[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]


                THE PRESIDENT'S FISCAL YEAR 2015 BUDGET
                    PROPOSAL WITH U.S. DEPARTMENT OF
                       HEALTH AND HUMAN SERVICES
                      SECRETARY KATHLEEN SEBELIUS

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

                                 HEARING

                               BEFORE THE

                      COMMITTEE ON WAYS AND MEANS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 12, 2014

                               __________

                          Serial No. 113-FC16

                               __________

         Printed for the use of the Committee on Ways and Means
         
         
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                      COMMITTEE ON WAYS AND MEANS

                     DAVE CAMP, Michigan, Chairman

SAM JOHNSON, Texas                   SANDER M. LEVIN, Michigan
KEVIN BRADY, Texas                   CHARLES B. RANGEL, New York
PAUL RYAN, Wisconsin                 JIM MCDERMOTT, Washington
DEVIN NUNES, California              JOHN LEWIS, Georgia
PATRICK J. TIBERI, Ohio              RICHARD E. NEAL, Massachusetts
DAVID G. REICHERT, Washington        XAVIER BECERRA, California
CHARLES W. BOUSTANY, JR., Louisiana  LLOYD DOGGETT, Texas
PETER J. ROSKAM, Illinois            MIKE THOMPSON, California
JIM GERLACH, Pennsylvania            JOHN B. LARSON, Connecticut
TOM PRICE, Georgia                   EARL BLUMENAUER, Oregon
VERN BUCHANAN, Florida               RON KIND, Wisconsin
ADRIAN SMITH, Nebraska               BILL PASCRELL, JR., New Jersey
AARON SCHOCK, Illinois               JOSEPH CROWLEY, New York
LYNN JENKINS, Kansas                 ALLYSON SCHWARTZ, Pennsylvania
ERIK PAULSEN, Minnesota              DANNY DAVIS, Illinois
KENNY MARCHANT, Texas                LINDA SANCHEZ, California
DIANE BLACK, Tennessee
TOM REED, New York
TODD YOUNG, Indiana
MIKE KELLY, Pennsylvania
TIM GRIFFIN, Arkansas
JIM RENACCI, Ohio

        Jennifer M. Safavian, Staff Director and General Counsel

                  Janice Mays, Minority Chief Counsel

.                            C O N T E N T S

                               __________

                                                                   Page

Advisory of March 12, 2014 announcing the hearing................     2

                                WITNESS

The Honorable Kathleen Sebelius, Secretary, U.S. Department of 
  Health and Human Services......................................     6

                       SUBMISSIONS FOR THE RECORD

The Honorable Jim Renacci........................................    58
The Honorable Todd Young.........................................    60
The Honorable Xavier Becerra.....................................    70
The Honorable Pat Tiberi.........................................    81
The Honorable Sander Levin (Submission 1)........................    90
The Honorable Sander Levin (Submission 2)........................    93

 
                THE PRESIDENT'S FISCAL YEAR 2015 BUDGET
                    PROPOSAL WITH U.S. DEPARTMENT OF
                       HEALTH AND HUMAN SERVICES
                      SECRETARY KATHLEEN SEBELIUS

                              ----------                              


                       WEDNESDAY, MARCH 12, 2014

                     U.S. House of Representatives,
                               Committee on Ways and Means,
                                                    Washington, DC.

    The Committee met, pursuant to call, at 10:00 a.m., in Room 
1100, Longworth House Office Building, Hon. Dave Camp [Chairman 
of the Committee] presiding.

    [The advisory announcing the hearing follows:]

               ADVISORY FROM THE COMMITTEE ON WAYS AND MEANS 

                        CONTACT: (202) 225-3625
FOR IMMEDIATE RELEASE
Wednesday, March 5, 2014
No. FC-16

                 Chairman Camp Announces Hearing on the

           President's Fiscal Year 2015 Budget Proposal with

              U.S. Department of Health and Human Services

                      Secretary Kathleen Sebelius

    House Ways and Means Committee Chairman Dave Camp (R-MI) today 
announced that the Committee on Ways and Means will hold a hearing on 
President Obama's budget proposals for the Department of Health and 
Human Services (HHS) for fiscal year 2015. The hearing will take place 
on Wednesday, March 12, 2014, in 1100 Longworth House Office Building, 
beginning at 10:00 a.m.

      
    In view of the limited time available to hear witnesses, oral 
testimony at this hearing will be from the invited witness only. The 
sole witness will be the Honorable Kathleen Sebelius, Secretary, U.S. 
Department of Health and Human Services. However, any individual or 
organization not scheduled for an oral appearance may submit a written 
statement for consideration by the Committee and for inclusion in the 
printed record of the hearing.

      

BACKGROUND:

      
    On March 4, 2014, President Obama submitted his fiscal year 2015 
budget proposal to Congress. The President's proposed budget contains 
his tax, spending and policy proposals for the coming fiscal year, 
including his proposed budget for the Department of Health and Human 
Services and the programs it oversees and operates. Many of the 
Department's programs such as Medicare, healthcare programs under the 
Affordable Care Act and Temporary Assistance for Needy Families are 
within the Committee's jurisdiction.

      
    In announcing this hearing, Chairman Camp said, ``Reviewing the 
budget, I am troubled by the President's decision to ignore what he 
once saw as a crisis in our entitlement programs. By leaving out any 
real reforms to protect and preserve Medicare, the President has chosen 
to provide political cover in an election year when what this country 
needs most are solutions that protect both today's seniors and future 
generations.

      
    ``We also must ask difficult questions about HHS' troubled efforts 
to implement the Affordable Care Act. Open enrollment is almost over, 
enrollment is behind schedule and the website is not completed. Most 
importantly, the American people are facing higher premiums, fewer 
healthcare choices and a loss of wages--the exact opposite of what they 
need in a tough economy. Administrative delays and exemptions cannot 
fix this law, and the Committee looks forward to hearing how Secretary 
Sebelius plans to work with Congress to solve this crisis.

      
    ``Members also look forward to reviewing the Administration's 
proposals affecting human services programs, including those that may 
help welfare recipients replace welfare checks with paychecks or assist 
youth in foster care become successful adults.''

FOCUS OF THE HEARING:

      
    U.S. Department of Health and Human Services Secretary Sebelius 
will discuss the details of the President's HHS FY15 budget proposals 
that are within the Committee's jurisdiction.
      

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

      
    Please Note: Any person(s) and/or organization(s) wishing to submit 
for the hearing record must follow the appropriate link on the hearing 
page of the Committee website and complete the informational forms. 
From the Committee homepage, http://waysandmeans.house.gov, select 
``Hearings.'' Select the hearing for which you would like to submit, 
and click on the link entitled, ``Click here to provide a submission 
for the record.'' Once you have followed the online instructions, 
submit all requested information. ATTACH your submission as a Word 
document, in compliance with the formatting requirements listed below, 
by the close of business on Wednesday, March 19, 2014. Finally, please 
note that due to the change in House mail policy, the U.S. Capitol 
Police will refuse sealed-package deliveries to all House Office 
Buildings. For questions, or if you encounter technical problems, 
please call (202) 225-1721 or (202) 225-3625.
      

FORMATTING REQUIREMENTS:

      
    The Committee relies on electronic submissions for printing the 
official hearing record. As always, submissions will be included in the 
record according to the discretion of the Committee. The Committee will 
not alter the content of your submission, but we reserve the right to 
format it according to our guidelines. Any submission provided to the 
Committee by a witness, any supplementary materials submitted for the 
printed record, and any written comments in response to a request for 
written comments must conform to the guidelines listed below. Any 
submission or supplementary item not in compliance with these 
guidelines will not be printed, but will be maintained in the Committee 
files for review and use by the Committee.
      
    1. All submissions and supplementary materials must be provided in 
Word format and MUST NOT exceed a total of 10 pages, including 
attachments. Witnesses and submitters are advised that the Committee 
relies on electronic submissions for printing the official hearing 
record.
      
    2. Copies of whole documents submitted as exhibit material will not 
be accepted for printing. Instead, exhibit material should be 
referenced and quoted or paraphrased. All exhibit material not meeting 
these specifications will be maintained in the Committee files for 
review and use by the Committee.
      
    3. All submissions must include a list of all clients, persons and/
or organizations on whose behalf the witness appears. A supplemental 
sheet must accompany each submission listing the name, company, 
address, telephone, and fax numbers of each witness.
      
    The Committee seeks to make its facilities accessible to persons 
with disabilities. If you are in need of special accommodations, please 
call 202-225-1721 or 202-226-3411 TDD/TTY in advance of the event (four 
business days notice is requested). Questions with regard to special 
accommodation needs in general (including availability of Committee 
materials in alternative formats) may be directed to the Committee as 
noted above.
      
    Note: All Committee advisories and news releases are available on 
the World Wide Web at http://www.waysandmeans.house.gov/.

                                 

    Chairman CAMP. Good morning. The Committee will come to 
order.
    Secretary Sebelius, thank you for joining us today for a 
discussion of the President's 2015 budget.
    It has been 4 years since Obamacare became the law of the 
land, and it has been a bumpy road since then. Millions of 
Americans are paying more for health care as a result of the 
law.
    The Committee will come to order. Please take your seats.
    It has been 4 years since Obamacare became the law of the 
land, and it has been a bumpy road since then. Millions of 
Americans are paying more for health care as a result of the 
law, a trend which will only continue to spike as a result of 
the failed healthcare exchange launch. All across the country, 
low- and middle-class income Americans are seeing smaller 
paychecks and working less. Towns, schools, restaurants, and 
businesses are struggling to comply with the law, finding that 
they are forced to cut hours or hold off on hiring. Millions of 
Americans have discovered the plan they have and like has been 
canceled or they can no longer rely on the care from their 
local doctor or hospital.
    I hear about how the healthcare law is affecting 
communities like my hometown of Midland, Michigan, and how 
families are dealing with the uncertainty this has brought them 
and their children.
    Unfortunately, despite Republican attempts to provide 
Americans relief from the burdens of this law, it appears that 
this is a road map of what is to come. We now know, after the 
failed launch of the exchanges, that since the Administration 
was unable to meet their enrollment targets and failed to sign 
up enough young and healthy individuals, premiums will be 
higher next year. The Congressional Budget Office has also 
found that compared to initial estimates, fewer individuals 
will find healthcare coverage through the exchanges, Medicaid, 
or employer-sponsored insurance.
    And while Democratic leaders promised that Obamacare would 
create 4 million jobs, 4,000 almost immediately, the CBO 
projects fewer Americans will be working as a result of 
Obamacare. In fact, the U.S. economy will see a decline in the 
number of full-time-equivalent workers of about 2 million in 
2017, rising to about 2.5 million in 2024, according to CBO. 
CBO went on to emphasize this should mean, and I am quoting, 
``The largest declines in labor supply will probably occur 
among lower-wage workers.''
    Secretary Sebelius, you have stated that there is 
absolutely no evidence, and every economist will tell you this, 
that there is any job loss related to the Affordable Care Act. 
But the evidence is everywhere. We hear it from employers back 
home, from testimony in front of Congress, and we read about it 
in the papers weekly.
    The law is not working as was promised, and yet the 
President's budget doubles down on this law and requests 
another $1.8 billion for its implementation. With so many 
unanswered questions, it is hard to understand how or why 
Congress would approve such a request. I am hopeful you will 
shed some light on those questions and provide some answers 
today, basic questions such as how much taxpayer money has been 
spent thus far and where did it come from, how much taxpayer 
money will be spent on subsidies for individuals outside of the 
exchange, how much did the failed launch of the exchange cost 
taxpayers, how many people have actually paid a premium, and 
how many previously uninsured Americans have signed up for 
Obamacare?
    And increasingly, we must all ask the question, when is the 
next delay or next administrative change in the law coming? It 
seems not a holiday goes by without a new announcement from the 
Administration that delays some part of Obamacare.
    Notably missing from this budget is any mention on how we 
can secure the promise of Medicare for seniors in the future. 
In just a few short years, Medicare will go broke. This 
Committee has released numerous discussion drafts, based on 
bipartisan ideas, to secure Medicare for current and future 
seniors, some of which were included in previous budgets from 
President Obama.
    We have the opportunity now to work toward reforms that 
strengthen the program, and the longer we wait, the harder the 
choices we must make will be. We need to have an open dialogue 
between the Administration and Congress on this, and I am 
disappointed that the Administration has walked away from this 
commitment and seemingly provided political cover during an 
election year rather than offer solutions.
    I appreciate your making the time to be here today, and I 
hope we can count on a more open, constructive dialogue between 
Congress and the Administration if we are going to make 
progress on resolving the law's failures and working toward 
solutions for our Nation's seniors.
    Before I recognize Ranking Member Levin for the purpose of 
an opening statement, I ask unanimous consent that all Members' 
written statements be included in the record. And without 
objection, so ordered.
    I now recognize Ranking Member Levin for his opening 
statement.
    Mr. LEVIN. Thank you very much.
    Madam Secretary, welcome. We really do welcome you here, a 
chance to have some dialogue. I hope that is what will occur. 
Instead of dialogue, what we have really had from the 
Republicans is diatribe. And we are going to see that further 
this week when there is an effort to take up our reform on SGR 
that is on a bipartisan basis and fund it with essentially the 
destruction of ACA.
    The New York Times talks about today where the enrollment 
is. And it is interesting, the Republicans often used to talk 
about Part D and how it proceeded. The Energy and Commerce 
Committee is going to come out with a report this morning, and 
it is going to turn out that ACA enrollment as a percentage of 
projected enrollment is already better than Part D's voluntary 
enrollment. So I hope you will be able to set the record 
straight. As we know, it is short of the original goal. And I 
hope you will address that, where we are, what the figures 
really mean. And also you may want to comment that 3 million 
young adults have already gained access to health insurance 
through their parents' policies, which would not have happened 
if it weren't for ACA.
    I just want to give one example of what this has meant for 
people in this country. A person from Brighton, Michigan, in 
her thirties, has lupus, a preexisting condition. She hasn't 
had insurance in 6 years because it was simply too expensive. 
She lived in constant fear of getting sick or injured, and she 
said, and I quote, ``There are lots of things I haven't done. I 
used to like to ski and mountain bike, but I know that if I 
broke a wrist it would cost me $10,000. It is that constant 
worry of what happens if.'' And that uncertainty ended January 
1, when her new insurance plan, costing $175 a month, took 
effect.
    The real contrast is an ad that has been running in 
Michigan about a cancer patient, and I won't go into the 
details. But essentially, she said her policy was unaffordable 
through the marketplace. The ad has been funded over a million 
dollars by Americans for Prosperity. It turns out, according to 
the Detroit News and others, that that ad and that statement 
together are just false. It turns out that this person will 
save more than $1,000 a year.
    So, Madam Secretary, I hope you will use your time to 
acknowledge the problems with the website at the beginning and 
put in perspective what has happened since then and where we 
are going, and indeed, to have a dialogue. What has been most 
short in the discussion of ACA has been dialogue. We welcome 
you here and look forward to your testimony.
    Chairman CAMP. Well, thank you, Mr. Levin.
    Again, I want to now welcome our witness, Secretary 
Kathleen Sebelius of the Department of Health and Human 
Services.
    Again, thank you for being with us today. The Committee has 
received your written statement and testimony, and it will be 
made part of the formal hearing record. You are now recognized 
for 5 minutes for your oral remarks. Thank you.

 STATEMENT OF THE HONORABLE KATHLEEN SEBELIUS, SECRETARY, U.S. 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Secretary SEBELIUS. Well, thank you, Chairman Camp, and 
Ranking Member Levin, and Members of the Committee.
    In his State of the Union, President Obama laid out values 
that are the backbone of his 2015 budget: opportunity for all, 
economic growth, and security, the notion that if you work hard 
and take responsibility you should have the opportunity to 
succeed in America. Our budget will allow our Department to 
move this mission forward.
    We start with the fact that every child deserves the 
opportunity for a healthy start and a high-quality learning 
environment. And as the President has said, research shows that 
one of the best investments we can make in a child's life is 
high-quality early education. Science has clearly demonstrated 
over and over that the return on early childhood investments is 
at least seven to one, far exceeding any investment in the 
stock market. And the fact of the matter is these investments 
are good for our kids, good for our economy, and good for a 
family's economic security.
    In every State, currently the cost of child care for two 
children now exceeds the median annual rent. Our budget puts a 
special focus on birth to kindergarten. It brings the total 
investment in child care and development funds to $6.1 billion, 
so more of our children have access to quality care.
    We also propose to expand early Head Start child care 
partnerships for more of our children. This allows us to build 
on the progress we are making in reforming Head Start. And by 
funding the President's Opportunity, Growth, and Security 
Initiative, we could provide an additional hundred thousand 
children with access to high-quality early learning.
    Our global competitors have figured out that investing in 
early education makes good economic sense. China plans to 
increase the preschool enrollment by 50 percent by 2020. And in 
Japan, virtually every 4-year-old attends preschool. So if we 
want our children to compete for the global jobs of the future, 
these investments really matter.
    This budget also extends and expands voluntary home 
visitation so we can empower our children's first and best 
teachers, their parents.
    The investments don't add a dime to the deficit. One of the 
ways they are paid for is through an increase to the tobacco 
tax, which we know encourages younger Americans from smoking. 
But here is the snapshot: Every day more than 3,000 children 
try their first cigarette, and nearly 1,000 a day become daily 
smokers. So the efforts to reduce their smoking habits are 
imperative.
    These investments have broad bipartisan support from 
governors, from business, military, and law enforcement 
leaders, from parents and health providers, and can make a huge 
difference in our Nation's prosperity.
    Of course no child can learn with a toothache that his or 
her family can't afford to have treated. No family can save for 
college when they are drowning in medical bills. This budget 
protects the progress we are making in helping more Americans 
obtain the opportunity of affordable health coverage. 
Yesterday, we announced that 4.2 million people had signed up 
through the end of February, which is an increase of 29 percent 
in the month of February in the number of signups. The number 
of people choosing a plan every day last month also increased 
from an average of 32,800 in January to 34,000 a day in 
February. We expect that number to rise by the March 31st 
deadline, as more Americans learn how affordable the 
marketplace coverage can be. We also know that we have had a 
total of 8.9 million people, as the last Medicaid report 
indicated, that have been determined eligible for either 
renewal or new Medicaid benefits.
    Now, one of our best tools also for expanding access to 
health care are the community health centers, which are 
throughout our urban and rural areas. This budget invests to 
help them serve an additional 31 million Americans at new and 
existing sites. The budget also protects our seniors by 
increasing investments for elder justice to protect them from 
abuse, neglect, and exploitation. It protects consumers with 
additional resources to help the FDA oversee the safety of our 
food supply and pharmaceutical resources. It expands the 
efforts to protect hospital patients from healthcare-associated 
infection.
    And because the opportunity, growth, and security mean very 
little when a family faces unemployment, the budget is a job 
creator. It invests in industries that drive our economy, 
innovation, science, and discovery. The investments fuel 
entrepreneurship and economic growth, while saving lives, the 
NIH-funded BRAIN Initiative, vaccine development, and other 
innovative products.
    Through the Health Care Workforce Initiative, the budget 
expands the National Health Service Corps, enabling us to focus 
training dollars on the primary care workforce by expanding 
residency training opportunities. And for all these proposed 
investments, the budget makes tough, fiscally responsible 
choices. It will contribute a net $369 billion to our deficit 
reduction over the next decade by incentivizing high-quality, 
efficient care, and by continuing to reduce healthcare cost 
growth, strengthen Medicare and Medicaid with $415 billion in 
net savings over 10 years.
    We will also produce budget savings for taxpayers by 
continuing to crack down on waste, fraud, and abuse. Every 
dollar we invest in the Health Care Fraud and Abuse Control 
Initiative, for example, returns $8.10 in money we recover, 
which last year was a record-breaking $4.3 billion.
    Now, in many ways the budget reflects the notion from the 
Book of Matthew that where your treasure is there also your 
heart will be. A budget is more than a ledger. It is a 
statement of a mission, intentions, and priorities. This budget 
succeeds in that mission by expanding opportunity, encouraging 
growth, and protecting both our families' economic security and 
our Nation's health security.
    Thank you, Mr. Chairman, and I would be pleased to answer 
your questions.
    [The prepared statement of Secretary Sebelius follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
    
    Chairman CAMP. Well, thank you, Madam Secretary.
    The Secretary has a hard stop at 12:15. And in the interest 
of time, questions will be limited to 3 minutes. I am going to 
hold my questions to the end of my time and yield to the Health 
Subcommittee Chairman, Kevin Brady, to begin questioning. I 
will then recognize Health Subcommittee Ranking Member 
McDermott, and then we will start in reverse order of 
seniority. If we run out of time before I have an opportunity 
to ask questions, I will submit mine for the record, and would 
ask that I get a timely response to those.
    The Committee still seeks some basic information about how 
many people have paid their premiums, how many uninsured are 
actually enrolled in the exchanges, how much the launch of 
exchanges has cost taxpayers, and what programs were cut to pay 
for the implementation that really didn't work. So if we can 
get answers to those questions during the hearing, I think that 
would be helpful.
    Mr. Brady is now recognized.
    Mr. BRADY. Thank you, Mr. Chairman.
    Madam Secretary, you were before the Committee in April of 
last year. You assured us all there would be absolutely no more 
delays in the Affordable Care Act. We have seen eight delays 
since you gave us those assurances, bringing the total now to 
35. So the question is, I think fairly for our families at 
home, what other delays should they expect? Are you going to 
delay the mandate that individuals have to buy government-
approved health care or pay a tax?
    Secretary SEBELIUS. No, sir.
    Mr. BRADY. Are you going to delay the open enrollment 
beyond March 31st?
    Secretary SEBELIUS. No, sir.
    Mr. BRADY. Is it correct that you don't have the authority 
to extend that deadline? The position that the Centers for 
Medicare & Medicaid Services have made, you agree with that?
    Secretary SEBELIUS. I haven't seen their statement, sir, 
but there is no delay beyond March 31st.
    Mr. BRADY. Well, my question is, the law very clearly makes 
the case that tax credits are available only to individuals who 
are enrolled through the exchanges. Yet 2 weeks ago in 
regulation you deemed that individuals who haven't enrolled in 
the exchanges are eligible for those tax credits. My question 
is, what specific provision in the Affordable Care Act grants 
you that authority?
    Secretary SEBELIUS. Well, sir, I can get you the specific 
cite, but the authority really comes from the law, which states 
if a person is eligible for the Affordable Care Act and in the 
exchange process, then they are eligible for a tax credit. We 
have made it clear that if through no fault of their own they 
were unable to enroll, that eligibility extends to a delayed 
enrollment period, and they will have a special enrollment 
period which we have the authority to grant.
    Mr. BRADY. Madam Secretary, to be very clear, the law is 
very plain, only people enrolled in exchanges are eligible for 
tax credits. As the Committee that handles the tax credits, we 
know this section well. So maybe you could ask the folks who 
are here today.
    Secretary SEBELIUS. Sir, I would be happy to get you the 
statutory authority.
    Mr. BRADY. Your experts are behind you. If you would like 
to ask them, please do. But there is no provision there.
    Secretary SEBELIUS. Sir, I will get you this in writing.
    There is a provision that indicates that if a person is 
eligible, the eligibility--and in the enrollment process--we 
can grant a special enrollment period.
    Mr. BRADY. I guarantee you, Madam Secretary, you won't be 
getting us back that provision because it is not there. And my 
point is, if you delayed this law because it is not workable 
for businesses, why aren't you delaying this law because it is 
not workable for our families? How is that fair?
    Secretary SEBELIUS. I am sorry, sir?
    Mr. BRADY. How is it fair that you delayed this law because 
it is unworkable for businesses of all sizes, but it is not 
workable for families? Why aren't they getting the same 
treatment?
    Secretary SEBELIUS. Well, sir, we haven't delayed the law's 
implementation across the board.
    Mr. BRADY. Not across the board, but for businesses, large 
businesses, medium and small.
    Secretary SEBELIUS. Ninety-four percent of business owners 
are less than 50, and the law has never applied to them. There 
are 2 percent of business owners who are in the above 100 
percent. They have an additional year to fill out paperwork. 
Another 2 percent----
    Mr. BRADY. Madam Secretary, it is just not fair.
    Chairman CAMP. Time has expired.
    Mr. McDermott.
    Mr. MCDERMOTT. Wow. Take a breath.
    Your budget contains several proposals for structural 
reforms to Medicare, all of which will increase the cost on 
beneficiaries. What I don't see in your budget is Medicare 
reforms that ask providers and pharmaceutical companies to 
share in the pain. Frankly, that concerns me. I think there 
ought to be a sharing of the pain among the providers and those 
who benefit from Medicare.
    As you know, Medicare beneficiaries already spend a 
disproportionate share of their income on health care compared 
to those under age 65, and upper-income Medicare patients pay 
more.
    Now, I understand these proposals, while they concern me, 
were put into the budget as a part of a so-called big, bold, 
balanced budget deficit reduction plan, one that calls for 
shared sacrifice among working and retired Americans, wealthy 
or not.
    So let me ask this question. The notion that completely 
seems to be around here is much different that you can cherry 
pick those Medicare reforms here and one there, sort of low-
hanging fruit as a way to offset or to pay for the SGR. Our 
Republican colleagues have been talking about doing this. And I 
think that it is hard for that to actually occur, because SGR 
needs to be fixed. There is not actually a documented access 
problem throughout the program. And it seems unconscionable to 
ask those with household incomes averaging $23,000 a year to 
pay more in order to increase payments to doctors.
    My question is this: Does the Administration support cherry 
picking structural reforms which would increase costs for 
Medicare beneficiaries, or are those reforms solely intended as 
a part of a substantial deficit reduction package with shared 
sacrifice for all Americans?
    Secretary SEBELIUS. Well, Congressman, as you know, the 
President has said for a number of years that he remains 
hopeful for a big deal, tax reform, entitlement reform package 
that would put us on the path to multiyear fiscal solvency. And 
so I think in the context of those reforms, that is why these 
proposals continue to be made in the budget, but it is in the 
context of a major effort. Entitlement reform is a piece of the 
puzzle, but only a piece of the puzzle if there is additional 
tax reform and revenue sharing that, as you say, involves 
everyone.
    Mr. MCDERMOTT. So the White House doesn't support selecting 
out pieces to pay for SGR.
    Secretary SEBELIUS. Well, I think the budget is a package 
that moves forward, and the cherry picking of one piece or 
another gives, as you say, undue burden on seniors.
    Chairman CAMP. All right. Thank you.
    Mr. Renacci is recognized.
    Mr. RENACCI. Thank you, Mr. Chairman, for holding this 
hearing on the President's budget.
    Chairman CAMP. I think you need to lean into the 
microphone.
    Mr. RENACCI. It is not working.
    Mr. CROWLEY. These aren't working. Are you pulling an Issa 
on us? This isn't an Issa, is it? Just making sure.
    Chairman CAMP. There we go. Mr. Renacci is recognized.
    Mr. RENACCI. Thank you, Mr. Chairman, for holding this very 
important hearing on the President's budget and allowing us the 
opportunity to question the Administration on behalf of our 
constituents.
    Secretary Sebelius, welcome back, and thank you for taking 
the time to speak with us today.
    Madam Secretary, Obamacare was sold to the American people 
as a bill that would make health care more affordable. In my 
State of Ohio, it has become clear this is not the case, as 
premiums, deductibles, and out-of-pocket costs have increased 
for a significant number of Americans, causing working-class 
families and young individuals to spend more of their hard-
earned pay on healthcare expenses. In fact, I have had many 
individuals in my district who are now covered who can't afford 
their deductibles now questioning me as to what they are 
supposed to do to access health care.
    Mr. Chairman, I would like to submit for the record a 
transcript of an interview between NBC News and Secretary 
Sebelius on September 30, 2013.
    Chairman CAMP. Without objection.
    Mr. RENACCI. Madam Secretary, in an interview on September 
30, 2013, you said, when asked regarding Obamacare, what 
success would look like. Your answer, and I quote, was, ``I 
think success looks like at least 7 million people signed up by 
the end of March 2014.'' Open enrollment ends this month, and 
you are well short of that target. Based on your own standards, 
Obamacare will not be successful at the end of March 2014. What 
do you now call success?
    Secretary SEBELIUS. Well, Congressman, I think that in 
answer to your initial question, I don't know the constituents 
you are speaking to, but I can give you a national snapshot 
where private insurance rates in the 10 years before Obamacare 
were running about 8.6----
    Mr. RENACCI. Madam Secretary, can I get you to answer that 
question on what is now success because I only have 3 minutes?
    Secretary SEBELIUS. Well, success looks like millions of 
people with affordable health coverage, which we will have by 
the end of March, in the private marketplace, in Medicaid, 
young adults on their family plan. So we will have I think a 
successful program. We have a market, we have competition. We 
have for the first time self-employed individuals who don't 
have affordable care through their worksite getting affordable 
coverage.
    Mr. RENACCI. So you are changing your standard of 7 million 
by the end of March 31st.
    Secretary SEBELIUS. I said success looks like millions of 
people having affordable health care.
    Mr. RENACCI. Actually, you said 7 million. I have one other 
question. In that interview, you also talked about deductibles, 
and your answer was, ``Well, I think families can make a 
choice. It isn't something they can pay for. A lot of people 
couldn't pay their out-of-pocket, they will want a lower 
deductible.'' Can you answer the question as to how about those 
people in my district who can't afford a lower deductible? What 
should they be doing?
    Secretary SEBELIUS. Again, sir, I think that the range of 
plans in the marketplace is more robust than the range of plans 
ever has been in the individual marketplace or in the small 
group marketplace. Some, as you know, have lower premiums in 
exchange for higher deductibles, some have lower deductibles 
and higher premiums. But that range has never been there, nor 
have the millions of Americans who now qualify for some 
financial help to get into the marketplace to have that 
benefit. So I meet people every day who are actually having 
affordable health care for the first time. They have never had 
employer-based health care, and they have an opportunity for 
health security for themselves and their families.
    Chairman CAMP. All right. Thank you.
    Ms. Sanchez is recognized.
    Ms. SANCHEZ. Okay. My mike is working. Thank you, Mr. 
Chairman.
    And, Madam Secretary, I want to thank you for taking the 
time to appear before the Committee today to discuss the 
Administration's fiscal year 2015 budget.
    I continue to believe that budgets are a reflection of what 
our priorities are in this country, and our priorities should 
be pretty clear: creating an environment for good-paying jobs 
that allow workers to support a family, properly funding health 
care for all, and protecting benefits for those who have earned 
them. Those should be the focus. And I am happy to see that the 
President's budget does reflect some of these goals.
    Specifically, just some things I wanted to point out, the 
proposed 2015 budget gets rid of a misguided approach to 
chained CPI, to change the chained CPI balanced on the backs of 
our seniors. It expands HIV/AIDS treatment and care through 
investments in the Ryan White HIV/AIDS program and CDC 
activities. It funds the National Institutes of Health at $30.2 
billion, and provides $140 million in services for victims of 
domestic violence.
    As one of the few women who sit on this Committee, I think 
I would be remiss if I didn't spend at least a few moments on 
issues that are specific to women's health care. I want to talk 
about Title X. It is the only Federal program exclusively 
dedicated to family planning and reproductive health services. 
Publicly funded family planning services have helped reduce the 
rates of unintended pregnancy and abortion in the United 
States. And in fact the CDC has included family planning on its 
list of the top 10 most valuable public health achievements of 
the 20th century, along with things like childhood vaccinations 
and fluoridation of drinking water.
    I was pleased to see that the President's budget calls for 
a slight increase in Title X funding. And I was wondering, 
Madam Secretary, if you agree that the investment in family 
planning services is a valuable one that reduces government 
healthcare expenditures in the long run.
    Secretary SEBELIUS. Well, I think it has been shown, 
Congresswoman, that family planning and having families be able 
to make choices about the timing of children and the timing of 
pregnancy is a huge health issue and a huge family security 
issue, and we have made some significant strides.
    I would also point out that as part of the Affordable Care 
Act, insurance policies now will cover a full range of health 
services for women, which was not necessarily the case. They 
will not be allowed to charge women more than men, which was 
typically a feature in the individual market, and for the first 
time have a focus on women's health issues, including family 
planning issues.
    Ms. SANCHEZ. And do you think that the increased access to 
affordable birth control will affect healthcare costs overall 
under the Affordable Care Act?
    Secretary SEBELIUS. Well, what we have seen, actuaries of 
private insurance companies will tell you that actually having 
contraception services as part of their package decreases costs 
because they pay for fewer unintended pregnancies and sometimes 
pregnancies that could result in very high birth and followup 
costs. So as an actuarial point of view, it is actually a net 
gain in terms of overall health costs. But more importantly, it 
allows families to make their own choices about families and 
timing, and the health of the mother and the health of the 
child are often significantly improved by that timing.
    Ms. SANCHEZ. Thank you, Madam Secretary, and I yield back.
    Chairman CAMP. Thank you.
    Mr. Griffin.
    Mr. GRIFFIN. Thank you, Mr. Chairman. Apparently it is not 
working now.
    Secretary SEBELIUS. It is just when you try to use it that 
it doesn't work.
    Chairman CAMP. Right. Why don't you come up.
    Mr. GRIFFIN. I think a website manufacturer and website 
developer has been working on our mike system.
    Thank you for coming. I appreciate it. What I would like to 
talk with you a little bit about is the issue of investments. 
You mentioned investments. Almost every constituent that comes 
to see me in my office talks about the need for additional 
funding, for example, for the NIH, for Alzheimer's research, 
for cancer research, MS, diabetes. They may talk about 
education, they may talk about some other program that is 
funded by discretionary spending. And a lot of times when 
people mention investments, that is what they are talking 
about.
    I have supported increasing NIH research funding. I wish we 
had the money to increase it drastically. But the reality is 
that that funding is getting pressured or squeezed out by the 
growth of entitlement spending. If you could look, I have a 
slide here.
    [Slide]
    So this is something that President Obama said in 2011. 
``If you look at the numbers, Medicare in particular will run 
out of money, and we will not be able to sustain that program 
no matter how much taxes go up. I mean, it is not an option for 
us to just sit by and do nothing.''
    Next slide.
    [Slide]
    This is what I call the Pac-Man problem. I use this to 
explain to folks who come to visit me why the funding that they 
are in favor of, which often I favor, NIH funding, for example, 
why it is under pressure. And it is under pressure because the 
yellow part, which we recognize as Pac-Man, is continuing to 
close its mouth on all the stuff that you refer to as 
investments. And HHS Secretary after HHS Secretary, I have 
talked to both Administrations, Republican and Democrat, praise 
their budget as fixing the problem. But the problem persists.
    And I just invite you to work with us for real reform on 
Medicaid and Medicare to fix this. And I would welcome your 
comments on how your budget will address this problem.
    Secretary SEBELIUS. Well, sir, I would welcome the 
opportunity to work on a serious, big budget deal, including 
entitlement reform, but also including tax reform and revenue 
sharing, and spread that equally across the board.
    I would say that the passage of the Affordable Care Act was 
one of the most significant issues of late to increase the 
solvency of the Medicare Trust Fund. The trustees put that 
passage at about a 12-year additional solvency. This budget 
adds an additional 5 years. So when this President came into 
office Medicare was likely to go broke in 2017. That window has 
now been significantly extended. And this Committee has voted 
50 times to repeal those very----
    Mr. GRIFFIN. But you are robbing Peter to pay Paul, and the 
seniors are bearing that burden.
    Chairman CAMP. All right. Time has expired.
    Mr. Crowley.
    Mr. CROWLEY. Thank you, Mr. Chairman.
    Madam Secretary, thanks so much for being here once again 
today. I am up here now. They moved me. Madam Secretary, they 
moved me up here. I am sorry. I know. Musical chairs. It is 
going to take a long time for me to get up here normally 
speaking. I thank the Chairman for this opportunity.
    Secretary SEBELIUS. Just don't give it up.
    Chairman CAMP. Don't get used to that seat.
    Mr. CROWLEY. I am not getting used to it. I am enjoying my 
time here. I have very little time.
    The Affordable Care Act has made great strides in improving 
access to quality health care, such as by closing the 
prescription drug coverage gap, strengthening the Medicare 
program, and establishing competitive marketplaces for working 
families to purchase insurance, for many people for the first 
time. I am glad that the budget sustains and builds upon these 
successes.
    I am also pleased to see that this budget looks toward the 
future on improving our healthcare system, such as through the 
new physician workforce proposal growing the need for more 
doctors at the same time. Projections show that by 2020 the 
United States will face a physician shortage of more than 
91,000 physicians, growing to over 130,000 physicians by 2025, 
not that long from now. That is both primary care physicians 
and specialists.
    So clearly there is a need for continued Federal investment 
in doctor training. Yet I am concerned that some of the 
proposals in this budget would fundamentally change this 
longstanding contract on how doctor training is supported in 
our country. Our Nation has long recognized the need for doctor 
training to be a shared investment between our medical schools, 
residency training programs, and the Federal Government. 
Medical schools have increased graduating classes, and teaching 
hospitals are training residents above and beyond what Medicare 
supports.
    In my home State of New York, there are almost 840 
residents currently being supported by hospitals alone because 
Medicare can't fund these positions. Nearly 10,000 residents 
nationwide are in a similar situation. There is a clear and 
obvious demand for more residency slots even within the 
Medicare program, demonstrating that this is not the time to be 
drawing teaching dollars away from Medicare to other programs.
    I have introduced legislation, the Resident Physician 
Shortage Reduction Act, to meet the real need of adding 
additional residency spots in these specialties, as well as in 
the primary care area. If you could, please comment in terms of 
the budget itself and the effect that this will have on 
teaching hospitals. I don't think this is the time to be taking 
away those moneys. We need to be adding money to produce the 
number of physicians we will need in lieu of the Affordable 
Care Act.
    Secretary SEBELIUS. Well, Congressman, I think the 
President definitely shares your view that the healthcare 
workforce is of enormous importance. And we certainly have been 
focusing on that since the beginning of this Administration.
    I would say there are three major components of a 
significant, $14.62 billion workforce initiative over the next 
10 years. Increasing the size of the National Health Service 
Corps, which goes a long way to putting doctors, nurses, mental 
health techs, dentists in underserved communities, growing that 
force to about 15,000 from its current 8,800 and keeping it 
there.
    Second, to focus on the targeted support for graduate 
medical education, really again driving not only the primary 
care workforce, but specific underserved specialty areas. 
Currently, hospitals kind of pick and choose which residencies 
they will slot. And we think at this point it is more helpful 
to really focus on the great need for primary care, preventive 
care, community-based care, nurse practitioners, so that the 
growing population of elderly and others, who hopefully will 
stay out of the hospital, will have that kind of care.
    And third, to continue the increase that was passed in the 
Affordable Care Act for primary care doctors who take Medicaid 
patients. And I think those three initiatives combined will 
really do a significant amount to increase the primary care 
workforce, but also to make sure that primary care docs and 
nurses are in the right places in the most underserved areas.
    Chairman CAMP. All right. Thank you.
    Mr. Kelly is recognized.
    Mr. KELLY. I thank the Chairman.
    Madam Secretary, thanks for being here today. I just want 
to get directly to the budget, because on page 33 of the budget 
it highlights or alludes to a potential large tax increase that 
is not defined. Now, reading from page 33, this is what it 
says: ``Even with reforms to Medicare and other entitlements 
and tough choices, we will need additional revenue to maintain 
our commitments to seniors.''
    Now, as I read this, it looks like an open-ended 
discussion, but with no real specifics. What specifically are 
we going to do? Because we are past the rug-cutting time. Where 
do we go? Where do we go to get this revenue? What taxes are 
going to have to come about?
    Secretary SEBELIUS. Well, I think, Congressman, as you 
know, there have been discussions over the last several years. 
The President has proposed a number of tax loopholes being 
closed.
    Mr. KELLY. And I understand. I don't want to cut you short. 
I have a very short period of time.
    Listen, we are playing ring around the rosy with this. 
There is no way that we can look at the metrics of this and say 
this is going to work. My question is, because the real choice 
right here is between entitlement reform or going to some other 
type of a tax, which I think a lot of people on the right and 
left are saying we are going to have to have a European-style 
VAT tax. This is going to put a tremendous burden on the 
middle-income folks, the lower-middle-income folks, and the 
lower-income folks because it hits every one of them hard, 
hard. Nobody walks away from this. Forget all the subsidies and 
everything else.
    I want to know where are you going to get the money? Show 
me the money. If there is not going to be reform, show me the 
money. Where is the revenue going to come from? Because we know 
in this model you tax it, you fine it, it is through taxes, 
fines, fees, or borrowing, or God forbid just printing our way 
out of it. So where is the money going to come from?
    Secretary SEBELIUS. Well, sir, nobody, as you know, in this 
Administration has ever suggested a VAT tax. I think what we 
are eager to do----
    Mr. KELLY. Not yet. Not yet.
    Secretary SEBELIUS [continuing]. Is work with Congress on a 
comprehensive program which shares the burden, not taking it 
out of the backs of seniors, of the backs of the poorest 
Americans.
    Mr. KELLY. No, no, no, no, no. Listen, listen.
    Secretary SEBELIUS. That has always been the proposal in 
the past.
    Mr. KELLY. Madam Secretary, we agree, we agree violently on 
that. It comes down to dollars and cents. You can't wave a 
magic wand and make this money appear. You can't do it. If we 
are not going to have serious entitlement reform, where is it 
going to come from? It is simple math. The President says it 
all the time. Just do the arithmetic. It doesn't float.
    Secretary SEBELIUS. Well, I would say some of the most 
serious entitlement reform is underway right now under this 
Administration. We have cut in half the cost trajectory of 
Medicare year in and year out. We are seeing the slowest growth 
in 50 years in the program. Plus more Medicare beneficiaries 
coming in and more benefits. So I would say that it is 
underway.
    Mr. KELLY. I understand that. But sometimes it is much 
easier to talk the talk than it is to walk the walk. We heard 
this wouldn't cost us anything, and now we are finding out it 
is trillions more than we thought. It is just not working. I am 
looking at this, and the reform is absolutely necessary. I just 
don't see anybody walking that plank.
    And I don't see any specifics of this. We can talk in 
flowery terms about what we want, what our hearts are willing 
to do, but what our wallets can't provide. The question is, how 
do you pay for it? It has to be tax increases. It can't come 
from anyplace else. I wish it was, just tap a magic wand and 
the money just magically appears. It doesn't. We are on a heck 
of a trajectory right here, and there is no way out of this 
absent real reform or huge tax increases. There is just no 
other way to do it.
    Chairman CAMP. All right. The time has expired. We will try 
the mikes again.
    So, Mr. Pascrell, you are recognized.
    Mr. PASCRELL. Thank you, Mr. Chairman.
    Madam Secretary, I am glad that we are now all talking 
about middle-income people. Well, we have come a long way in 3 
years. That is good. I think we are on the right trail.
    But let's change the pace a little bit. The commitment that 
the President has made to expanding educational opportunities 
and the investments in research and science within this budget 
are things I strongly support. The BRAIN Initiative is one of 
the investments that I think is particularly worthwhile. Today, 
we are celebrating what we have done for the past 14 years in 
the Rayburn Building, all the research that is being done both 
in the military and the civilian on traumatic brain injury, 
post-traumatic stress disorder, which has now helped in many, 
many ways to help our kids in making sport decisions.
    The BRAIN Initiative is one of the investments that I think 
is worthwhile. As cochair of the Traumatic Brain Injury Task 
Force, along with Congressman Rooney of Pennsylvania, I am well 
aware of the advances that we have made in research in the 
brain in recent years and how much we have learned and continue 
to learn.
    Your presence here today is very timely. As I said, the 
Congressional Brain Injury Awareness Day is evident on Capitol 
Hill, and a number of your offices are participating. The 
Centers for Disease Control and the CDC estimates that 2.4 
million TBIs occur each year and that 5.3 million Americans 
live with a lifelong disability as a result of TBI.
    Beyond those numbers, TBI has become the signature wound in 
Iraq, as well as in Afghanistan. Twenty percent of our soldiers 
deployed are estimated to have experienced brain injury. This 
is serious. What is even more serious is how many have fallen 
through the cracks.
    It is because of this Congress and the last three 
Presidents that we finally have come to the point of 
recognizing it and have stopped sweeping it under the rug, and 
we have insisted on it in a bipartisan way. Brain injuries can 
impact anyone at any time.
    I know this $200 million commitment, which is double the 
investment in last year's budget, is not just coming from your 
Department. But can you speak to the goals of the BRAIN 
Initiative and how important it is that we pay attention to 
what is going on in that research? Very briefly, if you would.
    Chairman CAMP. Okay. Time has expired. But if you will 
respond briefly. And if you want to supplement in writing a 
longer response, that would be fine.
    Secretary SEBELIUS. I would be glad to, Mr. Chairman. I 
would say that Dr. Collins, the head of the National Institutes 
of Health, has identified the BRAIN Initiative as one of his 
signature efforts going forward. He has assembled what he would 
call the dream team of top-notch researchers from a variety of 
institutions and mapped out really a very aggressive strategy, 
multi-year strategy.
    But the private sector will be intimately involved in this. 
Some of the key drug companies are at the table. There is an 
effort underway in the drug front to also get them involved in 
accelerating cures. So I would say it is a multifaceted 
project, and I would be glad to get you some more information.
    Chairman CAMP. All right. Thank you very much.
    Mr. Young is recognized.
    Mr. YOUNG. Madam Secretary, thanks for being here today. I 
am going to start on a couple of words of encouragement and 
appreciation. First, coming from the State of Indiana, know 
that our delegation, our Governor and the people of our State 
really appreciate your consideration of allowing the Healthy 
Indiana Plan, which covers 40,000 low-income Hoosiers, to play 
an important role in terms of our Medicaid expansion in our 
State. HIP is the first consumer-directed plan for Medicaid 
recipients in the country, and thank you for that.
    We also appreciate internally within HHS, and I know this 
is a priority for OMB, increasing the evaluation of the 
existing government programs so that we are focusing more on 
outcomes as opposed to inputs. I would love to work with you on 
that evidence-based approach in the future.
    One of the biggest concerns related to this healthcare law, 
of course, is its impact on jobs and wages. The CBO has 
indicated that the Affordable Care Act will shrink the 
workforce by the equivalent of 2.3 million full-time jobs. 
Teamsters President James Hoffa has said the law, quote, 
``destroys the foundation of the 40-hour workweek that is the 
backbone of the American middle class.'' UNITE HERE is a union 
representing 265,000 casino, hotel, and food service and 
warehouse workers. And they recently published a new report, 
``The Irony of Obamacare: Making Income Inequality Worse.'' And 
I would like to submit this report for the record.
    Chairman CAMP. Without objection.
    Mr. YOUNG. UNITE HERE supported what the President calls 
Obamacare, but they don't anymore. The report says, ``Without 
smart fixes, the ACA threatens the middle class with higher 
premiums, loss of hours, and a shift to part-time work and less 
comprehensive coverage.'' You have indicated, as reported in 
the press, ``There is absolutely no evidence, and every 
economist will tell you this, that there is any job loss 
related to the Affordable Care Act.''
    Based on the growing body of evidence, including this 
report, have you rethought whether or not the Affordable Care 
Act might in fact adversely impact wages, hours, and jobs for 
in particular low-income Americans?
    Secretary SEBELIUS. Congressman, I have had some great 
meetings with Governor Pence and look forward to continuing 
those around Healthy Indiana and the expansion. I would say 
that, unfortunately, the Congressional Budget Office report I 
think has been mischaracterized. It does not say that the 
passage of this healthcare law will lead to 2 million fewer 
jobs. It does indicate that people will have some choices that 
they don't have today. They won't have job lock until they get 
to 65, where they have healthcare guarantees with Medicare. 
They can choose to stay at home. A lot of farm families will 
have the choice of not having to have an off-farm job to get 
health insurance for the family.
    So there is an average that they give, and they say you 
could have an average number of hours worked less, or they say 
you could have an average number of hours worked more.
    Mr. YOUNG. I see our time has expired. I guess we could 
lower the definition of full-time employment to 20 hours, 
giving employees more flexibility under your analysis of the 
CBO report. But thanks so much for entertaining my questions.
    I yield back.
    Chairman CAMP. Mr. Kind is recognized.
    Mr. KIND. Thank you, Mr. Chairman.
    And, Madam Secretary, thanks for being here, and thanks 
again for your service to our Nation. I know this hasn't been 
the easiest time, the rollout of the ACA. We didn't think it 
would be easy, but it is worth trying to do.
    First a comment and then a question for you. My comment, 
coming from a very large rural congressional district, just 
keep an eye on those critical access hospitals. They face some 
unique challenges as far as recruitment, retention, and access 
issues. And I know we have had budget discussions about that in 
the past.
    The question is one of the great stories in recent years, 
the last few years, has been the trajectory of healthcare 
spending, costs per beneficiary, which has never been lower in 
the last 50 years. I wonder if you could just take a moment to 
tell us what you are seeing in regards to the health system 
that is leading to these cost reductions.
    Obviously, part of the Affordable Care Act is to reform not 
only the way health care is being delivered so it is more 
integrated and coordinated and patient-centered, but changing 
the financial incentives so it is more value and quality 
driven. But if you could take a moment and just let us know 
what you are seeing as far as costs and whether these reports 
are sustainable in the future.
    Secretary SEBELIUS. Well, Congressman, you and a number of 
the House delegation were instrumental in making sure that the 
sort of quality and value pieces were added to the Affordable 
Care Act, that that became a fundamental piece of this. And I 
would say that the framework of having for the first time real 
tools within the Medicare system to look at aligning value with 
payment is significant. And we are already seeing the first 
real reduction in preventable hospital readmissions, a very 
dramatic change in hospital infection rates. Good for patients, 
good for the bottom line.
    In terms of overall expenditures, the 10 years before the 
Affordable Care Act, Medicare cost growth was on average 6 
percent a year, year in and year out. Since the passage of the 
Act, 2010 to 2012, it was 1.6 percent, a dramatic drop. Last 
year, 0.7 percent. As you say, the lowest cost increases in 
history. And Medicare beneficiaries have more benefits, lower 
prescription drugs, additional costs. Private insurance costs 
have been cut in half during that same period of time. Overall 
health expenditures in the United States per capita were 
raising at about 6 percent a year. They now are at 3 percent a 
year, again cut in half. And Medicaid expenditures, again, are 
seeing the lowest cost increases.
    But in part, it is because I think some of the fundamental 
structure of looking at ways to deliver more effective 
preventive care, earlier intervention with very high-cost 
patients, some of the pieces you put in place with the dual 
eligibles, a very expensive population, only about 10 million 
individuals, but people who spend over a third of both the 
Medicare and Medicaid budgets, that work with the States is 
very much underway. So there are some very promising trends I 
think on the horizon.
    Mr. KIND. All right. Thank you.
    Chairman CAMP. Mr. Reed, and then we will go to Mr. 
Blumenauer. And then we will begin two to one.
    Mr. Reed.
    Mr. REED. Thank you, Mr. Chairman.
    Thank you, Madam Secretary, for being here today.
    I wanted to join with my colleague Mr. Kind to bring a 
message to you. Representing a rural district in western New 
York, I can tell you the Medicare and Medicaid reimbursement 
cuts that your proposals have done and implemented are 
seriously jeopardizing our critical access hospitals, our low-
volume Medicare-dependent hospitals. I am dealing with two 
right now, St. James Hospital and Lake Shore Hospital. Lake 
Shore is actually going through a closure. St. James is going 
through a rebuild.
    On the front line, in particular on rural hospitals, these 
cuts are causing significant problems for access to care for 
our people. So I am delivering to you some information, and 
join my colleague in highlighting that need.
    Now, what I wanted to talk to you today about is we just 
had an election in Florida last night. The Democratic opponent 
was talking a lot about ways to fix the Affordable Care Act. 
And what I wanted to get from you is that the Administration 
has had 37 significant changes in the Affordable Care Act that 
it has put forward by Executive order and other amendments. And 
what I am looking for from you, if you have any suggestions, 
have you supplied to Congress, to us, in areas that you want to 
fix the Affordable Care Act? Has there been any legislation 
sent from the Administration up to Congress in regards to those 
fixes?
    Secretary SEBELIUS. I have not sent legislation to 
Congress, no, sir.
    Mr. REED. Yeah, because the answer is zero. I knew the 
answer to that question. I just wanted to see exactly where you 
were coming at. So is the Administration's position that the 
Affordable Care Act is not fixable, therefore there is no need 
for any legislative fixes?
    Secretary SEBELIUS. No, sir, I don't think that is the 
case.
    Mr. REED. Okay. So it is fixable. There are areas that you 
want to fix. Could you state for the record what areas of the 
Affordable Care Act does the Administration want to work with 
us in order to fix?
    Secretary SEBELIUS. Sir, we have said from the outset, from 
the passage of the law in March of 2010, if there are 
suggestions or ways that we----
    Mr. REED. So the White House has no suggestions or ideas on 
how to fix it.
    Secretary SEBELIUS. We have implemented a number of changes 
in the way the law was written to ease the transition into the 
marketplace.
    Mr. REED. I appreciate that because we have had the same 
thing up here on the Hill with the employer mandate delay, that 
we passed legislation and then the White House vetoed that, or 
threatened to veto it, and then by Executive order implemented 
it.
    Secretary SEBELIUS. No legislation has passed the Congress.
    Mr. REED. So if we pass that you will say you will sign 
that?
    Secretary SEBELIUS. I don't sign legislation.
    Mr. REED. Well, the White House. What is the White House's 
position on that?
    Secretary SEBELIUS. The White House made their position 
clear. But no legislation has passed the Congress in the 3\1/2\ 
years that the law has been implemented. And the House has 
voted 50 times to repeal the Act.
    Mr. REED. Yeah. So when we pass a bill in the House and the 
White House issues a veto threat to it, that is an indication 
that the White House wants to work with us on policies that it 
is by Executive order implementing? I mean, we have the 
employer mandate delay. You have the health insurance plan, 
that you can keep if you like it. We get threats of veto from 
the White House on things that you are doing by Executive order 
over there. See, that doesn't make sense to us. Can you explain 
to the American people why that makes sense?
    Secretary SEBELIUS. Sir, I think that the issue is the 
breadth of some of the legislation. We believe strongly that 
having a transition for people who are already insured 
gradually into ACA-compliant plans makes sense. The measure 
considered by the House of Representatives was considerably 
broader than that. It would have basically destroyed the new 
marketplaces. So that was a very different piece of 
legislation.
    Mr. REED. That is not true. That is just not true.
    Chairman CAMP. All right. Time has expired.
    Mr. REED. Thank you.
    Thank you, Madam Secretary.
    Chairman CAMP. Mr. Blumenauer.
    Mr. BLUMENAUER. Thank you, Mr. Chairman.
    Madam Secretary, thank you again for being here. We 
appreciate your tenacity and your patience. I would like to 
just shift something that doesn't bear directly on the 
Affordable Care Act.
    I worked very hard on the House version, and it passed this 
Committee unanimously, provisions that would have provided 
reimbursement for voluntary consultation for patients who are 
facing difficult end-of-life circumstances. It stayed in the 
bill, but because of the reconciliation process it dropped out.
    Since then, the evidence is even more compelling for the 
need for this service. I would just cite Reverend Billy 
Graham's most recent book talking about the need for families 
to approach this, or as former Majority Leader Bill Frist, in 
one of the op-eds on Capitol Hill, pointed out that because of 
a lack of this planning and assistance, quote, ``patients are 
more likely to receive medical interventions that can actually 
prolong or worsen their suffering and will certainly increase 
the expense of their loved ones.''
    Yesterday, I joined with the American Association of 
Clinical Oncology, who had just a great report about this, and 
included a provision that I think is very compelling that they 
have research that shows, if you do this right, if you work 
with patients, you can actually, by adding palliative care, 
people will actually live up to 3 months longer while they get 
chemotherapy.
    Well, in November 2010, CMS released a final payment rule 
that would have reimbursed Medicare doctors to have 
conversations with their patients on options for end-of-life 
care. This provision would have given people more control. And 
it speaks to much of the legislation, bipartisan legislation 
cosponsored by a number of people on this Committee, that Dr. 
Roe and I have introduced. Yet just days after that final rule 
went into effect, the Administration reversed course, pulled it 
back, and it has been 4 years, because of some sort of 
procedural something.
    Is there some way that we can work with you and our 
legislation so that we can give people, at no cost to the 
Federal Government, something that 92 percent of the American 
public thinks they want? Is there a way that this 
Administration can work with this Committee on a bipartisan 
basis to solve this problem?
    Secretary SEBELIUS. Yes, Congressman, I would welcome that 
opportunity. I can tell you it is a personal passion of mine. 
My mother spent her last 10 weeks in three different hospitals 
with dozens of procedures, and basically I would see it as 
being tortured to death. So I welcome the chance to look at how 
families and patients and providers can have more control over 
those end-of-life decisions.
    I also think that--two things I would point out. One is 
that you did add to the Medicare benefits a wellness visit, a 
yearly wellness visit, which gives patients and doctors an 
opportunity to have conversations about health plans and 
potentially, you know, have a conversation about issues that 
arise in critical care. But, also, we are very much working 
with revisions in the hospice benefit area, and we hope soon 
to----
    Mr. BLUMENAUER. It is very important. I see my time has 
expired----
    Chairman CAMP. Thank you.
    Mr. BLUMENAUER [continuing]. But I would hope after 4 years 
that you could revisit the rule or that you support our 
bipartisan legislation so we can solve this.
    Chairman CAMP. All right.
    Mr. BLUMENAUER. Thank you very much.
    Chairman CAMP. Ms. Black and then Mr. Marchant. Ms. Black 
is recognized.
    Mrs. BLACK. Thank you, Mr. Chairman.
    And, Madam Secretary, thank you for being here. I think 
that this dialogue is so important for us to have because these 
are big issues that directly impact individuals and their 
lives.
    So my first question for you is, do you believe that the 
individual mandate tax penalty is an essential component of the 
implementation of Obamacare?
    Secretary SEBELIUS. Congresswoman, I think that the mandate 
issue came from, I think, originally the Heritage Foundation 
and some other legislative analysis that ties it to getting rid 
of the preexisting-condition barrier for insurance companies.
    Mrs. BLACK. So you do believe that it is an important 
component?
    Secretary SEBELIUS. You need to apply them together. Yes, 
ma'am.
    Mrs. BLACK. You do believe.
    So I ask this question because in the Wall Street Journal 
editorial today, it was exposed that a rule released last week 
quietly excused millions of people from the requirement to 
purchase insurance or else pay a tax. And the rule actually 
allows Americans whose coverage was cancelled to opt out of the 
mandate altogether.
    Now all you need to do, according to this, is fill out a 
form attesting that your plan was cancelled and that you 
believe that your plan options available in the Obamacare 
mandates in your area are more expensive than what was 
cancelled or that you consider other available policies 
unaffordable.
    Further, there is also a provision that says people can 
also qualify for hardship for the unspecified non-reason, and I 
quote, you experience another hardship in obtaining health 
insurance, which only requires documentation if possible. And 
yet another waiver is available to those who said they are 
merely unable to afford coverage regardless of their prior 
insurance.
    In a word, these shifting legal benchmarks offer an 
exemption to anyone who conceivably wants one. Keep in mind, 
though, that the White House actually argued at the Supreme 
Court that the individual mandate to buy insurance was 
indispensable to the law's success.
    So my question for you is: It just seems to me that only 
the people who might be subject to this individual tax are 
those who were never insured. Because these are the people that 
were insured and then for whatever reason--do you think that 
this is fair?
    Secretary SEBELIUS. Well, Congresswoman, I did not read the 
Wall Street Journal editorial. I will read that later today. 
But I can tell you the description that you have just made is 
not accurate.
    The hardship exemption was part of the law from the outset. 
There were some very specific rationale there, and it starts 
with the notion that if you can't afford coverage, you are not 
obligated to buy coverage. And that has always been a 
framework. What this says is, if your plan is unaffordable, you 
can file a hardship exemption. That was the part of the rule 
that was also included.
    Mrs. BLACK. So if your plan is unaffordable----
    Secretary SEBELIUS. It has always been based on 
affordability of coverage.
    Mrs. BLACK. And if you feel your plan is unaffordable, you 
sign a form to say, attestation, my plans--I can't find a plan 
that is affordable for me, you just sign a document----
    Secretary SEBELIUS. That is what the hardship exemption has 
always been based on, unaffordability of insurance. It has a 
measure in it----
    Mrs. BLACK. So all of these----
    Secretary SEBELIUS [continuing]. About income, that if you 
are offered employer coverage, but it has always been in----
    Mrs. BLACK. Madam Secretary, all of these provisions that 
came out in this rule that was sort of hidden, not very much 
exposed, you feel that was already in the law previously and 
this is not a new piece.
    Secretary SEBELIUS. What this allowed--the new piece is not 
the hardship exemption, which has always been part of the law.
    Mrs. BLACK. Okay.
    Secretary SEBELIUS. It allowed people who could not find an 
affordable option to also have the option of purchasing a 
catastrophic policy. That is the new piece, but it is not to 
get the exemption. The exemption has always been based on a 
hardship exemption. That has always been part of the law.
    Mrs. BLACK. I can tell you, with 37 different changes in 
this law, my folks are really confused about what this law does 
and doesn't do and what applies to them.
    Chairman CAMP. All right.
    Mr. Marchant.
    Mr. MARCHANT. Thank you, Mr. Chairman.
    Secretary Sebelius, I have been hearing from the seniors in 
my district who rely on Medicare Advantage plans to fund their 
health care. They are very concerned as they are seeing their 
benefit reductions increase and the result of the recent cuts 
to the program.
    It may come as a surprise to many seniors that only a small 
percentage of the cuts resulting from Obamacare have actually 
gone into effect. The vast majority of mandated Medicare 
Advantage cuts have not yet gone into effect and are backloaded 
in the Affordable Healthcare Act.
    Can you please tell the seniors in my district that depend 
every day on their Medicare Advantage plans what to expect in 
the coming years once the Obamacare Medicare cuts are fully 
imposed?
    Secretary SEBELIUS. Congressman, I think there is a very 
good story to tell on Medicare Advantage.
    Seniors are benefiting from what has happened since 2010 in 
a number of ways. The premiums in Medicare Advantage have 
fallen by 10 percent since 2010. The enrollment has increased 
to nearly 33 percent--has increased 33 percent to nearly 30 
percent of Medicare beneficiaries choosing Medicare Advantage 
plans. Quality has improved, with our five-star quality rating 
system. And taxpayers and other Medicare beneficiaries who were 
subsidizing the overpayment to insurance companies are now 
again seeing the benefits of that.
    So enrollment is higher, premiums are lower, quality is 
better. We have many more plan sponsors in the market. There is 
99.6 percent of Medicare beneficiaries who have Medicare 
Advantage choices. And I think we are seeing an even stronger 
program for the future.
    Mr. MARCHANT. The Administration has issued countless 
waivers, modifications, and forms of release for business and 
others affected by Obamacare.
    Forty percent of the enrollees in Medicare Advantage earn 
less than $20,000 a year. Many of these individuals will have a 
significant problem in dealing with the premiums and in the 
cuts that they are experiencing in their future.
    Can you guarantee that they will receive the same level of 
benefits and the same access to their doctors? Because this is 
their biggest fear.
    Secretary SEBELIUS. Well, sir, I can't guarantee the 
benefits that are outside of the Medicare benefit package. 
Insurance companies pick and choose. Some offer free gym 
memberships, some offer free eyeglasses. I can't guarantee 
that.
    What I can say is that seniors have more choices than they 
have ever had. They have lower premiums in Medicare Advantage 
plans than they have ever had. And they have higher quality. 
More Medicare beneficiaries are choosing higher-quality plans. 
And I think that is all very good news.
    Medicare Advantage plans are still being paid over 100 
percent of the costs of fee-for-service. And that is what is 
gradually coming down, but there is no evidence--in 2010, it 
was stated unequivocally that these cuts in Medicare Advantage 
plans would destroy Medicare Advantage, that seniors would have 
no choice. That was just flat-out wrong. And I think there is 
very good news for the seniors now who are choosing Medicare 
Advantage plans. They are paying less and having higher 
quality.
    Chairman CAMP. All right. Thank you.
    Mr. Larson.
    Mr. LARSON. Thank you, Mr. Chairman.
    Thank you, Secretary Sebelius, for your dedication and hard 
work, and we deeply appreciate it, and also your willingness to 
come before this Committee and others and focus on what has 
been a frustrating rollout but something that is vitally 
important to the American people, our economy, and, most 
importantly, to the wellbeing of our citizens.
    You know, this is an issue that has been debated for the 
last 4 years. I was impressed with something that John McCain 
had to say, and I want to submit that for the record.
    But to summarize, in talking about the Finance Committee 
and what went on and the kind of debate that was taking place 
in the Senate and actually took place here on the floor, what 
Mr. McCain said: The Finance Committee submitted 564 
amendments. One hundred thirty-five amendments were considered. 
Seventy-nine roll-call votes were taken. Forty-one amendments 
were adopted. Then the Senate Health, Education, Labor, and 
Pension Committee approved the Affordable Care Act by a 13-to-
10 vote. Five hundred amendments were considered. More than 160 
Republican amendments were accepted.
    It is that kind of framework, even though Senator McCain 
disagreed and wanted to see the bill--didn't vote for the bill. 
And what he said at the end of the day and I think what the 
American people expect is us to work together to improve the 
bill.
    What we see politically has been an attempt to total repeal 
to the far extreme, saying every single letter of the bill 
ought to be repealed, including preexisting conditions, 
including the great disparity that existed, especially for 
women, as it relates to health care.
    There are a lot of positive, straightforward, pragmatic, 
programmatic reforms that have been made and are 
extraordinarily helpful to the American people. It is appalling 
to the American public--I come from a State where this is 
working extraordinarily well, where people are able to get 
insurance when they didn't have it before, where what was 
called the insurance capital of the world is now embracing and 
changing and meeting these reforms, where genomic projects in 
the biosciences are moving forward in an area that is going to 
be helpful.
    And the only thing that drags the country down is this 
endless, mindless debate instead of constructive criticism 
about how we can work together to improve the health and 
wellbeing of the American citizens.
    Thank you for your service.
    Secretary SEBELIUS. Amen.
    Chairman CAMP. Thank you.
    Mr. Paulsen.
    Mr. PAULSEN. Thank you, Mr. Chairman.
    And, Madam Secretary, thanks for being here.
    You know, Americans needed real healthcare reform before 
the President signed the new healthcare law, and the fact is 
they still need it today. The more we learn about the 
President's new healthcare law, I think the more the facts show 
it is hurting more people than it is actually helping.
    I am hearing from constituents on a fairly regular basis 
right now who are genuinely concerned. Many are upset, many are 
confused because of the different delays in parts of the law. 
And they are fearful; they are fearful about the cost to their 
pocketbooks for increased healthcare costs for themselves and 
their families.
    And instead of getting what the President I think promised 
when it was rolled out, for having lower premiums and lower 
costs, many are now paying more for health care--significantly 
higher deductibles, more expensive premiums. Many have lost 
their insurance, the plans that they liked or the plans that 
they had. Many have fewer choices now for doctors and for their 
plans.
    And there is no doubt that some companies have been forced 
to scale back hours with more part-time jobs and less full-time 
jobs, and so those employees that had good full-time jobs now 
have part-time jobs. And there are jobs that are being lost. I 
know the medical device tax was a central component for the 
revenue stream of the Affordable Care Act, but we have 33,000 
jobs now that have been estimated to have been lost in this 
industry. And this is one of our best American success stories; 
this is where health innovations come from to help patients.
    And I have 51,000 seniors in my district that are part of 
that Medicare Advantage population. And some of the past cuts 
in the MA program and some of the proposed cuts are certainly 
giving them concern for losing benefits or maybe even losing 
some of their plans.
    And I think, Madam Secretary, the irony in all this is that 
in Minnesota, a State like Minnesota, where we had one of the 
lowest uninsured rates before the law was put into place, we 
are actually likely to see an increase in the uninsured number 
now because the law eliminated a lot of the reforms 
successfully that had been implemented in a State like 
Minnesota.
    So my question, Madam Secretary, is: Why should the 
Administration as a part of your budget request get another 
$1.8 billion for the exchanges and for all the other programs 
that are associated with the rollout of Obamacare?
    Secretary SEBELIUS. Well, again, Congressman, I think that 
the evidence out with the recent health survey in the last 2 
days indicates that the overall uninsured rate in this country 
is actually going down. So more people have insurance coverage, 
according to the survey, than did before this law was passed. 
So the evidence says that this actually is making an impact, 
and a positive impact.
    I would also say that the vast majority of Americans have 
coverage through their workplaces, and that coverage over the 
last 3 years has gotten stronger. There are more consumer 
protections, so they don't have an annual cap anymore and they 
can't run out of treatment during chemotherapy, they have some 
features that----
    Mr. PAULSEN. But, Madam Secretary----
    Secretary SEBELIUS [continuing]. They didn't have before. 
But that is in place.
    Mr. PAULSEN. But----
    Secretary SEBELIUS. Medicare has gotten stronger with this 
plan. There are additional people who now----
    Mr. PAULSEN. Madam Secretary----
    Secretary SEBELIUS [continuing]. Have Medicaid benefits. 
And the individual market----
    Mr. PAULSEN. I don't mean to interrupt, but can I just ask 
one more question? Do you expect healthcare premiums to 
increase again next year, on average? Will they go up? Because 
they certainly went up for a lot of folks this year, but do you 
expect that trend to continue next year again?
    Secretary SEBELIUS. I think premiums are likely to go up, 
but go up at a smaller pace. And what we have seen since 2010, 
the increases are far less significant than they were prior to 
the passage of the Affordable Care Act. Yes, sir.
    Chairman CAMP. All right.
    Ms. Jenkins.
    Ms. JENKINS. Thank you, Mr. Chairman.
    Thank you, Madam Secretary, for being here. Greetings from 
Kansas.
    Secretary SEBELIUS. Thank you.
    Ms. JENKINS. I wanted to visit with you about the 
President's healthcare law and the costs associated with it. 
The American taxpayer, it has been estimated, will be billed 
nearly $2 trillion over the budget window. And the costs 
continue to mount. A Government Accountability Office, GAO, 
report issued last year says that the law will increase the 
Federal deficit $6.2 trillion in the long run.
    The cost of this law seems to be rising every time we turn 
around. In the budget proposal that you are here to discuss 
with us today, the President is requesting another nearly $2 
trillion for the healthcare exchanges.
    And after all of the broken promises--like if you like what 
you have, you can keep it; if you like your doctor, you can 
keep it; premiums will go down by $2,500--I am wondering if you 
can tell us all today what happened to the President's promise. 
And I will quote him. He said, ``I will not sign a plan that 
adds one dime to our deficits, either now or in the future.'' 
This is what he told us in a joint session of Congress in 
September of 2009. ``I will not sign it if it adds one dime to 
the deficit now or in the future, period.''
    So given that the President's budget that you are here to 
defend today never, ever balances, can't ever point to a time 
in this Nation's future that you will stop spending more money 
than we take in, I am just wondering how you can explain his 
promise to us, first off.
    Secretary SEBELIUS. Well, Congresswoman, greetings back to 
Kansas.
    And the Congressional Budget Office, which I think you all 
rely on for scoring various pieces of legislation, when the 
Affordable Care Act was passed, said that the passage of the 
Act would save about $100 billion in the first 10 years and 
then closer to $1.1 trillion in the second decade. They updated 
that score and made it even more generous when cost trends 
began coming down.
    That is what the Congressional Budget Office said. They 
have scored that again. Every time there is a vote on repeal 
and questions are asked, they continue to say repealing the 
Affordable Care Act would actually add to the deficit, not that 
it would subtract from the deficit.
    So that, I think, is exactly what the President was talking 
about when he said he wouldn't sign a bill. Unlike the Medicare 
Part D, which was paid for on some credit card and added 
enormously to the deficit and still was never paid for, the 
Affordable Care Act was fully paid for within the scope of the 
law and was----
    Ms. JENKINS. But, Madam Secretary, it is not fully----
    Secretary SEBELIUS [continuing]. Scored as detracting from 
the deficit, so----
    Ms. JENKINS [continuing]. It is not fully paid for. How can 
you explain--and now that you have the data that indicates this 
will add over $6 trillion to our national debt, what have you 
proposed that is going to bring that into line?
    Secretary SEBELIUS. I have to tell you, Congresswoman, I 
would be happy to try to answer that. I have no idea what the 
$6 trillion to the national debt is based on, so I would love 
to----
    Ms. JENKINS. But you do know what the Government 
Accountability Office is. And are you questioning their----
    Secretary SEBELIUS. I have never seen the study that you 
are talking about. Yes, I----
    Chairman CAMP. All right.
    Secretary SEBELIUS [continuing]. Do know what the 
Government Accountability Office is. Thank you. But I will be 
happy to look up the study. I am not aware of that.
    I do know the scoring on the Affordable Care Act by the 
Congressional Budget Office, and it continues to be updated. 
And I would be happy to provide that to you.
    Chairman CAMP. All right.
    Mr. Thompson.
    Mr. THOMPSON. Thank you, Mr. Chairman.
    Madam Secretary, thank you very much for being here and for 
your tireless effort to ensure that people have access to 
quality, affordable health care.
    I would like to ask you questions about two things that are 
in the budget, and I will just ask the questions and give you 
time to respond.
    When is the new GME program? I think this is an issue. Ms. 
McMorris Rodgers and I have a bill that would hopefully provide 
more opportunity to train physicians. And, as you know, folks 
tend to practice where they train, and in especially rural and 
underserved areas, this is huge.
    The Administration has a targeted support program, and I am 
just interested in what sort of assurance we will have that 
they will provide training outside of hospitals and in 
community-based settings and what the certainty is going to be 
in this program. Because you know the residency programs take a 
long time, and I want to make sure that the program is in place 
so folks have a certainty.
    And then, second, on the administrative law judge appeals 
funding, the Administration has put $100 million in for 
Medicare hearings and appeals. And I know that is a little more 
than was in last year, but I question whether or not it is 
enough. And what are you going to do until the proper funding 
level is reached to make sure that our constituents don't get 
hung up in this void?
    Secretary SEBELIUS. Congressman, the training grants will 
be consistent with the workforce goals, which include targeting 
more physicians to primary care and understaffed specialties, 
encouraging the practice in rural and underserved areas, and 
encouraging training in some of the key competencies for 
delivery system reform.
    So I think it is very consistent with the outline that you 
have made about your goals in the workforce. And I think that 
HRSA, the Health Resources Services Administration, who would 
be administering these training dollars, has the expertise in 
identifying the underserved areas throughout the country and 
the whole workforce capacity issue. And that is why I think 
this program is really on target to try to not only train the 
providers that we are missing but making sure, connecting them 
to the areas that are the most underserved.
    In terms of--what was your second? Oh, yes, the 
administrative appeals. We are doing two things simultaneously, 
and we would welcome the opportunity to work with Congress. We 
don't want to recede from what are appropriate examinations of 
overcoding and overbilling and fraudulent activities; on the 
other hand, I think there are some system changes we can put in 
place.
    But we share your concern that beneficiaries should not be 
in some queue waiting for appeals to be made, and we are trying 
to triage the system. But we would love to work with you on it.
    Chairman CAMP. All right. Thank you.
    Mr. Smith.
    Mr. SMITH. Thank you, Mr. Chairman.
    And thank you, Madam Secretary, for taking time to have a 
conversation with us today. Obviously, the issues are very 
important. I am concerned that some of the policies enacted out 
of Washington, D.C. are actually hurting the very people, 
individuals they were intending to help.
    If you could elaborate or reflect a bit on critical access 
hospitals. We know that that is a singular designation for a 
number of different approaches in various parts of the country. 
And, obviously, I represent a large number of critical access 
hospitals in rural Nebraska. I am sure you are probably 
familiar with facilities in Kansas.
    The treatment of these hospitals, with kind of a cookie-
cutter, one-size-fits-all approach, whether it is the 96-hour 
rule or whether it is the physician supervision, these are very 
cumbersome and burdensome. I have tried to find out exactly how 
and why they were adopted or proposed, even from HHS and CMS.
    Have those saved money? I mean, can you point to the 
effectiveness of these things? Because it seems to me that the 
very professionals who are trained to make healthcare decisions 
find Washington, D.C. meddling and standing between a patient 
and their provider.
    Secretary SEBELIUS. Congressman, I certainly share your 
concern about the important nature of critical access 
hospitals. And, as you say, coming from the State of Kansas, 
where vast territory is rural and closing a hospital often 
means closing a community, I know how essential a hospital 
presence is.
    I think that what the administrators at CMS are trying to 
do is find the appropriate balance. As you know, critical 
access hospitals are still paid more than 100 percent of 
Medicare reimbursement. There is evidence that the proximity of 
one hospital to another, kind of, belies the definition of 
critical access----
    Mr. SMITH. But that doesn't lead to--these arbitrary 
regulations, say, physician supervision, for example, you know, 
requiring a physician to be on the premises, on the same floor 
of the premises, when a phlebotomist might draw blood in order 
to be reimbursed, it seems to me that that would actually drive 
up the cost of the delivery of care rather than find an 
efficiency.
    Secretary SEBELIUS. Well, again, I would be happy to take 
the specifics back and try to find the evidence behind why 
specific recommendations were made. I can assure you that at 
least the staff that is looking at these situations is very 
concerned that patients not be jeopardized by the care and 
trying to not add administrative burden.
    But I would be happy to, if you could give me some 
specifics----
    Mr. SMITH. Absolutely.
    Secretary SEBELIUS [continuing]. Get the evidence back to 
you.
    Mr. SMITH. Thank you. And, again, I think these are 
examples that I hope we can avoid of the Federal Government 
standing between a patient and his or her provider.
    Thank you. I yield back.
    Chairman CAMP. Thank you.
    Mr. Buchanan.
    Mr. BUCHANAN. Madam Secretary, thanks for being here today.
    I want to touch on the biggest issue in our area, employer 
mandates. A lot of people are concerned. I am looking at a New 
York Times article. It is about 2 weeks old; I would be glad to 
give it to you. But it says cities, counties, public schools, 
community colleges around the country are being limited or 
reducing hours in terms of part-time employees to avoid paying 
healthcare insurance under the ACA. And this is coming from 
State and national leaders from around the country.
    Are you aware of this? And do you have any sense of the 
impact that this is having on communities? And I can tell you 
in our community, in Sarasota-Bradenton, Florida, it is a 
gigantic issue.
    Secretary SEBELIUS. I have heard, Congressman, certainly, 
conversations about the 30-hour, kind of, cliff: that more than 
30, people would be required to provide health coverage for 
those employees; less than 30, they would not. Again, I think 
there is disputing evidence of what is happening with that, but 
we are watching it very closely----
    Mr. BUCHANAN. I would just ask you to take a look at it. We 
need to clearly--because this is--I know we are trying to get 
more health care out there, but everybody is taking, in a 
sense, a 25-percent pay cut.
    I also want to mention something you said earlier, about 
the fact that it only affects 2 percent of the businesses. Do 
you have any idea--it is one way to spin it or present it, but 
do you have any idea what the 2 percent make up in terms of the 
number of jobs, the impact in the country? Do you have any 
sense of what that 2 percent is?
    And I will say that because I have one employer in my area, 
they have over 1,000 employees. They are moving most of their 
employees from 40 hours to 29, and they are part of the 2 
percent. But I think you are looking at 20, 30 percent of the 
jobs across the country are going to be impacted by these 
mandates. And even though you are pushing the mandates off, 
people are making those adjustments in the public sector and 
the private sector today. So we are very concerned about that.
    But I would like to have you get back to me on what that 2 
percent makes up.
    One other thing I want to just mention, in terms of the 
taxes and revenues. Part of the reason we are having a record 
surplus this year--not a surplus, but record revenues this year 
is because we did increase taxes 25 percent. We went from 35 to 
44. That is what the passthrough entities are paying that 
create a lot of the jobs in the country. And if you look at the 
taxes for State and Federal, the average across the country is 
49.6.
    So I don't know how much more burden we can put on our 
employers across the country, as we, as you have mentioned, we 
need additional revenues. I hope you are not considering going 
after more passthrough entities that are the job creators of 
America.
    Secretary SEBELIUS. Congressman, one thing I would point 
out is that the recently released rules by the Treasury 
Department did look at the 30-hour employee and particularly 
the, kind of, mixed work group where you have part-time and 
full-time, and indicated that employers, if they offer coverage 
to 70 percent of their employees, would meet the criteria.
    I would tell you that the 30-hour definition came out of 
the offerings in the private-sector marketplace prior to the 
Affordable Care Act. That is what employers chose to do, that 
people who were working more than 30 hours were defined as 
full-time employees, people who were working less--so as the 
Congress looked across the country, that is where that hour 
rate came from.
    But we are watching, as I say, that very closely.
    Chairman CAMP. All right. Thank you.
    Mr. Doggett.
    Mr. DOGGETT. Thank you, Mr. Chairman.
    Madam Secretary, so much of the original promise of the 
Affordable Healthcare Act has been undermined by faulty 
implementation that has sometimes been indifferent to local 
concerns. Last month, the Congressional Budget Office, as you 
know, concluded that faulty implementation of the healthcare 
law, quote, ``impeded so many people's enrollment in exchanges 
that 1 million fewer people will actually obtain exchange 
coverage this year than they had previously projected.''
    From your testimony this morning, it is clear we will not 
have 7 million or even 6 million. And, of course, the number 
that is 
really important is not how many people have enrolled, but how 
many people have paid their premiums and are actually getting 
exchange-based coverage, a number we have never been given.
    As you are aware, since last August, I have been voicing 
concerns to your office about implementation in Texas. At best, 
less than 10 percent of exchange-eligible Texans have selected 
a plan. In other words, more than 90 percent of the people whom 
we wrote this law to get exchange coverage for have not been 
covered.
    To meet your projections, we would need to enroll and have 
premiums paid for as many people this month as have been 
enrolled since the beginning in October to yesterday, or last 
week.
    This is much more than a website problem, though I believe 
that the individual assistance program there has been handled 
with about the efficacy of the original website rollout. I have 
been unable to get straight answers about even who is 
responsible for coordinating in-person assistance in Texas--a 
place where we have multiple assisters in some areas and none 
in many others.
    I have sought to get even just a dedicated line so that the 
certified counselor, who yesterday had put in 10 hours trying 
to help one person, would be able to call a line dedicated to 
assistance counselors to be able to get prompt assistance and 
help people get enrolled in this. But there has been no 
response from HHS or CMS about that.
    It seems to me that we are to a point where, instead of 
just circling the wagons against all the political arrows that 
are shot against this plan, we need a little more 
accountability, and we need to ensure that the next enrollment 
period is not handled as poorly as the last one.
    I am very interested in answers to the questions that the 
Chairman raised at the beginning of this hearing. We haven't 
gotten them yet, and I hope that we do get them.
    We come at this from a different perspective, but taxpayers 
deserve to get their money's worth. And I think much of the 
focus as it relates to in-person assistance needs to be to find 
out--and I assume, Mr. Chairman, that some of these questions I 
have been raising since last fall can be submitted by you with 
your questions for prompt answers, such as how much it costs us 
per person who is actually insured through the exchange for 
some of these contractors that have been providing these 
services. Two Washington Beltway contractors have been paid $9 
million for in-person assistance in Texas. I have been unable 
to find out what it costs per enrollee for those persons.
    And so I think that, while our goal should be to try to 
improve and strengthen this Act, if it is to perform any better 
in the next enrollment period than it has in this one, we need 
answers to these questions to get the taxpayer their money's 
worth and to get the promise of this Act fulfilled.
    And I yield back.
    Chairman CAMP. All right.
    At this time, Dr. Price.
    Mr. PRICE. Thank you, Mr. Chairman.
    Welcome, Madam Secretary, back to the Committee.
    I think you sense a growing lack of trust that we reflect 
from our constituents. Americans have a growing lack of trust 
in their own Federal Government. I think there is no doubt 
about that. And I would suggest that Obamacare is really the 
poster child for one of the reasons that exists or that is 
increasing because word isn't matching deed. Promises have been 
made and absolutely broken.
    And as a former practicing physician, it is distressing 
because we are not talking about just some nebulous program 
now; we are talking about real people's lives. And in so many 
ways, some of the stories that you have heard here, real people 
are getting harmed.
    In spite of that, you have the Senate Majority Leader, 
Harry Reid, taking to the floor of the Senate and saying any 
story that decries a problem with Obamacare, all of them are 
lies. Do you agree that all of these stories that have been 
raised are lies?
    Secretary SEBELIUS. Congressman, I did not hear what 
Senator Reid said. And, of course, there are lots of anecdotes 
of lots of people and----
    Mr. PRICE. If you were to----
    Secretary SEBELIUS [continuing]. Lots of success stories.
    Mr. PRICE. If you were to have heard the Senate Majority 
Leader say all the stories----
    Secretary SEBELIUS. Yeah, I----
    Mr. PRICE [continuing]. About ACA are lies----
    Secretary SEBELIUS [continuing]. I really don't want to 
comment on his comments. I didn't hear them.
    Mr. PRICE. Again, it is--and that is the kind of trust that 
is lacking, because it begs for----
    Secretary SEBELIUS. I just said clearly there are lots of 
people and lots of real stories. I don't assume that people are 
lying, no.
    Mr. PRICE. Let me go to some specific questions. You 
mentioned in your opening remarks 4.2 million people have 
signed up on the exchange, and I want to get to some of the 
concerns that others have.
    How many of those that have signed up, that have enrolled 
in Obamacare, have paid their premium?
    Secretary SEBELIUS. I can't tell you that, sir, because I 
don't know that.
    Mr. PRICE. How can it be that HHS, in charge of this 
program, cites a number, 4.2 million people signed up, but has 
no idea how many people have paid?
    Secretary SEBELIUS. Because the consumers don't pay us; 
they pay their insurance company. We can tell you who has 
enrolled----
    Mr. PRICE. You can get information from the insurers?
    Secretary SEBELIUS. We get information now in aggregate 
form of the customers who qualify for----
    Mr. PRICE. Let me ask another question.
    Secretary SEBELIUS [continuing]. A tax credit. Not all 
their customers do, and----
    Mr. PRICE. How many of those, of the 4.2 million, were 
previously insured?
    Secretary SEBELIUS. I do not know that, sir.
    Mr. PRICE. Isn't it true that many Members of Congress are 
in that 4.2 million? We had insurance before; we were forced 
off that insurance----
    Secretary SEBELIUS. I assume if you have signed up on the 
exchange, you are in that number, yes, sir.
    Mr. PRICE. McKinsey did a recent survey that said 27 
percent of those joining the exchanges were previously 
uninsured. And that is a low number compared to what you all 
projected. Is that consistent with your information?
    Secretary SEBELIUS. Again, we don't collect information on 
the previously insured. I think these questions would be--we 
would be happy to give answers to you as soon as we have 
accurate information. In the meantime, insurers have this 
information about their customers, because that is who is being 
paid and that is who is enrolling.
    Mr. PRICE. It begs credulity, Madam Secretary, that you 
don't know the answers to these----
    Secretary SEBELIUS. These are private insurance plans, and 
customers are----
    Mr. PRICE. You all are charged with running the program.
    Secretary SEBELIUS [continuing]. Buying a private product 
from a private insurance plan. We qualify them, we get their 
tax information to make sure they qualify, and then send them 
to their company----
    Mr. PRICE. The American people trust that you----
    Secretary SEBELIUS [continuing]. And they enroll with the 
company.
    Mr. PRICE [continuing]. Know what you are doing, and you 
are not fulfilling the bill.
    Chairman CAMP. All right.
    Secretary SEBELIUS. This is not Medicare or Medicaid, sir. 
It is a private plan in the private market. It is not 
government insurance, in spite of the fact that it has been 
characterized that way. People are buying a product in the 
private market.
    As soon as we have accurate information, we will give it to 
you, but we do not currently have information about how many 
people have paid.
    Mr. PRICE. Sounds like last fall, Mr. Chairman.
    Chairman CAMP. All right.
    Mr. Gerlach.
    Mr. GERLACH. Thank you, Mr. Chairman.
    Madam Secretary, there is a section in the ACA on a 
reinsurance tax; is that correct?
    Secretary SEBELIUS. Yes.
    Mr. GERLACH. What is the purpose of that reinsurance tax, 
the proceeds from that tax?
    Secretary SEBELIUS. Well, there actually are three 
components of risk corridors, reinsurance tax, and risk 
adjustment. A 3-year program that, again, is paid for by the 
insurance companies----
    Mr. GERLACH. Right.
    Secretary SEBELIUS [continuing]. Operating in the market, 
and it is to really balance the risk pool. It is exactly the 
same as the risk program----
    Mr. GERLACH. Does the reinsurance tax----
    Secretary SEBELIUS [continuing]. In Part D when Part D 
started----
    Mr. GERLACH. I am focused on the reinsurance tax, in 
particular. Are the revenues to be used to fund other portions 
of the Act, including exchanges?
    Secretary SEBELIUS. The revenues will be used to balance 
the marketplace.
    Mr. GERLACH. How much is expected to be raised in the 
reinsurance tax this year?
    Secretary SEBELIUS. I was just told that figure is $10 
billion for this year.
    Mr. GERLACH. Okay. But there is also a proposal out there 
to provide waivers to some of those that are right now under 
the law to pay that reinsurance tax; is that correct? In 
particular, unions?
    Secretary SEBELIUS. Oh, yes, this is the--I am sorry--the 
rule that if you are self-administered and a self-funded plan, 
you do not pay the tax, and that is not exclusive to unions. 
There are a lot of self-administered, self-funded plans that 
are not paying the tax.
    Mr. GERLACH. Okay. So how much relief under this waiver 
will unions receive as a result of this rule?
    Secretary SEBELIUS. I could get you that information in 
writing.
    Mr. GERLACH. Could you give me a ballpark right now?
    Secretary SEBELIUS. I can't.
    Mr. GERLACH. Okay. Well, I find it curious that--the 
reinsurance tax section of ACA is very clear as to who is to 
pay that tax. It is to be used, then, to help fund aspects of 
the ACA, including exchanges. And yet the President is 
requesting an additional $1.8 billion in his budget request for 
program management to continue to build and operate exchanges.
    So what it seems to me is, you are providing a waiver to 
perhaps what would be termed ``political friends'' not to pay 
what the law requires them to pay, but then coming back to the 
taxpayers and asking them for more money to help fund the 
exchanges.
    Secretary SEBELIUS. Well, sir, the statutory language talks 
about issuers or those who operate plans with third-party 
administrators. And the self-funded, self-administered plans, 
which are a much broader category than you have just described, 
are not in the statutory configuration of the law.
    In addition----
    Mr. GERLACH. Okay. Just so----
    Secretary SEBELIUS [continuing]. The 1.8----
    Mr. GERLACH [continuing]. I am clear on what you are 
saying, Madam Secretary, just make sure I understand what you 
are saying, it is your determination that those that are being 
granted this waiver are not covered by the language of the Act, 
and therefore----
    Secretary SEBELIUS. They are not----
    Mr. GERLACH [continuing]. You are granting that waiver.
    Secretary SEBELIUS [continuing]. An issuer, nor do they 
operate with a third-party administrator, yes. Self-funded, 
self-administered plans--again, much broader than the category 
of unions; there are many who operate that way--are not 
specified in the statutory language.
    Mr. GERLACH. Then why were unions jumping up and down 
asking for this relief if they weren't covered by the tax to 
begin with?
    Secretary SEBELIUS. I can just tell you that is what the 
statutory language says. That was our interpretation of the 
statutory language. That is the rule we put out. The $1.8 
billion that you suggest, 1.2 of that will be paid for by user 
fees. Six hundred million dollars is the request for 
appropriation.
    Chairman CAMP. All right.
    Mr. GERLACH. Thank you.
    Chairman CAMP. Mr. Becerra.
    Mr. BECERRA. Thank you, Mr. Chairman.
    Madam Secretary, great to have you with us.
    Actually, before I go to some of the questions about the 
Affordable Care Act, I wanted to check in with you regarding 
the financial alignment demonstration project being carried out 
in California, called the Dual Eligible program, for 
beneficiaries who receive both Medicare and Medicaid.
    We share the goal of ensuring that everyone who transitions 
into this program will have uninterrupted, quality health care 
that they can count on. And I was just wondering, will you and 
CMS Administrator Tavenner keep us informed as you continue the 
rollout so we can make sure that there is a successful 
implementation of that program?
    Secretary SEBELIUS. Yes, sir, we will.
    Mr. BECERRA. Appreciate that.
    Now, I know that, even today, if anyone is watching, there 
is no reason why folks should not be left with some sense of 
misunderstanding about what is going on. The disinformation and 
scare tactics that have been used over and over again have been 
difficult to combat. But I wanted to just make sure about 
something.
    As I read the facts, since the passage of the Affordable 
Care Act, you mentioned that several million people have now 
become insured. In fact, I think you mentioned that over 4 
million people now have private health insurance.
    Did you mention the 3-or-so million young Americans who 
have insurance as a result of the Affordable Care Act, that now 
they can stay on their parents' insurance policy?
    Secretary SEBELIUS. I did not mention that.
    Mr. BECERRA. And that is about 3 million or so?
    Secretary SEBELIUS. Yes, sir.
    Mr. BECERRA. And we have some----
    Secretary SEBELIUS. Three million previously uninsured. Far 
more young adults are on their parents' plan, but 3 million 
previously uninsured young adults.
    Mr. BECERRA. Got it.
    And we have some 4 million or more individuals who now have 
health coverage as a result of Medicaid?
    Secretary SEBELIUS. Closer to 8.9 million in the Medicaid. 
Some of those are renewals; some of them are newly eligible in 
States that chose to expand their Medicaid program.
    Mr. BECERRA. Right. So the 8-million-plus number includes 
people who probably qualified before but had--or who just 
transitioned from current Medicaid, what they had before to 
what they have now.
    Secretary SEBELIUS. Some States require yearly renewals, 
and they are included in that, but there are close to 9 million 
people who will have Medicaid coverage. A number of those are 
newly insured.
    Mr. BECERRA. So if I do the quick math, 9 million under 
Medicaid, 4 million with the private insurance under the 
marketplace, 3 million young adults, that is about 16 million 
Americans who have health security today that they might not 
have had before.
    Secretary SEBELIUS. That is accurate.
    Mr. BECERRA. My understanding, as well, looking at the job 
numbers, that since the Affordable Care Act passed, more than 8 
million jobs have been created in this country, not lost. And, 
in fact, if you look just at the--I looked at just the 
healthcare sector, and in the healthcare sector, since the 
passage of the Affordable Care Act, we have seen over a million 
jobs created, just in the healthcare sector.
    So as we continue to hear folks talk about job loss, that 
the Affordable Care Act will result in job loss, just the 
opposite is occurring. And, of course, we are also finding that 
we have seen a decrease in the rate of increase of the cost of 
health care, which I would think you would agree is a good 
sign.
    Secretary SEBELIUS. I think that is a good sign.
    And on the job front, we also see that the number of people 
working part-time hours is decreasing, the number of full-time 
workers is increasing.
    Mr. BECERRA. Mr. Chairman, if I could just add to the 
record--ask unanimous consent to submit into the record the 
CBO's updated estimates that deal with job loss and the issues 
of employment and job creation.
    Chairman CAMP. Yeah, without objection.
    Mr. Roskam.
    Mr. ROSKAM. Thank you, Mr. Chairman.
    Madam Secretary, we just heard from Mr. Becerra, who 
criticized critics, characterizing it as disinformation and 
scare tactics, and yet that wasn't what we heard from Mr. 
Doggett. Mr. Doggett was essentially admonishing the Department 
for a lack of information and a lack of accountability.
    So I want to associate myself with the spirit of Mr. 
Doggett and also bring in one of the themes that Dr. Price was 
trying to articulate, and that is this: Wouldn't it be great, 
Madam Secretary, if Dr. Price, in the question that he asked, 
if you were able to say, here is the answer, here is the 
answer, when he made the inquiry and you said, you know what, I 
don't have that information, I am just the Secretary of Health 
and Human Services, that is what the private insurance 
company--that was your answer a minute ago. Wouldn't it be a 
great thing if you were to say, here is the information and 
here is the answer?
    And the problem is, at least as far as the construction of 
the Affordable Care Act, as it is currently constructed, some 
of this information you may not know, some of it you may, but 
it is because of the limitations of the Act itself.
    So we have an inspector general, and your own inspector 
general is only able, Madam Secretary, to go and ask inquiries 
of Health and Human Services. That inspector general who 
reports to you cannot go and make any inquiries to the 
Treasury.
    One of your earlier answers, you cited tax credits. Well, 
when it comes down to it, the HHS Secretary has no jurisdiction 
over tax credits. You don't know what is happening in that 
other department.
    Wouldn't it be a good thing if we were to amend the law and 
you had that information and there were a special inspector 
general that had broad jurisdiction? Wouldn't that be a good 
thing?
    Secretary SEBELIUS. I don't think that is necessary, and I 
think that is additional expenditure.
    I will give you the information as soon as we have it. And 
we will have it----
    Mr. ROSKAM. Yeah, but by your own admission----
    Secretary SEBELIUS [continuing]. From insurance companies, 
but we do not have it now.
    Mr. ROSKAM [continuing]. You don't know it.
    So why is it a good idea to have a Special Inspector 
General for Iraq Reconstruction? Why is it a good idea to have 
a Special Inspector General for Afghanistan Reconstruction? Why 
is it a good idea to have a Special Inspector General for TARP 
oversight? Cumulatively, all of these have literally saved 
billions of dollars.
    The Affordable Care Act, according to the Congressional 
Budget Office, is a $1.8-trillion expenditure. What is it that 
is sacrosanct that says that this should not be subject to that 
broad jurisdiction?
    By your own admission, you don't know the answers to these 
questions, do you?
    Secretary SEBELIUS. I could not answer Dr. Price's question 
because I don't have the information from the insurance 
companies yet.
    Mr. ROSKAM. Right, because you can't----
    Secretary SEBELIUS. We will have it, and I will----
    Mr. ROSKAM [continuing]. Reach out.
    Secretary SEBELIUS. This is in the private sector. This is 
not Treasury. This is private insurance companies----
    Mr. ROSKAM. Right. That even begs the question----
    Secretary SEBELIUS [continuing]. Three hundred of whom are 
selling policies in the marketplace.
    Mr. ROSKAM. You can't get to it. Your inspector general 
can't get to it.
    Secretary SEBELIUS. This is not an inspector general issue. 
It is private insurers who are selling plans to their 
customers. They can tell----
    Mr. ROSKAM. That is even worse.
    Secretary SEBELIUS [continuing]. You know how many of their 
customers have----
    Mr. ROSKAM. It is ongoing----
    Secretary SEBELIUS [continuing]. Paid their bills.
    Mr. ROSKAM [continuing]. And you don't have the 
information, and you don't have the capacity to have the 
information.
    Chairman CAMP. All right. I would just say, Madam 
Secretary, part of the frustration is that you did have the 
answer to the number of insured children, and that is also 
private-sector information, but yet, when we are trying to get 
further information, we don't----
    Secretary SEBELIUS. That came directly, Mr. Chairman, from 
the insurers. And I am telling you, as soon as we have this 
information from the insurers--we don't collect it. We didn't 
have it. They turned that in to us.
    Chairman CAMP. All right.
    Dr. Boustany.
    Mr. BOUSTANY. Thank you, Mr. Chairman.
    Madam Secretary, one of the glaring omissions in ACA was 
addressing the flawed physician payment formula under Medicare, 
SGR, the sustainable growth rate formula. A lot of work has 
been done. It has been a thorny problem facing Congress for 
quite a while, and over the past few years, we have actually 
gotten to an agreement on a policy--bicameral, bipartisan.
    So first question: Does the Administration agree with this 
policy, and will the Administration support this policy?
    Secretary SEBELIUS. Well, as you know, Congressman, the 
President has supported a long-term fix of the SGR long before 
the Affordable Care Act was signed into law. He has included it 
in every budget. And, yes, we do support the bicameral 
position.
    Mr. BOUSTANY. Okay.
    The other issue is going to be paying for this. And this 
will be a difficult fight, obviously, and it certainly can 
become a partisan fight. But in the interest of trying to get 
something done, will the Administration come forward and work 
with Congress, work with the Senate, to try to get to a 
solution on this?
    Secretary SEBELIUS. We would be eager to do that. The first 
couple of budgets that the President put forward had specific 
pay-fors. Those were rejected. He does assume that the SGR is 
fixed; we have put that in our baseline for the next 10 years. 
We would be happy to work with Congress.
    Mr. BOUSTANY. And pursuant to that same question, the 
President, in the past, put on the table some Medicare reforms 
that would help, I think, improve the outlook of Medicare over 
the long haul, one being combining Medicare Part A and Part B 
into a single structure, making it work more like a modern 
insurance type program. Second was limited means-testing.
    Does the President still support these?
    Secretary SEBELIUS. I think, as you know, Congressman, that 
was put on the table as part of a global package of both 
entitlement and structural spending reforms. And we would be 
eager to talk about those issues in that, kind of, global 
package.
    Mr. BOUSTANY. But not within the context of reforming SGR, 
which is a pretty big piece.
    Secretary SEBELIUS. Well, the SGR does impact, certainly, 
Medicare physicians. It is probably the single biggest threat 
to Medicare's future in terms of beneficiary service, the 
looming cuts.
    Mr. BOUSTANY. It is a threat to access.
    Secretary SEBELIUS. So we are eager to talk about pay-fors, 
but I think having a more global discussion about entitlement 
reform, tax reform, and revenues is also something we would be 
eager to----
    Mr. BOUSTANY. And, finally, is the Administration willing 
to put forth the capital to try to solve this before the end of 
March so that we can avoid another patch, which will be 
expensive?
    Secretary SEBELIUS. Put forward the capital--again, we 
would be happy to have the discussion with Members of Congress 
about what the pay-fors might look like.
    Mr. BOUSTANY. Thank you, Mr. Chairman.
    Chairman CAMP. Thank you.
    Mr. Neal.
    Mr. NEAL. Thank you, Mr. Chairman.
    Madam Secretary, I want to come back to you in a few 
moments about you as the trustee of Medicare and Social 
Security, but just a reminder here that the Democratic minority 
vigorously opposed the original Part D prescription drug 
benefit plan offered by the Bush Administration because we did 
not think it had gone far enough. Upon ascending to the 
majority right after, we took the role not to undo what had 
been done but instead to work hard to improve it, and closing 
the donut hole was a pretty masterful piece of work. And now 
there is broad acceptance of the whole notion of the Part D 
benefit. Now, I wish that that would have been the model that 
we would have adopted in Congress for working with ACA.
    But let me draw your attention specifically to a couple of 
issues: graduate medical education and the role of Medicare in 
financing our hospitals across the country. As you know, in 
Massachusetts, our hospitals would be the equivalent of what 
Boeing perhaps means to the Pacific Northwest. I think that is 
a reasonable description in terms of not only the success that 
they have but the employment opportunities that they present.
    You, I think, by law, have to sign every year a document 
certifying as to the longevity of Medicare. Is that correct?
    Secretary SEBELIUS. Yes, sir.
    Mr. NEAL. Would you talk a little bit about what ACA has 
done to that signing?
    Secretary SEBELIUS. Yes.
    The first year I was a Medicare trustee in 2009, the 
anticipation was--the actuarial projection was that Medicare 
would begin to be insolvent--not that they wouldn't have any 
money, but they would have about 70 cents on the dollar--by 
2017. So, in 2009, it was a 2017 cliff.
    The passage of the ACA added years to that solvency, 
according to the actuary who looked at the law and the impact 
over time, and subsequent budgets have also added years. So we 
are now, the 2015 budget, according to the actuarial 
projection, would add an additional 5 years to the solvency of 
the Medicare Trust Fund.
    So during this Administration, I would say significant 
solvency years have been added.
    Mr. NEAL. Are there Republican trustees?
    Secretary SEBELIUS. Yes.
    Mr. NEAL. Do they sign the document?
    Secretary SEBELIUS. Yes, they do.
    Mr. NEAL. And did they sign?
    Secretary SEBELIUS. Yes.
    Mr. NEAL. Okay.
    My point is that, here is an example, again, of a very good 
story, much like the one that Secretary Lew presented about 
deficits in his appearance before the Committee recently, and 
it is frequently underreported in terms of the good news, 
because the emphasis remains on the conflict of the story as 
opposed to the substance of the story.
    So I would hope that you use the opportunity, with Medicare 
solvency, graduate medical education, to promote the notion 
that this is a widespread success story on that basis.
    Secretary SEBELIUS. Thank you.
    Chairman CAMP. All right. Thank you.
    Mr. Reichert.
    Mr. REICHERT. Thank you, Mr. Chairman.
    Madam Secretary, in response to Mr. Reed's question 
regarding legislation, your answer was that there was no 
legislation that has passed Congress. Are you aware that there 
are actually eight pieces of legislation that have passed 
Congress and have been signed by the President in regard to the 
Affordable Care Act?
    There are eight pieces of legislation passed by Congress 
and actually signed into law by the President. So there is 
another--I think you ought to go back and review the laws that 
have been passed that affect the law that you are trying to 
implement.
    I want to go back real quick. It has been 4 years since 
passage of the healthcare law, nearly 6 months since the 
exchanges opened for business. So let's look back at the 4 
years.
    In January 2010, the President spoke at the White House 
Republican Retreat and acknowledged that some stray cats and 
dogs were added to the healthcare bill and that some of the 
provisions that got snuck in the law might have violated the 
pledge that, if you like your health care, you can keep it; if 
you like your doctor, you might be able to keep your doctor.
    In February 2011, during your testimony and my questioning, 
you said, in response to whether or not you can keep your 
doctor or your health care, you said, ``I don't think there is 
any language in the bill that interferes with the current 
system.'' Again, you were wrong.
    Again, in February 2012, when I raised these same concerns, 
you said, ``The notion that somehow companies in grandfathered 
plans will not be able to keep their grandfathered plan is 
really not accurate.'' Again, you were wrong.
    Yet, due to the law's many mandates and the regulations put 
out by HHS under your leadership, as many as 5 million 
Americans have lost their existing healthcare plans. The law 
has created so many disruptions that the President announced, 
perhaps illegally we think, that States and insurers can begin 
to ignore the law.
    In fact, as Mr. Reed said, there are 37 changes to the law. 
September 24th, September 26th, October 23rd, November 14th, 
there were seven more changes to the law. On November 21st, 
November 22nd, January 1st, November 27th, and 30th of 
November, December 12th, December 19th, December 23rd.
    And then, Secretary Sebelius, you were on Fox News and 
assured the American people who were watching Fox News at that 
time that there would be no more delays. Yet, on January 10th 
of this year, another delay; January 14th, another delay; and 
then February 10th, another delay.
    Are there any further delays? Can you make a promise to the 
American people today, another promise, Madam Secretary, that 
there will be no more delays to the so-called Affordable 
Healthcare Act?
    Secretary SEBELIUS. We will continue to put out 
regulations----
    Mr. REICHERT. Do you make a promise to the American----
    Secretary SEBELIUS [continuing]. And policies as we go 
through this Act.
    And, sir, I would like an opportunity to correct some of 
the, I think, misstatements.
    Mr. REICHERT. Will there be----
    Secretary SEBELIUS. There is nothing in the law that would 
stop insurance companies----
    Mr. REICHERT. Will there be further delays, Madam 
Secretary?
    Secretary SEBELIUS. There are no planned delays in the law 
that----
    Mr. REICHERT. Do you consult with HHS when you--or, pardon 
me. Do you consult with the Treasury Department before 
announcing any delays and changes?
    Secretary SEBELIUS. Sir, most----
    Mr. REICHERT. Do you consult with----
    Secretary SEBELIUS [continuing]. Of the regulations that 
we----
    Mr. REICHERT [continuing]. The Department of Treasury----
    Secretary SEBELIUS. Most of the regulations that are 
written are written----
    Mr. REICHERT. Do you consult with the Department of 
Treasury, yes or no?
    Secretary SEBELIUS. Sir, the regulations require three 
agencies' participation: Treasury, Labor, and HHS. So there is 
broad consultation.
    Mr. REICHERT. Okay. Thank you.
    Chairman CAMP. Mr. Ryan is recognized.
    Mr. RYAN. Thank you.
    I would just quickly say to my friend from Massachusetts, 
he should look at the unprecedented original appendix of the 
trustees' report that talks about the double counting that 
occurred. And the putting Part D on the credit card, the 
Democratic proposal was more than double the credit card bill.
    Here is what I want to ask, Madam Secretary. We keep this 
list here in the Ways and Means Committee about all the delays. 
We have 23 so far. One I want to ask you about is IPAB, the 
Independent Payment Advisory Board.
    In your Table S-9 of your budget, last year you claimed in 
your budget you are going to save $4 billion from IPAB's 
recommendations. This year, you tripled that to $12.9 billion 
for IPAB's recommendations. This is above and beyond all the 
provider cuts that are in the ACA to pay for the ACA.
    So here is my question: Where are we with IPAB? They have 
given us their last April report. I assume another one is 
forthcoming from the actuary. But where is IPAB itself? When 
are you going to submit the names?
    If you don't do that, as you know, the law lets you, one 
person, submit the plan to save the $12.9 billion. So what is 
happening with that? And if you are going to do it, how do you 
come up with the $12.9 billion? Where is that savings coming 
from?
    Secretary SEBELIUS. Well, Congressman, the President has 
not yet sent to Congress names for the nominees of IPAB. But, 
as you may know, the law is constructed in a way that IPAB 
wouldn't trigger any recommendations unless there is a gap 
between what the trajectory----
    Mr. RYAN. I realize that, and you are claiming $12.9 
billion.
    Secretary SEBELIUS. So they would not have any 
recommendations to make in the foreseeable future. Nor would I 
take any action in the foreseeable future----
    Mr. RYAN. Okay, so how----
    Secretary SEBELIUS [continuing]. As long as the cost 
trajectory is----
    Mr. RYAN. So are we to ignore the fact that you are 
claiming $12.9 billion in savings from IPAB?
    Secretary SEBELIUS. I think the President intends to submit 
names to Congress as we watch the cost trajectory--if the cost 
trajectory changes, the IPAB will be in full effect. And those 
recommendations are presented to Congress, as you know, not to 
me. They come to Congress.
    Mr. RYAN. No, I realize that.
    Secretary SEBELIUS. And if Congress doesn't change them, 
then they go into effect.
    Mr. RYAN. Or you just recommend them, if there is no IPAB 
at the time.
    Secretary SEBELIUS. If there is no IPAB, that is correct.
    Mr. RYAN. So you have no answer to where the $12.9 billion 
is going to come from?
    Secretary SEBELIUS. We are optimistic that the current 
trajectory of Medicare costs would actually negate any impact 
of IPAB or me taking any kind of action in the foreseeable 
future.
    Mr. RYAN. That is another way of saying, ignore our budget 
because it is not real.
    Secretary SEBELIUS. I think the IPAB recommendations are 
based on an actuarial----
    Mr. RYAN. No, I understand.
    Secretary SEBELIUS [continuing]. Of out-year costs----
    Mr. RYAN. You go from GDP of 1 to GDP of 5, I get all that. 
You did that last year; you went to GDP .5 last year. And you 
still had $4 billion. Now you triple your savings to 12.
    And the question is, where is it coming from? What are 
those justifications? What is the assumption you are using to 
claim this savings to show how your budget is put together?
    Secretary SEBELIUS. I think the actuarial projection is 
that out-year Medicare costs will rise again.
    Mr. RYAN. Right.
    Secretary SEBELIUS. So far, they have been incorrect about 
those increases. We are hoping that they continue to be 
incorrect. And so, if the IPAB indeed does rise--I mean, I am 
sorry----
    Mr. RYAN. Yeah, the--I understand.
    Secretary SEBELIUS [continuing]. The trajectory rises, IPAB 
would kick into gear, and we will make recommendations through 
the IPAB to Congress about those specifics.
    Mr. RYAN. Okay. So you are saying, though, just so you 
know, in your own budget, it is going to triple from this year 
to last year. That is coming. It is above projection. You have 
it in your budget. But you are telling me you have no idea 
where in Medicare you are going to cut to get that, is 
basically what you are saying.
    Secretary SEBELIUS. It is based, again, on what the 
actuary, the independent actuary----
    Mr. RYAN. I understand that.
    Secretary SEBELIUS [continuing]. Says will happen in out-
years. Currently, we have not made specific recommendations 
about any cost cuts because none of that is actually happening 
right now.
    Mr. RYAN. Okay. I know time is out. When are we going to 
see the names? What are we going to see IPAB----
    Secretary SEBELIUS. I can't tell you. They come from the 
President.
    Mr. RYAN. All right.
    Secretary SEBELIUS. I don't know when you will see them.
    Chairman CAMP. All right.
    Mr. Davis.
    Mr. DAVIS. Thank you, Mr. Chairman.
    Madam Secretary, thank you very much for being here. But, 
also, I want to thank you for the Medicaid waiver for Cook 
County in the State of Illinois. As a result of that action, 
the Governor's expansion of Medicaid, and a lot of hard work on 
the part of a lot of people, Illinois is doing much better in 
signups for the Affordable Care Act than many other States. And 
for that, we are indeed grateful.
    I am a big fan of home-visiting programs and community 
health centers, and I am pleased to note that both are included 
in the budget. As a matter of fact, I get my personal care at 
one of these centers in Chicago at the Mile Square.
    Could you elaborate on the value and effectiveness of these 
two programs that relates to providing health care for 
especially low-income people?
    Secretary SEBELIUS. Well, Congressman, I share your high 
regard for both programs. I think that there is no question the 
community health centers are the backbone of primary-care 
delivery in this country in rural and urban areas. They are 
proven time and time again to deliver lower-cost, high-value 
primary care.
    And thanks to both investments from the Recovery Act and 
ongoing investments through the Affordable Care Act, the 
footprint of health centers is spreading, increasing services 
and increasing clients. And we are now going to be able to 
serve about 31 million people, including yourself. And I think 
they are an incredibly important--play an incredibly important 
role, particularly in underserved communities.
    In terms of the home-visiting program, again, there is lots 
of very strong scientific evidence that it makes a huge 
difference to help give parents the tools to be the best parent 
they can be, that having a professional encounter with young 
parents is often extremely beneficial as a pathway to an early 
strong start in learning.
    So the President's budget, as you say, both increases the 
voluntary home-visiting program as well as continues to expand 
the footprint, both new sites and additional services at sites, 
for the community health center program.
    Mr. DAVIS. Thank you very much.
    And I would like to just point out that our experiences in 
Illinois with the Affordable Care Act have not been automatic, 
but our experiences have come as a result of a large number of 
people believing in the program, believing that it will work, 
and then working to make sure that it does work.
    So I thank you very much and----
    Secretary SEBELIUS. Well----
    Mr. DAVIS [continuing]. I yield back.
    Chairman CAMP. Thank you.
    Secretary SEBELIUS [continuing]. I don't think it comes as 
a surprise that in States where the Governor is very 
supportive, where there are delegation members, providers, 
others reaching out, there is a more positive experience than--
Congressman Doggett has mentioned Texas, where there are not 
only barriers but significant laws that have been passed which 
make it very difficult for a lot of the outreach people to even 
do the job they were contemplated to do.
    Chairman CAMP. All right. Thank you.
    Mr. Tiberi.
    Mr. TIBERI. Madam Secretary, Mr. Young submitted for the 
report this report, ``The Irony of Obamacare: Making Inequality 
Worse.'' I would like to read the conclusion, which says, ``For 
two years, labor unions, employer partners have patiently 
explained to the Obama Administration and Congress the 
potential damage that the ACA poses to these unique successful 
nonprofit plans.
    ``Having already made efforts to accommodate businesses, 
churches, congressional staff, it is ironic the Administration 
is now highlighting issues of economic inequality without 
acting to preserve health plans that have been achieving the 
goals of ACA for decades. Without a smart fix, the ACA will 
heighten the inequality that the Administration seeks to 
reduce.
    ``We take seriously the promise that if you liked your 
health plan you can keep it, period. UNITE HERE members like 
their health plans. UNITE HERE members' plans are ready to 
compete with the corporate giants of the healthcare industry if 
Washington will simply create a level playing field.''
    There were three articles in local papers in my district I 
would like to submit for the record, Mr. Chairman, that 
highlight this very issue.
    Chairman CAMP. Without objection.
    Mr. TIBERI. The Mansfield Journal reported on Monday that 
only six of the Obamacare exchange plans in Richland County 
include the only hospital in the county, MedCentral, in-
network. The Marion Star reported on Monday only 6 of the 26 
Obamacare plans in Marion County have Marion General Hospital, 
again, the only hospital in Marion County, in-network. And, 
finally, the Newark Advocate reported only 6 of the 26 
Obamacare exchange plans in Licking County consider the only 
hospital in Licking County, Licking Memorial, to be in-network.
    That means that three-quarters of the exchange insurance 
plans in these counties don't give access to county residents 
to the only hospital and hundreds of doctors in-network. And 
because many of my constituents now are facing the choice of 
being in-network and having to travel out of the county maybe 
100 miles to a hospital and are now losing doctors that they 
had--and these were people who had insurance and now have been 
forced to go into the exchanges. And in the county in which 
they reside, they can't even go to their hospital. This is a 
problem just beginning.
    We spoke to a lady in the office yesterday, a central 
Ohioan, who wanted me to give you her name. Her name is 
Colleen. She had health care; now she is one of the 4 million 
in the exchange. And she has a plan that she is paying more 
for, that she doesn't like, with which she actually lost her 
doctor. She liked what she had, she couldn't keep it, and now 
she can't even keep the doctor that she had.
    So the articles aren't misinformation or disinformation. 
The union report--not supportive of Republicans, by the way--is 
not disinformation. And yet there seems to be a disinformation 
campaign within the Administration that this is all just make-
believe.
    Madam Secretary, please help us reassure our constituents 
that the Administration is going to deal with the reality that 
is hitting the ground, and that is people are losing their 
doctor and now they are losing their hospital.
    Chairman CAMP. All right. Thank you.
    Mr. Schock.
    Mr. SCHOCK. Thank you, Mr. Chairman.
    Welcome, Madam Secretary.
    Yesterday, the House of Representatives passed a bill 
dealing with the Affordable Care Act that clarifies the 
religious exemption clause for a small segment of the 
population who, on their annual tax return, will have to 
basically verify that their religious conscience prohibits them 
from participating in traditional health care here in our 
country.
    This is modeled after a law that the State of Massachusetts 
put into effect. In the State of Massachusetts, since 2006, 
only 6,000 residents have taken advantage of it, primarily 
Christian Scientists and others.
    The bill passed out of the House yesterday unanimously. It 
is now headed to the Senate, where it enjoys bipartisan 
support--Senators Ayotte, Schatz, Durbin, Bernie Sanders.
    And I am just wondering if you could speak to whether or 
not you support this clarification in the religious exemption 
clause?
    Secretary SEBELIUS. Congressman, I haven't read the 
language, but I will take a strong look at it. And I do know 
that it passed yesterday, but I haven't read the bill.
    Mr. SCHOCK. Will you get back to us with your opinion on 
it?
    Secretary SEBELIUS. Sure.
    Mr. SCHOCK. Okay. Thank you.
    My second question has to do with the Administration's 
change in, or HHS's change in how you are handling the appeals 
process for Medicare providers. The Office of Medicare Hearings 
and Appeals has recently taken the unprecedented and unorthodox 
step in no longer accepting Medicare appeals for processing at 
the administrative law judge level.
    Obviously, I am concerned about the current healthcare 
providers and current seniors who could be denied 
reimbursement, what effect that will have downstream, if you 
will, if they are not allowed their due process.
    And then, of course, if we fast-forward into the 
implementation of the Affordable Care Act, if we set the 
precedent that HHS says we are not going to allow due process 
for current Medicare recipients, one would then assume perhaps 
that would be a practice that the agency would do for folks on 
the ACA.
    Are you working through that? Do you see the Administration 
standing firm in not allowing due process on the appeals?
    Secretary SEBELIUS. Congressman, this is a major problem 
and issue. And I know that our head of the Office of Medicare 
Appeals has been here on the Hill briefing, in a bipartisan 
nature, both the House and the Senate just on what has happened 
over the last couple of years.
    It is my understanding--and I don't want to misspeak, but I 
will tell you what my understanding is, and if it is incorrect, 
I will correct it immediately--that their initial decision to 
suspend hearings was not for beneficiaries but for hospitals 
and providers. So they were very concerned that beneficiaries 
not get caught in this----
    Mr. SCHOCK. Right.
    Secretary SEBELIUS [continuing]. Huge queue and go to the 
back of the line.
    In the meantime, they are looking at the whole array of 
systems which could alleviate the queue. The volume has about 
tripled over the last couple of years. We need to do some 
system changes. We need to work carefully with Congress. 
Because the last thing we want to do is have anybody give up 
their due process rights.
    Chairman CAMP. All right. Thank you.
    Mr. SCHOCK. Thank you.
    Chairman CAMP. Mr. Rangel.
    Mr. RANGEL. Thank you.
    Madam Secretary, I am convinced that when the final pages 
of history are written, that your name will be included among 
the courageous pioneers that have brought health care to all 
Americans.
    There seems to be some concern about the delay in the 
program. Do you recall when last we had a program for the 
Nation where all people would have access to health care?
    Secretary SEBELIUS. No, sir.
    Mr. RANGEL. So that is since the beginning of the Republic?
    Secretary SEBELIUS. Yes.
    Mr. RANGEL. And so this is the first time.
    When we had Social Security, were there delays and 
legislation necessary to improve it?
    Secretary SEBELIUS. Well, I would say both Social Security 
and Medicare certainly has transformed over time since they 
have been in place.
    Mr. RANGEL. So I understand that the enrollments are going 
up and that people young and old are applying?
    Secretary SEBELIUS. That is correct. We put out information 
yesterday that, as of the end of February, about 4.2 million 
people had enrolled in the private market, another almost 9 
million have qualified to be Medicaid-eligible, and 3 million 
young adults got their coverage earlier in the program thanks 
to their parents' plan.
    Mr. RANGEL. And that is young and healthier people, to 
bring the balance that we need.
    Secretary SEBELIUS. Yes, sir.
    Mr. RANGEL. Is there any indication that they are all 
Democrats?
    Secretary SEBELIUS. We don't have that information 
currently.
    Mr. RANGEL. Well, is there any reason to believe that 
Republicans are not in need of health insurance or they don't 
have preconditions or that they all are insured? Is there any 
evidence that Republicans will not receive the benefits of the 
Affordable Care Act?
    Secretary SEBELIUS. No, sir.
    Mr. RANGEL. Well, in the 50 attempts to derail or to repeal 
the Affordable Care Act, which has passed the House, the 
Senate, and has been approved by the Supreme Court, is there 
any indication from the President if, by some stretch of our 
imagination, the repeal goes through the Senate as to what the 
President would be inclined to do?
    Secretary SEBELIUS. I think he has indicated he would veto 
a repeal of the Act.
    Mr. RANGEL. And so, has there been any suggestions, then, 
from the Republican leadership, since this is the law of the 
land and is universal and bipartisan as it relates to the 
beneficiary, have there been any suggestions from the 
Republicans as to how we can improve upon this bill--that is, 
the provision to provide health care for everyone? Have they 
suggested to you anything that makes sense?
    Secretary SEBELIUS. Well, there have been a number of 
conversations, and I would say some productive conversations. 
Unfortunately, I think the suggestions of how to improve are 
often tied to suggestions of----
    Mr. RANGEL. Well, Madam Secretary----
    Secretary SEBELIUS [continuing]. How to repeal.
    Chairman CAMP. All right. Time has expired. And I would 
just say----
    Mr. RANGEL. Oh, that is terrible----
    Chairman CAMP [continuing]. There have been suggestions----
    Mr. RANGEL [continuing]. Because I wanted to congratulate 
the Chair, and I will insist on congratulating him, as being a 
part of that Republican Party that has tried to be constructive 
on legislation. And I thank you----
    Chairman CAMP. Well, thank you.
    Mr. RANGEL [continuing]. For your courtesy.
    Chairman CAMP. There is always time for that.
    We are just down to Mr. Levin and myself. And I just want 
to return to this issue about how many individuals have paid 
their first month's premiums. And I realize that you have 
repeatedly said under questioning that you don't have that 
information yet.
    But I just want to make the point that we are 2 weeks away 
from the end of the 6-month open enrollment. And, you know, I 
know there has been--you know, HHS has spent $2 billion 
building these exchanges. And your own budget document states, 
and I quote, ``CMS administers the insurance affordability 
programs on behalf of all marketplaces. This process involves 
receiving enrollment information from marketplaces, including 
the level of APTC selected to calculate and distribute monthly 
aggregate payments to issuers for APTC and CSR owed.''
    But given all the time and the critical need that your own 
department has for this basic information, I think it is just 
absolutely critical that we find a way to get this information.
    And there are reports that up to 20 percent of individuals 
who have selected plans have not actually paid their premiums. 
And I don't know if this is in line with what you are seeing. 
Do you have any information along that line about, is the 20 
percent in line with what you have been finding out?
    Secretary SEBELIUS. I think, again, Mr. Chairman, the 20-
percent number came from insurance companies, if I recall, 
about the first of the year, where they were heartened by the 
fact that, even though the deadline for payment of the first 
month's premium--and many people, if you will, enrolled for the 
first time in December, and we have had, kind of, 3 months of 
strong enrollment--they were heartened by the fact that they 
had about an 80-percent payment rate.
    But, again, that did not come from us. We will eventually, 
when the fully automated financial system is in place, have 
that information and be glad to share it with the Committee on 
a real-time basis. We just don't have it right now.
    Chairman CAMP. Well, and I think there is such an interest 
in this for one reason, that we know that at least one and--
that you have made at least one, and you are about to make the 
second payment to insurers for the premium tax credits and 
cost-sharing subsidies.
    Secretary SEBELIUS. Yes, sir.
    Chairman CAMP. And so these payments reflect what insurers 
are telling you about how many people have paid their premiums.
    Secretary SEBELIUS. They are an aggregate number based on 
only those customers who would be qualified for either cost-
sharing or APTC. And that is not at all the entire look of the 
marketplace.
    So we don't even have any information at this point, even 
in aggregate. We don't have individual information about the 
group that is premium tax credit. And the insurance companies, 
to get paid month two, just restated the first month, as an 
indication that they did not have the full information.
    So we are getting aggregate data about a portion of the 
marketplace and not individual data about customers.
    Chairman CAMP. Well, unless they have paid their first 
month's premium, they can't get a premium tax credit.
    Secretary SEBELIUS. That is correct.
    Chairman CAMP. And so, obviously, that is in the 
jurisdiction of this Committee. We are very interested to make 
sure that that is being used. And my----
    Secretary SEBELIUS. And we are, too. And we will be trueing 
up with insurance companies a person at a time. We just don't 
have that at this particular point.
    Chairman CAMP. Have you asked the insurers for this 
information?
    Secretary SEBELIUS. We have. We are working, Mr. Chairman, 
on the automated system, which, at the end of the day, the 834, 
which is the process by which we send to the insurance company 
from the website Chairman Camp's name and that he wants to 
enroll in Blue Cross of Michigan, and there will be a process 
where they will send back the confirmed 834 that Chairman Camp 
paid his premium, and that will be the end of the loop. 
Currently, that part of the process is not in place.
    Chairman CAMP. Is there a coordination between the agencies 
on this? Because, obviously, some of this is administered 
between IRS and Treasury. Are you coordinating? I know in 
answer to some other questions you mentioned that some of this 
is involving more than one agency. So are IRS and Treasury----
    Secretary SEBELIUS. Well, as in most bills, Treasury 
basically pays the bills. And they pay them based on a system 
of our presenting them with information, much the way Medicare 
bills are paid.
    Chairman CAMP. All right.
    Mr. Levin, and then we will conclude.
    Mr. LEVIN. Thank you.
    Well, welcome.
    I just want to ask that there be entered into the record, 
Mr. Chairman, three documents relating to the Medicare 
Advantage rates: one from the Secretary to the Speaker, one an 
article from the New York Times, and one a letter from 
beneficiary groups.
    Chairman CAMP. Without objection, they will be entered into 
the record.
    Mr. LEVIN. And I also ask that the CBO table on 4015 that 
will be coming up in the next couple days, with your amendment, 
showing that about 13 million people more would be uninsured, I 
ask that be entered into the record also.
    Chairman CAMP. Without objection, as well.
    Mr. LEVIN. Thank you.
    Chairman CAMP. Well, with that, again, I thank you for your 
time this morning and----
    Secretary SEBELIUS. Yes, sir.
    Chairman CAMP [continuing]. Appreciate that.
    With that, this hearing is now adjourned.
    [Whereupon, at 12:25 p.m., the Committee was adjourned.]
    [Submissions for the Record follow:]
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