't a good enough number 
to help seniors who can't afford it, what is the best number? 
This idea that all seniors, no matter how wealthy, deserve for 
the Federal Government, through part D, to help them pay for 
their drugs doesn't seem to really benefit the system or be the 
kind of reforms we need in Medicare generally. And I am just 
troubled by this idea that somehow all seniors are 
disadvantaged by this, and no matter how much money they have, 
they shouldn't have to worry about this donut hole.
    Secretary Sebelius. Well, Senator--I mean Congressman, 
running for Senator Congressman. We would be happy to work with 
you if you would like to talk about a cap or a limit for 
applicability to close the donut hole. At this point I think 
there is no differential if you are a wealthy senior or a poor 
senior.
    Mr. Blunt. Well, of course there is a differential. You 
just said there was, 150 percent of poverty.
    Secretary Sebelius. No, I am saying at the original 
benefits of the program there isn't a differential. I think if 
you are ill, if you are wealthy or poor you are likely, much 
more likely to hit the cap than if you are in great shape. It 
has I think more to do with someone's health and well-being 
than economic status.
    Mr. Blunt. I actually thought it had to do with the 
capacity to pay. The chairman said seniors should not have to 
go without their medicine due to lack of money. Now I don't 
disagree with that at all. I do disagree with the idea that 
somehow a problem that can't be solved any way other than 
eliminating this one area where you have to think about whether 
you get above a spending cap or not.
    Mr. Waxman. Would the gentleman yield?
    Mr. Blunt. I don't have much time, Mr. Chairman. I don't 
think I probably can.
    On the question of high risk pools, I don't know, Governor, 
if Kansas had one or not, Missouri says--and we have both used 
them and are both familiar with them. Do you have any idea why 
there is no money in this budget for high risk pools?
    Secretary Sebelius. Well, Congressman, at least in Kansas, 
and I think it is true across the country, the Federal 
Government really provides very little in the way of support 
for----
    Mr. Blunt. On this budget they provide nothing.
    Secretary Sebelius. I understand. It is about 2 percent. 
And what was anticipated with the passage of health reform that 
we would actually have a whole different situation with high 
risk pools. Many of the people in Kansas in high risk pools are 
those who are blocked out of the insurance market, because 
insurance companies refused to take them with preexisting 
conditions. Health reform solves that piece of the puzzle, they 
would have affordable coverage. So there was money in health 
reform for a new basis of high risk pools that could create 
some stop loss policies for those and a stop gap method between 
now and the time the exchanges are set up, but we anticipated 
that actually the high risk pool as they are seen right now, 
which is a very modest safety net, often way to expensive for 
most people to afford, would cease to exist. That is why the 
budget----
    Mr. Blunt. I think the percentage of the premium in 
Missouri is about 135 percent of what the normal premium would 
be. I would certainly be glad to work with you on, assuming 
where we are today on this issue, that we can figure out ways 
to expand access to the high risk pools.
    Mr. Chairman, I am over my time.
    Mr. Waxman. The gentleman's time has expired. Mr. Dingell.
    Mr. Dingell. Chairman, thank you. Again Madam Secretary, 
welcome. Madam Secretary, there have been a lot of scandals and 
unfortunate news about food safety and foods. You will recall 
last year this committee reported unanimously with the support 
of both sides. My Republican colleague Mr. Barton was one of 
the cosponsors as was our chairman and Mr. Pallone and other 
members of this committee. That was a bill which passed the 
House with an overwhelming vote and it is now sitting in--I 
hope in a position where maybe we could get it up to the floor 
so it could get to conference and we can pass it to law.
    Do you have the authority you need now to protect the 
American people, yes or no, from unsafe food products both in 
this country and coming in from abroad?
    Secretary Sebelius. No, sir.
    Mr. Dingell. Madam Secretary, I am very pleased at the 
commitment to medical product safety in the bill and also to 
food. Do you believe that Food and Drug authorities have the 
authorities they need to carry their regulation in the 21st 
century?
    Secretary Sebelius. Not at this time.
    Mr. Dingell. Now in the bill that was introduced by my 
colleagues, I, Mr. Stupak and the others, it had a number of 
things, annual registration fees, increased inspections, strong 
new enforcement tools, greater responsibility for manufacturers 
to identify the control risks, tougher scrutiny of ingredient 
and raw materials supplies, documentation of safety for 
imported food products, and of course the ability to see to it 
that good manufacturing practices are followed around the 
world. Do you need that authority?
    Secretary Sebelius. Yes, sir.
    Mr. Dingell. Madam Secretary, I note that that has some 
$220 million in food registration and inspection user fees, 
that those are in the President's budget. Are they necessary 
for the Food and Drug Administration to carry out its proper 
responsibilities?
    Secretary Sebelius. Yes, sir, I think they are.
    Mr. Dingell. Madam Secretary, we now confront a serious 
problem about health care data improvement. The President has 
included 110 million for comprehensive health care data 
improvement initiative at CMS. The initiative appears to be a 
key part of the Medicare and Medicaid delivery system reform 
puzzle. It appears that the administration is on to something 
here.
    I have wrestled with a number of department agencies over 
the past of their adequacy and of their systems to upgrade 
these matters. They have had good motivation and noble 
intentions, but the implementation was also lacking, causing 
substantial waste and confusion.
    Madam Secretary, regarding the 110 million, is this to be a 
one-time investment?
    Secretary Sebelius. No, sir, this is I think a multiyear 
strategy to actually build a 21st century----
    Mr. Dingell. Should we anticipate, Madam Secretary, that 
you will be coming back up here to continue to move toward 
adequate resources to sustain this project over the years?
    Secretary Sebelius. Yes, we will.
    Mr. Dingell. Madam Secretary, one matter of concern, will 
you provide the necessary and proper oversight of contractors 
and HHS employees responsible for seeing this project through?
    Secretary Sebelius. Yes. And we finally have an information 
officer who also is helping us oversee this project who is not 
directly connected with CMS.
    Mr. Dingell. Madam Secretary, is your plan to consult 
appropriate stakeholders to ensure that all potential issues 
are properly identified and addressed?
    Secretary Sebelius. Yes, sir.
    Mr. Dingell. And I am sure, Madam Secretary, that you will 
do the things that are necessary to ensure a smooth and 
effective transition.
    Secretary Sebelius. It is my plan to do just that.
    Mr. Dingell. Madam Secretary, last year the President 
signed a monumental tobacco bill into law. I am pleased to see 
the administration's commitment to the FDA tobacco program in 
this year's budget. However, I have been concerned about the 
recent court activity surrounding FDA's actions related to 
tobacco products.
    Can you give us a very brief update here and then further 
information and a submission for the record on the progress of 
the tobacco program and comment on the administration's 
thoughts on some recent unfortunate court decisions?
    Secretary Sebelius. Well, Congressman Dingell, we are 
taking the responsibility to regulate tobacco products very 
seriously and I would say approaching them----
    Mr. Dingell. I am satisfied you are, but I note that the 
courts have just recently said you couldn't regulate electronic 
cigarettes.
    Secretary Sebelius. Right.
    Mr. Dingell. I note that electronic cigarettes were set 
forth as a device, which is a device which would inject 
narcotics or drugs into the human system. I note that the court 
has held that they are not. I find this most curious. I note 
you have appealed this matter, and I ask do you need additional 
authorities to address that problem?
    Secretary Sebelius. Well, once we hear back from the court 
we may well be back in Congress with some request for 
additional authorities, but we have a new center, we have a new 
director, we are publishing regulations. We have taken on the 
flavored cigarettes, we are looking at the avenues that were 
outlined by Congress. And when we hit a logjam we may well 
return to you for legislative clarification.
    Mr. Pallone [presiding]. Mr. Chairman, Chairman Dingell, I 
know your time is over and it is also that we have a vote.
    Mr. Dingell. My time is up. I am going to yield. Go ahead.
    Mr. Pallone. Thank you. We have two votes coming up and 
those are the last votes of the day. But I am going to try to 
get in two more people. So I just want everyone to know we are 
going to go to Mr. Deal if he is ready.
    Mr. Deal. Yes.
    Mr. Pallone. And then we will go to Mr. Engel and then we 
will break for the votes and come back.
    Mr. Deal. Thank you, Mr. Chairman. Mr. Chairman, I would 
ask unanimous consent to include in the record the letter of 
September 14th, 2009, which was the letter that Mr. Barton 
referred to that was addressed to the Secretary.
    Mr. Waxman [presiding]. Without objection, that will be the 
order.
    [The information appears at the conclusion of the hearing.]
    Mr. Deal. Madam Secretary, welcome.
    Secretary Sebelius. Thank you.
    Mr. Deal. I am going to refer to a letter also. This is one 
that was sent to the Acting Administrator at CMS by Mr. Barton, 
myself, and Mr. Walden on June the 17th. It is a letter that 
asked for information as to the potential impact on State 
Medicaid programs with the proposed expansion of Medicaid under 
the House version of health care reform. And I would ask if you 
would--we have not received a response to this June letter and 
I would ask if you would please try to get us an answer to 
that.
    Secretary Sebelius. I will do that, sir. We are collecting 
that data. It is not data that we hold and the States hold, and 
we are working on collecting that right now.
    Mr. Deal. Thank you.
    In that regard the best I can determine and the best 
information that we can get from CBO is that the House version 
would add about 15 million Americans to the Medicaid rolls and 
would produce about $34 billion in unfunded mandates on the 
States between the years 2015 and 2019.
    Now you mentioned earlier you had been talking to Governors 
about other issues. I wondered if you have talked to any 
Governors who support this mandatory expansion of their State 
Medicaid programs and, if so, would you be courageous enough to 
tell us who they might be?
    Secretary Sebelius. Sir, I have had lots of conversations 
with Governors. Clearly they would like as much help as 
possible on critical health needs, not only expended FMAP but 
if the Federal Government were to pay for 100 percent of 
Medicaid coverage on into the future they would be very 
grateful. They are appreciative of the notion that there are 
changes in the drug reimbursement rules also anticipated. There 
are changes in the way that States would be treated in terms of 
qualifying for various services.
    So we have tried on a case-by-case basis to give States 
regular kind of updates on what impact the various versions of 
various measures were and we will continue to do that.
    Certainly the President's inclusion of the FMAP extension 
in his budget is an indication, I think, that he takes very 
seriously the States' situation with regard to FMAP. We are 
also working with a lot of Governors on the dual eligible 
situation, which is currently one of the more expensive 
populations that any Governor deals with and looking at ways 
through our current CMS authority that we can give more 
flexibility to States, more innovative abilities to coordinate 
and manage care and hopefully return some of those savings to 
States.
    Mr. Deal. As you may know, one of the provisions of the 
House bill, which is section 1703, with regard to expanded 
Medicaid and the enhanced FMAP, is the requirement that States 
enter into a maintenance of effort requirement. And our 
understanding is that that would prevent States from 
implementing any new procedures to reduce the prevalence of 
fraud in their Medicaid program, for example, because the 
language is that if it is more restrictive than the procedures 
in effect on June the 16th, 2009, and it may very well be that 
States would want to enhance their antifraud provisions and 
make it more restrictive than what was in effect last summer.
    I wonder if as Governor of Kansas you would have taken very 
kindly to us telling the States that they would be prohibited 
from incorporating any new antifraud provisions into their 
State Medicaid program. And is that your interpretation of that 
section?
    Secretary Sebelius. It certainly is not. I think that there 
is no question this administration and I think the Congress 
takes fraud and abuse very seriously. We have actually enhanced 
and have in not only the budget but in health reform a number 
of enhancements for fraud and abuse efforts. I think that the 
maintenance of effort language that you refer to has been in 
place since the Recovery Act was passed. It was defined to 
legislators--I mean to Governors. I was certainly as I say a 
Governor at the time. No one ever suggested that maintenance of 
effort meant that you could not enhance antifraud efforts in 
the State. And in fact we had very aggressive antifraud efforts 
in Kansas and have for years.
    Mr. Deal. Does the maintenance of effort requirement that 
was part of the stimulus money, does that requirement expire 
upon the expiration of the stimulus funds received by the 
States?
    Secretary Sebelius. Yes, it does.
    Mr. Deal. Thank you, Mr. Chairman.
    Mr. Waxman. The gentleman's time has expired. Mr. Engel.
    Mr. Engel. Thank you, Mr. Chairman. Madam Secretary, 
welcome. I have three issues which I am going to raise quickly 
and I would like your comments on them. I chair the Western 
Hemisphere Subcommittee in the Foreign Affairs Committee, and I 
have been really grateful for all the wonderful support the 
Obama administration has given in the immediate and ongoing 
aftermath of the earthquake in Haiti, but as you know the hard 
work continues. We expect a great number of Haitians to join 
their relatives in New York and in other areas of the country. 
We welcome these children and families, but we need to ensure 
the States and localities have enough resources to give them 
and our existing students the support and education they 
require. And as you know, our States and localities are already 
cash strapped during this difficult economic time.
    Within the HHS Office of Refugee Resettlement, the Refugee 
School Impact Grant Program has stayed flat funded at $15 
million for the past 5 years, even in this year's budget which 
came out after the earthquake.
    In a letter that Senator Gillibrand and I sent you 
yesterday, we asked if the administration would support either 
a one-time emergency grant program for school districts that 
receive a high influx of Haitians or alternatively if you would 
increase the funding for the Refugee School Impact Program. 
While the broader social services and refugee program which 
funds the school impact program was granted an extra 25 million 
in the fiscal year 2011 budget, your staff said the school 
impact program would be unlikely to see a bump in funding. I 
find that troubling. So I would like to ask you, would you 
commit to working with me on this important issue to give our 
schools and communities the support they need if there is an 
influx, and we know there will be, of Haitian children putting 
strains on school districts.
    Secretary Sebelius. Congressman, we would be glad to work 
with you on all the ramifications of the Haitian situation, 
which as you know we are just beginning to try and sort out. 
But yes, I would be very happy to continue that dialogue.
    Mr. Engel. Thank you very much.
    Madam Secretary, the New York delegation last week or the 
week before met with you, and I thank you for meeting with us, 
and we had a very good discussion about 9/11 health issues. As 
you know when we had discussed it, all Americans 9 years after 
September 11th, first responders who came and were selflessly 
trying to save and help others now find themselves because of 
the toxicity of the air sick. We estimate there are about 
20,000 people who are sick, coming from 431 of the 435 
districts across the country. And some have died unfortunately, 
others are disabled.
    We were hit, New York was hit, not because we were New 
York, but because we were a symbol of this country, and it is 
an ongoing fight in the war against terror. We had had a 
discussion about whether the administration would commit to 
funding in the bill the health that we need--the health care 
that we need for this bill. I know we are talking about it.
    So I am going to ask you if you would commit to working 
with us to pass comprehensive 9/11 health care that is paid 
for.
    Secretary Sebelius. I would very much like to work with you 
on that issue. As you know, the President's budget doubles the 
amount of funding in the project for 2011 and we look forward 
to working with you and others in the delegation on a long-term 
permanent solution.
    Mr. Engel. Thank you. My final question, in last Congress 
the ALS Registry Act, Lou Gehrig's disease, a bill that I 
authored with my friend Lee Terry on the other side of the 
aisle was signed into law. It came through this committee, it 
had great bipartisan support and over in the Senate as well.
    I was disappointed though to see that the administration 
cut the ALS registry's funding by over $200,000 in fiscal year 
2011 from what Congress appropriated last year. And Congress 
did not appropriate the full money. The act was authorized for 
over $10 million per year and it is funded at just under 5.8 
million. So to take 200,000 away from the underfunding of 5.8 
million is something that is very disappointing.
    So I will ask you again, will you continue to work me and 
with Congress to ensure that the CDC has the resources it needs 
to fully implement the ALS registry?
    Secretary Sebelius. We are aggressively, Congressman, 
moving toward the implementation of the full registry which we 
anticipate having online at 2011. The full funding that you 
refer to, the $10 million, is not essential during the planning 
phases, and the cut that you are referring to is really out of 
travel and some contracting cuts that the leadership of the CDC 
felt could be made without at all jeopardizing the 
implementation timetable or the full implementation of the 
registry. So we would look forward to working with you on that.
    Mr. Engel. Thank you. And Mr. Chairman, may I just ask 
unanimous consent that my letter to Secretary Sebelius on the 
funding for the HHS Refugee Resettlement Office be included in 
the record.
    Mr. Waxman. Without objection, that will be the order.
    [The information appears at the conclusion of the hearing.]
    Mr. Waxman. Madam Secretary, we are going to take a recess. 
We have two votes, and as soon as we have completed the two 
votes we will come back and reconvene.
    Thank you.
    [Recess.] 
    Mr. Waxman. The committee will come back to order. Who 
seeks recognition? The gentleman is recognized.
    Mr. Whitfield. Mr. Chairman, thank you. And Madam 
Secretary, we appreciate you taking time to be with us this 
afternoon. Last weekend President Obama came over to Baltimore 
to meet with our caucus and I am sure you read some about that. 
One of his comments that he made, we were talking about the 
right to keep your current insurance policy if this health care 
reform bill passes. And he said, I think some of the provisions 
that were put into this bill have violated my pledge to allow 
people to keep their insurance if they want to keep it. And 
when I look at section 202 of the House bill, which is about 3 
or 4 pages in that section relating to protecting the choice to 
keep current coverage, there are all sorts of exceptions in 
here. And one of the frustrating things that I personally have 
is we keep hearing this you can keep your coverage, you can 
keep your coverage, you can keep your coverage. And even the 
President said there were provisions put in at the last bit 
that cannot guarantee that.
    Now is that your understanding, that there is no guarantee 
that a person can keep their current insurance coverage if this 
bill passes?
    Secretary Sebelius. Well, Congressman, I can't speak for 
exactly what the President was talking about. I do know that in 
today's market nothing ensures an employee that his or her 
employer is going to continue employer based coverage. Nothing 
ensures that if you have employer based coverage that that 
employer will use the same network or the same doctors. That 
changes every day with contracts. So I don't know if that is 
what he is--I really don't know. But clearly there is not a way 
to guarantee. I think that the attempt has been to say we are 
not mandating anybody have to move----
    Mr. Whitfield. I really appreciate your saying that 
because, to use his exact words, he said some of the provisions 
that were snuck in have violated that pledge. And when we hear 
people emphatically saying you have the right to keep your 
existing insurance policy, that is really not true. And so I am 
delighted that you clarified that----
    Secretary Sebelius. In the current market, I am saying 
absent any health reform legislation, no one is sort of 
guaranteed that.
    Mr. Whitfield. Right. One more comment I would make, if 
this bill passes we know that the coverage for Medicaid is 
going to be expanded, so the States normally pick up that cost 
and we are trying to provide additional funds from the Federal 
Government because the States need it. The fact that bothers me 
about that is that the Federal Government needs money, too. So 
basically we have a program here that is expanding, that is 
going to cost the States more money. And because they need more 
money from us, it is going to cost the Federal Government more 
money.
    But the part of this process that has bothered me the most, 
and I think because I have heard so many comments from people 
not only in my district but really from all over the place, and 
that is the whole process when you are endeavoring to 
comprehensively change the health care system in America and 
you see side deals being cut, when all of us represent the same 
taxpayer and you see Nebraska getting a special deal, you see 
Vermont getting a special deal, you see Massachusetts getting a 
special deal, you see three counties in Florida where they are 
able to keep their Medicare Advantage program and yet in my 
district we have 15,000 people on Medicare Advantage that may 
not be able to keep theirs because of the reduction in money 
available for Medicare Advantage. It is just patently unfair.
    And I am assuming that HHS worked with some of the staff on 
cutting some of these deals, which we understand is done to 
obtain votes, but as a citizen does it bother you that if you 
are in a certain State or you are in a certain county that you 
get benefits that other taxpayers simply are not going to be 
able to have?
    Secretary Sebelius. Congressman, I think that unfortunately 
it seems to be endemic of any legislative process that money is 
never distributed exactly equally and it always is a problem 
for those who don't get the resources, and I think this is no 
different. But it has been my experience that that is 
unfortunately a pattern, whether it is appropriations or where 
projects are sited, or who is on the committee, there often is 
not an actually equal distribution of any course of resources, 
and I think it does make people unhappy.
    Mr. Whitfield. I think so, too, and I think that the one 
area where we should get away from that is in the health care 
area.
    Thank you very much, Mr. Chairman.
    Mr. Pallone [presiding]. The gentlewoman from California, 
Ms. Eshoo.
    Ms. Eshoo. Thank you, Mr. Chairman. And welcome, Madam 
Secretary. It is wonderful to see you. A warm welcome to our 
great friend who was with the committee for years and I think 
will always be part of this family, and that is Bridgett 
Taylor. It is really great to see you.
    Madam Secretary, thank you first for----
    Secretary Sebelius. She is now part of our family.
    Ms. Eshoo. That is right, that is right, but she was a 
long-time member of ours. You are lucky to have her.
    Thank you for your very, very thorough responses to letters 
that I wrote to you. I appreciate that. It took some time to 
get the responses, but they were worth waiting for because 
there were direct answers about exploring the use of adjuvants 
and vaccines and thimerosal as well as promoting the new 
generation of subculture-based vaccines and on the issue of 
BioShield and BARDA.
    It is more than refreshing to see an HHS budget that 
emphasizes science. We have gotten away from it in our country 
for too long. I think we paid a price for that because time is 
really the most precious thing that we are given. And for 
almost a decade we lost that time relative to science. So 
rather than applying political science we now are honoring 
science, and I think that that really honors the American 
people.
    I also would like to applaud many different parts of the 
budget because they are, I believe--and this budget is most 
frankly what I hear from my constituents, from my constituents 
mostly about. Most of the e-mails, questions, factions, 
meetings have something to do with your budget, with HHS. So I 
think it is a good one.
    Now, on the issue--I know there is an emphasis on fraud and 
an effort to root it out, which I think is really very 
important. The last time we visited that is in the Clinton 
administration. That is a long time ago. I remember Secretary 
Shalala sitting there and describing for us what they were 
undertaking.
    How much of a return do you expect from the HEAT effort and 
I know that there is $1.7 billion invested in that. What do you 
think the return is going to be?
    Secretary Sebelius. The most conservative estimate I would 
say is that we get somewhere from $1.10 to $1.50 on every 
dollar invested. The Attorney General's numbers look more than 
4 to 1. Our actual experience with the current fraud efforts 
are that we get somewhere between $14 and $17 for every dollar 
invested. So we have a wide range. What we know is we get back 
more than we spend.
    Ms. Eshoo. Well, it is an area that is galling to the 
American people. There have been things on 60 Minutes, you 
know, these store front ripoffs. It really is the private 
sector ripping off the public sector. But I think that this 
HEAT effort better be white hot because there is a lot of money 
to be found in this, and I wish you well on that.
    The other area that I want to ask you about is the area of, 
as I mentioned earlier, on BioShield and BARDA. There have been 
dollars that have been moved around, not a lot but you have 
moved, I think, 36 million or 136 million out of one area to 
another, and that is the--what I am concerned about is the SRF 
and you have moved some funding out of that. Admittedly it is 
not a ton, but I worry about what remains because the whole 
area of developing and acquiring chemical, biological, 
radiological, and nuclear medical countermeasures is very 
important for our country. I mean we have just gone through 
H1N1. I think that is something that will look like something 
out of a seed catalogue, God forbid, if our country, God 
forbid, had to endure a bio attack.
    So are you comfortable with that? I mean why the movement 
of the funds, how much is left?
    I know that you said in your prepared remarks that there is 
going to be a report due on March 31st of this year. Maybe we 
can revisit this when the report comes to us. If you could see 
that the committee gets that ASAP when you put it out. But it 
is an area that Mr. Rogers and I both worked on, and I have a 
continuing interest in it both from this committee's standpoint 
and also from the other hat that I wear from the Intelligence 
Committee.
    And lastly, I want to say something, I know that--let me 
just say this.
    Mr. Pallone. The gentlewoman's time is over, but go ahead, 
finish.
    Ms. Eshoo. I am going to take about 30 seconds. And that 
our colleagues on the other side of the aisle are continually 
banging on all kind of drums relative to health care, all kinds 
of ideas, offer everything to everyone, cure everyone, give 
everyone insurance, and it is not going to cost a cent. I don't 
know where your budget is on this, but I think you need to put 
it on the table.
    Furthermore, most frankly, you were in control for a long 
time and you are on this committee that has----
    Mr. Pallone. The gentlewoman is a minute over.
    Mr. Gingrey. Regular order, Mr. Chairman.
    Ms. Eshoo. Why didn't you pass all these things when you 
were in control?
    Mr. Gingrey. Regular order.
    Mr. Pallone. Move on.
    Ms. Eshoo. Answer the question. You don't like it when 
someone raises it.
    Thank you, Mr. Chairman.
    Mr. Pallone. Gentleman from Illinois, Mr. Shimkus.
    Mr. Shimkus. Thank you, Mr. Chairman. I think that the 
benefit of having the President in Baltimore is that we did 
give him the package of gop.gov and I want to encourage my 
colleagues on the other side to take a look at those, because I 
do think, Madam Secretary, when we met with the RFC before the 
bill moved to the floor, I did talk about private insurance, a 
national health exchange, and a way to do it on a market based 
solution. The Democrat leadership did not decide to go in that 
manner. I hope we relook at that. If we really want to move 
legislation and provide health care to all Americans, there is 
a compromise out there and you can model it out a Medicare D. 
That is what I proposed, I don't know, a year ago, or 8 months 
ago, but we could really get there if we shelve the centralized 
control, one big government solution and go back to the market.
    But for my questions, according to the Congressional Budget 
Office, the House-passed health reform bill would add 15 
million Americans to the Medicaid rolls, producing 34 billion 
in unfunded mandates on States during the 2015-2019 period. Now 
this is following up from Mr. Deal's question, which he asked 
has any Governor said, no, this is a bad idea. You failed to 
answer that question, and I am wondering if based upon--did you 
have any Governor say I don't want these additional unfunded 
mandates because we know Medicaid requires the State, some 
States a 50/50 share, some States 70/30 share, depends on the 
State. Do you have any Governors that said no, don't do this, 
the Medicaid expansion is bad, we can't afford it?
    Secretary Sebelius. We have had Governors who have 
expressed that they want more adequate Federal funding if there 
is expansion and other Governors who are very enthusiastic 
about the plan. So we have had both.
    Mr. Shimkus. So there are 35 States right now moving 
referendums against this, and I think the Virginia Senate just 
passed legislation through the Virginia Senate against the 
expansion of Medicaid.
    Secretary Sebelius. My understanding is the Virginia issue 
deals with a mandate to purchase insurance coverage.
    Mr. Shimkus. Well, I think that 35 States--yes, we can 
address that, but the issue is States are saying no, they can't 
afford it. Illinois is broke, California is broke.
    Secretary Sebelius. And many States, as you know, 
Representative already exceeding the 133 percent. So we have 
States that are kind of all over the place.
    Mr. Shimkus. I would just say expanding Medicaid to States 
who can't afford to expand it by mandate, and that is where the 
debate comes, so then the Federal Government, which doesn't 
have a balanced budget requirement that many States do, that is 
where then we pick up the tab and we go into historic national 
debt as we find ourselves today just passing an increased--it 
is not mine--an increase in the debt limit.
    Let me go to--would the President sign the Senate health 
care reform bill into law as it is alone?
    Secretary Sebelius. Sir, you would have to ask the 
President. Maybe you did in Baltimore.
    Mr. Shimkus. Let me set the groundwork. When you came here 
the first time the health bill was just in draft form, so you 
refused to take any questions on the health reform bill. You 
promised to return, which that never happened. So a lot of the 
frustration today is not having a chance to talk to you in the 
committee process to debate health care reform that was going 
to go through this committee. So that is where a lot of this 
angst and now we are only given 2\1/2\ hours to--no one is 
allowed to give opening statements as a whole and then we are--
yes, they did extend it for an hour, but we had votes, two 
votes in between. And that is part of the incredible 
frustration here.
    So does the President support cutting half a trillion 
dollars from Medicare as do the Senate and House reform bills?
    Secretary Sebelius. Does----
    Mr. Shimkus. Yes or no? I will use the John Dingell 
approach, yes or no.
    Secretary Sebelius. The President supports the health 
reform bill.
    Mr. Shimkus. So he supports cutting $500 billion from 
Medicare?
    Secretary Sebelius. He supports making sure that Medicare 
is solvent into the future.
    Mr. Shimkus. So that is a yes. The President supports 
cutting 500 billion? The Senate bill says 500 billion, the 
House bill says----
    Secretary Sebelius. Well, they had different numbers in 
them, but the President----
    Mr. Shimkus. So the President supports cutting $500 billion 
in Medicare, yes or no?
    Secretary Sebelius. The President is supportive of the 
health reform legislation.
    Mr. Shimkus. Is that a yes?
    Secretary Sebelius. I said yes, sir.
    Mr. Shimkus. OK, thank you.
    Let me just talk about one issue that was hit on with Mr. 
Whitfield. These three counties are what we talk about as 
Gatorade, the negotiated deal that Florida cut for their 
Medicare Advantage folks. These three counties, Palm Beach, 
Broward and Miami Dade, will not feel the effect of the 
Medicare cuts for Medicare Advantage. Was HHS involved in 
negotiating this deal with the Senate?
    Secretary Sebelius. Sir, I was not----
    Mr. Shimkus. No HHS staffer was involved?
    Mr. Pallone. The gentleman's time is over.
    Mr. Shimkus. Thank you.
    Mr. Pallone. Sure.
    The gentleman from Texas, Mr. Green.
    Mr. Green. Thank you, Mr. Chairman. And welcome, Madam 
Secretary. And obviously our country has had a problem with 
excessive spending for decades. And I hate to keep reminding 
our colleagues on the Republican side, we had a balanced budget 
in 1999 and 2000 and we ended PAYGO the next year or two, and 
literally for the first part of this decade, for the first 7 
years, we spent without worrying about it, everything went to 
the national debt. And now we are trying to do so many things 
with 10 percent unemployment.
    Let me get back to health care and the President's budget. 
First of all, I appreciate you being a longtime champion to 
community health centers and the sponsor of the most recent 
health care center authorization. And as the sponsor of the 
most recent health care reauthorization that passed our 
committee in 2008, I want to commend the President's budget for 
the proposed increase in health center funding. Although it is 
below the amount we have authorized given the physical 
constraints you are working with, I am very much appreciate 
this increase. I am especially grateful the administration 
appears to propose that a portion of this increase goes toward 
ensuring that operating funds that health centers receive 
through the Recovery Act will continue. I know in my own 
district a number of our community-based health centers 
expanded, see more patients and are actually hiring personnel. 
It was part of the stimulus bill. Health centers to date 
extended care to 1 million Americans using this funding and 
expect to surpass their goal of two million new patients by the 
end of the stimulus period.
    Can you confirm for us that you intend for existing health 
centers to continue to receive the funding in order to maintain 
the capacity to care for the new patients they have added over 
the past year?
    Secretary Sebelius. Certainly, Congressman, it is our 
intent to provide resources so that the health centers can 
deliver care to the 20 million people.
    Mr. Green. Of course community-based health centers really 
is a bipartisan issue. President Bush suggested increases that 
we tried to match. Because the district I represent has the 
highest uninsured rates in the country, I want to significantly 
expand the health centers program because of their 40-year 
track record for providing high quality and cost effective 
care. I support the efforts of the President to continue access 
to care for those two million served by the health centers 
through the stimulus bill and to continue to grow the health 
centers program by providing the $290 million increase that is 
in the budget.
    Would you agree that this funding request is based on what 
you see is possible through the limitations and the 
discretionary appropriations process that is even more 
significant growth through dedicated funding or has been 
proposed in both the House and Senate reform bills is still 
necessary, that growth is still necessary even though we have 
seen both the House and Senate health care bills?
    Secretary Sebelius. Well, I absolutely think that delivery 
of primary care services through community health centers is 
one of the great success stories. Low cost, high quality care, 
and really dealing with the whole family. So I am very 
supportive, I try to visit those centers wherever I go in the 
country, and they are remarkable, community based centers that 
deliver high quality, lower cost primary care.
    Mr. Green. If we get to pass the health care bill, I 
consider that the boots on the ground is our community-based 
health centers throughout the country.
    I also appreciate you being an outspoken proponent that 
schools can play in vaccination, both with seasonal and 
pandemic influenza and appreciate your leadership on that. I do 
have some concern, in 2008 I was the sponsor and we passed the 
Tuberculosis Elimination Act. I strongly support increased 
funding for TB. TB is the second leading global infectious 
disease killer and because it is an airborne infectious disease 
it has always been a present danger in the U.S.
    Many States, such as California and Texas, where I 
represent, are struggling with steady increasing rates of drug 
resistant TB, which is extremely costly and complicated to 
treat. Yet the TB will receive a funding cut under the 
President's proposed 2011 budget. Public health history in the 
U.S. has shown that cutting back on TB control programs can 
cause costly resurgence of the disease such as happened in the 
U.S. in 1988 to 1992, when New York City had to spend over a 
billion dollars to regain control over TB.
    Can you assure us that the States will adequately be 
equipped to protect our communities if we have outbreaks, 
additional outbreaks of the drug resistant tuberculosis.
    Secretary Sebelius. Congressman, I look forward to having a 
chance to visit with you more about this issue where you 
clearly have some considerable expertise. Our new Director of 
the Centers for Disease Control and Prevention, Dr. Tom 
Frieden, did a large portion of his work on TB. He takes it 
very, very seriously. So I think working with him and you to 
make sure we have the resources available is something that I 
am committed to doing.
    Mr. Green. Again, thank you for being here.
    Mr. Chairman, I actually didn't ask for any extra time.
    Mr. Pallone. I appreciate it. Thank you.
    The gentlewoman from California.
    Mrs. Bono Mack. Thank you, Mr. Chairman. And Madam 
Secretary, welcome. I have two brief questions that I would 
appreciate your insight regarding two requests I have pending 
before your Department.
    Right now at least two and a half million adolescents 
suffer from substance abuse disorders and surveys sponsored by 
your Department showed continued and increasing trends of the 
abuse of prescription drugs like Vicodin, Xanax and in my 
opinion the very powerful and deadly OxyContin. This problem 
has been largely ignored in the health care reform debate. I 
have concerns that proposed generalized programs like the 
Prepared Communities Program and counterparts at the DOE will 
dilute the important focus on drug addiction and prevention.
    So my first question for you is will you ensure that a 
clear focus remains on strategies aimed directly at preventing 
drug use and underaged drinking?
    Secretary Sebelius. I look forward to working with you on 
that, absolutely.
    Mrs. Bono Mack. Thank you.
    Last year, I asked the FDA--late last year--some specific 
questions regarding a new formulation which, from what I am 
hearing, it is not tamper-proof, actually it might allow the 
drug OxyContin to be more abused. So I wrote a letter to the 
FDA with these specific questions, given the tragic abuse of 
prescription drugs among our Nation's youth. I am hopeful you 
can encourage your staff to respond to this inquiry.
    Secretary Sebelius. I would be very happy to do that. And 
Congresswoman, I would like to also have our new Director of 
the Substance Abuse and Mental Health Administration get in 
touch with you. As you probably know, substance abuse with 
prescription drugs is only slightly behind alcohol abuse right 
now and rising dramatically among children. It is an issue that 
she takes very seriously, has done a lot of work on. We are 
using her to help inform a number of our outreach and strategy 
efforts. So again, I think it is going to be a renewed and 
specific emphasis throughout our Department.
    Mrs. Bono Mack. I am encouraged to hear that, and I thank 
you. I think it is very, very important for us to do that.
    Finally, I request your assistance with an issue that is 
important to our shared goal of rooting out waste, fraud and 
abuse. In my district, the 45th District of California, a 
tribal TANF program is operating, and the tribe has received 
over $30 million a year, on average, to administer this 
program. It is troubling that government audits have shown a 
repeated misuse of Federal taxpayer dollars, including Federal 
allegations of misuse of $6 million alone in 2002 and 2003. 
Years later, penalties assessed to the program have still not 
been resolved.
    I recently requested that the IG at HHS and ACF investigate 
this matter further. The IG stated that the concerns would be 
best addressed by ACF. Knowing the charge of the IG's office, I 
hope that they and the ACF can aggressively seek answers and 
come to a resolution of what appears to be years of 
insufficient accounting and a wasteful use of taxpayer dollars. 
I fear that prolonging this problem only hurts the Native 
Americans for which this program was designed to serve in this 
difficult economy.
    Are you willing to consider protecting taxpayer dollars by 
withholding new funds until the situation can be resolved?
    Secretary Sebelius. Congresswoman, I must confess, I am not 
aware of this situation, but I will commit to going back and 
dealing with both the head of ACF and the IG's office and 
putting together the information. I can't commit to anything 
until I know what the situation is and what the history is, but 
I will definitely take that as a personal commitment.
    Mrs. Bono Mack. Thank you very much. I think it is 
extremely important. It is a very blatant example of this 
waste, fraud, and abuse, and it is hurting the people that are 
designed to be helped by this kind of a program.
    Lastly, I am sorry that my colleague from California left, 
Ms. Eshoo. I just would like to say that her questions about 
what has happened in the past on health care really ring hollow 
to my constituents; they care about what is happening today. 
And I can tell you that they do not like government takeover of 
health care in any way, shape or form. But I am sorry that she 
has left, but I did need to say my frustration as well that 
pointing the finger, my constituents are tired of that 
argument. They want to have answers, and government takeover of 
health care is not what they want to hear.
    So I appreciate your being here today, and I look forward 
to working with you in the future.
    I yield back the balance of my time.
    Mr. Pallone. Thank you.
    Next is the gentlewoman from Illinois, Ms. Schakowsky.
    Ms. Schakowsky. Thank you, Mr. Chairman. And thank you, 
Madam Secretary, for being here and sticking with us this 
afternoon.
    I wanted to just make a comment about the exchange that you 
had earlier on the issue of the donut hole. I wanted to make it 
very clear that as important as the low-income assistance is 
for people up to 150 percent of poverty, we have to understand 
how low an income that is and what difficulty people over 
that--150 percent of poverty is $16,250, and to suggest that 
seniors that make that much money can even think about getting 
out of a donut hole that is $3,500, it doesn't really compute 
for me if you think about the other expenses.
    So based on your experience, is a $3,500 coverage gap just 
for prescription drugs--that doesn't count premiums and 
copays--just for prescription drugs affordable for someone 
whose income is $16,500?
    Secretary Sebelius. Well, certainly not at that income 
level. And while there may be, as I told the Congressman in his 
follow-up discussion, some individuals at a very high income 
level, I think typically we are talking about people using 
prescriptions who tend to be sicker needing more medicine, 
which also is often a problem because they are spending more 
expenses on all kinds of other areas. So 150 percent of poverty 
is not a wealthy senior.
    Ms. Schakowsky. Is $20,000 a year--I would even ask if 
$35,000 a year, if that is what you make, to get out of the 
donut hole at about $3,500. These prices are exorbitant, and as 
you say, these are the sicker people.
    Secretary Sebelius. Well, unfortunately, what at least my 
experience is working with seniors, is that too often there 
really is not a great deal of understanding of what is going to 
happen. So filling that next prescription, you are suddenly out 
of any kind of assistance, and you go from paying--and you 
continue to pay your premium for part D.
    Ms. Schakowsky. Absolutely.
    Secretary Sebelius. So you pay a premium, and you are 
paying out of pocket 100 percent of the cost. And I know what 
happens all too often is people just don't fill the 
prescriptions, do not take the medicine, and can't keep 
themselves out of the hospital.
    Ms. Schakowsky. That is why I prefer the House bill, of 
course, that actually does eliminate the donut hole altogether.
    You may not have the answer because it is kind of an 
esoteric question, but I want to pose this to you and maybe you 
can get back to me. We have some nursing home reform advocacy 
groups in Illinois, Illinois Citizens for Better Care for one, 
and this is a problem that was brought to my attention. 
Recently there was a change that means they can no longer 
obtain Aspen survey data on disk, but have to get case-by-case 
reports on paper, which is a big cost burden and time burden to 
them. So I hope that you will review that decision in order to 
reduce the burdens on small not-for-profit groups that do 
inspections, they monitor how nursing homes are doing--and of 
course it is a huge problem--quality care in nursing homes, and 
to ensure transparency. So if you could just look into that.
    Secretary Sebelius. We will be glad to and get back to you 
about that.
    Ms. Schakowsky. Thank you. I yield back.
    Mr. Pallone. Thank you.
    Mr. Terry is next.
    Mr. Terry. Governor, I appreciate you being here.
    First of all, what is your understanding of where the 
health care legislation is today? Are there plans that you are 
discussing with the White House and congressional leadership to 
move the House bill or the Senate bill? Or is there a movement 
that you are aware of to throw those two away, start anew, 
where we could focus on consensus items?
    Secretary Sebelius. Congressman, I think there are lots of 
discussions going on. As you know, the House passed a bill and 
the Senate passed a bill----
    Mr. Terry. I asked you what is your understanding, not what 
other people are doing.
    Secretary Sebelius. I am telling you what my understanding 
is.
    Mr. Terry. I am sorry, you said that you didn't know what 
other people were doing, so----
    Secretary Sebelius. No. There are lots of discussions going 
on.
    Mr. Terry. So you are not going to answer the question?
    Secretary Sebelius. There are lots of discussions going on. 
That is the answer to the question. There is no one single 
discussion----
    Mr. Terry. OK. Then would you be specific about the ones 
that you are involved with, what are the options? I am sorry, I 
wasn't more clear in my question evidently.
    Secretary Sebelius. Congressman, I think no matter who you 
talk to, any number of options are on the table, start again--
--
    Mr. Terry. What are the options that you are advocating?
    Secretary Sebelius. I don't have a single advocacy piece 
other than let's move the health reform forward. I favor, as 
the President does, a comprehensive plan. I favor looking at 
the similarities in the House and Senate version and hopefully 
finding a way to move comprehensive legislation forward as 
quickly as possible.
    Mr. Terry. OK. During the exchange with the gentlelady--
this wasn't on my list to ask, but I have to now----
    Secretary Sebelius. Which gentlelady?
    Mr. Terry. Ms. Eshoo. There was a comment that you agreed 
to that in regard to looking for fraud, nothing has been done 
since the Clinton----
    Secretary Sebelius. Sir, that was her statement----
    Mr. Terry. Well, you agreed with it.
    Secretary Sebelius. I sat here.
    Mr. Terry. Well, let me ask you; do you agree that the Bush 
administration has done nothing in 8 years to find fraud and 
waste? Because that was the statement, and you didn't counter 
that at all.
    Secretary Sebelius. Sir, I don't have any expertise on what 
the Bush administration did or what the Clinton administration 
did. I assume that----
    Mr. Terry. Is it your opinion they have done nothing?
    Secretary Sebelius. It is not my opinion one way or the 
other. I don't want to offer opinions.
    Mr. Terry. Well, you didn't correct the gentlelady, so I 
assume since you had the opportunity to say there has been 
efforts. Well, with the HEAT program in place, wouldn't it be 
beneficial that you looked at what past administrations have 
done?
    Secretary Sebelius. We certainly have looked at what past 
administrations have done. I know----
    Mr. Terry. So what has the Bush administration done? You 
just said you didn't know.
    Secretary Sebelius. I am very sorry. I am happy to go back 
and document. I don't want to give you incorrect information. I 
am not an expert on what the Bush administration did, or as 
Congresswoman Eshoo said, what the Clinton administration did, 
so I didn't enter into that discussion. I would be happy to 
come back and report to you.
    There clearly has been a fraud and abuse effort underway. 
There never has been the effort put forward by this President 
which asks the Justice Department and HHS to collaborate and 
cooperate at the Cabinet level to put strike forces on the 
ground to try to get out ahead. It has been a pay-and-chase 
operation, often auditing sometimes well after the fact has 
been in place for a long time.
    Mr. Terry. OK. Well, very good.
    I have had some of my pharmacies back home tell me they 
have yet to get their inspections, even with the extension that 
Congress passed, to allow them to get their appropriate license 
to sell durable medical goods. Is there another effort by HHS 
to give them an opportunity to get licensed or whatever the 
appropriate language would be? It has already been extended 
once.
    Secretary Sebelius. I can't answer that specifically, but I 
would be happy to get back to you. I don't know the reference, 
the time frame that you are referring to.
    Mr. Terry. Well, I only have 28 more seconds.
    Lastly, in the environmental health section of the budget, 
it is reduced a little bit. There are two programs in here that 
I would appreciate you taking a look at, one is the Healthy 
Homes Child Lead Poisoning program. That is an extremely 
important program in Omaha. We are a Superfund site for lead, 
but if you ask our health folks, they will tell you that most 
of the lead poisoning that is occurring is from unhealthy homes 
that are significantly older than 1973. So for that to be one 
of the programs cut is a concern to me. The other is the ALS 
registration, which seems to be already below what the CDC has 
said they need to do the registration, and that is one that is 
cut.
    One that is a new program put in--it seems to be sucking up 
a lot of the money from the programs that are cut--is the Built 
Environment and Health Initiative. Can you tell me what that 
is?
    Secretary Sebelius. Congressman, I am sorry, I cannot, but 
I would be happy to get that answer back to you.
    Mr. Terry. I am just curious. Thank you.
    Mr. Pallone. I thank the gentleman.
    Next is the gentlewoman from the Virgin Islands, Mrs. 
Christensen.
    Mrs. Christensen. Thank you, Mr. Chairman. And thank you, 
Madam Secretary, for being here.
    We appreciate the increases that we are seeing in the 2011 
budget, and hopefully we can do some more with health care 
reform as we move on from here.
    You know of our commitment to stopping the preventable 
early excess deaths in African Americans and other people of 
color, and yet as I try to get a handle on what is happening in 
the Department, I seem to sense a moving away from focusing on 
racial and ethnic minority populations in the Department's 
efforts to eliminate these huge disparities that have existed 
far too long.
    So one of my questions, which applies to the Office of 
Minority Health, the National Center for Minority and Health 
Disparity Research and the National Minority AIDS Education and 
Training Center, can you reassure me that the needed focus on 
the racial and ethnic minority populations will continue--not 
because they are minority populations per se, but because they 
are so disproportionately burdened by disease, and would you 
support, as we are trying to do in health care reform and in 
other stand-alone bills as well, the strengthening and 
expanding of the Office of Minority Health to other agencies 
and the elevation of the national center at NIH to an 
institute?
    Secretary Sebelius. Congresswoman, I would definitely 
commit to you that there has been no lack of focus or attention 
or interest in closing the gap in health disparities, which 
continue to be alarming and appalling. The new Assistant 
Secretary of Health, Dr. Howard Koh, also takes that very 
seriously. He is the umbrella agency supervising a number of 
the offices that you have just described.
    Mrs. Christensen. So the Office of Minority Health, for 
example, will stay Office of Minority Health; it is not going 
to not change the disparity and move away from minority that 
you know of. It is going to stay Office of Minority Health. The 
Office of Minority Health will continue to be the Office of 
Minority Health?
    Secretary Sebelius. Yes.
    Mrs. Christensen. With all of the other AIDS Education and 
Training Centers open to everyone, and given the need for 
cultural competency and the fact that 70 percent or more of the 
patients with HIV and AIDS are people of color, we have this 
one National Minority AIDS Education and Training Center, it 
works with all of the minority-serving institutions, community-
based organizations, race and ethnicity, but it seems as though 
HRSA is changing how they are dealing with this particular 
center, trying to fix something that is not broken, putting 
barriers in the way of minority-serving institutions, 
continuing to provide the service at a time when minorities are 
still disproportionately burdened by HIV and AIDS.
    So do you know yourself what is happening within National 
Minority AIDS Education and Training Center; is there a move 
within your Department to open that up to every majority 
institution, better funded, better able to compete, or can we 
try to keep that within a minority-serving institution?
    Secretary Sebelius. Well, again, Congresswoman, I think the 
very good news is that President Obama has taken very seriously 
the commitment to have a very aggressive domestic AIDS/HIV 
agenda, feeling that while the focus of PEPFAR has been a great 
success globally, we have really not paid as careful attention 
to what was happening in the United States. And as you just 
stated, the overwhelming number of new infections and new cases 
are focused directly in the minority community, in African 
Americans, in Latinos, and in American Indians.
    First, I would tell you that I just participated in 
greeting and swearing in the new PACHA Council, a diverse and 
very committed group of individuals. We intend to have a very 
aggressive focus that is well funded, and our office is clearly 
a part of that. And I will have that conversation with Dr. 
Wakefield.
    Mrs. Christensen. Understanding the need to focus on racial 
and ethnic minorities, who are hardest hit.
    I would just like to get in a word about ADAP, $20 million 
this year, $20 million next year. They need more than $200 
million to end the waiting lists. We would like to see a 
stronger commitment to ensuring that everyone with HIV and AIDS 
has access to treatment and not lose sight of the fact that not 
only will people die as they wait on these waiting lists, but 
that treatment is a major form of prevention as well. So it is 
very important that we try to close that gap for ADAP.
    Mr. Waxman. The gentlewoman's time has expired. Thank you.
    The gentleman from Texas, Mr. Burgess.
    Dr. Burgess. Thank you, Mr. Chairman.
    Madam Secretary, last week--I hope you are aware that this 
committee took up the business of a resolution of inquiry to 
obtain documents from the White House and from your Department 
on deals that were made with six major stakeholders early in 
the health care reform debate. Thanks to Chairman Waxman, we 
had a unanimous vote in this committee in support of obtaining 
many of the documents that I think the committee really should 
have to see how the legislative process might have been 
circumvented. So Chairman Waxman and Ranking Member Barton will 
be delivering to you a letter detailing the six areas where we 
would like more information.
    Do I have your commitment to work with Chairman Waxman and 
this committee to obtain those documents from your Department?
    Secretary Sebelius. Yes, sir.
    Dr. Burgess. Thank you.
    Now, yesterday you testified at Senate Finance that you and 
your staff were not enveloped in health care reform 
negotiations. Was that correct testimony to the Senate Finance 
Committee yesterday?
    Secretary Sebelius. Congressman, what I testified to was 
that I don't have a vote in the committee. I have certainly 
been present at not only dozens of conversations with Members 
of Congress and the White House, I have traveled all over this 
country talking to stakeholders and seniors, doctors and 
nurses, teachers, union members. I have been involved literally 
in hundreds of meetings----
    Dr. Burgess. I am sorry. I am going to interrupt you 
because time is going to run out. It was reported in the New 
York Times yesterday quoting you, ``I am not a principal in the 
negotiations.'' So you were present, but----
    Secretary Sebelius. What I said is we play a role of 
providing technical advice and assistance. We certainly have 
encouraged people, but I don't have a principal's vote. I have 
been a member of the executive branch and the legislative 
branch, I am not a legislator at this point.
    Dr. Burgess. I am not meaning to interrupt, but in Politico 
on December 2, it was reported that there were strategy 
sessions that involved yourself, Interior Secretary Ken 
Salazar, White House health czar Nancy-Ann DeParle and White 
House Deputy Chief of Staff Jim Messina. Is that an accurate 
reportage, is that an accurate assessment?
    Secretary Sebelius. I have no idea what they are referring 
to. I have certainly been in a room with those folks. And 
again, I will go through my calendar and give you information.
    Dr. Burgess. That gets then to my question, will you be 
willing to provide us any notes or e-mails that you had, for 
example, with the health care czar Nancy-Ann DeParle or the 
White House Deputy Chief of Staff, Jim Messina----
    Secretary Sebelius. Sir, I will look at the request as it 
comes to me and assure you we will get back to you.
    Dr. Burgess. Well, here is the frustration, we are the 
committee that is charged with writing the legislation. And the 
President, to his credit, last March said that he was going to 
set boundaries and deadlines, but the committees were going to 
write the legislation. And then we find out that last May and 
June there were all kinds of deals cut with American Hospital 
Association, AHIP and PHARMA down at the White House, the AMA. 
We don't get to be privy to any of those deals. The AMA 
endorsed the bill before we even got it in committee. What did 
they give, what did they get? Why did that happen that way? Why 
was it in the Senate Finance Committee last fall that Senator 
Nelson, when he was trying to work some of the cost cutting 
that was going on, the whole bill had to go back to CBO to be 
scored because the hospital said we had a different deal?
    You can understand the frustration at the legislative side 
with trying to deal with legislation that is this complex--and 
we all agree that it is complex--and yet we don't know on the 
legislative side what deals you have made on the administrative 
side. So that is very frustrating. In fact, I think it 
disrespects the role of this committee to not be privy to those 
discussions that were carried on behind closed doors, 
especially when the President promised over and over and over 
again that this would be a transparent process--you mentioned 
that in your opening statement, that transparency was going to 
be critical, and yet we have had nothing that resembles 
transparency, everything has been opaque from the 
administration in regards to how these health care deals were 
worked out.
    Secretary Sebelius. Well, again, Congressman, I would 
suggest this conversation basically has gone on for a year. 
There have been hundreds of hearings, lots of C-SPAN coverage, 
lots of public forums and town hall meetings over and over and 
over again, three different committees have now tons of 
amendments----
    Dr. Burgess. I am well aware of that, I don't need to hear 
that recitation. But the Senate confirmed you as the 
President's principal health care advisor; is that correct? You 
went through the Senate confirmation process?
    Secretary Sebelius. Confirmed me as the Secretary, yes.
    Dr. Burgess. Then it seems like--and what you tell this 
committee, what you told Mr. Terry is, well, you are really not 
a principal in these negotiations. Is that because the 
President doesn't trust you to carry on this type of 
negotiation?
    Secretary Sebelius. Congressman, what I said yesterday, and 
I will say it again, is I am not a principal to vote on the 
bill. I am not a member of the legislative body, I am a member 
of the executive branch.
    Dr. Burgess. You are the primary adviser to the President 
of the United States on health care policy, you were confirmed 
by the Senate. It is your obligation to be a principal in these 
discussions.
    Mr. Pallone. The gentleman's time has expired. The 
gentleman has expressed his opinion, we have to move on.
    Next is the gentleman from North Carolina, Mr. Butterfield.
    Mr. Butterfield. Thank you very much, Mr. Chairman. Let me 
start by thanking you for being here today. I know it has been 
a long afternoon for you, but thank you very much for your 
patience.
    Let me also thank you for your leadership throughout this 
whole health care reform debate. I happen to believe that you 
have been an integral part of this debate and you have played a 
very valuable role in this debate. And even though my friend 
from the other side of the aisle may feel that you were not at 
the table, I believe that you were. So thank you for your 
leadership.
    Madam Secretary, I am particularly interested in the area 
of health IT and the investments made in the Office of the 
National Coordinator of Health IT. Your testimony makes mention 
of the administration's plan to encourage the adoption of 
electronic health records through Medicare and Medicaid 
incentive payments, as provided in the recovery bill. I think 
this should be applauded, and I appreciate the leadership the 
administration has shown on the issue.
    I must express some concern, however, with the proposed 
rule issued by CMS on the definition of meaningful use of EHRs, 
particularly regarding the requirements for hospitals and 
doctors to receive the incentive payments. How will rural 
hospitals, including critical access hospitals, be able to meet 
these objectives? I happen to be from a low-income district, 
and you and I have had that conversation many times. I 
represent a very low-income district with major chronic health 
issues prevalent among constituents. How will those hospitals 
that serve low-income communities have the resources to meet 
these objectives? Can you help me with this?
    Secretary Sebelius. Certainly, Congressman. I think, as you 
know, that Congress anticipated the Office of Technology would 
develop a definition for ``meaningful use,'' it is part of the 
legislative mandate, it is part of the law moving forward. 
There is an assumption that small providers, small critical 
care hospitals, those who are not necessarily as 
technologically savvy right now, haven't started this process, 
may need more assistance, which is why I think wisely the 
legislation also anticipates these regional extension centers 
which will be available. And their primary charge is to focus 
on underserved areas, to focus on more reduced poverty 
populations, on hospitals and providers who need additional 
assistance. So that is part of the framework that is moving 
forward. So there will be financial incentives, but more than 
that, there will be actual practical help resource centers, 
kind of hands-on assistance.
    Mr. Butterfield. But it is not only the small hospitals, it 
is the medium-size hospitals as well; they just don't have the 
resources to meet these objectives.
    Secretary Sebelius. That is right. Well, the resources will 
be part of the incentives as the bill moves forward. As quickly 
as people are ready to become part of meaningful users again 
with assistance and help and support, they will be able to 
qualify for the payments that Congress allocated in the 
measure.
    Mr. Butterfield. Let me conclude by thanking you for your 
support for community health centers. That is a big deal in 
rural communities as you well know. You have been very 
sensitive to our needs. This administration has been sensitive. 
And the President's budget speaks to increased community health 
centers. The bill that we reported out of this committee was 
very strong on community health centers. And I just want to 
thank you and urge you to continue to support the concept of 
community health centers. They are very valuable in low-income 
communities.
    Thank you. I yield back.
    Mr. Pallone. I thank the gentleman.
    And next is the gentleman from Georgia, Mr. Gingrey.
    Mr. Gingrey. Mr. Chairman, thank you. Madam Secretary, 
thank you for your patience and staying with us.
    We have an entitlement crisis on our hands. And the 
unfunded liability, as you know, Madam Secretary, for Medicare 
alone is $35 trillion by the year 2075, $35 trillion. If left 
unaddressed, this obligation alone could ruin our future 
economy. Yet in the President's budget, this $3.8 trillion 
budget request, I don't see any concrete proposals to improve 
the Medicare solvency outside the $251 million that you 
mentioned in your budget increase to fight waste, fraud and 
abuse. Surely there are more initiatives available. They 
certainly are needed to strengthen the Medicare program for our 
seniors. Why are there no other initiatives included in the 
budget request so that we can extend the Medicare solvency?
    Secretary Sebelius. Well, Congressman, again, the budget 
was put together as a companion piece to a number of the 
features in health reform, and we hope to be able to move 
forward aggressively in both fronts.
    Moving toward more of a coordinated care strategy on 
bundled payments, which is a way to actually ensure that we can 
do everything from reducing the return of one out of every five 
Medicare patients to the hospital and keep folks not only 
healthier, but at home, working on hospital-based infections 
which not only kill 100,000 Americans every year, but actually 
cost hundreds of millions of dollars year in and year out, 
those strategies are very much a part of the look forward. We 
are beginning to focus more of the payment on primary care and 
general practitioners recognizing that keeping people well at 
the front end----
    Mr. Gingrey. Madam Secretary, I am going to interrupt you. 
I have a couple more questions I want to ask. I agree with you 
on that point, certainly wellness is the way to go rather than 
waiting until people get sick. I certainly don't disagree with 
you on that as a physician member.
    The mandatory part of our budget is probably 60 percent of 
our spending, and yet in the President's budget there is some 
shifting of some of the discretionary spending, particularly on 
the money that was going to be given to the States to help 
create these high-risk pools--I think something like $55 
million--and make that mandatory spending. It makes it easy, of 
course, to freeze discretionary and fulfill his pledge to do 
that over a 3-year period, but it seems to me it is pretty 
irresponsible to create additional mandatory spending of any 
amount at a time when we are suffering so badly with these $1.6 
trillion deficits as far as the eye can see.
    Would you agree with me that creating additional mandatory 
spending is certainly not in our best interests?
    Secretary Sebelius. Well, I think any additional mandatory 
spending needs to be looked at very carefully. I would 
certainly agree with that.
    Mr. Gingrey. Well, thank you, Madam Secretary. I appreciate 
that response.
    Let me ask you one quick last question. You know from 
previous times that you have been with us I have always had 
some concern over the amount of money that we spent on H1N1 and 
where that money goes and what we do with the amount that is 
left over, and indeed what we do with the vaccine that is not 
used. Under the CDC portion of the budget I see there are $225 
million listed as balances from the pandemic flu fund that was 
passed in June.
    Just to be clear, how much of the original $7.7 billion 
that was given to the President in June to combat H1N1 virus 
remains? How much of that money has been unspent at this point?
    Secretary Sebelius. Congressman, I don't want to give you 
an incomplete answer. What I would very much like to do is give 
you a very thorough breakdown of where exactly the money has 
been spent and where it is. I know that a portion of the 
supplemental funding, that 209 supplemental funding that was 
designed to deal with the H1N1----
    Mr. Gingrey. Madam Secretary, fair enough. If you would 
give me--I know you don't have time now, and I want to ask you 
one last thing, but if I would give me a report back on that, I 
would very much appreciate if you would get back to me in a 
timely fashion.
    Secretary Sebelius. I would be glad to do that.
    Mr. Gingrey. The last thing real quickly. In regard to the 
stockpile of H1N1, how many people have we actually reached 
that have been vaccinated? And of the remaining stockpile, what 
percentage actually of the stockpile remains, what happens with 
that next year? Can we utilize that in any effective way or do 
we have to discard it?
    Secretary Sebelius. Congressman, my last numbers from CDC I 
think were in the 64-65 million range in terms of people who 
have been vaccinated. States are continuing to order vaccine, 
as you know. Just at the first of the year the vaccine 
opportunities opened up, so seniors are beginning to be 
vaccinated, populations who weren't in the high-risk pool are 
being vaccinated. And what is happening is that the bulk 
antigen is absolutely able to be used for future vaccinations. 
The fill and finish has a more limited time period, so there 
has been an attempt not to fill and finish every amount of the 
bulk antigen that has been purchased, and that is being looked 
at. But the States are continuing to order vaccine, and so we 
are looking at that issue very carefully.
    Mr. Gingrey. Madam Secretary, thank you. Thank you for your 
patience.
    I yield back.
    Mr. Pallone. I thank the gentleman.
    The gentlewoman from Florida, Ms. Castor.
    Ms. Castor. Thank you, Mr. Chairman. And welcome, Madam 
Secretary.
    The collective cheer you heard from Florida families and 
hospitals last Friday afternoon was the result of your effort 
to work with us on a 1115 Medicaid waiver, an amendment to 
that. I want to thank you very much, and Sydney Mann and 
Bridgett Taylor and your entire team for helping us get that 
done.
    And then you came to our aid again this week because HHS 
rightfully activated the National Disaster Medical System 
because after the January 12 earthquake in Haiti, hundreds of 
evacuees have come to the State of Florida for medical care and 
treatment that is not available in Haiti. In fact, the State of 
Florida has treated 618 people from Haiti who were injured in 
the earthquake. Many are still in our hospitals receiving 
treatment, and that National Disaster Medical System is helping 
evacuate Americans and Haitians, and we really appreciate it.
    Here is my question: How long will it remain activated?
    Secretary Sebelius. I think, Congresswoman, that is a 
question that we are not quite sure that we can answer right 
now. What was clear in the conversations with your Governor and 
other State officials like yourself is that the 
disproportionate brunt that Florida was bearing did not seem 
appropriate when there was really a national and international 
response to the crisis.
    The effort is to stand up medical care in Haiti as quickly 
as possible. A number of the people being evacuated right now 
are actually doing post-op care. They have surgical treatment 
on the USNS Comfort and then need to be brought somewhere for 
care. That, hopefully, will be available in Haiti in the very 
near future. There is a 325 bed hospital that should be up and 
running within days, literally, that can be expanded to 1,000 
beds, doctors and medical supplies being gathered. So the 
government of Haiti, and others, would far prefer, frankly, 
that we help build those assets in Haiti, and that is what 
really the international community is responding to. So this is 
a stopgap, but I can't tell you exactly how long.
    Ms. Castor. So we will continue to have a dialogue on that.
    And Florida's Department of Children and Families has begun 
repatriation efforts for more than 25 Haitians following the 
earthquake. Under the current law, Haitians who are granted 
temporary protective status are considered Cuban Haitian 
entrants and they are, therefore, eligible for medical Federal 
assistance such as Medicaid for 7 years after they arrive in 
the United States. Consequently, Florida, and I am sure other 
States, will have a sizeable number of newly Medicaid-eligible 
residents for years to come. Does the administration's budget 
consider this? I know that the budget probably was mostly put 
together before this time, so does it consider this?
    Secretary Sebelius. No. The budget really was put together 
before the earthquake hit, and so we are having conversations 
not only in our agency, but government-wide, about what this 
assistance needs to encompass.
    Ms. Castor. So you will continue to work with us----
    Secretary Sebelius. Your Office of Children and Families 
has been absolutely spectacular.
    Ms. Castor. Well, I appreciate that, and I will pass that 
on to the Secretary.
    Will this be handled through FMAP or some other means? Or 
we will have that dialogue going forward.
    Secretary Sebelius. Currently, Congresswoman, there are 
lots of alternatives. Our Office of Refugee Assistance is one, 
there are other avenues, but those conversations are really 
underway.
    Ms. Castor. OK. In a somewhat related vein, there are many 
States that are prone to natural disasters. For example, in 
Florida, in recent years we were hit by seven hurricanes, and 
it skewed our FMAP calculation because after the hurricanes we 
had a huge run-up of reconstruction and jobs so that when the 
recession hit, the formula really hurt us, we didn't have the 
money coming in under FMAP. Now, fortunately through the 
Recovery Act we have made some of that up. But I would like to 
look at a permanent solution for States that run into these 
kind of problems so that at the worst time we are not penalized 
just because of a post-disaster run-up in employment.
    Would you work with me on that type of solution, or do you 
have any recommendations at this time on how to----
    Secretary Sebelius. No, I think that is a very real issue 
and problem that is not unique to Florida. It has been 
experienced by a number of States, and I think there are also a 
number of Members who think that the entire FMAP formula needs 
to be revisited. So this could be one aspect of that.
    Ms. Castor. Thank you very much.
    Mr. Pallone. The gentlewoman's time is expired.
    The gentleman from Maryland, Mr. Sarbanes.
    Mr. Sarbanes. I know you are delighted to see me because I 
am the last one to ask you questions.
    Secretary Sebelius. Always delighted to see you, 
Congressman.
    Mr. Sarbanes. Thank you.
    First of all, I want to commend you on your remarkable 
composure, which I judge as remarkable because if I had to sit 
where you are sitting and bear some of the hectoring that you 
did today, I don't think I would have been able to exhibit the 
same composure. And you don't have to respond to that.
    I do want to say that I think you are doing a wonderful job 
in your position. And you have a bearing which I think will 
stand the agency in good stead and has been very effective in 
dealing with the public on all manner of issues, including the 
H1N1 flu virus, and others. We are really blessed to have you 
there.
    It cannot have been easy to put this budget together given 
what a moving target the health reform bill has been. And 
regardless of what happens with that reform effort, your work 
will remain really at the center of the health system, and 
particularly the public health system. So I thank you for the 
work you are doing. You have clearly put together a tremendous 
staff that I know is working around the clock on these issues.
    There are so many good things that are in those health 
reform bills, and many of them are ones that your budget 
reflects as well. I just wanted to point to a couple of them 
and ask a couple of questions.
    First of all, there is a discussion of these Medicare 
demonstration projects and some other initiatives to determine 
how to better align provider payments with the kinds of 
outcomes and treatments and regimens that we want to see. I 
have been long fascinated by the, I think, overemphasis on 
procedure reimbursement versus time spent with patients. I am 
wondering if you could just speak to whether some of these 
demonstration projects are intended to determine how we can 
enhance outcomes and treatment approaches if we look to 
providing better reimbursement so that physicians can be 
rewarded for spending a little extra time with their patients.
    Secretary Sebelius. Well, I think that is certainly one of 
the outcomes that would be most desirable, not only providing 
financial incentives to spend more time, but certainly the kind 
of coordinated care strategies which we know work well with not 
just physicians, but sort of medical teams that, following a 
patient's release from a hospital, can be much more effective 
at keeping that patient well and healthy and on a pathway to 
success. So we have added Medicare to a demonstration project 
that is going on in the Northeast, which we think can be a 
great success.
    We know that too often physicians--and, Dr. Gingrey, you 
may have this experience--talk about not being able to see 
people on a regular basis to keep them well, but they get the 
incentives tilt toward sick care and not health care. So I 
think we have got a great deal of opportunity to move into that 
preventative care, wellness strategy space with financial 
incentives and other strategies to make sure that providers can 
be providers.
    Mr. Sarbanes. Great. I wanted to congratulate you on the 
resources going towards the National Health Service Corps, 
enhancing the number of primary care providers out there, and 
other initiatives which include as a component of helping 
students with the debt burden that they carry--that is 
something that I am particularly focused on across the board 
and authored a provision that actually the President mentioned 
the other day relating to loan forgiveness for those who go 
into public service. So I really encourage that effort.
    The last thing I will just mention, because I am running 
out of time, is I am very interested as well in this idea of 
what I call place-based health care, which is to think about 
instead of relying on the patient to come to our health care 
system, we think about how we can bring the system to the 
patient, and think about where people are already gathered, 
where there is a captive audience. The most obvious example of 
this is schools. I would love to continue to work with your 
office on all things school-based when it comes to health 
initiatives because I think there is tremendous opportunity 
there to provide screening and preventive services and other 
things, potentially even help with the enrollment around CHIP, 
although I know that is something that has to be worked through 
perhaps on a State-by-State basis, but there is tremendous 
potential there. And you know that the H1N1 outbreak in New 
York City, for example, was spotted by a school nurse. There is 
so much more we can do to enhance the public health 
infrastructure of the country if we focus in on these places 
where people already are. So I look forward to continued 
efforts in that regard as well.
    Secretary Sebelius. Well, Congressman, I think not only is 
your effort in that area appreciated, but one of the great 
success stories of H1N1 will be the school-base vaccination 
clinics, where schools really were great partners. They were 
even better when there was a school-based health clinic that 
was then reaching out to the parents and grandparents and 
younger siblings of those children.
    I can tell you that the new Secretary of Education and I 
have already had discussions about how we can accelerate and 
encourage more school-based health clinics because I agree with 
you, it is a great way to provide cost-effective health care 
and reach folks where they are comfortable and coming on a 
regular basis. Unfortunately, the number of school-based health 
clinics is kind of frozen. It was a large investment, and then 
it has kind of flattened out. But I think the way community 
health centers have become part of the infrastructure, I think 
school-based health clinics also need to be looked at as one of 
the ways to expand access site and deliver low-cost, high-
quality preventative care not only to children, but to their 
parents and grandparents, to the neighborhoods around the 
schools and have the schools be a health center.
    Mr. Pallone. Thank you, Madam Secretary.
    Mr. Shimkus. Mr. Chairman, I ask unanimous consent for a 
second round of questions.
    Ms. Castor. Objection.
    Mr. Shimkus. Is the gentlewoman from Florida the one who 
objected? I am just trying to identify which person objected in 
the front row. Is it the gentlelady from Florida?
    Mr. Pallone. She did object.
    Mr. Shimkus. Objected to a second round of questions of the 
Secretary? I would like to thank her.
    Mr. Chairman, point of order.
    Mr. Pallone. Let me just respond to you.
    The chairman, Chairman Waxman, made it very clear from the 
beginning that what we were doing is having everyone have 5 
minutes to either ask questions or make a comment, or whatever. 
It was quite clear that we were not having a second round and 
that that is what we were doing today. So I am not going to 
proceed to a second round because I think it was quite clear 
from the beginning that that is not what we were doing.
    Mr. Shimkus. A unanimous consent request, Mr. Chairman. 
Just for anyone who has questions to be able to submit them to 
the Secretary.
    Mr. Pallone. Yes, absolutely.
    Mr. Shimkus. I don't know if that question was made prior.
    Mr. Pallone. I know you have some written questions you 
would like to submit to the Secretary, I know others will, so 
we will allow--I mean, we always do, but I will specifically 
say today that we will have some written questions, and we 
would like you to get back to us in a timely fashion, Madam 
Secretary.
    Mr. Shimkus. Mr. Chairman, will there be a time limit that 
we expect these responses to be made? As we saw, some came 
quick, quite a few came long.
    Mr. Pallone. I believe that, generally speaking--but I 
don't want to put you in any kind of a straitjacket here--but 
generally speaking, we ask the Members to submit those 
questions within 10 days, I believe. And I would ask that for 
whatever you get within those 10 days, that you get back to us 
in a reasonable time, a few weeks.
    Mr. Shimkus. Mr. Chairman, is this the last time we will 
see the Secretary this year before this committee?
    Mr. Pallone. I certainly hope not. I have thoroughly 
enjoyed seeing her.
    Mr. Shimkus. Part of the frustration is we have the head of 
one of the largest departments in the Federal Government and we 
have 3 hours with her.
    Mr. Pallone. I understand.
    Mr. Shimkus. With the major policy decisions that health 
care has been, with a promise that she would have been here 
after the rollout of the bill, which never occurred. So that is 
our frustration, and we would like to have more time.
    Mr. Pallone. Well, we are not doing it today. We will see 
if there is another opportunity, but I don't want to make any 
commitments at this time.
    But I do want to thank you for being here today. I know it 
was suggested that it was tough; it wasn't really that tough 
compared to some of our meetings. But we do appreciate all that 
you have done really, not only on health reform, but also on 
all the different health issues that come before your 
Department. Thanks so much.
    Without objection, this committee is adjourned.
    [Whereupon, at 5:20 p.m., the committee was adjourned.]
    [Material submitted for inclusion in the record follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


