[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
EXAMINING THE FISCAL YEAR 2016 HHS BUDGET
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
FEBRUARY 26, 2015
__________
Serial No. 114-13
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
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COMMITTEE ON ENERGY AND COMMERCE
FRED UPTON, Michigan
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Chairman Emeritus Ranking Member
ED WHITFIELD, Kentucky BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
JOSEPH R. PITTS, Pennsylvania ELIOT L. ENGEL, New York
GREG WALDEN, Oregon GENE GREEN, Texas
TIM MURPHY, Pennsylvania DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee MICHAEL F. DOYLE, Pennsylvania
Vice Chairman JANICE D. SCHAKOWSKY, Illinois
STEVE SCALISE, Louisiana G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington KATHY CASTOR, Florida
GREGG HARPER, Mississippi JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey JERRY McNERNEY, California
BRETT GUTHRIE, Kentucky PETER WELCH, Vermont
PETE OLSON, Texas BEN RAY LUJAN, New Mexico
DAVID B. McKINLEY, West Virginia PAUL TONKO, New York
MIKE POMPEO, Kansas JOHN A. YARMUTH, Kentucky
ADAM KINZINGER, Illinois YVETTE D. CLARKE, New York
H. MORGAN GRIFFITH, Virginia DAVID LOEBSACK, Iowa
GUS M. BILIRAKIS, Florida KURT SCHRADER, Oregon
BILL JOHNSON, Ohio JOSEPH P. KENNEDY, III,
BILLY LONG, Missouri Massachusetts
RENEE L. ELLMERS, North Carolina TONY CARDENAS, California
LARRY BUCSHON, Indiana
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota
Subcommittee on Health
JOSEPH R. PITTS, Pennsylvania
Chairman
BRETT GUTHRIE, Kentucky GENE GREEN, Texas
Vice Chairman Ranking Member
ED WHITFIELD, Kentucky ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois LOIS CAPPS, California
TIM MURPHY, Pennsylvania JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey DORIS O. MATSUI, California
H. MORGAN GRIFFITH, Virginia BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida KURT SCHRADER, Oregon
BILLY LONG, Missouri JOSEPH P. KENNEDY, III,
RENEE L. ELLMERS, North Carolina Massachusetts
LARRY BUCSHON, Indiana TONY CARDENAS, California
SUSAN W. BROOKS, Indiana FRANK PALLONE, Jr., New Jersey (ex
CHRIS COLLINS, New York officio)
JOE BARTON, Texas
FRED UPTON, Michigan (ex officio)
C O N T E N T S
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Page
Hon. Joseph R. Pitts, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement........................................... 3
Hon. Gene Green, a Representative in Congress from the State of
Texas, opening statement....................................... 4
Hon. Fred Upton, a Representative in Congress from the State of
Michigan, opening statement.................................... 6
Prepared statement........................................... 7
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 8
Witnesses
Sylvia Mathews Burwell, Secretary, Department of Health and Human
Services....................................................... 10
Prepared statement........................................... 12
Answers to submitted questions \1\
Submitted Material
Congressional Research Service memorandum, submitted by Mr.
Griffith....................................................... 81
Congressional Research Service report, \2\ submitted by Mr.
Griffith....................................................... 62
Statement of the American Academy of Actuaries, submitted by Mr.
Burgess........................................................ 91
Statement of nearly 60 patient groups............................ 94
Article entitled, ``How Medicaid for Children Partly Pays for
Itself,'' The New York Times, January 12, 2015, submitted by
Mr. Pallone.................................................... 97
Article entitled, ``Save the Children's Insurance: Hillary
Clinton and Bill Frist on Health Care for America's Kids,'' The
New York Times, February 12, 2015, submitted by Mr. Pallone.... 101
----------
\1\ Secretary Burwell did not respond to submitted questions by
the time of printing.
\2\ Available at: http://docs.house.gov/meetings/if/if14/
20150226/103028/hmtg-114-if14-20150226-sd008.pdf
EXAMINING THE FISCAL YEAR 2016 HHS BUDGET
----------
THURSDAY, FEBRUARY 26, 2015
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:03 a.m., in
room 2123 of the Rayburn House Office Building, Hon. Joe Pitts
(chairman of the subcommittee) presiding.
Members present: Representatives Pitts, Guthrie, Barton,
Whitfield, Shimkus, Murphy, Burgess, Lance, Griffith,
Bilirakis, Ellmers, Bucshon, Collins, Upton (ex officio),
Green, Engel, Capps, Schakowsky, Butterfield, Castor, Sarbanes,
Matsui, Lujan, Schrader, Kennedy, Cardenas, and Pallone (ex
officio).
Staff present: Clay Alspach, Chief Counsel, Health; Gary
Andres, Staff Director; Sean Bonyun, Communications Director;
Leighton Brown, Press Assistant; Noelle Clemente, Press
Secretary; Andy Duberstein, Deputy Press Secretary; Paul
Edattel, Professional Staff Member, Health; Robert Horne,
Professional Staff Member, Health; Charles Ingebretson, Chief
Counsel, Oversight and Investigations; Peter Kielty, Deputy
General Counsel; Carly McWilliams, Professional Staff Member,
Health; Emily Newman, Counsel, Oversight; Katie Novaria,
Professional Staff Member, Health; Tim Pataki, Professional
Staff Member; Michelle Rosenberg, GAO Detailee, Health; Krista
Rosenthall, Counsel to Chairman Emeritus; Adrianna Simonelli,
Legislative Clerk; Alan Slobodin, Deputy Chief Counsel,
Oversight; Heidi Stirrup, Health Policy Coordinator; Josh
Trent, Professional Staff Member, Health; Traci Vitek,
Detailee, HHS; Ziky Ababiya, Democratic Policy Analyst; Jeff
Carroll, Democratic Staff Director; Eric Flamm, Democratic FDA
Detailee; Hannah Green, Democratic Public Health Analyst;
Tiffany Guarascio, Democratic Deputy Staff Director and Chief
Health Advisor; Rachel Pryor, Democratic Health Policy Advisor;
Tim Robinson, Democratic Chief Counsel; and Arielle Woronoff,
Democratic Health Counsel.
OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Mr. Pitts. The subcommittee will come to order. Chair will
recognize himself for an opening statement.
I would like to thank Secretary Burwell for appearing
before the subcommittee to discuss the Administration's fiscal
year 2016 budget request for the Department of Health and Human
Services. Earlier this year, Madam Secretary, you stated that,
``The hallmark of effective leadership is instilling a culture
of transparency, ownership, and accountability.'' These are all
laudable goals, and I appreciate your verbal commitment to
these principles, however, your department's actions have
failed to adhere to the same standard. For example, we have
only heard silence from the White House on how the
Administration is preparing for an adverse ruling in King v.
Burwell. We did receive a reply from you, and I thank you for
that courtesy.
But your letter contained no substantive answers to our
questions. During your testimony to the Senate Finance
Committee you were again asked about the Administration's
plans, and again you repeatedly declined to provide a direct
answer. And this is not the transparency that we had hoped for.
Understandably, we were very frustrated with the Administration
witnesses artfully dodging the questions that we ask here. So I
am asking you today, please let your guard down a little, and
give us direct and complete answers to our questions.
In 2009 the President correctly said, ``The real problem
with our long term deficit actually has to do with our
entitlement obligations.'' Since then we have had the Simpson-
Bowles Commission, a super-committee, sequestration, and a
government shutdown, and never once in all this time did the
Administration propose a plan to get the Nation's fiscal house
in order by recommending reforms to entitlements. The 2014
Medicare Trustees' Report, which you signed, tells us that
Medicare will be bankrupt very soon. We recently had Senator
Joe Lieberman and former OMB Director Alice Rivlin here, and
they told us much the same. And we stand ready to do the hard
work of saving and strengthening Medicare, but we need a
willing partner.
Once again, the President's budget fails to propose serious
entitlement reform. The proposals in the budget related to
Medicaid amount to saving just 15 days' worth of program
spending over the next 10 years. The plan, apparently, is to
let Medicare expenditures continue to grow without any of the
structural reforms needed to strengthen and save this critical
program, and this is not taking ownership. If we are going to
save and strengthen our safety net programs for the most
vulnerable, we have to do better than the President's budget.
Both parties have to work together. You, we, the President need
to work together to save our entitlement programs, make them
sustainable, so we ask that you please work with us.
On another subject, you may also remember that in early
November of last year we spoke on the phone about why HHS has
so far failed to hold California accountable under Federal law.
As you know, on August 22, 2014 the California Department of
Managed Health care, DMHC, issued a directive mandating that
all plans under DMHC authority immediately include coverage for
all legal abortions. This is in direct violation of the Weldon
Amendment, a civil rights statute that prohibits Federal
taxpayer funding for Federal agencies and state or local
governments that discriminate because a health care entity does
not pay for or provide coverage of, or refer for abortions.
What California is doing is clearly illegal. It is also
morally wrong, and violates the fundamental principles of
freedom and conscience that our democracy is founded on, and it
is your job to stop them, and so for that hasn't happened. So I
will have more to say about this when we get to the questions.
In the meantime, Madam Secretary, we look forward to your
testimony. We hope that you will stay to answer all of our
questions. And, with only 5 minutes of questions per member, we
respectfully ask that you keep your answers concise and to the
point.
[The prepared statement of Mr. Pitts follows:]
Prepared statement of Hon. Joseph R. Pitts
The Subcommittee will come to order.
The Chair will recognize himself for an opening statement.
I would like to thank Secretary Burwell for appearing
before the Subcommittee to discuss the Administration's FY2016
budget request for the Department of Health and Human Services.
Earlier this year, Madam Secretary, you stated that ``the
hallmark of effective leadership is instilling a culture of
transparency, ownership, and accountability.''
These are all laudable goals and I appreciate your verbal
commitment to these principles. However, your Department's
actions have failed to adhere to the same standard.
For example, we have only heard silence from the White
House on how the Administration is preparing for an adverse
ruling in King v. Burwell.
We did receive a reply from you, and I thank you for that
courtesy. But your letter contained no substantive answers to
our questions.
During your testimony to the Senate Finance Committee, you
were again asked about the Administration's plans. Again, you
repeatedly declined to provide a direct answer.
This is not the transparency you promised. Understandably,
we are very frustrated with Administration witnesses artfully
dodging the questions we ask here. So I'm asking you: please
let your guard down a little today, and give us direct and
complete answers to our questions.
In 2009, the President correctly said, ``The real problem
with our long-term deficit actually has to do with our
entitlements obligations.''
Since then we have had the Simpson-Bowles Commission, a
Supercommittee, Sequestration, and a government shut down.
Never once in all this time did the Administration propose a
plan to get the nation's fiscal house in order by recommending
reforms to entitlements.
The 2014 Medicare Trustees Report, which you signed, tells
us that Medicare will be bankrupt very soon. We recently had
Senator Joe Lieberman and former OMB Director Alice Rivlin
here. They told us much the same. We stand ready to do the hard
work of saving Medicare, but we need a willing partner.
Once again, the President's budget fails to propose serious
entitlement reform. The proposals in the budget related to
Medicaid amount to saving just 15 days' worth of program
spending over the next ten years.
The plan, apparently, is to let Medicare expenditures
continue to grow without any of the structural reforms needed
to strengthen and save this critical program.
This is not taking ownership.
If we are going to save and strengthen our safety net
programs for the most vulnerable, we have to do better than the
President's budget. Both parties have to work together. You,
we, and the President need to work together to save our
entitlement programs and make them sustainable. Please work
with us.
On another subject, you may also remember that, in early
November of last year, we spoke on the phone about why HHS has
so far failed to hold California accountable under federal law.
As you know, on August 22, 2014, the California Department
for Managed Health Care (DMHC) issued a directive mandating
that all plans under DMHC authority immediately include
coverage for all legal abortions.
This is in direct violation of the Weldon Amendment, a
civil rights statute that prohibits federal taxpayer funding
for Federal agencies and state or local governments that
discriminate because a health care entity does not provide, pay
for, provide coverage of, or refer for abortions.
What California is doing is clearly illegal. It is also
morally wrong, and violates the fundamental principles of
freedom and conscience that our democracy is founded on. It is
your job to stop them, and so far that hasn't happened. I'll
have more to say about this when we get to questions.
In the meantime, Madam Secretary, we look forward to your
testimony. We hope that you will stay to answer all of our
questions, and, with only five minutes of questions per Member,
we respectfully ask that you keep your answers concise and to
the point.
Thank you, and I yield the remainder of my time to Rep. --
--------------------------------.
Mr. Pitts. And, Dr. Burgess, do you want the remaining
time?
Mr. Burgess. Thank you, Mr. Chairman, that is very kind of
you. And, Secretary, thank you for coming to our humble little
subcommittee. I am frustrated over the Administration's lack of
transparency, and the ability for Congress to get information
that, realistically, we have been asking for for the last 4 or
5 years, but specifically around ACA created entities, the
Center for Medicare and Medicaid Innovation, the Prevention and
Public Health Fund, the Consumer--the Office of Consumer
Information and Insurance Oversight, and the Patient Center for
Outcomes and Research Initiative. Year after year they have
failed to achieve their mission of reducing health care costs
and improving quality. We can't hold them accountable if we
don't know how you are spending the dollars. So you and I have
talked about this, and I do look forward to your responses and
being able to finally get that information regarding those
agencies under your----
Mr. Pitts. Chair thanks the gentleman. Now recognize the
Ranking Member, Mr. Green, 5 minutes for opening statement.
OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS
Mr. Green. Good morning, and thank you, Secretary Burwell,
for being here today to discuss the President's FY '16 budget
proposal for the Department of Health and Human Services. A
budget is more than a line of items on a page. It is a
reflection of the priorities of our country. Our commitment
must be to protect the progress that we made, and to make
strategic investments so that progress will continue in the
future.
This year marks the 50th anniversary of the creation of
Medicare and Medicaid. Since the Children's Health Insurance
Program was created to ensure America's children have
insurance, most recently Congress passed the Affordable Care
Act, dramatically expanding access to health coverage and high
quality care. The Affordable Care Act took historic--steps
toward laying the foundation for a better and more efficient
health care system, and expanding access to cover for millions
of Americans for whom it was previously out of reach. It also
took important steps to restore the fiscal solvency of our
health care system. According to the most recent estimates by
the Congressional Budget Office, the Affordable Care Act will
reduce the deficit by more than $100 billion for the first
decade, and by more than a trillion in the second decade.
As we have seen through the second enrollment period, the
Affordable Care Act has already succeeded in ensuring every
American can have access to high quality affordable coverage.
Thanks to the ACA, nearly 30 million Americans got covered.
These are people who would otherwise be uninsured. We have made
great progress, but the work is not done. I thank the agency
for implementing the landmark health reform law, and continuing
to work with us so that we can build on these successes.
In addition to prioritizing essential services and
programs, I was pleased to see that the budget makes strategic
investments to improve our health care system, and clear the
way for the progress into the future. This includes funding to
support training of the next generation of health care
providers, national preparedness against threats to public
health, biomedical research, drug safety, and mental health
services. The budget invests in community health centers to
support the care they provide for 22 million patients. In their
role of providing an accessible, reliable source of primary
care in underserved communities, health centers will continue
to be a critical element of our health system.
The President's proposal takes a critical important step by
including four years of funding for the Children's Health care
Insurance Program. Currently more than 10 million children get
health insurance through CHIP. Additional funding for CHIP must
be authorized so that there is no disruption in coverage, and
the states are able to continue operating their programs. The
budget proposes an increase in NIH funding. Since its creation,
NIH has fostered remarkable advancements in human health, but
for the past decade NIH has suffered inadequate funding.
Without significant funding increases, the U.S. will lose its
status as a global leader in science and innovation. Additional
resources will help defeat our Nation's most harmful diseases,
and ensure that the United States continues to lead biomedical
research and scientific breakthroughs.
The budget proposal strengthens national preparedness for
threats to public health, including naturally occurring
threats, and deliberate attacks. It also includes funding to
reinforce our Nation's ability to move quickly to detect
infectious disease outbreaks through new advanced molecular
detection initiative, maintaining strong expertise at the
Centers of Disease Control and Prevention. These are just a few
highlights of what is included in the proposed HHS budget. I
look forward to hearing more about the Administration's
proposal during today's hearing.
Thank you, Madam Secretary, for joining the committee to
discuss the HHS budget. And if someone would like about a
minute and 20 seconds? My colleague from California, Ms.
Matsui.
Ms. Matsui. Thank you very much for yielding the time, and
welcome, Secretary Burwell. I appreciate the goals the
President and you have laid forth in the fiscal budget 2016
Department of HHS Services Budget. Building on the improvements
made by the Affordable Care Act, we are seeking to move our
Nation's health system by rewarding volume, and forgetting
about the waste business. So--do this is working to achieve the
triple aim in health care, better care, better outcomes, and
reduced costs. We do this by making health insurance more
affordable, by emphasizing prevention and public health, by
encouraging scientific and clinical research, by taking
advantage of the benefits of technology, and building up our
Nation's mental health system.
Many of the proposals in the budget find savings in the
Medicare and Medicaid programs by streamlining processes and
realigning systems to ensure that patients get the right
service at the right time. The budget would make the SGR fix
permanent, which we need to do to provide stability for
doctors, and for seniors, and people with disabilities in the
Medicare program. The budget would also extend the Children's
Health Insurance Program, or CHIP, that provides much needed
pediatric coverage to our Nation's children.
To conclude, I want to emphasize the Affordable Care Act is
working. Over 11 million Americans signed up this year,
including 500,000 in California alone. The Administration just
announced that since the law was enacted in 2010, 9.4 million
people with Medicare have saved over $15 billion in
prescription drugs. This is what we set out to do, and I
appreciate working with you as we move forward. Thank you.
Yield back.
Mr. Pitts. Gentlelady yields back. Chair now recognizes
Chairman of the full Committee, Mr. Upton, for 5 minutes for an
opening statement.
OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MICHIGAN
Mr. Upton. Well, thank you, Mr. Chairman. Secretary
Burwell, welcome. Today marks your first official appearance
before the Health Subcommittee, but I know that this is not
your first time in this room, as you participated in one of our
21st Century Cures roundtables last year, and we very much
appreciate that participation.
Your testimony does come at a very pivotal point in health
policy, from our exciting cures effort, to next week's Supreme
Court oral arguments. We look forward to hearing the
Administration's perspective on the many important issues
facing the American people. You have said during your tenure at
HHS that transparency, ownership, and accountability are
important values for the Department of demonstrate, which we
certainly welcome.
In that spirit, we look forward to gaining straightforward
answers here today about implementation of the President's
health care law. There have been quite a few red flags raised
in recent weeks on the continued struggles to implement key
pieces of that health law. Just in the last week, 800,000
households learned that key tax forms sent out by the
Administration contained major errors. Those Americans were
asked to delay tax filing, therefore also delaying their
refunds. A recent analysis from H&R Block estimates that the
majority of Obamacare customers are being forced to pay back
some of those subsidies. Millions of Americans are also
learning about the law's IRS fines for failing to comply with
the individual mandate.
The backlash has been so intense that the Administration
has resorted to yet another special enrollment period to quell
some of the anger of those who are just coming to learn about
the individual mandate penalty. In this last week, the
healthcare.gov CEO, Kevin Counihan, suggested that the backend
functions of the exchange would undergo a 2-year development
plan. That means that this key part of the law will not be
fully complete until President Obama leaves the White House.
Collectively, these revelations suggest that the health
care law is still not working. Our constituents deserve better,
we know that. That is why I have worked on introducing the
Patient Care Act, a health care reform blueprint, with my
colleagues in the Senate, Chairman Hatch and Mr. Burr. I look
forward to working with my colleagues about these ideas to
improve health care in America by empowering states and
families, not Washington.
Yes, we have concerns with the President's signature law,
but there are other important health care areas that we believe
are fertile for collaboration. For the past year, almost year
and a half, this committee has undertaken the bipartisan 21st
Century Cures Initiative to accelerate the pace of the
discovery, development, and delivery of new treatments and
cures for American patients.
I would like to thank you for your personal engagement on
the 21st Century Cures Initiative. As you know, this is a top
priority for our committee this year. Patients and families in
my district in Michigan, as well as across the country are
looking for hope, and that is what we seek to instill. And this
effort is also important to many job creators, whether it be
Stryker, Perrigo, or Pfizer in southwest Michigan. I also want
to thank the staff throughout the administration, particularly
at the FDA and the NIH for their work, their time, and effort
to help us improve the ideas released by our committee at the
end of last month. We have established a very good foundation,
I think, for bipartisan success. And I will yield to other
Republican members on this side. Seeing none----
Mr. Pitts. Anyone seeking time?
Mr. Upton [continuing]. Yield back.
[The prepared statement of Mr. Upton follows:]
Prepared statement of Hon. Fred Upton
Secretary Burwell, welcome. Today marks your first official
appearance before the Health Subcommittee--but I know it isn't
your first time this room as you participated in one of our
21st Century Cures roundtables last year. Your testimony today
comes at a pivotal point in health policy, from our exciting
cures effort to next week's Supreme Court oral arguments. We
look forward to hearing the administration's perspective on the
many important issues facing the American people. You have said
that during your tenure at HHS, transparency, ownership, and
accountability are important values for the department to
demonstrate, which we welcome.
In that spirit, we look forward to gaining straightforward
answers here today about implementation of the president's
health care law. There have been quite a few red flags raised
in recent weeks on the continued struggles to implement key
pieces of the health law.
Just in the past week, 800,000 households learned that key
tax forms sent out by the administration contained major
errors. Those Americans were asked to delay tax filing,
therefore also delaying refunds. A recent analysis from H&R
Block estimates that the majority of Obamacare customers are
being forced to pay back some of their subsidies.
Millions of Americans are also now learning about the law's
IRS fines for failing to comply with the individual mandate.
The backlash has been so intense that the administration has
resorted to yet another ``special enrollment period'' to quell
some of the anger of those who are just coming to learn about
the individual mandate penalty.
And this week, the HealthCare,gov CEO Kevin Counihan
suggested that the back-end functions of the exchanges would
undergo a two-year development plan. That means this key part
of the law will not be fully complete until President Obama
leaves the White House.
Collectively, these revelations suggest that the health
care law is still not working. Our constituents deserve better.
That is why I have worked on introducing the Patient CARE Act,
a health care reform blueprint with my colleagues in the
Senate, Chairman Hatch, and Mr. Burr. I look forward to working
with my colleagues about these ideas to improve health care in
America by empowering states and families, not Washington.
Yes we have concerns with the president's signature law.
But there are other important health areas that we believe are
fertile for collaboration. For the past year, this committee
has undertaken the bipartisan 21st Century Cures initiative to
accelerate the pace of the discovery, development, and delivery
of new treatments and cures for American patients.
I would like to thank you for your personal engagement on
the 21st Century Cures initiative. As you know, this is a top
priority for our committee this year. Patients and families in
my district in Michigan and across the country are looking for
hope, and that's what we seek to instill. And this effort is
also important to many job creators as well, firms like
Stryker, Perrigo, and Pfizer in southwest Michigan. I would
also like to thank the staff throughout the administration,
particularly at the FDA and NIH, their time, work, and effort
to help us improve the ideas released by our committee at the
end of January. We have established a great foundation for
bipartisan success.
Mr. Pitts. The Chair thanks the gentleman, and now
recognizes the Ranking Member of the full Committee, Mr.
Pallone, 5 minutes for an opening statement.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Chairman Pitts, and welcome,
Secretary Burwell. Thank you for being with us today. Today we
are going to hear about the President's fiscal year 2016 Health
and Human Services budget proposal, and there are many
important provisions in the President's budget that we in
Congress must work to support. I was pleased to see that the
budget proposed a funding increase of $1 billion for the NIH,
investing in early stage basic research, is one of the most
promising ways that we can accelerate the discovery of new
treatments and cures. And support for NIH is critical to
building our economy as well. Every dollar of NIH funding
generates over $2 in local economic growth, yet we have let NIH
purchasing power decline by over 20 percent since 2003, and
that is why finding a way to significantly increase funding for
NIH will be my top priority, as the 21st Century Cures
Initiative continues.
I was also pleased to see that the budget fully funds a 4-
year extension of the Children Health Insurance Program, or
CHIP. We must act on this proposal immediately. With more than
\4/5\ of state legislatures adjourning the by the end of June,
lack of action and clarify from Congress will make budgeting
and planning virtually impossible. By every measure, CHIP has
become enormously successful, and always has had strong
bipartisan support, so extending CHIP funding should be the top
priority of this committee to ensure consistent coverage for
the millions of children who depend on this program. And I
think we can all agree that no child should be left worse off
because of the actions, or lack thereof, of Congress.
The budget also adopts the framework of the bipartisan,
bicameral SGR repeal and replace legislation that Congress
agreed to last year. I believe that because the Sustainable
Growth Rate is the result of a budget gimmick, and we already
spent $169 billion paying to fix the problem, that offsets,
especially those within our health programs, are not necessary.
And if we must include offsets, the war savings, which are
known as the Overseas Contingency Operation Funds, could be
used. I know some on the other side of the aisle don't share
this view. What I do hope is that we can agree that, first, SGR
should not be paid off of the backs of the beneficiaries.
Beneficiaries will already pay for their share of the cost of
SGR repeal through higher premiums, and half of all
beneficiaries live on less than $23,500.
And that is why some of the proposals in the President's
budget concern me. The President's budget proposes to further
increase Part B and Part D premiums, increase the Part B
deductible for new enrollees, and impose a new surcharge on the
Part B premium for beneficiaries with certain Medigap policies,
and also institutes a $100 copayment per home health episode.
And this increases out of pocket costs on beneficiaries, and I
think that we have seen enough of that. Beneficiaries may
forego necessary services, and, in result, use more high cost
acute care services, and such policies will disproportionately
affect lower and middle income beneficiaries who are not poor
enough for Medicaid, nor have access to employer sponsored
retiree health care. So I urge the President and my colleagues
to be extremely cautious when proposing cuts to Medicare, and
consider impacts on our seniors.
The last thing I wanted to mention is--well, first to
commend you, Secretary, for your agency's hard work
implementing the Affordable Care Act. Because of your efforts,
19 million uninsured Americans will be covered in this year,
2015. And I recognize the challenge your agency faces in
implementing this law with limited resources, however, despite
what I call Republican obstructionism, the Affordable Care Act
is working.
In sum, I think this is a sound budget, and I look forward
to hearing from you today. And I would yield the remainder of
my time to the gentlewoman from Florida, Ms. Castor.
Ms. Castor. Well, I thank the Ranking Member for yielding
time, and I welcome Secretary Burwell. We are very excited to
hear about the budget, the investments in medical research and
Children's Health Insurance, improvements in Medicare, and the
Centers for Disease Control. But I couldn't help but ask Mr.
Pallone for a minute to highlight the Florida enrollment
numbers under the ACA. It is remarkable. And I know you have
seen them, and we have talked about it. As of February 15, over
1.6 million Floridians have signed up for health insurance in
the federally facilitated marketplace. We are surprised. This
exceeded all of our expectations, to beat California and Texas,
especially in a state that had many fits and starts over
whether to assist our neighbors in signing up.
But I wanted to highlight a couple of stories. A 27-year-
old third year law student at the University of South Florida
got assistance from a navigator. His income is about $16,000 a
year in scholarships. He was able to find insurance for
approximately $10 per month, zero deductible. It is his second
year enrolling in the marketplace. He is very happy with his
coverage. There are stories like that again, and again, and
again, so I look forward to talking about it. Thank you.
Mr. Pitts. Gentlelady yields back. That concludes the oral
opening statements. As usual, all the written opening
statements of the members will be made a part of the record.
And so we will go now to Secretary Burwell. First of all, thank
you for appearing before us today, Madam Secretary. Your
written testimony will be made a part of the record. You will
be given 5 minutes to summarize your testimony, and we
certainly appreciate you being here this morning. And you are
recognized for 5 minutes for your summary.
STATEMENT OF THE HONORABLE SYLVIA MATHEWS BURWELL, SECRETARY,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Secretary Burwell. Thank you Chairman Pitts, Chairman
Upton, Ranking Member Pallone, and Ranking Member Green, and
members of the committee. I appreciate the invitation to be
here today. I want to thank you for the opportunity to discuss
the President's budget for the Department of Health and Human
Services.
I believe firmly that we all share common interests, and
therefore we have a number of opportunities for common ground,
from preventing and treating substance abuse, to advancing the
promise of precision medicine, to building an innovation
economy, and strengthening the American middle class. The
budget before you makes critical investments in health care,
science, innovation, and human services. It maintains our
responsible stewardship of the taxpayers' dollars. It
strengthens our work together with the Congress to prepare our
Nation for key challenges, both at home and abroad.
For HHS, it proposes $83.8 billion in discretionary budget
authority, and this is a $4.8 billion increase, which will
allow our department to deliver impact today, and lay a strong
foundation for tomorrow. It is a fiscally responsible budget,
which, in tandem with accompanying legislative proposals, would
save taxpayers a net estimated $250 billion over the next
decade. In addition, it is projected to continue slowing the
growth of Medicare. It could secure 423 billion in savings as
we build a smarter, healthier, better system.
In terms of providing all Americans with access to quality,
affordable health care, it builds upon our historic progress in
reducing the number of uninsured, and improving coverage for
families who already have insurance. We saw a recent example of
this progress with the about 11.4 million Americans who either
signed up or re-enrolled in this past open enrollment. It
extends CHIP for 4 years, it covers newly eligible adults in
the 28 states, plus D.C., which have expanded Medicaid, and it
improves access to health for Native Americans. To support
communities throughout the country, including underserved
communities, it invests $4.2 billion in health centers, and
$14.12 billion to bolster our Nation's health workforce. It is
more than 50,000 National Health Service Corps clinicians,
serving nearly 16 million patients in high need areas across
the country. With health center mandatory funding ending in
2016, we estimate that more than seven million Americans may
lose access to essential cost-effective primary care, and this
could approximately result in 40,000 jobs lost.
To advance our common interests in building a better,
smarter, healthier delivery system, the budget supports
improvements to the way care is delivered, providers are paid,
and information is distributed. On an issue for which there is
bipartisan agreement, it replaces Medicare's flawed sustainable
growth rate formula, and supports a long term policy solution
to fix the SGR. The Administration supports the type of
bipartisan, bicameral efforts that the Congress took last year.
To advance our shared vision for leading the world in
science and innovation, it increases funding for the NIH by a
billion dollars to advance biomedical and behavioral research.
In addition, it invests 250 million for the Precision Medicine
Initiative, an effort to focus on developing treatments,
diagnostics, and prevention strategies tailored to individual
genetic characteristics. To further our common interests in
providing Americans with the building blocks for success at
every stage of life, this budget outlines an ambitious plan to
make affordable quality child care available to every working
class--middle class family.
To keep Americans health, the budget strengthens our public
health infrastructure, with $975 million for domestic and
international preparedness, including critical funds to the
Global Health Security Agenda. The budget will support CDC's
critical infrastructure and cost-cutting research to facilitate
rapid response to public health emergencies, and other public
health threats, like the recent measles outbreak. It also
invests in behavioral health sciences, and substance use
prevention. Finally, as we look to leave our department
stronger, the budget invests in our shared priorities of
cracking down on waste, fraud, and abuse initiatives, and are
projected to yield $22 billion in gross savings for Medicare.
We are also addressing our Medicare appeals backlog with a
variety of approaches, and we are investing in cybersecurity.
As a close, I want to make one final point, and that is I
am personally committed to responding quickly and thoughtfully
to the concerns of Congress and members. Since I was confirmed,
I have made it the top priority of our department to respond
promptly and thoroughly, and work with you as we can. I also
just want to take one moment to thank the HHS employees for all
their work on Ebola, unaccompanied children, and all the other
issues. With that, I look forward to your questions. Thank you.
[The prepared statement of Secretary Burwell follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Pitts. Thank you, Madam Secretary. I will begin the
questioning, and recognize myself for 5 minutes for that
purpose.
Let me start with King v. Burwell. In a few short days, the
Supreme Court will be hearing oral arguments in the King v.
Burwell case that could have a major impact on Obamacare. In
January we sent you a letter, asking for any actions, analysis,
and/or contingency plans that HHS has undertaken to prepare if
the IRS rule is overturned. And while we received a letter from
you earlier this week, your response failed to actually answer
our question. The letter simply stated that you believed no
administrative action by HHS could reverse the effects of a
decision in favor of the Plaintiffs.
Madam Secretary, your statement of opinion in the letter
does not answer a simple question, so let me ask you the
question this way. Have you or senior Department officials
instructed counselors within HHS to prepare any potential
actions or approaches if the Supreme Court rules against the
IRS?
Secretary Burwell. Mr. Chairman, with regard to what is in
the letter, one of the things that I think is important to
reflect that is in the letter is the analysis of what would
happen. That is a part of the letter. And in terms of what
would happen--and I first should state that we believe that the
Court will decide in favor of the position we hold, which is we
believe that this law says that--people have traveled across
the country--people in Texas should have the same subsidies as
people in New York. It is an important starting point.
But with regard to what would happen, because I think that
is an important part of answering the question, first, what
would happen is, when those subsidies go away, 11.4 million
people, that was the number I gave you--as of January 30, when
we did our most recent analysis, 87 percent of the individuals
in the marketplace are eligible for subsidies. Those subsidies
are, on average, estimated to be $268 per individual, per
month. Those subsidies, number one, would go away.
Mr. Pitts. Yes.
Secretary Burwell. That would lead to a number----
Mr. Pitts. Madam Secretary, I understand that. I am asking
if you know of any plan to respond to approaches if the Supreme
Court rules against the IRS? Has the White House, has OMB, or
other Administration officials directed or asked you about any
approaches in response to King v. Burwell, or to work with the
Treasury Department on potential responses? That is my
question.
Secretary Burwell. So, in order to respond to the question,
Mr. Chairman, in order to think about the question of a plan,
one needs to, I think, analyze the problem, which is what I was
articulating, in terms of the three major things that would
occur if the Court decides with the Plaintiffs.
Mr. Pitts. Let me ask it a different way. I would like to
provide you some more information as to why we expect an answer
from you today. The Committee received recently specific
information from a source within your department about the
existence of an approximately 100-page document related to
potential actions HHS may take if the Supreme Court rules
against the Administration in King v. Burwell. Are you, or
senior staff at HHS, aware of this document?
Secretary Burwell. Mr. Chairman, this is a document I am
not aware of.
Mr. Pitts. OK.
Secretary Burwell. With regard to the question that you
have asked, as I said in the letter, we believe--and I think it
is very important to understand the damage, because it is
related to the answer. The damage comes in the number of
uninsured that would occur. Number two, it occurs in what
happens in the individual marketplace, where a group of less
health individuals come in, and that drives premiums up in that
marketplace. And, number three, the indigent care that occurs
from the uninsured, and what that means in both those states,
in terms of their economies, as well as what it means for
employer base. Those are the ramifications. With regard to
those things, which we believe are the damage, as I state in
the letter, we believe we do not have any administrative
actions, and, therefore, there is not----
Mr. Pitts. All right, let me go on to another issue. I, as
you know, as we discussed over the phone, am deeply concerned
about the lack of HHS action regarding California, and the DMHC
authority to immediately include coverage for abortion. And
this mandate, California mandate is a clear violation of the
Weldon Amendment, which provides civil rights protections, and
prohibits funding to government entities discriminating against
health care entities for following their conscience. Do you
agree that the Weldon Amendment prohibits funding for states
that mandate abortion coverage in insurance plans?
Secretary Burwell. We take the Weldon Amendment very
seriously. And since you spoke with me, Mr. Chairman, and we
received those letters, we have opened an investigation in the
Office of Civil Rights at HHS to investigate the concerns that
you and others have articulated. We take this seriously, and
are trying to move through that investigation as expeditiously
as possible.
Mr. Pitts. So since it is clear that California is in
violation of Federal law, can you project a date by which you
expect the violation to be stopped?
Secretary Burwell. With regard to the issue of the
investigation, Mr. Chairman, that is not something--I need to
let the investigation go, and I have asked the team to make
sure they do it as expeditiously as possible, but in order--
that I stay away from the investigation, in terms of my
interference in any way. I want to let them go forward, but I
have asked for due speed.
Mr. Pitts. OK. We will follow up. Thank you. Chair
recognizes the Ranking Member Green, 5 minutes for questions.
Mr. Green. Thank you, Mr. Chairman.
Madam Secretary, it has been almost 5 years since the
Affordable Care Act was passed, and have yet to see any
legislation introduced by my Republican colleagues to replace
the Affordable Care Act, even though we have had at least 56
votes on the House floor to repeal it. Given all this talk of
repealing the Affordable Care Act, are you aware of any request
for technical assistance from Republicans on legislation that
would replace the Affordable Care Act with a credible proposal
to provide comprehensive health coverage to millions of
Americans?
Secretary Burwell. I am not aware of those requests.
Mr. Green. Madam Secretary, over the last couple days we
have heard a lot about contingency plans. If the millions of
Americans who received financial help through the Affordable
Care Act would lose them, are you aware of any Republican
legislative proposals that would provide millions of Americans
with the financial assistance to help them with affordable
health care coverage?
Secretary Burwell. I am not aware.
Mr. Green. Secretary, I want to get your input on an issue
that I know you are concerned--I appreciate you addressing it
in your opening remarks, that myself, and a lot of members of
our committee--there is a funding cliff that is facing our
community health centers. Health centers serve nearly 22
million patients, and are projected to serve 28.6 million
patients in over 9,000 locations across the country in the
fiscal year of 2016. Because of the current patient
demographics and statutory mandate to locate in underserved
areas, or to serve underserved populations, health centers are
well positioned to provide health care service to millions of
newly insured Americans. They are particularly important in our
district, which is a federally designated underserved community
in Houston, Texas.
Secretary Burwell, I was pleased to see the President's
budget included a multi-year extension of mandatory funding for
health centers. As you know, the health centers patients face a
major loss of access in a few months if we don't act to prevent
the funding cliff caused by the expiration of the mandatory
funding at the end of the fiscal year. Can you speak about the
importance of community health centers within our health system
as we look at the issues of access, quality, and cost?
Secretary Burwell. We believe that they are a fundamental
underpinning, and not just in terms of health care in
communities, but they are also an important part of the
economics of communities, when you think about the fact that we
could lose up to 40,000 estimated jobs in terms of who we don't
extend. But as you think about the numbers, thinking that 1 in
15 Americans actually are served by these health centers, how
integral they are to providing primary care throughout the
country.
And so we think it is extremely important to continue that
so that we can--as we have reduced the number of uninsured, we
also want to make sure that those people are having care, and
those that had care before still have access to that care,
especially in our underserved communities across the country,
not all, but many of which are very rural.
Mr. Green. Can you comment on the impact that the funding
cuts would have on patients' access to care? Can you estimate
how many fewer people would be able to receive services at our
local health centers?
Secretary Burwell. Our estimates are that if we aren't able
to extend, that it could be up to seven million patients who
would no longer be able to have access to that care. We
estimate that perhaps over 2,000 of the centers would shut down
without that, and that--then there are the patients who would
not be served because people would have to scale back in a
number of the centers with reduced funding.
Mr. Green. In those 2,000 centers, do you know how many
jobs we lost?
Secretary Burwell. Approximately--the estimates are up to
40,000.
Mr. Green. OK. Thank you. The health centers are a crucial
part of our Nation's primary care infrastructure for 50 years,
and have long had truly bipartisan support. In the last year,
along with my colleagues on both sides, including
Representative Lance, support--reiterating our support for
health centers, and calling for a bipartisan solution, we had
250 co-signers, including 31 members of our committee. A
similar letter in the Senate gathered 60--gained 66 votes, and
more than 100 national organizations have called for a fix.
Consensus is something must be done, and we have to act as soon
as possible.
This issue is a top priority of mine, and I know a lot of
other members, literally, Republican and Democrat across the
country, who look forward to working with you and our
colleagues on the committee on a bipartisan basis to find a
solution to avert that funding cliff.
Mr. Chairman, I have 43 seconds left, and I would like to
yield for somebody for that 43 seconds on our side. Anybody
want about 30 seconds now? OK. Well, Mr. Chairman, I yield
back.
Mr. Pitts. Thank you. Chair now recognizes the Chairman of
the full Committee, Mr. Upton, 5 minutes for questions.
Mr. Upton. Thank you again, Mr. Chairman. Secretary
Burwell, there are a number of health care law implementation
issues that continue to trouble us. In the interest of time, I
would ask that you submit answers to the following questions in
writing within 2 weeks.
The CEO of healthcare.gov recently stated that there is a 2
year development plan for the backend of the healthcare.gov. If
you could provide us an estimate of when the backend will
finally be fully automated, would be great. Second one is HHS
recently announced that 800,000 Americans enrolled in coverage
through healthcare.gov received inaccurate tax forms under the
ACA. We would like a detailed assessment on when the Department
expects these taxpayers will have accurate information in hand
so that they can file their taxes. And third, many Americans
were automatically re-enrolled in exchange plans, raising
concerns that individuals and families may be getting
unexpected premium bills, or inaccurate exchange subsidies in
2015. We would ask that you submit specific data on the number
of Americans who have been automatically re-enrolled in those
exchange plans. So that would be helpful.
Now I will return to 21st Century Cures, and again,
appreciate your personal assistance with this. And I, for the
record, want to certainly thank Dr. Collins, Commissioner
Hamburg, Dr. Woodcock, and Dr. Shuren, countless others at your
department for the help on 21st Century Cures. Because of that
participation, and participation of folks from across the
country, we have been able to learn more about the status of
innovation in this country, and we hear about ways to
accelerate the discovery, development, delivery of cures and
treatments for patients.
As we heard at our first roundtable, there are over 10,000
diseases, and we have only cures and treatments for about 500,
so we have a great deal of work ahead to do. We released a
discussion document last month, and have been working with
Congresswoman DeGette, Ranking Member Pallone, Mr. Green, other
members of our Committee, and on both sides of the aisle to
improve that document. One area that includes a placeholder is
precision medicine, something the President talked about in the
State of the Union Address, and subsequently a White House
event a couple weeks ago. We did put that placeholder into the
draft, and we look forward to continuing to work with you, and
the White House, the Administration, on that important issue.
Could you give us a background on the Administration's
precision medicine policy, and what we should look forward to?
Secretary Burwell. Thank you, and thank you for the
partnership, as we work through these issues together, and it
is exciting to have the energy around these issues, including
the precision medicine, which is, I think, a subset of the
broader issues you are looking at. Our precision medicine
initiative is $215 million, with regard to--as we think about
it from a budget perspective.
But I think thinking about it from the pieces and what it
is doing, one part of the initiative is creating a very large
database of a million people through NIH, but we will access
that through other channels, so that we are drawing from
existing databases to get the information we need, because, as
we are talking about what this is, precision medicine, or
personalized medicine, is getting the information so that we
can do treatments that are to the individual.
I was at NIH recently, had the opportunity to both see the
tumors and meet the cancer patient of a kidney cancer patient,
where he had a group of tumors removed. They came back, but
then, using precision medicine, which meant looking
specifically at the genetic makeup of his tumors--be treated in
a different way. I met him. That happened months ago, and now
he--the patient was there, discussing it with me, and is a very
different place. So, one, that large database. Two,
specifically focusing in the area of cancer, because we already
are seeing some progress there, and we believe that place is
right for it.
The other thing we need to do is FDA. Make sure that, as we
think about precision medicine, we regulate, and think about
how to improve these things in ways of a different type of
medicine. And then finally, we need the health records, the
Office of National Coordinator for Health--Electronic Health
Records to be a part of making sure this will do with payments,
and how clinicians will use. Those are the elements.
Mr. Upton. Well, I just want to say, that is very helpful,
and we are excited as well. And though I have been out to the
NIH a number of times in the past number of years, I want to
remind members here that we have got a committee trip--I have
invited, I think, all the members on this subcommittee to go
out to the NIH next Monday morning. Dr. Collins has been very
interested in having us out to kick the tires, like you saw
yourself.
And I know that, because we have votes tomorrow, Friday,
and again on Monday, and perhaps over the weekend, there may be
more of us here over the weekend than originally thought. So I
want to remind members that they are invited to join with us
and not miss votes come Monday on a trip there, and I yield
back. Thank you very much.
Mr. Pitts. Chair thanks the gentlemen. Now recognize the
Ranking Member of the full Committee, Mr. Pallone, 5 minutes
for questions.
Mr. Pallone. Hello, Secretary Burwell. I am sure you can
sense that I am very proud of the Affordable Care Act, and
concerned about Republican efforts to repeal it, or now take it
to court, in the case of King vs. Burwell.
Are you aware of any Republican bill that would reduce the
number of uninsured in this country by 11 million people--I
said 11, it is actually 19 million people, the way that the
Affordable Care Act does? I mean, obviously I am saying this
because I don't see them coming up with any alternative.
Secretary Burwell. You know, we haven't, and I think it is
important to reflect, historically, when one looks at the
history, and actually I have gone back to Teddy Roosevelt, and
the quotations from Teddy Roosevelt forward, through both
Republican and Democratic administrations, we see--whether it
was President Bush, President Nixon, President--Republican and
Democrat, President Clinton, the conversation about how we make
this next step forward, with regard to reducing uninsured, is
something that we struggled with as a Nation.
And this is the first time, and someone reflected on the
anniversary of Medicare, and that 50 year anniversary, this is
the first time that we have seen that. And so the plan that we
have in place, the implementation of the Affordable Care Act,
has done that. But we have not seen any alternatives.
Mr. Pallone. All right. Let me ask you about CHIP. All the
Democrats on the Committee recently introduced a bill to extend
the CHIP program, and I want to emphasize again that we have to
act on this legislation immediately, when we consider SGR,
which expires at the end of March. While funding may not expire
until the end of September for CHIP, in fact, 20 states will
finish their legislative sessions by the end of April, and more
than half by June 1, so it is clear that Congress needs to act
swiftly to ensure states can budget appropriately for CHIP, and
avoid any disruption in children's coverage. So, given the
bipartisan history of this program, I see no reason why
Congress can't act very soon.
Can you comment on the impact on states if the CHIP funding
isn't extended soon?
Secretary Burwell. I would comment on that from two
different perspectives, one as former director of OMB, and the
issues of predictability of funding, and the issues of
management, and ability to manage. And so, for the states to be
able to do that, this is something that is important. When we
have had predictability in our own budget system, we have seen
the benefits of that economically throughout the past years--2
years.
And the other thing I would say is, having just spent a lot
of time with the governors this weekend when they were in town,
this is a very important issue to them. We have seen that
letter that 40 governors have signed with regard to knowing
that they have that predictability of a program that is
providing great benefits to the children in their states.
Mr. Pallone. Now, the Senate and House Republicans have
released a CHIP proposal this week, however, this proposal
would institute a 12-month waiting period, needlessly forces
low income children off of Medicaid and onto CHIP, and reduces
or completely discontinues coverage for children above 250
percent of the Federal poverty level, despite the choice of 28
states around our Nation to cover those kids. Can you discuss
the impact of policies like this on some of our most vulnerable
children?
Secretary Burwell. So we think that the CHIP program is a
program--bipartisan program, and a program that is working a
delivering results, in terms of that quality health care for
those children, and has worked. We believe, that is in our
budget, a 4-year extension of the program, is a very important
thing, and that we need to do that in a timely fashion to both
make sure those children are covered, and receive the care that
they need, but also, in addition, to have that predictability
for states, especially those states that are in their
legislative process right now.
Mr. Pallone. And I know you mentioned the 4-year extension.
The budget includes a 4-year extension of the CHIP program. Can
you talk about why that full extension of 4 years is so
critical for the kids that depend on this health coverage? And
maybe also mention, as part of the extension, the budget
includes a permanent extension of express lane eligibility. If
you would talk about the success of express lane eligibility as
an option for states?
Secretary Burwell. So the express lane eligibility, and
those issues, we--folks ask us to try and figure out ways to
simplify, to make things easier, and that is making things
easier in two ways. When we hear from folks, it is about both
the customer, in terms of when they came in, as well as the
states. And we believe this is a program that has been
successful in getting to that simplicity, and the simplicity
often can work to create either A, better quality, or B, lower
costs, and so we think that is important--4 years, we believe
that is a good amount of time, and the right amount of time for
us to do this extension. There will be interaction with the
Affordable Care Act, we know that, and we believe that the 4-
year period is the right period for us to understand and look
at that.
Mr. Pallone. Thank you. Mr. Chairman, I would like to
submit for the record two CHIP articles. The first is an op-ed
published in the New York Times this month by former Secretary
Hilary Clinton, and former Senator Bill Frist, discussing the
long term bipartisan history of the program, and the importance
of a 4-year extension. And the second article was published in
the New York Times last month, shows how health coverage for
children pays for itself, and all the research showing that
when children have health coverage, future earnings are
boosted. If I could----
Mr. Pitts. Without objection----
Mr. Pallone. Thank you, Mr.----
Mr. Pitts [continuing]. Ordered.
Mr. Pallone [continuing]. Chairman.
Mr. Pitts. The gentleman yields back. Chair now recognizes
the Chair Emeritus of the full Committee, Mr. Barton, 5 minutes
for questions.
Mr. Barton. Thank you, Mr. Chairman. Thank you, Secretary,
for being here. As I have talked to you before, there are lots
of problems that we have to deal with, you in your position,
and the Committee in our position. But there are some
opportunities for bipartisanship, and one of them is a piece of
legislation that we call the Ace Kids Act. The original co-
sponsors are Ms. Castor of Florida, I think Ms. Eshoo of
California, Mr. Green of Texas, myself, on the Republican side,
along with several other members of this committee on the
majority side.
You said in your opening statement that Medicaid is going
to be about $345 billion this year, an increase, I believe, of
over 16 billion. Well, there is one piece of legislation we
could pass on a bipartisan basis that would actually save money
in Medicaid, and that is the Ace Kids Act. It creates a home
for families that have medically complex children, based on an
anchor hospital concept with the major children's hospitals in
America. I think there are about 60 of them. So if a parent has
a child that is medically complex, and qualifies for the
program, that child gets access to the network on kind of a one
stop shop. All the specialties, all the various procedures are
provided, and Medicaid is billed on time. We think there are
about 12 million children that would qualify for the program,
and we believe that it will save billions of dollars over a 10
year period.
It has been introduced in the Senate, the identical bill,
with three Republican co-sponsors, three Democrat co-sponsors.
So here is a rare piece of legislation that both sides of the
aisle support. The Republican leadership supports it. Chairman
Upton supports it. Chairman Pitts supports it. Does your
department have a position on the bill, and if so, could you
explain to the Committee what that position is?
Secretary Burwell. So with regard to the specific
legislation, I don't think we, as an administration, have
issued--but what I would say is all of the concepts, we agree,
and we welcome the opportunity. The idea that we can improve
both quality and cost for these children, who are very complex,
and who are moving state to state, and the current system
doesn't afford us the opportunity, both with regard to making
sure we don't have duplicative payments, we obviously do not
want that, fiscal responsibility, and we want that ease that
the parent can have the child at the right place with the right
care, even if it is across state lines.
So I would just say we look forward to working with you,
welcome the opportunity, if there are questions and ways that
we can provide technical assistance and other things as part of
this, we welcome that opportunity, because we agree with the
fundamental of what we are trying to do here, and believe this
is something that could improve both cost and quality.
Mr. Barton. Well, I would encourage you and your department
to take a look at the bill. It is not illegal or immoral for
the Administration to issue a letter of support, and this is
one that I think, with Chairman Upton and Chairman Pitts, and
the Ranking Member in the full Committee and Subcommittee, and
leadership on both sides of the aisle of the House said this
bill could go. It could be a part of Chairman Upton's 21st
Century effort, or it could be a stand-alone bill.
I also, in the brief time I have, want to concur with what
Ranking Member Green said about community health centers. I
hope we can work together in a bipartisan fashion to find an
answer to keep those funded. I know there is a funding issue
this year that we need to address, and reauthorize the program.
I have a number of those health centers in my Congressional
district, and they are very helpful, providing indigent care.
And, finally, I wasn't going to ask this question, but I am
a little bit puzzled. When Chairman Pitts asked you the
question about this report that deals with planning in case----
Secretary Burwell. Yes.
Mr. Barton [continuing]. The health exchanges at the state
level under the Affordable Care Act are found to not be legal
the way they are currently funded, if there was a plan, and if
you had seen the plan, I take you at your word that you haven't
seen the plan, but don't you think it is prudent that there
should be a plan? I hope I don't have a primary opponent, I
hope I don't have a general election opponent, but I have a
plan in case I do. I know you hope that the Court upholds your
position, but shouldn't the Administration and your agency have
a plan in case it fails?
Secretary Burwell. Congressman, what we state in the
letter, and what we believe is, if the Court decides, which we
don't believe they will, but if the Court decides on behalf of
the Plaintiffs, if the Supreme Court of the United States says
that the subsidies are not available to the people of Texas, we
don't have an administrative action that we could take. So the
question of having a plan, we don't have an administrative
action that we believe can undo the damage.
And that is why, when I was answering the Chairman, I think
it is important to understand what the damage is, because then
it comes to the question of--we don't believe we have any
administrative----
Mr. Barton. So, my time has expired, but if the Court
strikes it down, the Administration is just going to hold up
your hands and say, we surrender?
Secretary Burwell. We believe the law as it stands is how
it should be implemented.
Mr. Barton. I understand.
Secretary Burwell. And with regard to--when the Supreme
Court speaks, if the Supreme Court speaks to this issue, we do
not believe that there is an administrative authority that we
have in our----
Mr. Barton. All right.
Secretary Burwell [continuing]. To undo it. And so that
is----
Mr. Barton. That is----
Secretary Burwell [continuing]. Something we don't believe
we have and----
Mr. Barton. That is puzzling but I accept that. Thank you,
Mr. Chairman, for your courtesy, and the minority, for letting
me have extra time.
Mr. Pitts. Chair thanks the gentleman, and now recognize
the gentleman from New York, Mr. Engel, 5 minutes for
questions.
Mr. Engel. Thank you very much, Mr. Chairman, and welcome,
Secretary Burwell. Let me piggyback on a backup plan. I was
part of this committee. I participated in months and months of
deliberations for the Affordable Health care Act. We had weeks
of markups, this committee did, and not once was there mention
of subsidies not being available to individuals in states that
did not set up their own exchanges. I have heard a lot of
complaints on the other side of the aisle about the law, but
never was this issue discussed until they lost at the Supreme
Court in 2012.
Some of my friends signed on to amicus briefs, and wasting
credible time forcing votes on the full repeal of the law, yet
they are upset that the Administration doesn't have a backup
plan, should the Supreme Court ruling threaten the availability
of subsidies for 8.6 million Americans. And I think it is
somewhat ironic that my Republican friends are demanding that
this Administration fix problems that they themselves created,
and have shown zero interest in fixing. Should Republicans get
what they want, and the Supreme Court rules in favor of King, I
would urge my colleagues, if that should happen, to pass
legislation to ensure that Americans have continued access to
affordable coverage through the Federally facilitated exchange,
just as Democrats intended.
Next month the Affordable Care Act will have been the law
of the land for 5 years. It is not a perfect law, and there are
issues that need to be changed with it, but I would like to see
those issues addressed. And let us both of us, in a bipartisan
way, turn our focus on improving the law, and enabling more
quality coverage options for our constituents, instead of
trying to kill it, repeal it, take it to court, and things like
that. So I just wanted to say that I am sure that you agree
with what I just said.
Secretary Burwell. Yes. We look forward to moving forward,
and we do want to make improvements as we can.
Mr. Engel. Thank you. And I want to use my home State of
New York as a great example of what is possible when the
Federal Government has a willing and enthusiastic partner in
the Affordable Health care implementation. As a result of our
successful exchange and Medicaid expansion, more than 2.1
million New Yorkers have quality health care coverage. Our
state's uninsured rate has dropped to only 10 percent. And
there is clear evidence we are reaching the right people too,
since 88 percent of people who obtained coverage through the
exchange reported being uninsured at the time they enrolled, so
it is really working in New York. And the health insurance
options available through New York State of Health are on
average 50 percent cheaper than the comparable coverage
available before the exchange was established.
So I want you to know, I am sure you know it, that the ACA
is working, and working well in New York, and that is why I
really think it is terrible that I have been forced to take
more than 50 votes to repeal some or all of this law. We should
fix what is wrong. But in my state, it has really been a
tremendous success.
Secretary Burwell. And, fortunately, I have had the
opportunity to travel the country and see the individuals,
those are the numbers, and the individuals, and whether it is
Laura in Florida, 26 years old, married to someone who is a
truck driver, who does not have coverage. She is training to be
an X-ray tech, they have two children. They did not have
insurance. She now has insurance with a premium of $41 a month.
Or a woman who had MS in the State of Texas, and for 17 years
she had not had health insurance. And so how people go about--
she treated her MS through the emergency room, and she has four
children, and she works. And so, when it would get bad enough,
that is what she would do. And so the stories of what it means
to people, in terms of their financial and health security, I
think are--the numbers are important, but it is those stories
which really make this real.
Mr. Engel. And Secretary Burwell, I understand that we have
seen robust exchange enrollment nationwide, even in states
where Republican governors refuse to set up a state exchange,
or expand their Medicaid programs. Isn't this true?
Secretary Burwell. So the numbers--and I spoke to this
yesterday, when we would been able to look at the numbers, 53
percent of the enrollees in the marketplace this year, in the
Federal marketplace, are new enrollments. And so I think that
is indicating that--the demand for the product, and the need
for the product.
Mr. Engel. Thank you. I want to second Mr. Pallone's
positive discussions about CHIP. I have always been a strong
supporter, and, as of July 2014, an estimated 476,000 children
were enrolled in this affordable coverage option for their care
in New York, and so I think that that is really, really
important. I was pleased, therefore, to see with the budget
proposal for fiscal year 2016 included funding for CHIP for the
next 4 years, through fiscal year 2019. So can you elaborate on
why you believe increasing tobacco taxes is a viable means for
funding this program while we sort out the transition issues
associated with the Affordable Care Act?
Secretary Burwell. We believe one of the things of trying
to be fiscally responsible, and indicating how we are paying
for things, we believe that this is a legitimate way to pay for
things, especially in the context of we are providing health
care, and something that will hopefully create a deterrent, and
help health care, in terms of the issue of a tobacco tax. As
one analyzes across the Department, and whether it is at CMS or
CDC, the impact that tobacco has on health in our Nation, and
the cost of health care in our Nation, is one that we think is
a fair place to go to pay for this care for the children.
Mr. Engel. I agree with you. And, finally, I want to talk
about graduate medical education, because I was concerned that
the Administration's proposal to cut enduring GME funding--one
in six physicians in America obtains training in my home State
of New York, and we have some of the finest academic medical
centers in the country. So you require significant funding and
time to develop the infrastructure and expertise necessary to
ensure quality care is available. So how do we ensure stability
for these academic medical centers, and the patients they
serve, if we put GME funding at risk?
Secretary Burwell. We believe and hope that our proposal
does not do that, and meets the objectives of making sure we
are training appropriate positions for both primary care and
specialties, where we don't have as many as we should, at the
same time, making sure we target it. There is $100 million for
pediatric, and then a wider pool for competition. It is an
issue that we want to meet the same objectives at the same time
we do it in a fiscally responsible way.
Mr. Engel. Thank you. Thank you, Mr. Chairman.
Mr. Pitts. Chair thanks the gentleman. Now recognize the
Vice Chairman of the Subcommittee, Mr. Guthrie, 5 minutes for
questions.
Mr. Guthrie. Thank you, Madam Secretary for coming, and I
really look forward to working on 21st Century Cures, and all
the things that we could work on over the next years as Vice
Chair.
But first I would like to direct your attention to the cost
share reduction program contained in the ACA, specifically
Sections 1402 and 1412. Does any part of this budget request,
or does any part of this budget that we are talking about today
request any new authority, including any transfer authority to
pay insurers under the cost share reduction program?
Secretary Burwell. With regard to the program, which, as a
program, as you know, is about making sure that the costs of
health care to this individuals that are coming into the
marketplace is something that they afford, that is what it is
about, and we believe that we do have the authorities to do the
cost sharing.
Mr. Guthrie. Is there any new authority requested in this
budget?
Secretary Burwell. No new language.
Mr. Guthrie. There is no new language? And so we do know it
is up and running. I think we spent $3 billion already on the
cost share reduction program, that are then paid to insurers
with taxpayer funds. The budget that is being submitted
estimates 11.2 billion over 2015-2016, and CBO says 175 billion
over the next 10 years is what they have estimated. And could
you cite where the appropriations authority is? You said you do
believe you have the--can you cite where that is?
Secretary Burwell. We do believe we do, and I am sure you
know that right now this is an issue that is under litigation,
and a court case that has been brought. And so, with regard to
that, that is an issue that I will let our colleagues at the
Justice Department speak to, because of the place it is in
litigation.
Mr. Guthrie. I understand that, but we are doing oversight
here. I am not an attorney, so--when you were at OMB in 2014,
there actually was a request in the 2014 budget for direct
appropriation, and that didn't happen, for whatever reason, but
we are spending money. So whether we spend a penny or 100--this
is $175 billion over 10 year program. We feel like we--this is
an oversight hearing, and so we feel like it is our
responsibility to make sure to our taxpayers that we have good
answers on where this is coming from. So we are just asking for
where the appropriation comes from authority.
Secretary Burwell. I understand and I appreciate the
question, and I am sorry that it is in litigation. I wish we
weren't in a place where we are in litigation, but once
something has entered into that place, it does create a
difficult circumstance. I respect the issue of oversight, but
because the litigation has been brought by the House----
Mr. Guthrie. Yes.
Secretary Burwell [continuing]. On this issue, we are in a
place where I think that is the appropriate place for this
conversation.
Mr. Guthrie. We are really--I am just not aware of any
pending litigation exception at oversight hearing questions,
and--is there, like, a legal case, or authority, or did the
Justice Department say you don't have to----
Secretary Burwell. With regard to issues that are being
litigated, generally those are matters that we refer, and let
the Justice Department continue on.
Mr. Guthrie. And--that we have never been able to get an
answer from the Administration for where the language--nobody
has even been able to point to us where that appropriation
language comes from. And it was--and you previously had
requested appropriation.
Let me ask you another question. You had recently said--you
received--I think 18 employer groups sent you a letter, urging
that small groups be maintained at 50 employees. And they were
citing an actuarial analysis that showed when they go to 50--to
51, actuarial analysis said that it would--estimated that \2/3\
of the members--so they would receive an increase, and--of 18
percent. And I just don't believe that these small employers,
50 to 100 employees, can accept an 18 percent increase in their
premiums. Also, the promise that if you like the plan, you can
keep it, because if the 50 to 100 have to go into the new plan,
they will have to meet the requirements of the health care law
that--essential benefits, and the other things that have caused
other people to lose the plans that they liked, that they could
keep.
And due to this impact, would you support allowing states
to keep their market at 50 or below, not go to the 51 to 100?
Secretary Burwell. This is an issue that we are looking at
and examining because we have a number of comments on it. And
what I would say is I would welcome the opportunity to see the
piece of work that you are talking about and referring to so
that we can see and understand that. I think what we want to do
is understand the facts around this type of thing, so I would
welcome the opportunity to see the study and piece of work that
you are articulating.
Mr. Guthrie. OK. My understanding, it has been submitted, a
letter from these 18 employers, but we will make sure that that
is----
Secretary Burwell. OK.
Mr. Guthrie. Well, thank you, Mr. Chairman. I yield back.
Mr. Pitts. Chair thanks the gentleman. Now recognize the
gentlelady from Illinois, Ms. Schakowsky, 5 minutes for
questions.
Ms. Schakowsky. Thank you, Mr. Chairman, and thank you,
Madam Secretary, for being here today. I wanted to ask you if
you are aware of any Republican legislative proposal that would
keep insurance companies from denying coverage from people with
pre-existing conditions, like cancer, or dropping someone from
coverage because they got in an accident, or got sick?
Secretary Burwell. I am not aware of a piece----
Ms. Schakowsky. That is right.
Secretary Burwell [continuing]. Of legislation that would
take care of that issue.
Ms. Schakowsky. And are you aware of any Republican
legislative proposal that would provide access to preventive
services, like cancer screenings, yearly wellness exams, and do
that at no additional out of pocket cost to consumers?
Secretary Burwell. I am not aware of a piece of legislation
that would do that in the way that the ACA does.
Ms. Schakowsky. Thank you. I wanted to talk a little bit
about something that is a growing concern, and that is
Alzheimer's disease, and the cost that it is in personal lives,
and also in funding. So scores of public agencies, including
many HHS agencies, as well as numerous private and non-profit
organizations, are trying to address this challenge of
preventing Alzheimer's, serving those who have dementia today,
finding a cure. Shouldn't the Federal Government be
coordinating a plan on Alzheimer's?
Secretary Burwell. In terms of the issue of coordination,
there is a body, an advisory group, that includes both people
from the Federal Government, as well as external folks, to be a
part of putting together our thoughts and strategies, and it
has informed the way that we are doing investments. There are
members of the Federal Government across the government, as
well as external bodies that are a part of that.
With regard to the work at the Department, the work cuts
across a number of different areas. NIH and research is
generally what comes to mind for most people, but where the
biggest dollars are spent is actually in CMS, and making sure
that we are thinking through the issues in that space, because
that is where the dollars--the other thing is the
Administration for Community Living is where we work on and
think about things like those that are caregivers, and those
that are going through that process of dementia, and how they
deal with it. So at the Department we work through all of
those. There is this overall advisory group that we have
externally, and includes internal members.
Ms. Schakowsky. So the population is aging rapidly,
obviously, and Alzheimer's is taking a much bigger toll than
ever on families, on health care systems, on people who have
the disease, and the number of people living with dementia will
continue to grow as baby boomers age. So you had mentioned the
research that is going on, so what is HHS, NIH doing to find a
cure?
Secretary Burwell. So in this budget you see a 24 percent
increase to funding for Alzheimer's, which is much greater than
the percentage increase even within the other NIH, so focusing
deeply on doing that. It is also part of the BRAIN Initiative,
as we think through their specific issues. But we are also
making progress on something called TAL, which is a protein
that is indicative of Alzheimer's. That is one of the pieces of
research that is going on, and if we can make progress there--
the other piece of research is seeing if there are ways that we
can slow the progression by understanding how the neural
channels move, and what is happening in the disease. Those are
pieces of research that we are starting, we believe that, with
the funding we are asking for, that we can move that research--
we can broaden it, and we can make it faster.
Ms. Schakowsky. So dementia is a major focus of work in the
United Kingdom and other developed countries. Are we keeping up
with the rest of the world in research activities and
investments?
Secretary Burwell. You know, we believe that we are, with
regard to that, and I have been in touch with my colleagues and
the secretary--or the minister in the U.K., and continue to
have those conversations. So we make sure that we are leaning,
and staying connected to our colleagues, especially that
particular example, where I have been in touch with Mr. Hunt,
and will continue to do that so that we make sure that we are
learning everything we can from our colleagues. And in places
where we can work together, see if we can leverage the efforts
that are going on in each of our countries. And that is both
across the research, the regulation, as well as the more social
issues.
Ms. Schakowsky. And who is on the Alzheimer's Advisory
Committee? I am asking that because shouldn't there be a person
with Alzheimer's as part of the group?
Secretary Burwell. I want to get back to you directly, but
it is my understanding that there is a person, that there is a
slot, and that either there is or will be a person that does
have that is part of the committee. I will want to get back to
you on that, though, specifically.
Ms. Schakowsky. Well, I want to thank you for the focus,
and, as the coach here of the Seniors Task Force of the
Democratic Caucus, I really want to work with you on that,
because this is a problem affecting so many families and
individuals. I appreciate it, and yield back.
Secretary Burwell. Thank you.
Mr. Pitts. Chair thanks the gentlelady. Now recognize the
gentleman from Kentucky, Mr. Whitfield, 5 minutes for
questions.
Mr. Whitfield. Thank you. Well, Secretary Burwell, I also
want to thank you for being with us today, and I want to just
follow up on my colleague Brett Guthrie's question. We are
concerned about this cost sharing program because it is $170-
some billion dollars over a number of years, and we understand
that that is one of the issues involved in the lawsuit. But all
we are asking you is, since you all are dispersing the money,
what is your opinion as to where the appropriation is
designated that you are working from?
Secretary Burwell. This is an issue--as I said, I
understand the question. We believe we have the authorities.
With regard to the specifics of that, because we are in
litigation----
Mr. Whitfield. But you can't tell us where the money is
coming from?
Secretary Burwell. With regard to having that conversation,
that is what the----
Mr. Whitfield. Were you instructed by DOJ not to answer
that question?
Secretary Burwell. With regard to that specific issue, that
is at the root of the litigation.
Mr. Whitfield. Were you instructed by DOJ not to answer the
question?
Secretary Burwell. With regard to--when there are issues of
litigation like this, our standard----
Mr. Whitfield. Well, yesterday we had Gina McCarthy here,
and we were talking about 111(d), which is before the Supreme
Court right now, and she gave us her theory of why she thought
she was right. We are not saying that we are right or you are
right, we are simply asking what is your theory? Where does the
money come from, in your view?
Secretary Burwell. That is something, as I said--why don't
I work to get back to you on where we feel comfortable----
Mr. Whitfield. OK.
Secretary Burwell [continuing]. With regard to where the
litigation is, and I would like to come back on that.
Mr. Whitfield. Well, I must say, I have been impressed with
your facility to use numbers. You are really tuned into the
budget, responding to Mr. Pitts, responding to Mr. Green about
the community health centers. I was at a Rotary Club meeting
recently----
Secretary Burwell. Yes.
Mr. Whitfield [continuing]. And I was asked the question--
they said, Congressman, can you tell us what dollar amount has
been incurred by the Federal Government as a result of state
expansion of Medicaid programs pursuant to the Affordable Care
Act? Because we picked up a larger percentage of the normal
cost.
Secretary Burwell. Yes.
Mr. Whitfield. And I would ask you that question. I didn't
know the answer, but could you tell me what is the total dollar
amount incurred by the Federal Government by the expansion of
the state Medicaid programs as a result of the Affordable Care
Act?
Secretary Burwell. In terms of the Federal dollars versus
the state dollars?
Mr. Whitfield. Yes, just the additional dollar----
Secretary Burwell. Yes, I----
Mr. Whitfield [continuing]. Amount incurred by us.
Secretary Burwell. Let me go back and look, because the
question of being able to disaggregate whether a person came in
because of expansion, or were under the old rules, I think--I
would want to make sure that we could----
Mr. Whitfield. But you don't have a dollar amount for that?
Secretary Burwell. I don't know. I will check with the
Department if we do. The one thing that I think we----
Mr. Whitfield. You would think that you all would
definitely know that--we can all talk about the advantages and
disadvantages of this program, but there is a big additional
cost to the Federal Government, and I am asking what is that
total dollar amount incurred?
Secretary Burwell. I think the question that I am not sure
is how one breaks out the actual number from expansion. Because
when people come through----
Mr. Whitfield. Well, let me ask you this question----
Secretary Burwell [continuing]. That is where----
Mr. Whitfield [continuing]. At what year does--the states
were encouraged to expand Medicaid, which is fine, because the
Federal Government is picking up more of that dollar amount.
Secretary Burwell. Yes.
Mr. Whitfield. But at some point in the future the Federal
Government is not going to be picking up those additional
costs. What year is that?
Secretary Burwell. What year that is is--the Federal
Government never goes below a 90 percent of the payment of the
additional, and that is----
Mr. Whitfield. Until when?
Secretary Burwell [continuing]. 2020 is----
Mr. Whitfield. 2020?
Secretary Burwell. And so 2016 is the year through which
there is 100 percent.
Mr. Whitfield. OK.
Secretary Burwell. And in your own state----
Mr. Whitfield. Well, do you have any projected cost over
that period of time for the Federal----
Secretary Burwell. We do have those incorporated in our
budget. But one of the things, in terms of these cost issues,
that I think are important in the State of Kentucky----
Mr. Whitfield. OK. Well, that is OK. Listen, you can't
answer the question, but I appreciate it anyway. Let me ask you
this. I noticed that you all made $2.5 billion in loans in the
co-ops, and Kentucky has a good co-op program as well. We sent
a letter last year, and we were concerned about the solvency of
some of these co-ops. And the Federal Government, as I said,
has loaned $2.5 billion. We now see that in Iowa and Nebraska,
those co-ops are in bankruptcy. Have you all done any analysis
to project--are there other states that there is a chance that
these co-ops will go into bankruptcy? Are you looking at that?
Secretary Burwell. We are looking at the co-ops. The one
thing I think is very important to note is the cuts, the deep
cuts in the funding for co-ops. When the program was originally
designed, and the passage of the Affordable Care Act occurred,
the amount of money for the co-ops to do the loans, and the
loans that states like Iowa felt would have made a difference,
at the end, because those monies were cut, they were cut as
part of sequestration. They were cut in '12, they were cut in
'11, they were cut in '13.
Mr. Whitfield. So are you saying the bankruptcy occurred
because of sequestration?
Secretary Burwell. What I am saying is that, had we had
more funding in order to provide the additional loans to the
co-ops, it could have made a difference. With regard to the
fundamental of your question, which was are we looking at the
co-ops? And there are two things that we want to do, understand
whether they are stable, and then the second is where we can
provide technical assistance.
Mr. Whitfield. Well, those questions that you couldn't
answer, or were not familiar with, I do hope that you will get
back with us with those answers soon.
Secretary Burwell. Be happy----
Mr. Whitfield. Within 7 days, if possible. Thank you.
Secretary Burwell. I will----
Mr. Whitfield. Thank you.
Secretary Burwell [continuing]. Want to make sure that--we
will get back as quickly as----
Mr. Whitfield. Because I have got to be back at that Rotary
Club next week.
Secretary Burwell. As a neighboring state, I appreciate
that.
Mr. Pitts. Gentleman yields back. Chair recognizes
gentlelady from Florida, Ms. Castor, 5 minutes.
Ms. Castor. Thank you, Mr. Chairman. Madam Secretary, thank
you again on behalf of the 1.6 million Floridians that were
able to buy affordable health insurance in our exchange. I will
give you due credit, and everyone at HHS, but I think the real
credit goes to our terrific navigators that were on the ground,
hospitals across the State of Florida, community health
centers, and family members that probably put in a good word
for their sons and daughters, or aunts and uncles, to sign up.
You probably want to give them a pat on the back yourself this
morning. I encourage you to do that.
Secretary Burwell. I do. I want to express appreciation. I
have seen the local stakeholders, and met with them across this
country, and it was the communities coming together, it was
individuals, it was people in the community health centers, as
was mentioned, it was the businesspeople, it was everyone. When
I would visit, the hospitals would be there, everyone would be
around the table working on this issue together, and it was
that kind of work--and then the individuals that I visited----
Ms. Castor. OK.
Secretary Burwell [continuing]. On Second Sunday in Texas--
actually was given the opportunity to speak at one of the
churches. And it was all of that coming together to give this
information to people so that they could make choices, and have
that financial and health security.
Ms. Castor. So, in Florida, we have a very competitive
marketplace as well. Consumers could choose from 14 different
issuers in the marketplace this year. That was up from last
year, where we had 11. And Florida consumers could choose from
an average of 42 health plans in their county for 2015
coverage.
So with 1.6 million now enrolled, it really demonstrates
the high stakes involved with the Supreme Court case that the
Court will hear next week. I cannot imagine that the Court
would rule to take that away from over a million and a half
Floridians, and then millions more all across the country. And
just like Representative Engel said, I was here during the
hearings in advance of the Affordable Care Act, the adoption,
during the markup, during the amendment process, during
negotiations with the United States Senate. Never in those
discussions was there any dichotomy between a state exchange,
and a Federal exchange, and the availability of tax credits.
Have you seen any evidence to the contrary, in your review of
the record, and the case that is before the Supreme Court?
Secretary Burwell. With regard--I would let the Justice
Department, who has reviewed everything--but the thing that I
agree with is we we just don't believe that that is what the
law says, or what was intended by the law either.
Ms. Castor. Yes, and I can say straightforwardly, as a
member of this committee, what the legislative intent was, and
it was for those tax credits to be available to every American,
no matter if they are in the state marketplace or a Federal
marketplace. But I would say if the Court rules otherwise, they
are going to create chaos, and they are going to strike right
at the heart of the economic security of so many of my
neighbors in Florida, and many Americans. So I know that they
will study the legislative intent, and I hope they rule the
right way, and we don't have the address that chaotic
situation.
But I think, with the Affordable Care Act, the real untold
story is what has happened to people who have insurance,
because I can cheer on the million and a half Floridians that
now have it, but most of my neighbors already had insurance,
private insurance or Medicare, and I noticed some more good
news that was announced this week for my neighbors that rely on
Medicare. Just in Florida alone, Floridians have saved almost a
billion dollars since 2010 because of the ACA's donut hole
discount. Almost 350,000 beneficiaries saw savings in 2014, to
the tune of about $300 million last year. The average discount
per beneficiary was $884.
Then, for private insurance--how come we haven't been able
to get the word out on how much better an insurance policy is
that a consumer can't be kicked off if they get sick? In
Florida alone, over 200,000 young adults can stay on their
parents' plan. Floridians have received millions of dollars in
rebates because the law says, you have new rights and
protections, and insurance companies cannot spend that money on
profits. It has to go to--it can't spend the profits on
salaries and excessive profits. It has to go to health care.
What else can the administration do to tell this good news
story?
Secretary Burwell. I think we can do a better job of making
sure people do know. And another area is the issue of
preventative care, and the importance of the fact that your
childhood visits and those things are no longer--require co-
pays or cost sharing, in terms of when you go in for that, or
measles, an important thing, I think, right now, and a timely
thing. And so I think we need to do a better job of making sure
people know about those improvements to quality.
Ms. Castor. Thank you. I yield back.
Mr. Pitts. Chair thanks the gentlelady. Now recognize the
gentleman from Illinois, Mr. Shimkus, 5 minutes for questions.
Mr. Shimkus. Thank you. Secretary Burwell, thank you. I
talked to your staff prior. I appreciate your outreach, trying
to call. It was a crazy day, and I talked to them before you--
--
Secretary Burwell. Thank you.
Mr. Shimkus [continuing]. Came to the table. And I do have
great respect for that. But I also want to make sure that, you
know, this happy clap talk about how great health care is, and
the Affordable Care Act, is moderated by real concerns out
there.
Remember, the bill that passed, signed into law, we had
nothing to do with on the House side. It was a Senate health
bill that came over to us that we passed, all right? So that is
the health care law that we have today, and the language of the
law is pretty clear, and I am concerned also that the Supreme
Court will rule that the Federal exchanges and states are not
authorized to receive subsidies, and we need to be prepared for
that here, and I would hope the Administration would be too.
I promised two ladies from my Congressional district that I
would mention their names. Angie Esker from Teutopolis, who is
pro-life, a strong family, and she cannot buy a policy that
does not have abortion coverage. And for millions of Americans,
this is a really important issue, and she--this is an
emotional--just like on the other side, you know how this
debate is.
Secretary Burwell. Yes.
Mr. Shimkus. And I think part of the agreement from some of
my pro-life Democrats was to ensure that that option would be
available----
Secretary Burwell. Yes.
Mr. Shimkus [continuing]. And it is just not for her. The
other one is Debbie McKinney-Huff from a town called Highland.
She is a Democrat. Her premiums went up astronomically last
year. This year they have gone up another $2,000, with a
$10,000 deductible, and she can't afford it. So for all the
happy dances, there are challenges out there that--we don't do
our constituents service if we don't understand that there are
problems that have to be resolved. There are some budget
requests that I want to talk about, so I am going to move
forward, but I just put that in the record.
I am a big supporter of Medicare Advantage. I was here when
we passed it. Seniors didn't have any prescription drug
coverage. It has been very successful, it is very popular. The
budget request makes a reduction again in that, where the
enrollment is going up, favorable are high, and 670,000 people
weren't able to access Medicaid Advantage. And if you are from
rural parts of this country, that option is very limited, or it
doesn't exist. So I would ask that we look at that, so that
seniors who want to have this option can choose that. And our
concern is your budget hurts the ability for that to happen.
Secretary Burwell. So with regard to the first issue, in
terms of your two constituents, want to make sure we understand
that. On the issue of the question of abortion, and that----
Mr. Shimkus. Well, let us just answer this question,
because I have got to keep more on budget----
Secretary Burwell [continuing]. Medicare Advantage issue.
Mr. Shimkus. Thank you.
Secretary Burwell. With regard to that, we want to make
sure--the program during the period of changes that we have
had, we have seen a large increase in the number of people in
Medicare Advantage plans. I want to understand your 670,
because 99 percent of beneficiaries have access to MA plans,
and there may be something, and so I would like to understand
that 670 better.
The third thing is that we know that those number of plans
quality that have gone from four stars to the higher ratings,
we have offered 67 percent in the two highest rating
categories, 17 percent to 67 percent, so we are improving
quality. More people are coming in the system, and there is
premium control, so I want to understand the 670. We want to
make sure, and are listening. We alter our plans as we hear
concerns. That is why I want to understand that 670, because we
believe that we can continue making these changes. It comes
back to some of the points the Chairman raised with regard to
deficits, and making sure that----
Mr. Shimkus. OK.
Secretary Burwell [continuing]. We are being responsible.
MedPAC and the GAO have recommended that there is upcoding, and
we need to work on it.
Mr. Shimkus. OK. Thank you. Are you aware of any efforts by
FDA to accelerate the next round of user fee negotiations? And
our concern is, if they are, and they are not doing due
diligence about the fees and the return on investment, we would
hope that they would not accelerate it until due diligence is
done.
And the last thing I wanted to address was the Biologics
Price Competition and Innovation Act. Stakeholders have to be
involved in that. That is really part of the 21st Century Cures
debate, not just having bureaucrats or panels, but bringing
patients, bringing physicians, bringing in alike--and our
concern is that is not happening on this--on the Biologics
Price Competition and Innovation Act, and those concerns.
So if you would take that for suggestions, and if you want
to come back and follow up on a lot of these issues, we would
be happy to talk with you again. I do appreciate you reaching
out personally, and I look forward to working with you.
Secretary Burwell. I do appreciate this issue of
stakeholder input. We think it is important to making sure we
get this right.
Mr. Shimkus. Thank you very much.
Mr. Pitts. Chair thanks the gentleman. Chair now recognizes
gentlelady from California, Ms. Matsui, for 5 minutes for
questions.
Ms. Matsui. Thank you, Mr. Chairman. Secretary Burwell,
thank you for being here. I want to talk about mental health.
When we think about health, we need to consider the whole
person. Mental health has historically taken a back seat to
physical health, but the head is connected to the body, and one
affects the other.
I have been working for years with my colleagues on both
sides of the aisle, and both sides of the Capitol, to make
changes to fix our broken mental health system. And as you
know, a demonstration project based on the Excellence in Mental
Health Act, that I co-authored with my colleague here,
Congressman Lance, into law last year, and I look forward to
working with you and the Administrator to make sure this is
implemented properly, and in a way that states can demonstrate
success.
I also look forward to working with you to make further
changes and improve our mental health system. I was pleased to
see that the budget will eliminate Medicare's 190 day mental
health services more in line--and keep that more in line with
physical, for which no limit exists. Can you briefly talk about
that policy, and how it would benefit seniors and people with
disabilities who need psychiatric services?
Secretary Burwell. Our overall approach in the mental
health space, and it is one that we consider a priority, is to
try and get, in terms of both care and payment, to parity with
how we think about other health issues. And there are steps
that we are taking throughout the budget, and whether it is the
implementation of the piece of legislation that you referred
to, and the issue that your colleague just raised about
stakeholder engagement, and making sure we are getting that
input as we implement. So we are implementing, and thinking
about the policies to promote behavioral and mental health
through our payment system, and making sure that there is
parity. That seems to be something that is been important.
We are trying to focus on access, because many people--the
question of access to the right types of providers, in terms of
behavioral health, that is something you see in some of our now
is the time budgeting work, in terms of making sure that SAMSA
and others are ensuring that we have providers. And then there
is access, and that is an issue for all people of all ages, but
especially young people getting the access that they need.
So as we think about all the pieces working together, about
the funding, about the access, and then that there are
providers that can provide.
Ms. Matsui. I appreciate that, and as we move forward,
there is a continuum of mental health issues that we need to
address. And it is a complicated issue, and we would certainly
like to work with you as we move forward on that.
And now I would also like to talk about seniors, because
that is a special interest area of mine too. And, as we
consider changes to the Medicare program, our first priority
should always be seniors, especially knowing that seniors spend
about 14 percent of their household income on health care
costs, compared to five percent--households who do not have a
Medicare beneficiary. And we need to find ways to save money in
the Medicare program, and we have been, but not by cutting
benefits, but by re-aligning incentives to improve outcomes in
patient care. If a senior gets the right care at the right
time, it is not only better for the senior, but also saves the
system a lot of money.
Now, I appreciate some of the provisions in the budget, and
I would like to discuss these further with you. The budget
seeks to save money by restoring drug rebates for the dual-
eligible population on Medicare. Secretary Burwell, can you
please elaborate on that?
Secretary Burwell. In terms of the dual-eligible----
Ms. Matsui. Yes, right. The drug rebates for dual-eligible
population.
Secretary Burwell. One of the things that--the dual-
eligible population has two elements to it. Is both a very
complicated population----
Ms. Matsui. Yes.
Secretary Burwell [continuing]. Because they are people who
have a number of different conditions that are being treated in
different ways. It is also a very expensive population. And as
we work to improve both the quality and affordability of the
care, that is what we are trying to do, as we look at these
proposals. And it is all a part of the broader issue of
delivery system reform, which you touched on a little bit, and
we have set out clear goals.
For the first time ever we have said that in the area of
Medicare, that by 2016 we have set a goal that 30 percent of
all payments will be in different payment systems, where we are
not paying for volume, but paying for value. And as a part of--
we move forward to this change system, we want to do that. That
is about price, but it is also about quality, and this is a
proposal that we are trying to move forward on both.
Ms. Matsui. And I know that this is going to be difficult
because there are areas where you have to look at the budget,
but as we look at this, we have to also look at the seniors.
And that is really why, when we look at this--I know you seek
to increase the skin in the game for Medicare beneficiaries,
however, I would argue that seniors already have a lot skin in
the game, and Medicare, and the additional cost sharing, will
not bring down costs in the program.
And as you know, as they have increased costs, you look
at--most of them are supported by Social Security, and then
that--what they do is shift over the costs to pay for their
health care from Social Security. So I think it is something we
really have to look at more holistically. So thank you very
much for everything that you are doing.
Secretary Burwell. Thank you.
Ms. Matsui. Yield back.
Mr. Pitts. Chair thanks the gentlelady, now recognizes the
gentleman from Pennsylvania, Dr. Murphy, 5 minutes for
questions.
Mr. Murphy. Welcome here, Madam Secretary. We appreciate
you being here. I also want to associate myself with the
comments of my friend, Ms. Matsui of California, about mental
health, and look forward to working with you on those things.
In a related area, we have had a number of hearings here
regarding mental health, and among them has been the Substance
Abuse and Mental Health Service Administration. We have asked
them repeatedly for information over almost a year for getting
some records. Chairman Upton and I have asked for these things.
We have not gotten those documents, and we are concerned about
their delays. I wonder if you could help us get some assurance
that we will get those documents from SAMSA?
Secretary Burwell. As you and I had the opportunity to
discuss, this is something that we are working on, and I am
hopeful that very soon you will have some of those documents,
and we will continue to work with you on it.
Mr. Murphy. Thank you. I appreciate your teamwork on this.
On another question, when we passed the SGR patch, I think it
was last year, there was also a demo project, which is what Ms.
Matsui was also referring to, for certified community
behavioral health clinics to improve access.
Secretary Burwell. Yes.
Mr. Murphy. Now, as part of this, we also attached
something for AOT, assisted outpatient treatment, for counties
and communities to also have access to some grants to
facilitate that, as long as they also were--so those community
behavioral health clinics would get those--to also help for
those who are cycling through with histories of violence,
prison, homelessness, et cetera. That small one percent of one
percent that are persistent chronically mentally ill going
through the system.
One of the things I want to make sure and find out from you
is--the way this was designed is to make sure that only those
counties who really have AOT would be eligible for those grant
programs, if they are going to attach those to those community
health centers. Is that something you are aware of, and can you
work with us to make sure that those grant programs are
available in that sense?
Secretary Burwell. We do want to work with you on that, and
yes, we are working on that, and would like to work with you to
make sure that we do have those standards in----
Mr. Murphy. Thank you. Another one has to do with a program
that was discussed by SAMSA which is called iCare, which is to
help with those going into emergency rooms----
Secretary Burwell. Yes.
Mr. Murphy [continuing]. To deal with those in crisis. One
of the concerns I have, and certainly we have seen headlines,
some tragic, sad cases, such as that with the Virginia Senator,
Creigh Deeds, his son Gus. The problem is that there are
thousands this occurs in this country every year, where there
just simply aren't enough psychiatric hospital beds, and so
people languish in emergency rooms, often in a five point tie-
down, and given chemical sedatives until a room opens up. It
could be hours, or days, or weeks, in some cases. We wouldn't
have this problem if we had more psych beds.
And so I am hoping that, since the demand for psychiatric
beds exceeds the current supply of inpatient psychiatric beds,
that is something else you can work with us in legislation to
say, we ought to have a place for those in crisis to get
stabilized, not go to jail, not sit in a jail cell and languish
there, or sit in an emergency room, but work with us on that.
Would you be willing to work with us on that too?
Secretary Burwell. Yes, looking----
Mr. Murphy. Thank you.
Secretary Burwell [continuing]. Forward to that.
Mr. Murphy. And another issue, then, related to the
assisted outpatient treatment grant program as a stand-alone
thing, I want to show you--I think I have a poster here of--I
just want to show you some of the outcome measures. This comes
out of a Duke University study.
Secretary Burwell. Yes.
Mr. Murphy. And when you have assisted outpatient
treatment, so working with someone from the court, or judge,
working with a person, saying, you need to stay in treatment
for a number of months, outpatient treatment, not inpatient,
take your medication, see this person to report back, like with
the mental health court or something, they saw an 87 percent
reduction in incarcerations, an 83 percent reduction in
arrests, 77 percent reduction in psychiatric inpatient
hospitalizations, and a 33 percent reduction in ER
hospitalizations. So I just want to show you that too. And, by
the way, the costs are cut in half for these folks too.
But there is one that--in working with the issues of CBO
scoring, et cetera, we are really going to have to, I think,
team up together on this, and say there ought to be some
options for people to be in outpatient care. And this is
psychiatry, psychology, peer support, social workers, people
helping with job training, housing, all those things together,
but there has to be this coordination of programs. You will
work with us on this too?
Secretary Burwell. Well--and I think it is part of the
broader issue of delivery system reform, and how we deliver
quality. You are focused in a very important area, in mental
health. When we look at diabetes, in the clinics that I have
visited across the country, when we get these adherence numbers
up, and people participating, and that usually has to do with
coordinated care, and the type of interaction and communication
you are talking about, we get adherence, we get less of the
disease or problem, and we get lower costs because the things
that happen when we have the bad things that go wrong when
people aren't adhering.
Mr. Murphy. Yes, it is going to require that different view
of some things. And I think you may be familiar with the
hearing we had in the Oversight Committee 2 weeks ago, where a
GAO report identified--I was amazed by this--112 Federal
agencies and programs, scattered across eight departments, that
deal with mental illness. They said the interagency
coordination program supporting individuals with serious mental
illness is lacking. It was, to me, a really dizzying and sad
description of the process here. I hope you will also work with
us as we work to coordinate those programs. And can I have that
assurance from you as well?
Secretary Burwell. We will, and we do coordinate. We
coordinate them across the overarching issue, and then within
their areas, like veterans' homelessness, and the issues that
relate. And so I want to have the conversation about how we
think about where we can strengthen those things.
Mr. Murphy. Thank you. Let us continue work with that.
Thank you, Mr. Chairman. I yield back.
Mr. Pitts. Chair thanks the gentleman. Now recognize the
gentleman from Oregon, Mr. Schrader, 5 minutes for questions.
Mr. Schrader. Thank you, Mr. Chairman. Thank you for being
here, Madam Secretary.
Secretary Burwell. Thank you.
Mr. Schrader. Last year health care spending grew at the
slowest rate on record since 1960. Health care price inflation
is at its lowest rate in 50 years, and the ACA's gotten a lot
of attribution by CBO for making a big difference in that
result. Have you seen Republican legislative language that
would give us that same result?
Secretary Burwell. We haven't seen a proposal that would
continue us on our path with regard to some of the changes we
have put in place.
Mr. Schrader. Seniors have also benefitted dramatically
from the ACA. Prescription drug costs are a big issue for them.
Secretary Burwell. Yes.
Mr. Schrader. Over eight million seniors have actually
benefitted from, and saved, over $11 billion, as I understand
it, on prescription drugs since the enactment of the ACA. Is
there a Republican proposal out there that does a similar
thing?
Secretary Burwell. We haven't seen a proposal that would
take care of this issue, the donut hole. And, actually, on
Tuesday we actually were able to update our numbers in that
space, and it is now $15 billion in terms of the savings. And
on average in the country, that is about $1,600 per----
Mr. Schrader. I find that ironic, that my colleagues on the
other side of the aisle keep asking for a contingency plan from
the Administration on this bogus lawsuit, and yet, as a firm
believer in Article I, legislative supremacy, with all due
respect, Madam Secretary, I think it is our responsibility, and
the majority party controls both chambers, where the heck is
their contingency plan? That is a rhetorical question, Madam
Secretary.
One of the things that has been really good, I think, in my
state is the expansion of the Affordable Care Act into the
Medicaid population and into the private sector. We have had
some unqualified success. Emergency room visits are down, like,
21 percent. We have actually gotten hospital admissions,
complications from diabetes alone down nine percent, not to
mention other diseases. COPD, Chronic Obstructive Pulmonary
Disease, hospital stays down almost 50 percent. Are you getting
any of the same--those same type of results from other states?
What--could you----
Secretary Burwell. So we are, and recently, actually, in
the last 2 weeks, out of the State of Kentucky, we have seen a
piece of analysis done by the University of Louisville in
Deloitte, and that piece of analysis showed they did it at the
beginning of the expansion, and then they did the analysis now.
And what the analysis showed is that the expansion will
contribute to 40,000 jobs in the State of Kentucky, and will
contribute to their GDP by $30 billion. And that is the period
to 2021, so that is over a period of time. But we are starting
to see both the economic and job impacts, as well as some of
the health impacts that you were describing.
Mr. Schrader. Well, contrary to popular demagoguery on
right-wing radio and TV, this is a marketplace system we set
up. Federal Government is the facilitator in that. The state--
some of the state exchanges are a facilitator. Like everyone, I
think, here, we all believe in the power of marketplace
competition. My own state, for instance, over the last year,
instead of seeing the double digit increases in insurance
premiums on average, ours actually stayed level, or decreased
slightly.
That, to me, is a key indicator for the working or non-
working of the Affordable Care Act. Our uninsured rate in
Oregon went down 63 percent. I have had testimonials from
hospitals and doctors about how people actually have health
care access at this point in time. Could you talk about what
you see nationally in increased competition----
Secretary Burwell. So with regard to the issue of increased
competition, we saw 25 percent more issuers come into the
marketplace this year, and so more issuers means more plans and
competition.
Mr. Schrader. They wouldn't be doing this if they weren't
making some money at this, and the program wasn't working,
Madam Secretary.
Secretary Burwell. And so--and also, with regard to the
issue of competition, what we know is, in many plans that are
employer-based plans, people do not come in and shop. They just
automatically re-enroll. And, as you know, we had that as part
of the marketplace this year. But we know that, actually, the
majority of people came in and shopped. And that, I think, is
related to the competition, and it is related to a consumer who
wants to make the best choice. And that choice, sometimes based
on benefit, that choice sometimes based on cost, and cost has a
number of different elements, whether that is premium or
deductible.
Mr. Schrader. Correct.
Secretary Burwell. So we are seeing more players come in,
and we are also seeing the consumer behave in a way that is
indicative that they want that competition and shopping.
Mr. Schrader. I would like to call out some kudos on the
GME increase in the budget, the money you put in for Medicare
appeals. Back home we do a lot of work, of course, with people
that are having trouble navigating the system big time, and the
investment in primary care docs. I think that is important.
Quick little comment, the only thing I am a little
concerned about is if we are going for bundled payments and
increased competition, why we are hammering on the Medicare
Advantage plans a little bit?
Secretary Burwell. As I mentioned to your colleague, I
think what we are trying to do is balance, making sure that
those plans are good and strong, and we have seen that over the
period of the changes we have done. We try and do the changes
in a measured way that gets to things that actually have to do
with what we believe is strong representation of the taxpayer,
in terms of places where we believe there are issues, like up-
coding, that is occurring, and that MedPAC has articulated
those, and others. We always want to listen and hear, and we
want to watch carefully if we are seeing problems that occur
with the changes, and to date, we haven't.
Mr. Schrader. Thank you, and I yield back.
Mr. Pitts. Chair thanks the gentleman. Now recognize the
gentleman from New Jersey, Mr. Lance, 5 minutes for questions.
Mr. Lance. Thank you, Mr. Chairman. Madam Secretary,
regarding King vs. Burwell, I understand what you have said,
that there can be no administrative action should the Plaintiff
win the case. You have stated that explicitly, and repeatedly,
and that this not my question. My question relates back to the
Chairman, who said in his opening line of questioning, that we
have a specific source within your department that there is a
document related to what HHS might do, should the Supreme Court
rule against the Administration. I understand that your point
of view is that there can be no administrative action. You have
stated that explicitly. Are you aware of any such document? And
I am not asking you about your position on administrative
action. I am asking about a document in this regard.
Secretary Burwell. Congressman, if there is this document,
and you know of it, I would certainly like to know of the
document, because I don't have knowledge of a 100 page----
Mr. Lance. I didn't say 100 page, now did I?
Secretary Burwell. Sorry.
Mr. Lance. I just said a document.
Secretary Burwell [continuing]. Chairman----
Mr. Lance. I don't know how many pages it is. You are not
aware of any document?
Secretary Burwell. As I have said, there isn't
administrative action----
Mr. Lance. Yes, I have made that clear that I understand
your point of view on that. Is there a document as to a
reaction from HHS should the case be won by the Plaintiff in
the Supreme Court?
Secretary Burwell. With regard to a reaction, as I said--
because I have articulated that--I want to be careful, because
I have articulated----
Mr. Lance. As I have tried to be careful.
Secretary Burwell [continuing]. The problems with regard to
the question of what will happen, we know how many people are
in the marketplace, how many----
Mr. Lance. Yes. That is filibustering. I understand that. I
am asking whether there is any document, we have a source
indicating there is a document, as to what might be the
response from HHS?
Secretary Burwell. I am not familiar with the document you
are referring to.
Mr. Lance. And let me say that a former CMS administrator,
Tom Scully of, I believe, the Bush Administration has said, of
course they have a document. He said, of course they have one,
I think he referred to a document, they should all resign if
they don't. I would hope that your department, Madam Secretary,
would have some sort of contingency plan should the Court rule
for Plaintiff. Do you believe that the suit is bogus?
Secretary Burwell. With regard to the lawsuit, as I said,
what I believe is that the law is clear----
Mr. Lance. Yes, I understand that. Do you believe the suit
is bogus?
Secretary Burwell. That is a characterization. I--my point
about the suit is--what I believe is that we hold the right
position, and that our position----
Mr. Lance. Yes, I understand that, and it will be argued
next week, and a decision will be made by the end of June.
Formerly, when I asked questions about this, not from you, but
regarding prior officials, there was the impression that it was
a frivolous suit. Do you believe the suit is frivolous or
bogus?
Secretary Burwell. What I believe is that we should
continue making progress for the American people on three
things that the Affordable Care Act----
Mr. Lance. Yes, I am aware of that. Do you believe the suit
is----
Secretary Burwell [continuing]. Access----
Mr. Lance [continuing]. Frivolous or bogus?
Secretary Burwell. May I finish, Congressman? I believe
that we, as the Executive Branch and the Legislative Branch,
should be working together on three things we agree with. That
is affordability, access, and quality.
Mr. Lance. I agree with all----
Secretary Burwell. And what I would hope that we can do is
build on the progress that we have seen. And that progress is
that 11.4 million people----
Mr. Lance. Reclaiming my time, do you believe that the
Supreme Court is likely rule unanimously on this decision?
Secretary Burwell. As I have indicated, we believe that the
Court will rule in our favor.
Mr. Lance. Yes. Do you believe the suit is bogus or
frivolous?
Secretary Burwell. With regard to characterization, what I
think is valuable is that we believe that our position is the
position that will stand, and that we believe we are right. The
people in the State of New Jersey should not have their
subsidies taken away because they do or don't have a
marketplace, when people right across the border in New York
will get those----
Mr. Lance. I believe, Madam Secretary, in equal justice
under law, as is inscribed across the street on the Supreme
Court building. I believe this is a very serious case. I think
it is closely contested. Under no circumstances do I believe
that Plaintiff will win nine to nothing. I think there are good
arguments on both sides. I have read the briefs, all of the
briefs. I have read the Solicitor General's brief. I have read
the brief of the Plaintiff. I think it is a very serious case,
and you and I may disagree on the case. I respect that, and I
understand that.
It is frustrating to me that, here in Washington, there
cannot be an intellectual argument as to pros and cons, and I
certainly would encourage the Administration to have a
contingency plan, and to work with us in Congress, including
the Republican majority in both the House and the Senate,
should the Court rule for Plaintiff. Thank you, Mr. Chairman.
Secretary Burwell. Congressman, with regard to the question
of our authorities, what you just ended with was the issue of
the legislation, and I want to make sure that I touch on that.
As we have said all along, we are willing, and look forward to
working with the Congress on any legislation that would work on
those three things we talked about, affordability, access, and
quality, and preserves the economy, and supports working middle
class. That is how we will look at legislation. We want to do
that now, and we want to do that in any----
Mr. Lance. And I was part of a group that had an
alternative piece of legislation that didn't see the light of
day put forth by the Tuesday lunch group, of whom I am a member
of that group. It was different from the Affordable Care Act,
but it was an alternative piece of legislation. Of course, it
didn't see the light of day in any way, shape, or form in 2009
and 2010. Thank you, Mr.----
Mr. Pitts. Chair thanks the gentleman. Now recognize the
gentleman from Massachusetts, Mr. Kennedy, 5 minutes for
questions.
Mr. Kennedy. Thank you very much, Mr. Chairman. Madam
Secretary, thank you very much for being here. You touched on,
a moment ago, about legislation that you said you were eager to
work with Democrats and Republicans on. Have you seen any such
legislation?
Secretary Burwell. With regard to legislation that would
promote and move forward on those three things, making sure we
are expanding that insured population, have not seen things
that would work toward that.
Mr. Kennedy. Madam Secretary, are you aware of how many
bills were passed and signed--or bills were passed by the 115th
Congress?
Secretary Burwell. I don't know the exact number.
Mr. Kennedy. Give or take a few, 931, ballpark, sound about
right? Any idea on how many of those bills were signed into
law? 296 sound about right? Any idea how many times in my first
term in Congress we repealed all or part of the Affordable Care
Act? 55 sound about right? Any idea how many times those were
signed into law? None.
Secretary Burwell. None.
Mr. Kennedy. Are you aware of how many times we voted on
some sort of replacement bill to the Affordable Care Act, that
we voted to repeal 55 times, to provide Americans with quality
affordable access and financial assistance to access to health
care that they deserve? None.
Secretary Burwell. I think the number is none.
Mr. Kennedy. OK. I would agree with you. So I think, given
all of the discussion we have had over the course of the past
several hours about contingencies, about other options, in the
time that I have been in Congress, over 55 times in my first
term, including another time in my second term, to repeal all
or part of the Affordable Care Act, and under the time that I
have been here under Republican leadership, to not have a
single bill that has seen the House floor to vote on an
alternative to provide quality, affordable, accessible health
care to millions of Americans, I would respectfully ask, as my
colleagues have, for the Administration to work with Democrats
and Republicans to work on any such legislation, should they
decide to bring that to the light of day.
Secretary Burwell. And in our budget, I would just like to
mention we actually do have a proposal to improve the small
business provisions of the Affordable Care Act, to try and both
simplify and make the tax credits better for small businesses.
That is feedback we have received about that, and that is
something that is included in our budget.
Mr. Kennedy. Now, turning to a couple--well, hopefully more
substantive questions that I can get to with you, Madam
Secretary, I was pleased to see that the Democratic CHIP
reauthorization bill, that the was included in the President's
budget extended the Medicaid primary care payment increase. The
rate of increase that was initially included in the ACA has
been absolutely critical, and for the last 2 years, it has
boosted payments to doctors who treat the most vulnerable
populations, making access an attainable goal, not just an
aspirational target.
According to a recent report from the Urban Institute,
however, the expiration of that payment bump at the end of last
year will result in Medicaid provider payments that are going
to be cut on average of 43 percent, and over 50 percent in some
states. The impact on wait times could be drastic and
immediate. I was hoping, Madam Secretary, you might be able to
comment on the importance of parity between Medicare and
Medicaid payment to our primary care providers, and when they
have to choose between seeing some of most vulnerable
populations like seniors, pregnant women, and children, why
would there possibly be a reimbursement discrepancy?
Secretary Burwell. So, I think, as you are indicating, why
we have proposed the continuation of these payments is because
we believe it is making a difference, and it is making a
difference to the access and coverage that people are getting
in the system. And so we have proposed it as a continuation,
and we hope that that is something that the Congress will
consider and support.
Mr. Kennedy. Thank you. The second topic that I want to
touch on today, actually, my colleague, Mr. Murphy, touched on
it quite extensively in his comments, but it is about substance
abuse and mental health. Back in Massachusetts, Madam
Secretary, I see communities on the front lines of a growing
and extraordinarily devastating opiate abuse crisis, and we are
looking to the Federal Government for some support as
prescription drug abuse, and a number of heroin overdoses,
continue to mount.
Madam Secretary, I was a prosecutor before I ran for
office. I saw the impacts of this on a daily basis, not just in
terms of addiction and people needing treatment, but in terms
of property crimes, personal crimes for folks that are looking
to try to find a way to get help, but the treatment options
just aren't there. There are not enough doctors. There are not
enough beds, as Mr. Murphy indicated. There are not enough
wrap-around services. There are not enough care. And I was
hoping that you might be able to touch on the importance of
actually creating these incentives through Medicaid largely,
which is our largest mental health provider, to actually make
sure that--not just another grant program, but to make sure the
incentives are in place to allow that marketplace to provide
that care?
Secretary Burwell. So the bad news is, as you indicate,
there were 259 million prescriptions for painkillers, opioids,
during 2012. That is more than one per adult in the Nation.
That is the bad news. The good news is that I believe that
there is bipartisan support for us to do something, and I
believe that that is both in the Executive and Legislative
Branch here in Washington, D.C., as well as with the governors,
who I met with over the weekend on this issue.
I think with regard to payment, it is an important place,
but there are three fundamental things that we believe we need
to work with the Congress and work with the governors to do.
One is, in terms of the prescribing, that is at the root of
much of the problem. We have seen progress in states like
Florida, where they are watching the prescribing. The plans
that states can put in place to oversee that is an important
part, but we have a part two. Second is the issue of things
like--and access to those, which I think gets to some of the
payment issues. And the third is making sure there is medical
treatment, and I think that was the third part of what you were
mentioning. Those three elements, I think, is--that is a basic
agreed upon.
And whether it is Senator Portman and Senator Widen, or Mr.
Rogers, or--it is across the board. There is bipartisan support
because states from Massachusetts to Kentucky, and West
Virginia, my own home state, are suffering in devastating ways.
And the one piece you didn't mention, which is the economic
impact. And, having come from a large employer like Walmart,
what it means in terms of having an employee base that can pass
a drug test.
Mr. Kennedy. Thank you, Madam Secretary.
Secretary Burwell. Thank you.
Mr. Pitts. Chair thanks the gentleman. Chair will note that
we have just been joined by a group of students from the
Houston area. The Ranking Member has informed me--you want to
say anything, Gene?
Mr. Green. Mr. Chairman, I would just like to recognize a
number of our chiropractic students from the Houston area, and
Dr. Mossad, who actually retired as the president of our
chiropractic college in Pasadena, Texas. And I invited them
last night because I wanted to show how the health care policy
is made in the health care subcommittee. Thank you, Mr. Chair.
Mr. Pitts. Thank you. You are certainly welcome to be here.
And the Chair now recognize the gentleman from Virginia, Mr.
Griffith, 5 minutes for questions.
Mr. Griffith. Thank you, Mr. Chairman, I appreciate that.
Appreciate the students being here. We may have some
disagreements today, but I will tell you that the Ranking
Member, Mr. Green, and I worked very hard on a health care bill
that was signed into law last year, so no matter what you may
see today, we do get along more often than the press lets you
know. All right.
That being said, Madam Secretary, in response to a previous
question, you indicated you weren't aware of any of the laws
being signed in. I am sitting here with a CRS report,
Congressional Research Service, indicating that there are 12
bills that repealed parts of Obamacare that were, in fact,
signed into law. You are not aware of that, is that correct, in
relationship to your previous answer?
Secretary Burwell. With regard to the specifics of the
answer, those were repeal questions, I thought.
Mr. Griffith. Yes, and this was part----
Secretary Burwell. Full repeal.
Mr. Griffith. He said----
Secretary Burwell. Full repeal was----
Mr. Griffith. He said full or a part. So you were mistaken,
and weren't aware of these 12 that were partially repeals?
Secretary Burwell. I was referring to the issue of full
repeal.
Mr. Griffith. But you are aware of these?
Secretary Burwell. I would have to look and see----
Mr. Griffith. OK. And if I could just have this entered
into the record, I would appreciate----
Mr. Pitts. Without objection, so ordered. \1\
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\1\ The report has been retained in committee files and is also
available at http://docs.house.gov/meetings/if/if14/20150226/103028/
hmtg-114-if14-20150226-sd008.pdf.
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Mr. Griffith. Thank you, Mr. Chair. Also, are you familiar
with my H.R. 130?
Secretary Burwell. Apologize, don't know what that bill is.
Maybe if it is described I might----
Mr. Griffith. And are you--it is a bill that deals with the
black lung provisions of Obamacare.
Secretary Burwell. I am not familiar with that----
Mr. Griffith. I appreciate that. Are you----
Secretary Burwell [continuing]. Legislation.
Mr. Griffith [continuing]. Familiar with my H.R. 790, which
is the Compassionate Freedom of Choice Act?
Secretary Burwell. Not familiar with the specific names of
the legislation----
Mr. Griffith. And I appreciate that. And are you familiar
with H.R. 793, which deals with preferred pharmacy networks and
Part D?
Secretary Burwell. Depending on a----
Mr. Griffith. Another one of mine.
Secretary Burwell [continuing]. Description, that may----
Mr. Griffith. And so the reason I ask those questions is--
been very well orchestrated today, from a political standpoint.
The other side of the aisle has asked you repeatedly are you
aware of Republican legislation that deals with the issues that
we are dealing with related to Obamacare? I would submit to you
that, in some way or another, the three points that you pointed
out, each one of those bills did. You are not intimately
familiar with them, and I understand that, and I am not blaming
you, because you have been put into that unenviable position
that sometimes happens, where there is a difference between
negative evidence, and a lack of evidence. And what you
presented today is a lack of evidence, and I appreciate that.
That doesn't mean that these bills don't exist, just as I
gave you the numbers on those three. It doesn't mean that there
aren't other bills that other members have that are out there
that are Republican proposals to take care of the American
citizen while we are in the process of repealing Obamacare. And
so you are just submitting that you are not aware of it, but
there are, in fact, bills out there that may be doing that, and
also further discussions behind the scenes that may be doing
that that you are unaware of. Isn't that correct?
Secretary Burwell. Would welcome--there was a veterans'
bill that we all agreed on. The firefighters, I haven't----
Mr. Griffith. I am just saying, though, that----
Secretary Burwell [continuing]. Legislation----
Mr. Griffith [continuing]. When you say, though, in the
answer to any number of members on the other side of the aisle
that you aren't aware, that doesn't mean they don't exist, it
just means you are not aware, am I correct? Yes? All right, we
will move on.
The President's fiscal year 2016 budget calls for 92
million for the Office of National Coordinator, ONC, for
purposes including the transition to a governance approach for
health information exchange. In 2012, an HHS request for
information noted that Congressional authorities granted to the
ONC in the 2009 High Tech Act would support this governance
mechanism. Madam Secretary, I hold in my hand a copy of a
Congressional Research Report dated January 7, 2015 that
suggests ONC does not have the authority to support the ONC
governance structure outlined in the President's budget. Don't
you agree that when agencies take action they should be
supported by congressional authorization?
Secretary Burwell. Not familiar with the report, would
welcome seeing it. With regard to the Office of the National
Coordinator, I think you know we just came out with the plan to
continue moving us towards electronic medical records. We back
that up with specific things. We continue to work on something
that cuts across many of the issues, and whether it is----
Mr. Griffith. But you would agree with the principle, that
there ought to be congressional authority for an agency to take
action, would you not? Yes or no?
Secretary Burwell. I would agree that we----
Mr. Griffith. Yes, ma'am.
Secretary Burwell [continuing]. Need----
Mr. Griffith. And, Mr. Chairman, if I could also have that
Congressional Research Service report placed into the record, I
would----
Mr. Pitts. Without objection, so ordered.
Mr. Griffith. As a part of its governance push, ONC awarded
a contract to RTI to develop its Health IT Safety Center. RTI
said at the time of the award that it would define the focus,
functions, governance, and value of the national health IT
safety content. I am just concerned, as I pointed out a minute
ago, that when you have these comments being made--now, we
haven't seen it yet, and the report that I just had entered
into the record shows we haven't seen the final analysis of
what they are going to do, but when you have comments that they
are planning to work on governance, and they don't have that
authority, I am concerned, when the experts are telling me,
both legal and otherwise, that this agency is going beyond its
scope of authority, that this is a problem in this
Administration, and that we should be careful that we have any
agency moving forward without congressional authority.
I am going to ask you to work with me as we move forward on
this. I am going to follow up with some questions and some
other things, and ask that you work with me to make sure that
the ONC does not overstep its authority granted to it in
legislation by this Congress.
Secretary Burwell. I would like to work with you to
understand, and understand what these concerns on governance
are. This is new to me, and so I would like to----
Mr. Kennedy. Yes, ma'am.
Secretary Burwell [continuing]. Understand further what the
concern is.
Mr. Griffith. And I appreciate that, and I yield back.
Thank you, Mr. Chairman.
Secretary Burwell. Yes.
Mr. Pitts. Chair thanks the gentleman. Now recognize the
gentlelady from California, Ms. Capps, 5 minutes for questions.
Mrs. Capps. I thank my Chair--colleague for yielding me
time, and I do have a different topic to discuss with you,
Secretary Burwell, but my colleague from Texas has asked for 10
seconds.
Mr. Green. I will do my 10 seconds. I want to thank the
Congressman from Virginia, but I think the clarification is
that up until Congressman Kennedy, all our statements were
repeal the Affordable Care Act without an alternative. Now,
there were bills that were passed, and none of us--up until----
Secretary Burwell. That is right.
Mr. Green [continuing]. Congressman Kennedy, but there is
no repeal and replace. There is only repeal for 56 times. And
thank you for----
Secretary Burwell. And that is why I responded to full
repeal. It was----
Mrs. Capps. I want--thank you. You know, I want to go back
to the President's budget this year, which I think, on the
whole, strikes an important balance between controlling
spending and promoting public health. These public health
topics are what I want to bring to your attention.
I was pleased to see that there was continued support for
nursing workforce development. I believe, and I know you did
too, a strong nursing workforce improves the health of our
communities, as well as the quality of the health care system.
And we now have the significant challenge in our Nation of
caring for a growing patient population with limited resources.
And I am a nurse, so I know that we can't reach our health care
goals without a strong health care workforce made up of a range
of health care professionals. And these are the development
programs, such as Title 8, that are proven to be a solution
that can help address this challenge.
And so would you please discuss briefly, because I have two
more topics, what this budget request does to make sure that we
have a diverse health care workforce, well equipped, and large
enough to meet our needs?
Secretary Burwell. I will just be very brief----
Mrs. Capps. Sure.
Secretary Burwell [continuing]. Which is, I think one of
the core and anchor places that we do that is making sure that
we are funding our National Health Service Corps. And the
increases that we have asked for are a very important part of
that across, and it is especially important because we serve
that group of people--30 percent are diverse in that----
Mrs. Capps. Yes.
Secretary Burwell [continuing]. Group. And in the Nation as
a whole, the number is 10 percent, so we are over-indexing for
that, and we think that is a very important place.
Mrs. Capps. Right.
Secretary Burwell. I will stop. There are other things, but
I want to----
Mrs. Capps. Right, because this one that I am going to
mention is near and dear to my heart, and that is the maternal,
infant, and early childhood home visiting programs. Such bang
for the buck that you get with this. If you have ever seen it
as I have, been part of one, it is such a proactive and
preventive service. And there is an increase in commitment in
this home visiting program in the budget for 2016. These are
evidence-based, as you know, bipartisan programs, helping to
ensure that all children across the board get an opportunity to
be healthy and successful. And they are so critical to
improving health outcomes for both women and children and
families.
So my question is how increased funding for these programs
is going to address disparities and improve the health? How can
we make it better?
Secretary Burwell. So with regard to this issue, because I
am a mother of a 5- and a 7-year-old, I have----
Mrs. Capps. There you go.
Secretary Burwell [continuing]. Learned the importance of
that information very recently, in terms of being able to give
your children what they need. And so the program that you are
describing, and why we think it is important to continue on the
pace, it is an evidence-based program. We have seen----
Mrs. Capps. Yes.
Secretary Burwell [continuing]. The results in terms of
reading, and other analytical skills, up to 12 years old, in
terms of the benefits. That is as far as it has been tested.
And we see that has happened. When we give mothers and parents
that opportunity to get the information they need in home----
Mrs. Capps. Yes.
Secretary Burwell [continuing]. When you go to them, it is
making the difference. And so we believe this is a very
important part, and part of a continuum that you see in the
budget. That home visiting, next comes to that early child
care, and making sure that we fund child care so working
Americans can be a part of that. And then the issues of Head
Start, and improving Head Start, both in terms of the length of
day, the time of year, and the quality that we require. So it
is a continuum in terms----
Mrs. Capps. Yes.
Secretary Burwell [continuing]. Of making sure we are
taking care of those children along the way for working
families, and pressing ourselves to improve quality.
Mrs. Capps. Right. And, to build on that, and the focus on
children and family, this question was asked about graduate
medical education, but I want to focus on children's hospital
GME, because children's hospitals programs are so critical for
training pediatricians, pediatric specialists, and pediatric
researchers. It is less than one percent of hospitals. They
train 51 percent of all pediatric specialists, and the
children's hospital graduate medical education programs
currently receive much less funding than other, you know,
children don't lobby. We have to do this on their behalf. And
would you explain the proposed changes to funding for
children's hospital graduate medical education programs, and
what steps are being taken to ensure that we are meeting the
demand for pediatric care?
Secretary Burwell. We want to meet that demand, and we want
to meet that demand for both primary care, and the specialties
where we don't necessarily have the number of practicing
physicians that we need. And so the proposal that we have tries
to respond to the criticisms that we received last year with
our proposal, and that there is $100 million that is dedicated
firmly to the children's programs. In addition to that, they
are able to compete. Right now what we do is we cover the
direct costs, but we don't continue to cover the indirect cost.
Mrs. Capps. Thank you very much.
Mr. Pitts. Chair thanks the gentlelady. Now recognize the
gentleman from Texas, Dr. Burgess, 5 minutes for questions.
Mr. Burgess. Thank you, Mr. Chairman. Again, Madam
Secretary, my apologies for being out of the hearing, at
another hearing. And I also apologize for not having the
President's budget here with me this morning. But the President
did outline a number of savings in the Medicare space in the
Presidential budget, is that correct? Do I understand----
Secretary Burwell. Yes.
Mr. Burgess [continuing]. That correctly?
Secretary Burwell. That is correct.
Mr. Burgess. And in general, as the head of HHS, are you
supportive of those proposals in the President's budget?
Secretary Burwell. Yes.
Mr. Burgess. Let me ask you a question, then. You know that
one of the things--I mean, I have just been pounding my head
against the wall for 12 years on the sustainable growth rate
formula. We were very close last year. We almost cracked the
nut, but we didn't quite get there. But I thought we had a good
proposal, and we are very close to introducing the same policy
language again in this Congress. Offsets have been difficult,
as everyone would expect.
So let me just ask you, those savings that the President
identified, those Medicare savings that the President
identified in the Presidential budget, do you think it would be
a good idea to apply those savings toward the permanent repeal
of the sustainable growth rate formula?
Secretary Burwell. With regard to how we pay for it in the
President's budget, it is within the baseline, and we include
it that way. With regard to the specific question of just using
our approach to the Medicare, those savings are part of a
broader context. It is a budget, and we put the budget together
in its entirety. We view that those savings need to be paired
with other elements of the budget.
Mr. Burgess. But to the extent that those savers are
identified, and those offsets are identified in the budget, it
seems to me that would perhaps be a reasonable place to begin
the discussion of what are the offsets that are used to put in
place for the permanent, universal, complete, forever repeal of
the sustainable growth rate formula.
Secretary Burwell. First, I want to agree with the concept
that we are talking about. In my opening remarks, I
specifically said that we support the bipartisan, bicameral
concepts that were put forward, and so on that we agree. With
regard to the question of offsets, why I started with how we do
it, which is building it into the baseline, is because that is
the way we believe it should be done, and that uses the balance
of things that we use to pay for things in our entire budget.
So, in terms of where we start, and what we believe, we
believe that it needs to be a range of things, and not simply
focused on those.
Mr. Burgess. Yes, but at the same time, as you know, the
difficulty with the sustainable growth rate formula is the
budget baseline, and the fact that it was built in years ago,
and it accumulates over time. It is never corrected, even
though a number of patches have been passed by Congress. We
basically paid for this damn thing at least 1.4 times----
Secretary Burwell. I am----
Mr. Burgess [continuing]. Over the past 12 years. Again----
Secretary Burwell. Yes.
Mr. Burgess [continuing]. I just want you to know that. I
like the fact that the President put forward cost savers in his
budget. Fair warning to you that these are where I am going to
go. The lack of participation and people who are willing to
come forward and talk seriously about offsets leads me to go
the President's budget as the only place I can go for
Democratic ideas for an offset. And that is the critical
missing piece in getting this SGR settled.
Secretary Burwell. I think your colleague, Mr. Pallone,
actually mentioned his specific idea for this when he spoke to
this issue. And you may disagree with that, but that was in
terms of contributing to the debate.
Mr. Burgess. And my door is always open to Mr. Pallone, and
I await his invitation, and I will be glad to come to his
office.
Let me ask you a question. I know you probably are tired of
hearing about King vs. Burwell, but I will bring it up yet one
more time, since I haven't been here, it is not exhausting to
me yet. On the whole concept around contingency plans, the
American Academy of Actuaries, is concerned because insurance
companies are supposed to disclose the data upon which they are
basing their rates in May, but there could be something that
changes the equation in June. So, to the extent that the
insurance companies are having to deal with an unsettled
future, I mean, they are going to have to deal with contingency
plans, are they not? Why should the Department not have a
contingency plan, as recommended by the American Academy of
Actuaries?
Secretary Burwell. So, with regard to things that I have
authority to plan for, I will plan for. In the current budget
that you see in front of you, the unaccompanied children issue,
one that I know is a difficult issue, and that there is
controversy around, we have put in monies to plan up to 60,
have asked for a contingency fund in case. We don't believe it
will, but in case the numbers--where there are places that I
can plan, we will.
With regard to this issue, while the letter was simple, it
actually gets to the core and the fundamental. We do not
believe we have administrative authorities--if the Court makes
a decision, and as I want to always repeat, we don't believe
the Court will decide this way, but if the Court makes a
decision and rules for Plaintiff, and says that those subsidies
are not available, we don't believe we have an authority to
undo the damage that would then occur, which is subsidies go
away, individuals can no longer pay. They go off of their
insurance, they become uninsured, it drives premiums up in that
marketplace. They become uninsured, there is indigent care, it
goes up.
We don't believe that we have an authority. It is the
Court, makes that decision at that level, that we have an
authority to do it, and therefore that is why you are not
hearing a plan. It is because we don't have an authority.
Mr. Burgess. Well, I think you have to agree it will change
the structure of the risk pools for the insurance companies.
And, Mr. Chair, for that reason, I would like to submit the
letter from the American Academy of Actuaries for the record.
And I will yield back.
Mr. Pitts. Without objection----
Secretary Burwell. I do think, though----
Mr. Pitts [continuing]. So ordered.
Secretary Burwell [continuing]. That is why one does see
those companies filing their briefs that they had filed in the
case, that articulate the point you are making.
[The information appears at the conclusion of the hearing.]
Mr. Pitts. Gentleman yields back. Chair recognizes the
Maryland, Mr. Sarbanes, 5 minutes for questions.
Mr. Sarbanes. Thank you, Mr. Chairman. Thank you, Madam
Secretary. First, thank you for stepping into public service as
you have done. Your tenure at OMB, and now at HHS, is, I think,
a real service to the country.
I wanted to talk about this concept of full repeal, which
has been a drumbeat for years, it seems, now from the other
side of the aisle, to understand the implications of a full
repeal. And so I wanted to go through some of the things that
were part of the ACA, and ask you--and it may not be that every
one of them is jeopardized by a full repeal, but I think
certainly some of them are, the ACA included a measure that
would allow young people to stay on their parents' health care
up to age 26, and I think upwards of three million younger
adults have benefitted from that. If there was a full repeal of
the ACA, would that benefit and provision be in jeopardy, do
you know?
Secretary Burwell. It was part of the original Act, so yes.
Mr. Sarbanes. Then there was an effort to begin closing the
donut hole on prescription drugs under the Part D program,
which has bedeviled many of our seniors, who kind of fall into
that doughnut hole, often at a critical stage, in terms of
needing to access prescription drugs. And the ACA reform
included an effort that is begin, it is underway, to close that
doughnut hole. Would that be in jeopardy if there was a full
repeal?
Secretary Burwell. It would, and the $15 billion in savings
that those seniors have received to date would stop.
Mr. Sarbanes. Right. Then there was terrific provisions, in
terms of benefits and reimbursement. So, on the benefits side,
for Medicare beneficiaries, you had more preventive care being
covered fully, eliminating co-payments for certain kinds of
preventive care, screening for annual wellness visits, et
cetera. That was part of the ACA. A full repeal, I imagine,
would jeopardize that reform as well?
Secretary Burwell. Yes, and we actually just were able to
have the numbers, and we have seen an increase in the number of
seniors that are using that preventative are. And the
percentage of seniors that are using at least one preventative
service continues to go up.
Mr. Sarbanes. Excellent. We put in some enhanced payment
and reimbursement for primary care physicians, recognizing that
we need to make sure we are incentivizing that part of the
profession, in terms of getting into the pipeline, and also
having the opportunity to spend more time with their patients,
and have there be some economic rewards for that, which the
patients themselves also want. I presume that that would be a
peril with a full repeal as well?
Secretary Burwell. A full repeal would imperil.
Mr. Sarbanes. What about the provisions that have
eliminated discrimination based on pre-existing conditions? Of
course, we have started right out of the gate eliminating that
discrimination in the case of children, now that is been
expanded more broadly. But I imagine that also would be
undermined by a full----
Secretary Burwell. It----
Mr. Sarbanes [continuing]. Repeal?
Secretary Burwell. It would, and, having had the chance to
meet a young woman who had cancer when she was 7--when she was
12 years old she first had colon cancer, and then had thyroid
cancer later, and now is in her 20s, and was engaged, but not
continuing her graduate education or getting married because
her focus was paying for her health care. And now the
opportunity to have affordable care--because she had a pre-
existing condition, obviously, is now allowing her to go on
with her life. The issues of health security are very
important, but for many individuals, the financial security is
as well.
Mr. Sarbanes. Thank you for those comments. The medical
loss ratio requirement that now requires insurance plans to
direct more of the insurance premium dollar to care, as opposed
to overhead costs and so forth, that was part of the ACA,
adhering to a particular standard. That would be eliminated, I
would expect, in a full repeal?
Secretary Burwell. In full repeal.
Mr. Sarbanes. Subsidies and tax credits for small
businesses who want to do the right thing and provide health
care coverage for their employees was part of the ACA, so small
businesses would be impacted by a full repeal, in terms of
their ability to offer that kind of benefit to their workers,
isn't that correct?
Secretary Burwell. It would take away the tax credit if it
were a full repeal.
Mr. Sarbanes. So even before we get to a discussion of the
pros and cons of the health exchanges, which have now offered
up coverage to millions of Americans, there are so many other
reasons, in addition to that, that we wouldn't want to repeal
the Affordable Care Act. Thank you very much for being here. I
appreciate your testimony.
Secretary Burwell. Thank you.
Mr. Pitts. The Chair thanks the gentlemen. Now recognize
the gentleman from Florida, Mr. Bilirakis, for questions.
Mr. Bilirakis. Thank you, Mr. Chairman, very much. Thank
you, Madam Secretary for your testimony. Thanks for your
appearance, welcome. I want to talk about Medicare Advantage.
According to 2012 data, there were about 145,000 seniors in my
district. About 40 percent of them are on Medicare Advantage, a
little higher than the national average. They love their plans,
and they want to keep their plans. They love their benefits,
and their choices. Unfortunately, this Administration may not
love Medicare Advantage as much as my seniors.
The actuarial firm of Oliver Wyman did an analysis of the
proposed 2016 Medicare Advantage rate notice. Reading the
report, I am troubled to learn that it estimates that the
combined impact of cuts from 2014 to 2016 will cost seniors on
an average of $60 to $160 a month, or as much as $1,920 a year.
Many of the seniors in my district live on a modest income--
fixed income. Why is the Administration forcing many seniors to
pay more than $100 a month to keep the plan they like?
Secretary Burwell. So, with regard to the issue of Medicare
Advantage, first I want to say we think the program is a good
program. During the period when changes have been enacted, we
have seen the program expand by, I think, well over 40 percent.
We have seen a number of Medicare Advantage plans that have the
top two ratings go from 17 percent to 67 percent. And we have
seen that premiums have not been increasing, in terms of the
changes that we have done to date.
Why we are proposing these changes is they have been
recommended by MedPAC and others with regard to over-coding
that is occurring, and as part of our efforts to make sure we
are using the taxpayer dollar wisely. We want to promote the
program, we want to keep the program healthy, but we also
believe that there are opportunities for those who may be not
using the system as well as they might. And that is what our
changes are about, and that is what we are trying to do,
preserve and build the system, but make sure we do it in the
fiscally responsible way.
Mr. Bilirakis. Thank you, Madam Secretary. Many seniors who
like the Medicare Advantage program they have are going to lose
it in the following years. In fact, a recent--Milliman report
details a nearly four-fold increase in the number of U.S.
counties that no longer have Medicare Advantage as an option,
growing from 55 counties in 2012 to 211 counties in 2015. Isn't
it concerning to you that seniors are losing the ability to
choose a Medicare plan that provides high quality and
coordinated care? This is a very successful program, and,
again, this is extremely important to my constituents.
Secretary Burwell. Agreed that it is a very important
program, and we want to make sure that it continues, want to
see the studies and the underpinning of that. The most recent
numbers that I have seen are that 99 percent of beneficiaries
have access, and so those numbers may not align with that most
recent study, and I want to understand what the difference in
that is.
Mr. Bilirakis. Thank you, Madam Secretary. One more
question. The impact of seniors to Medicare Advantage,
according to Oliver Wyman, could result in seniors losing
access to their current coverage, or facing higher premiums,
reduced benefits, and changes to their network as a result of
the proposed cuts. When I talked with seniors in my district
about Medicare Advantage, again, they believe the Medicare
Advantage model offers high quality coordinated care. Yet
further cuts will disrupt the benefits upon which millions of
seniors rely.
Your agency likes to tout the so-called affordable premiums
and better consumer choices under the Affordable Care Act, but
when it comes to Medicare Advantage, why is the Administration
pursuing policies that would increase premiums and reduce
choices for seniors? And, again, this is very concerning.
Secretary Burwell. I think the responses with regard to the
issue that we have seen, with the changes we have done to date,
have not had the premium pressure that is described. We want to
continue to watch and monitor. And also that we have seen more
people enter in, and the quality improved. And so that is what
we have seen to date. We want to continue to work and monitor.
We want the program to succeed. We want to support it, and we
want to try and do it in the way that is the most fiscally
responsible.
Mr. Bilirakis. Well, thank you, Madam Secretary. I
appreciate it. I yield back, Mr. Chairman.
Mr. Pitts. Chair thanks the gentleman. Now recognize the
gentleman from California, Mr. Cardenas, 5 minutes for
questions.
Mr. Cardenas. Thank you very much, Mr. Chairman. Appreciate
the opportunity to have this public dialogue for the benefit
not only of the members, but for the public as well.
Preserving access to prescription drugs that work for every
senior is important, I think, to everybody on this dais, and I
think every person who cares about a senior in this country,
which probably makes everybody. So my question has to do with
what proposals in the President's budget would increase access
for seniors?
Secretary Burwell. With regard to the specific access for
seniors, across the board on prescription drugs, I think, in
terms of the programs, whether that is the way we use some of
the programs we have just been discussing, but I also think one
of the most important things that has happened is that seniors
have access to preventative services that they historically may
not have. And just announced on Tuesday that what we are seeing
is, because the seniors have that access to those preventative
services, they are increasing the use of that.
I think throughout our budget one the things we are
attempting to do is work very hard to do a delivery system
reform, which means getting better quality at a better price
for the Nation. And I recently announced, about 3 weeks ago,
that in the Medicare space, we are going to try and move to 30
percent of all Medicare payments will be in new payment models,
payment models that are about improving that quality and
reducing that cost. And so those are some of the areas that I
think the budget focuses on this.
Mr. Cardenas. Now, that effort, is it likely to create an
environment, individual by individual, that is likely to
increase their quality of extended life versus--because when we
are talking about access to preventative care, that means that
if you catch something in its early stages--we all know what
today's modern medicine, and opportunities--you can actually
thwart it, or actually overcome it, versus finding something
late in stages, it might even take your life, correct?
Secretary Burwell. And across the department there are a
number of investments that get to that, and whether that is the
NIH investments in research, or in the Center for Innovation in
Medicare and Medicaid, one of the things where we have out--a
proposal that we are getting response to has to do with hospice
and curative care, and how to combine those two in a way that
will maximize for the quality of the patient. And so it is
throughout the budget these issues of cost and quality are
things that we focus on.
Mr. Cardenas. Thank you. On that note, I would also like to
add for the record, if you would allow me unanimous consent,
Mr. Chairman, to submit a letter for the record from my office
that lays out the issues that we are discussing at the moment.
Mr. Pitts. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Secretary Burwell. Thank you.
Mr. Cardenas. I keep hearing a lot from some of my
colleagues about their constituents losing choices. But, then
again, one of the things that--it is my understanding, please
clarify, that when people are talking about losing choices,
they may be describing policies that were, in fact more
expensive on the front, and perhaps didn't have minimum
benefits standards to the person paying. Is that, in many
cases, what people are describing when people are losing
choices?
Secretary Burwell. It can be. I would want to understand
the specific----
Mr. Cardenas. And that is why I say the word maybe----
Secretary Burwell [continuing]. In the marketplace.
Mr. Cardenas. Maybe, yes.
Secretary Burwell. Within the marketplace, there are 25
percent more issuers, which means more choice. The essential
health benefits do important things, I think, as you are
reflecting, and they get to some of the issues that Mr. Murphy
and Ms. Matsui--on mental health. And having those benefits be
clear and incorporated is extremely important. So, without
understand the specific case, I think it is a little hard to
know.
Mr. Cardenas. But there are, in fact, in some areas where
certain kinds of policies are not allowed, but that was--that
is based on a new minimum standard, correct?
Secretary Burwell. That is correct.
Mr. Cardenas. And one of the things that I have discussed
with some of my constituents, and my staff, and some of the
providers, and experts that we pulled together, we registered
at least over 1,000 families. And I personally tried to speak
to as many of those individuals as possible. And what was sad
is many of them were even scared to be there. They were
thinking about this big Obamacare dragon that was going to
obliterate either their finances or their health care.
But what--almost to a person, every person that got up
from--once they sat down and figured out what was available to
them, or what have you, had a big smile on their face, and they
were very pleased, and very relieved, and glad they came. And
in one instance I was talking to a gentleman who was paying $60
a month. He was making $9 an hour, single income family. He had
a wife and a daughter, and I met all three of them. And when he
was done, he had a big smile on his face. He almost got up and
left when he met me. But when he was done, he actually realized
that he now was able to provide for his family without having
to spend $60 a month, and now his entire family has coverage.
So I think that is a perfect example of what this is--what is
good in the Affordable Care Act.
Thank you, Mr. Chairman. I yield back my time.
Mr. Pitts. Chair thanks the gentleman. Now recognize the
gentleman from Indiana, Dr. Buschon, 5 minutes for questions.
Mr. Buschon. Thank you, Secretary Burwell, and thanks for
coming. And, first of all, I want to thank you for working with
Governor Mike Pence of Indiana on Health Indiana Plan 2.0,
which will help to cover 350,000 low income Hoosiers in a
state-based program that, I think, has been shown historically
to not only save money, but is very popular with the enrollees,
so thank you very much for that work.
Before I came to Congress, I was a cardiothoracic surgeon,
and I treated most of my patients for many weeks after their
surgery. And, as you probably know, that falls under a global
payment, a 90-day global surgical payment by CMS. Now CMS wants
to repeal that rule, and eliminate global payments for surgical
services. Why?
Secretary Burwell. With regard to our understanding of how
the global payments are used, the reason that we want to do
this is to make sure that, while we are promoting quality care,
that we do it in a way that is most cost-effective for the
taxpayer. Most of the changes that we do in the Medicare space
are focused on those two things, and trying to balance those
two.
Mr. Buschon. OK. And has HHS or CMS looked into the
administrative costs the new systems will have on doctors and
CMS? The reason I ask is, in my practice--I will give you some
examples of how this actually will work----
Secretary Burwell. Yes.
Mr. Buschon [continuing]. Or won't work if you do it. We
would bill a global payment, for everything, including follow-
up visits.
Secretary Burwell. Yes.
Mr. Buschon. And now doctors will be billing for the
surgery, every hospital round that they make, every follow-up
appointment, all separately, let me finish. And not only would
the medical practice have to pay employees to submit what I
consider excessive claims, but then CMS will have to process
each claim. And how can that not cost CMS more money, not less?
That is my first question.
Secretary Burwell. With regard to the global payment issue,
and one of the things--Dr. Patrick Conway--we try and have
physicians who are practicing at the table as we have these
conversations. Want to understand the point that you are making
and how we believe--I want to look into this one, in terms of a
specific answer to your----
Mr. Buschon. It will be a dramatic increase. Let me tell
you why. If I did an open heart surgery on a patient, I would
see them in the ICU anywhere from 3 to 5 days every day, and
then probably two to three follow-up appointments. That is all
under a global.
Secretary Burwell. Yes.
Mr. Buschon. And so now that--those numbers will be
submitted as individual bills. From a surgeon's perspective, I
see this as--and I think seniors should be paying attention to
these comments. This is going to be a dramatic pay cut for
surgeons across this country, and that is--in my view, that is
where any potential savings will be coming from. So as you look
at this, you should really--I would encourage you to pay
attention to that, because what will happen is there is going
to have to be re-evaluation of every code, re-evaluation of
every follow-up appointment. You are going to have to discern
whether there is duplicate billing. For example, if I see a
patient post-op in the ICU, and a critical care physician is
also seeing my patient that day, who gets paid, who doesn't get
paid? There will be increased denials. My point is this. Global
payments were put in place to save money----
Secretary Burwell. Yes.
Mr. Buschon [continuing]. Administratively, and also
simplify, and I think improve, quality of health care. And I
think going backwards away from that is regressing backwards.
Yes, it will save money. This will save money by dramatically
cutting provider reimbursement. And if that is the intent, that
is unfortunate, because what will also result is access issues
for seniors for health care services, and, I would argue, less
quality health care.
And so, most of these bundles are re-examined every few
years by--and so the argument that overbilling is occurring, if
that were to be true, then these bundles are looked at every
couple years and re-evaluated, so, on that subject, I would
encourage you to take a really hard look at global payments.
They save money, and they don't cost money. The savings will be
on the backs of seniors' access to health care, and quality, in
my opinion.
The other thing is the President's budget would seek to
save 20.9 billion in savings over the next 10 years by
strengthening the IPAD Board, a board of unelected members
selected by the President to cut--in my view, to cut Medicare
payments to providers. I understand the President has not yet
nominated anyone to sit on the IPAD Board, so it could not
recommend Medicare cuts this year. So in what year under the
President's budget will IPAD begin to make recommendations on
Medicare costs?
Secretary Burwell. In the current President's budget, IPAD
would not kick in until 2019.
Mr. Buschon. 2019?
Secretary Burwell. That is right.
Mr. Buschon. OK. Thank you. Thank you, Mr. Chairman. I
yield back.
Mr. Pitts. Chair thanks the gentleman. Now recognize the
gentleman from New York, Mr. Collins, 5 minutes for questions.
Mr. Collins. Thank you, Mr. Chairman, and thank you,
Secretary, for being here today. I am from Western New York,
which is a very rural community. We have one of the highest
enrollments for Medicare Advantage. I know prior to the
Affordable Care Act I would say that without a doubt one of the
bright spots in the delivery of health care in the United
States was Medicare Advantage. Dealt with the donut hole. It
was a lot of comfort for the seniors to be able to go in, much
like we do with HMOs--a great program. And yet, as was brought
out earlier, and I want to get into this, it seems as though
the President, and the Administration, and HHS views Medicare
Advantage with some level of disdain, in that it is the piece
that keeps getting cut.
And as I look through some of the data, and I am kind of a
data-driven guy, the interesting thing I found about Medicare
Advantage, there are over seven million enrollees, represents
almost 30 percent of the Medicare population, which would
indicate it works. Number two, when you look at who uses it,
lower income beneficiaries have a higher enrollment in Medicare
Advantage than do wealthier individuals, which means it is
serving best some of the lower income populations. We have also
seen that, when I look at the rural plans, again, in rural
America, which I represent, a higher percentage of folks from
rural America are using it.
So I am just asking the question, as--and the interesting
thing too, the--that information we got today was from AHIP.
They said the current 0.9 percent, the 0.9 percent cut that is
coming now in the subsidy to insurance companies for Medicare
Advantage, is going to add another $20 a month to
beneficiaries, either in higher premiums, or reduced benefits.
So could you speak to just the opinion of older Americans on
Medicare, that they are being used as the funding source for
the expansion in Medicaid, and all of those increased costs on
the back of our seniors, who have depended on this great
program for all these years? A frustration level exists within
that population.
Secretary Burwell. Appreciate that, and as I responded to
your colleague with regard to the issues of Medicare Advantage,
I would say we support the program, believe the program is a
good program, but also believe that our responsibility, where
we think there are things that are happening, whether that is
up-coding or other things, that we try and take care of that.
The changes that we have done, we have tried to transition
those changes. We have tried to do those changes slowly so that
we watch and monitor. We have seen an increase in the number of
people in Medicare Advantage. We have seen premiums hold
steady. We have seen an increase in quality. So the negative
impacts that were articulated at the beginning of those
proposals, we have not seen. We want to continue to monitor and
make sure that we don't see some of the negative impacts that
you were talking about. We value the program. We think the
changes--they have been recommended by MedPAC and others.
We understand the concerns, but trying to operate in a
world--and with regard to the other issue that you mentioned, I
would just say across the board--and whether it is the issue
that your colleague just mentioned, with regard to--or the $780
million we do in discretionary cuts, we try to spread these
things across the entire parts of our budget.
Mr. Collins. But are you aware that there now over 200
counties in the United States that don't have a Medicare
Advantage plan at all to offer their seniors as a direct result
of the cuts you have made? So when you say it hasn't had this
impact, there are seniors in over 200 counties in the United
States that can't even buy the coverage.
Secretary Burwell. So 99 percent of the Nation has
coverage, in terms of the beneficiaries' accessibility.
Mr. Collins. But yet the number who don't has increased,
from 55 counties before the ACA to over 200 today. So there is
a direct impact. I mean, the data is the data. You can't make
it go away.
Secretary Burwell. With regard to those numbers, as I said,
I have the number of the current coverage, and would want to
understand the change over the----
Mr. Collins. Yes. What I am trying to point out is it has
had--the reason you are looking for this funding is to pay for
the expansion of Medicaid. I mean, whether it is the health
insurance tax, or the individual mandate, or whatever, the big
cost driver has been this huge expansion in Medicaid, would be
my observation.
Secretary Burwell. What I would observe is some of the
comments that have been stated about the question of overall
entitlements and the growth, we have a bulge of population. We
have a large group of people who are elderly in Medicare. The
Medicare costs, even though we have controlled per capita costs
for Medicare over the period of what we are seeing, because
more people from the baby boom are retiring and older, that is
an issue that we, as a Nation, are going to have to look at and
deal with. Medicare costs are going to continue to increase
because of volume, even if we can control per capita cost.
And so with regard to the questions of what will be costing
the Nation money over periods of time, the issue of Medicare is
one on a--because we are going to have the baby boom, and the
echo come through, we are going to continue to have to make
good on the commitments we have made. And that will cost us,
because even if you control it per capita, volume is greater.
Mr. Collins. Well, thank you for the answer. My time has
expired. Yield back.
Mr. Pitts. Chair recognize the gentleman from New Mexico,
Mr. Lujan, 5 minutes for questions.
Mr. Lujan. Thank you very much, Mr. Chairman, and I would
yield to our Ranking Member, Mr. Green, for a quick response as
well.
Mr. Green. Thank you, Mr. Chairman. I want to respond to my
colleague from New York. I have not had any of my seniors
question the expansion of Medicaid, based on what is happening
with Medicare. The Affordable Care Act was totally paid for,
and, in fact, Medicare was improved under the Affordable Care
Act. And, Madam Secretary, this is the first I have heard that
seniors are complaining that the Medicaid expansion is being
paid out of Medicare. That is just not, in fact, that I hear
about. Did you have any information on that?
Secretary Burwell. That is the first that I have heard that
anyone felt that that was an issue, with regard to the Federal
budget, because I assume that is what they are referring to.
Mr. Collins. If the gentleman would yield one minute----
Mr. Lujan. Thank you. Reclaiming my time, thank you, Madam
Secretary, for your testimony today. I want to reiterate what
many of my colleagues have said, that we must repeal the SGR,
but not on the backs of seniors, and that a strong CHIP
extension must be included with the SGR in March as well. Also
that the Affordable Care Act is working, despite an attempt of
over 50 Republican repeal attempts. The ACA has had a positive
impact on New Mexico, in my home state. In my home district,
25,000 people now have quality, affordable health coverage
because of the Affordable Care Act that didn't before, and
overall the numbers of uninsured has declined by 17 percent.
With the law now full in effect, Americans can never be
discriminated against because of pre-existing conditions. Women
can never be charged more for coverage because of their gender,
and Americans will never be sold health insurance policies that
disappear when they need coverage most, when they hit those
lifetime caps, and suddenly coverage goes away. I think that it
is time that we come together and work to strengthen the law,
and stop playing political games that will strip millions of
Americans of the health coverage they depend on. As my father
would say, enough is enough.
Madam Secretary, in your opinion, has the Affordable Care
Act had a positive impact on places around the country,
including my home state of New Mexico?
Secretary Burwell. Yes, and I think it has in three areas,
affordability, access, and quality. With regard to the issues
of quality, you touched upon a number of the areas where I
believe there is been an improvement in quality, and those are
the fact that people can have their children covered up to 26,
the quality that you don't--if you have a pre-existing
condition, you can't be kept out, or thrown off of your health
care. If you take your child in for their wellness visit, there
isn't co-insurance. You don't have to pay, in terms of that
preventative care. So increases in quality. We have also seen
increases in quality through partnerships we are doing with
physicians, and we have seen a 17 percent reduction in harms.
Those are things like infections and falls in hospitals. That
is also about saving lives, but it is also about money.
With regard to the issue of affordability, and the progress
that we have made on affordability, while we can all still
continue to make more, we have in that space, and what we have
seen is that, in the years 2011, '12, and '13, we have seen a
record in terms of per capita health care cost growth. It is
one of the lowest that we have seen on record, and we have seen
that. That is in the broader marketplace.
With regard to the individual market, what we have seen is
that people--the vast majority, over 8 in 10 folks in the
marketplace can find coverage using a subsidy that is $100 or
less in a month. That is affordability in that marketplace.
With regard to affordability and the taxpayer, CBO estimates
pre the Affordable Care Act would have estimated that spending
in Medicare would have been $116 billion greater. Affordability
for the taxpayer.
Lastly, access. The question of access, and the fact that
11.4 million people have come through the marketplace this
time, but let us even use last year's number, where we saw a 10
million person drop in the number of uninsured. So, against the
three fundamental measures, that is how I would think about it.
Mr. Lujan. I appreciate that, Madam Secretary. Thank you
for your response there, and I do want to raise an issue that
has great concern to my constituents and to myself back in New
Mexico. It has now been over 18 months since the State of New
Mexico claimed credible allegations of fraud, or their
allegations of fraud, against 15 behavioral health providers,
resulting in the eventual closure or replacement by five
Arizona behavioral health providers. This transition and
turmoil has raised significant concerns across access to care,
especially in light of recent reports that the new providers
are financially unstable. In fact, one provider is already
pulling out of New Mexico.
The recently elected New Mexico Attorney General has also
released the audit that led to the suspension, and it shows a
lack of underlying basis for many of the allegations of fraud.
My staff has had several meetings with CMS, and I am very
concerned that we are not making progress. When payment
suspensions are put into place, what CMS do to ensure states
are acting in good faith, and what is CMS doing to stop the
reoccurrence of this happening, both in New Mexico and other
states, and can I have your commitment that we can work
together on this particular issue and met with the delegation?
Secretary Burwell. Do want to work with you on this issue.
Know it is one of concern, in terms of making sure that people
have access to those benefits.
Mr. Lujan. I appreciate that. Thank you very much. I yield
back the balance of my time.
Mr. Pitts. Thank the gentleman. Now recognize the
gentlelady from North Carolina, Ms. Ellmers, 5 minutes for----
Mrs. Ellmers. Thank you. And thank you, Madam Secretary,
for being with us today. I do have three different questions to
ask you about, but I do want to address the issue of Medicare,
and our seniors who are concerned. It is my recollection, and I
am just going back to history, that over $700 billion was taken
out of Medicare in order to pay for Obamacare. About 300
billion of that was Medicare Advantage. So to the question of
whether or not our seniors are concerned about that, I say yes,
they are concerned about that, and they want to make sure that
they will be able to continue to get the care they deserve.
I want to start off by talking about Medicare reimbursement
in relation to the two percent sequester cuts that were put in
place a number of years ago, which dramatically affected our
chemotherapy drugs and Part B drugs. As you know, this has
affected our industry. Back on January 14 of 2013, Office of
Management and Budget put out a letter asking Federal agencies
to, ``use any available flexibility to reduce operational
risks, and minimize impacts of the agency's core mission in
service of the American people.''
Some adverse things happened as a result. of the two
percent cut over 16 months, after CMS started applying the two
percent cut, We basically ended up with 25 community oncology
clinics closing, one of which was a very large clinic in my own
district. Seventy five others merged with hospitals. CMS's own
numbers show that it costs $6,500 more per year per patient on
oncology services if they are part of the hospital system,
versus the clinic setting, or outpatient setting, which is
about $650 more out of pocket.
Why hasn't CMS taken the recommendation of OMB and
addressed that situation?
Secretary Burwell. Congresswomen, we agree with you about
sequester, and in this budget, we fully get rid of sequester,
both on the mandatory side, and on the discretionary side. We
believe there are other choices that are better choices, and so
agree with you, this is not an approach--when you use an
approach like this----
Mrs. Ellmers. Yes.
Secretary Burwell [continuing]. You end up doing things
like the types of things you are talking about. And so what we
want to do is fully replace it, and that is what our budget
does. We are willing to make other choices, in terms of how we
get those savings.
Mrs. Ellmers. Thank you. And I will go on to a very
important question, having to do, essentially, with our tobacco
products. My question for you is, do you agree with Mitch
Zeller, Director of FDA Center for Tobacco Products, that if
the smokers, and I am quoting him, ``who are otherwise unable
or unwilling to quit were to completely switch to smokeless
tobacco products, it would be good for the public health.'' Do
you agree with this statement?
Secretary Burwell. I would have to understand the context
in which he made that statement. With regard to the question, I
think, you know, we want to promote the public health. We want
to----
Mrs. Ellmers. Yes.
Secretary Burwell [continuing]. Make sure we are doing the
right research to understand that, and put in place the right
guidelines and regulations to do it.
Mrs. Ellmers. Well, thank you. I do want to add that there
are no government Web sites that help promote or address this
issue, including CDC, FDA, NIH. It would be helpful for the
public to understand that there are the non-tobacco products
available, and this is an approach we need to make. I would
welcome the ability to continue to work with you, and your
office, on any way that we can better help to get the
information out, and address the needs from a scientific basis,
using the scientific research that is out there.
I do want to switch gears to our vaccines and to BARDA.
Right now BARDA maintains a stockpile of roughly $1.7 billion
worth of pandemic influenza vaccine. This year's budget, I
believe, is about $20 million in order to take care of that
stockpile and maintain it. Does the 2016 budget increase that
amount, and how does BARDA plan on dealing with those issues,
especially when our situation is very timely?
Secretary Burwell. Across the board our budget has worked
to do a couple of things with regard to the preparedness,
making sure that that vaccine stockpile, and that the issues
that BARDA handles----
Mrs. Ellmers. Yes.
Secretary Burwell [continuing]. Which are making sure that
what we have on hand in stockpile, and that we have the ability
to work with manufacturers to bring new products online, where
that is appropriate----
Mrs. Ellmers. Yes.
Secretary Burwell [continuing]. For different types of
issues that we as a Nation may face, either man-made or
otherwise. But we also have paired that with things in our
budget which are about the preparedness in our communities----
Mrs. Ellmers. Yes.
Secretary Burwell [continuing]. And we have seen that front
and center, certainly, in our time period. We are implementing
the dollars we appreciate from Congress as part of that, in
terms of Ebola, but also broader preparedness----
Mrs. Ellmers. Yes.
Secretary Burwell [continuing]. Where we have been given
that authority by the Congress.
Mrs. Ellmers. Thank you, Secretary Burwell, for being here
today. I truly appreciate your input. Thank you.
Secretary Burwell. Thank you.
Mr. Pitts. Chair thanks the gentlelady. That concludes the
questions of the members who are present. I am sure we will
have lots of follow up and written questions from some of the
members, so we will get those to you promptly. We ask that you
please respond to the questions promptly. I remind members that
they have 10 business days to submit questions for the record,
and that means they should submit their questions by the close
of business on Thursday, March the 12th.
Thank you very much, Madam Secretary, for your attendance
today and your answers. Without objection, subcommittee is
adjourned.
[Whereupon, at 12:55 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
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[Secretary Burwell did not respond to submitted questions
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