[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]








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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

                              ----------                              
                                                                   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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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 
by the time of printing.]

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