    [House Hearing, 114 Congress]
    [From the U.S. Government Publishing Office]

                           EXAMINING THE POLICIES AND
                               PRIORITIES OF THE
                           U.S. DEPARTMENT OF HEALTH
                               AND HUMAN SERVICES

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

                                    HEARING

                                   before the

                             COMMITTEE ON EDUCATION
                               AND THE WORKFORCE
                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                 HEARING HELD IN WASHINGTON, DC, MARCH 15, 2016

                                   __________

                               Serial No. 114-41

                                   __________

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                    COMMITTEE ON EDUCATION AND THE WORKFORCE

                        JOHN KLINE, Minnesota, Chairman

    Joe Wilson, South Carolina           Robert C. ``Bobby'' Scott,
    Virginia Foxx, North Carolina            Virginia
    Duncan Hunter, California              Ranking Member
    David P. Roe, Tennessee              Ruben Hinojosa, Texas
    Glenn Thompson, Pennsylvania         Susan A. Davis, California
    Tim Walberg, Michigan                Raul M. Grijalva, Arizona
    Matt Salmon, Arizona                 Joe Courtney, Connecticut
    Brett Guthrie, Kentucky              Marcia L. Fudge, Ohio
    Todd Rokita, Indiana                 Jared Polis, Colorado
    Lou Barletta, Pennsylvania           Gregorio Kilili Camacho Sablan,
    Joseph J. Heck, Nevada                 Northern Mariana Islands
    Luke Messer, Indiana                 Frederica S. Wilson, Florida
    Bradley Byrne, Alabama               Suzanne Bonamici, Oregon
    David Brat, Virginia                 Mark Pocan, Wisconsin
    Buddy Carter, Georgia                Mark Takano, California
    Michael D. Bishop, Michigan          Hakeem S. Jeffries, New York
    Glenn Grothman, Wisconsin            Katherine M. Clark, Massachusetts
    Steve Russell, Oklahoma              Alma S. Adams, North Carolina
    Carlos Curbelo, Florida              Mark DeSaulnier, California
    Elise Stefanik, New York
    Rick Allen, Georgia

                        Juliane Sullivan, Staff Director
                     Denise Forte, Minority Staff Director

                                C O N T E N T S

                                  ----------
                                                                       Page

    Hearing held on March 15, 2016...................................     1

    Statement of Members:
        Kline, Hon. John, Chairman, Committee on Education and the
          Workforce..................................................     1
            Prepared statement of....................................     3
        Scott, Hon. Robert C. ``Bobby'', Ranking Member, Committee on
          Education and the Workforce................................     4
            Prepared statement of....................................     7

    Statement of Witnesses:
        Burwell, Hon. Sylvia Mathews, Secretary, U.S. Department of
          Health and Human Services, Washington, DC..................     9
            Prepared statement of....................................    12

    Additional Submissions:
        Byrne, Hon. Bradley, a Representative in Congress from the
          state of Alabama:
            Slides...................................................    37
        Carter, Hon. Buddy, a Representative in Congress from the
          state of Georgia:
            Letter dated March 22, 2016, from Secretary Burwell......    65
        Chairman Kline:
            Prepared statement of the U.S. Chamber of Commerce.......    67
        Pocan, Hon. Mark, a Representative in Congress from the state
          of Wisconsin:
            Letter from Brent Nathan Brown...........................    72
        Questions submitted for the record by:
            Allen, Hon. Rick, a Representative in Congress from the
              state of Georgia.......................................    83
            Bishop, Hon. Michael D., a Representative in Congress
              from the state of Michigan.............................    82
            Mr Byrne.................................................    81
            Mr. Carter...............................................    82
            Clark, Hon. Katherine M., a Representative in Congress
              from the state of Massachusetts........................    86
            Foxx, Hon. Virginia, a Representative in Congress from
              the state of North Carolina............................    77
            Fudge, Hon. Marcia L., a Representative in Congress from
              the state of Ohio......................................    84
            Heck, Hon. Joseph J., a Representative in Congress from
              the state of Nevada....................................    79
            Chairman Kline...........................................    76
            Messer, Hon. Luke, a Representative in Congress from the
              state of Indiana.......................................    81
            Polis, Hon. Jared, a Representative in Congress from the
              state of Colorado......................................    85
            Roe, Hon. David P., a Representative in Congress from the
              state of Tennessee.....................................    78
            Mr. Scott................................................    83
            Walberg, Hon. Tim, a Representative in Congress from the
              state of Michigan......................................    78
            Wilson, Hon. Frederica S., a Representative in Congress
              from the state of Florida..............................    85
        Secretary Burwell's responses to questions submitted for the
          record.....................................................    88

                     EXAMINING THE POLICIES AND PRIORITIES
                        OF THE U.S. DEPARTMENT OF HEALTH
                               AND HUMAN SERVICES

                                  ----------

                            Tuesday, March 15, 2016

                         U.S. House of Representatives

                    Committee on Education and the Workforce

                                Washington, D.C.

                                  ----------

        The Committee met, pursuant to call, at 10:00 a.m., in room
    2176 Rayburn House Office Building. Hon. John Kline [chairman
    of the committee] presiding.
        Present: Representatives Kline, Foxx, Roe, Thompson,
    Salmon, Rokita, Barletta, Messer, Byrne, Carter, Bishop,
    Russell, Curbelo, Stefanik, Allen, Scott, Hinojosa, Davis,
    Courtney, Fudge, Polis, Sablan, Wilson, Bonamici, Pocan,
    Takano, Jeffries, Clark, Adams, and DeSaulnier.
        Staff Present: Andrew Banducci, Workforce Policy Counsel;
    Janelle Belland, Coalitions and Members Services Coordinator;
    Kathlyn Ehl, Professional Staff Member; Ed Gilroy, Director of
    Workforce Policy; Callie Harman, Legislative Assistant;
    Christie Herman, Professional Staff Member; Tyler Hernandez,
    Press Secretary; Amy Raaf Jones, Director of Education and
    Human Resources Policy; Nancy Locke, Chief Clerk; Michelle
    Neblett, Professional Staff Member; Brian Newell,
    Communications Director; Krisann Pearce, General Counsel;
    Alexandra Pena, Staff Assistant; Lauren Reddington, Deputy
    Press Secretary; Alissa Strawcutter, Deputy Clerk; Juliane
    Sullivan, Staff Director; Leslie Tatum, Professional Staff
    Member; Olivia Voslow, Staff Assistant; Tylease Alli, Minority
    Clerk/Intern and Fellow Coordinator; Pierce Blue, Minority
    Labor Detailee; Jacque Chevalier, Minority Senior Education
    Policy Advisor; Denise Forte, Minority Staff Director;
    Christine Godinez, Minority Staff Assistant; Carolyn Hughes,
    Minority Senior Labor Policy Advisor; Eunice Ikene, Minority
    Labor Policy Associate; Brian Kennedy, Minority General
    Counsel; Richard Miller, Minority Senior Labor Policy Advisor;
    Alexander Payne, Minority Education Policy Advisor; Veronique
    Pluviose, Minority Civil Rights Counsel; and Marni von Wilpert,
    Minority Labor Detailee.
        Chairman Kline. A quorum being present, the Committee on
    Education and the Workforce will come to order. Good morning,
    everyone, and welcome, Secretary Burwell. We appreciate you
    joining us to discuss the policies and priorities of the
    Department of Health and Human Services.
        From welfare and health care to early childhood development
    and support services for older Americans, the policies your
    department oversees affect the lives of millions of Americans.
        Conversations like this one are vitally important as we
    work to ensure that the Department is acting in the best
    interest of the taxpayers and those in need.
        As we examine what programs and policies are working and
    which ones are in need of improvement, I hope there are a
    number of areas where we can find common ground.
        Of course, there are also areas where we will ultimately
    agree to disagree, and perhaps the most prominent example is
    the President's health care law. As has been the case for
    nearly six years, this flawed law continues to hurt working
    families, students, and small businesses. It is still
    depressing hours and wages for low-income workers, still making
    it harder for individuals to receive the care they need, and
    still driving up health care costs.
        One Emory University professor recently wrote that his
    family's health insurance premium is now their biggest expense,
    even greater than their mortgage. Before the health care law
    went into effect, this man was able to cover his entire family
    of four for less than $13,000. Now, the cost of insuring just
    him and his wife is nearly $28,000. Twice the cost to cover
    half as many people. In fact, paying more for less is becoming
    a hallmark of the health care law.
        Over the years, Republicans have put forward a number of
    health care reform ideas, ones that would expand access to
    affordable care and lead to a more patient-centered health care
    system. We will continue to do so, because we firmly believe
    the President's health care law is fatally flawed and
    unsustainable, and more importantly, because we believe the
    American people deserve better.
        Again, I suspect we will have to agree to disagree, but as
    I mentioned, there are areas where I am hopeful we can find
    common ground.
        Head Start, for example, currently supports nearly 1
    million children at a cost of more than $9 billion annually. It
    is an important program for many low-income families. However,
    concerns persist that it is not providing children with long-
    term results.
        We both agree, I am sure, changes need to be made, but so
    far we have different ideas of what reform should look like.
    The Department is in the process of fundamentally transforming
    Head Start through regulations that will have serious
    consequences for the vulnerable families this important program
    serves.
        We, on the other hand, have outlined a number of key
    principles that we believe will strengthen the program based on
    feedback we collected from parents and providers.
        I look forward to discussing where we might be able to find
    middle ground and work together so that these children can have
    the solid foundation they need to succeed in school and in
    life.
        I am also hopeful that we can work together to ensure
    changes to the Preschool Development Grants program are
    implemented as Congress intended. The Every Student Succeeds
    Act reformed the program to help States streamline and
    strengthen early learning efforts.
        To accomplish this goal, Congress moved the program from
    the Department of Education to HHS, which already oversees the
    bulk of early learning programs. As you take on this
    responsibility, Madam Secretary, please know we intend to stay
    engaged with the Department to ensure a successful transition.
        Finally, the Department is also responsible for helping
    States to prevent and respond to child abuse and neglect,
    specifically those outlined in the Child Abuse Prevention and
    Treatment Act or CAPTA. As I am sure you are aware, this law
    provides States with resources to improve their child
    protective service systems, if they make a number of assurances
    concerning their child welfare policies.
        It has come to our attention that some States are making
    these assurances without putting the necessary policies in
    place. Yet, not a single State is being denied Federal funds.
        A Reuters' investigation recently revealed the shocking and
    deadly consequences of this neglect and cast serious doubts as
    to whether basic requirements of the law are being met and
    enforced.
        In light of this tragic report, we wrote to you to better
    understand the Department's process in reviewing and approving
    State plans under CAPTA, and I would like to continue that
    discussion here today.
        It is clear that the current system is failing some of our
    country's most vulnerable children and families, and something
    has to change.
        As you can see, we have quite a bit to cover today. These
    and other issues are vitally important to the men and women we
    serve, and we have a responsibility to ensure that we are
    serving those individuals in the best way possible.
        With that, I will now recognize the ranking member, Mr.
    Scott, for his opening remarks.
        [The information follows:]

               Prepared Statement of Hon. John Kline, Chairman,
                    Committee on Education and the Workforce

        From welfare and health care to early childhood development and
    support services for older Americans, the policies the Department of
    Health and Human Services oversees affect the lives of millions of
    Americans. Conversations like this one are vitally important as we work
    to ensure the department is acting in the best interests of taxpayers
    and those in need. As we examine what programs and policies are
    working, and which ones are in need of improvement, I hope there are a
    number of areas where we can find common ground.
        Of course, there are also areas where we will ultimately agree to
    disagree, and perhaps the most prominent example is the president's
    health care law. As has been the case for nearly six years, this flawed
    law continues to hurt working families, students, and small businesses.
    It's still depressing hours and wages for low-income workers, still
    making it harder for individuals to receive the care they need, and
    still driving up health care costs.
        One Emory University professor recently wrote that his family's
    health-insurance premium is now their biggest expense - even greater
    than their mortgage. Before the health care law went into effect, this
    man was able to cover his entire family of four for less than $13,000.
    Now, the cost of insuring just him and his wife is nearly $28,000.
    That's right - twice the cost to cover half as many people. In fact,
    paying more for less is becoming a hallmark of the health care law.
        Over the years, Republicans have put forward a number of health
    care reform ideas, ones that would expand access to affordable care and
    lead to a more patient-centered health care system. We will continue to
    do so, because we firmly believe the president's health care law is
    fatally flawed and unsustainable, and more importantly, because we
    believe the American people deserve better.
        Again, I suspect we will have to agree to disagree, but as I
    mentioned, there are areas where I am hopeful we can find common
    ground.
        Head Start, for example, currently supports nearly one million
    children at a cost of more than $9 billion annually. It's an important
    program for many low-income families. However, concerns persist that
    it's not providing children with long-term results.
        We both agree changes need to be made, but so far, we have
    different ideas on what reform should look like. The department is in
    the process of fundamentally transforming Head Start through
    regulations that will have serious consequences for the vulnerable
    families this important program serves. We, on the other hand, have
    outlined a number of key principles that we believe will strengthen the
    program based on feedback we collected from parents and providers. I
    look forward to discussing where we might be able to find middle ground
    and work together so that these children can have the solid foundation
    they need to succeed in school and in life.
        I'm also hopeful that we can work together to ensure changes to the
    Preschool Development Grants Program are implemented as Congress
    intended. The Every Student Succeeds Act reformed the program to help
    states streamline and strengthen early learning efforts. To accomplish
    this goal, Congress moved the program from the Department of Education
    to HHS, which already oversees the bulk of early learning programs. As
    you take on this responsibility, Secretary Burwell, please know we
    intend to stay engaged with the department to ensure a successful
    transition.
        Finally, the department is also responsible for helping states to
    prevent and respond to child abuse and neglect, specifically those
    outlined in the Child Abuse Prevention and Treatment Act or CAPTA. As
    I'm sure you're aware, this law provides states with resources to
    improve their child protective services systems - if they make a number
    of assurances concerning their child welfare policies. It's come to our
    attention that some states are making these assurances without putting
    the necessary policies in place. Yet, not a single state is being
    denied federal funds.
        A Reuters' investigation recently revealed the shocking and deadly
    consequences of this neglect and cast serious doubts as to whether
    basic requirements of the law are being met and enforced. In light of
    this tragic report, we wrote to you to better understand the
    department's process in reviewing and approving state plans under
    CAPTA, and I'd like to continue that discussion today. It's clear that
    the current system is failing some of our country's most vulnerable
    children and families, and something has to change.
        As you can see, we have quite a bit to cover today. These and other
    issues are vitally important to the men and women we serve, and we have
    a responsibility to ensure they are serving those individuals in the
    best way possible.
                                     ______

        Mr. Scott. Thank you, Chairman Kline, and welcome,
    Secretary Burwell. Thank you for being with us. We look forward
    to your testimony.
        Today, we will hear about the President's Fiscal Year 2017
    Health and Human Services' budget proposal and the Department's
    policy priorities. Once again, I commend the Secretary for her
    work to ensure that the budget reflects the priorities of this
    committee, protecting access to health care for all Americans,
    giving all children the chance to succeed, and making sure that
    we meet the needs of families and children affected by public
    health threats when they occur.
        In many areas, I believe we have made great progress on
    these priorities. In the not so distant past, many families
    were left without affordable health care options and many more
    could not have access to basic consumer protections in their
    insurance.
        Double digit increases in prices were routine every year.
    Women routinely charged more for insurance than men. If you
    lost you lost your job and wanted to start a new business and
    you had a preexisting condition, you were essentially out of
    luck. If you were a senior and fell into the Part D doughnut
    hole, you did not get any help, and when we consider the
    Affordable Care Act, thousands of people every day were losing
    their insurance.
        Passage of the Affordable Care Act has given millions of
    Americans access to health care coverage, many for the first
    time in their lives. The ACA has helped slow the growth in
    health care costs, it is closing the doughnut hole for seniors,
    and has encouraged and improved access to mental health
    services and preventive care. Instead of thousands losing their
    insurance, millions more have gained insurance.
        So, I thank Secretary Burwell for her efforts and her
    Department's hard work in implementing the Affordable Care Act.
    I recognize the challenge your department faces in implementing
    this law with limited resources and unlimited attacks.
        Despite these challenges, the ACA has expanded coverage to
    millions and given millions more robust consumer protections in
    their health coverage. The ACA has provided a historic
    foundation for which we are going to accomplish our ultimate
    goal, making sure that all Americans have the opportunity to
    succeed.
        I do not believe that we have reached the finish line yet,
    but I look forward to working with the Department and my
    congressional colleagues to make meaningful improvements as we
    strengthen the law.
        I also pleased that the President's budget has placed a
    priority on giving all children a chance to succeed by ensuring
    robust funding to increase both access to and quality of early
    learning and child care programs. We must invest in high
    quality early learning programs because all children deserve to
    enter kindergarten with the building blocks to success.
        Decades of research have shown that properly nurturing
    children in the first five years of life is essential to
    supporting enhanced brain development, cognitive functioning,
    and emotional and physical health.
        All too often, low-income working families lack access to
    high quality affordable child care in their early childhood
    education, and these children tend to fall behind. Beyond the
    achievement gap, children that do not participate in high
    quality early learning programs are more likely to have weaker
    educational outcomes, lower earnings, increased involvement in
    the criminal justice system, and affordable high quality child
    care is, therefore, not just critical for children, it is also
    critical for working parents.
        Child care is a two generation program. Parents of young
    children need child care to work and go to school, and lack of
    stable child care is associated with job interruptions and job
    loss for working parents. Child care ought to be a national
    priority for America's children and working families.
        Just two programs survived the bulk of the Federal role in
    early education, the Head Start program and the Child Care and
    Development Block Grant. Unfortunately, because of limited
    Federal funding, too few children have appropriate access. This
    unmet need continues to grow. Only four of 10 eligible children
    have access to a Head Start program, and fewer than one out of
    six eligible children receive Federal child care assistance.
        We have decades of evidence that investing in programs like
    Head Start and the Child Care and Development Block Grant
    works. This is the time to invest in these programs and ensure
    that we are giving all children the chance to succeed.
        I also want to commend the Secretary and her department for
    their efforts in response to some of the most troubling health
    crises of our time, the Ebola outbreak, Zika and opioid crisis.
    The Department has been in the forefront of responding and
    keeping Americans safe and healthy, particularly when you talk
    about budgeting, some do not always see the value of investing
    in prevention or readiness activities so that we are equipped
    to deal with a public health crisis.
        Like many Federal programs, in fact, like health care
    insurance itself, you often do not miss it until it is gone. It
    is important now more than ever that we invest in our Nation's
    current and future health and well-being. The President's
    proposal does this with the Cancer Moonshot and other long-term
    investments.
        Lastly, I would like to thank the Department and the
    Secretary for their efforts to respond to the catastrophic
    situation in Flint, Michigan. The research is clear on the
    impact of exposure to lead on young children, the adverse
    effects of lead exposure range from decreased academic
    attainment to increased needs for special education, and a
    higher likelihood of behavioral challenges. These impacts can
    result in a significant decline in earnings, loss of tax
    revenue, additional burdens to the criminal justice system, and
    increased stress on our hospital systems.
        The opportunity for a strong start to a successful life
    will be stunted for Flint's children if they are not given the
    necessary resources, including early intervention and access to
    high quality early learning programs, such as Head Start, to
    help them overcome the lifelong effects of exposure to lead.
        We need to come up with the money to make that possible,
    and make no mistake, we should not expect to fix this crisis
    easy or on the cheap. In fact, it will cost approximately $1.2
    billion to provide long-term comprehensive services to all
    Flint children exposed to lead just in the areas that cover
    programs under this committee's jurisdiction.
        Furthermore, it is imperative that this committee and the
    Department continue to examine how Federal programs can be
    responsive and ensure that every Flint youth is receiving the
    necessary services to mitigate the effects of lead exposure.
        The Department's response so far has been commendable.
    Additional funding for health centers in Flint, Medicaid
    expansion to provide vital health coverage and important health
    screenings, $3.6 million onetime emergency funding to help Head
    Start grantees expand early childhood education, health care
    and nutritional services.
        These are examples of targeted Federal solutions, but this
    committee and this Congress has to do more. The impact of lead
    exposure on young children is long-lasting, and a response must
    have a long-term approach.
        We must use all of the tools available to us, starting with
    prenatal care and screenings of pregnant moms, early literacy
    resources, early interventions to identify special education
    needs, Title I and Title II funding from the Elementary and
    Secondary Education Act, after school programs, at-risk youth
    prevention programs, even investments in college access
    efforts.
        I know with all the Department's leadership, we can
    continue to respond to this crisis, and I am hopeful that
    together we can put forward real solutions and help mitigate
    the damage from the water crisis in Flint, and make sure young
    children there get back on track to a prosperous fulfilling
    life.
        So, thank you, Mr. Chairman, and thank you, Secretary
    Burwell. I look forward to your testimony.
        [The information follows:]

     Prepared Statement of Hon. Robert C. ``Bobby'' Scott, Ranking Member,
                    Committee on Education and the Workforce

        Thank you Chairman Kline, and welcome Secretary Burwell. Thank you,
    Secretary, for being with us and I look forward to your testimony.
        Today, we will hear about the President's Fiscal Year 2017 Health
    and Human Services Budget proposal and the Department's policy
    priorities. Once again, I commend the Secretary for her work to ensure
    that the budget reflects the priorities of this Committee - protecting
    access to healthcare for all Americans, giving all children a chance to
    succeed, and making sure that we meet the needs of families and
    children affected by public health threats when they occur.
        In many areas, I believe we have made great progress in these
    priorities. In the not so distant past, too many families were left
    without affordable health care options and many more did not have
    access to basic consumer protections in their insurance. Women were
    routinely charged more for insurance than men. If you lost your job or
    wanted to start a new business and you had a preexisting condition, you
    were out of luck. If you were a senior and fell into the Part D donut
    hole, you didn't get any help.
        The passage of the Affordable Care Act has given millions of
    Americans access to health coverage, many for the first time in their
    lives. The ACA has helped slow the growth in health care costs, is
    closing the donut hole for seniors, and has encouraged and improved
    access to mental health services and preventive care.
        I thank Secretary Burwell for her efforts and her Department's hard
    work implementing the Affordable Care Act. As I've said before, I
    recognize the challenge your Department faces in implementing this law
    with limited resources and unlimited attacks. Despite these challenges,
    the ACA has
        expanded health coverage to millions and given millions more robust
    consumer protections in their health coverage. The ACA has provided a
    historic foundation on which we can work to accomplish our ultimate
    goal - making sure all Americans have the opportunity to succeed. I do
    not believe that we have yet reached the finish line and I look forward
    to working with the Department and my Congressional colleagues to make
    meaningful improvements to strengthen the law.
        I was also pleased that the President's budget request placed
    priority on giving all children a chance to succeed by ensuring robust
    funding to increase both access to and the quality of early learning
    and child care programs. We must invest in high-quality early learning
    programs because all children deserve to enter kindergarten with the
    building blocks to success.
        Decades of research has shown that properly nurturing children in
    the first five years of life is instrumental to supporting enhanced
    brain development, cognitive functioning, and emotional and physical
    health. But all too often, low-income working families lack access to
    high-quality, affordable child care
        and early childhood education, and these children tend to fall
    behind. Beyond the achievement gap, children who don't participate in
    high-quality early education programs are more likely to have weaker
    educational outcomes, lower earnings, and increased involvement in the
    criminal justice system. Affordable, high-quality child care is not
    just critical for children, it is also critical for working parents.
    Child care is a two-generation program. Parents of young children need
    child care to work or go to school. And a lack of stable child care is
    associated with job interruptions and job loss for working parents.
    Child care ought to be a national priority for America's children and
    working families.
        Just two programs provide for the bulk of the federal role in early
    education: the Head Start Program and the Child Care and Development
    Block Grant. Unfortunately, because of limited federal funding, too few
    young children have access. This unmet need continues to grow - only 4
    out of 10 eligible children have access to Head Start, and fewer than 1
    out of 6 federally-eligible children receive federal child care
    assistance. We have decades of evidence that investing in programs like
    Head Start and the Child Care and
        Development Block Grant works. It is time to invest in these
    programs and ensure that we are giving ALL children the chance to
    succeed.
        I want also to commend Secretary Burwell and her Department on
    their efforts to respond to some of the most troubling health crises of
    our time. From the Ebola outbreak to Zika to the opioid crisis, the
    Department of Health and Human Services has been at the forefront of
    responding and keeping Americans safe and healthy. Particularly when
    you talk about budgeting, some do not always see the value of investing
    in prevention or readiness activities so that we are equipped to deal
    with a public health crisis. But like many federal programs and in fact
    like health care insurance itself, you often don't miss it until it's
    gone. So it's important, now more than ever, that we invest in our
    nation's current and future health and well-being. The President's
    budget proposal does this with the ``Cancer Moonshot'' and other long-
    term investments.
        Lastly, I sincerely thank the Department's for their efforts to
    respond to the
        catastrophic situation in Flint. The research is clear on the
    impact of exposure
        to lead on young children. The adverse effects of lead exposure
    range from decreased academic attainment to increased need for special
    education and a higher likelihood of behavioral challenges. These
    impacts can result in a significant decline in earnings, loss of tax
    revenues, additional burdens to the criminal justice system, and
    increased stress on our hospital systems.
        The opportunity for a strong start to a successful life will be
    stunted for Flint's children if they are not given the necessary
    resources, including early-intervention and access to high-quality
    early learning programs, such as Head Start, to help them overcome the
    life-long effects of exposure to lead.
        We need to come up with the money to make that possible. Make no
    mistake - we should not expect the fix to this crisis to be easy or
    cheap. In fact, it will cost approximately $1.2 billion to provide
    long-term, comprehensive services to all Flint children exposed to
    lead. And that cost only covers the programs that fall under this
    Committee's jurisdiction. Furthermore, it is a moral imperative for
    this Committee and the Department to continue to examine
        how federal programs can be responsive and ensure every Flint youth
    is receiving the necessary services to mitigate the effects of lead
    exposure.
        The Department's response has been commendable - additional funding
    for health centers in Flint, Medicaid expansion that will provide vital
    health coverage and important health screenings, and $3.6 million in
    one-time emergency funding to help Head Start grantees expand early
    childhood education, health, and nutrition services. These are examples
    of targeted federal solutions. But this Committee and this Congress
    should do more.
        The impact of lead exposure on young children is long lasting and
    our response must have a long-term approach. We must use all the tools
    available to us, starting with pre-natal care and screenings for
    pregnant moms, early literacy resources, early interventions to
    identify special education needs, Title I and II funding from ESEA,
    after-school programs, at-risk youth prevention programs, even
    investments in college access efforts. I know that with the
    Department's leadership, we can continue to respond to this crisis. I
    am hopeful that, together, we can put forward real solutions to help
    mitigate the
        damage from the water crisis in Flint and make sure the young
    children there get back on track to a prosperous, fulfilling life.
        Thank you and Secretary Burwell, I look forward to hearing from you
    today.
                                     ______

        Chairman Kline. I thank the gentleman. Pursuant to
    Committee Rule 7(c), all members will be permitted to submit
    written statements to be included in the permanent hearing
    record. Without objection, the hearing record will remain open
    for 14 days to allow such statements and other extraneous
    material referenced during the hearing to be submitted for the
    official hearing record.
        It is now my pleasure to introduce our distinguished
    witness, welcome back to our new environs here. The Honorable
    Sylvia Mathews Burwell serves as Secretary of the U.S.
    Department of Health and Human Services. Prior to joining HHS,
    she served as director of the Office of Management and Budget
    under President Obama and in a whole bunch of other positions
    in the Clinton Administration. This will be the Secretary's
    second appearance before the Committee during her tenure at
    HHS.
        Secretary Burwell, I will now ask you to please stand and
    raise your right hand.
        [Witness sworn.]
        Chairman Kline. Let the record reflect she answered in the
    affirmative. Before I recognize you to provide your testimony,
    let me remind you of our lighting system. It is pretty
    straightforward. It is a green, yellow, red system. The lights
    are right in front of you. As in the past, I have no intention
    of ever dropping a gavel while you are speaking, but I would
    ask that you try not to go on too long so that members have a
    chance to engage in the discussion.
        Members will each have five minutes to ask questions, and
    as my colleagues know, I am not quite as reluctant to drop the
    gavel if they are exceeding the five minutes, and, I would ask
    my colleagues, please do not talk for 4.5 minutes and then ask
    a question that will take her five minutes to respond to.
        We do not have time for that today, because I would advise
    all of you that the Secretary has a hard stop time at noon. We
    are going to try to give everybody the five minutes, but we may
    have to curtail that time if we start running short. So, I
    would appreciate your cooperation.
        Madam Secretary, you are recognized.

     TESTIMONY OF THE HONORABLE SYLVIA MATHEWS BURWELL, SECRETARY,
     U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON, D.C.

        Secretary Burwell. Chairman Kline, Ranking Member Scott,
    and members of the Committee, thank you for the opportunity to
    discuss the President's budget for the Department of Health and
    Human Services today.
        As many of you know, I believe all of us share common
    interests and that we can find common ground. In recent
    legislative sessions, this committee took important steps to
    strengthen our workforce and open the doors to new early
    learning opportunities. Thank you for your leadership in
    passing the Workforce Innovation and Opportunity Act and the
    Child Care and Development Block Grant Act of 2014. We look
    forward to working with you on both of these in the year ahead.
        The budget before you today is the final budget for this
    administration and my final budget as Secretary. It makes
    critical investments to protect the health and well-being of
    the American people. It helps ensure that we can do our job to
    keep people safe and healthy, accelerates our progress in
    scientific research and medical innovation, expands and
    strengthens our health care system, and helps us continue to be
    responsible stewards of the taxpayers' dollars.
        For HHS, the budget proposal is $82.8 billion in
    discretionary budget authority. Our request recognizes the
    constraints in our budget environment and includes targeted
    reforms to Medicare, Medicaid, and other programs. Over the
    next 10 years, these reforms to Medicare would result in net
    savings of $419 billion.
        Let me start with an issue we have been working on here at
    home and abroad, and as we work aggressively to combat the
    spread of Zika. The administration is requesting $1.9 billion
    in emergency funding, including $1.5 billion for the Department
    of Health and Human Services. We appreciate Congress'
    consideration of this important request. This funding will help
    us implement the essential strategies to prevent, detect, and
    respond to this virus, with a focus on reducing the risks to
    pregnant woman.
        I know the rise of opioid misuse, abuse, and overdose has
    affected many of your constituents. Every day in America, 78
    people die of opioid related deaths, and that is why this
    budget proposes significant funding, over $1 billion, to combat
    the opioid epidemic.
        Research shows that early learning programs, as the
    Chairman mentioned, can set a course for a child's success
    throughout their life. That is why over the course of this
    administration, together with congressional support, we have
    more than doubled access to early Head Start services for
    infants and toddlers.
        Our budget proposes a total of $9.6 billion to the Head
    Start program and an investment in child care services that
    would allow us to serve over 2.6 million children. Beyond this
    budget, for the children in Flint, Michigan, we have already
    announced $3.6 million, as Mr. Scott mentioned, in one-time
    emergency for Head Start money.
        With these funds, they can expand early childhood
    education, behavioral health services, and other vital
    nutrition services. Today, too many of our Nation's children
    and adults with diagnosable mental health disorders do not
    receive the treatment they need. So, this budget proposes $780
    million in new mandatory and discretionary resources over the
    next two years to close that gap.
        While we invest in the safety and health of Americans
    today, we must also relentlessly push forward on the frontiers
    of science and medicine. This budget invests in the Vice
    President's cancer initiative. Today, we are entering a new era
    in medical science. With proposed increases of $107 million for
    the precision medicine initiative and $45 million for the
    administration's BRAIN initiative; we can continue this
    progress.
        In order for Americans to benefit from our recent
    breakthroughs in medical science, we need to ensure that all
    Americans have access to quality affordable health care. The
    Affordable Care Act has helped us make historic progress.
    Today, more than 90 percent of Americans have health coverage--
    the first time in our Nation's history that has been true.
        The budget seeks to build on that progress by improving the
    quality of care that patients receive and spending dollars more
    wisely. It proposes investments to improve the access to care
    for underserved groups across the United States, including many
    in rural communities, with $5.1 billion in health center
    funding and nearly $14 billion over the next decade for our
    Nation's health care workforce.
        By advancing and improving the way we pay doctors,
    coordinate care, and use health data and information, we build
    a better, smarter system.
        Finally, I want to thank the employees of HHS. In the past
    year, they fought Ebola in West Africa, helped millions gain
    health coverage, and have done the quiet day-to-day work that
    makes our Nation healthier and stronger. I am honored to be a
    part of the team, and as members of this committee know, I am
    personally committed to working closely with you and your staff
    to find common ground to deliver for the American people.
        Thank you.
        [The statement of Secretary Burwell follows:]

     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Kline. Thank you, Madam Secretary. That is close
    to a record, seven seconds over five minutes. Well done. Thank
    you very much.
        I mentioned in my opening remarks that we are concerned
    about the recent Reuters' investigation into abuse and neglect
    of children born in families battling drug addiction, and there
    was a law, CAPTA, that falls under your department's
    jurisdiction.
        We sent a letter to you asking for information. The
    Department responded, and we thank you for that, but clearly,
    we still have a problem out there, it seems to me.
        Congress has taken steps to streamline the application
    process, but the application still goes through the Children's
    Bureau at HHS, where they review States' applications and sign
    off that it is adequate before Federal funds are dispersed.
        So, I know you looked at this. Do you feel like that within
    the law, the Department is doing everything it can to ensure
    that States are upholding the law, or is there more that should
    or could be done?
        Secretary Burwell. So, when these issues were raised, some
    of the issues raised in the Reuters' articles, we have gone and
    followed up on the examples that were raised, and right now,
    the State of South Carolina is being put on a performance
    improvement plan. So, specific actions are being taken where we
    have found there is wrongdoing. That is in terms of when things
    are brought to our attention.
        As part of this process of review, we also put in place a
    different process to review what the States are saying. When
    they say they have a plan, in this next year's round, we will
    be asking for more details of those plans, so we can understand
    that the States actually have something that is a workable
    plan. So, we have taken steps in terms of where we understand
    there is something wrong and trying to get in front of it by
    making sure that we do a different process with regard to
    review of the plan.
        The other thing I would just say is it will be an important
    part of the Administration for Children and Families as we
    review their budget.
        Chairman Kline. Okay. That is a change to the practice--
        Secretary Burwell. It is a change.
        Chairman Kline. We will be watching with interest. It does
    seem to us there needed to be a way for the Department to be
    able to confirm that the States are doing what they are
    supposed to be doing, without waiting for somebody to come and
    complain.
        Secretary Burwell. Which is why we have taken that step to
    do it in a more proactive fashion with the proposal, so we will
    look forward to the Committee's support for the Administration
    for Children and Families as a part of the budget process that
    we are able to enforce and do, I think, what the Committee
    rightfully is raising.
        Chairman Kline. Thank you. We just passed and the President
    signed into law the Every Student Succeeds Act. It took six,
    seven, eight, or 12 years or something to get to it and through
    it, but it is done, and it is the law. Under the Act, as I
    mentioned in my opening remarks, the Act now authorizes a
    preexisting program known as the ``Preschool Development Grants
    Program.''
        Your department now has the lead under the law, with
    respect to funding authority and responsibilities. As I
    mentioned, it seemed to us that was clear because you already
    have billions of dollars in preschool funding through $9
    billion in Head Start alone.
        We believe that Congress specifically limited Federal
    interference in State early childhood systems to maximize State
    and local control over the improvement or development of the
    early childhood systems.
        So, given the language of the law and what I think are
    clear protections in the law, what are you doing, where are you
    in the process in effecting that transition from the
    appropriated but not authorized program that was in Education
    and is now authorized and will be appropriated, I am sure,
    program that is in your jurisdiction?
        Secretary Burwell. So, the transition by statute will occur
    in 2017, not in this fiscal year. Right now, we are working
    with our colleagues at the Department of Education to actually
    formulize the relationship between us. We are going to do an
    MOU, a Memorandum of Understanding, to formalize the way we
    incorporate the best practices from Education and their input,
    as we integrate this program into the continuum.
        I think you know at the Department, we have home visiting.
    We have early childhood. We have early Head Start. We have this
    program. We will integrate across that continuum, having the
    Department of Education be a contributor, and we decided to
    formalize the relationship.
        Chairman Kline. I am very pleased to hear that. It is
    because you are involved in all of those programs and you have
    that continuum that made sense to many of us to put this
    program there so it can be managed altogether.
        I am going to try to set the example for my colleagues and
    yield back the balance of my time. Pay attention, please, all.
    Mr. Scott, you are recognized.
        Mr. Scott. Nice try. Thank you. Madam Secretary, much has
    been made about the increasing cost of health care. Can you
    tell us briefly how the increases in health care costs now
    compare to what they were before the Affordable Care Act?
        Secretary Burwell. So, we have some of the lowest levels of
    Medicare growth on record that we have had since the passage of
    the ACA and the implementation. So, that has been a very
    important part. We have seen four of the five lowest years of
    growth in Medicare spending, and that is important for the
    taxpayer and for the Federal budget.
        With regard to employer-based care, and that is the care
    that the vast majority of Americans have in this country, last
    year, the increase in employer-based care was around 4.2
    percent in terms of the premiums. When we look at the period
    from 2000 to 2010, that number was 7.6. So, what we see is a
    decrease in the premium growth costs for those in the employer
    system.
        With regard to the marketplace itself and the individual
    market, last year in the marketplace, the premium increases
    averaged in about the 7 percent range, and what we know is
    before the Affordable Care Act, in the individual market,
    premium increases were regularly in the double digit space.
        So, whether one is looking at employer-based care,
    Medicare, which I know we are all concerned about from a
    taxpayer perspective, or looking at the marketplace itself,
    what you see is slowing in the growth of health care costs. It
    brings us to slowing but still increasing, and that is why I
    believe we need to spend a lot of time on delivery system
    reform and reforming the way we provide quality care at more
    affordable prices. I hope we will be able to talk about that
    some today.
        Mr. Scott. How much more do people with preexisting
    conditions have to pay?
        Secretary Burwell. With regard to the preexisting, and I
    think this gets to the quality portion of what I was just
    talking about, in the system today, and I think everyone in
    this room knows someone who has had cancer or has asthma or
    some other condition, for all of those individuals, they no
    longer need to worry that they will either be cut off from
    their care or not be able to access the care.
        I have had the opportunity to travel around the country and
    meet those people who previously did not have that opportunity.
    Making sure that those with preexisting conditions can no
    longer be discriminated against is a very important part of the
    progress on quality of care that we have seen.
        Mr. Scott. Do the people with preexisting conditions have
    to pay any extra?
        Secretary Burwell. No. They are neither kept out nor do
    they pay extra in terms of what they would pay in their
    premiums.
        Mr. Scott. Can you say briefly how the failure to expand
    Medicaid in some States affects those who have insurance?
        Secretary Burwell. With regard to how that impacts those
    who have insurance, it comes in the form of uncompensated
    costs. So, the work that we have done--we have seen about a
    $7.8 billion reduction in uncompensated costs since the passage
    of the implementation of the Affordable Care Act. The vast
    majority of those benefits are going to the States that have
    expanded Medicaid. What that means is that reduction in
    uncompensated care gets translated through the system, and it
    gets translated through the system to individuals and to
    hospitals and communities.
        We know that now in terms of rural hospital closures, which
    are something many are concerned about, we see more of those
    rural hospital closures in States that have not expanded. This
    is because of the uncompensated care issue. It flows to
    individuals. It flows to communities, and it flows to
    hospitals.
        Mr. Scott. Thank you. Disasters can happen anywhere. If a
    disaster were to happen in one of our districts, we could look
    at how you respond to Flint, Michigan to see how you would
    respond in our areas. Can you say what you are doing in Flint,
    Michigan for that disaster, particularly in Head Start?
        Secretary Burwell. So, the President asked that the
    Department of Health and Human Services lead the Federal
    response, which we are doing. So, we are coordinating the
    response of FEMA delivering water, SBA making sure that loans
    can get through, HUD helping housing get different pipes into
    public housing, and then the work we are doing.
        You mentioned our Medicaid expansion, as well as our Head
    Start work. The Head Start work, we have done a $3.6 million
    addition to expand both coverage and services, and that is
    because a lot of what you do to mitigate lead has to do with
    education and nutrition.
        Our colleagues at USDA are working very closely with us as
    well on the nutrition component, and put in place an ability
    for mothers to use WIC money to do formula that was not water
    based, because obviously that was a problem for those children
    focused on 0 to 6.
        Mr. Scott. Does the Zika request include research?
        Secretary Burwell. Yes, it does, and I hope we will have
    more time to discuss Zika. I just got the report today, and for
    U.S. citizens, there were over 450 million cases, and I hope we
    will have an opportunity to discuss that more.
        Chairman Kline. The gentleman's time has expired. Dr. Roe?
        Mr. Roe. Thank you, Mr. Chairman. Thank you, Madam
    Secretary, for your pushing the rule for the end of life
    counseling. That is a huge thing. I have heard a lot of
    positives about that. I want to thank you for that.
        Just a couple of quick questions.
        Stop-loss insurance regulation, as you know, in the private
    sector, a majority of those plans are basically self-insured
    plans, like we had in the City of Johnson City when I was the
    mayor. We used stop-loss insurance to protect our losses if
    they went above what we calculated they might be.
        Would you commit to the Committee not to regulate stop-loss
    insurance as health insurance because it is clearly not, in the
    future as Secretary of HHS?
        Secretary Burwell. I want to understand exactly what the
    regulations and laws are, I apologize, this is one I am not
    familiar with, I want to look into it, and we will get back to
    you in terms of how we think about that issue.
        Mr. Roe. Okay. Thank you. Just for the record, our increase
    in the marketplace in Tennessee was over 30 percent this year.
        A couple of things on Meaningful Use and electronic health
    records. As you know, physicians are struggling to meet the
    Meaningful Use and full disclosure. The primary care group I
    was in had over 100 physicians, and we have met--1 of the 12
    percent in the country--they have met that, and about 40
    percent of hospitals in Stage 2.
        Why would you go to the penalty phase of Stage 3 this year,
    which I think you are going to do, when 80 plus percent have
    not met Stage 2 yet? So, you know that the doctors, providers,
    hospitals, and physicians are going to be cut; why not just put
    it on pause for a year until they can get the systems to help?
    They are trying. They are out there trying to do this day and
    night, so why not do that? Why not pause for a year?
        Secretary Burwell. I think what we have tried to do is hear
    the concerns that have been expressed, and I think you know in
    the rulemaking that we recently put out, we were working to
    also include the legislation you all recently gave us on MACRA,
    and transferring to that system that we have been given
    legislatively to work through.
        So, working to make sure that we can get to the place where
    we are listening to providers--
        Mr. Roe. That is what I am hearing out in the real world,
    that you are not listening. That is a concern because they are
    going to get the penalty phase this year. So, I appreciate you
    are working on that, but what I think I am hearing out there in
    the real world is we are trying the best we can to comply with
    these things, but there are so many things with electronic
    health records and so forth, and I say this jokingly, but an
    electronic health record, I think, made me a congressman not a
    doctor any more.
        A couple of other things I want to go through very quickly,
    and I wrote you a letter about the breast cancer screening
    guidelines. I appreciate you putting that on hold for two
    years. One of my partners in practice, if he had followed the
    guidelines, one doctor in one practice, 24 patients would have
    fallen through the cracks and not been picked up early: 24
    breast cancers, one doctor.
        The other I want to mention is the PSA screening. The
    United States Preventive Task Force Services, which had no
    urologists and no oncologists, made a recommendation that
    absolutely should not be done, and you, as the Secretary, are
    going to penalize the primary care doctor if they order a PSA
    regardless of the patient's family history, regardless of their
    race, and regardless of their symptoms, essentially.
        So, I want to know--last night, I got a call from someone
    who had a PSA of two, a 59-year-old man, got up to go to the
    bathroom one time at night, went to his doctor. His primary
    doctor had ordered one previously, ordered another one,
    ignoring these guidelines, it was three. He said we better
    check it again in 90 days. It was five point something then.
    Sent to an urologist. This man has prostate cancer at 59. He
    would have been missed by these guidelines and might have died.
        I think these guidelines are going to cost people their
    lives. I think we need to seriously step back and take a look
    at them, at least let the science get worked out before you
    penalize a primary care doctor for ordering a PSA, a test that
    is not perfect, but it is an adjunct to clinical history and
    other things. I would strongly encourage you to do that.
        This was last night. I do not know how you would answer
    that patient's family when that patient would very likely have
    died had they followed these guidelines.
        Another issue I want to just bring up briefly:
    affordability of health insurance. I am in a billion dollar
    health care system at home where I practiced, 60 percent of the
    uncollectible debt in that hospital are people with insurance.
    To make these plans affordable, we have increased the out-of-
    the-pockets and co-pays so high, that people cannot pay those,
    just average, normal people, rural America, where I live.
        The last comment, we mentioned this last year. In rural
    America, where I live, what is killing our hospitals in
    Medicare is the Medicare Wage Index, which is very unfair to
    rural areas. We get 0.74 cents to what another place might get
    $1.50. I would like to hear from you on that. I want to work
    with you on that.
        With that, Mr. Chairman, I yield back.
        Chairman Kline. I thank the gentleman. Mr. Hinojosa?
        Mr. Hinojosa. Thank you, Chairman Kline and Ranking Member
    Scott. I support President Obama's Fiscal Year 2017 budget for
    the Department of Health and Human Services because the
    administration's priorities for HHS support the well-being of
    all Americans, and are closely aligned with the needs of my
    congressional district.
        Madam Secretary, it is a pleasure to have you testify
    before this committee, and I want to ask the chairman as a
    member of this committee for unanimous consent that the three
    pages of my opening remarks be included in today's report.
        Chairman Kline. Without objection. I am sorry. I am blaming
    it all on the ranking member here.
        Mr. Hinojosa. Thank you, Mr. Chairman. Madam Secretary, as
    you know, the State of Texas did not expand Medicaid, and that
    has hurt us a great deal. I am pleased to hear of your efforts
    to incentivize these vital programs. In your view, why is it
    important for States to expand Medicaid?
        Secretary Burwell. So, the Medicaid expansion issue, I
    think, has two different elements to it. It has the element of
    the individual, and it is about providing financial and health
    security for the individual.
        In the State of Texas, over 40 percent of those who would
    be eligible are working folks, so for many working people,
    making sure they can have both that financial and health
    security is a very important thing to their individual well-
    being.
        Separately, there is the issue of what it means
    economically to hospitals and to the States. We know that in
    the State of Kentucky, what we have seen in terms of an
    analysis by Deloitte as well as the University of Louisville,
    that until 2021, 40,000 new jobs would be created in Kentucky,
    and $30 billion would flow into the State of Kentucky.
        So, it is an economic issue in a broader sense, but it is
    also about the individuals and how their lives can be changed,
    and certainly as you reflect, we have a budget proposal to try
    and keep encouraging States to come in.
        Mr. Hinojosa. Thank you. Parental engagement and
    involvement has been one of the most critical if not the most
    critical part of a Head Start program over the last 50 years.
    This holistic approach ensures that children are ready for
    school. How does this proposed rule for Head Start strengthen
    parental involvement?
        Secretary Burwell. So, Head Start, and I think you know I
    am a Head Start kid, it has been a successful program for many
    years, and certainly not just my professional opinion but my
    personal opinion, but the issue of the intergenerational part
    of this, and Mr. Scott referenced it in his opening testimony,
    is an essential part, and it is essential both to get the full
    benefit of the program, and as we work forward, that is some of
    the changes in the proposed rule.
        It is everything from making it easier--in the current rule
    that is there, one-third of some of the requirements are cut
    out, in trying to get to simplification, to make things easier
    for parents and easier for providers, so they can engage and
    participate.
        As a parent of a 6 and 8 year old, I am very clear about
    the engagement and what it means in terms of children's well-
    being, and also having quality places for your children to be
    in terms of your ability to focus on your work.
        So, it is about--
        Mr. Hinojosa. Thank you for that clarification. Thank you,
    Madam Secretary. Helping children and young people who qualify
    for help through DACA, Deferred Action for Childhood Arrivals,
    is very important to my region because I have such a large
    number of students, K-12, who qualify.
        How do the priorities in your proposal help them?
        Secretary Burwell. With regard to the DACA issues, I am
    afraid I will most likely need to defer to my colleagues at
    Justice and DHS, who are much more engaged in those issues.
        With regard to the programs that are available, I think you
    know that the health centers throughout the Department are an
    important part of health care for people who do not have
    coverage or coverage access any other way.
        Mr. Hinojosa. Thank you. Madam Secretary, the ACA has been
    instrumental in increasing access to health care for residents
    in my district and across the Nation. What can communities such
    as mine do to increase participation in ACA's health insurance
    marketplace? What are some of the best practices that you can
    share?
        Secretary Burwell. So, open enrollment, I would just remind
    everyone, November 1 through the end of January next year, and
    preparing for that open enrollment is a very important thing
    because it is about the communities' engagement.
        Having visited communities all over the country, what I see
    are stakeholder groups and groups that have come together. The
    hospitals, the insurers, all kinds of local community groups
    come together and make sure that the information is there, and
    that people have a place to go.
        I have visited in the State of Texas. There is some great
    United Way 2-1-1, you just dial 2-1-1 and you are able to get
    that kind of access.
        Mr. Hinojosa. Madam Secretary, in my district, the
    uninsured was 40 percent before ACA. Today, it is only 18
    percent. So, we have made great progress. Thank you.
        Secretary Burwell. Thank you.
        Chairman Kline. The gentleman's time has expired. Mr.
    Byrne?
        Mr. Byrne. Thank you. Madam Secretary, I want to talk to
    you about the transitional reinsurance program and some current
    concerns that I and others have about the legality of the way
    these funds have been used.
        We are going to put on the screen the actual text of the
    law, that you see there now. I also have here the same legal
    memorandum that my colleague, Chairman Pitts, showed you two
    weeks ago when you testified before the Energy and Commerce
    Committee.
        The nonpartisan Congressional Research Service, which put
    out this memo, analyzed this issue and stated, and I am going
    to quote them, ``Insofar as CMS' interpretation allows the
    entire contribution of an issue in any given year to be used
    only for reinsurance payments such that no part of it is
    allocated for the U.S. Treasury contribution, and that would
    appear to be a conflict with a plain reading of Section
    1341(b)4,'' that is the language up there.
        ``Because the statute unambiguously states that each
    issuer's contribution contain an amount that reflects its
    proportionate share of the U.S. Treasury contribution, and that
    these amounts should be deposited in the General Fund of the
    U.S. Treasury, a contrary agency interpretation would not be
    entitled to deference under the Chevron decision.''
        We have that second piece of language up there now. So, you
    have had two weeks since Chairman Pitts brought this to your
    attention. You had the legal memorandum. I assume you have had
    a chance to go over this with your staff and your counsel.
        [Additional submission by Mr. Byrne follows:]

      [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        You would agree that you did not put $5 billion in the
    Treasury that you were required to. My question now is do you
    know not agree that you violated the law in not putting the $5
    billion with Treasury?
        Secretary Burwell. We believe that our reading of the law
    is accurate and correct. As we put out--
        Mr. Byrne. Can you give me some authorization for that?
        Secretary Burwell. Yes. What we did was we actually put out
    our reading of the law in a Notice of Proposed Rulemaking for
    public comment. We put out our logic. We put out our reasoning
    to the public to review our proposal, not in an interim final
    rule, but in a Notice of Proposed Rulemaking, so we could have
    comments.
        A wide range of groups commented on our rule, as is regular
    practice. No one raised any concerns--
        Mr. Byrne. Madam Secretary, let me take my time back on
    that. Whether they commented or not, the law is plain on its
    face. It does not matter what you think or somebody outside of
    your department thinks if the law is plain, you do not get to
    interpret it any other way, and the nonpartisan Congressional
    Research Service says you directly contradicted the law in the
    way you actually carried it out.
        So, are you saying now that because you put it out in
    comment that you get to interpret it any way you want to,
    despite the plain wording of the statute?
        Secretary Burwell. What I am suggesting is that we believe
    our reading is accurate. The public had an opportunity to point
    out if they thought it was inaccurate. That was not done. We
    believe that our reading of the law is accurate.
        Mr. Byrne. Well, Madam Secretary, let me just say this, the
    nonpartisan Congressional Research Service directly contradicts
    you. They say you read it completely wrong and that you clearly
    violated the law.
        Now, there is a lot of concern in America right now about
    the anger among the electorate. I just came through a primary a
    few weeks ago. The electorate is angry. They are angry because
    people in positions of responsibility like you violate the law.
    You violated the law. The nonpartisan Congressional Research
    Service has said you violated the law.
        Here we are today with some excuse that you put it out for
    comment. The fact that you put it out for comment does not
    relieve you of the responsibility to enforce the law as it is
    plainly written. It is plainly written. There is no wriggle
    room around this.
        The fact that you have had two weeks to look at this and
    you cannot offer me any legal authority for what you did tells
    me that you just decided or your staff decided we are not going
    to put the $5 billion in the Treasury as we are required to do
    by law.
        I can tell you my constituents and the people across the
    United States of America are sick and tired of that. So, if you
    want to provide to this committee at a later date whatever your
    legal staff wants to provide as whatever legal basis for their
    interpretation, that is fine, but telling me you put it out for
    notice and comment does not answer the question as to how you
    get around the clear requirements of this law, and it is not
    just my interpretation that I am going on here, I am going on
    the interpretation of the nonpartisan Congressional Research
    Service.
        I appreciate you telling us what you have told us here
    today, but it is not an answer. I hope you and your legal staff
    after this is over will put something together and send it back
    to us. I yield back.
        Secretary Burwell. Congressman, I would like to reflect
    that what I said was we have put out our legal argument. I
    understand and respect there is a disagreement in the
    interpretation of the law.
        What I was saying is we have articulated why we believe our
    reading of the law is correct, not only have we articulated
    that through communication, we did it in a very public way. We
    believe our reading of the law is correct, and I would also
    reflect that with regard to this, and this particular issue,
    there have been 71 IG and GAO investigations in terms of the
    question that you are raising.
        We are working hard to implement the law. There are thirty
    open, there have been over 100 examinations. With regard to
    what I am hopeful for is that we can get to the place where we
    can have the conversations about how to control costs and
    improve quality in this country in our health care system. That
    is what we are working to do.
        Chairman Kline. Madam Secretary, the gentleman's time
    really has expired. We will not get to any of that if we do not
    try to stay within the five minutes. Mrs. Davis?
        Mrs. Davis. Thank you, Mr. Chairman, and good to have you
    with us, Madam Secretary. I wanted to really go to one of the
    areas where as you said we are trying to create a smarter
    system.
        In that regard, I think there has been some early success
    of the diabetes prevention program. We have seen evidence that
    really is common sense, I think, that if you speak to the need
    for providing better nutrition, exercise training, that you are
    going to see a reduce on the onset of diabetes. We have seen
    that particularly in seniors.
        I just wanted to mention that there is bipartisan
    legislation to expand the diabetes prevention program to
    Medicare. There have been numerous pilots to demonstrate that
    really can have a demonstrable effect on saving lives, as well
    as cutting costs.
        I am hoping that you can take a look at that as well, how
    can we work to expand that. I would love to see all my
    colleagues come together on that legislation, but there may be
    some other tools that we have as well. I hope you will take a
    look at that.
        I want to shift quickly to early childhood, because that is
    an area that you are going to be working heavily in as we go
    forward, and certainly reflected in the legislation, the
    transition is in 2017.
        I know that within that legislation, there is a call to
    expand the length of the school day among other requirements. I
    am wondering what you are doing, what the staff is looking at
    now, how are we going to move forward with that while at the
    same time being certain we are keeping the quality the same or
    at least better, maintaining quality, and certainly finding
    ways that we hit the bar of lengthening but we are not losing
    some of the other ingredients that make up such a successful
    program.
        Secretary Burwell. So, as part of our Head Start rulemaking
    right now, it is an open rulemaking, so with regard to what the
    conclusion will be, it is not something I can comment on. At
    this point in time, we are reviewing a number of comments in
    different places.
        It does get, I think, to a little bit of the chairman's
    comment at the beginning, about making sure we are continuing
    to make strides, so that the benefits of these programs are
    known for the children in the short-term as well as the long-
    term, in terms of that third grade level and some of the
    research that we have seen.
        One of the suggestions out of that research that had some
    questions was the question of lengthening of time, that time
    there makes a difference to the child's ability to gain and
    retain what they need in order to build the building blocks,
    especially at that critical point in the third grade where we
    really need them reading in a way that it will take off,
    because then they are using the reading for learning when they
    get to the third grade.
        So, the time issue is related to the quality issue that the
    Chairman had raised earlier.
        Mrs. Davis. I appreciate that. I know that what we do not
    want to see is enrollment have to drop as a result of that.
    That is a big concern.
        The other one is regarding homeless children. In San Diego,
    we certainly have a number of children who come in and out of
    the school year. As you are working on the rulemaking, how can
    we provide for spaces for children who may be in and out of the
    program and be sure we guarantee they have a spot when in fact
    they are present and they need to be part of that program?
        Secretary Burwell. I think it has two elements to it, as we
    continue to think about the issue of making sure there is
    flexibility for those children, but also working deeply on the
    issue of homelessness as well, so that you are addressing the
    problem for those that are, but taking on that issue.
        At the beginning of this year, I became the chair of the
    United States Government's Interagency Council on Homelessness,
    and because of the work that we actually share, this committee
    and the Department, we will be focusing on youth homelessness
    as one of the main priorities.
        We will continue the work on veterans' homelessness because
    great progress has been made, but we want to take that next
    step. So, working on flexibility within the programs but also
    trying to get to the root of the issue, we will engage in.
        Mrs. Davis. Yes, thank you so much. I know in terms of
    stability of young children's lives, it is key they are in a
    program and they can count on that when their families are
    moving and not stable. That is so important to them.
        Very quickly, just on one other issue. In the
    Administration for Children and Families, the plan is to
    provide about $9.5 million in demonstration grants to help
    prevent youth sex trafficking. I am wondering if you could just
    speak briefly to how you expect different States to utilize
    these funds.
        Secretary Burwell. You know, I think this is a place where
    different States are going to use different tools based on
    their problems and their approach to those problems. This is
    also a place where our regional offices are engaging directly
    with the communities.
        Mrs. Davis. Thank you.
        Chairman Kline. The gentlelady's time has expired. Mr.
    Curbelo?
        Mr. Curbelo. Thank you, Mr. Chairman. Madam Secretary, more
    than 4,000 foreign children and adolescents have resettled in
    Miami, Dade County, in Fiscal Year 2015, and 937 more in the
    first quarter of Fiscal Year 2016. Foreign born students add an
    average of $2,720 in extraordinary costs to local school
    districts, above and beyond the per pupil State reimbursements.
        The numbers of refugees, especially Cuban refugees, has
    increased substantially in our community. The estimated number
    was over 4,000 last year and is expected to be on a similar
    pace in the current year. However, this could be an understated
    number because many parents are immigrating without their
    children, and their children join them later once they have
    adjusted their status.
        This presents a problem because the later arriving children
    of refugee parents do not count under refugee data, but they
    still represent major costs to local communities.
        Since school districts are barred from inquiring into
    immigration status, is there a proxy measure for school-wide
    services that can be used to determine the actual impact of the
    significant influx on affected school districts?
        Secretary Burwell. You know, I apologize, but I am going to
    need to defer to my colleague at the Department of Education
    with regard to how those measures would be done in schools. I
    apologize.
        Our role, I think you know, is with the parents as they
    come in terms of the Office of Refugee Resettlement. So, I
    apologize, but we can get that to my colleague.
        Mr. Curbelo. Okay. Let me ask you, what is HHS doing, if
    anything, to address the recent increase in foreign born
    students that are challenging communities like ours? How can we
    help school districts like Miami, Dade County, serve these
    students?
        Secretary Burwell. You know, with regard to our role, I
    think one of the things that we can do is make sure that those
    transitions of the individuals--the Office of Refugee
    Resettlement, which is a part of HHS--the thing that I think we
    can do is make those resettlements as successful as possible.
        Part of that success, I think, is making sure they become
    employed members of communities. At that point, our
    contribution can be making sure they are engaged, employed, and
    contributing members of the community in terms of employment
    and taxes, so that then is a part of the regular system.
        With regard to other issues, again, I will defer to my
    colleague at Education.
        Mr. Curbelo. So, let me ask you also, because this is a
    critical issue for our community, and as you know in the past,
    we have seen over 50,000 or close to 50,000 Cubans resettle in
    the United States, and the Miami, Dade County School District
    and Monroe County Schools, for that matter, obviously carry a
    heavy burden.
        Do you know if funding from the Cuban Haitians Social
    Services Set-Aside--can school districts draw from those funds
    to mitigate some of the impacts on these school districts?
        Secretary Burwell. I am not familiar that they can, but why
    do we not go back and check, and I am happy to get back to you
    on that issue.
        Mr. Curbelo. Well, this is just a critical issue for our
    community, Madam Secretary. I hope to work with you and with
    your department to find ways, to find more support for Miami,
    Dade County. This is another case where a local community faces
    the results or the consequences of what I believe is a flawed
    Federal immigration policy, a flawed Federal refugee policy in
    this case, and I think it is incumbent on the Federal
    Government to help communities like ours solve these problems
    because it is unfair for all of these costs, for all of the
    burden, to fall on local school districts and on local
    municipalities.
        Thank you, Mr. Chairman. I yield back.
        Chairman Kline. I thank the gentleman. Mr. Courtney?
        Mr. Courtney. Thank you, Mr. Chairman, and thank you, Madam
    Secretary, for your outstanding service. Your portfolio is
    about as complex and broad as any in government, and I think
    you are doing an outstanding job. Thank you.
        Secretary Burwell. Thank you.
        Mr. Courtney. In your testimony on page 11 you talked about
    the heroin and opioid component in the President's budget, $1.1
    billion. Again, it is allocated to help law enforcement,
    treatment, prevention, and education, which is what I am
    hearing back home in my district, 28,000 people lost their
    lives to accidental overdoses, as you pointed out, in 2014.
        That is a 14 percent increase from the year before. The
    2015 numbers are not going to be any better, and I know that
    because in Connecticut we saw a 20 percent increase since 2015
    numbers by the Office of the Medical Examiner just a few weeks
    ago.
        Director Botticelli was up in Eastern Connecticut talking
    to folks who are on the front lines on this, and you know, what
    is striking is police and law enforcement are totally engaged
    in doing their job, but they are the first to say you cannot
    arrest your way out of this problem.
        Emergency room providers who are saving lives with Narcan
    are frustrated because there is not enough detox beds and
    treatment beds, so there is a revolving door for a lot of these
    folks who are addicted and have no place to go after they have
    been revived.
        The medical provider community is ready, I think, to talk
    about reforming the prescription overprescribing of pain
    killers.
        What I think is of concern is that again, you just released
    new funding to HRSA, to community health centers, which is much
    appreciated, but there is no request for emergency funding this
    year.
        When you look at Zika and you look at OCO, what Mr. Kline
    and I are going to be voting on, billions in emergency funding
    for our overseas military operations on the Armed Services
    Committee, but when you look at a problem where we are losing
    28,000 people a year--Senator Shaheen and myself have a bill to
    sort of move that push to get resources into this year, which
    is so obviously needed.
        I just wondered if you could just sort of talk about your
    perspective on that, you know, the administration's willingness
    to work with us, who really want to get folks who are on
    standby ready to help with a solution.
        Secretary Burwell. So, the issue of the treatment and
    treatment opportunities, that is the biggest part of the money,
    the $1 billion that we have asked for. It is about treatment.
        I think all of you know in your communities as you visit,
    behavioral health is something that was paid for at the
    community level, and so it has never been built up, and now we
    have a very acute problem with people dying but as your law
    enforcement reflect, every law enforcement I talk to, they tell
    you I am not a social worker or a health worker, so that is why
    it is so critically important that we get funds to move,
    because those funds move to the States and the communities--
        Mr. Courtney. Right.
        Secretary Burwell. To get that treatment. The other parts
    are very important, but without the treatment, we now have a
    bolus of people who are addicted, sadly. I wish that was not
    the case. We need to prevent any more, but we have to take care
    of that which we have.
        Right now, Narcan or preventing an overdose death is not
    the only solution. If people are in medication assisted
    treatment, we can make progress. That is why we are pushing
    hard. We appreciate your leadership and others in terms of
    trying to make sure we get that funding for the treatment.
    Funding will also go to other issues, as to Naloxone, getting
    access to people, because not all--I am sure you hear this in
    your communities--not everybody in terms of first responders
    have access.
        We also have work at FDA. They have approved a nasal
    approach which will be easier for others to use that do not
    have to be a trained first responder to do that.
        So, we will work across, but the money for treatment, which
    I think is what you are focused on right now, is an essential
    part of getting to another place in this crisis.
        Mr. Courtney. So, again, the Senate sort of went partway
    there last week in terms of the Comprehensive Addiction
    Recovery Act, but again, it is authorizing legislation without
    resources, and as Congressman Kildee used to say, ``An unfunded
    authorization is kind of like a get well card to somebody who
    is sick, it does not really fix the problem.''
        Again, that is where I think the HRSA funding that was put
    out last week is getting to the house on fire that is happening
    out there, but again, the budget priorities are totally on
    target, as you said, but the question right now is on timing,
    because this issue is accelerating and intensifying.
        I hope all of us are going to work together because it
    affects every district, rural, suburban, urban. It is hitting
    veterans again because of Service connected injuries. This
    should be an easy one for us to work together on.
        Secretary Burwell. Yes. The fire alarm, this is a seven
    alarm fire and we sent one department. We need seven or eight
    others to get to the real issues and the problem.
        Mr. Courtney. Thank you. I yield back.
        Chairman Kline. The gentleman yields back, without
    mentioning basketball. Ms. Stefanik?
        Ms. Stefanik. Thank you, Mr. Chairman. First, I want to
    echo my friend and colleague, Mr. Courtney's, statements that
    the heroin and opioid epidemic is an issue that I have been
    focused on in my district, and I look forward to working with
    you on that issue.
        Thank you, Madam Secretary, for being here today. Shifting
    gears, I think we can all agree here that we need to make sure
    that our seniors receive the best care possible, and in order
    to do that, we must accept there are differing needs across
    this country.
        The Older Americans Act is an important law that helps
    seniors remain in their homes and out of expensive
    institutional care. As you know, what may work for seniors
    receiving meals or care in urban areas is likely to be
    inadequate to the unique challenges facing rural areas such as
    the district I represent in New York's North country, where we
    have one of the highest concentrations of seniors in New York
    State.
        One of the hallmarks of the Older Americans Act is the
    State and local control provided through the structure of the
    aging network. This is a great example of legislation that
    understands one-size-fits-all does not always work.
        Can you speak to how this structure is important to meeting
    the needs of this Nation's elderly and what we will do to
    continue the successful model?
        Secretary Burwell. Yes, and thank you for your leadership
    in terms of the reauthorization, we think it is important to
    continue. I think what you are reflecting is we need to make
    sure we maintain the flexibility for States because it is in
    very wide variance in terms of what it means to serve that
    community and serve that community well.
        So, we want to continue. We think the reauthorization does
    not need major changes, but some small changes that can help us
    with making sure we are using the best data and evidence that
    we have, which is based on some of our learnings that different
    things are working in different places, and keep that
    flexibility in place.
        I think you know in this budget that is before us, even
    without the reauthorization, we have some funding increases in
    particularized areas, and whether that is protecting against
    elder abuse and how that is done in rural areas versus urban
    areas, protecting in that space as well as some of the food
    programs that you mentioned, but we want to work across the
    spectrum of needs and work with those communities on what their
    priorities are.
        Ms. Stefanik. Great. Thank you for that, and I yield back.
        Chairman Kline. The gentlelady yields back. Mr. Polis?
        Mr. Polis. Thank you, Mr. Chairman. I want to thank the
    Secretary for joining the committee today, and I want to thank
    her and the administration for putting forward a budget that
    reduces our deficit, makes important investments in health and
    education that our country needs.
        I applaud the work of the Department of Health and Human
    Services for working to implement the Affordable Care Act. I
    congratulate on the especially successful 2016 third quarter
    enrollment period and 4.9 million new customers in the Federal
    Exchange.
        Madam Secretary, you have seen firsthand, of course, the
    positive effects of the Affordable Care Act. I know in my home
    State of Colorado, 16.5 percent of people lacked health care
    insurance before the Affordable Care Act, and last year, the
    number fell to 6.7 percent, a historic low.
        I am concerned, however, about how the geographic rating
    areas for each State can skew the cost of health care. My
    constituents in Grand County, for example, face among the very
    highest premium increases in the country. Their premiums went
    up at least 25 percent this year. They pay, by the way, nearly
    twice as much as other Coloradoans for insurance.
        How is the Department helping States to guarantee that
    families and individuals who live in rural mountain communities
    are able to access high quality care at a reasonable cost the
    way the Affordable Care Act intended?
        Secretary Burwell. So, one of the things that is important
    in both the employer-based market as well as the individual
    market is the fact that the Affordable Care Act actually put
    out-of-pocket caps in terms of what people will spend, and that
    is another important benefit getting to quality and
    affordability that we have not touched on, and I think that is
    important.
        With regard to the other issues in terms of the Affordable
    Care Act and the steps it is taking to work on places where I
    think it is fair to say that in our country there are pockets,
    such as that you have described, and in some cases, States,
    such as the State of Alaska, where a market is not working in
    terms of creating the amount of competition either in providers
    or insurance companies to put downward pressure on price.
        I think a part of that is why some of the changes that came
    in the Affordable Care Act that help us with delivery system
    reform and some of the work we are doing in the innovation
    centers to create models that people can use to have that
    downward pressure.
        So, there are two parts to it. It is focusing on specific
    markets themselves where the problems exist, but then overall,
    as a Nation, figuring out the steps we need to take to put that
    downward pressure, and our Accountable Care Organizations, we
    have already seen hundreds of millions of dollars of savings,
    and while the statutory level that you all gave us is very high
    to meet success before one can replicate, we have met that, and
    are now in a phase two of that.
        So, it is about regional and retail strategy, and then a
    strategy across the Nation.
        Mr. Polis. Are there are some States that have rolled out
    single geographic rating areas for their entire State?
        Secretary Burwell. I will have to go and check. I think--I
    will check.
        Mr. Polis. Thank you.
        Secretary Burwell. I do not want to give you an incorrect
    answer, so we will come back on that.
        Mr. Polis. Sure. To transition to Head Start, of course, I
    am a firm believer in the benefits of Head Start for kids and
    communities, and in my district and my State, we also have many
    high quality charter schools that serve at risk kids. Public
    charter schools have the autonomy to offer a unique curriculum,
    many students and parents take advantage of that. In Denver
    Public Schools, about a quarter of the kids attend public
    charter schools.
        You know Head Start grants are given to non-profits,
    community centers, sometimes traditional public schools, but to
    my knowledge, no charter school has received Head Start grants
    and few have applied.
        Can you talk about what your agency is doing to clarify
    guidance and do outreach so that high quality charter schools
    know they are eligible for Head Start grants and understand how
    to meet the Head Start requirements so they can offer those
    services for families?
        Secretary Burwell. Out of our conversation last year, this
    is something that we have followed up on, and are issuing
    hopefully clearer guidance. I think we believe it is possible
    and people can do it, but clearly, I think as you reflect,
    people do not understand that charters can do it, so we are
    issuing guidance to make that clearer, and then we will work to
    implement that so people can know what process they need to do
    to do it, because we think it is quite possible and people can
    do it.
        Mr. Polis. Thank you. I also wanted to briefly address
    transgender health. I have worked closely with my colleagues in
    the Equality Caucus, Representative Takano, Representative
    Pocan, also on this committee.
        HHS proposed a rule to implement the non-discrimination
    provisions of the Affordable Care Act that would prohibit
    discrimination on the basis of gender identity. When can we
    expect a final rule, and are there improvements to the proposed
    form to the final rule, which is so important to the LGBT
    community?
        Secretary Burwell. Because it is an open rulemaking
    process, we will not be able to talk about the specifics of the
    final rule, but a rule that is very important. I think you
    probably know that 1557 we were implementing before, but it had
    been five years.
        Mr. Polis. You will have time to complete that rule,
    correct?
        Secretary Burwell. Yes.
        Mr. Polis. Okay. Thank you. I will have some other
    questions for the record, and I will yield back.
        Chairman Kline. The gentleman yields back. I need to advise
    my colleagues that we are going to restrict the time now to
    four minutes and hope we do not have to go to three minutes.
    The math shows we have too many people and not enough time.
        Mr. Russell, you are recognized for four minutes.
        Mr. Russell. Thank you, Mr. Chairman, and thank you, Madam
    Secretary, for being here today.
        As a returning combat veteran, I had some firsthand
    experience with prescription pain killers. In my case,
    Percocet, but, while it did reduce the pain, it left me with a
    clouded mind. I became concerned about that. I did not like not
    having my faculties, so I quit taking them.
        However, pain management, and not just among our veterans,
    has resulted in perhaps a lot of what is categorized as
    suicides, it might have been accidental death. On a broader
    scale nationally, at least 18 States now have more deaths due
    to prescription opioids than car fatalities.
        Secretary Burwell. Correct.
        Mr. Russell. The fatality rates have increased five-fold
    since 1990. Accidental overdoses are up 360 percent since 1999.
    In 2004, prescription and other over-the-counter drugs were
    responsible for more years of lost potential life than all
    accidents from falls, firearms, drownings, fires, and non-
    medication poisonings combined.
        Opioid pain killer prescriptions have increased 800 percent
    from 1997 to 2006, and the data for the next decade will
    probably exceed even further.
        America now has had an increase in these, but I cannot
    imagine they have had an 800 percent increase in pain. Instead,
    America now has seen a health science environment that allowed
    law makers to pass these laws in the first place, and I think
    America has been sold faulty health science and a bill of
    goods.
        So, my question to you, Madam Secretary, in the $1.1
    billion spending program to provide treatment to those exposed
    and suffering this abuse, we have been exposed to prescription
    heroin nationwide, what actions will you be taking to curtail
    the science that suggested these laws be passed in the first
    place?
        Secretary Burwell. The research on pain and pain treatment,
    I think, is an important part of the solution. I think when we
    look at the steps that we need to take to push back on many of
    the statistics you articulated, number one, we need to change
    prescribing practices, because that is how many folks are
    getting the prescription, and then that is sometimes a transfer
    to heroin itself. I think you were referring to both. We need
    to work on the medication assisted treatment, and we need to
    get access to Naloxone.
        With regard to the research issues, at NIH, there are two
    parts to this, and one part is making sure that we are
    researching pain issues as well as the treatment of pain, and
    this is a space where I actually work with my colleague at the
    Department of VA, because they have much of the research and
    are doing some of the advances. As you articulated, it is a
    pool of people, sadly, who have these issues in terms of pain.
        So, we are working on it there. We are working on it at
    NIH, and with regard to FDA, what we are trying to do is speed
    along the process for those that can find drugs that are not
    opioid based in terms of pain, as well as those that are
    tamper-resistant. Those are some of the changes we most
    recently made at FDA.
        Mr. Russell. I would hope rather than chase more money
    after bad practices that we would take these things off the
    market. I think we existed for a long time as a country, we
    fought world wars, we did a lot of other things. America has
    not had an 800 percent increase in pain.
        I would hope that you would devote more effort towards the
    faulty science that has allowed these laws to pass. We are
    creating an epidemic that we are not likely to recover from. I
    do appreciate your efforts thus far. Thank you. Mr. Chairman, I
    yield back.
        Chairman Kline. The gentleman yields back. Mr. Sablan?
        Mr. Sablan. Thank you very much, Mr. Chairman. Madam
    Secretary, you mentioned this would be your last budget
    hearing. I think you should be proud. There are so many things
    in the proposal that would serve Americans greatly.
        I am the only member here who is not representing a State.
    I am going to limit my conversation to one issue. The President
    proposed in his fiscal 2017 budget that the National Medicaid
    program be available to the 4 million Americans who live in the
    insular areas, including my constituents, in the Northern
    Mariana Islands, and thank you, this is a very welcomed
    proposal.
        The people of the Mariana Islands are not as well off as
    the rest of Americans. Our median household income is about
    $20,000, and the national median income is $50,000. Because we
    have so many who are poor, we have many who qualify for
    Medicaid, 15,036 of our total population of 53,000 receive
    medical care through the Medicaid program.
        As you know, Medicaid in the Mariana Islands and the other
    insular areas is not the same as Medicaid elsewhere. There is a
    cap on the amount of Federal Medicaid money that goes to our
    islands, only about $5 million per year to the Marianas.
        The local cost-share of Medicaid is not computed on overall
    income as it is with the rest of America. So our Commonwealth,
    our local government has to pay 45 percent of the cost more
    like one of the richer US states would pay. We are not rich,
    however.
        So, we welcome the additional Medicaid money provided by
    the Affordable Care Act beginning in 2011, about $13 million
    per year. That new money kept our only hospital open when the
    local government had to stop its annual funding for our
    hospital because of the Great Recession and loss of tax
    revenues.
        That Affordable Care Act money is only available through
    2019. What happens then? Does our hospital close? What about
    those now on Medicaid, do they lose coverage? I would like to
    give you the time to please explain to the committee about the
    President's proposal and how we are going to make sure that
    Americans in my district get the same access to health care as
    Americans elsewhere, everywhere else in our Nation?
        Secretary Burwell. So, our proposal is a proposal that we
    hope will address the issue of a cliff and not create further
    cliffs with regard to putting in place a proposal that will
    transfer away from a cap and create matches that are more
    aligned with the matches that other Americans receive, at the
    same time, the proposal includes steps to make sure that there
    are reforms and governance is put in place.
        So, it would happen over a period of time where steps would
    have to be met in order for the changes to occur. It is a
    proposal both about getting out of where we have a cliff and
    the problems that you have described in terms of the need, but
    do it in a way that is also encouraging high quality Medicaid
    performance and program integrity.
        So, the proposal combines those two things. We believe it
    is a reasonable and a very needed proposal, and we should get
    ahead of this issue, and that is why we have it in our budget.
        Mr. Sablan. Thank you very much. It is very needed, not
    just for the Northern Marianas but for Puerto Rico, American
    Samoa, Guam, and the U.S. Virgin Islands. I yield back my time.
    Thank you.
        Chairman Kline. I thank the gentleman. He yields back. Mr.
    Barletta?
        Mr. Barletta. Thank you, Mr. Chairman, and thank you,
    Secretary Burwell, for being here today.
        I was deeply disturbed by a recent Senate report that found
    the Centers for Medicare and Medicaid Services, which is part
    of your department, had billed out roughly $750 million in
    Obamacare subsidies to half a million people who were unable to
    prove their citizenship or lawful presence in our country.
        These tax credits are solely to be used to purchase health
    insurance by United States citizens and those lawfully residing
    here. Instead, they were improperly distributed, and the
    Federal Government will likely never see a cent returned.
        This report was just one of many reports that have recently
    come to light detailing the rapid fraud and waste under
    Obamacare mismanagement that hard working Americans have had to
    foot the bill for.
        I have been working to fight illegal immigration for more
    than a decade now, and I find it extremely troubling that, at a
    time when our national debt is $19 trillion and counting, the
    Federal Government continues to throw money away with no regard
    for the consequences.
        I would have a hard time explaining to families in my
    district, many of whom are struggling to put food on the table,
    as to why they should be helping to pay for the health expenses
    of someone who broke the law to get here and has no right to
    those Federal dollars.
        Secretary Burwell, whose decision was it to prioritize
    illegal immigrants over American citizens?
        Secretary Burwell. So, with regard to the Senate report --I
    take the issues of program integrity and budgets very
    seriously. You probably know, it was during the years that I
    was at OMB that we actually had balanced budgets, close to the
    only time during my lifetime. So I take these issues of program
    integrity very seriously.
        With regard to the Senate report, I think what the Senate
    report reflects and says is that they were not able to
    provide--they did not provide--the documentation, we do not
    know whether they did or did not.
        I think with regard to the program integrity that you
    raised, as one looks at what happened in the first year of the
    Affordable Care Act, and there were about 250,000 people who
    were taken off last year, in terms of changes, both immigration
    and income, 1.6 million people in terms of when we reviewed and
    we were not able to receive the documentation, not knowing
    whether they could or could not, and that was both for
    immigration, the immigration number is about 500, and the other
    number is about--
        Mr. Barletta. Am I correct in that the tax credits are
    used, if somebody cannot produce legal documents at the time,
    the tax credits are used until they can come back, it gives
    them an opportunity to come back and prove their legal status?
        Secretary Burwell. It is a 90-day period which is given by
    statute.
        Mr. Barletta. Right. So, my question is after the 90 days,
    why then did the Federal Government not go back, why did we not
    go back to those people after we gave them the tax credits to
    get the money back of the tax credits that could have been used
    for someone else?
        As the head of an agency that knows what it is like to
    scratch for every penny, please explain to me how the
    administration is going to make up to my constituents and
    ensure that three-quarters of a billion dollars is returned to
    the American taxpayers?
        Secretary Burwell. With regard to that, that is the regular
    tax process. For any of these individuals, what will happen is
    they will owe those in taxes, in terms of reconciling, so the
    IRS in its processes--
        Mr. Barletta. We can count on that money coming back?
        Secretary Burwell. So, what will happen is when they go in,
    this will be reconciled through the IRS process. That is the
    way the enforcement will occur because it is a tax matter, so
    it occurs on the IRS side of the house.
        Mr. Barletta. Thank you, Mr. Chairman.
        Chairman Kline. The gentleman yields back. Ms. Bonamici?
        Ms. Bonamici. Thank you, Mr. Chairman. Thank you, Secretary
    Burwell. Your work covers so many areas that affect the daily
    lives of Oregonians and Americans. I appreciate that.
        I want to thank my colleague and friend, Representative
    Stefanik, for bringing up the Older Americans Act. I want to
    ask you about the Home & Community-Based Supportive Services
    program that funds services like legal assistance, elder abuse
    and prevention, transportation and meal sites, medical
    appointments, referral assistance for seniors and their
    caregivers.
        Now, I am supporting the additional $10 million in the
    President's request as well as many of my colleagues. Why is it
    important to increase funding for the Older Americans Act
    programs, especially the Home & Community-Based Supportive
    Services, given the rapidly rising population of older
    Americans? I do want to save time for another.
        Secretary Burwell. I will just quickly say I think there
    are two elements. It is about what it means for the individuals
    in terms of these programs we know are making a difference in
    terms of supporting people to be able to have care at home, if
    that is what is appropriate for them. So, it is about the
    individual.
        It is also about the economics as well, in terms of the
    success of these programs contributes economically.
        Ms. Bonamici. Keeping seniors in their homes, it is less
    expensive. Thank you. The Oregon Health Science University has
    been working in collaboration with Intel on genome mapping.
    That is especially useful in cancer research. The goal is to
    make personalized genomic analysis faster, less costly, more
    routine.
        What are some of the challenges that research institutions
    face regarding the collection and sharing of information, and
    what opportunities might the Cancer Moonshot provide to
    overcome some of these obstacles in advanced precision
    medicine?
        Secretary Burwell. Some of the limitations are the fact
    that the areas of science do not work together, and you
    actually need an engineer to help deliver through the system. A
    biologist figures out what it needs, but an engineer actually
    delivers the delivery mechanism, and we have not broken down
    those silos as we think about the science. I think it can help
    with that.
        The other thing I think it can help with is data and
    information, because one of the things, and this is part of
    what precision medicine is about, making sure data and
    information can be widely accessed in safe, secure ways. That
    is both about privacy and cybersecurity. That information can
    be used widely and broadly to discover and understand more
    quickly.
        It also in the end will save costs because how one accesses
    information for trials will become easier and less costly,
    which is a very important cost element to drugs.
        Ms. Bonamici. Thank you. I look forward to working with my
    colleagues on those important issues. Finally, I think my
    colleagues brought up the issues with opioid overdose and abuse
    and all the resulting deaths, and we have had an explosion in
    my State as well as the country.
        I applaud your three-pronged evidence-based approach. Can
    you talk a little bit about the prong of improving prescribing
    practices?
        Secretary Burwell. An extremely important part, and the
    Center for Disease Control and Prevention will be issuing new
    prescriber guidelines in terms of the issue of how we can talk
    about these issues and think about these issues.
        One of the problems is many physicians say I do not know, I
    was not trained in this way. We want to get those out and make
    sure people are using those. When you think that over 250
    million prescriptions a year for opioids, we know we do not
    need that many as a country, so prescribing is an issue, so we
    are going to target that as an issue, get out new guidelines,
    and then we need to probably work with the Congress to make
    sure those guidelines are used.
        Ms. Bonamici. Thank you. I know my State just received
    about $2.7 million to expand substance abuse services,
    particularly focused on treating opioid abuse. I know that is
    not enough. We still have more work to do.
        I had a fourth question but the Chairman asked already
    about preschool development grants, and I look forward to
    watching that and hope the transition is seamless as the HHS
    continues to manage those grants.
        I yield back. Thank you, Mr. Chairman.
        Chairman Kline. The gentlelady yields back. Dr. Foxx?
        Ms. Foxx. Thank you, Mr. Chairman. Secretary Burwell, I
    want to follow up somewhat on what my colleague, Mr. Byrne, was
    talking about in his line of questioning, but first I want to
    say I have heard from employers who self-insure that this
    transitional reinsurance fee is particularly burdensome to
    them, depriving them of resources that could be used instead to
    create jobs.
        You asserted that HHS interpreted the law accurately and
    appropriately. You claim that the comment period for the NPRM
    resulted in no objections to the Department's interpretation of
    the law.
        However, most of us believe that the NPRM was drafted in
    such a complicated way that no one could interpret it in the
    way your department did, where you used convoluted language to
    create a loophole to justify your reasoning. Given your dubious
    interpretation of the law thus far--you have heard members of
    this committee, and you will hear us say we think you have
    interpreted it wrong. I agree with Mr. Byrne, you have
    interpreted it wrong. You are hearing directly from members of
    Congress that you have interpreted it wrong.
        I am now concerned that you are going to find a way to
    extend the transitional reinsurance program even though the law
    clearly states that it expires this year. So, could you expand
    in greater detail your legal interpretation of implementing the
    transitional reinsurance program contrary to the letter of the
    law?
        Can you commit to this committee that you will follow the
    letter of the law which states the program must cease
    collections for the program at the end of this year? Do you
    plan to distribute funds after 2016?
        Secretary Burwell. With regard to the question of the
    reinsurance program, I think it is actually important to focus
    on what the substance of this program is about, and the
    substance of this is an issue that we have actually talked
    about in a number of places, which is pressure on costs, and
    you were indicating another space, in terms of this is about
    putting downward pressure on costs by creating an ability for
    the issuers in a new market.
        This is one of the transitional programs, and there are no
    plans to extend it beyond.
        Ms. Foxx. Okay. So, you consider the transition period time
    is over?
        Secretary Burwell. We have no plans to change our
    reinsurance time table that was set out. Risk adjustment is the
    only program that will continue beyond right now.
        Ms. Foxx. Okay. When you say ``we have no plans,'' would
    you be a little more explicit, you will or you will not?
        Secretary Burwell. I am being very clear, we have no plans.
    We just issued our rulemakings - our Proposed Notice, a Payment
    Notice--there is nothing that indicates anything that we do
    other than where we are.
        Ms. Foxx. Alright. Madam Secretary, I have some other
    questions, but Mr. Chairman, in the interest of time and my
    colleagues, I will yield back the balance of my time.
        Chairman Kline. I thank the gentlelady. Mr. Pocan?
        Mr. Pocan. Thank you, Mr. Chairman. Thank you, Madam
    Secretary, for being here today. I am trying to get to three
    subjects in four minutes. I am going to try to go fast.
        Does the name Brent Brown from Wisconsin ring a bell to
    you? This is a gentleman who wrote a letter to the President,
    and I would like to ask unanimous consent to enter this letter
    into the record.
        Chairman Kline. Without objection.
        Secretary Burwell. I do know.
        Mr. Pocan. Yes. A gentleman who had spent his entire life
    savings on health care, he was literally a dead man walking,
    could not get health insurance because he had a preexisting
    condition, and because of the Affordable Care Act, he is alive
    today.
        What is unique about the letter, and I just want to read
    two or three of the paragraphs, this is in his letter, ``I
    probably wore pins and planted banners to display my Republican
    loyalty. I was vocal in my opposition to you, particularly the
    ACA. Before I briefly explain my story, allow me to say this, I
    am very sorry. I understand written content cannot convey
    emotions very well, but my level of conviction has me in tears
    as I write this. I was so very wrong, so very wrong.'' He goes
    on to explain about his preexisting condition and had it not
    been for the Affordable Care Act, he would not be alive today.
        So, I just think that is a wonderful example and story, and
    more importantly, part of his appeal was to try to tell people
    maybe on the other side of the aisle who have been trying to
    repeal this for 63-64 times, you know, maybe it is time to move
    on. I just wanted to mention that.
        One of the issues that came up was about the Affordable
    Care Act when it first came out, that on the employer rolls you
    were going to reduce employees because of the part-time hour
    commitment, do you very quickly have any updates on that, how
    we're doing?
        Secretary Burwell. We have seen no evidence, and we have
    continued the recovery in terms of involuntary part-time
    employment. The involuntary part-time employment increased as
    part of the recession, but we continue to see progress and a
    normal recovery, so there are no analytics that show there has
    been an impact in terms of part-time work.
        Mr. Pocan. Great. Thank you. I know a number of us talked
    about opioid abuse. I would like to talk about something
    different than behavioral health, mental health issues.
        I know that while the opioid issue is really getting a lot
    of attention right now, I think mental health issues,
    especially as someone who is a former legislator, 25 to 30
    percent of the people in the prison system in Wisconsin are
    there for mental health. If they were there because they had
    cancer, people would be in the streets, but that is not how we
    are dealing with this issue and the amount of costs that go
    into it, very supportive of the President's budget and the
    increases he is trying to do.
        I just want to make sure we are keeping the focus on mental
    health as we do this because not just the State government, in
    Wisconsin, that is $250 to $300 million a year just for the
    people who have mental health in the corrections system, but in
    the local jails, local government, et cetera.
        I think it is really sad commentary on how we treat the
    disease and not have enough efforts there, and anything we can
    do would be much appreciated.
        Secretary Burwell. I think the Affordable Care Act together
    with the Mental Health Parity Act are the two most important
    steps we can make as a Nation to get parity in this space.
        Mr. Pocan. Great. The final issue I just want to raise in
    the last minute I have, prescription drugs. One of the issues
    that we have seen is prices are rising again, going up. I
    recently was at our VA, and he was telling me about what he had
    to do for one of his patients, a drug that was $125,000 a dose.
        We know that recently companies like Pfizer are trying to
    do tax inversions so they do not have to pay taxes here and go
    to Ireland, by buying a smaller company, yet at the same time,
    they are not going to charge us the prescription prices that
    they pay in Ireland, which is considerably less than they are
    paying here.
        I would just like to advocate for anything we can do and
    you can do within your department to help us look at that issue
    because I think we may need to work with those folks working on
    inversions, because I think it is a real tragedy that we are
    paying more and more for prescription drugs, including 27
    percent, I think, of mental health is on prescription drugs,
    and we need to do something more.
        Secretary Burwell. High cost drugs is a priority, and there
    are a number of elements in the budget we think would help
    address it.
        Mr. Pocan. Thank you. I yield back.
        Chairman Kline. The gentleman's time has expired. Mr.
    Bishop?
        Mr. Bishop. Thank you, Mr. Chairman. Thank you, Madam
    Secretary, for your testimony this morning.
        On February 19, as part of the Fiscal Year 2017 Medicare
    Advantage Rate Notice, CMS proposed a cut to Medicare Advantage
    employer group waiver plans, otherwise known as Medicare
    Advantage retiree coverage, 3.3 million seniors received their
    Medicare Advantage coverage through this plan.
        In fact, in Michigan alone, there are more than 300,000
    retirees, including labor unions, State and local government,
    and private employer retirees who rely on Medicare Advantage
    retiree coverage.
        These proposed cuts would jeopardize the high quality care
    that they depend on for their health and financial security.
    That is why, last week, my colleague, Representative Debbie
    Dingell, and I, led a bipartisan Michigan delegation letter
    that included 11 of our colleagues in Michigan, to raise
    concerns with regard to the impact these proposed cuts would
    have on our constituents, and we also urged the agency to
    remove the cut to the Medicare Advantage retiree coverage from
    the final rate notice.
        Earlier this month, the UAW Retiree Medical Benefits Trust,
    which provides health coverage to retirees and their dependents
    of the United Auto Workers Union, who formerly worked for the
    Michigan Big Three (GM, Ford, and Chrysler) submitted comments
    to CMS expressing concerns with CMS' proposed cuts to Medicare
    Advantage retiree coverage and the impact these cuts would have
    on their retirees.
        The Trust currently provides coverage to 719,000 people. Of
    this population, 534,000 are covered by Medicare. The Trust
    offers their retirees a choice of plans in which they can
    enroll. At the present time, 161,000 of these retirees have
    selected and are covered by Medicare Advantage plans.
        In comments submitted to CMS, the UAW Retiree Medical
    Benefits Trust expressed concerns that the proposed cuts to
    Medicare Advantage retiree coverage might result in diminishing
    the quality of care available to retirees and the proposal
    would lead to substantial reduction in payment to employer
    group waiver plans, thereby resulting in premium increases and/
    or benefit reductions.
        This leads me to my question. I did send you this letter,
    and I appreciate the fact that you have acknowledged receipt of
    that letter. Thank you very much for that.
        Having said what I just said, and the grave concerns they
    represent to in particular my constituents in the State of
    Michigan, can you tell me whether or not CMS considered the
    impact the cuts to the Medicare Advantage retiree coverage
    would have on the 3.3 million seniors who depend on this form
    of coverage when developing the Advanced Notice?
        Secretary Burwell. So, we did, and appreciate that, and
    appreciate the letter you have sent. We are in an open comment
    period, so welcome the comments and the concerns. We did
    consider this issue.
        We actually looked to our experience when we did this
    change in Part D. We did not see the impact that folks are
    saying could happen. We did not see that impact occur. We, like
    you, want to make sure affordability is an important part of it
    in our work, but we try to balance affordability for the
    individual as well as affordability for the taxpayer with the
    Medicare dollars, and feel it is a proposal that meets those,
    but we want to continue to hear the comments and see if there
    is something that would distinguish it from the experience we
    previously had.
        Mr. Bishop. Have you responded to the UAW's concerns?
        Secretary Burwell. Probably because it is a part of the
    comment and the rulemaking process, most likely we took it in
    as a formal comment, but I am not sure how they did it, whether
    it was in the form of a letter or a comment. I do not know
    specifically, but it will most likely be a part of the record
    for the comment period.
        Mr. Bishop. Thank you, Madam Secretary. I yield back.
        Chairman Kline. The gentleman yields back. Mr. Takano?
        Mr. Takano. Thank you, Mr. Chairman. Madam Secretary, it is
    truly a pleasure to hear from you this morning about your
    department's priorities. I am glad to hear about the
    administration's continuing commitment to programs that support
    working families, educate our children, and keep Americans
    healthy.
        First, I would like to ask you about the Department's work
    to support LGBT seniors. As you may know, the Congressional
    LGBT Equality Caucus, of which I am co-chair, has formed an
    LGBT Aging Issues Task Force. We sent a letter to Administrator
    Greenlee asking for ACL to require each State plan to assess
    whether State units on aging are meeting the needs of the LGBT
    community in their area.
        As you know, LGBT elders have poorer physical health, worse
    mental health, lower income, and fewer close ties on average
    than other seniors.
        Can you speak to whether ACL will be rolling out a guidance
    focused on LGBT older Americans, and if not, what will they be
    doing to assist this aging population?
        Secretary Burwell. With regard to this population, which as
    you articulated has a higher level of challenges than other
    parts of our elderly populations as a nation, there have been a
    number of steps that we as an entire department have taken in
    this space.
        I think you are familiar with our LGBT Coordinating
    Committee, which is a part of what has led to another thing
    that will be coming to fruition, which I think is a very
    important part of understanding the problem better, which is
    data collection, a five-year data collection, that will be
    targeted, so we can better understand the specifics of both
    what is happening in terms of the results, but what is causing
    many of the things you talked about in terms of the
    discrepancies that we see among the elderly.
        The third piece that I would actually mention is we have
    created a National Resource Center, specifically focused on
    LGBT issues, for communities to access so they can find out
    information and better serve the community.
        So, we are going to continue to work on these issues,
    appreciate your leadership, and look forward to continuing with
    the things you think we can do more in this space.
        Mr. Takano. Well, thank you, Madam Secretary. I wonder if
    you would be willing to have a meeting with the members of the
    LGBT Caucus to discuss these important issues?
        Secretary Burwell. I am sure that we and our team can
    figure out how we can do that and the best way to get action
    taken.
        Mr. Takano. Wonderful. Madam Secretary, in your testimony
    you mentioned the administration's commitment to growing our
    health care workforce by making continued investments in the
    National Health Service Corps, and graduate medical education.
        Ensuring that we have a robust health care workforce is one
    of my top priorities. In Riverside County, which I represent,
    there are only 34 primary care physicians for every 100,000
    people. Half the number of doctors needed to provide adequate
    access to care.
        Can you share more about the administration's efforts to
    guarantee we have the health care workforce that we are going
    to need?
        Secretary Burwell. So, it has a number of different
    elements. You mentioned one in terms of the National Health
    Service Corps and our emphasis on the National Health Service
    Corps, and building that up, and continuing to add members to
    the Corps.
        In addition, the funding that we do for HRSA, our Health
    Resources Services Administration, is another important part of
    making sure that we are building up a Corps.
        I think the other thing is how we do the policies. Our
    graduate medical education funding proposal, we actually
    shifted to the mandatory side because we believe that funding
    should be a dependable, continual part of funding, so we are
    encouraging people to go into these fields and know they will
    have an ability to have help with their loans.
        The other thing that I would mention is the focus on
    primary care, because we believe that is at the center and core
    of transitioning our system to where people have primary care
    homes.
        So, it is both in policy and funding across the Department
    that we are working on the issue of making sure we have enough
    health providers.
        The other thing is people at the top of their licenses,
    right now, we want to make sure there is more access for nurses
    and others to be able to do certain types of functions, and
    lastly, telemedicine. There are three proposals on that.
        Mr. Takano. Mr. Chairman, I almost made it. I am sorry.
        Chairman Kline. The gentleman's time has expired. Mr.
    Rokita?
        Secretary Burwell. I am sorry. That was me, sorry.
        Mr. Rokita. I thank the Chairman. Thank you for coming, it
    is good to see you. On behalf of the Governor of the State of
    Indiana, Mike Pence, and many of us in the State, thanks for
    working with us on what we call ``HIP 2.0,'' consumer driven
    health care, that I think will be a model to help the
    Department and others around the country really get at cost
    constraints while serving more people. Thank you for your
    cooperation and leadership in that regard.
        Secretary Burwell. Thank you.
        Mr. Rokita. I wanted to talk to you a little bit about the
    budget this morning. I thought I heard in your opening
    statement that you were able to get savings from Medicare and
    Medicaid, or did I misunderstand that?
        Secretary Burwell. There are Medicaid proposals as well as
    Medicare proposals.
        Mr. Rokita. I heard Medicaid and Medicare reforms.
        Secretary Burwell. Yes.
        Mr. Rokita. You did not mean spending reforms or did you
    mean spending reforms? What is the effect of the reforms?
        Secretary Burwell. Savings. The effect is savings, $419
    billion for Medicare, Medicaid, and other areas.
        Mr. Rokita. Over the 10 year window?
        Secretary Burwell. That is right.
        Mr. Rokita. Thank you. In your written statement on page
    two, you say that taken together, there is an estimated savings
    of $242 billion over 10 years. What is the difference in those
    numbers?
        Secretary Burwell. We pay for our child care. We pay for
    the other mandatory issues, so we pay for. That is the savings
    in that space, the entitlement space. We use some of that for
    savings and we use some of that to do things like fund child
    care.
        Mr. Rokita. Thank you. How do you save, in terms of
    Medicaid particularly, how do you save money when I thought
    CBO's January report said Medicare spending will grow by $200
    billion in 10 years, what is your--
        Secretary Burwell. Medicare or Medicaid?
        Mr. Rokita. Medicaid.
        Secretary Burwell. Medicaid spending. With regard to some
    of the proposals in the Medicaid space, one of the proposals,
    and I will have to see if this is one of the ones that scores
    into those numbers, but what we want to do is work with States
    so they can do purchasing for drugs together, help States do
    combined purchasing, which can drive down Medicaid costs for
    them and for us. That one, I have to check to see if it is one
    of the scorable ones, but those are the types of things that we
    are looking at.
        Mr. Rokita. Okay. What do you think about flexibility
    grants or block grants or making finite--instead of an open-
    ending fee for service kind of structure--what about taking a
    finite amount of money and saying look, this is what you have
    to spend, State X, find out who really is poor, what the poor
    really need, and how the poor should get it?
        Secretary Burwell. So, I think the question of capping
    Medicaid--the concerns we have with it are front and center
    right now in Puerto Rico, where we have almost 250 cases of
    Zika, we have over 10 cases of pregnant women who have tested
    for Zika, and you have a situation where you have a population
    whose needs were not being met before this started, and then
    you have a situation like Zika layered on top.
        So, having a program that is about the ability to be
    flexible with the needs of the people, to meet the needs,
    what--
        Mr. Rokita. That example is a little extreme. That is what
    a supplemental funding measure could be for, something like
    that. We do not have to--
        Secretary Burwell. I hope that is an expression of support
    for our Zika sup----
        Mr. Rokita. Well, it is an expression that Congress can act
    in emergencies, and you are describing an emergency. You are
    not describing day-to-day, in Puerto Rico. I am running out of
    time, so thank you.
        This is not meant to be a political ``gotcha'' in any way,
    but I clearly remember and see evidence where the President in
    2008 when he was running for office the first time said he
    would be able to lower insurance premiums with his Affordable
    Care Act at $2,500 per family on average.
        Your testimony describes the fact that we have slowed the
    growth in health care costs. What happened? What is different?
        Secretary Burwell. I think in terms of that number, that is
    the projected growth, the amount of the projected growth, the--
        Mr. Rokita. He said lower premiums.
        Secretary Burwell. With regard to the specifics, I
    apologize, I am just--
        Chairman Kline. I am sorry, the gentleman's time has
    expired, and we are rapidly approaching--Ms. Clark?
        Ms. Clark. Thank you, Mr. Chairman, and thank you,
    Secretary Burwell, for not only your testimony today but the
    incredible work that you are doing. I especially want to
    highlight your commitment to addressing the opioid crisis,
    coming from a State like Massachusetts where it has just been a
    devastating effect, we so appreciate your partnership and your
    commitment.
        I specifically want to ask you about adolescents and young
    adults. I have spoken with many experts who treat this
    population. They have been clear that this population needs
    special protocols to be able to tailor the treatment to their
    unique social and biological needs. They are also clear there
    has not been enough emphasis on programming or research in this
    area.
        Can you discuss any efforts that are underway to target
    action towards young adults and adolescents, and if you see
    this as an important area for fighting the opioid crisis?
        Secretary Burwell. So, with regard to the fighting it in
    the here and now, a couple of elements and steps. One is you
    are right, because what happens is--I heard a story this past
    week of a young person at Cornell, an athlete injury, got on
    the opioids, overdosed and is dead.
        So, there is special need especially because of these
    athletic injuries, this gets to the prescribing guidelines, and
    making sure there are alternative approaches to helping these
    students and young people through their pain and their athletic
    injuries. That is one whole category.
        There is another category that we know sadly that while I
    think people think alcohol is an okay alternative for these
    young people, it is not, because I think what we know is that
    is a gateway often to the prescription. Those that are
    participating in those activities are more likely as they get
    older to participate in other activities.
        That is the here and now and things we need to focus on.
    The research that we need to do with regard to the question of
    opioids across the board is a broad part of the research. The
    questions of does it help for long-term pain and acute pain,
    that sort of thing, and making sure we are thinking about young
    people as we do the research is a more longer term issue but
    one we need to focus on.
        Ms. Clark. And one we would love to work with you on. I
    want to quickly get back to Zika. You spoke about some
    startling numbers, even here in the United States. Every day we
    are seeing more of the connection being verified by research
    about the connection and danger for pregnant women. We are also
    seeing countries around the globe that have very restricted
    access to family planning for women saying do not become
    pregnant at this time.
        Can you elaborate on what is being done both here at home
    and abroad to make sure that women have access to a full range
    of health care options?
        Secretary Burwell. So, three fundamental things as part of
    the strategy. Number one, a deep focus on pregnant women
    because of the concerns around microcephaly, and the very
    extreme birth defects that can occur with women who have Zika
    while they are pregnant.
        Number two, communication, making sure we are reaching as
    many people as possible who are either traveling to that region
    or have a partner who has traveled to the region, because we
    know sexual transmission is possible. So, communicating about
    the guidelines as much as we know as quickly as we know.
        And number three is making sure that we are focused on the
    research that we need to do to understand more about the
    disease, including how to do better vector control. This is a
    disease that is spread by a mosquito that can bite four people
    in one setting. It is an indoor mosquito. It can breed in a
    capful of water. It is a very difficult mosquito to control.
        We are continuing to use best practices, but more research
    on the disease, on the vaccine, and the vector need to be done.
        Ms. Clark. Great. Thank you.
        Chairman Kline. The gentlelady's time has expired. We are
    shrinking the available time even more. I am telling my
    colleagues as we are moving towards the hard stop. Mr. Allen,
    you are recognized for three minutes.
        Mr. Allen. Thank you, Mr. Chairman, and thank you, Madam
    Secretary, and thanks for your call, by the way. I am sorry I
    did not get back to you.
        I wanted to just comment on a couple of things. One is you
    mentioned you have lowered the taxpayer growth in Medicare. I
    need some background on that, because I am not seeing that, so
    if you could get that to me.
        The other number that I am seeing is ``totally insured.'' I
    am not seeing that in my district. In fact, a very small
    percentage of my district is insured. In fact, doctors tell me
    at the emergency room that nothing has changed, many people are
    showing up without insurance as before.
        Also, on your comment about you do not pay more for
    preexisting conditions, I met a lady yesterday that told me
    about her son and his condition, and she wanted to know why his
    premiums had gotten so high and his deductible was like
    $10,000. I said well, I will get an answer for you. I need you
    to get that to me.
        Last but not least, the President signed into law, and I
    voted for, the Hyde Amendment, which was an attachment to the
    appropriations bill. How are you monitoring your funding of
    these various claims that no taxpayer funds are being used for
    abortions? How do you monitor that, and what are you doing to
    oversee that?
        Secretary Burwell. With regard to where that would occur,
    it would occur in HRSA, the Health Resources Services
    Administration, which are the clinics that we fund directly,
    and there are stringent guidelines with regard to that, that
    the clinics both know and are educated on, so it is not just a
    matter of telling the clinics, it is a matter of HRSA making
    sure they know and understand what those guidelines are so we
    can follow them.
        Mr. Allen. You are auditing these clinics?
        Secretary Burwell. With regard to the specifics of how that
    goes, I will come back to you.
        Mr. Allen. Okay. Alright. The other thing, we have some
    States that are opting out of the Exchanges. I think Oregon and
    Kentucky is talking about getting out of the State Exchanges
    and going back to the Federal Exchange.
        Do you want to explain why that is going on? I mean our
    governor was criticized because he did not opt to go into the
    State Exchange, because he knew eventually the Federal
    Government was not going to fund it any more. Of course, in
    Georgia, we are required to balance our budget. He did not
    think the funds would be there.
        What is your take on this?
        Secretary Burwell. With regard to either approach, I think
    it is about a State's choice and a decision in terms of whether
    or not they want to do the setup of the piece that will attach
    their consumer to their ability to access it.
        In Kentucky, it is a system that is a well-integrated
    system that helps with and creates efficiencies for both their
    CHIP and Medicaid. I think they decided to do it because it
    creates that. Other States choose not to and use the Federal
    marketplace.
        Either way can work as a system. We just want to work with
    States to do what is their preference as a State.
        Mr. Allen. I yield back.
        Chairman Kline. The gentleman yields back. Ms. Wilson?
        Ms. Wilson. Thank you, Mr. Chair. Welcome, Madam Secretary.
        Secretary Burwell. Thank you.
        Ms. Wilson. Unfortunately, Florida, my State, is one of 19
    States that has failed to expand Medicaid under the ACA. Can
    you speak to why Medicaid expansion is so important for
    communities of color, especially in my home State, and across
    the country?
        Secretary Burwell. So, while we have made great progress in
    terms of communities of color, 3 million uninsured reduction in
    the African American community, 4 million in the Latino
    community, we know that the uninsured rates are still
    disproportionately high. We know that if Medicaid expansion
    occurs, that a disproportionate number of folks that are
    minorities will be covered.
        So, we are excited to continue pushing and pushing hard
    because we think it will have a disproportionate benefit to
    communities of color.
        Ms. Wilson. Our governor has repeatedly rejected expansion,
    citing budget restraints. Can you speak to how Florida and
    other States may actually see budgetary relief under Medicaid
    expansion?
        Secretary Burwell. So, what we know, and the University of
    Louisville together with Deloitte has done a piece of work and
    a piece of research on their work and their expansion, and it
    led to the creation--it would lead to the creation by 2021 of
    40,000 jobs, as well as $30 billion flowing into the State.
        We know we see reductions in uncompensated care for
    hospitals and communities across the State when expansion
    occurs. It is about the individual, but it is also about the
    economic impact.
        Ms. Wilson. How are we assured that our communities of
    color are getting the information they need to successfully
    enroll?
        Secretary Burwell. One of the things we do during open
    enrollment, and I had the opportunity to spend a lot of time in
    your State, have gone to every place from beauty salons to
    barber shops, because we need to meet people where there are
    trusted voices.
        In Texas, actually in all States, we do second Sunday,
    where on Sundays, we work with the faith communities across the
    States to help people get information that is important
    information from trusted voices.
        Ms. Wilson. Just keep up the good work. I yield back.
        Chairman Kline. The gentlelady yields back. Mr. Carter?
        Mr. Carter. Thank you, Mr. Chairman. Thank you, Madam
    Secretary, for being here. Madam Secretary, as you know, I am a
    pharmacist, so I am very concerned about issues, obviously,
    dealing with patients and dealing with them getting their
    medications.
        Specifically, I wanted to ask you about compounding,
    compounding for office use only. I am very concerned about the
    FDA interpreting legislative intent, and certainly this is
    something that comes into play when we are talking about for
    office use only.
        I know the FDA continues to prevent medications to be
    compounded for office use only, and what this causes is for the
    patients to have to go back to the pharmacy, get a specific
    prescription, compound it for them, then go back to the doctor
    to have it applied.
        I am wondering where you are at in that process? Many
    States have already allowed for this to take place. Many States
    have already had regulations and laws in place that allow for
    office use only, for compounds to be made, and for the
    physician to have them there in the office where the physician
    has the ability to apply and use that medication instead of the
    patient having to go get a specific prescription filled for
    them as opposed to having it for office use only.
        I just want to know where we are at in that process.
        Secretary Burwell. So, we do not have any guidance out
    preventing that, so maybe I can follow up with your staff to
    understand, that our team can follow up to understand. We
    welcome the input on the guidance on the issue.
        It does not exist, so right now, compounding should be
    occurring.
        Mr. Carter. Compounding is occurring--
        Secretary Burwell. There is not a problem in terms of any
    guidance or any rules about it right now.
        Mr. Carter. I beg to differ. The problem is you are
    requiring each specific patient to have a specific prescription
    for medication, for a compounded medication. What in the past
    we have been able to do is just to supply--
        Secretary Burwell. In the doctor's office?
        Mr. Carter. Exactly, with a compound that is for office use
    only, in which they can apply that medication.
        Secretary Burwell. It is my understanding that is able to
    be done--if there is something that is happening that is not,
    that is why I would like to follow up because what you are
    articulating is not my understanding. Let's understand.
        Mr. Carter. Absolutely.
        Secretary Burwell. Is it a State issue or something else or
    maybe we are not communicating.
        Mr. Carter. We are looking for guidance from the FDA on
    this, and this is an issue that we are very concerned with
    because again it has to do with patient care. We want to make
    sure that patients are getting the care they need.
        Secretary Burwell. And we would like your input on any
    guidance that we would do in this space.
        Mr. Carter. Okay, thank you. Mr. Chairman, I yield back.
        Chairman Kline. I thank the gentleman. Ms. Adams?
        Ms. Adams. Thank you, Mr. Chair, and thank you, Madam
    Secretary, for being here. I am going to move along quickly. I
    just want to give a shout out to my police department in High
    Point for the work they are doing in opioid abuse, and I thank
    you for your work.
        Let me ask you about the health of our Nation's most
    marginalized young people as it relates to sexual health
    services. A lot of data and research performed by CDC, American
    Academy of Pediatrics, and even your Office of Adolescent
    Health show that far too many young people in the U.S. face
    barriers accessing and receiving adequate health care services
    regarding sexual health education.
        So, can you please speak to existing efforts that HHS is
    leading to ensure that our Nation's youth, especially those
    most vulnerable, have the education, skills, and access to
    sexual education services?
        Secretary Burwell. So, across the board in terms of our
    tools, it is our community clinics that we have talked about.
    It is the CDC, as you mentioned. It is also our funding in
    terms of access through Title X. Those are three different ways
    we do that.
        Also, some of the most vulnerable that you are talking
    about are through our minority health issues as well, so that
    is the other place I would mention that we work on these
    issues.
        Ms. Adams. One follow up. So, what is the administration
    doing to address not only the Southern States that are
    disproportionately affected by HIV disease, but also the rural
    communities that are seeing the majority of the diagnoses?
        Secretary Burwell. There is $54 million in minority health
    for HIV specifically proposed in our budget that we will hope
    will continue these efforts and work with those Southern States
    that have a disproportionate number, like North Carolina.
        Ms. Adams. Okay. Thank you very much. Mr. Chairman, I am
    yielding back.
        Chairman Kline. I thank the gentlelady. Mr. Thompson?
        Mr. Thompson. Thank you, Mr. Chairman. Secretary Burwell,
    thank you so much for the phone call, very much appreciate you
    reaching out.
        I just want to note the current crisis with the opioids,
    there is obviously some impact from infants to the elderly. We
    need to approach this from a broader perspective, this is
    symptomatic. I view it as a broader epidemic of substance
    abuse. It does not matter how large or how small the community
    is, it is present.
        This is kind of an all hands on deck for the Executive
    Branch, Legislative Branch, and all of the partners, we need to
    be working together.
        My question though is regarding access to health care. In
    your testimony, you state that through targeted investments,
    the administration's budget expands access to health care,
    particularly for rural and underserved areas. I represent
    Pennsylvania's Fifth Congressional District. It is the State's
    most rural, largest congressional district, about 24 percent of
    the land mass. I know rural. I know it well.
        As a former health care provider for almost 30 years,
    access requires the presence of providers in our communities,
    first. I do not care how you pay for it or all the other moving
    parts of it. You have to have that access. There has to be a
    presence.
        Really, a tremendous concern considering the fact that more
    than 45 rural hospitals have closed since 2010, and
    approximately 300 others are in danger of closing. I struggle
    to understand how these facts support your conclusion that the
    Affordable Care Act is having a positive effect on the well-
    being of employers, employees, providers, health care
    professionals, and most importantly, patients in rural areas.
        Can you expand on your statement in regard to those facts?
    That is a trend line that is not good and it scares me.
        Secretary Burwell. It is a trend line that started before
    the passage of the Affordable Care Act, and it is a trend line
    that has a number of different elements that contributed to it,
    and I think as you articulated, as you described your district,
    the issues of population density, the issue of providers being
    willing to go to places where there is not a lot of population
    density in terms of their choices they make, as well as one of
    the contributors I think we do see is uncompensated care in the
    form of Medicaid expansion.
        So, we do see a difference in the places where it has
    expanded, and the number of hospitals that are closing. We see
    a reduction in that because of the reduction in uncompensated
    care.
        Mr. Thompson. Obviously, I keep my finger on the pulse of
    this because that was my life, working to provide access to
    cost effective care. I see rapid expansion monopolies, that
    compounds it by raising costs, monopolies tend to do that, it
    takes the pressure off for increased quality. I think there are
    a lot of issues going on, and I would say they have been
    compounded since that time.
        Thank you so much. I look forward to continuing the
    discussion offline.
        Chairman Kline. The gentleman yields back. We have rapidly
    run out of time. Let me yield to Mr. Scott for any closing
    remarks he might have.
        Mr. Scott. Thank you, Mr. Chairman. Madam Secretary, I
    thank you particularly for your comments on the Affordable Care
    Act, where we have changed the situation from thousands of
    people every day losing their insurance to millions more being
    covered, and the cost savings, rather than often double digit
    increases to the lowest increases in modern history, showing a
    significant savings over what the costs would have been had it
    not for the Affordable Care Act. And people with preexisting
    conditions with no insurance to being able to get insurance at
    standard rates, and more progress could be made if Medicaid
    were expanded in those States, and those with insurance are
    actually picking up a lot of that cost, because of
    uncompensated care is cost shifted to those with insurance.
        I appreciate your response to the opioid situation.
    Finally, I think we are getting a consensus that early
    intervention and prevention is better than hospitalization and
    jails.
        We put all the money in the criminal justice system, and
    when have you ever heard a dealer tell a customer I could not
    get any heroin today because the police have cracked down, and
    a customer say, oh, my God, my dealer got busted, I cannot get
    any heroin.
        All that money spent on the criminal justice system could
    have been spent on research-based and evidence-based approaches
    that would actually reduce the amount of opioids being
    consumed.
        Appreciate your work with Head Start, homeless youth. We
    did not get into foster care. I do appreciate your request for
    additional resources in foster care to achieve permanent
    placements, to the extent that we can get young people on the
    right track and keep them on the right track, we will have
    fewer problems in the future.
        And finally, I express appreciation for your effective
    response to Zika, and the request you have made, I hope we can
    fund that, and to Flint, Michigan.
        So, thank you for your testimony, and look forward to
    continuing to work with you.
        Chairman Kline. Madam Secretary, I want to thank you also.
    I want to thank you for your testimony, for your service, for
    your engagement with the members here, and for allowing us to
    go three minutes over the closing time.
        There being no further business, the Committee stands
    adjourned.
        [Additional submission by Mr. Carter follows:]

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        [Additional submission by Chairman Kline follows:]

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        [Additional submission by Mr. Pocan follows:]

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        [Questions for the record and their responses follow:]

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        [Whereupon, at 12:03 p.m., the Committee was adjourned.]

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