    [Senate Hearing 115-229]
    [From the U.S. Government Publishing Office]

                                                           S. Hrg. 115-229

                           NOMINATION OF THOMAS PRICE

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

                                     HEARING

                                   BEFORE THE

                              COMMITTEE ON FINANCE
                              UNITED STATES SENATE

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 FIRST SESSION

                                     on the

                                 NOMINATION OF

                        THOMAS PRICE, TO BE SECRETARY,
                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                                   __________

                                JANUARY 24, 2017

                                   __________

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                Printed for the use of the Committee on Finance

                                   __________

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                              COMMITTEE ON FINANCE

                         ORRIN G. HATCH, Utah, Chairman

    CHUCK GRASSLEY, Iowa                 RON WYDEN, Oregon
    MIKE CRAPO, Idaho                    DEBBIE STABENOW, Michigan
    PAT ROBERTS, Kansas                  MARIA CANTWELL, Washington
    MICHAEL B. ENZI, Wyoming             BILL NELSON, Florida
    JOHN CORNYN, Texas                   ROBERT MENENDEZ, New Jersey
    JOHN THUNE, South Dakota             THOMAS R. CARPER, Delaware
    RICHARD BURR, North Carolina         BENJAMIN L. CARDIN, Maryland
    JOHNNY ISAKSON, Georgia              SHERROD BROWN, Ohio
    ROB PORTMAN, Ohio                    MICHAEL F. BENNET, Colorado
    PATRICK J. TOOMEY, Pennsylvania      ROBERT P. CASEY, Jr., Pennsylvania
    DEAN HELLER, Nevada                  MARK R. WARNER, Virginia
    TIM SCOTT, South Carolina            CLAIRE McCASKILL, Missouri
    BILL CASSIDY, Louisiana

                         Chris Campbell, Staff Director

                  Joshua Sheinkman, Democratic Staff Director

                                      (ii)

                                C O N T E N T S

                                  ----------

                               OPENING STATEMENTS

                                                                       Page
    Hatch, Hon. Orrin G., a U.S. Senator from Utah, chairman,
      Committee on Finance...........................................     1
    Wyden, Hon. Ron, a U.S. Senator from Oregon......................     4
    Isakson, Hon. Johnny, a U.S. Senator from Georgia................     6

                             ADMINISTRATION NOMINEE

    Price, Hon. Thomas, M.D., nominated to be Secretary, Department
      of Health and Human Services, Washington, DC...................     9

                   ALPHABETICAL LISTING AND APPENDIX MATERIAL

    Grassley, Hon. Chuck:
        ``Grassley Says Emory Psychiatrist Didn't Report $500,000 in
          Payments,'' by Jacob Goldstein, The Wall Street Journal,
          October 3, 2008............................................    77
        ``Top Psychiatrist Didn't Report Drug Makers' Pay,'' by
          Gardiner Harris, Money and Policy, October 3, 2008.........    78
    Hatch, Hon. Orrin G.:
        Opening statement............................................     1
        Prepared statement with attachments..........................    80
    Heller, Hon. Dean:
        Letter From Hon. Aaron D. Ford and Hon. Jason Frierson to
          Senator Heller, January 10, 2017...........................    89
    Isakson, Hon. Johnny:
        Opening statement............................................     6
    McCaskill, Hon. Claire:
        Distribution of Federal Tax Change by Expanded Cash Income
          Level, 2017, Summary Table, Tax Policy Center, December 15,
          2016.......................................................    91
    Nelson, Hon. Bill:
        ``A Premium Support System for Medicare: Analysis of
          Illustrative Options,'' Congressional Budget Office,
          September 2013.............................................    92
        ``GOP Split on Reforming Health Care,'' by Jennifer
          Haberkorn, Politico, April 30, 2012........................   138
    Price, Hon. Thomas, M.D.:
        Testimony....................................................     9
        Prepared statement...........................................   139
        Biographical information.....................................   141
        Responses to questions from committee members................   171
    Stabenow, Hon. Debbie:
        Statements and testimonials..................................   253
    Wyden, Hon. Ron:
        Opening statement............................................     4
        Prepared statement with attachments..........................   281

                                 Communications

    American Association of Hip and Knee Surgeons (AAHKS)............   289
    Association of Web-Based Health Insurance Brokers (AWHIB)........   289
    Brasch, Steven P., M.D...........................................   292
    Choat, Lesli, MT (ASCP)..........................................   293
    Claybour, Richard and Jill.......................................   294
    Darrow, Robert K.................................................   294
    Gyetvan, Angela Wilson...........................................   295
    Human Rights Campaign............................................   296
    LeadingAge.......................................................   298
    Murzyn, Debbie...................................................   299
    National Center for Lesbian Rights (NCLR)........................   300
    Quinn, Marilyn D.................................................   303
    Ravanesi, Stacey.................................................   304
    Subaiya, Indu, M.D., MBA.........................................   305
    Treatment Action Group (TAG).....................................   307
    Vallance, Elizabeth..............................................   309

                          NOMINATION OF THOMAS PRICE,
                         TO BE SECRETARY, DEPARTMENT OF
                           HEALTH AND HUMAN SERVICES

                                  ----------

                           THURSDAY, JANUARY 24, 2017

                                           U.S. Senate,
                                          Committee on Finance,
                                                        Washington, DC.
        The hearing was convened, pursuant to notice, at 10:02
    a.m., in room SD-215, Dirksen Senate Office Building, Hon.
    Orrin G. Hatch (chairman of the committee) presiding.
        Present: Senators Grassley, Crapo, Roberts, Enzi, Cornyn,
    Thune, Burr, Isakson, Portman, Toomey, Heller, Scott, Cassidy,
    Wyden, Stabenow, Cantwell, Nelson, Menendez, Carper, Cardin,
    Brown, Bennet, Casey, Warner, and McCaskill.
        Also present: Republican Staff: Chris Campbell, Staff
    Director; Nicholas Wyatt, Tax and Nominations Professional
    Staff Member; Jay Khosla, Chief Health Counsel and Policy
    Director; Kimberly Brandt, Chief Health-care Investigative
    Counsel; Brett Baker, Health Policy Advisor; and Erin Dempsey,
    Health-care Policy Advisor. Democratic Staff: Joshua Sheinkman,
    Staff Director; Michael Evans, General Counsel; Elizabeth
    Jurinka, Chief Health Advisor; David Berick, Chief
    Investigator; Laura Berntsen, Senior Advisor for Health and
    Human Services; Beth Vrabel, Senior Health Counsel; Adam
    Carasso, Senior Tax and Economic Advisor; Matt Kazan, Health
    Policy Advisor; Anne Dwyer, Health-care Counsel; and Ryan
    Carey, Press Secretary and Speech Writer.

     OPENING STATEMENT OF HON. ORRIN G. HATCH, A U.S. SENATOR FROM
                  UTAH, CHAIRMAN, COMMITTEE ON FINANCE

        The Chairman. The committee will come to order. I would
    like to welcome everyone to this morning's hearing. Today we
    will consider the nomination of Dr. Tom Price to be the
    Secretary of the Department of Health and Human Services.
        I want to welcome Dr. Price to the Finance Committee. And I
    appreciate his willingness to serve in a position of this
    magnitude, especially at this particularly crucial time.
        When Obamacare was pushed through on a series of party-line
    votes, Republicans in Congress warned that the new health-care
    law basically would harm patients, families, and businesses.
    Not to put too fine a point on it, but we were right. And the
    next HHS Secretary will play a pivotal role as we work to
    repeal Obamacare and replace it with patient-centered reforms
    that will actually address costs, among other things. This will
    be an important endeavor, one that will and should get a lot of
    attention here today, but it should not be the sole focus of
    the next HHS Secretary.
        HHS has an annual budget of well over $1 trillion. Let me
    repeat that: one department, $1 trillion. HHS encompasses the
    Centers for Medicare and Medicaid Services, the Centers for
    Disease Control and Prevention, the National Institutes of
    Health, the Food and Drug Administration, and many others. It
    is no exaggeration to say that HHS touches more of the U.S.
    economy and affects the daily lives of more Americans than any
    other part of the U.S. Government.
        I firmly believe that Dr. Price has the experience and
    qualifications necessary to effectively lead this large and
    diverse set of agencies, and many people share that view. He
    has had a wealth of experience in the practice of medicine,
    understands these problems, and has been a great member of the
    House of Representatives.
        For example, past HHS Secretaries Mike Leavitt and Tommy
    Thompson strongly support his nomination. Physician
    organizations that know Dr. Price's work, including the
    American Medical Association and most surgical specialty
    groups, enthusiastically support him. The American Hospital
    Association and other health-care stakeholder groups do as
    well.
        Perhaps the Healthcare Leadership Council, representing the
    broad swath of health-care providers, said it best in stating
    that, quote, ``It is difficult to imagine anyone more capable
    of serving this Nation as the Secretary of HHS than Congressman
    Tom Price.''
        Unfortunately, in the current political environment,
    qualifications, experience, and endorsements from experts and
    key stakeholders sometimes do not seem to matter to some of our
    colleagues. At least that appears to be the case, since none of
    those who say they oppose Dr. Price's nomination seem to be
    talking about whether he is qualified. Instead, we have heard
    grossly exaggerated and distorted attacks on his views and his
    ethics. On top of that, we have heard complaints and a series
    of unreasonable demands regarding the confirmation process
    itself. Of course, these tactics have not been limited to Dr.
    Price.
        My Democratic friends have taken this approach with almost
    all of President Trump's Cabinet nominees, as Senate Democrats'
    unprecedented efforts to delay and derail the confirmation
    process and apply a radically new set of confirmation standards
    has continued unabated.
        To that point, let me say this. I have been in the Senate
    for 40 years, and I think my record for being willing to reach
    across the aisle is beyond any reasonable dispute. And I have
    certainly done it with my fellow Democrats here on this
    committee. In fact, from time to time I have taken lumps in
    some conservative circles for working closely with my
    Democratic colleagues. I have, on some occasions, voted against
    confirming executive branch nominees, but far more often than
    not I have opted to defer to the occupants of the White House
    and allowed them to choose who serves in their administrations.
    I have taken some lumps for that too.
        I am not bringing any of this up to brag or to solicit
    praise from anyone in the audience. I raise all of this today
    so that people can know I am serious when I say that I am
    worried about what my colleagues on the minority side are doing
    to the Senate as an institution. While the overriding sense of
    comity and courtesy among Senators has admittedly been in
    decline in recent years, I have never seen this level of
    partisan rancor when it comes to dealing with a President from
    an opposing party. I have never seen a party in the Senate,
    from its leaders on down, publicly commit to not only opposing
    virtually every nomination, but to attacking and maligning
    virtually every single nominee.
        Now, let me be clear. I am not suggesting that the Senate
    start rubber-stamping nominees, nor am I suggesting that any
    member of the Senate should vote against their conscience or
    preferences simply out of respect for tradition or deference.
    What I am saying is that the same rules, processes, courtesies,
    and assumptions of good faith that have long been the hallmark
    of the Senate confirmation process, especially in this
    committee, should continue to apply regardless of who is
    President. If what we are seeing now is the new normal for
    every time control of the White House changes hands, the
    Senate, quite frankly, will be a much lesser institution.
        Unfortunately, our committee has not been entirely immune
    to the hyper-politicization of the nomination process. We saw
    that last week with the Mnuchin hearing. And I regret to say
    that I think we are likely to see more of it today. I hope not.
        Case in point: I expect that during today's hearing, we are
    going to hear quite a bit about process and claims that Dr.
    Price's nomination is being rushed and that the nominee has not
    been fully vetted. These allegations are simply untrue.
        President Trump announced his intent to nominate Dr. Price
    just 3 weeks after the election. Dr. Price submitted the
    required tax returns and completed questionnaire on December
    21st. That was 35 days ago. And by any reasonable standard,
    that is sufficient time for a full and fair examination of the
    nominee's record and disclosures.
        By comparison, the committee held a hearing on the
    nomination of Secretary Sebelius, the Democrat nominee, 16 days
    after she submitted her paperwork. For Secretary Burwell, it
    was 17 days. In other words, the time between the completion of
    Dr. Price's file and his hearing has been more than that of the
    last two HHS Secretaries combined. And by the way, both of
    those nominees received at least a few Republican votes in this
    committee and on the floor.
        Outside of extraordinary process demands, Dr. Price has
    faced a number of unfair attacks on both his record as a
    legislator and his finances. On the question surrounding
    finances, I will defer on any substantive discussion and first
    allow Dr. Price to defend himself from what are, by and large,
    specious and distorted attacks. For now I will just say that I
    hope that my colleagues do not invent new standards for
    finances, ethics, and disclosure that are different from those
    that have generally applied in the past. There is a saying
    involving both stones and glass houses that might be applicable
    as well.
        With regard to Dr. Price's views and voting record, I will
    simply say that virtually all the attempts I have witnessed to
    characterize Dr. Price's views as being, quote, ``outside of
    the mainstream'' have been patently absurd unless, of course,
    the only ideas that are in the, quote, ``mainstream'' are those
    that endorse the status quo on health care and our entitlement
    programs.
        In conclusion, I just want to note that the overly partisan
    treatment of nominees and distortions of their records is a
    relatively new development on this committee. My hope is that
    we can begin to set a new standard here that we can all be
    proud of, and that we will work to reverse recent trends and
    have a fair and open discussion of the nominee and his
    qualifications.
        So with that, I will turn to our distinguished ranking
    member, Senator Wyden.
        [The prepared statement of Chairman Hatch appears in the
    appendix.]

                 OPENING STATEMENT OF HON. RON WYDEN,
                       A U.S. SENATOR FROM OREGON

        Senator Wyden. Thank you very much, Mr. Chairman.
        Colleagues, the American public heard many promises about
    health care from the new administration. No cuts to Medicare or
    Medicaid. Nobody hurt by ACA repeal. ``Insurance for everybody
    . . . much less expensive and much better.'' Congressman
    Price's own record undercuts these promises.
        I am going to start with ethics and undisclosed assets.
    Congressman Price owns stock in an Australian biomedical firm
    called Innate Immunotherapeutics. His first stock purchase came
    in 2015 after consulting Representative Chris Collins, the
    company's top shareholder and a member of its board. In 2016,
    the Congressman was invited to participate in a special stock
    sale called a private placement. The company offered the
    private placement to raise funds for testing on an experimental
    treatment it intends to put up for FDA approval. Through this
    private placement, the Congressman increased his stake in the
    company more than 500 percent. He has said he was unaware he
    paid a price below market value.
        It is hard to see how this claim passes the smell test.
    Company filings with the Australia Stock Exchange clearly state
    that this specific private placement would be made at below-
    market prices. The Treasury Department handbook on private
    placements states, and I will quote: ``They are offered only to
    sophisticated investors in a nonpublic manner.'' The
    Congressman also said last week he directed this stock purchase
    himself, departing from what he said was his typical practice.
        Then there is the matter of what was omitted from the
    Congressman's notarized disclosures. The Congressman's stake in
    Innate is more than five times larger than the figure he
    reported to ethics officials when he became a nominee. He
    disclosed owning less than $50,000 of Innate stock. At the time
    the disclosure was filed, by my calculation, his shares had a
    value of more than $250,000. Today his stake is valued at more
    than a half-million dollars. Based on the math, it appears that
    the private placement was excluded entirely from the
    Congressman's financial disclosure. This company's fortunes
    could be affected directly by legislation and treaties that
    come before Congress.
        It also appears the Congressman failed to consult the House
    Ethics Committee following other trades of health-care stocks.
    That was required, as they are directly related to two bills he
    introduced and promoted. Even if some of those trades were not
    made at his direction, he would have been made aware of them
    when he filed his Periodic Transaction Reports with the House
    of Representatives.
        Set aside the legal issues. It is hard to see this as
    anything but a conflict of interest and an abuse of position.
        Another key question on the Finance Committee's
    biographical questionnaire is whether nominees have been
    investigated for ethics violations. The Congressman has been
    the subject of two investigations stemming from fundraising
    practices. This too was not disclosed. The committee needs to
    look into these matters before moving the nomination forward.
        Now to policy. On the Affordable Care Act specifically, and
    the scheme known as ``repeal and run,'' the secret replacement
    plan is still hidden away, but already the administration
    charges ahead with a broad executive order that endangers
    Americans' health.
        As the Budget chairman, Congressman Price is the architect
    of repeal and run. If his repeal bill became law, 18 million
    Americans would lose their health care in less than 2 years. In
    1 decade, you would go from 26 million uninsured to 59 million.
    Repeal and run raises premiums 50 percent in less than 2 years.
    Costs skyrocket from there. The market for individuals to buy
    health insurance collapses. No-cost contraceptive coverage for
    millions of women, gone. By defunding Planned Parenthood,
    nearly 400,000 women would lose access to care almost
    immediately, hundreds of thousands more would lose their choice
    to see the doctors they trust. The Price plan takes America
    back to the dark days when health care was for the healthy and
    the wealthy.
        His other proposals do not offer much hope that the damage
    will be undone. There is a big gap between the Trump pledge of
    ``insurance for everybody and great health care'' and the
    Congressman's proposals.
        In another bill, the Empowering Patients First Act, the
    Congressman brings back discrimination against people with
    preexisting conditions such as pregnancy or heart disease. He
    gives insurers the power to deny care and raise costs on those
    with preexisting conditions if they did not maintain coverage.
    In effect, the bill said insurance companies could take
    patients' money and skip out on paying for the care they need.
        The Price bill also gave insurers the okay to reinstate
    lifetime limits on coverage and charge women higher rates
    because they are women. It gutted the tax benefits that help
    working people afford high-quality coverage. It slashed the
    minimum standards that protect patients by defining exactly
    what health plans have to cover. All this from a bill called
    Empowering Patients First. I have seen a lot of bills with
    ironic titles. This one, colleagues, takes the cake.
        Here's the constant. The Congressman's proposals push new
    costs onto patients. Massive cuts to Medicare were proposed in
    the Price budget, as another example. In my view, the Congress
    has a duty to uphold the promise of Medicare. It is a promise
    of guaranteed benefits.
        The Congressman advocated privatizing Medicare, cutting it
    almost a half-trillion dollars. After his nomination, he said
    he wanted to turn the program into one with vouchers within the
    first 6 to 8 months of the administration. He supports
    ``balance billing'' so seniors would have to cover extra
    charges above what Medicare pays when they go to the doctor.
    More extra costs for seniors on a tight budget. In addition,
    the Congressman calls for block-granting and capping Medicaid,
    which would shred a vital safety net for our most vulnerable.
        Medicaid insures 74 million people. More Americans rely on
    Medicaid to pay for nursing home care and home-based care than
    any other program. The program pays for nearly half of all
    births and covers millions of children. It is a critical source
    of mental health coverage and substance abuse treatment, vital
    at a time when our communities are battling the opioid
    epidemic.
        I will close with just two additional points. If confirmed,
    the head of HHS, the Health and Human Services Department, is
    the captain of the Trump health-care team. Now the Congressman
    says patients should be at the center of care. I agree with
    that. When I look, however, at the Congressman's proposals, I
    do not see the patient at the center of health care. I see
    money and I see special interests at the center of health care.
        Now finally, let me just make a point with respect to the
    process and the comments of my good friend, Chairman Hatch.
        Colleagues, the process here is exactly the same process to
    a ``t'' that this committee has used for 20 years. It is the
    process that applied, for example, to Tom Daschle; it applied
    to Ron Kirk.
        I will enter into the record a specific set of details
    about how this is the process that is exactly what was done on
    a bipartisan basis for 20 years. And I will make that a part of
    the record.
        [The information appears in the appendix on p. 278.]
        Senator Wyden. Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator.
        [The prepared statement of Senator Wyden appears in the
    appendix.]
        The Chairman. I am pleased to hand over my normal witness
    introduction duties today to our colleague, the distinguished
    Senator from Georgia, Senator Isakson, who will introduce Dr.
    Price.
        And so, Senator Isakson, please proceed.

               OPENING STATEMENT OF HON. JOHNNY ISAKSON,
                      A U.S. SENATOR FROM GEORGIA

        Senator Isakson. Well, thank you, Chairman Hatch, Ranking
    Member Wyden, and fellow members of the committee. I am proud
    to have a seat right up there on this committee and enjoy being
    a part of it.
        And I could not be prouder than to introduce Tom Price to
    you today. This is the second time I have had the occasion to
    introduce Tom in the last week. The first time I was called, it
    was to introduce him at the HELP Committee, which I also serve
    on, and I was proud to do that. And I gave what I hope was the
    best introduction I could possibly give for a man whom I have
    known for 30 years. I have known him as a family man, as a
    legislator, as a member of our community, as a great physician,
    and a great friend.
        And it was easy to do that one. But since that last week,
    things have changed. I feel like I have been asked to be a
    character witness in a felony trial in the sentencing phase of
    a conviction.
        There are things that have been said the last week or so,
    just to me, that need to be refuted. So I am going to take all
    the positive things and say them at the end, but try and begin
    by saying there are a few things out there that need a
    perspective all the way around.
        I am very proud that Tom has submitted his income tax
    returns. A couple of things that the ranking member mentioned
    came from those submissions. Some of the things that came out
    in a memo last night about property taxes, those were de
    minimis items that came out, one late tax payment in Nashville,
    TN, one late tax payment in Washington, DC. Late, not unpaid--
    just late, and I have done that myself a couple of times.
        On Innate Immunotherapeutics, that was a disclosure that he
    made, and the valuation difference on a private placement is a
    normal thing. It is an eyes-of-the-beholder placement in terms
    of what you assess it at. And this was merely an assessment as
    to what you disclose in terms of its worth, not whether you
    disclose it or not.
        Tom is a good man. He is a family man. He is a physician.
    He is an honorable man. And I am proud to be here today, not to
    defend him, because he does not need defending, but to praise
    him for the things that he has done.
        You know, I think it is important for all of us to look at
    a Secretary nomination, whether it is Secretary of Defense,
    whether it is Health and Human Services, and say, ``What am I
    really looking for in terms of this person?''
        Well, first and foremost, I am looking for a person who
    understands the American family. Tom is a great family man. In
    fact, his wife Betty is here. Raise your hand, Betty.
        Last week I told her to stand up, and she was in a crowd
    and I could not get her to do it, so I am going to get her to
    raise her hand this time around. Betty is a great lady and a
    great wife. Their son Robert, I guess, is still in Nashville,
    TN singing country music. Is that right? So he could not be
    here today, but Lamar Alexander appreciates that part very
    well.
        Tom is active in his church, active in his community,
    understands the needs of families, and understands the
    relationship of health care to a good family.
        Secondly, who would I ask to spend $1.1 trillion of my
    money? I do not have that much, of course, but that is how much
    Tom will oversee at HHS. What would I look for in a person to
    handle that much money?
        I would look for a little bit of experience. And Tom has it
    in terms of being a legislator. I would look for somebody who
    understood where that cost was going and what he needed to do
    to manage it. And Tom is that type of person. I would look for
    somebody I would trust with that amount of money, even though I
    do not have it, but if it were mine.
        Third, does he understand health care? Let me tell you a
    little bit about Tom and his medical practice. It is called
    Resurgens Orthopaedics. Resurgens Orthopaedics is the
    consolidation of a number of small orthopaedics firms around
    the State of Georgia into the largest orthopaedic provider in
    our State.
        Tom was one of the leading persons who pulled that together
    and, in fact, ran the practice for a while himself. They are my
    doctors. In fact, 26 years ago Resurgens saved my young son
    Kevin's right leg after a terrible automobile accident. And I
    have never forgotten what they did for him in a terrible crisis
    that we had in our family.
        But they are a great medical firm. He understands medicine.
    And he has run a comprehensive medical program.
        Fourth, I would want to understand if he knew the
    legislative process. You know, when the President calls Tom in
    and says, okay, we are going to go to the Senate and the House,
    we are going to sell our package, Tom has to have the ability
    to convince 535 people that the President is right or that the
    administration is right. You do not want somebody going up
    there who has not walked into a legislative meeting before,
    somebody who has not been in the political process before. Tom
    has been there and done that. And he is the type of guy you
    could trust to make the sale and represent the administration
    and the people.
        Fifth, I would want somebody who is accountable. Tom is an
    accountable type of guy. In fact, I joked last week and said he
    is one of those rare ones of us who actually reads the bills.
    In fact, when I have a big question, I will usually come talk
    to Tom late at night and say, ``Tom, what do you know about
    House Resolution 3742?'' and he will tell me.
        He is not exciting. He is sometimes boring, but he is
    always right, because he is always prepared. But he understands
    you need to be accountable in this business. You need to be
    responsible for what you do and responsible for what you say.
        Now, there is a rumor that has been spread around by some
    people that Tom does not support the saving of Social Security.
    Let me tell you a little story. A few weeks ago, in fact at the
    end of the campaign in October, I was called by AARP and Tom
    was called by AARP. They said, will you two go on the road for
    us and do presentations around the State in your congressional
    districts about how you are going to save Social Security?
        And I guess Alpharetta, GA was the first place. Tom and I
    went one night and spent the whole night before a room full of
    seniors defending saving Social Security. So anybody who is
    passing that rumor around, hey, go ask AARP who is going to
    save Social Security, go ask the people who are active in that
    business who is going to do it. Tom Price understands the value
    of Social Security and the value of Medicare. And being
    eligible for both, I would not be up here promoting somebody
    who is going to take it away from me, I guarantee you that.
        Now, let me tell you one other thing. Four years ago, I sat
    in this committee room and in the HELP Committee and I
    questioned and I asked all that I could of Sylvia Burwell. And
    when it came time for a vote, I voted for her because she was
    the right person at the right time for the administration to
    put in as head of HHS.
        Dr. Tom Price is the right man at the right time for the
    right job. He is my friend. He is a man I have known for 30
    years. He has unquestioned character and unquestioned ability.
    And he will be a great Secretary of HHS.
        I thank all of you for taking my calls earlier when I
    called before this meeting. I urge you to give him the courtesy
    of your time to listen to what he has to say, ask your thorough
    questions, and I hope you will see fit to nominate an honorable
    man, an accountable man, and a good man to be the next
    Secretary of Health and Human Services.
        And I yield back, Mr. Chairman.
        The Chairman. Well, thank you, Senator Isakson.
        I tell you, Tom, you could not have a better introducer
    than Senator Isakson. I mean, he is not only highly respected
    by all of us in the Senate, Democrats and Republicans, but he
    is very, very articulate, as you can see. And I think he did a
    very good job talking about you and your future here in this
    committee.
        Now, I have some obligatory questions for the nominee.
    First, is there anything that you are aware of in your
    background that might present a conflict of interest with the
    duties of the office to which you have been nominated?
        Dr. Price. I am not.
        The Chairman. Do you know of any reason, personal or
    otherwise, that would in any way prevent you from fully and
    honorably fulfilling this responsibility?
        Dr. Price. I do not.
        The Chairman. Do you agree, without reservation, to respond
    to any reasonable summons to appear and testify before any duly
    constituted committee of the Congress, if you are confirmed?
        Dr. Price. I look forward to that.
        The Chairman. Finally, do you commit to provide a prompt
    response in writing to any questions that may be submitted to
    you or addressed to you by any Senator of this committee?
        Dr. Price. I do.
        The Chairman. Well, thank you. Those are the obligatory
    questions that we ask of everybody.
        Let us turn the time over to you, Dr. Price, Congressman
    Price, to state whatever you would like to state here for the
    committee this morning.

         STATEMENT OF HON. THOMAS PRICE, M.D., NOMINATED TO BE
    SECRETARY, DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON,
                                   DC

        Dr. Price. Thank you so much, Chairman Hatch and Ranking
    Member Wyden, and to all the members of this committee, for the
    opportunity to speak with you today and to engage in a
    discussion about the road ahead for our great Nation.
        I want to thank Senator Johnny Isakson so much for his
    incredibly gracious introduction. As he mentioned, we have
    known each other for 30 years or so. I am so grateful for his
    friendship and his kindness. Our State is so grateful for his
    leadership and his service. And we are blessed to have had it.
        I wish also to especially thank my wife Betty, of 33 years,
    who joins me here today. Her support and her encouragement and
    her advice--which I will remind you is always correct--and her
    love that she has given me over those past 33 years, I am more
    grateful for that than I could ever say.
        Over the past couple of weeks and months, I have met with
    many of you individually and gained a real appreciation for the
    passion that you all have for the critical work that is done at
    the Department of Health and Human Services. Please know that I
    share that passion, which is why I am here today and why I am
    honored to have been nominated to serve as the next Secretary
    of Health and Human Services.
        We all come to public service in our own unique ways that
    inform who we are and why we serve. My first professional
    calling was to care for patients. That experience as a
    physician and later as a legislator has provided me a holistic
    view of the complex interactions that take place every single
    day across our communities. And today I hope to share with you
    how my experience has helped shape my understanding of and
    appreciation for the Department of Health and Human Services.
        From an early age, I had an interest in medicine. My
    earliest memories, though, were of growing up on a farm in
    Michigan, where I lived until I was 5 years old when our family
    moved to suburban Detroit.
        I spent most of my formative years being raised by a single
    mom. Some of my fondest memories as a child were those spent
    with my grandfather, who was a physician, and I would
    occasionally spend some weekends with him when he would make
    rounds, which meant that we got in a car and went to people's
    homes and made house calls. And I will never forget the warmth
    and the love with which he was greeted at every single door.
    Those impressions are seared in my memory.
        After graduating from medical school from the University of
    Michigan, I moved to Atlanta, which I have called home for
    nearly 40 years. It is where I met my wife Betty. It is where
    we raised our son. I did my residency at Emory University and
    Grady Memorial Hospital, where I would later return in my
    career to serve as the medical director of the orthopaedic
    clinic.
        Throughout my professional career, I cared for and treated
    patients from all walks of life, including many, many children.
    And anyone who has ever had the privilege of treating a child
    knows how fulfilling it is to look into the eyes of a mom or a
    dad and say how we helped heal their son or their daughter. My
    memories of Grady are filled with the gracious comments of
    parents and of patients for the team of health-care specialists
    with whom I had the privilege of working.
        After 25 years of school and training, I started a solo
    orthopaedic practice. Over the years, this practice grew, as
    Senator Isakson mentioned, and it eventually became one of the
    largest non-
    academic group practices of orthopaedics in the country, for
    which I eventually served as chairman of the board. During 20
    years as a practicing physician, I learned a good bit about not
    just treating patients, but about the broader health-care
    system and where it intersects with government.
        A couple of vivid memories stand out. One is the number of
    times when patients were remarkably angry about the individuals
    figuratively, not literally, standing between themselves and
    their physician in the clinic room, making it so that what the
    physician was recommending might or might not be possible,
    whether it was from insurance or regulators or government or
    the like.
        And then there was the day that I remember vividly when I
    realized there were more people in the office behind the door
    where we saw patients in the front clinic area trying to fight
    with insurance and regulators and government than there were in
    front of the door actually caring and treating patients. And it
    became clear to me that our health-care system was losing focus
    on its number-one priority, and that is the patient.
        As a result, I felt compelled to broaden my role in public
    service and help solve the issues harming the delivery of
    medicine, and so I ran for the Georgia State Senate.
        I found Georgia's State Senate to oftentimes be a
    remarkably bipartisan place where collegial relationships were
    the norm. This is the environment in which I learned to
    legislate, reaching across the aisle to get work done.
        In Congress, I have been fortunate to have been part of a
    collaboration that broke through party lines as well to solve
    problems. Just this past Congress, as you will recall, it was a
    bipartisan effort that succeeded in ridding Medicare of a
    broken physician payment system and which has now begun the
    creation of a system that, if implemented properly, will help
    ensure that seniors have access to higher-quality care.
        If confirmed, my obligation will be to carry to the
    Department of Health and Human Services an appreciation for the
    bipartisan, team-driven policymaking in what has been a
    lifetime of commitment to improving the health and well-being
    of the American people. That commitment extends to what I call
    the six principles of health care: affordability,
    accessibility, quality, responsiveness, innovation, and
    choices.
        But Health and Human Services is more than health care.
    There are real heroes at this department doing incredible work
    to keep our food safe and to develop drugs and treatment
    options driven by scientists conducting truly remarkable
    research. There are heroes among the talented, dedicated men
    and women working to provide critical social services, helping
    families and particularly children have a higher quality of
    living and the opportunity to rise up and achieve their
    American dream.
        The role of the Health and Human Services Department in
    improving lives means it must carry out its responsibilities
    with compassion. It also must be efficient and effective and
    accountable as well as willing to partner with those in our
    communities already doing remarkable work. Across the spectrum
    of issues and services this department handles, there endures a
    promise that has been made to the American people. And we must
    strengthen our resolve to keep the promises our society has
    made to senior citizens and to those most in need of care and
    support.
        That means saving and strengthening and securing Medicare
    for today's beneficiaries and future generations. It means
    ensuring that our Nation's Medicaid population has access to
    quality care. It means maintaining and expanding America's
    leading role in medical innovation and of the treatment and
    eradication of disease.
        So I share your passion for these issues, having spent my
    life in service to them. And yet, there is no doubt that we do
    not all share the same point of view when it comes to
    addressing each and every one of these issues. Our approaches
    to policies may differ, but surely there exists a common
    commitment to public service and compassion for those whom we
    serve.
        We all hope to improve the lives of the American people, to
    help heal individuals and whole communities. So with a healthy
    dose of humility and an appreciation for the scope of the
    challenges before us, with your assistance and with God's will,
    we can make it happen. And I look forward to working with you
    to do just that.
        Mr. Chairman, I thank you for the opportunity to be with
    you today.
        [The prepared statement of Dr. Price appears in the
    appendix.]
        The Chairman. Well, thank you, Dr. Price. I cannot think of
    anybody who could give a better analysis of why this position
    is so important to them.
        Let me start with this question. The Department of Health
    and Human Services is one of the largest departments in
    government, employing, I think, nearly 80,000 employees and
    encompassing over 100 programs covering a large range of
    complex and diverse issues.
        Now, you have described to a degree, but if you could
    elaborate a little bit more, can you describe how you will
    prioritize and oversee the large array of issues for which you
    will be responsible? And tell us, what in your history has
    prepared you to lead the Department of Health and Human
    Services, such a multifaceted department?
        Dr. Price. Thank you, Mr. Chairman. As you and members
    know, the mission of the Department of Health and Human
    Services is to improve the health and the safety and the well-
    being of the American people. I am committed to that mission,
    but in order to do that, you have to put together teams of
    individuals in each sector of health and human services. And my
    history, wherever I was--whether it was in my clinical practice
    or in the State legislature or Congress or the work that I did
    in communities--was just to bring forward the greatest quality
    of talent that we could assemble.
        Second is to understand the scope and the issues. And
    clearly, having the experience both in the clinical arena as
    well as in the legislative arena, I understand the scope and
    the issues.
        And then finally, focusing on results. I think oftentimes
    it gets kind of muddy up here in Washington, what we do. We
    name the programs, we make certain that the resources are there
    to be able to provide money for the programs to be run, but
    oftentimes I think we drop the ball on whether or not we are
    actually accomplishing the mission. Are we truly improving the
    health and the safety and the well-being of the American
    people?
        So one of the major goals that I have is to look at the
    metrics that we are looking at at the department to make
    certain that we are accomplishing that mission and that goal.
        The Chairman. Thank you. The Center for Medicare and
    Medicaid innovation, CMMI, has begun numerous initiatives over
    the past few years, some of which have generated much
    controversy. Could you tell us your position on the work in
    CMMI and how it should or should not be continued in the
    future?
        Dr. Price. Thank you, Mr. Chairman. Innovation is so
    incredibly important to health care and the vibrant quality of
    health care that we need to be able to provide to our citizens.
    Innovation, in fact, is what leads quality health care. It is
    what expands the ability of health-care professionals to be
    able to treat patients. So I am a strong supporter of
    innovation, and I think one of the roles that we as
    policymakers have is to incentivize innovation.
        The Center for Medicare and Medicaid Innovation is a
    vehicle that might do just that. I think, however, that CMMI
    has gotten off track a bit. I think that what it has done is
    defined areas where it is mandatorily dictating to physicians
    and other providers in this country, in certain areas, how they
    must practice. So whether it is a geographic area that includes
    67 or 68 areas in our country that have to perform a certain
    procedure in a certain way and use a certain implant in a
    certain way because the government says they have to
    mandatorily, without exception, or whether it is 75 percent of
    the Part B Medicare drug demo, what is called a demonstration
    project, which dictates to physicians and other providers they
    must use an in-patient setting, that, to me, is no longer a
    trial, that is no longer an experiment, that is no longer a
    pilot project to determine whether or not an innovative
    solution might work. That is changing the way that American
    medicine is practiced by folks making decisions here in
    Washington as opposed to patients and families and doctors
    making those decisions.
        So I am a strong supporter of innovation, but I hope that
    we can move CMMI in a direction that actually makes sense for
    patients.
        The Chairman. Well, thank you so much. Medicare has lost
    more than $130 billion--that is with a ``b''--to improper
    payments over the past 3 years. The program has also been above
    the legal billing error rate threshold of 10 percent for the
    past 4 years.
        Given that Medicare trustees have issued grave concerns
    about looming Medicare insolvency if we stay at the current
    spending levels, will your administration actively champion our
    Medicare Integrity Program so that we can recover a much higher
    percentage of the billions of taxpayer dollars lost each year
    to billing mistakes and ensure that Medicare will be in place
    for future American seniors?
        And also, as a former practicing physician who has
    experience with Medicare and Medicaid programs, do you have any
    insights into steps you think should be taken to address the
    multi-billion-dollar problem of waste, fraud, and abuse in
    these programs?
        Dr. Price. Yes, thanks, Mr. Chairman. Nobody supports care
    being billed that is not needed or has not been provided. And
    this is one of those areas that I think we need to be very,
    very focused on.
        I am certain that there are some bad actors out there. I
    think they are a minority, but there are some bad actors out
    there. And I am certain that if we were to focus specifically
    on those bad actors in real time--which is what happens in
    every other industry in our country where that real-time
    information is available and acted upon--instead of trying to
    determine whether every single incident of care is necessary,
    if we were to focus on those individuals who were the bad
    actors specifically, then I think we could do a much better job
    of not just identifying the fraud that exists out there, but
    ending that fraud.
        The Chairman. Well, thank you.
        Senator Wyden, we will turn to you now.
        Senator Wyden. Thank you, Mr. Chairman.
        Congressman, I am going to start with the trading in
    health-care stocks. Your position is that the trading was legal
    because, in your view, it complied with House rules. I think
    there are debatable legal questions, but there are other
    matters.
        Innate Immunotherapeutics is an obscure Australian company
    that develops a treatment for immune system disorders and plans
    to seek FDA approval. Innate's fortunes are affected by
    congressional action.
        Today, the total value of your shares exceeds a half-
    million dollars. Yet on the Office of Government Ethics
    disclosure form you filed as a nominee, you significantly
    undervalued the stock. You failed to include the value of more
    than 400,000 shares you bought at a significant discount during
    a private stock sale made available to specially chosen
    investors around Labor Day. You also significantly
    underreported the value of this purchase to the committee. It
    is worth more than twice what you reported.
        You heard about the stock from a House colleague who is a
    board director of this Australian drug company and the largest
    shareholder. You got in on private placements not available to
    the public. In these private placements, you bought over
    400,000 shares at discounts that were as much as 40 percent
    cheaper than the price on the Australian Stock Exchange. And
    you were sitting at the time on committees that have
    jurisdiction over major health-care programs and trade policy.
        ``Yes'' or ``no,'' does this not show bad judgment?
        Dr. Price. Well, if what you said was true it might. But
    the fact of the matter is, that is not the case.
        Senator Wyden. We have a paper trail, Congressman. We have
    a paper trail for every comment I have made. ``Yes'' or ``no,''
    does this not show bad judgment?
        Dr. Price. No.
        Senator Wyden. Well, I just----
        The Chairman. Well, let him answer the question too. I
    mean, you have kind of indicated he did something wrong. Let
    him explain why it was not wrong.
        Senator Wyden. It was a ``yes'' or ``no'' answer.
        The Chairman. No, I want him to be able to handle that
    problem.
        Dr. Price. Maybe it would be helpful if you laid out the
    accusation, sir.
        The Chairman. Be fair.
        Senator Wyden. Well, you purchased stock in an Australian
    company through private offerings at discounts not available to
    the public.
        Dr. Price. If I may, they were available to every single
    individual who was an investor at the time.
        Senator Wyden. Well, that is not what we learned from
    company filings. Company filings with the Australian Stock
    Exchange state that this specific private placement would be
    made at below-
    market rates. The Treasury Department says it is only offered
    to sophisticated investors in a non-public manner. We have a
    paper trail for every one of the statements that I have gone
    into. And trading in stocks while you sit on two committees
    introducing legislation that directly impacts the value of the
    stocks----
        Dr. Price. What legislation would that be, Senator?
        Senator Wyden. We will take you through the various bills.
    But the reality is, this has been cited on a number of
    occasions.
        Dr. Price. The reality is that everything that I did was
    ethical, above-board, legal, and transparent. The reason that
    you know about these things is because we have made that
    information available in real time as required by the House
    Ethics Committee.
        So there is not anything that you have divulged here that
    has not been public knowledge.
        Senator Wyden. Your stake in Innate is more than five times
    larger than the figure you reported to ethics officials when
    you became a nominee.
        Dr. Price. And if you had listened to your committee staff,
    I believe you would know that our belief is that that was a
    clerical error at the time that the 278E was filed. We do not
    know where it happened, whether it was on our end, whether it
    was on the end of the individuals of OGE. But there was not any
    malicious intent at all.
        Senator Wyden. Congressman, you also reported it in the
    questionnaire to the committee, and you had to revise it
    yesterday because it was wrong.
        Dr. Price. And the reason for that is because I, when asked
    about the value, thought it meant the value at the time that I
    purchased the stock, not the value at some nebulous time when
    we supposedly made a specific gain.
        Senator Wyden. I want to get in one other question, if I
    might. This weekend, the President issued an executive order
    instructing the Department and other agencies to do everything
    possible to roll back the Affordable Care Act. If confirmed,
    you will be the captain of the health team and in charge of
    implementing the order.
        ``Yes'' or ``no,'' under the executive order, will you
    commit that no one will be worse off?
        Dr. Price. What I commit to, Senator, is working with you
    and every single member of Congress to make certain that we
    have the highest-quality health care and that every single
    American has access to affordable coverage.
        Senator Wyden. That is not what I asked. I asked, will you
    commit that no one will be worse off under the executive order?
    You ducked the question. Will you guarantee that no one will
    lose coverage under the executive order?
        Dr. Price. I guarantee you that the individuals who lost
    coverage under the Affordable Care Act, we will commit to
    making certain that they do not lose coverage under whatever
    replacement plan comes forward. That is the commitment that I
    provide to you.
        Senator Wyden. The question again is, will anyone lose
    coverage, and you answered something I did not ask.
        I will wrap up this round by saying, will you commit to not
    implementing the order until the replacement plan is in place?
        Dr. Price. As I mentioned, Senator, what I commit to you
    and what I commit to the American people is to keep patients at
    the center of health care. And what that means to me is making
    certain that every single American has access to affordable
    health coverage that will provide the highest-quality health
    care that the world can provide.
        Senator Wyden. I am going to close by way of saying that
    what the Congressman is saying is that the order could go into
    effect before there is a replacement plan. And independent
    experts say that this is going to destroy the market on which
    millions of working families buy health coverage. And on the
    questions that I asked, will the Congressman commit that nobody
    will be worse off, nobody will lose coverage, we did not get an
    answer.
        Thank you, Mr. Chairman.
        The Chairman. Well, how can anybody commit to that?
    [Laughter.]
        Let me just say, Dr. Price, you have been accused here of
    investing in securities that you had a direct effect over in
    Congress and you disclosed the wrong value of shares you owned
    in Innate Immunotherapeutics.
        Now Dr. Price, let me just say this, has a diversified
    portfolio with Morgan Stanley in a broker-directed account.
    Correct me if I am wrong on any of this, Doctor. The portfolio
    includes both health-care and non-health-care stocks. His
    financial adviser designed the portfolio and directed all
    trades in the account. The advisers and not Dr. Price have the
    discretion to decide which securities to buy and sell.
        On March 17, 2016 in a rebalancing of the portfolio, the
    financial adviser directed the purchase of 26 shares in Zimmer
    Biomet worth under $3,000. The adviser notified Dr. Price of
    the purchase on April 4, 2016, and Dr. Price disclosed them on
    his House periodic transaction report on April 15th.
        Now, Dr. Price began his legislative effort related to the
    comprehensive joint replacement demonstration project in 2015.
    With one exception, all of Dr. Price's stocks are held in three
    broker-
    directed accounts. Neither he nor his wife direct or provide
    input regarding investments in these accounts. Innate
    Immunotherapeutics is the one exception.
        Now, Dr. Price decided to invest based on public
    information regarding his work on multiple sclerosis treatments
    as a disease. He has been intimately involved in treating for
    years. He directed the investments based on his own research
    into the company. He invested $10,000 in the company in January
    2015 and reported the investments to House Ethics in February
    of that year. He made an additional investment in September
    2016 and also disclosed that investment.
        He has corrected his filing regarding the value of his
    shares. He has agreed to divest all shares in the company. Is
    that a correct set of remarks?
        Dr. Price. I think your summation is correct, sir. And I
    just would point out that anybody who knows me well knows that
    I would never violate their trust. And I know the environment
    that we are in here--you mentioned it in your opening
    statement--but I appreciate you correcting the record.
        The Chairman. Well, thank you.
        Senator Carper. Mr. Chairman?
        The Chairman. Yes, sir?
        Senator Carper. Just an inquiry. You just consumed about 2
    minutes beyond your opening statement. And in the interest of
    fair play, is it appropriate for someone to note that 2 minutes
    is also owed to Senator Wyden or somebody on our side?
        The Chairman. Well, he already did go over 2 minutes, so it
    is no problem.
        Senator Carper. Okay. But as we go forward in this process,
    I would just ask you to keep that in mind.
        The Chairman. Well, I am not going to relinquish my role as
    chairman----
        Senator Carper. No, I understand.
        The Chairman [continuing]. To correct errors that are
    promulgated here. But I have always been good about giving time
    that you need, so I will try to do that.
        Senator Carper. Thank you.
        The Chairman. But I am also not going to allow things that
    are false to go forward without some sort of comment.
        Senator Carper. All right.
        The Chairman. We just cannot allow this to happen.
        Senator Wyden. Mr. Chairman, just a unanimous consent
    request.
        The Chairman. Yes.
        Senator Wyden. I have a bipartisan disclosure memo I would
    like to ask be made a part of the record, because it will
    document what I have stated.
        The Chairman. Without objection.
        [The memorandum appears in the appendix on p. 283.]
        The Chairman. Senator Roberts?
        Senator Roberts. Did you really wink at me and smile? Bless
    your heart, thank you. [Laughter.]
        Good Doctor, thank you for coming. I think it is important
    to make clear right off the bat that, even if Congress and the
    incoming administration were to do nothing, absolutely nothing
    amending or repealing parts of the Affordable Care Act, the law
    is not working.
        Dr. Price. Right.
        Senator Roberts. It is collapsing. The prices are
    unaffordable, the market is nearly nonexistent, with few
    options in several States and counties. This year, one out of
    every three counties in this country only has one insurer
    offering coverage on the exchange.
        What tools do you have, or will you have when you are
    confirmed, which could be utilized over the next couple of
    months to provide stability and improve the individual
    insurance markets, make them more appealing so that insurance
    carriers will want to come back and provide more coverage
    options as we transition away from the Affordable Care Act?
        Dr. Price. Well, thank you, Senator. I think it is
    incredibly important for us to admit here what the American
    people know, and that is that this law is not working. It
    certainly is not working for folks in the individual and small-
    group market.
        You have premiums that are up significantly; they were
    supposed to go down by 2,500 bucks; now they are up more than
    2,500 bucks on average. You have deductibles that have
    escalated to $6,000 to $12,000. You have, as you mentioned,
    States where there is only one insurance provider. You have
    one-third of the counties in this country where there is only
    one insurance carrier.
        This is maybe working for government, maybe working for
    insurance companies, but it is not working for patients. And so
    what we need to do is make an effort to try to reconstitute the
    individual and small-group market. And that begins, I believe,
    by providing stability in our conversation and in our tone.
        And one of the goals that I have is to lower the
    temperature in this debate, to say to those providing the
    insurance products across this country, we understand; we heard
    the challenges that you have.
        They are already exiting the market. What we need to do is
    to say, there is help on the way to allow us to reconstitute
    the individual and small-group market and allow for folks to
    gain the kind of coverage that they want for themselves and for
    their family--not what the government forces them to buy--that
    allows them to purchase coverage at a reasonable amount, that
    makes it so that they do not have deductibles through the roof,
    where they have the ability to pay the premiums and the
    deductible as well.
        So there are so many things that we ought to be focusing on
    to make certain, again, that the American people have access to
    the highest-quality care that is affordable for them.
        Senator Roberts. Doctor, I have 84 critical access
    hospitals in my State. They are all part of the rural health-
    care delivery system, which is under great stress. As we have
    seen when I visit with hospital administrators all throughout
    Kansas--there was a time I knew every one of them--they are
    scratching their heads over regulations coming out of HHS, CMS,
    and all the other agencies that you will oversee when you are
    confirmed.
        I mention the meaningful use program for electronic health
    care records. Doctors used to spend, what, 10 to 15 minutes
    with patients. It is now down to about 2 or 3, and then they
    have to report immediately on what was going on.
        The 96-hour rule for critical access hospitals, numerous
    other documentation requirements--it seems to me there is a
    lack of understanding of our provider shortages in our rural
    areas. We are just hanging on by a thread, and these one-size
    regulations from Washington simply do not translate to rural
    Kansas or any other rural area as far as population----
        My question is, how will you work to ensure an effective
    but smarter, less-burdensome rulemaking process?
        Dr. Price. Well, this is really critical, Senator, because,
    as you mentioned, in the rural areas--Georgia is the largest
    State geographically east of the Mississippi, and we have a
    large rural population, and critical access hospitals are so
    important to communities around our State and truly around this
    Nation.
        But the regulatory scheme that has been put in place is
    choking the individuals who are actually trying to provide the
    care, so much so that you have physicians and other providers
    who are leaving the practice, who are leaving the caring for
    patients, not because they have forgotten how to do it or they
    have grown tired of it, but because of the onerous nature of
    the regulatory scheme coming out of Washington, DC.
        The meaningful use project that you mentioned makes it that
    much more difficult. We have turned physicians into data-entry
    clerks. And you just have to ask them what they are doing. And
    if you talk to patients, what they recognize is that, when they
    go in to see their doctor, they see the top of his or her head
    as they are punching the information, the data into a computer,
    as opposed to that sharing of information that is so vital and
    necessary between the physician and the patient for quality
    health care.
        So, one, a recognition of the problem is incredibly
    important, a recognition of the importance of rural health care
    in our Nation and how it needs to be bolstered up, and then
    looking at the consequences of what we do as government.
        As I mentioned earlier, oftentimes I do not think we look
    at the consequences. We pass the rule, we pass the regulation,
    we institute it, we think it is the greatest thing since sliced
    bread, but in fact what it is doing is harming the very
    individuals who are trying to provide the care. You do not get
    that information unless you ask.
        Senator Roberts. All right, I appreciate that. My time is
    up.
        Thank you, Mr. Chairman.
        The Chairman. Senator Nelson?
        Senator Nelson. Thank you, Mr. Chairman.
        Congressman, I enjoyed our visit yesterday. We had a
    discussion, when you were kind enough to come visit me, about
    the fact that I have in the State of Florida 4 million-plus
    seniors on Medicare, and they are petrified of the idea of
    privatized Medicare.
        And I talked to you about this. And you talked about the
    premium support system that you are advocating. And you pointed
    to a study that was done by CBO. You mentioned that you would
    send me a copy, and we have not gotten it. So what I did, I
    went and got the copy myself, and it is from September of 2013.
    And what it concludes is opposite of what you said with regard
    to high-cost States like Florida.
        Medicare is going to be spending 4 percent less under the
    proposal that you were talking about in this CBO report, lower
    than current law, and beneficiary costs will decrease by 6
    percent on the average, which is what you said yesterday. But
    in high-cost regions like Florida, you are going to have a
    higher beneficiary cost than current law under your premium
    support proposal.
        Annual premiums in Florida would increase 125 percent
    according to the CBO chart on page 71. CBO says that the annual
    premium in a high-cost region like Florida would be $3,600
    compared to the current law of $1,600. That is a 125-percent
    increase. So please help clarify what you were saying yesterday
    as it applies to Florida.
        Dr. Price. Yes, thank you, Senator. And I enjoyed our time
    together as well.
        When we talk about Medicare, it is important for everybody
    to appreciate, as I know that you and your colleagues do, that
    the Medicare trustees, not Republicans or Democrats, the
    Medicare trustees have told all of us that Medicare in a very
    short period of time, less than 10 years, is going to be out of
    the kind of resources that will allow us as a society to keep
    the promise to beneficiaries in the Medicare program.
        What that means is--and it is important to appreciate what
    that means--it means that we will not be able to provide the
    services to Medicare patients at that time, which is very, very
    close, if nothing is done.
        So my goal is to work with each and every one of you to
    make certain that we save and strengthen and secure Medicare. I
    think it is irresponsible of us as policymakers to allow a
    program to continue, knowing--knowing--that in a few short
    years it is not going to be able to cover the services that we
    are providing. So that is the first point, that the current
    Medicare program, if nothing is done, as some have described
    it, goes broke.
        The second point is that my role, if I am confirmed and
    have the privilege of serving as the Secretary of Health and
    Human Services, my role will be one of carrying out the law
    that you all in Congress pass. It is not the role of a
    legislator, which I had when I was working to try to formulate
    ideas to hopefully generate discussion and get to a solution--
    --
        Senator Nelson. Okay. Let me be so rude as to stop you,
    because I am running out of time. Remember that Donald Trump in
    the campaign said that he was not going to cut Medicare
    spending.
        And I would also point out to you a legislative solution--
    one of the greatest examples on Medicare is 1983, when we were
    just about to go bust and it took two old Irishmen, Reagan and
    O'Neill, to agree to come to an agreement that made, in this
    case it was not Medicare, it was Social Security, actuarily
    sound for the next half-century.
        Let me ask you, Representative Price: you had made a
    statement that it was a terrible idea for people who had
    preexisting conditions to have the protection of insurance
    against those preexisting conditions.
        And what I would like to ask you is, if you please, in
    light of President Trump expressing his desire to retain this
    basic protection, do you think his proposal to continue the ban
    on discriminating against people with preexisting conditions is
    a terrible idea?
        Dr. Price. No, and I am not certain where you are getting
    that quote from. What I have always----
        Senator Nelson. It came from a Politico talking points
    memo, May 1, 2012.
        Dr. Price. Well now, there is a reliable source.
    [Laughter.]
        What I have always said, Senator, is that nobody--nobody--
    --
        Senator Nelson. So you did not say it is a terrible idea?
        Dr. Price. I do not believe I ever made that statement.
    What I have always said about preexisting conditions is that
    nobody, in a system that pays attention to patients, nobody
    ought to be priced out of the market for having a bad
    diagnosis. Nobody. That is a system, again, that may work for
    insurance companies, may work for government, but it does not
    work for patients.
        So I believe firmly that what we need is a system that
    recognizes that preexisting conditions do indeed exist and that
    we need to accommodate them and make certain that nobody loses
    their insurance or is unable to gain insurance because of a
    preexisting condition.
        Senator Nelson. Mr. Chairman, as I close, I would like to
    insert in the record the September 2013 Congressional Budget
    Office analysis of premium support systems for Medicare.
        [The analysis appears in the appendix on p. 92.]
        Senator Nelson. And I would invite you, Congressman, to
    please respond with the CBO report that you said yesterday
    supports your position, because this one does not.
        Dr. Price. I look forward to that. Thank you, sir.
        The Chairman. Senator Menendez?
        Senator Menendez. Well, thank you, Mr. Chairman.
        Congratulations, Congressman Price.
        Let me ask you a series of questions. Given your medical
    training and time spent as a practicing physician, I have a
    couple of simple ``yes'' or ``no'' questions to start off with.
        In your medical opinion, does HIV cause AIDS?
        Dr. Price. I think that the scientific evidence is clear
    that HIV and AIDS are clinically, directly related.
        Senator Menendez. In your medical opinion, have immigrants
    led to outbreaks of leprosy in the United States?
        Dr. Price. I do not know what you are referring to, but I
    suspect that there are instances where individuals have an
    infectious disease, and they come to the United States and that
    that----
        Senator Menendez. I am not asking about an infectious
    disease. I am asking specifically about immigrants in the
    United States causing leprosy in the United States, in your
    medical opinion and scientific background.
        Dr. Price. Again, I do not know the incident to which you
    refer. Are you referring to a specific incident?
        Senator Menendez. There are statements that have been made
    in the public domain that immigrants have led to outbreaks of
    leprosy in the United States. As the person who is going to be
    designated as the director of Health and Human Services, that
    is not only the national, but the world's health epicenter, I
    want to know, in your medical opinion, is there such a
    causation?
        Dr. Price. Any time you get two individuals together in any
    relationship whatsoever, whether it is an immigrant or a
    visitor, and one individual has an infectious disease, then it
    is possible that that individual transmits that infectious
    disease----
        Senator Menendez. Including leprosy?
        Dr. Price [continuing]. Whether it is the flu or a cold.
        Senator Menendez. Including leprosy? Including leprosy?
        Dr. Price. Any infectious disease whatsoever.
        Senator Menendez. In your medical opinion, do abortions
    cause breast cancer?
        Dr. Price. I think the science is relatively clear that
    that is not the case.
        Senator Menendez. In your medical opinion, do vaccines
    cause autism?
        Dr. Price. Again, I think the science in that instance is
    that they do not, but there are individuals across our country
    who are very----
        Senator Menendez. I am not asking about individuals; I am
    talking about science, because you are going to head a
    department in which science, not alternate universes of
    people's views, is going to be central to a trillion-dollar
    budget and the health of the Nation.
        Can you commit to this committee and the American people
    today that, should you be confirmed, you will swiftly and
    unequivocally debunk false claims to protect the public health?
        Dr. Price. What I will commit to doing is doing the due
    diligence that the Department is known for and must do to make
    certain that the factual information is conveyed to, obviously,
    the President and to the American people.
        Senator Menendez. And that factual information will be
    dictated by science, I would hope?
        Dr. Price. Without a doubt.
        Senator Menendez. Okay. So let me ask you about Medicaid
    specifically. And let me just say I am a little taken back
    about your answer on the question of immigrants and leprosy. I
    think the science is pretty well dictated in that regard too.
        Let me ask you this. One of the most beneficial components
    of the Affordable Care Act was the expansion of the Medicaid
    program that resulted in 11 million people nationwide and over
    half a million in New Jersey gaining coverage, many for the
    first time. It is one of the biggest programs on the Republican
    chopping block with proposals to not only repeal the Affordable
    Care Act's Medicaid expansion, but going further and gutting
    billions in Federal funding to the States.
        There is no doubt that this would result in catastrophic
    loss of coverage for tens of millions of low-income families
    and lead to tens of billions in losses to safety-net and other
    health-care providers.
        Do you recognize Medicaid to be a valuable program and
    consider the coverage it provides to 74 million Americans to be
    comprehensive?
        Dr. Price. Medicaid is a vital program for health care for
    many individuals in this country, but one that has significant
    challenges. There is one out of every three physicians who
    should be seeing Medicaid patients who are not taking any
    Medicaid patients. There is a reason for that.
        If we are honest with ourselves, we would be asking the
    question, why?
        Senator Menendez. Well, if that is the case that one in
    three does not treat Medicaid patients, you have to ask
    yourself, is that because Medicaid reimbursements are so low?
    And since provider reimbursements are set at a State level,
    will not cutting Federal funding and hitting States with higher
    costs only lead to lower provider rates? And how many doctors
    would actually treat former Medicaid beneficiaries when they no
    longer have any coverage or ability to pay?
        So, even if there is only one of three, there are still two
    of three who are providing the services; imagine if you do not
    have coverage.
        Which goes to my next question. You have advocated to, in
    essence, block-grant Medicaid. Now, the essence of Medicaid is
    an entitlement, which under the law means, if I meet these
    criteria, I have the right to have that coverage under the law.
    When you move to a block grant, you remove the right and you
    make it a possibility subject to whatever funding there is
    going to be.
        Do you recognize that in doing so you risk the potential of
    millions of Americans who presently enjoy health-care coverage
    through Medicaid no longer having that right?
        Dr. Price. I think that it is important to appreciate that
    no system that the President has supported or that I have
    supported would leave anybody without the opportunity to gain
    coverage. Nobody.
        Senator Menendez. Well, that is not my question, so let me
    reiterate my question. Medicaid, under the law as it exists
    today, is a right. Is that not the case, ``yes'' or ``no''?
        Dr. Price. It is an entitlement program----
        Senator Menendez. And as an entitlement, does that not
    mean, if you meet the criteria, that you are entitled to the
    services?
        Dr. Price. If one is eligible, that is correct.
        Senator Menendez. One is eligible, meaning you have a
    right. When you move to a block grant, do you still have the
    right?
        Dr. Price. No. I think it would be determined by how that
    was set up if, in fact, that was what Congress did. Again, the
    role of the Department of Health and Human Services is to
    administer the laws that you pass, not to make the law.
        Senator Menendez. Yes, but I would just simply say to you,
    I know in our private conversation--and I appreciate you coming
    by to visit me--you suggested that your role is that of an
    administrator of a large department. Well, that is not even
    what the Vice President said when you were nominated. He said
    he expected your experience, both medically and legislatively,
    to help drive policy. And even beyond the expectations of the
    Vice President in that regard, when we have the ability of the
    Secretary to dictate regulation, that is policy.
        So please do not say to me, I am here just to do what
    Congress says. I respect that you will follow the law and do
    whatever Congress says. But you will have an enormous impact.
    And based upon your previous opinion as it relates to Medicaid,
    ultimately block-granting means a loss of a right. And then it
    is just a question of funding, and then we will have a bigger
    problem with a number of providers' will to provide.
        And so I hope we can get to a better understanding of your
    commitment to Medicaid as it is, as an entitlement, as a right.
        Dr. Price. Thank you, sir.
        The Chairman. Senator, your time is up.
        We will go to Senator Carper now.
        Senator Carper. Congressman Price, welcome to you and to
    your wife.
        There is a verse of scripture--you mentioned earlier that
    you are active in your church--in the New Testament, in Matthew
    25, which speaks to the ``least of these.'' When I was hungry,
    did you feed me? When I was naked, did you clothe me? When I
    was thirsty, did you give me to drink? When I was sick and in
    prison, did you visit me? When I was a stranger in your land,
    did you take me in? It says nothing about, when my only access
    to health-care coverage was going into the emergency room of a
    hospital, did you do anything about it?
        What we sought to do with the ACA was to do something about
    it. And we did not, in this room, invent the Affordable Care
    Act. The genesis of the Affordable Care Act goes back to 1993
    when Hillary Clinton, first lady, was working on what was
    called Hillarycare. And a group of Senators, led by Senator
    John Chafee, a Republican from Rhode Island, developed
    legislation co-sponsored by, I think, 23 Senators, including,
    as I recall, Senator Orrin Hatch and Senator Grassley.
        And what he did in his legislation, what he proposed in his
    legislation, was to use really five major concepts. One, to
    create large purchasing pools for folks who otherwise may not
    have access to health-care coverage. He called them exchanges
    or marketplaces.
        He also proposed that there be a sliding scale tax credit
    to buy down the cost of people getting coverage in those
    exchanges within the different States.
        The third thing he proposed was the notion that there
    should be an individual mandate. He wanted to make sure people
    got covered, and he realized if they did not mandate coverage
    or people getting coverage, then you would end up with
    insurance pools that health insurance companies could not begin
    to cover; it just would be unworkable.
        He proposed, as well, employer mandates. And he proposed,
    as well, the notion that people should not lose their coverage
    because of preexisting conditions.
        Those are not Democratic ideas. Those were proposed by
    Republican leadership actually in the Congress at the time. And
    when Governor Romney developed his own plan in Massachusetts, I
    do not know, a decade or so later, he borrowed liberally from
    those ideas.
        When they instituted it, as you may recall--they instituted
    what I call, what others call, Romneycare--they found they were
    doing a pretty good job on covering people, but not such a good
    job on affordability. And what took place over time was, they
    found out they had insurance pools where a lot of the people
    were not young, they were not very healthy, they were older,
    and they needed more health care. And as a result, the
    insurance companies, in order to be able to stay in business,
    had to raise the premiums.
        I do not know if any of this sounds familiar to you, but it
    sure sounds similar to what we have seen in the last 6 years or
    so with the Affordable Care Act.
        To the ideas of Senator Chafee and the ideas of Governor
    Romney, we have added some things. We have encouraged States to
    increase the number of people they cover under Medicaid by
    raising to about 135 percent of the poverty level the
    eligibility under which people can receive health care. We have
    encouraged a focus on prevention and wellness: not just
    treating people when they are sick, but also trying to make
    sure that people stay healthy in the first place. We provide
    funding for contraception. We provide funding for programs that
    are intended to reduce obesity. We have programs that are
    intended to reduce smoking, the use of tobacco.
        This is not a ``yes'' or ``no'' question. What was wrong
    with that approach? What is wrong with that approach?
        And the last thing I will say is this, before you answer.
    The health insurance companies found it difficult to stay in
    business in the State group exchanges across the country. One
    of the reasons why they were unable to is because, I think--
    really we learned this from Massachusetts--we did not raise the
    fine or, if you will, we did not have the incentive high enough
    to get young, healthy people, like my sons, into the exchanges
    across the country.
        S&P, I am told, has just put out, about a month ago, an
    update looking at the financial health of the health insurance
    companies in this country as they have tried to figure out how
    to price this product. And it seems like, according to S&P,
    believe it or not, they seem to have sort of figured it out,
    because the financial health of the health insurance companies
    has begun to stabilize. Your reaction to this, please?
        Dr. Price. Well, as I mentioned either in my opening or in
    response to a question, the principles of health care that all
    of us hold dear--affordability and accessibility and quality
    and choices for patients--I think are the things that we all
    embrace.
        The next step, how we get to accomplish and meet those
    goals and those principles, is where it takes working together
    to do so.
        The program that you outline has much merit, whether it is
    making sure that individuals with preexisting illness and
    disease are able to access coverage, whether it is the pooling
    mechanisms which I have actively and aggressively supported for
    years, there is a lot of merit there.
        So again, what I am hopeful that we are able to do is to,
    in a collegial, bipartisan way, work together to solve the
    remarkable challenges that we have.
        One of my physician colleagues used to tell me that he
    never operated on a Democrat patient or a Republican patient,
    he operated on a patient. And that is the way that I view the
    system. It is not a Republican system, it is not a Democrat
    system, it is a system where hopefully we are focusing on the
    patients to, again, make certain that they have the access to
    the highest-quality care possible.
        Senator Carper. Thank you for that. Let me just conclude,
    Mr. Chairman, by saying I will use an analogy. There is a large
    building, and there are people in the large building. And there
    is a fire in the large building, but for some reason they
    cannot use the stairways and they cannot use the elevators. And
    they look out the windows and there are firefighters down in
    the street saying, ``Go ahead and jump, we will save you,'' but
    they do not have any safety nets.
        And my fear is, if we repeal what I have described, the
    system that I described, that we put in place, the Affordable
    Care Act, largely founded on Republican ideas which I think
    were good ideas, and we do not have something at least as good
    in place to catch those people as they fall from the building,
    we will have done a disservice to them and to our country.
        Thank you.
        Dr. Price. Thank you.
        The Chairman. Thanks, Senator. Your time is up.
        Senator Burr?
        Senator Burr. Thank you, Mr. Chairman.
        And a quick reminder that the Affordable Care Act was
    passed with not one Republican vote in the House or the Senate.
        So, Dr. Price, a couple of questions just to cut to the
    chase. Are all of your assets currently disclosed publicly?
        Dr. Price. They are now and they always have been.
        Senator Burr. Okay. Are you covered by the STOCK Act
    legislation passed by Congress that requires you and every
    other member to publicly disclose all sales and purchases of
    assets within 30 days?
        Dr. Price. Yes, sir.
        Senator Burr. Now, you have been accused of not providing
    the committee information related to your tax and financial
    records that were required of you. Are there any records you
    have been asked to provide that you have refused to provide?
        Dr. Price. None whatsoever.
        Senator Burr. So all of your records are in?
        Dr. Price. Absolutely.
        Senator Burr. Now, I have to ask you, does it trouble you
    at all that, as a nominee to serve in this administration, some
    want to hold you to a different standard than you were held to
    as a member of Congress, and I might say the same standard that
    they currently buy and sell and trade assets on? Does it burn
    you that they want to hold you to a different standard now that
    you are a nominee than they are held to as a member?
        Dr. Price. Well, we know what is going on here.
        Senator Burr. Well, we do. We do.
        Dr. Price. And I understand. And as my wife tells me, I
    volunteered for this.
        Senator Burr. So let us go to substance. You and I have a
    lot in common. We both spoke out in opposition to Obamacare
    early. We predicted massive premium increases. When the
    President promised, if you like your doctors, you can keep
    them, if you like your plan, you can keep it, we both said
    these promises would be broken, and, in fact, they were.
        Over the last 7 years, you and I, Senator Hatch,
    Congressman Upton, and others have actually written our own
    health-care plans because we were, I think, brave enough to say
    that, if you are going to be critical of something, then put
    your ideas on the table.
        In your opinion, was it clear to the American people that
    repeal of Obamacare was a promise that Donald Trump made before
    he was elected president?
        Dr. Price. Well, I have no doubt that it played a very
    prominent role in this past election and that the President is
    committed to fulfilling that promise.
        Senator Burr. And as the nominee and hopefully--and I think
    you will be--the Secretary of HHS, what are the main goals of
    an Obamacare replacement plan?
        Dr. Price. The main goals, as I mentioned, are outlined in
    those principles. That it is imperative that we have a system
    that is accessible for every single American, that is
    affordable for every single American, that incentivizes and
    provides the highest-quality health care that the world knows,
    and provides choices to patients so that they are the ones
    selecting who is treating them, when, where, and the like.
        So it is complicated to do, but it is pretty simple stuff.
        Senator Burr. I want to thank you for not only testifying
    here, but testifying in front of the HELP Committee when Johnny
    and I both had you over there. You are brave to go through
    this, but the country will be much better off with your
    guidance and your knowledge in this slot.
        Mr. Chairman, I yield back.
        Dr. Price. Thank you, sir.
        The Chairman. Thank you.
        Senator Cardin?
        Senator Cardin. Thank you, Mr. Chairman.
        Dr. Price, again, thank you for your willingness to serve
    in this position. And we also thank your family for being
    willing to put up with your voluntary choices.
        I want to talk about a few issues in the time that I have.
    One, yesterday the President by executive order reinstituted
    the global gag rule, but he also did it in a way that is more
    comprehensive than the previous. The new policy would prohibit
    any Federal aid to foreign organizations that provide or
    promote abortion.
        In the past, the policy only applied to organizations that
    got family planning funding; now it will apply to organizations
    that get global health funding, potentially including maternal
    health programs, anti-Zika efforts, and expansion of PEPFAR to
    stop HIV/AIDS.
        My question to you is this: if confirmed, how will you make
    sure that the U.S. can fully participate in these global health
    efforts to help with maternal health, to help in stopping of
    the spread of and ending HIV/AIDS, to make sure that the next
    Zika virus is contained so it does not cause catastrophic
    effects, if the global gag rule is enforced in a way that
    prevents us from participating in international health
    organizations?
        Dr. Price. Okay. This is really important, Senator, and I
    appreciate the question. The Department is full of all sorts of
    heroes, as you well know, and incredibly talented individuals.
    And my goal, if I am confirmed and given the privilege of
    serving as the Secretary of Health and Human Services, is to
    gather the best minds and the best talent that we have within
    the Department and without and determine what is the wisest
    policy for this Nation to have as it relates to, in this
    instance, infectious disease.
        Germs no know geographic boundaries. And we do incredible
    work, the work that the CDC does and the work that is done by
    others in our Nation, to try to work to prevent infectious
    disease, work to detect the spread of infectious disease. And
    then providing a logical and methodical and aggressive response
    to the outbreak of any infectious disease is absolutely vital
    to protect the American people, and we are committed to doing
    so.
        Senator Cardin. And I agree with that. I just hope that you
    will look at perhaps unintended consequences from these
    executive orders that could compromise our ability to be as
    effective as we need to, using all tools at our disposal.
        I want to get to tobacco regulation for one moment, an area
    that I think is now clear within the medical community, the
    impact that tobacco has, the fact that the Family Smoking
    Prevention and Tobacco Control Act of 2009 authorizes the HHS
    Secretary, through FDA, to regulate tobacco products, including
    restricting the sale of tobacco products to minors. It also has
    been expanded to include the selling of e-cigarettes, et
    cetera.
        I know initially you did not support that legislation. If
    confirmed, can you commit to us that you would rigorously
    enforce that act to make sure particularly our children are not
    subjected to the new forms of tobacco products?
        Dr. Price. If I am confirmed, the responsibility that we
    will have is to enforce the law of the land, and we will do so.
        Senator Cardin. It also requires keeping up with new
    technologies that are being used by the industry that may
    require modifications, as we see with e-cigarettes. Are you
    prepared to not only enforce the law, but to enforce our intent
    to make sure our children are protected?
        Dr. Price. Yes, I look forward to working with you,
    Senator, on just that.
        Senator Cardin. I was listening to some of the exchanges
    related to the Affordable Care Act, and we will continue to
    debate the merits of the Affordable Care Act. I am a strong
    supporter of it. I think millions of people have coverage who
    did not have it before, the quality of coverage that Americans
    now have did not exist before, and the rate of growth of our
    health-care premiums is far lower than it would have been but
    for the Act. We will debate that later.
        The question is, what is coming along? I mean, we have
    heard you say several times the principles that the President
    has articulated as to what would be in place of the Affordable
    Care Act.
        I would like just to drill down a little bit, if I could,
    on essential health benefits. We have talked about preventive
    care now being available. We know that we have now mental
    health and addiction services that are available. We also know
    we have oral health, pediatric dental, that is now available,
    which is particularly important in my State because of the
    tragic loss of Deamonte Driver in 2007.
        Can you assure us that, as you look at what will be the
    health-care system moving forward, you are prepared to make
    sure that Americans have quality insurance coverage to deal
    with issues such as preventive care, mental health services,
    addiction services, and pediatric dental?
        Dr. Price. What I can commit to you, Senator, is that we
    will do all that we can within the Department with the
    incredible knowledge and expertise that is there to define
    whether or not the program is actually working as intended or
    not, if coverage equals care. In many instances, I would
    suggest that many individuals right now have ``coverage.'' They
    have a card, but they do not have any care, because they cannot
    afford the deductible that allows them to get the care.
        So we are committed to making certain that the program
    works, not just for government, not just for the insurance
    companies, but for the patients.
        Senator Cardin. And as you know, we eliminated any copays
    on preventive care. But we can talk about the specifics going
    forward. I look forward to those discussions. Thank you, Mr.
    Chairman.
        Dr. Price. Thank you.
        The Chairman. Thank you, Senator.
        Senator Isakson?
        Senator Isakson. Thank you, Mr. Chairman.
        Tom, as Secretary-to-be, let me ask you a few ``yes'' or
    ``no'' questions. You have been asked a lot of them with the
    intent of trying to get you to say ``yes'' that you are going
    to cut Medicare when you are not going to cut Medicare; you are
    going to try to improve it and reform it.
        But ``yes'' or ``no'' to these questions. Question number
    one: we have been hearing about the joint replacement program
    that Secretary Burwell launched in 2015. You and many others
    have raised concerns about this program saving money, that it
    could actually harm the quality of patient care. So in other
    words, was this an administrative action by HHS that actually
    cut a Medicare benefit?
        Dr. Price. Potentially, yes.
        Senator Isakson. Second: last year, HHS proposed a new way
    of paying for cancer drugs so as to reduce Medicare spending on
    these drugs. Many of us opposed this from our side of the aisle
    as well as the other. We were concerned it would cut cancer
    patients' benefits and, more often, it would be a cut to the
    Medicare benefit to seniors. Is that correct?
        Dr. Price. I believe that is correct. Yes.
        Senator Isakson. Last one: what about all the recent
    changes HHS has made to cut Medicare payments to Medicare
    Advantage? Nearly one-third of all Medicare beneficiaries are
    on Medicare Advantage. Would these cuts not also break the
    pledge of not cutting Medicare?
        Dr. Price. I believe so.
        Senator Isakson. My point being, any one of us can sit at
    this dais and say give me ``yes'' or ``no'' answers and
    demonstrate the point we want to make, but that all of us,
    Republican and Democrat alike, are interested in saving Social
    Security for our seniors, making Medicare work, and saving the
    taxpayers' money in the United States of America. Is that not
    true?
        Dr. Price. Absolutely.
        Senator Isakson. And one other point. Any one of us can
    take a financial disclosure, using something called disparate
    impact, where you take two facts, one over here and one over
    there, to make a wrong. Any one of us could do it to disrupt or
    misdirect people's thoughts on somebody. It has been happening
    to you a lot because people have taken things that you have
    disclosed and tried to extrapolate some evil that would keep
    you from being Secretary of HHS when, in fact, it should not be
    true.
        For example, if you go to Senator Wyden's annual report, he
    owns an interest in BlackRock Floating Rate Income Fund. The
    major holding of that fund is Valeant Pharmaceuticals. They are
    the people we jumped all over for 2,700-percent increases last
    year in pharmaceutical products. But we are not accusing the
    ranking member of being for raising pharmaceutical prices, but
    you could take that extrapolation out of that and then indict
    somebody and accuse them. Is that not true?
        Dr. Price. I think that is correct, yes, sir.
        Senator Isakson. So the point of that is, we ought to in
    the end be looking for the best person, man or woman, for the
    job and not trying to trick them into agreeing to something
    that is wrong, but in fact let them execute the programs that
    improve Medicare for the American people.
        Dr. Price. Yes, sir.
        Senator Isakson. I thank you for your time. And I reserve
    the rest of my time.
        Senator Wyden. A point of personal privilege, Mr. Chairman.
        The Chairman. Senator Wyden?
        Senator Wyden. I do not trade in health-care stocks.
        The Chairman. Okay. Did you care to----
        Senator Isakson. My only point to the Senator from Oregon
    is, you do have mutual funds like most of us have. The mutual
    funds have holdings in pharmaceuticals, many of them, one of
    them you own. But nobody should accuse somebody of holding
    pharmaceutical stocks if they have a mutual fund by pulling----
        Senator Wyden. Mr. Chairman, to continue on this point of
    personal privilege. Mutual funds in particular, by independent
    experts, ethics experts, are considered in a completely
    different category than personal trading in stocks. Even past
    Republican ethics experts make that same point, and they have
    never seen anything like what the Congressman has engaged in.
        Thank you, Mr. Chairman.
        The Chairman. Senator Brown?
        Senator Brown. Thank you, Mr. Chairman.
        And welcome, Congressman Price.
        Dr. Price. Thank you, Senator.
        Senator Brown. I was troubled by your response to Senator
    Wyden when he asked the question, if you repeal the Affordable
    Care Act, will you commit that no one will lose insurance? That
    is 22 million Americans, almost 1 million in my State.
        He asked, will you commit that no one will lose their
    insurance? And you ignored the question and responded that no
    one who lost their insurance under the Affordable Care Act--and
    to my knowledge that is 2 million to 4 million people, and
    almost all of them ended up getting reinsured--you said that no
    one who lost their insurance under the Affordable Care Act will
    basically lose it after they have been reinstated.
        So you pretty much ignored the 22 million, and that is the
    problem we all face. But I want to ask you about something
    else.
        If you are confirmed, obviously you will play a role in the
    repeal of the Affordable Care Act. I would like to ask you
    ``yes'' or ``no'' questions, and they really are ``yes'' or
    ``no'' questions; they are not meant as a trap.
        Marguerite is from Lyndhurst, OH. She suffers from a
    chronic condition. She was turned down by insurance companies
    for 25 years before the ACA. She will lose her insurance if the
    ban against discrimination based on existing conditions is
    weakened.
        My question is, if you are confirmed, will you maintain the
    current scope of the law and continue to vigorously enforce the
    law's ban against discriminating against individuals with
    preexisting conditions, ``yes'' or ``no''?
        Dr. Price. I commit to you that we will not abandon
    individuals with preexisting illness or disease.
        Senator Brown. Thank you. Victoria is from Buckeye Lake,
    OH. As a senior on Medicare, she relies on free preventive
    services provided by the ACA. Will you commit to ensuring
    seniors like Victoria, who rely on Medicare, continue to get
    their preventive care--no copays, no deductibles, no out-of-
    pocket costs, ``yes'' or ``no''?
        Dr. Price. Preventive care and wellness care are absolutely
    vital for so many members of our population.
        Senator Brown. That is part of ACA. You will commit to
    that?
        Dr. Price. And I believe it is a part of health care and
    health coverage, and it ought to be a priority.
        Senator Brown. Yes, and we did that. Okay, I do not mean to
    be rude. We did that under the ACA.
        Grace is from Westlake, OH. She is 24. She was diagnosed
    with stage four metastatic melanoma in 2015. She is still on
    her parent's health insurance, which was purchased through the
    ACA marketplace, and she benefits from the ACA's ban on annual
    lifetime coverage maximums. Her first 3 months of treatment
    cost $800,000. As Secretary of HHS, if an insurer asks you for
    an exception to the current ban on out-of-pocket maximums as
    provided in Friday's executive order, will you commit to stand
    up for patients like Grace and refuse to grant any insurer this
    exception?
        Dr. Price. As I mentioned, I think patients ought to be at
    the center, and our goal is to make certain that every single
    patient has access to the highest-quality care.
        Senator Brown. I do not want it as your goal, I want you to
    commit that you will stand firm, as the ACA does, on this
    provision of canceling care, canceling insurance, because
    patients are too expensive.
        Dr. Price. As I said, nobody ought to lose their insurance
    because they get a bad diagnosis.
        Senator Brown. Okay. Alice is from Bethel, OH. Prior to the
    ACA, she could not afford her preferred method of birth
    control. Now thanks to the law, she benefits from covered
    contraceptive coverage. Are you able to set aside any personal
    political views and protect the doctor/patient relationship by
    committing to ensure every woman's right to access the form of
    contraception deemed best for her by her doctor at no cost, as
    currently provided in the ACA?
        Dr. Price. I think that contraception is absolutely
    imperative for many, many women. And the system that we ought
    to have in place is one that allows women to be able to
    purchase the kind of contraception that they desire, between
    their doctor and themselves.
        Senator Brown. As the law is now with the ACA. Thank you.
        President Trump said he is working with you on a
    replacement plan for the ACA, which is nearly finished and will
    be revealed after your confirmation. Is that true?
        Dr. Price. It is true that he said that, yes. [Laughter.]
        Senator Brown. So not that he has ever done this before,
    but did the President lie? Did the President lie about this,
    that he is working with you? He said he is working with you. I
    know we do not use the word ``lie'' here because we are polite
    when Presidents say statements that are not true. But did he
    lie to the public about working with you?
        Dr. Price. I have had conversations with the President
    about health care, yes.
        Senator Brown. Which is not quite an answer, so will you
    commit, with this President's plan, to maintaining the
    protections for those Ohioans you just committed to in the
    replacement plan?
        Dr. Price. Our commitment is to make certain that every
    single American has access to the highest-quality coverage and
    care possible.
        Senator Brown. I am still not sure if the President lied,
    not to you, but to us, the public, about whether he is actually
    working with you. It sounds like he did.
        Last series of questions briefly, Mr. Chairman.
        I want to find out about the Children's Health Insurance
    Program. You said last week to staff that it has been a
    remarkably successful program. You once earlier had said it
    sounds like socialized medicine to you. I do not quite know
    what that means.
        Ninety-five percent of children in America are currently
    insured. I know about the chairman's interest in CHIP, the
    Children's Health Insurance Program. Ninety-five percent of
    American children are insured now, partly because of Medicaid
    expansion, partly because of CHIP.
        You discussed the importance of using the right metrics, so
    my question is this. Funding for CHIP, I think you know, is set
    to expire in September. If confirmed, would you advise the
    President to support an extension of CHIP and the Pediatric
    Quality Measures Program beyond September of this year?
        Dr. Price. Absolutely, but I want to expand a little bit
    because, after last week's hearing in the HELP Committee, the
    same question was asked, quoting me as saying that CHIP was
    socialized medicine. And so I went back and looked at that
    article, and as so often happens, as you well know, though this
    may have never happened to you, it was a characterization in
    the article by the author of the article to push a political
    point of view.
        And I knew that was the case because I rarely, if ever, use
    that word. I talk about patients as being the focus. I do not
    talk about government being the focus.
        Senator Brown. Okay. I am sorry. That is fine. I want to
    ask you specifically on CHIP. Last week, MACPAC submitted a
    report to Congress advising we extend the current CHIP program
    and the Quality Measures Program for 5 more years. Do you agree
    with this?
        Dr. Price. I think the CHIP program, with policymakers, has
    to be looked at, and I believe it ought to be extended.
        Senator Brown. For 5 years?
        Dr. Price. Well, if we could extend it for 8, it would
    probably be better than 5.
        Senator Brown. Okay. Thank you, Mr. Chairman.
        The Chairman. Well, thank you, Senator.
        Let us go to Senator Portman.
        Senator Portman. Thank you, Mr. Chairman.
        I have a lot of questions, so I am glad you are letting
    people go a couple of minutes over, because I may need that
    time.
        Dr. Price. I am not. [Laughter.]
        The Chairman. We have been letting the other side go a
    couple of minutes over. We are not going to let our side go a
    couple of minutes over.
        Senator Portman. Okay, well I would like that time back.
    [Laughter.]
        First of all, Dr. Price, thank you very much for your
    willingness to serve. We need you.
        As you know, a couple of weeks ago Congress passed a budget
    resolution to set up a process that gives us the possibility of
    replacing the Affordable Care Act with policies that work
    better, particularly to reduce skyrocketing health-care costs
    that affect my constituents in Ohio. It is not just premiums.
    It is deductibles and copays, and also, people need more
    choices in health care.
        I did join with four of my colleagues, as you know--we
    talked about this--introducing an amendment that would have
    ensured we had enough time for the next step in the process.
    And I believe we got assurances for that to ensure that we have
    time to work with you, frankly. We need somebody at HHS in
    place who can work with us to be sure that the legislative and
    the administrative policies are working together and that this
    is done carefully.
        Prior to the Affordable Care Act, we had a very competitive
    insurance market in Ohio; now we do not. In fact, if you look
    at what has happened due to the increased regulations and
    mandates, we have a dramatically decreased competitive market.
    We went from having 17 insurers offering plans last year on the
    exchanges to 11 now. We have 20 counties now in Ohio, over one-
    quarter of our counties, that only have one health-care
    insurance company offering plans. We used to have no counties
    in that situation.
        I know we are doing better than the rest of the country,
    actually, because about a third of the counties only have one
    insurer, and some of them have only one insurer in the entire
    State.
        Now that we have begun this process of replacement and the
    President has issued his executive order, what can we do,
    briefly? What actions can you take through your authority as
    Secretary to ensure that my constituents in Ohio have access to
    affordable health-care coverage with a healthy insurance
    market?
        Dr. Price. Well, what you laid out is the challenge that we
    have all across the Nation. And Ohio is doing better than other
    States, as you noted.
        But it is important to appreciate that things have gotten
    worse for the individual and small-group market, and we
    believe, I believe, that it is a direct result of policies that
    have come from Washington, DC, directly from the Affordable
    Care Act.
        So if we are honest with ourselves and honest with our
    constituents about trying to solve the challenges that they
    have to gain access to coverage that they want, then we ought
    to look at that and say, how do we fix that? And the way that
    you fix that is to make it so that individuals have the
    choices--one of the principles I mentioned--that we allow for
    pooling mechanisms that provide for individuals to have
    opportunities to recreate and reconstitute that individual and
    small-group market, which now does not exist.
        Senator Portman. And by the way, I appreciate your response
    to my colleague from Ohio about protecting people who have
    preexisting conditions. And one way you do that, obviously, is
    through those risk pools, and, again, many States had good risk
    pools that were working before the Affordable Care Act to help
    in that regard.
        As you know, Congress recently passed legislation authored
    with Senator Whitehouse called CARA, our Comprehensive
    Addiction and Recovery Act. And it is meant to address this
    opioid crisis we face--heroin, prescription drugs.
        We are now working to both fully fund--and the funding is
    there in place for this new program--and now to implement it.
    And a lot of the implementation goes through SAMHSA; almost
    half of the funding under new grant programs goes through HHS
    and SAMHSA.
        What should be done to ensure access to addiction treatment
    for those individuals currently getting insurance coverage
    through the exchanges or Medicaid expansion? And do you commit
    to us today to fully implement and implement promptly the new
    legislation?
        Dr. Price. Without a doubt. As you know, Senator, this is a
    scourge that has gone all across the country, and it is in
    communities large and small, destroying lives, destroying
    families, harming communities. And it is growing.
        And so what we must do is absolutely commit to carrying out
    the law as it was passed, but also--as I have talked about with
    some other challenges--make certain that we have the right
    metrics in place. Are we actually helping with what we are
    doing?
        There may be better things to do there, maybe things that
    we think we ought to do that in fact do not help, and we ought
    to be identifying those as much in real time as possible so
    that we can bring about a program that is actually making it
    work for the patients, for the individuals who are actually
    being harmed.
        Senator Portman. One example of that, quickly. You are
    aware, I think, of the Institution for Mental Disease rule that
    says if you have an inpatient treatment center, it has to be
    limited to 16 beds. Would you be willing to look at that rule
    to see if we can get that number up to be able to provide more
    of this treatment?
        Dr. Price. I think that is one of the rules that has to be
    looked at. I think the 3-day stay rule in facilities is
    another, where oftentimes many of these individuals have some
    mental illness as well, and the limitation on being able to
    keep folks on an inpatient basis when all of the health-care
    professionals involved in their care say they ought to, but in
    fact that is not what is covered, makes no sense. And
    therefore, they are put back out on the street, and the
    challenge is, we just get in this revolving door.
        Senator Portman. A final question, and maybe you could
    respond to this in writing, because my time is expiring based
    on the allocation here.
        With regard to the waivers, you know, Ohio applied for a
    waiver, and this was an 1115 waiver for Medicaid, to be able to
    better cover people under Medicaid. We were rejected by CMS. I
    know you have Seema Verma coming in who has worked on these
    over time.
        Do you believe that during this replacement time we should
    cover people under Medicaid expansion but then move to a
    program that is more flexible to provide better care under
    Medicaid?
        Dr. Price. I think there have to be better ways to provide
    care to the Medicaid population, because there are huge
    challenges right now, as I mentioned before. And the people
    whom we need to be listening to are the Governors and the State
    insurance commissioners and the folks on the ground actually
    providing the care. And if we listen to them, I think they will
    guide us in the right direction in terms of policy.
        The Chairman. Senator, your time is up.
        Senator Portman. Thank you, Mr. Chairman.
        The Chairman. Senator Bennet?
        Senator Bennet. Thank you, Mr. Chairman.
        I want to thank my colleague from Ohio for his graciousness
    in not going too over.
        Congressman Price, you have said a couple of times--I may
    misquote you a little, I hope not--that the goal here is access
    to the highest-quality coverage and the highest-quality health
    care for all Americans. Is that roughly where you would like to
    head? And I think that is a worthy goal.
        Dr. Price. Yes.
        Senator Bennet. And just piggybacking on what Senator
    Portman was asking you about, I am worried today--whether it is
    the Affordable Care Act or not the Affordable Care Act, whether
    it is the insurance market--that people, especially in rural
    parts of this country, in rural parts of my State, are not
    getting the access they need to high-quality health care, are
    not getting the access they need to high-quality choices in
    terms of insurance.
        I worry a little bit, and whether we are trying to repeal
    the Affordable Care Act or we are trying to fix the Affordable
    Care Act, I think it is incumbent on all of us not to make
    matters worse for rural America in doing what we are doing. And
    I know you share that goal.
        Dr. Price. Absolutely.
        Senator Bennet. And you talked about pooling as one
    solution. I wanted to talk a little bit or ask you a little bit
    about your projected quality of insurance in these markets,
    because one answer that I have heard from folks, including
    yourself, over the weeks has been making sure that people have
    the opportunity to buy coverage for catastrophic care.
        I wonder whether you also believe that it is essential that
    there be a floor for insurance providers. You know, some of the
    things that the Affordable Care Act requires for coverage
    include outpatient care, emergency services, hospitalization,
    maternity and newborn care, prescription drugs, rehab services,
    lab services, preventative care such as birth control and
    mammograms, pediatric services like vaccines, and routine
    dental exams for children younger than 19.
        I am not going to ask you to go through each one of those.
    But directionally, are we headed to a world where people in
    rural America have to settle for coverage for catastrophic
    care? Are we headed to a place where there is regulation of
    insurance providers that says if you are going to be in the
    insurance market, particularly if we are in a world where you
    are selling across State lines, there has to be a floor on the
    services you are willing to pay for?
        Dr. Price. I think there has to be absolutely credible
    coverage. And I think that it is important that individuals
    ought to be able to purchase the coverage that they want.
        Senator Bennet. I just do not want us to get to a place
    where people in America have to settle for something that no
    one else in the industrialized world has to settle for. Why
    should they have to pay out of pocket month after month after
    month for something that is not going to cover something as
    basic as a hospitalization or maternity services or, you know,
    the rest of this list? There may be certain things on the list
    we disagree with.
        But I am worried that we are heading toward a place where
    somehow that choice is accepting a world that no one else in
    the industrialized world has to accept. And I applaud your
    goal, and I hope we can work together to make it so.
        Dr. Price. As do I.
        Senator Bennet. You mentioned that we should listen to the
    Governors, which brings me to my second question and your
    answer to Senator Portman.
        In Colorado--you may have heard of this--we have something
    called the Accountable Care Collaborative that is a unique
    approach to Medicaid. It connects members with coordinated
    primary care providers while reducing barriers to access. It
    also provides coordinated care for those with dual eligibility
    for Medicare and Medicaid. I do not have it today, but I could
    show you that the cost curve there is really starting to turn
    around because of the coordinated care that is happening out
    there.
        When asked about the need for more State flexibility, which
    is an argument that is made to carry out innovative programs
    like the one in Colorado, our Governor said that, quote,
    ``Greater flexibility cannot make up for the lack of funding.
    Should the Federal Government pull back its financial
    commitments, we simply cannot afford to make up the
    difference.''
        So I would ask you whether you agree with our Governor's
    assessment that while flexibility is helpful, it is not a
    replacement for critical funding needs.
        Dr. Price. I think so. And the decision for funding
    obviously is a legislative decision.
        Senator Bennet. But that is a very fundamental component of
    the Affordable Care Act, the expansion of Medicaid, would you
    not agree?
        Dr. Price. And that decision whether or not to change that
    is a decision that you and every member of the committee and
    Congress will be involved in. And if I am fortunate enough to
    serve as the Secretary of Health and Human Services, we will
    carry out the law that you pass.
        Senator Bennet. I appreciate that. In your mind, though,
    does the repeal of the Affordable Care Act include a repeal of
    the expansion of Medicaid that was part of the passage of the
    Affordable Care Act?
        Dr. Price. Any reform or improvement that I would envision
    for any portion of the Affordable Care Act would be one that
    would include an opportunity for individuals to gain coverage,
    the kind of coverage, again, that they want, the highest-
    quality health care.
        Senator Bennet. But that is not the question I asked.
        And I am sorry, Mr. Chairman; I realize I am at the end of
    my time.
        Do you believe that a repeal--I mean, this is what the
    President ran on--of the Affordable Care Act includes the
    repeal of the expansion of Medicaid that was a fundamental part
    of the Affordable Care Act?
        Dr. Price. Again, that is a decision that you all would
    make.
        Senator Bennet. That is true.
        Dr. Price. What I believe is that any reform or improvement
    must include a coverage option and opportunity for every single
    American, including those who are either currently in or close
    to joining the Medicaid population in a given State, which
    changes depending on the State.
        Senator Bennet. Okay.
        Thank you, Mr. Chairman.
        The Chairman. Well, thank you, Senator Bennet.
        Let us go to Senator Toomey.
        Senator Toomey. Thank you, Mr. Chairman.
        Congressman Price, thank you for joining us.
        Dr. Price. Thank you.
        Senator Toomey. Thanks for the great work you have done in
    the House and your willingness to serve in this extremely
    important post. I appreciate it, and I enjoyed the conversation
    that we had a little while back.
        I do think it bears reminding everyone as we talk about
    Obamacare that certainly the individual market is in a classic
    death spiral. The adverse selection is destroying that market.
    It is in a freefall. In Pennsylvania, 40 percent of all
    Pennsylvanians in the Obamacare exchanges have a grand total of
    one choice, and that very typically does not include whatever
    they had before and were promised they could keep, which, of
    course, was never true.
        So we have a system that is in collapse. And what we are
    trying to do is figure out what is a better way to go forward.
    Now, when we talk about repeal, sometimes I hear people say,
    well, but we have to keep coverage of preexisting conditions
    because, you know, we have to keep that. And when I hear that,
    I think that we are missing something here.
        And here is what I am getting at. There are obviously a
    number of Americans who suffer from chronic, expensive health-
    care needs. They have had these conditions sometimes all their
    lives, sometimes for some other period of time. And for many of
    them, the proper care for those conditions is unaffordable.
        I think we agree that we want to make sure those people get
    the health care they need. Now, one way to force it is to force
    insurance companies to provide health insurance coverage for
    someone as soon as they show up, regardless of what condition
    they have, which is kind of like asking the property casualty
    company to rebuild the house after it has burned down. But that
    is only one way to deal with this.
        And so am I correct, is it your view that there are other,
    perhaps more effective ways, since, after all, Obamacare is in
    a collapse, to make sure that people with these preexisting,
    chronic conditions get the health care that they need at an
    affordable price without necessarily having the guaranteed
    issue mandate in the general population?
        Dr. Price. I think there are other options. And I think it
    is important, again, to appreciate that the position that we
    currently find ourselves in with policy in this Nation is that
    those folks, in a very short period of time, are going to have
    nothing because of the collapse of the market.
        Senator Toomey. Right. The second topic is, I think you and
    I share a goal of having health care that is much, much more
    driven by individuals, families, patients, consumers--consumer-
    centric rather than bureaucrat-centric, which is what Obamacare
    is.
        Do you agree with me that to get there we need to do more
    about the transparency of health-care outcomes so that informed
    consumers can evaluate among different physicians, different
    hospitals that really get the best outcomes? Do we need to do
    more there?
        Dr. Price. Absolutely. And this is an important point. And
    it is not just in outcomes. Outcomes are important, and we need
    to be measuring what actually makes sense from a quality
    standpoint and allow patients and others to see what those
    outcomes are.
        But it is transparency in pricing as well, and right now we
    do not have that. So if you are individual out there and you,
    in fact, want to know what something costs, it is virtually
    impossible to find out what that is. There are all sorts of
    reasons for that.
        But if we are honest with ourselves as policymakers and we
    want to make the system patient-friendly, not insurance-
    friendly or
    government-friendly, but patient-friendly, then we would make
    that a priority. And if I am confirmed, I hope to do so.
        Senator Toomey. I think Medicare and Medicaid, CMS, can
    play a big role in advancing that. Ultimately, I think the more
    we diminish dependence on third-party payers and allow the
    evolution of a market that responds to individuals, individuals
    will demand that information the way they do in every other
    market.
        Dr. Price. Right.
        Senator Toomey. The last point I want to touch on, if I
    could, has to do with NIH research and specifically Alzheimers.
    It is my view that we ought to think of Alzheimers as a disease
    in a category of its own. And I say that because there is no
    disease like it that we know of that afflicts Americans today.
    There are 5.2 million Americans with the disease right now. It
    is 100-percent fatal. It is the sixth-leading cause of death.
    There is no cure, there is no treatment; there is nothing.
        And yet, for fiscal year 2016, NIH spending is a grand
    total of $168 per diagnosed patient. It seems to me that the
    expenditures are wildly out of line with the severity and the
    breadth and the scope of this disease. And I wonder if you
    would commit to working with me and others who share this view
    to ensure that we have a better proportionality in terms of the
    allocation of resources in the breadth and severity of
    illnesses.
        Dr. Price. I think it is absolutely imperative, Senator,
    and I look forward to working with you.
        Senator Toomey. Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator.
        Senator Thune?
        Senator Thune. Thank you, Mr. Chairman.
        Dr. Price, welcome, and thank you for your willingness to
    serve in this very important capacity. We have a lot of
    challenges ahead that we need to take on.
        As I met with you a couple of weeks ago, one of the issues
    that is of particular interest to me, which I conveyed to you,
    is this issue of Indian Health Service. In 2010, there were
    some systemic problems that were uncovered in South Dakota. And
    an administrative action plan was set in motion to help remedy
    many of these findings. Similar issues popped up again
    throughout South Dakota in 2015, and they continue to this day.
    And after oversight hearings, it became abundantly clear that,
    time and again, there was a lack of follow-through by the
    agency.
        And my question is, will you commit to follow up with me in
    writing that you will designate someone at HHS to be the point
    person that my staff and I can contact to ensure, one, that
    reforms are being implemented, and two, that we continue to
    collaborate on reform in the IHS?
        Dr. Price. Absolutely, Senator. This is an area that is of
    significant concern, because it appears to me, as I know you
    shared with me, that in the Indian Health Service there are so
    many areas where we are not meeting the goal of the highest-
    quality care being provided to individuals accessing that
    system.
        And so we are not doing what we ought to do in that system.
    And I am committed to making certain, should I be confirmed, to
    turn that system around.
        Senator Thune. And as I shared with you, Senator Barrasso
    and I introduced a bill last year called the IHS Accountability
    Act which we believe will bring about a lot of structural
    changes within the IHS. And as I have said many times, that
    act, although we think it addresses a lot of the problems that
    have cropped up--and it was based upon consultation that we
    received from the tribes--really is merely a first step in the
    process that is necessary to improve that agency.
        If confirmed, what types of reforms could you see yourself
    supporting when it comes to the IHS and, obviously, starting
    perhaps with our legislation? I do not know, you probably have
    not had a chance to look carefully at that yet, so I will not
    ask you to comment specifically on it. But are there thoughts
    that you have with respect to the IHS when it comes to reforms
    that you could work with us on?
        Dr. Price. Yes, I appreciate that. I have had the privilege
    of visiting some IHS facilities in the State of Wisconsin and a
    couple of facilities that were doing remarkable work. And it
    appears to me that what we have not done--and if I am
    confirmed, I look forward to getting into this area within the
    Department itself--is identified best practices within the IHS
    system itself and shared those and incentivized the ability to
    move that kind of activity that is providing high-quality care
    for individuals in that system in certain areas to make certain
    that we are able to extend that across the country in the IHS.
        Senator Thune. Okay. Well, we look forward to working with
    you on that. I think best practices is a good place to start.
    And obviously, those have not been employed in a lot of
    facilities in our State.
        In 2009, CMS issued a final rule that required all
    outpatient therapeutic services to be provided under direct
    supervision. Every year since then, the rule has been delayed,
    either administratively or legislatively, for critical access
    and small and rural hospitals.
        And I shared this with you as well. In my State, obviously,
    we have a lot of critical access hospitals, a lot of very rural
    areas, big geography to cover, and it is sometimes difficult to
    get providers out to these areas. So the question is, if
    confirmed, will you work to permanently extend the
    nonenforcement of this regulation of these hospitals in order
    to remove this regulatory burden?
        Dr. Price. Yes, I look forward to working with you on it,
    Senator. I think there are areas, from a technological
    standpoint, where we are missing the boat, especially in our
    rural areas and the critical access hospitals. In every other
    industry out there, the information technology age has arrived
    and is moving across the land with rapid speed and has done so.
        However, it seems that in health care we have put
    roadblocks up to the expansion of technology, especially into
    the rural areas. And we ought to be incentivizing that so that,
    again, the patients are able to receive the highest-quality
    care.
        It is possible now, for example, in our State, if you are
    an individual who is suspected of having a stroke, you go to a
    critical access hospital in a rural area, it is possible by
    telemedicine to be able to access one of the world's foremost
    specialists in stroke treatment by telemedicine at the
    university health center. So that is improving the lives and
    care of patients across our State.
        And I think there are so many things that we could do that
    would mirror that kind of technological expansion.
        Senator Thune. Thank you. There is one final point I will
    make, because my time is expiring. But I know you have probably
    been questioned already a good amount about what happens next
    with respect to replacing Obamacare. I would simply say that I
    hope we can work with you in beginning to shift a lot of the--
    giving the States, I guess I would say, more flexibility when
    it comes to designing plans that work in our States.
        I think one of the problems that we have had with this is
    there is just too much dictation from Washington, DC and too
    much one-size-fits-all. And that is something I think that most
    States would probably agree with, and certainly, I think, most
    providers would agree with as well.
        So we look forward to working with you and designing
    programs that get that flexibility to our States and put them
    more in charge of some of these issues in a way that removes
    that power from Washington, DC, where I think too many of the
    problems have been happening.
        Thank you, Mr. Chairman.
        Dr. Price. Yes, sir. I look forward to it.
        The Chairman. Senator Casey?
        Senator Casey. Thank you, Mr. Chairman.
        Dr. Price, good to be with you again.
        Dr. Price. Thank you.
        Senator Casey. I want to ask you a couple of questions that
    center principally on children and individuals with
    disabilities.
        First, with regard to children, I think if we are doing the
    right thing, not only as a government, but as a society, if we
    are really about the business of justice and if we are really
    about the business of growing the economy, we should invest a
    lot and spend a lot of time making sure that every child has
    health care. The good news is, despite a lot of years of not
    getting to that point, not moving in the right direction, we
    have made a lot of progress.
        The Urban Institute in an April 2016 report--I will not ask
    the report to be made part of the record, but I will read a
    line from this Urban Institute report ``Uninsurance Among
    Children, 1997 to 2015,'' dated April 2016. It said as follows
    on page 3: the ``decline in children's uninsurance rate
    occurred at a relatively steady pace and includes a significant
    drop following implementation of the Affordable Care Act's key
    coverage provisions from 7.1 percent in 2013 to 4.8 percent in
    2015.''
        So that is a significant drop, 7.1 percent to 4.8. Millions
    of kids have health insurance today who would not have it
    absent the Affordable Care Act and including the Medicaid
    provisions as well. That 4.8-percent uninsured rate for kids is
    an all-time low. That means we are at a 95-percent insured rate
    across the country for children.
        Kaiser Foundation, a separate authority, tells us that even
    with that, even with all that progress made in the last couple
    of years and even some progress before that, we still have more
    than 4.1 million children uninsured.
        Would you agree with me, first of all, that we should get
    that number down, the number of uninsured children?
        Dr. Price. I think that throughout our population we ought
    to identify individuals who are uninsured and strive to make
    certain that they gain coverage.
        Senator Casey. Right. And you would agree with me with
    regard to children especially?
        Dr. Price. Everybody in the population. Children are
    precious and are our future.
        Senator Casey. Great. And just with regard to children, now
    that we have that number, we know the number that we have
    arrived at, we know the percentage, will you commit, if you are
    successful in your confirmation, to maintain or to even reduce
    that uninsured number even further--in other words, that you
    will be able to commit to us today that the number of uninsured
    children will not increase during your time as Secretary, were
    you to be confirmed, and the percentage of uninsured would not
    increase while you are Secretary?
        Dr. Price. Our goal is to decrease the number of uninsured
    individuals in the population under age 18 and over 18.
        Senator Casey. Well, I hope you maintain that, because I
    think that is going to be critically important.
        The reason I ask that question is not just to validate that
    as a critically important goal for the Nation, but your answer
    seems to be contrary or in conflict with what you have
    advocated for as a member of the House of Representatives, not
    only in your individual capacity, but as chairman of the Budget
    Committee.
        Looking at now for reference an op-ed by Gene Sperling--you
    know who Gene Sperling is. He was head of the Council of
    Economic Advisers to two Presidents, both President Clinton and
    President Obama--Chair of that National Economic Council, I
    should say, is the proper title.
        In an op-ed on Christmas Day, the fifth paragraph, here is
    what he said in a pertinent part referencing you and your
    budget proposals. He said, quote, ``Together,'' meaning the two
    areas of policy that you have a long record on, full repeal of
    ACA and block-granting of Medicaid, which we now know is Trump
    administration policy, ``they would cut Medicaid and the
    Children's Health Insurance Program funding by about $2.1
    trillion over the next 10 years, a 40-percent cut.''
        How can you answer the questions that I just asked you
    about making sure that that number of uninsured children does
    not get worse under your tenure if that is the case with regard
    to your policies, the effect of what your policies would be--
    and now apparently, contrary to what was said during the
    campaign, it is now the policy of the Trump administration to
    block-grant Medicaid?
        Dr. Price. Yes. With respect to both you and to Mr.
    Sperling, it is because you all are looking at this in a silo.
    We do not look at it in a silo. We believe that it is possible
    to imagine, in fact put in place, a system that allows for
    greater coverage for individuals, in fact coverage that
    actually equals care.
        Right now, many of those individuals--the ACA actually
    increased coverage in this country. It is one of the things
    that it actually did. The problem is that a lot of folks have
    coverage, but they do not have care. So they have the insurance
    card, they go to the doctor, the doctor says, ``This is what we
    believe you need,'' and they say, ``I am sorry, I cannot afford
    that.''
        Senator Casey. A cut of a trillion dollars, a combined cut
    of a trillion dollars that would adversely impact the
    Children's Health Insurance Program and the Medicaid program,
    is totally unacceptable, I think, to most Americans, Democrat,
    Republican, or otherwise.
        Dr. Price. And you are looking at that in a silo. You are
    not looking at what the reform and improvement would be.
        Senator Casey. We will see the rebuttal to what not only
    Gene Sperling has said, but a whole long line of public policy
    advocates and experts. And I think the burden for you, sir, is
    to make sure that you fulfill your commitment to make sure that
    no children will lose health insurance coverage while you are
    Secretary.
        Dr. Price. I look forward to working with you.
        The Chairman. Okay. Senator Heller?
        Senator Heller. Thank you, Mr. Chairman.
        And, Dr. Price, thank you for being here today. And thanks
    for your patience in working with us throughout this
    confirmation process.
        Mr. Chairman, as you can imagine, I am committed to
    ensuring that all Nevadans have access to high-quality and
    affordable health insurance.
        I have a letter here that came to my attention January 10th
    from the Nevada legislature. The letter comes directly from our
    majority leader of the State Senate and our Speaker of the
    Assembly. And they are good questions, five questions.
    Obviously, they want to get the same answers that all of us
    want here.
        We have about 88,000 Nevadans who have health insurance
    through the health exchange, 77,000 Nevadans who are eligible
    for Federal tax credits, 217,000 Nevadans who receive health-
    care coverage under Medicaid expansion. Basic questions.
        Mr. Chairman, if I may, can I submit this letter for the
    record, and also, if I may, ask Dr. Price if he would respond
    to this particular letter, to these legislators? Again, I think
    they are very good questions.
        The Chairman. Without objection.
        [The letter appears in the appendix on p. 89.]
        Senator Heller. Also, if I may add, if you could CC the
    Governor also. I think the Governor also would like answers to
    these questions. And I think you are in a great position to
    answer these particular questions.
        Dr. Price. Thank you, sir.
        Senator Heller. Thank you.
        If I may, can I get your opinion on the Cadillac tax?
        Dr. Price. I think the Cadillac tax is one that has made it
    such that individuals who are gaining their coverage through
    their employer--there may be a better way to make it so that
    individuals gaining their coverage through their employer are
    able to gain access to the kind of coverage that they desire.
        Senator Heller. The Cadillac tax would affect about 1.3
    million Nevadans: school teachers, union members, senior
    citizens. And there is some disagreement as to whether or not
    these individuals are wealthy or not. There are some on this
    committee who believe that the $1.1-trillion tax increase in
    Obamacare does not affect the middle class. Do you agree with
    that?
        Dr. Price. I think it does affect the middle class.
        Senator Heller. I do too. Do you believe that school
    teachers are wealthy?
        Dr. Price. Everybody has their own metric of what wealthy
    is, and some people use things to determine wealth that are not
    the greenbacks in----
        Senator Heller. I would argue that most school teachers do
    not think they are wealthy.
        Do you think most union members are wealthy?
        Dr. Price. I doubt that they think they are wealthy.
        Senator Heller. Yes, I would agree with that.
        Do you think most senior citizens are wealthy?
        Dr. Price. Most senior citizens are on a fixed income.
        Senator Heller. They would argue that they are not wealthy.
    And that is my argument on this particular tax. In fact,
    Obamacare as a whole is just another middle-class tax increase
    of $1.1 trillion.
        I guess my request and question for you is if I can get
    your commitment to work with this committee and work with
    myself and the Treasury Secretary to repeal the Cadillac tax.
        Dr. Price. Well, we will certainly work to make certain
    that those who gain their coverage through their employer have
    the access to the highest-quality care and coverage possible in
    a way that makes the most sense for individuals from a
    financial standpoint as well.
        Senator Heller. Does the Cadillac tax make the most sense?
        Dr. Price. As I mentioned, I think there are other options
    that may work better.
        Senator Heller. And do you believe it is an increase, a
    health insurance increase, to middle-class America?
        Dr. Price. I do.
        Senator Heller. Okay. I want to go to Medicaid expansion
    for just a minute. Nevada was one of 36 States that chose to
    expand eligibility for Medicaid. We went from--I think the
    enrollment went from 350,000 to over 600,000.
        And I guess the concern, and I think it is part of the
    letter that I gave to the chairman, is whether or not that will
    have an impact and what we are going to do to see that those
    individuals are not impacted. Probably the biggest question
    that we have here for you today is, what are we going to do
    about those who are part of the Medicaid expansion and how that
    is going to impact them?
        Dr. Price. Yes. Again, as I mentioned to a question on the
    other side, I believe this is a policy question that needs to
    be worked out through both the House and the Senate. We look
    forward to working with you and others, if I am able to be
    confirmed, on making certain that individuals who are currently
    covered through Medicaid expansion either retain that coverage
    or in some way have coverage through a different vehicle. But
    every single individual ought to be able to have access to
    coverage.
        Senator Heller. Dr. Price, thank you. Thank you for being
    here.
        Mr. Chairman, thank you.
        Dr. Price. Thanks, Senator.
        The Chairman. Thank you.
        Senator Warner?
        Senator Warner. Thank you, Mr. Chairman.
        Good to see you again, Dr. Price.
        Dr. Price. Thank you.
        Senator Warner. Let me start on something we discussed in
    my office. One of the issues I have been working on since I
    have been Governor, that I have been working on very closely
    with your friend, Senator Isakson, is the issue of how we as
    Americans address the end of life and sort through those
    issues. I think we both shared personal stories on that
    subject.
        Senator Isakson and I have legislation that we call the
    Care Planning Act that does not remove anyone's choices, it
    simply allows families to have those discussions with their
    health-care provider and religious faith leader if needed or
    desired in a way to prepare for that stage of life.
        This year, CMS took a step by introducing a payment code
    into the fee schedule to provide initial reimbursement for
    providers to have these conversations with, as mentioned, a
    multidisciplinary case team. It also ran a pilot program that
    allowed hospice-type benefits to be given to individuals who
    were still receiving some level of curative services, called
    the Medicare Care Choices.
        I believe it is very important that we do not go backwards
    on these issues. And as I think we talked about, we are maybe
    the only industrial nation in the world that has not had this
    kind of adult conversation about this part of life. Again, it
    is not about limiting anyone's choices.
        But would you, if you are confirmed, continue to work with
    Senator Isakson and me and others on this very important issue?
        Dr. Price. I look forward to doing so----
        Senator Warner [continuing]. And not be part of any effort
    to kind of roll back those efforts that CMS has already taken?
        Dr. Price. I think it is important to look at the broad
    array of issues here. And one of the issues is liability. And I
    cannot remember whether we discussed that in your office. But
    the whole issue of liability surrounding these conversations is
    real. We need to be talking about it openly and honestly and
    working together to try to find a solution to just that.
        Senator Warner. I would concur with that, but I also think
    this is something that more families need to take advantage of.
        On Friday, January 20th, President Trump issued an
    executive order that says Federal agencies, especially HHS,
    should do everything they can to, quote, ``eliminate any fiscal
    burden on any State or any cost, fee, tax penalty, or
    regulatory burden on individuals and providers.''
        Dr. Price, if you are confirmed in this position, will you
    use this executive order in any way to try to cut back on
    implementation or follow the individual mandate before there is
    a replacement plan in place?
        Dr. Price. Well, I think that, if I am confirmed, then I am
    humble enough to appreciate and understand that I do not have
    all the answers and that the people at the Department have
    incredible knowledge and expertise, and that my first action
    within the Department itself as it relates to this is to gain
    that insight, gain that information, so that whatever decisions
    we can make with you and with Governors and others can be the
    most informed and intelligence decisions possible.
        Senator Warner. I am not sure you answered my question.
    What I would not want to see happen as we take--I understand
    your concerns with the Cadillac tax. I know there are concerns
    you and others have raised about the individual mandate. There
    are some who are concerned about the income tax surcharges.
        It is just remarkable to me--and this is one of the reasons
    why I think so many of us are anxious to see your replacement
    plan--that the President has said he wants insurance for
    everybody, he wants to keep the prohibitions on preexisting
    conditions, he wants to keep young people on their parents'
    policies until 26, and it seems like there is at the same time
    a rush to eliminate all of the things that pay for the ability
    of Americans to have those kind of services.
        And I would just want your assurance that you would not use
    this executive order prior to a legal replacement to eliminate
    the individual mandate, which I believe helps actually shore up
    the cost coverage and the shifting of costs that are required
    in an insurance system.
        Dr. Price. Yes. No, a replacement, a reform, an improvement
    of the program, I believe is imperative to be instituted
    simultaneously or at a time----
        Senator Warner. But you will not use this executive order
    as a reason to kind of, in effect, bypass the law prior to a
    replacement being in place?
        Dr. Price. Our commitment is to carry out the law of the
    land.
        Senator Warner. I want to, in these last couple of minutes,
    go on. I know you have been in the past a strong critic of the
    Center for Medicare and Medicaid Innovation, CMMI. I believe in
    your testimony last week you saw great promise in it.
        To me, if we are going to move towards a system that
    emphasizes quality of care rather than simply quantity of care,
    we have to have this kind of experimentation. There is one such
    program, the Diabetes Prevention Program, that last year CMS
    certified saved money on a per-beneficiary basis.
        And I know my time is running out, so let me just ask these
    questions. I think they can probably be answered ``yes'' or
    ``no.''
        Do you support CMMI delivery system reform demonstrations
    that have the potential to reduce spending without harming the
    quality of care?
        Dr. Price. The second clause is the most important one. I
    support making certain that we deliver care in a cost-effective
    manner. But we absolutely must not do things that harm the
    quality of care being provided to patients.
        Senator Warner. But if part of that quality of care--and I
    would agree with you--would mean bundled and episodic payment
    models that actually move us towards quality over volume, would
    you support those efforts?
        Dr. Price. For certain patient populations, bundled
    payments make a lot of sense.
        Senator Warner. And if these experiments are successful,
    would you allow the expansion of these across the whole system?
        Dr. Price. I think that what we ought to do is allow for
    all sorts of innovation, not just in this area. There are
    things I am certain that have not been thought up yet, that
    would actually improve quality and delivery of health care in
    our country, and we ought to be incentivizing that kind of
    innovation.
        Senator Warner. Well, I would simply say, Mr. Chairman,
    that CMMI seems to be one of the areas where I would like to
    have seen more, but I think it is a model and a tool we ought
    not to discard. Thank you.
        The Chairman. Well, thank you, Senator.
        Senator Scott?
        Senator Scott. Thank you, Mr. Chairman.
        Dr. Price, good to see you again.
        Dr. Price. Tim.
        Senator Scott. South Carolina launched the Nation's first
    statewide pay-for-success project with Nurse Family Partnership
    with the use of Medicaid funds. Twenty percent of the babies
    born in South Carolina are born to first-time, low-income
    mothers. We also have a much higher than average infant
    mortality rate.
        Nurse Family Partnership is evidence-based and has already
    shown real results, both in the health of the mother and the
    babies, but also in other aspects of the mother's life, such as
    high school graduation rates for teen moms and unemployment
    rates.
        What are your thoughts on incorporating a pay-for-success
    model to achieve success metrics?
        Dr. Price. Well, it sounds like a great program that
    actually has the right metric, and that is the quality of care
    and the improvement of lives. And as you state, if it is having
    that kind of success, it probably ought to be put out there
    again as a best practice for other States to look at and try to
    model.
        Senator Scott. Yes, sir. Thank you.
        I believe you were the director of the orthopaedic clinic
    at Grady Memorial Hospital in Atlanta.
        Dr. Price. I was.
        Senator Scott. You just mentioned something that I think is
    very important. I believe Grady Hospital had the highest level
    of uninsured Georgians. You talked about having coverage, but
    really not access. Can you elaborate on how your experience at
    Grady may help inform you and direct you as it relates to the
    uninsured population?
        Dr. Price. Well, it was an incredible privilege to work at
    Grady for the number of years that I did. And we saw patients
    from all walks of life and many, many uninsured individuals.
    And they come with the same kinds of concerns, the same kinds
    of challenges that every other individual has. And they have an
    additional concern, and that is, is somebody going to be caring
    for me? Is somebody going to be able to help me?
        And that is why it was so incredibly fulfilling to be able
    to have the privilege of working at Grady and assisting people
    at a time when they were not only challenged from a health-care
    standpoint, but challenged from a concern about whether or not
    people were going to be there to help them.
        Senator Scott. Yes, sir. I know that you are aware of title
    I of the Every Student Succeeds Act. It allows for the
    population of Head Start to have access to resources. It seems
    to me that it would be imperative for the Secretary of HHS and
    the Secretary of Education to look at ways to synergize your
    efforts to help the underprivileged student, the
    underprivileged child.
        Can I get your commitment that you will look for ways to
    work with the Secretary of Education where it makes sense to
    help those students? You know, we have Head Start under you and
    other programs under ESSA. It would be wonderful for us to take
    the taxpayer in one hand, the child in the other hand, and look
    for ways to make sure that they both win.
        Dr. Price. Yes, you have identified an area that is a pet
    peeve of many of us, and that is that we do not seem to
    collaborate across jurisdictional lines, not just in Congress,
    but certainly on the administrative side. And so I look forward
    to doing just that and having as a metric how the kids are
    doing.
        Senator Scott. Yes.
        Dr. Price. Are they actually getting the kind of service
    and education that they need? Are they improving? Are we just
    being custodians? Are we just parking kids in a spot, or are we
    actually assisting and improving their lives? And are we able
    to demonstrate that?
        And if we are not asking the right questions, if we are not
    looking at the right metrics, then we will not get the right
    answer that allows us to either expand what is actually working
    or to modify it and move it in a better direction.
        Senator Scott. Thank you. I think that is one of the more
    important parts of your opportunity in this position: looking
    at those kids. I know that you know as well as anyone who is a
    doctor that those ages, before you ever get into pre-K or
    Kindergarten, the development of the child between those first
    3 or 4 years is a powerful opportunity for us to direct a
    child's potential so that they maximize it.
        And sometimes we are missing those opportunities. We think
    that somehow the education system will help that child catch
    up. But there are things that have to happen before they ever
    get in the education system. So I thank you for your
    willingness to work in that direction.
        And my last question has to do with the employer-sponsored
    health-care system that we are so accustomed to in this country
    that provides about 175 million Americans with their insurance.
    In my home State of South Carolina, of course, we have about
    2.5 million people covered by their employer coverage.
        If confirmed as HHS Secretary, how would you support
    American employers in their effort to provide effective family
    health coverage in a consistent and affordable manner? Said
    differently, there has been some conversation about looking for
    ways to decouple having health insurance through your employer.
        Dr. Price. I think the employer system has been absolutely
    a remarkable success in allowing individuals to gain coverage
    that they otherwise might not gain. I think that preserving the
    employer system is imperative.
        That being said, I think that there may be ways in which
    employers--I have heard from employers who say, if you just
    give me an opportunity to provide my employee the kind of
    resources so that he or she is able to select the coverage that
    they want, then that makes more sense to them. And if that
    works from a voluntary standpoint for employers and for
    employees, then it may be something to look at.
        Senator Scott. That would be more like the HRA approach
    where the employer funds an account and the employee chooses
    health insurance, not necessarily under the umbrella of the
    employer specifically.
        Dr. Price. Exactly--and gains the same tax benefit.
        Senator Scott. Yes.
        Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator.
        Senator McCaskill?
        Senator McCaskill. At the risk, Mr. Chairman, of being way,
    way away from you and you being someone I have worked with and
    respected greatly, I do want to gently correct something in
    your opening statement.
        The first nominee of President Trump that this Senate
    considered was confirmed by a vote of 98 to one. I would not
    consider that a partisan vote.
        The second nominee of President Trump was confirmed by a
    vote of 88 to 11. Once again, I would not consider that a
    partisan vote.
        So I really do think we are all trying to look at each
    nominee individually. And I have had a chance to review
    Congressman Price's questioning of Secretary Sebelius, and I
    can assure you, Mr. Chairman, it was no beanbag. It was tough
    stuff.
        So I think all of this looks different depending on where
    we are sitting. And I wanted to make that point.
        And as to passing Obamacare without one Republican vote, we
    are about to repeal Obamacare without one Democratic vote. This
    will be a partisan exercise under reconciliation. It will not
    be a bipartisan effort. And what we have after the repeal is
    Trumpcare. Whatever is left after the dust settles is
    Trumpcare.
        Now, I know the President likes to pay close attention to
    what he puts his name on. And I have a feeling, Congressman,
    that even though you keep saying today that Congress will
    decide, you are not really believing, are you, that your new
    boss is not going to weigh in on what he wants Congress to
    pass? We are not going to have a plan from him?
        Dr. Price. Well, I think we look forward to working with
    you and other members of the House and Senate.
        Senator McCaskill. No, my question is, are we going to have
    a plan from the President? Will he have a plan?
        Dr. Price. If I have the privilege to be confirmed, I look
    forward to working with the President and brining a plan to
    you.
        Senator McCaskill. Great. So the plan will come from
    President Trump and you will have the most important role in
    shaping that plan as his Secretary of Health and Human
    Services, correct?
        Dr. Price. I hope I have input, yes, ma'am.
        Senator McCaskill. Yes. Okay. So whatever Trumpcare ends up
    being, you will have a role in it. And I think it is really
    important to get that on the record.
        Now, when we repeal Obamacare, we are going to do a tax
    cut. Does anybody in America who makes less than $200,000--are
    any of them going to benefit from that tax cut?
        Dr. Price. It's a hypothetical, and you all are the ones
    who are going to----
        Senator McCaskill. No, no, no, no, it's not a hypothetical.
    When we repeal Obamacare, there are taxes in Obamacare. And
    when it is repealed, there is no question the taxes are going
    to be repealed. I promise you the taxes are going to be
    repealed. When those taxes are repealed, will anyone in America
    who makes less than $200,000 benefit from the repeal of those
    taxes?
        Dr. Price. I look forward to working with you on that plan,
    and hopefully that will be the case.
        Senator McCaskill. No, no, no, no, no. I am asking, the
    taxes that are in there now, does anybody who makes less than
    $200,000 pay those taxes now?
        Dr. Price. It depends how you define the taxes. There are
    many individuals who are paying much more than they did prior
    to that point. The ACA----
        Senator McCaskill. No, I am talking about taxes.
        Dr. Price. I understand.
        Senator McCaskill. Taxes, you know--the Cadillac tax has
    not been implemented, so that does not affect anybody. I am
    trying to get at the very simple question--and I do not think
    you want to answer it--that, in fact, when Obamacare is
    repealed, no one in America who makes less than $200,000 is
    going to enjoy the benefit of that.
        Dr. Price. As I say, I look forward, if I am confirmed, to
    working with you to make certain that that is the case.
        Senator McCaskill. That is not an answer, but we will go
    on.
        Okay. We talked in my office. Ending Medicare as we know
    it, your plan that you have worked on for years is converting
    Medicare to private insurance markets with government
    subsidies. Correct?
        Dr. Price. Not correct.
        Senator McCaskill. Well, we talked yesterday, and we kind
    of went through this in my office. And by the end of our
    conversation, you admitted to me, and I am going to quote you,
    that your plan for Medicare in terms of people getting either
    tax credits or subsidies or however you are going to pay for
    the Medicare recipients would be them having choices on a
    private market. And you said yes, it was pretty similar to
    Obamacare with the exception of the mandate. Did you not say
    that to me yesterday?
        Dr. Price. That's a fairly significant exception.
        Senator McCaskill. Well, but these people are old. They do
    not need to be mandated to get insurance. It is not like a 27-
    year old who does not think he is going to get sick. You do not
    need a mandate for people who are elderly; they have to have
    health insurance. So the mandate is not as relevant. But did
    you not admit to me that Obamacare and the private markets are
    very similar to what you are envisioning for Medicare? Did you
    not use the phrase ``pretty similar?''
        Dr. Price. There are some similarities. I think what I
    said, though, was that the mandate was significant.
        Senator McCaskill. Well, the mandate I get in Obamacare is
    significant. But we do not need a mandate for seniors. Would
    you agree with that, that you do not have to tell seniors they
    need health insurance?
        Dr. Price. What I hope is that we do not need a mandate for
    anybody so that they are able to purchase the kind of coverage
    that they want, not that the government forces them to buy.
        Senator McCaskill. Okay. Finally, you want to block-grant
    Medicaid for State flexibility and efficiency. Correct?
        Dr. Price. I believe that Medicaid is a system that is now
    not responding necessarily to the needs of the recipients, and
    consequently, it is incumbent upon all of us as policymakers to
    look for a better way to solve that challenge.
        Senator McCaskill. Are you in favor of block-granting
    Medicaid?
        Dr. Price. I am in favor of a system that is more
    responsive to patients in the Medicaid system.
        Senator McCaskill. Are you in favor of block-granting
    Medicaid? It is a really simple question, Congressman. I mean,
    you are at your confirmation hearing for the most powerful job
    in health care in the country. I do not know why you would not
    be willing to answer whether or not you are in favor of block-
    granting Medicaid. That is not complicated.
        Dr. Price. I am in favor of making certain that Medicaid is
    a system that responds to patients, not the government.
        Senator McCaskill. Okay. I do not understand why you will
    not answer that. And I do not have time. I know I am over. I
    will probably--I do not know if we are going to get another
    round, Mr. Chairman. Should I ask my last question, or are we
    going to get another chance?
        The Chairman. I am going to allow additional questions. I
    hope that not everybody will take the opportunity. [Laughter.]
        Senator McCaskill. Okay. I will disappoint you; I am sorry.
        The Chairman. I will not call it a second round, however.
        Senator McCaskill. Not many, I just have one more.
        The Chairman. Let me just on that point say that Obamacare
    raised taxes on millions of American families across income
    levels. The nonpartisan Joint Committee on Taxation analysis in
    May 2010 identified significant, widespread tax increases on
    taxpayers earning under $200,000 contained in the ACA.
        And then, for example, for 2017, 13.8 million taxpayers
    with incomes below $200,000 will be hit with more than $3.7
    billion--with a ``b''--in Obamacare tax hikes from an increase
    in the income floor for the medical expense deductions.
        Obamacare has led to middle-class tax hikes, without
    question. It has led to fewer insurance options, higher
    deductibles and higher premiums.
        So I think those are facts that cannot be denied.
        Senator McCaskill. I will look forward to looking at those
    facts, because somewhere in this mix we have alternative facts.
    [Laughter.]
        Senator Wyden. Well, and just on that----
        The Chairman. Well, I think these are right, I can tell you
    that.
        Senator McCaskill. Well, I think mine are right.
        Senator Wyden. Mr. Chairman, just a point of privilege to
    respond.
        The Chairman. Yes, sir. Yes, sir.
        Senator Wyden. On this point, no alternative facts. The
    Republicans in last year's reconciliation bill cut taxes for
    one group of people. They cut taxes for the most fortunate in
    the country. That is a matter of public record. It is not an
    alternative fact or universe. People making $200,000 and up got
    their taxes cut. That was in the reconciliation bill of the
    Republicans last year.
        The Chairman. Well, let us see who is next here. I do not
    agree with that, but we will see who is next.
        Senator Cassidy and then Senator Grassley.
        Senator Cassidy. Thank you, Mr. Chairman.
        Dr. Price, how are you?
        Dr. Price. I am well, Senator.
        Senator Cassidy. Let us talk a little about Medicaid,
    because we are getting this kind of rosy scenario of Obamacare
    and of the Republican attempt to replace it. It does seem a
    little bit odd.
        First, I want to note for the record that President Trump
    has said in various ways that he does not want people to lose
    coverage. He actually would like to cover as many people as
    under Obamacare. He wishes to take care of those with
    preexisting conditions and to do it without mandates and lower
    cost. Those will be your marching orders. Fair statement?
        Dr. Price. Absolutely.
        Senator Cassidy. Now let us go to--you and I, we talked at
    a previous meeting. We have both worked in public hospitals for
    the uninsured and for the poorly insured, folks on Medicaid.
        Now, let us just talk a little bit about Medicaid. Why
    would we see patients on Medicaid at a hospital for the
    uninsured? If they wanted to see an orthopaedist in private
    practice, does Medicaid pay a provider well enough to cover the
    cost of seeing an orthopaedic patient?
        Dr. Price. Oftentimes it does not. And in fact, as you well
    know and as mentioned before, one out of three physicians who
    ought to be able to see Medicaid patients in this Nation does
    not take any Medicaid patients. And there is a reason for that,
    whether it is reimbursement or whether it is the hassle factor
    or whether it is regulations or the like.
        But that is a system that is not working for those
    patients. And we ought to be honest about that and look at that
    and answer the question ``why?'' and then address that.
        Senator Cassidy. I will note that when the House version of
    the ACA passed, Robert Pear in The New York Times wrote an
    article about a Michigan physician, an oncologist, who had so
    many Medicaid patients from Michigan Medicaid that she was
    going bankrupt. And she had to discharge patients from her
    practice.
        Now, the ranking member said we cannot have alternative
    facts. I agree with that. We also know that a New England
    Journal of Medicine article spoke about Medicaid expansion in
    Oregon, about how when they expanded Medicaid in Oregon
    outcomes did not improve. So I suppose that kind of informs
    you--as you say, we need to make Medicaid something that works
    better for patients.
        Dr. Price. Absolutely. And we need to look at the right
    metrics. Just gaining coverage for individuals is an admirable
    goal, but it ought not be the only goal. And we must have a
    goal in health care especially to keep the patient at the
    center and realize what kind of care and coverage we are
    providing for people on the ground, for real people in real
    lives, and whether or not we are affecting them in a positive
    way or a negative way.
        If we are affecting them in a negative way, then, again, we
    need to be honest with ourselves and say, how can we improve
    that?
        Senator Cassidy. Now, a lot of times there is this kind of
    conflation of per-beneficiary payments to the States per
    Medicaid enrollee and block grants, which to me is a
    conflation.
        I will note that Bill Clinton on the left and Phil Gramm
    and Rick Santorum on the right proposed per-beneficiary payment
    some time ago. And that is actually how, would you agree with
    this, how the Federal Employees Health Benefits Program pays
    for these Federal employees? They pay a per-beneficiary payment
    to an insurer. Fair statement?
        Dr. Price. Correct.
        Senator Cassidy. Would it not be great if Medicaid worked
    as well as the Federal Employees Health Benefits Program in
    terms of improved outcomes?
        Dr. Price. It would indeed. In fact, when you talk about
    the Medicaid population, it is not a monolithic population, as
    you well know. There are four different demographic groups
    within it: seniors, disabled, and then healthy moms, and kids,
    by and large. And we treat each one of those folks exactly the
    same under the Medicaid rules.
        Senator Cassidy. So when you are pressed on whether, by
    golly, you believe in block grants, is there any nuance? I do
    not hear any of the nuances that we are discussing offered in
    that question.
        Dr. Price. Not at all.
        Senator Cassidy. But frankly, you cannot address that. Are
    you speaking about a per-beneficiary payment? Are you speaking
    about each of those four, one of those four? How do you dice
    that? New York is an older State, demographically. Utah is a
    very young State. Fair statement?
        Dr. Price. Absolutely. And those are the things that I
    think we tend not to look at, because they are more difficult
    to measure. They are more difficult to look at. But when we are
    talking about people's lives, when we are talking about
    people's health care, then it is imperative that we do the
    extra work that needs to be done to determine whether or not,
    yes, indeed, the public policy that we are putting forward is
    going to help you and not harm you.
        Senator Cassidy. Now, let me ask, because there is also
    some criticism of your proposal about Health Savings Accounts.
    I love them because they activate the patient. I think we are
    both familiar with the Healthy Indiana Plan where, on a waiver,
    they gave folks of a lower income Health Savings Accounts and
    had better outcomes, decreased ER usage. Can you comment on
    that?
        Dr. Price. Just that when people do engage in their health
    care, they tend to demand more, they tend to demand better
    services. And individuals who have greater opportunity for
    choices of who they see, where they are treated, when they are
    treated, and the like have greater opportunity to gain better
    health care.
        Senator Cassidy. So going back to not wanting to have
    alternative facts, if we contrast the experience in Healthy
    Indiana with the experience in Oregon where the National Bureau
    of Economic Research--I think, if I got that acronym correct--
    published in the New England Journal of Medicine that they
    found no difference in outcomes in those who are fulfilled
    through a Medicaid expansion program in Oregon, contrast that
    absence of good effect, if you will, in outcomes with that in
    which Indiana attempted to engage patients to become activated
    in their own care. ER usage actually fell, but outcomes
    improved.
        I think in our world of standard facts, I kind of like your
    position. Thanks for bringing a nuanced, informed view to the
    health-care reform debate, Dr. Price.
        Dr. Price. Thank you, sir.
        The Chairman. Thanks, Senator.
        Senator Grassley?
        Senator Grassley. Two statements before I ask a couple of
    questions. One is, it is kind of a welcome relief to have
    somebody of your profession in this very important role,
    particularly knowing the importance of the doctor/patient
    relationship. Because in my dealing with CMS and HHS over a
    long period of time, I think that the bureaucracy has been
    short of a lot of that hands-on information that people ought
    to have.
        And secondly, when you were in my office, we discussed the
    necessity of your responding to congressional inquiries. And
    you very definitely said you would. I tongue-in-cheek said
    maybe you ought to say ``maybe'' because a lot of times
    nominees do not do it. But since you said you would, I will
    hold you to that and appreciate anything you can do to help us
    do our oversight.
        As a result of oversight, I got legislation passed a few
    years ago called the Physicians Payment Sunshine Act. And the
    only reason I bring this up is because it took Senator Wyden
    and me, last December, working hard to stop the House of
    Representatives from gutting that legislation in the Cures Act
    that passed.
        And I want to make very clear that the legislation I am
    talking about does not prohibit anything. It only has reporting
    requirements because it makes it very, very--well, it brings
    about the principle of transparency, brings accountability.
        And I have some studies here that we did and some newspaper
    reports on them, particularly one about a psychiatrist at Emory
    University who was not reporting everything that he should
    report, and even the president of Emory University came to my
    office and said, ``Thank you for making us aware of this
    stuff.''
        I want to put those in the record.
        [The studies and reports appear in the appendix beginning
    on p. 77.]
        Senator Grassley. But since you are administering this
    legislation and since Senator Blumenthal and I will think about
    expanding this legislation to include nurse practitioners and
    physician assistants, I hope that I could get your commitment
    that you will enforce this act the way it was intended to be
    enforced, because even under the Obama administration, after we
    got it passed, it was 3 years getting these regulations,
    getting it carried out. So effectively, it has only been
    working for about 2 or maybe 2\1/2\ years.
        So I would like to know, if you are confirmed, would you
    and the Department of Health and Human Services work with me to
    ensure that this transparency initiative is not weakened?
        Dr. Price. We look forward to working with you, sir. I
    think transparency in this area and so many others is vital,
    again, not just in outcomes or in pricing, but in so many
    areas, so that patients are able to understand what is going on
    in the health-care system.
        Senator Grassley. Thank you. Now, the last question deals
    with vaccine safety. You are a physician. I believe you would
    agree that immunization is very important for modern medicine
    and that we have been able to get rid of small pox way back in
    1977, worldwide polio I think in 1991, at least in the Western
    Hemisphere, and all that.
        So as a physician, would you recommend that families follow
    the recommended vaccine schedule that has been established by
    experts and is constantly reviewed?
        Dr. Price. I think that science and health care have
    identified a very important aspect of public health, and that
    is the role of vaccinations.
        Senator Grassley. Thank you very much.
        I yield back my time.
        The Chairman. Thank you, Senator.
        Senator Stabenow?
        Senator Stabenow. Thank you, Mr. Chairman.
        First, I would ask unanimous consent that a series of
    stories from individuals at a public forum that was held last
    week with my colleagues--people concerned about policies that
    our nominee has authored and about issues we are talking about
    today--be included in the record.
        The Chairman. Without objection.
        [The information appears in the appendix beginning on p.
    253.]
        Senator Stabenow. Thank you very much.
        Welcome, Congressman Price.
        Dr. Price. Senator.
        Senator Stabenow. And I appreciate our private discussion
    as well as the discussion this morning. I want to start right
    out--lots of questions--to see if we can move through some
    things quickly.
        You have said this morning that you would not abandon
    people with preexisting conditions. Is that basically what you
    are talking about with high-risk pools? Is that one of the
    strategies that you are thinking about? I have heard that
    talked about this morning.
        Dr. Price. I think high-risk pools can be incredibly
    helpful in making certain that individuals who have preexisting
    illness are able to be cared for in the highest-quality manner
    possible.
        I think there are other methods as well. We have talked
    about other pooling mechanisms. The destruction of the
    individual and small-group market has made it such that folks
    cannot find coverage that is affordable for them. And one of
    the ways to solve that challenge is to allow folks in the
    individual and small-group market to pull together. In fact, I
    think we talked about this in your office, with the Blue Shield
    model being the template for it----
        Senator Stabenow. Yes, right.
        Dr. Price [continuing]. Where individuals who are not
    economically aligned are able to pool together their resources
    solely for the purpose of purchasing coverage.
        Senator Stabenow. But let me just stress that, for about 35
    years, we have tried high-risk pools. Thirty-five States had
    them before the Affordable Care Act. And frankly, they did not
    produce great results.
        In 2011, .2 percent of the people with preexisting
    conditions--.2 percent--were actually in a high-risk pool. And
    the premiums were 150- to 200-percent higher than standard
    rates for healthy individuals, and they had lifetime and annual
    limits on coverage and cost States money. So that was the
    reality before we passed the Affordable Care Act.
        So let me also ask you, when President Trump said last
    weekend that insurance was going to be much better, do you
    think that insurance without protections for those preexisting
    conditions or without maternity coverage or without mental
    health coverage or insurance that would reinstate caps on
    cancer treatments is better?
        Dr. Price. Well, I do not know that that is what he was
    referring to. I think that----
        Senator Stabenow. Well, he said that it would be better.
    And if we in fact took away, if we went to high-risk pools
    instead of covering people with preexisting conditions, or if
    we stop the other coverage we have now, I am just wondering if
    you define that as better.
        Dr. Price. Well, I mean, you would have to give me a
    specific instance. What is better for you may not be better for
    me or somebody else. And that is the important thing that I am
    trying to get across, and that is that patients need to be at
    the center of this, not government.
        Should government be deciding these things, or should
    patients be deciding things?
        Senator Stabenow. Prior to the Affordable Care Act, about
    70 percent of the private plans that a woman could purchase in
    a marketplace did not cover basic maternity care. Do you think
    that it is better not to cover basic maternity care?
        Dr. Price. And I presume that she would purchase that
    coverage if she needed it then.
        Senator Stabenow. She would have to pay more, just as in
    general for many women. Just being a woman was a preexisting
    condition. That is the reason why we have a basic set of
    services covered under health care. So it is just a different
    way of looking at this.
        This is something where, sure, if a woman wanted to pay a
    premium, wanted to pay more, she could find maternity care. We
    said in the Affordable Care Act, that is pretty basic. And for
    over half the population who are women, maternity care ought to
    be covered.
        Let me go to another one. Do you believe that mental health
    services should be a guaranteed benefit in all health insurance
    plans?
        Dr. Price. I have been a supporter of mental health parity
    inclusion, yes.
        Senator Stabenow. So mental health should be a defined
    benefit under health insurance plans?
        Dr. Price. I think that mental health illnesses ought to be
    treated with the same model as other physical illnesses.
        Senator Stabenow. I agree with you. On Medicare, there has
    been a lot of discussion--and I have to say also, with the
    nominee for the Office of Management Budget talking today about
    Medicare and Social Security, I personally believe people on
    Medicare should be very worried right now in terms of what we
    are hearing overall.
        But I did want--and my time is up--I did want, Congressman,
    just to relay a message from my mom who is 90 years old, who
    said she does not want more choices, she just wants to be able
    to see her doctor and get the medical care that she needs. She
    is not at all supportive of the idea of Medicare in some way
    being changed into premium support, into a voucher.
        So I am conveying to you this is somebody who is getting
    great care right now and is not interested in more choices, she
    just wants to keep her care.
        Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator.
        Dr. Price. Well, if I may, Mr. Chairman, I would just
    convey to the Medicare population in this Nation that they do
    not have reason to be concerned. We look forward to assisting
    them in gaining the care and coverage that they need.
        Senator Stabenow. Thank you.
        The Chairman. Thank you.
        Senator Cantwell?
        Senator Cantwell. Thank you, Mr. Chairman.
        Congressman Price, sorry we have not had a chance to talk.
        Dr. Price. I apologize.
        Senator Cantwell. No, I think both of us have tried, and it
    is just a myriad of consequences.
        Dr. Price. Weather.
        Senator Cantwell. But I wanted to ask you broadly, I know a
    lot of my colleagues have been asking you about Medicaid, but
    what do you think is behind the rise in Medicaid costs? What is
    it due to?
        Dr. Price. Well, I think it is multifactorial. I think that
    we have a system that has many, many controls that are creating
    greater costs to the provision of the care that is being
    provided.
        I think that, oftentimes, we are not identifying the best
    practices in the Medicaid system so that patients move through
    the system in a way that is much more economical and much more
    efficient and effective, not just from a cost standpoint, but
    from a patient standpoint. There are so many things that could
    be done for, especially the sickest of the sick in the Medicaid
    population, where we could put greater resources and greater
    individual attention to individual patients.
        As you know, in a bell curve of patients in any population,
    there are those who are the outliers on the high side, where
    the resources spent to be able to provide their care is
    significant. And if you focus on those individuals
    specifically, then you oftentimes can provide a higher level of
    care and a higher quality of care for those folks and a more
    responsive care for those folks at a lower cost to move them
    down into the mainstream of the bell curve.
        Senator Cantwell. Okay. Well, you have brought up a couple
    of interesting points, and I want to follow up on them. But
    specifically, if I started that conversation, I would start
    with two big phenomena: one, people living longer, because the
    longer they live, the more Medicaid they are going to consume.
    If they are living 10 or 15 years longer than we have had in
    the past, they are going to consume more health care. And
    second, the baby boomer population is reaching retirement age.
    Those two things are ballooning the cost of health care in
    general, and specifically for the Medicaid population.
        And I want to make sure I understand where you are, because
    I feel like the administration is creating a war on Medicaid.
    You are saying that you want to cap and control the cost. And
    what we have already established in the Affordable Care Act are
    best practice incentives and ways to give the Medicaid
    population leverage in getting affordable health care. So I
    want to understand if you are for these things.
        For example, we provided resources in the Affordable Care
    Act to rebalance Medicaid patients out of nursing home care
    into
    community-based care. Why? Because it is more affordable.
        So, do you support that rebalancing effort?
        Dr. Price. I would respectfully, Senator, take issue with
    your description of a war on Medicaid. What we desire and want
    to do is to make certain that the Medicaid population is able
    to receive the highest-quality care.
        I have cared for thousands of Medicaid patients. The last
    thing that we want is to decrease the quality of care that they
    have access to. And clearly, the system is not working right
    now. So moving toward home-based care is something that is, if
    it is right for the patient, a wonderful thing to be able to
    do, and we ought to incentivize that.
        There are so many things we could do in Medicaid that would
    provide greater quality of care that we do not incentivize
    right now.
        Senator Cantwell. We did incentivize it in the Affordable
    Care Act, and your State and about 20 other States actually did
    it. They took the money from the Affordable Care Act. In fact,
    Georgia was approved for $57 million to make sure Medicaid
    beneficiaries got care in community-based care, and it has been
    able to shift 10 percent of its long-term costs from
    institutional care to that community-based care. So it is
    working. So are you for repealing that part of the Affordable
    Care Act?
        Dr. Price. What I am for is making certain, again, that the
    Medicaid population has access to the highest-quality care
    possible. And we will do everything to improve that, because
    right now so many in the Medicaid population do not have access
    to the highest-quality care.
        Senator Cantwell. I would hope you would look at this model
    and you would also look at the Basic Health Plan model. Again,
    what I think you are proposing and what the administration is
    refusing to refute is, when the President said, ``I am going to
    protect these things,'' and my colleague, Senator Sanders,
    brought this up and asked, ``Are you going to protect this?''
    and then senior White House staff are now saying, ``No, no, no,
    we are going to basically cap Medicaid spending,'' it is a
    problem.
        What we want to do is, we want to give these individuals
    leverage in the marketplace. That is what the Basic Health Plan
    does. That is what the community-based care plan does. It gives
    them the ability to get more affordable care and better
    outcomes, and it is saving us money.
        So if you could give us a response--I see my time is
    expired--look at those two programs and tell me whether you
    support those delivery system reforms in the Affordable Care
    Act.
        Dr. Price. I would be happy to.
        Senator Cantwell. Thank you.
        The Chairman. Well, thank you, Senator.
        That would end our first round. I would like to not go
    through a full second round, but we have some additional
    Senators here who would like to ask some more questions, so I
    guess we will start with Senator Wyden.
        Senator Wyden. Thank you, Mr. Chairman.
        Congressman, I have several ideas on how to lower the price
    of medicine. But I would like to set those aside and start with
    the President's idea: lower drug prices through bidding or
    negotiation.
        If confirmed, you are going to be the captain of the
    President's health team, and you are going to have to persuade
    Republicans to change the law so that the President can fulfill
    his pledge: more affordable prices for medicine through
    bidding.
        As captain of the health team, will you do that?
        Dr. Price. As you know, Senator, we are committed to making
    certain that drug prices are affordable for individuals so they
    can have access to the high-quality care. Right now, that
    negotiation from a Part D standpoint, which I would remind
    folks is a real success story--the cost for medications for
    seniors is about half of what it was projected to be when Part
    D passed--the Pharmacy Benefit Managers are doing that
    negotiation right now.
        I think it is important to have a conversation about
    whether or not----
        Senator Wyden. Congressman, I am asking about a specific
    idea, and it is not mine, it is the President's.
        Dr. Price. I was going----
        Senator Wyden. And the question is, will you advocate to
    Republicans for authority to negotiate? It is ``yes'' or
    ``no.''
        Dr. Price. What I was going to respond, Senator, if you
    will allow me, is to say right now the PBMs are doing that
    negotiation. I think it is important to have the conversation
    and look at whether or not there is a better way to do that.
    And if there is, then I am certainly open to it.
        Senator Wyden. On Saturday, hundreds of thousands of women
    of all ages and backgrounds came to Washington to speak out in
    support of policies that you have opposed. This includes the
    Violence Against Women Act, provisions in the Affordable Care
    Act to prevent insurance companies from charging them more
    because they are women, access to no-cost contraceptive
    coverage, and the choice to see the provider they trust.
        Now, Speaker Ryan has publicly stated that no one will be
    worse off if the Affordable Care Act is repealed. But the
    nonpartisan Congressional Budget Office does not share that
    view. They have indicated nearly 400,000 women would lose
    access to care, including lifesaving cancer screenings, in the
    first year if Planned Parenthood is defunded and cut off from
    Medicaid.
        So again, Congressman, this is not my opinion as Democrat
    or Republican, this is the nonpartisan Congressional Budget
    Office.
        You are going to be the point person for health. Will you
    advise the President to reject any proposal that cuts coverage
    for or otherwise limits a woman's ability to see the provider
    she trusts?
        Dr. Price. Well, there were multiple inaccuracies in your
    premise, Senator, and I would take significant issue with the
    Congressional Budget Office conclusion because, again, as I
    mentioned to a question over here, it looks at it in a silo,
    looks at it as saying, this is what you are doing without doing
    anything else to provide coverage for individuals. And that is
    simply--that is not anybody's plan.
        Senator Wyden. Well, again, this is what is in the bill you
    wrote. And these silos--you know, we keep hearing all kinds of
    happy talk about silos and dreams and the like. What we want to
    know is one thing above everything else: is there going to be a
    replacement before there is repeal?
        And you have been asked this now by a whole host of
    members. We have not been able to get any answers on it. It
    seems to me that your own bill is out of step with what the new
    President has said. The new President said the two were going
    to be intertwined. Your own bill was repeal and run, repeal it
    now, come back some other time.
        So I want to let my other colleagues have a chance to ask
    their questions. But when you talk about silos, that is the
    view of someone--I respect your right to state it--who would
    like to be confirmed.
        The nonpartisan Congressional Budget Office says women, who
    were speaking out in communities across this country, women are
    going to lose access to those vital cancer screenings. And that
    is not a partisan statement. That is from a nonpartisan agency.
        Dr. Price. I respect----
        Senator Wyden. I hope you will reconsider your position.
        Dr. Price. I respectfully disagree with the conclusion.
        The Chairman. Okay, hopefully we can finish in the next 20
    minutes.
        Senator Cardin?
        Senator Cardin. Thank you, Mr. Chairman.
        Again, thank you, Dr. Price, for your response to our
    questions.
        One of the major objectives of the Affordable Care Act was
    to deal with the historic discrimination against minority
    communities in our health-care system. And we can give you
    chapter and verse--the medical research that was done was very
    much not directed towards the priorities in the minority
    community. The access to providers was always challenging in
    minority communities. The affordability and quality of
    insurance products were not the same in minority communities.
        So there were various provisions included in the Affordable
    Care Act to deal with that. One was an amendment that I offered
    that elevated the National Institute for Minority Health and
    Health Disparities to a full institute, as well as creating
    offices for minority health and health disparities within the
    health-related agencies.
        Are you committed to continuing progress so that we have a
    focal point, so that we draw attention to the needs of minority
    communities?
        Dr. Price. Senator, this is a really important question,
    because there are many in our society in the minority community
    who, if you look at the right metrics, are not having the same
    outcomes or same quality of health that others in society are.
        And I believe that it is incumbent upon us as individuals
    administering these programs to ask the question why, why is
    that, and then reach a plan, a strategic plan, to be able to
    help correct that. Whether that is through the current offices
    or a different mechanism, you have my commitment to look at
    that and make certain----
        Senator Cardin. I appreciate that. The National Institute
    for Minority Health and Health Disparities funded a program in
    Maryland, in Baltimore, to show disparities, and that has been
    extremely helpful. And I would just encourage you to look at
    that institute as a real, valuable resource to you to carry out
    that commitment.
        The Affordable Care Act also increased dramatically the
    funding for Qualified Health Centers that allow access to care
    in minority communities. Are you committed to maintaining the
    support for Qualified Health Centers?
        Dr. Price. Qualified Health Centers play a vital role in
    our Nation's health-care delivery system right now. And so I
    think it is imperative that we retain them or improve the
    delivery of care in that area.
        Senator Cardin. So now I am going to get to the subject
    that has been talked about by many members: Medicaid. And the
    reason I mention Medicaid--and I appreciate your response that
    you do not want to disadvantage anyone who is currently on the
    Medicaid system--is blacks, Latinos, American Indians, and
    Native Alaskans are almost twice as likely to be in Medicaid
    than the white population. In my State, 70 percent of our
    Medicaid population are people of color, so it is by far the
    dominant population that relies on Medicaid.
        So I hope you understand our concern, that when we talk
    about changing Medicaid, talk about block-granting Medicaid,
    talk about new approaches to Medicaid, it sends a signal that
    what we are going to do is cut the Federal Government's
    commitment to access for minorities. And it is a major area of
    concern.
        We have seen budget rounds where cuts to Medicaid dollar-
    for-dollar would have reduced access to minority communities
    for their health-care needs. We know States have challenged
    budgets, and the more you put on the State, the more likely it
    is that many States will not be able to meet their full
    commitments to the Medicaid population.
        Can you just share with me a little bit more your vision.
    When you look at the resources we are putting into health
    care--everybody wants to do it more efficiently--but if you
    just look at the Medicaid population, what you are doing is
    taking resources away from minority communities and making the
    problem even worse.
        How can you give me a comfort level that you are committed
    to the minority communities that depend so heavily on the
    Medicaid program?
        Dr. Price. Well, Senator, let me try to assuage your
    concerns. I think, of the individuals at the dais and at this
    table, I am the only one who has ever treated a patient in the
    Medicaid system, in fact treated thousands of patients in the
    Medicaid system.
        And when we as a society use as the only major metric for
    determining whether or not we are providing care for
    individuals in the Medicaid system, the amount of money that we
    are putting into the system instead of the outcome, whether or
    not people are getting covered, whether they are able to see
    the doctor they want to see, whether they are able to get the
    kind of care that they want----
        Senator Cardin. And I agree with that. I agree with what
    you are saying, but I would just make this point----
        Dr. Price [continuing]. Then we are measuring the wrong
    thing.
        So my commitment to you is to make certain that we measure
    the right things.
        Senator Cardin. I agree with you, but if you look at the
    relative resources that are going into the Medicaid population
    versus the general population, you will find in many cases it
    is less resources. And as we said on quality education, money
    is not the only thing, but it is part of the problem.
        I just really urge us to recognize, yes, we want a better
    outcome, we all want a better outcome in our health-care
    system. But you do not do that by taking money away from our
    most vulnerable.
        Dr. Price. Thank you.
        Senator Cardin. Thank you, Mr. Chairman.
        The Chairman. Senator Nelson?
        Senator Nelson. Thank you, Mr. Chairman.
        Congressman, just to follow up our last conversation, you
    said that you did not recall having said it is a terrible idea.
    I quoted the source, Politico, and that was ``Most Republicans
    support''--and I am quoting from the Politico article of 2002,
    April the 30th, ``Most Republicans----''
        Dr. Price. 2002?
        Senator Nelson. 2012.
        Dr. Price. 2012.
        Senator Nelson. April 30th. ``Most Republicans support the
    health law's requirement that insurance companies accept all
    applicants. But the replacement plan on preexisting conditions
    put forth by the most prominent Republican ignores the idea''--
    talking about preexisting conditions.
        Dr. Price. Yes, I would disagree.
        Senator Nelson. Quote, `` `It is a terrible idea,'
    Representative Tom Price, the sponsor of the plan, told
    Politico.''
        So, Mr. Chairman, I would like to insert that Politico
    article into the record for clarification.
        The Chairman. Without objection.
        [The article appears in the appendix on p. 138.]
        Senator Nelson. You and I had the opportunity yesterday to
    talk about Puerto Rico. We do not know the origin of this, but
    they are not treated like the States where the poorer of the
    population that you have, the more Federal assistance for
    Medicaid that you get. Instead it is a block grant, and the
    block grant is going to run out this year. And they are in a
    heck of problem, not only financially on the island, but now
    with a third of the population, according to the CDC, being
    infected with the Zika virus.
        Do you want to comment on what you might do going forward?
        Dr. Price. Well, as we talked about in your office
    yesterday, Senator, we absolutely need to find the resources to
    be able to make certain that they have access to the care that
    they need. These are American citizens, and it is incumbent
    upon us to take that responsibility seriously.
        Senator Nelson. I mentioned earlier, and I did so
    yesterday, that senior citizens--we have 4 million in Florida
    on Medicare, but there are almost 2 million people in Florida
    who now get their health care through the ACA.
        And on Medicare Part D, the drugs, what we have tried to do
    is close the amount of money that seniors have to pull out of
    their own pocket, otherwise known as the doughnut hole.
        Do you want to comment, Congressman, about whether or not
    seniors should have retained that Federal ability to purchase
    their drugs?
        Dr. Price. Well, in view of the fact that two of those
    senior citizens in your State are my mother-in-law and my
    father-in-law, I need to tread very carefully here.
        One of the concerns that I have about drugs being available
    for seniors is the accessibility of the drugs that they need
    and desire. So we need to make certain that formularies are not
    limited, that we are not decreasing the access and availability
    of medications that seniors have available to them for the care
    that they receive.
        Senator Nelson. And so, the part of the ACA that closed
    that doughnut hole for senior citizens, you would support that
    part?
        Dr. Price. As I say, I think it is imperative that we
    provide the greatest amount of opportunity for individual
    seniors to be able to gain access to the drugs that they need.
        So oftentimes in these discussions, we think that whatever
    we are doing right now is the only solution that is possible.
    And I just, again, I am humble enough to believe that there are
    better ideas out there. And if we find a better idea that
    actually provides greater coverage at a lower cost more
    efficiently and is more responsive to patients, then we ought
    to be able to admit to ourselves that we would embrace that if
    it were to come along.
        Senator Nelson. Congressman, as their Senator and as their
    protector of senior citizens in Florida, I cannot get away with
    an answer like that. I have to tell them that I am going to
    support their right to get drugs under Medicare Part D just
    like they are getting them now and not take that away from
    them.
        Dr. Price. And I understand that. And I would respectfully
    suggest that if we used, as a society, the line, we are going
    to maintain the kind of quality coverage that we have right now
    unless we are able to improve it, then we might just be able to
    do that for you.
        Senator Nelson. And if I gave them that answer, I would get
    run out of the room by a group of senior citizens.
        Thank you, Mr. Chairman.
        The Chairman. Senator Menendez?
        Senator Menendez. Thank you, Mr. Chairman.
        Congressman Price, one of the main policy priorities that
    you share with Speaker Ryan is to radically reform or alter, I
    should say, Medicare from its current structure to one where
    seniors would, in essence, receive a coupon to buy coverage.
    Now, despite the fact that President Trump has made repeated
    promises throughout the campaign that he will not touch
    Medicare, it seems that it is still one of your top agenda
    items.
        I have heard serious concerns about privatizing Medicare,
    not only from seniors worried about increased costs and
    decreased coverage, but also from providers in my State
    concerned about the serious negative impacts such underfunding
    will have on their ability to continue caring for Medicare
    seniors.
        So if the stated goal of Medicare privatization is to
    reduce Federal expenditures on health care for seniors, then
    does it not stand to reason that every dollar the Federal
    Government saves is going to have to come out of the pocket of
    seniors on Medicare?
        Dr. Price. Well, I disagree with the characterization of
    the program as you described it. I think it is inaccurate.
        Senator Menendez. Okay. So let us go through the specifics.
    Do you not seek to privatize Medicare?
        Dr. Price. No.
        Senator Menendez. Do you not seek to ultimately offer a
    voucher as your way of creating greater affordability?
        Dr. Price. No.
        Senator Menendez. Well, it is interesting you say that,
    because studies that have been done on your and Speaker Ryan's
    Medicare privatization plans have shown that an average 65-year
    old will pay more than twice what they pay now since the
    vouchers that you would give out are, by design, far short of
    what the current Medicare program covers.
        Dr. Price. Well, Senator, with respect, I have no reason to
    believe that the President, in his statement that he is not
    interested in modifying Medicare, that that position of the
    President has changed.
        If you want to talk about what my role as a legislator was
    in fashioning legislation and trying to solve the challenges
    that we have in Medicare, I am happy to do that. But that is
    not the role that I would play if I am given the privilege of
    being confirmed to serve as the Secretary of Health and Human
    Services; that would be to administer the changes that you all
    come up with in the Congress of the United States and the
    programs that are----
        Senator Menendez. Well, let me respond to that, because I
    know I have heard you at various times, both here and before
    the HELP Committee, say that you are going to have more of an
    administrative role, not a legislative role. And I said to you
    privately, I think that that is a little disingenuous.
        I noticed last week, the day of the hearing before the HELP
    Committee, Vice President Pence was on TV, and he said, quote,
    ``I could not be more enthusiastic that someone with his
    background,'' referring to yourself, ``in medicine, but also
    his understanding of the President-elect's vision for health-
    care reform and his ability to help us shape what that replace
    bill looks like once we repeal Obamacare. . . .''
        Clearly, they think, the President and the Vice President,
    that you are going to be playing a policy development role, not
    just simply the administration of whatever the Congress
    decides.
        So in your advocacy with the President as he deals with his
    desire to replace Obamacare, the reality is, you are going to
    have more than an administrative role; you are going to have a
    policy role. And if past is prologue, then your views as a
    legislator as to what you think is best for the American people
    is of concern to me because that, in essence, is a plan towards
    privatizing Medicare.
        So if that is not the case, would you commit to ensuring
    that, under your watch, Medicare will not increase costs or
    limit the coverage to current or future beneficiaries as a
    result of a change in the plan?
        Dr. Price. Senator, a couple of things. One, the comments
    that you referenced, I think, were related to the ACA, not to
    Medicare.
        Second, as I mentioned to you yesterday in our conversation
    in your office and as I have said before here, I am humble
    enough to understand and appreciate that the work that I did as
    a legislator is not necessarily the work that I would promote
    as Secretary of Health and Human Services.
        The work that has been done within the Department--the
    experts within the Department have significant knowledge and
    expertise in the work that they have done----
        Senator Menendez. Well, I appreciate that. But the essence
    of my question, then, if you dispute that your past views are
    going to be your future views, that your past views and
    legislative activity are not going to be your advocacy with the
    presidency, then I would ask you to go to the core of my
    question. Are you willing to commit that we will not see
    increased costs or less coverage for seniors under a revision
    of Medicare as you might advocate or the President might
    pursue?
        Dr. Price. What I can commit to you and will commit to you
    and have committed to you, sir, and others on this committee
    and in other conversations, is that our goal is to make certain
    that seniors have access to the highest-quality health care
    possible at an affordable price.
        Senator Menendez. Well, access without the ability to
    afford it--and I will end on this.
        Dr. Price. That is what I said: affordable price.
        Senator Menendez. Well, affordability, still a question, is
    not just an affordable price; it is your ability to have the
    wherewithal even to access an affordable price.
        Medicare guarantees as a right, it guarantees care for
    seniors, like my late mother who worked in the factories of New
    Jersey as a seamstress, was not in a unionized factory, did not
    have private insurance. After working a lifetime of hard work
    to help her family achieve what they did, she faced an enormous
    struggle with Alzheimer's that ultimately took her life. For
    her, her health-care security was Medicare. And without it, she
    would not have lived with the dignity that she deserved in the
    twilight of her life.
        So changing Medicare from a commitment and an entitlement
    to vouchers that might hope to create affordability but do not
    guarantee it, that is a fundamental shift in the nature of how
    we take care of seniors in this country. And that is why I am
    so passionate about it.
        I said this to you privately, and I just wanted to explore
    it with you publicly, but your answer does not assuage me that,
    in fact, you are committed to Medicare as we know it today in
    terms of the guarantee. Can we improve? I am always open to
    improving it, but the guarantee is what I am concerned about.
        Dr. Price. I share those concerns as well, but I disagree
    with your characterization and can also share with you a story
    of my mom, who, in the twilight of her years, had an illness
    that took her from us. And she enjoyed the benefits of Medicare
    and, without that, would not have been able to have the care
    that she received.
        Senator Menendez. Well, I hope that will be compelling to
    you in the days ahead, that it will instruct you as to how we
    should pursue Medicare.
        Thank you, Mr. Chairman.
        The Chairman. Senator Brown?
        Senator Brown. Thank you, Mr. Chairman.
        I began with the comments of Congressman Price about not
    using the word ``socialized medicine,'' the term. In 2007 in
    the Congressional Record, debating CHIP, he talked about being
    eligible for government-run socialized medicine, referring to
    CHIP. But I do not want to debate that, I just want to point
    that out. You may have forgotten--it has been 10 years--I
    certainly understand that.
        I want to follow up on what Senator Menendez said about
    Medicare, with a slightly different twist. In December, you
    said you expected lawmakers to push forward an overhaul of
    Medicare, and I quote, ``in the first 6 to 8 months of the
    Trump presidency.''
        Today, Congressman Mulvaney, the Budget Director designee,
    said that he would support raising the eligibility age for
    Social Security. He seemed to be open to raising the
    eligibility age for Medicare too, in his comments. And like
    you, he supported efforts to raise it in legislation, in
    Speaker Ryan's so-called A Better Way plan.
        That is in exact contradiction, I understand, of what
    President Trump has said; he said he opposes both cuts and
    raising the eligibility age.
        I would like you to--I asked you to clarify your position
    in a letter. I have not received a response yet. I know you are
    busy. But my question is this: if Congress passes legislation
    to raise the eligibility age for Medicare, as laid out in
    Speaker Ryan's A Better Way plan, will you advise President
    Trump to veto that legislation?
        Dr. Price. I do not anticipate a single piece of
    legislation related to just that. So we would have to look at
    the constellation, if I am confirmed.
        Senator Brown. So if something else is part of it, you
    would consider supporting raising the eligibility age? If you
    are not willing to say, no matter what else is in it--you stand
    firm on that?
        Dr. Price. If I am confirmed, it would be my responsibility
    to talk with the President about the various aspects of any
    piece of legislation, lay out the pros and cons and the
    consequences of the decisions that would be made by the
    Congress of the United States and make a recommendation.
        Senator Brown. When I think about a barber in Warren, OH or
    a factory worker in Logan, OH or a woman who works in a diner
    in Mansfield, OH or someone working construction in Troy, OH
    and saying to them, you know, I know that you think Medicare's
    eligibility age is 65, you have worked all your life, you do
    not have these jobs where we can work to older ages--you and I
    are close to the same age; unfortunately I am a bit older--but
    I just cannot imagine the morality of telling these people who
    have worked all their lives and their bodies have broken down
    more than ours do in these jobs, that we would even consider
    the possibility, as you all did in Congressman Ryan's bill, you
    did, Budget Director Mulvaney did, raising the eligibility age
    for Medicare. It is just stunning to me.
        Let me talk about something----
        Dr. Price. Senator, if I may, I struggle with the morality
    of a system that looks at Medicare, which is broken and is----
        Senator Brown. Yes, I know. I know what you are going to
    say. You have said that already. I appreciate that. I do not
    agree with that. I do not agree that Medicare is broken the way
    you say.
        Let me talk about something else. You said good things
    about innovation. I want to bring up one really quick issue and
    ask you to continue to work with us on it.
        Last summer, Secretary Burwell visited my hometown of
    Mansfield, OH to witness firsthand the effective and cost-
    efficient role of community health workers in reducing infant
    mortality rates. I will talk to you more privately--and thank
    you for trying to get together in the last few days--about
    working to ensure that community health workers are recognized
    and included in new payment and delivery system reforms. They
    have been very effective at bringing down the low birth weight
    baby rate and cutting back the rate of infant mortality.
        My State is, unfortunately, maybe last in black infant
    mortality and pretty bad overall in infant mortality. I just
    want a commitment from you to at least sit and work with us on
    what Secretary Burwell and I began for dealing with community
    health workers.
        Dr. Price. Absolutely.
        Senator Brown. Okay, thank you.
        Last question--and thank you for your indulgence, Mr.
    Chairman, on this second round.
        Do you support guaranteed health care for our Nation's
    veterans?
        Dr. Price. I think the commitment that has been made by
    this Nation is that veterans should receive health care, yes.
        Senator Brown. But we do not. I mean, not all veterans
    qualify for care through the VA. On Tricare they do and there
    are a lot of them in your State as in my State. But because of
    these gaps, additional coverage options, like those provided
    through the ACA, are critical to ensure that they are covered.
        So what is the answer? The VA does not do it alone; the ACA
    complements the VA. So if we repeal the ACA, how do you
    guarantee health care for my State's thousands, your State's
    thousands of veterans who served their country, but do not have
    real health care?
        Dr. Price. Right. Well, currently, as you know, Senator,
    there are real challenges in the VA system. Again, I think I am
    the only individual on the dais here who has ever taken care of
    a patient in a VA hospital. And I know the challenges. And I
    know----
        Senator Brown. Well, but you want to repeal--thank you--but
    you want to repeal the Affordable Care Act, and we have used
    the Affordable Care Act in such a way that these veterans now
    have guaranteed health care. Almost all veterans have
    guaranteed health care, yet you are going to repeal the
    Affordable Care Act with no plans that anybody has seen yet to
    make sure these veterans have guaranteed health care.
        Dr. Price. I understand and appreciate the promise that has
    been made to veterans. And sadly, in many instances, we are not
    keeping that promise right now.
        Senator Brown. So is that part of your----
        Dr. Price. And I look forward to working with you to put
    together a better system that will----
        Senator Brown. Well, I appreciate that. I appreciate that,
    Congressman.
        Dr. Price [continuing]. Allow us to care for veterans in
    the way that we should.
        Senator Brown. Now, you had said when I asked you about
    President Trump saying he has been working with you on this
    repeal and replace plan, you said he has not really been
    working with you. So, I mean, you did not call the President a
    liar, but, you know, putting two and two together is pretty
    easy; it adds up to four.
        What does that mean? If you and he are working together,
    are you going to suggest to him that we find a way in repeal
    and replace to make sure there is guaranteed health care for
    our Nation's veterans?
        Dr. Price. Well, I think it is vital, again, as I have
    mentioned before, that every single American have access to
    affordable coverage that is of high quality. And that is our
    goal, and that is our commitment.
        Senator Brown. And so when we replace the Affordable Care
    Act after your party repeals it in this Congress, you will find
    a way for all 22 million Americans, including a lot of those
    who are veterans, to have health insurance, so they do not lose
    it with the replace part of repeal and replace?
        Dr. Price. I look forward to working with you to make that
    happen, sir.
        Senator Brown. That is not quite a ``yes,'' Congressman.
        Dr. Price. That is my answer.
        Senator Brown. Okay. Inadequate, but thank you.
        The Chairman. Okay. Thank you.
        Senator Casey?
        Senator Casey. Thank you, Mr. Chairman. Thanks for the
    additional round of questioning.
        Representative Price, I want to move to the topic I hoped I
    would have gotten to in the first round, which is individuals
    with disabilities, many of whom, I do not have the exact
    number, but many of whom rely upon Medicaid.
        One of them is actually a young child whom I just got a
    letter from his mother about--Pam Simpson, who is from
    Coatesville, PA, which is in southeastern Pennsylvania--talking
    about her son, Rowan Simpson, who was diagnosed in 2015 with
    autism. And among the things she said about the great care they
    get, that he gets in their family benefits from Medicaid, she
    says, without Medicaid, quote, ``we would be bankrupt or my son
    would go without the therapies he sincerely needs.''
        Can you guarantee today that his family is going to benefit
    from and he, Rowan Simpson, will have that kind of coverage and
    protection that Medicaid provides, that he will have that if
    you are Secretary of Health and Human Services?
        Dr. Price. We are absolutely committed to making certain
    that that child and every other child and every other
    individual in this Nation has access to the highest-quality
    care possible.
        Senator Casey. Okay, not access, he will have the medical
    care that he has right now, or better. If you can come up with
    a better level of care, that is fine. But he will have at least
    the coverage of Medicaid and all that that entails that he has
    right now? And that is either ``yes'' or ``no,'' that is not--
    --
        Dr. Price. No, it is not a ``yes'' or ``no,'' because the
    fact of the matter is that, in order for the current law to
    change, you all have to change it. If I am given the privilege
    of leading at the Department of Health and Human Services----
        Senator Casey. Yes. Here is why it is ``yes''----
        Dr. Price [continuing]. And I am responsible for----
        Senator Casey. Look, you should stop talking around this.
    You have led the fight in the House, backed up by Speaker Ryan,
    for years----
        Dr. Price. To improve Medicaid.
        Senator Casey [continuing]. To block-grant Medicaid, okay?
        Dr. Price. To improve Medicaid.
        Senator Casey. To block-grant Medicaid. What that means is,
    States will have to decide whether or not this child gets the
    Medicaid that he deserves. That is what happens. So you push it
    back to the States and hope it works out.
        One estimate by the Center on Budget and Policy Priorities,
    long before you were named, said that--here is the headline of
    a chart: ``House budget chair's plan would slash Medicaid by
    one-third by 2026.'' This was not developed because you are now
    in front of this committee. That is what they were saying, that
    Medicaid would be cut by a third and by a trillion dollars.
        So let me ask you this question.
        Dr. Price. May I respond?
        Senator Casey. Let me just get this question in. Can you
    commit to us right now that no person with a disability who is
    currently covered by Medicaid, so that is everyone--that is
    Rowan and that is everyone else--that no person with a
    disability who is currently covered by Medicaid will lose
    health-care coverage, not access but coverage, under the block-
    granting plan that the administration now embraces as of
    Sunday?
        Dr. Price. What I can commit to you is that in our Medicaid
    system, if I am given the privilege of service, working with
    CMS administrators, the metrics that we will use for Rowan and
    every single other patient are the quality of care that they
    are receiving----
        Senator Casey. That is fine----
        Dr. Price [continuing]. And whether or not they are
    receiving that care. The metric that you want to use----
        Senator Casey. Metrics are fine. What I am asking you again
    is, will you commit to ensure that Rowan and every other person
    in the country who has a disability, who benefits from Medicaid
    today, will they have that same coverage and the same health
    care and coverage they have today?
        Dr. Price. Our commitment is to make it so that they have
    that coverage or greater.
        Senator Casey. That is a commitment you are making.
        Dr. Price. That is a commitment.
        Senator Casey. For every person with a disability who
    benefits from Medicaid.
        Dr. Price. As I said, the goal is and our desire is to make
    sure that people have better health care, not less health care.
    And it is astounding to me----
        Senator Casey. Well, here is the problem with that. Here is
    the problem with your answer. Until Sunday, there was a
    question as to whether or not President Trump or his
    administration would fully embrace block-granting of Medicaid,
    because he said when he was campaigning that he would not cut
    Medicare and Medicaid and Social Security. As of Sunday, the
    administration has said on the record, in at least one and
    maybe two interviews, that they are going to pursue a block-
    granting policy with regard to Medicaid.
        What flows from that are the following: he has a majority
    in both houses, so what you have been working on in the House
    for years that you could vote for now may become the law of the
    land. So this is a live issue; this is not theory or some
    policy among House Republicans. This is a potential enactment
    of law to block-grant Medicaid.
        And I hope you can keep your promise to make sure that no
    one with a disability suffers any diminution of care or
    coverage. That is the promise you just made, and I hope you can
    keep that in light of a trillion-dollar cut in Medicaid
    pursuant to block-granting.
        The Chairman. Senator McCaskill, you are the last one.
        Senator McCaskill. Thank you. And thank you for your
    patience in letting us have another round of questions, Mr.
    Chairman. We sincerely appreciate it.
        I would like to put in the record a table prepared by the
    Tax Policy Center on December 15, 2016 that lays out what
    happens with a repeal of all ACA taxes, including premium
    credits based on income level, if I could make that part of the
    record.
        The Chairman. Without objection, it will be placed in the
    record.
        [The table appears in the appendix on p. 91.]
        Senator McCaskill. You were chairman of the Budget
    Committee. I am going to try not to be--I get frustrated when
    people will not answer, especially when your record is so clear
    on this, Congressman. I do not really understand why you want
    to divorce yourself from your record.
        You were chairman of the Budget Committee, correct?
        Dr. Price. Yes.
        Senator McCaskill. And in that role, you had the most
    important--we all know the power of the chairman around here.
    You had incredible power to influence what was in that
    document, correct?
        Dr. Price. Which document do you refer to?
        Senator McCaskill. The budget that you prepared for 2017.
        Dr. Price. Absolutely, along with my colleagues.
        Senator McCaskill. Along with your colleagues. Was there
    anything in that document that you disagreed with on principle
    when you supported it?
        Dr. Price. Oh, absolutely.
        Senator McCaskill. Okay. What was in the document you
    disagreed with on principle when you supported it?
        Dr. Price. I would have to go back and look.
        Senator McCaskill. All right.
        Dr. Price. But it was a combined effort. But again, you
    know, as I mentioned before, if I am given the privilege of
    serving as Secretary of Health and Human Services, I appreciate
    and understand that that is a completely different role than as
    a legislator.
        Senator McCaskill. I know it is a completely different
    role. That is not what I am asking you, Congressman. I am not
    asking you about the difference.
        Dr. Price. Each of your questions refers to that role.
        Senator McCaskill. I am not asking you about the difference
    in your roles. What I am asking you is, what do you believe in?
    What do you believe in? You have been respected around these
    halls for a man of integrity because you believed in certain
    principles. And one of those was the principle that you
    embraced as chairman of the Budget Committee to block-grant
    Medicaid.
        Dr. Price. No, on the contrary. What I believe in is this
    great country and the people of this great country and the
    principles of health care that I defined earlier. And those are
    the principles that we all share, I believe, and they are that
    we need a system that is affordable for everybody, we need a
    system that is accessible for everybody.
        Senator McCaskill. I get that.
        Dr. Price. We need a system that is of the highest
    quality----
        Senator McCaskill. You have said that over and over again--
    --
        Dr. Price [continuing]. That is responsive to patients, not
    to insurance companies and government.
        Senator McCaskill. I am just trying to figure out----
        Dr. Price. We need a system that incentivizes innovation,
    and a system that provides choices to patients. That is what I
    believe.
        Senator McCaskill. I understand. I understand the
    aspirational goal you have. But there is a record, Congressman.
    That is on record. And the record is that as chairman of the
    Budget Committee, controlled by your party, you put out a
    budget document, and you said over and over again that you
    favored block-granting Medicaid.
        In fact, your budget in 2017 when you were the chairman,
    you want to run away from that today as if it never happened,
    and I cannot figure out why. You are going to be influential.
    What you really believe matters. And you want to run away from
    that.
        You cut Medicaid by a trillion dollars in your 2017 budget.
    And yet today, you want to stand on some notion that, well,
    whatever you guys do is fine. And that is just not reality,
    Congressman.
        What is reality is, you have been chosen because of your
    beliefs, and your beliefs are reflected in your budget that you
    wrote as chairman of the Budget Committee. And that is the
    point I am trying to make.
        Dr. Price. Can I respond?
        Senator McCaskill. And I have a hard time understanding why
    you will not say, listen, it may not turn out the way I
    believe, but yes, I favored block grants to Medicaid.
        Dr. Price. What I believe in is a Medicaid system that is
    responsive to the patients and provides the highest-quality
    care possible.
        And I would respectfully suggest to you that that is not
    the Medicaid system that we currently have. So it is incumbent
    upon you, it is incumbent upon me, if I am given the privilege
    of serving in this capacity, to work together to find the
    solution so that we provide the highest-quality care for
    Medicaid patients and everybody else in this country.
        Senator McCaskill. And I understand. And by the way, the
    argument being made in favor of block grants is, they give more
    flexibility and efficiency to the States. That is the argument
    you have made before, that is the argument that was made around
    the budget that you crafted, that when you block-grant things
    to States, it gives them more efficiency.
        So I want to turn to a block grant that we have now, which
    is the Social Services Block Grant, which you have voted
    repeatedly to repeal. You have said that you wanted to zero it
    out. And you have voted that way as a member of Congress. And I
    want to make sure that you understand that that efficiency and
    effectiveness that you say you get with a block grant of
    Medicaid is what is happening in my State with the Social
    Services Block Grants, which, by the way, came about with
    Ronald Reagan.
        They are deciding where to use that money. And right now,
    just so you know where it is being used--in case you want to
    advise the President, the same way you voted--it is being used
    for residential treatment for detoxing off heroin, it is being
    used for daycare for seniors to keep them in their home so we
    are not paying the bill on Medicaid in a nursing home, it is
    being used for adoption services, and it is being used for case
    management to save money so that the cases are being managed
    effectively and efficiently in terms of accessing Federal
    safety net programs.
        Will you continue to advocate, as you have in Congress, for
    a repeal of the Social Services Block Grants?
        Dr. Price. Senator, with respect, I think there is likely a
    better way to provide those services in a much more efficient,
    effective, and economical way for the individuals receiving the
    care. And I would also respectfully suggest to you that another
    State flexibility model that is held up by many is the TANF
    program that has been extremely successful, and so there are
    different ways to do things.
        And again, it ought to be a collegial conversation that we
    have to lay out what the challenges are before us, working
    together to solve those challenges. And that is what I would
    like to do.
        Senator McCaskill. I just was trying to point out the
    inconsistency of saying block grants to Medicaid are good
    because of flexibility and efficiency and block grants to
    States on social services are bad. And that has been your
    record in Congress, Congressman, and that is why I brought it
    up.
        Dr. Price. And with respect, for individuals to say that
    State flexibility for Medicaid is bad, but State flexibility
    for TANF is fine, again, is a little bit inconsistent as well.
        Senator McCaskill. I understand.
        Thank you, Mr. Chairman.
        The Chairman. Well, thank you.
        Now, we are going to close this, Senator Wyden and myself,
    so we will just ask Senator Wyden to make his closing remarks,
    and then I will make mine.
        Senator Wyden. Thank you very much, Mr. Chairman.
        As we wrap up another quiet, subdued hearing in the Finance
    Committee [laughter], I just have a couple of thoughts. And the
    first is for you, Congressman. Despite our policy differences,
    I want you to know I very much respect your willingness to
    serve. As you know--we have talked about it--you and I have a
    lot of mutual friends, and I know they are very supportive of
    your career. And I want you to know I respect your willingness
    to serve.
        Here is where we are in terms of the substance. Several
    hours ago, I asked you, with respect to the executive order on
    the Affordable Care Act, will you commit that no one will be
    worse off? And you ducked it. I asked you, will you guarantee
    that no one will lose coverage? You ducked that. I asked you,
    would there be a replacement before all of this went into
    effect to avoid hurting working families? And that was ducked
    as well.
        And it just seems to me there is a big gap between the
    answers you have given on the executive order with respect to
    repealing the Affordable Care Act and what the new President
    said all through the campaign. Everybody was going to be okay,
    nobody would be worse off, there would be no gap between repeal
    and replace.
        My colleagues have gone through in great length the debate
    about the Medicaid block grant. Prediction? I think some of
    your biggest critics are going to be Republican Governors on
    this, because I think Republican Governors--and they will be
    probably more diplomatic than I--are going to see this as a
    Trojan horse to cut spending. And that is why a lot of us are
    concerned about shredding the safety net.
        I asked you about women's health care, and here the concern
    is that women all across the country are going to lose the
    choice of providers that they want and they have today and
    coverage. And you just said, ``Hey, I disagree with the
    Congressional Budget Office.''
        I asked about drugs and how we are going to lower these
    pharmaceutical prices, and you told me about pharmaceutical
    benefit managers. You told me about Part D--I voted for Part D,
    one of the relatively few Democrats who did--but you did not
    answer the question about whether you would get Republicans to
    help you fulfill the President's pledge on bargaining. So that
    is what concerns me about all of this.
        On the ethics questions, we want to correct one key point
    that was said earlier in the hearing, that the Congressman does
    not have control over his brokered accounts. First, the
    Congressman has not provided copies of the agreements that
    would clarify his level of control.
        Second, last week the Congressman told Senator Murray
    regarding the purchase of Innate, quote, ``I did it through a
    broker, I directed the broker to purchase the stock, but I did
    it through a broker.''
        And third on this point, these are not blind trusts. I just
    want the record to reflect that.
        I am also going to put an article in the record, Mr.
    Chairman, that ran this morning about investments in other
    health-care stocks, specifically in four companies that
    manufacture products in Puerto Rico.
        The Chairman. Without objection.
        [The article appears in the appendix on p. 286.]
        Senator Wyden. And so, Mr. Chairman, I will wrap up with
    just one last point. Ever since I was director of the Gray
    Panthers, the Oregon Gray Panthers--I did it for almost 7
    years--I was interested in one thing: changing a system that
    was largely for the healthy and the wealthy.
        And as you and I have talked about, I had eight Democrats
    and eight Republicans on a bipartisan bill that would do that.
    I did not get my way. But the Affordable Care Act had many,
    many good features, and one of them was, it made clear all
    across this country we were not going to go back to the days
    when health care was for the healthy and wealthy.
        And I am especially troubled as we wrap up this morning--we
    have been at it close to 4 hours--that when you take all of
    these policies together that you have described this morning,
    that is really where we are headed, that is where we are going
    to be. And that is why I am so strongly opposed to these
    positions.
        My hope is--we still have some additional questions to look
    at with the ethics issues. I can just tell the Congressman that
    George W. Bush's ethics lawyer was in the paper this morning
    talking about your stock trades, and he said ``I have not seen
    anything like this before, and I have been practicing and
    teaching about securities law for 30 years.''
        So I think there are very troubling questions that remain,
    Mr. Chairman, with respect to this. I know that we are being
    told that members have to get any written questions in by this
    evening. But with respect to what we have heard this morning
    and the lodestar that I see, that America will end up with
    health care that works for the healthy and wealthy, I am going
    to oppose it. I am very troubled by what we have heard today.
    And I appreciate the chance to make these closing remarks.
        The Chairman. Well, thank you, Senator.
        If we keep going the way we are going, there will not be
    any health care for anybody. We will not be able to afford it;
    we will not be able to provide for it. There are so many things
    that are wrong with the current system, but it is just
    pathetic, and it is gradually eating up the whole doggone
    Federal budget.
        Now, I have been around here only 40 years, but I will tell
    you I have never had a witness for any position in government
    who has performed as well as you have, who has an impeccable
    reputation in medicine and in the Congress. And to be treated
    like, if you do not agree with some concepts that some of my
    colleagues do, there is something wrong with you, is just
    beyond the pale.
        Like I say, you not only have a great deal of experience in
    medicine, but you have been a great Congressman, and you have
    been trying to get things under control around here. And you
    have found that it is almost impossible, because we have all
    these people saying we have to do everything in the world, and
    they do not care what the costs are. And that is why this
    country is broke.
        We have to find some way of delivering all these health-
    care benefits to people without totally ruining the country so
    nobody gets any health-care benefits, which is where we are
    headed. I do not know how in the world we can continue to buy
    into this liberal claptrap that you do not have to pay the
    piper.
        Now, what you have said is, we are going to try, within
    this current system, to make it work and to cover everybody and
    to help people, whether they be poor or whether they be rich.
        Now, I do not know if you can say much more than that. But
    I get a kick out of how many of these people are constantly
    blathering about, we have to do everything for everybody when
    we know we are $20 trillion in debt. And this money does not
    grow on trees, and yet every one of us wants to make sure
    health care works, every one of us wants to make sure every
    deserving person in our society is cared for.
        And I say that as a person who, over the last 40 years,
    almost every health-care bill that works has my name on it,
    starting with the Orphan Drug Act. How about Hatch-Waxman that
    created the modern generic drug industry? Name it all.
        The fact of the matter is that you have been very
    forthright, very honest, and you have indicated that, in spite
    of all the problems of trying to fund health care and all the
    problems around health care, you are going to do your doggone
    level best to make sure health care is delivered to our
    American people.
        You know, I wonder how many of my colleagues on the other
    side are going to vote for you. And if they do not, it kind of
    says something about what is happening in this country.
        Now, I want to thank you for being here today. You know, I
    do not think you ducked any questions. You answered them
    forthrightly. It might not have pleased the individual
    Senators, but you did. And I look forward to Dr. Price being
    confirmed and assuming his position so he can begin working
    with us here in Congress to improve the Nation's health and the
    whole health-care system and to ensure that taxpayer dollars
    are used efficiently and effectively.
        Now, we owe that to the dedicated taxpayers and citizens of
    this great country. And to that end, several groups and
    individuals have submitted letters of support for Dr. Price.
    And I would like to ask that those be entered into the record
    at this point, without objection.
        [The letters appear in the appendix beginning on p. 82.]
        The Chairman. In closing, this committee takes its
    responsibilities very seriously. As you can see, this is a very
    intelligent committee. We have a lot of really great people on
    both sides on this committee, and they are serious about what
    goes on. But that is why we have such a thorough review process
    for nominees. This is why the committee is following and will
    continue to follow our longstanding process in the future.
        Now, I would ask that any written questions for the record
    be submitted by 8 p.m. tonight, which is 2 hours more than what
    the Democrats gave us. This is a timeline that is consistent
    with the committee's consideration of previous nominees for HHS
    Secretary. And that's a direct quote, by the way.
        Now, I want to thank you and your family for sitting
    through this and for answering these questions. I think this
    was the best I have ever heard them answered, understanding
    that there are no answers to some of these problems.
        And I just want to personally thank you. My gosh, you could
    have such a great life without doing this kind of stuff, and
    you are willing to give your life to working for the American
    people and in trying to do what really needs to be done in the
    area of health care. And I want to commend you for it, because
    I just do not think there is a justifiable reason to vote
    against you.
        Dr. Price. Thank you, sir.
        The Chairman. Well, with that----
        Senator Wyden. Mr. Chairman, just a unanimous consent
    request.
        The Chairman. Yes, sir.
        Senator Wyden. I would just like to put in a statement by
    me under this unanimous consent request----
        The Chairman. That would be fine.
        Senator Wyden [continuing]. On how important it is that
    Congressman Price respond to the questions he has been asked by
    the HELP Committee. It is a different committee, but it is
    something of great importance to me. And I appreciate it.
        The Chairman. Well, that is fine. But see, in my
    estimation, the HELP Committee should not have held a hearing
    to begin with. This is the committee of jurisdiction. This is
    the committee that has to stand up and vote on whether or not
    our congressional friend is going to serve this country in this
    great capacity. And I believe we will vote for him and get him
    out of here. And by getting him out of here, I do not mean out
    of this room, okay, we have to get him out of the Congress and
    get him up there where he can really help with all this medical
    expertise that he has.
        And it is apparent that you have it. I mean, there is no
    question about that in my mind. And it is hard for me to
    understand why anybody would give you a rough time. It is good
    to ask tough questions, and we have had a lot of tough
    questions here today, but you have answered them very, very
    well, as far as I am concerned, much better than a lot of other
    people who have held this position.
        Many of the others, even recently, could not answer these
    questions that you have been asked. And it is wonderful that we
    have a doctor who has had a long life in medical practice
    willing to give up that life, give up the freedoms that you
    have to have to repeatedly come up here and justify everything
    you do down there. I think it is a wonderful thing, and I just
    personally want to congratulate you and your wife and family
    for giving so much to this country.
        With that, we will recess, and we will reconvene again to
    vote on you promptly.
        [Whereupon, at 1:54 p.m., the hearing was adjourned.]

                                A P P E N D I X

                  Additional Material Submitted for the Record

                                  ----------

                        Submitted by Hon. Chuck Grassley

                    The Wall Street Journal, October 3, 2008

      Grassley Says Emory Psychiatrist Didn't Report $500,000 in Payments
                               By Jacob Goldstein
    For a while now, Senator Chuck Grassley has been writing to
    universities around the country to ask about ties between high-profile
    doctors and the drug industry--an interest related to a bill he's
    sponsoring that would require drug makers to report payments to
    doctors.

    In the latest letter, Grassley says a prominent Emory psychiatrist
    failed to disclose a half-million dollars in payments from
    GlaxoSmithKline.

    Charles Nemeroff, the chair of Emory's psychiatry department, was paid
    by Glaxo to give speeches to doctors around the country, the Grassley
    letter said. Nemeroff was also the main investigator on a federally
    funded trial of Glaxo drugs.

    Emory requires its doctors to disclose potential conflicts of interest
    when they receive payments of over $10,000. In a statement to the WSJ,
    Emory said the allegations made by Senator Grassley are ``serious'' and
    that the university is ``working diligently to determine whether our
    policies have been observed consistently with regard to the matters
    cited'' by Grassley.

    The New York Times posted a copy of a 2004 letter from Emory to
    Nemeroff telling him that he had to limit his Glaxo consulting fees to
    less than $10,000 a year to avoid a conflict that would violate federal
    regulations. This week's letter from Grassley says Glaxo paid Nemeroff
    more than $70,000 in 2005 and more than $30,000 in 2006, according to
    reports from the company.

    Nemeroff didn't return a call from the WSJ, but the university said
    Nemerov told Emory officials that ``to the best of my knowledge, I have
    followed the appropriate university regulations concerning financial
    disclosures.'' Glaxo said it has ``rigorous guidelines governing our
    interaction with healthcare professionals who participate in GSK-
    supported speaking events,'' and that it requires them to disclose
    those relationships.

    Grassley has previously investigated similar issues regarding
    psychiatrists at Harvard, Stanford, the University of Cincinnati and
    the University of Texas Medical Branch. For more on Grassley's
    investigations, check out the recent interview from the HealthCare
    Channel.

    The Physician Payment Sunshine Act, which Grassley sponsors, would
    require drug makers to report payments to doctors. The industry
    supports the bill--finding it preferable to a patchwork of state laws--
    which has been working its way through Congress for a while now.

                                     ______

                       Money and Policy, October 3, 2008

                Top Psychiatrist Didn't Report Drug Makers' Pay
                               By Gardiner Harris
    One of the nation's most influential psychiatrists earned more than
    $2.8 million in consulting arrangements with drug makers from 2000 to
    2007, failed to report at least $1.2 million of that income to his
    university and violated federal research rules, according to documents
    provided to Congressional investigators.

    The psychiatrist, Dr. Charles B. Nemeroff of Emory University, is the
    most prominent figure to date in a series of disclosures that is
    shaking the world of academic medicine and seems likely to force broad
    changes in the relationships between doctors and drug makers.

    In one telling example, Dr. Nemeroff signed a letter dated July 15,
    2004, promising Emory administrators that he would earn less than
    $10,000 a year from GlaxoSmithKline to comply with federal rules. But
    on that day, he was at the Four Seasons Resort in Jackson Hole, WY,
    earning $3,000 of what would become $170,000 in income that year from
    that company--17 times the figure he had agreed on.

    The Congressional inquiry, led by Senator Charles E. Grassley,
    Republican of Iowa, is systematically asking some of the nation's
    leading researchers to provide their conflict-of-interest disclosures,
    and Mr. Grassley is comparing those documents with records of actual
    payments from drug companies. The records often conflict, sometimes
    starkly.

    ``After questioning about 20 doctors and research institutions, it
    looks like problems with transparency are everywhere,'' Mr. Grassley
    said. ``The current system for tracking financial relationships isn't
    working.'' The findings suggest that universities are all but incapable
    of policing their faculty's conflicts of interest. Almost every major
    medical school and medical society is now reassessing its relationships
    with drug and device makers.

    ``Everyone is concerned,'' said Dr. James H. Scully Jr., the president-
    elect of the Council of Medical Specialty Societies, whose 30 members
    represent more than 500,000 doctors.

    Dr. Nemeroff is a charismatic speaker and a widely admired scientist
    who has written more than 850 research reports and reviews. He was
    editor-in-chief of the influential journal Neuropsychopharmacology. His
    research has focused on the long-term mental health risks associated
    with child abuse as well as the relationship between depression and
    cardiovascular disease.

    Dr. Nemeroff did not respond to calls and e-mail messages seeking
    comment. Jeffrey L. Molter, an Emory spokesman, wrote in an e-mail
    statement that the university was ``working diligently to determine
    whether our policies have been observed consistently with regard to the
    matters cited by Senator Grassley.''

    The statement continued: ``Dr. Nemeroff has assured us that: `To the
    best of my knowledge, I have followed the appropriate university
    regulations concerning financial disclosures.' '' On Friday night,
    Emory announced that Dr. Nemeroff would ``voluntarily step down as
    chairman of the department, effective immediately, pending resolution
    of these issues.''

    Mr. Grassley began his investigation in the spring by questioning Dr.
    Melissa P. DelBello of the University of Cincinnati after The New York
    Times reported her connections to drug makers. Dr. DelBello told
    university officials that she earned about $100,000 from 2005 to 2007
    from eight drug makers, but AstraZeneca alone paid her $238,000 during
    the period, Mr. Grassley found.

    Then in early June, the Senator reported to Congress that Dr. Joseph
    Biederman, a renowned child psychiatrist at Harvard Medical School, and
    a colleague, Dr. Timothy E. Wilens, had reported to university
    officials earning several hundred thousand dollars each in consulting
    fees from drug makers from 2000 to 2007, when in fact they had earned
    at least $1.6 million each.

    Then the Senator focused on Dr. Alan F. Schatzberg of Stanford,
    president-elect of the American Psychiatric Association, whose $4.8
    million in stock holdings in a drug development company raised
    concerns.

    Mr. Grassley has sponsored legislation called the Physician Payment
    Sunshine Act, which would require drug and device companies to publicly
    list payments to doctors that exceed $500. Several states already
    require such disclosures.

    As revelations from Mr. Grassley's investigation have dribbled out,
    trade organizations for the pharmaceutical industry and medical
    colleges have agreed to support the bill. Eli Lilly and Merck have
    announced that they would list doctor payments next year even without
    legislation.

    The National Institutes of Health have strict rules regarding conflicts
    of interest among grantees, but the institutes rely on universities for
    oversight. If a university fails, the agency has the power to suspend
    its entire portfolio of grants, which for Emory amounted to $190
    million in 2005, although the agency rarely takes such drastic
    measures.

    Dr. Nemeroff was the principal investigator for a 5-year $3.9 million
    grant financed by the National Institute of Mental Health for which
    GlaxoSmithKline provided drugs.

    Income of $10,000 or more from the company in any year of the grant--a
    threshold Dr. Nemeroff crossed in 2003, 2004, 2005 and 2006, records
    show--would have required Emory to inform the institutes and take steps
    to deal with the conflict or to remove Dr. Nemeroff as the
    investigator.

    Repeatedly assured by Dr. Nemeroff that he had not exceeded the limit,
    Emory did nothing.

    ``Results from N.I.H.-funded research must not be biased by any
    conflicting financial interests,'' John Burklow, a spokesman for the
    health institutes, said in the kind of tough statement that in the past
    has rarely been followed by real sanctions. ``Officials at Emory are
    investigating the concerns.''

    ``Failure to follow N.I.H. standards'' on conflict of interest, Mr.
    Burklow continued, ``is very serious, and N.I.H. will take all
    appropriate action to ensure compliance.''

    In 2004, Emory investigated Dr. Nemeroff's outside consulting
    arrangements. In a 14-page report, Emory's conflict of interest
    committee detailed multiple ``serious'' and ``significant'' violations
    of university procedures intended to protect patients.

    But the university apparently took little action against Dr. Nemeroff
    and made no effort to independently audit his consulting income,
    documents show.

    Universities, too, can benefit from the fame and money the deals can
    bring--a point Dr. Nemeroff made in a May 2000 letter stamped
    ``confidential'' that he sent to the dean of Emory's medical school.
    The letter, which was part of a record from a Congressional hearing,
    addressed Dr. Nemeroff's membership on a dozen corporate advisory
    boards (some of the companies' names have since changed).

    ``Surely you remember that Smith-Kline Beecham Pharmaceuticals donated
    an endowed chair to the department and that there is some reasonable
    likelihood that Janssen Pharmaceuticals will do so as well,'' he wrote.

    ``In addition, Wyeth-Ayerst Pharmaceuticals has funded a Research
    Career Development Award program in the department, and I have asked
    both AstraZeneca Pharmaceuticals and Bristol-Meyers [sic] Squibb to do
    the same. Part of the rationale for their funding our faculty in such a
    manner would be my service on these boards.''

    Universities once looked askance at professors who consulted for more
    than one or two drug companies, but that changed after a 1980 law gave
    the universities ownership of patents discovered with federal money.

    The law helped give birth to the biotechnology industry and led to the
    discovery of dozens of life-saving medicines. Consulting arrangements
    soon proliferated at medical schools, and Dr. Nemeroff--who at one
    point consulted for 21 drug and device companies simultaneously--became
    a national model.

    He may now become a model for a broad reassessment of industry
    relationships. Many medical schools, societies and groups are
    considering barring doctors from giving lectures on drug or device
    marketing.

    For all his fame in the world of psychiatry, Dr. Nemeroff has faced
    ethics troubles before. In 2006, he blamed a clerical mix-up for his
    failing to disclose that he and his co-authors had financial ties to
    Cyberonics, the maker of a controversial device that they reviewed
    favorably in a journal he edited.

    The Cyberonics paper led to a bitter e-mail exchange between Dr.
    Nemeroff and Claudia R. Adkison, an associate dean at Emory, according
    to Congressional records. Dr. Adkison noted that Cyberonics had not
    only paid Dr. Nemeroff and his co-
    authors but had also given an unrestricted educational grant to Dr.
    Nemeroff's department.

    ``I can't believe that anyone in the public or in academia would
    believe anything except that this paper was a piece of paid
    marketing,'' Dr. Adkison wrote on July 20, 2006.

    Two years earlier, unknown to the public, Emory's conflict of interest
    committee discovered that Dr. Nemeroff had made more serious blunders,
    including failing to disclose conflicts of interest in trials of drugs
    from Merck, Eli Lilly and Johnson and Johnson.

    His continuing oversight of a federally financed trial using
    GlaxoSmithKline medicines led Dr. Adkison to write Dr. Nemeroff on July
    15, 2004, that ``you must clearly certify on your annual disclosure
    form that you do not receive more than $10,000 from GSK.''

    In a reply dated August 4, Dr. Nemeroff wrote that he had already done
    so but promised again that ``my consulting fees from GSK will be less
    than $10,000 per year throughout the period of this N.I.H. grant.''

    When he sent that letter, Dr. Nemeroff had already earned more than
    $98,000 that year from GlaxoSmithKline. Three weeks later, he received
    another $3,844.56 for giving a marketing talk at the Passion Fish
    Restaurant in Woodbury, NY.

    From 2000 through 2006, Dr. Nemeroff earned more than $960,000 from
    GlaxoSmithKline but listed earnings of less than $35,000 for the period
    on his university disclosure forms, according to Congressional
    documents.

    Sarah Alspach, a GlaxoSmithKline spokeswoman, said via e-mail that
    ``Dr. Nemeroff is a recognized world leader in the field of
    psychiatry,'' and that the company requires its paid speakers to
    ``proactively disclose their financial relationship with GSK, and we
    believe that healthcare professionals are responsible for making those
    disclosures.''

    http://www.nytimes.com/2008/10/04/health/policy/04drug.html

                                     ______

                  Prepared Statement of Hon. Orrin G. Hatch,
                            a U.S. Senator From Utah
    WASHINGTON--Senate Finance Committee Chairman Orrin G. Hatch (R-Utah)
    today delivered the following opening statement at a hearing to
    consider the nomination of Rep. Tom Price (R-Georgia) to head the
    Health and Human Services (HHS) Department:

        Today we will consider the nomination of Dr. Tom Price to be the
    Secretary of the Department of Health and Human Services.

        I want to welcome Dr. Price to the Finance Committee. I appreciate
    his willingness to serve in a position of this magnitude, especially at
    this crucial time.

        When Obamacare was pushed through on a series of party-line votes,
    Republicans in Congress warned that the new health law would harm
    patients, families, and businesses.

        Not to put too fine a point on it, but, we were right. And, the
    next HHS Secretary will play a pivotal role as we work to repeal
    Obamacare and replace it with patient-centered reforms that will
    actually address cost. This will be an important endeavor, one that
    will and should get a lot of attention here today, but it should not be
    the sole focus of the next HHS Secretary.

        HHS has an annual budget of well over $1 trillion. Let me repeat
    that: One department, $1 trillion.

        HHS encompasses the Centers for Medicare and Medicaid Services, the
    Centers for Disease Control and Prevention, the National Institutes of
    Health, the Food and Drug Administration, and many others. It is no
    exaggeration to say that HHS touches more of the U.S. economy and
    affects the daily lives of more Americans than any other part of the
    U.S. Government.

        I firmly believe that Dr. Price has the experience and
    qualifications necessary to effectively lead this large and diverse set
    of agencies, and many people share that view.

        For example, past HHS Secretaries Mike Leavitt and Tommie Thompson
    strongly support his nomination.

        Physician organizations that know Dr. Price's work--including the
    American Medical Association and most surgical specialty groups--
    enthusiastically support him. The American Hospital Association and
    other health-care stakeholder groups do as well.

        Perhaps the Healthcare Leadership Council, representing the broad
    swath of health-care providers, said it best in stating that, ``It is
    difficult to imagine anyone more capable of serving this Nation as the
    Secretary of HHS than Congressman Tom Price.''

        Unfortunately, in the current political environment,
    qualifications, experience, and endorsements from experts and key
    stakeholders don't seem to matter to some of our colleagues. At least,
    that appears to be the case, as none of those who say they oppose Dr.
    Price's nomination seem to be talking about whether he is qualified.

        Instead, we've heard grossly exaggerated and distorted attacks on
    his views and his ethics. On top of that, we've heard complaints and a
    series of unreasonable demands regarding the confirmation process
    itself.

        Of course, these tactics haven't been limited to Dr. Price. My
    Democratic friends have taken this approach with almost all of
    President Trump's cabinet nominees as Senate Democrats' unprecedented
    efforts to delay and derail the confirmation process and apply a
    radically new set of confirmation standards has continued unabated.

        To that point, let me say this: I have been in the Senate for 40
    years and I think my record for being willing to reach across the aisle
    is beyond any reasonable dispute. In fact, from time to time, I've
    taken lumps in some conservative circles for working closely with my
    Democrat colleagues.

        I have, on some occasions, voted against confirming executive
    branch nominees, but far more often than not, I have opted to defer to
    the occupants of the White House and allow them to choose who serves in
    their administrations. I've taken some lumps for that too.

        I'm not bringing any of this up to brag or to solicit praise from
    anyone in the audience. I raise all of this today so that people can
    know I'm serious when I say that I am worried about what my colleagues
    on the minority side are doing to the Senate as an institution. While
    the overriding sense of comity and courtesy among Senators has
    admittedly been in decline in recent years, I have never seen this
    level of partisan rancor when it comes to dealing with a President from
    an opposing party. I have never seen a party in the Senate--from its
    leaders on down--publicly commit to not only opposing virtually every
    nomination, but to attacking and maligning virtually every single
    nominee.

        Let me be clear: I'm not suggesting that the Senate start rubber-
    stamping nominees. Nor am I suggesting that any member of the Senate
    should vote against their conscience or preferences simply out of
    respect for tradition or deference. What I am saying is that the same
    rules, processes, courtesies, and assumptions of good faith that have
    long been the hallmark of the Senate confirmation process should
    continue to apply regardless of who is President. If what we're seeing
    now is the new normal for every time control of the White House changes
    hands, the Senate, quite frankly, will be a much lesser institution.

        Unfortunately, our committee has not been entirely immune to the
    hyper-politicization of the nomination process. We saw that last week
    with the Mnuchin hearing, and I regret to say that I think we're likely
    to see more of it today.

        Case in point: I expect that, during today's hearing, we're going
    hear quite a bit about process, with claims that Dr. Price's nomination
    is being rushed and that the nominee hasn't been fully vetted.

        This is simply untrue.

        President Trump announced his intent to nominate Dr. Price just 3
    weeks after the election. Dr. Price submitted the required tax returns
    and completed questionnaire on December 21st. That was 35 days ago,
    and, by any reasonable standard, that is sufficient time for a full and
    fair examination of the nominee's record and disclosures.

        By comparison, the committee held a hearing on the nomination of
    Secretary Sebelius 16 days after she submitted her paperwork. For
    Secretary Burwell, it was 17 days. In other words, the time between the
    completion of Dr. Price's file and his hearing has been more than that
    of the last two HHS Secretaries combined. And, by the way, both of
    those nominees received at least a few Republican votes on this
    committee and on the floor.

        Outside of extraordinary process demands, Dr. Price has faced a
    number of unfair attacks on both his record as a legislator and his
    finances.

        On the questions surrounding finances, I'll defer on any
    substantive discussion and first allow Dr. Price to defend himself from
    what are, by and large, specious and distorted attacks. For now, I'll
    just say that I hope that my colleagues don't invent new standards for
    finances, ethics, and disclosure that are different from those that
    have generally applied in the past.

        There is a saying involving both stones and glass houses that might
    be applicable as well.

        With regard to Dr. Price's views and voting record, I'll simply say
    that virtually all the attempts I've witnessed to characterize Dr.
    Price's views as being ``outside of the mainstream'' have been absurd,
    unless, of course, the only ideas that are in the ``mainstream'' are
    those that endorse the status quo on healthcare and our entitlement
    programs.

        In conclusion, I just want to note that the overly partisan
    treatment of nominees and distortions of their records is a relatively
    new development on this committee. My hope is that we can begin today
    to reverse recent trends and have a fair and open discussion of the
    nominee and his qualifications.

                                     ______

                  American Academy of Dermatology Association

                      1445 New York Avenue, NW, Suite 800

                           Washington, DC 20005-2134

                               Main: 202-842-3555

                               Fax: 202-842-4355

                              Website: www.aad.org

    January 30, 2017

    The Honorable Orrin Hatch           The Honorable Ron Wyden
    Chairman                            Ranking Member
    U.S. Senate                         U.S. Senate
    Committee on Finance                Committee on Finance
    104 Hart Senate Office Building     221 Dirksen Senate Office Building
    Washington, DC 20510                Washington, DC 20510

    Dear Chairman Hatch and Ranking Member Wyden:

    The American Academy of Dermatology Association (Academy), which
    represents more than 13,500 dermatologists nationwide, wishes to
    express its support for the nomination of Representative Tom Price,
    M.D., for the position of U.S. Secretary of the Department of Health
    and Human Services (HHS).

    Dr. Price, in his active role in health care policy in Congress as well
    as his years of service at the state level of government, has
    demonstrated a proven understanding of the intricate complexities of
    our nation's health care system. Additionally, as someone who has
    worked as a practicing physician, Dr. Price would bring to the position
    of Secretary a personal understanding of how the policies enacted in
    Washington impact the practice of medicine and delivery of care to
    patients across the country.

    Specifically, Dr. Price understands the importance of the physician-
    patient relationship and recognizes the critical role that physicians
    play in the delivery of care to their patients. He has often supported
    dermatology's position on integrated electronic health care records and
    the challenges of meaningful use. Dr. Price has also been a leading
    voice to reduce burdensome regulations which have limited the time
    physicians can devote to caring for and treating patients.

    During his time in Congress, Dr. Price worked with colleagues on both
    sides of the aisle to enact a new Medicare physician payment system
    that streamlines multiple reporting requirements for physician
    practices within Medicare. More recently, with the roll out of the new
    Medicare Quality Payment Program (QPP), Dr. Price sought input
    regarding proposed regulations and their potential impact on physicians
    and patients, working with stakeholders and advocating with the Centers
    for Medicare and Medicaid Services (CMS), to help provide flexibility
    for physician practices both small and large.

    The Academy appreciates your consideration of Dr. Price's nomination as
    Secretary of Health and Human Services, and supports his nomination as
    Secretary. At this important time in health care for our nation, Dr.
    Price's experience as a physician and his in-depth understanding of
    health care policy will provide HHS and our nation the direction needed
    to guide our health care system as it addresses the needs of a growing
    and diversifying patient population. Should you have any questions or
    need additional information, please contact Shawn Friesen, the
    Academy's Director, Legislative, Political and Grassroots Advocacy at
    sfriesen@aad.org or (202) 712- 2601.

    Sincerely,

    Abel Torres, M.D., JD, FAAD
    President, American Academy of Dermatology Association

                                     ______

                 American Association of Neurological Surgeons

                     Kathleen T. Craig, Executive Director

                             5550 Meadowbrook Drive

                           Rolling Meadows, IL 60008

                              Phone: 888-566-AANS

                               Fax: 847-378-0600

                                 info@aans.org

                                      and

                       Congress of Neurological Surgeons

                               Regina Shupak, CEO

                      10 North Martingale Road, Suite 190

                              Schaumburg, IL 60173

                              Phone: 877-517-1CNS

                               FAX: 847-240-0804

                                 info@1CNS.org

    January 4, 2017

    The Honorable Orrin Hatch
    Chairman
    Committee on Finance
    U.S. Senate
    Washington, DC 20510

        SUBJECT: Rep. Tom Price Nomination for HHS Secretary

    Dear Chairman Hatch:

    On behalf of the American Association of Neurological Surgeons (AANS)
    and Congress of Neurological Surgeons (CNS), representing more than
    4,000 practicing neurosurgeons in the United States, we are writing in
    strong support of Representative Tom Price, M.D. (R-GA) to become the
    next Secretary of the U.S. Department of Health and Human Services
    (HHS).

    Throughout his time in Congress, Dr. Price, an orthopaedic surgeon, has
    been a staunch advocate for the preservation of the doctor-patient
    relationship, a fierce protector of private practice, and a stalwart
    supporter of academic medicine. As a practicing physician, and because
    of his work on key congressional committees with jurisdiction over
    health care issues, he understands all aspects of the health care
    system, which is essential to run HHS effectively.

    We have every confidence that Dr. Price will work tirelessly to create
    a health care delivery system that promotes high-quality, high-value,
    and better-coordinated care for our nation's patients. We, therefore,
    urge the Senate Finance Committee to favorably report Dr. Price's
    nomination to the full Senate vote swiftly.

    Thank you for considering our views.

                Sincerely,

    Frederick A. Boop, M.D., President   Alan M. Scarrow, M.D., President
    American Association of
    Neurological Surgeons               Congress of Neurological Surgeons

    Staff Contact:

    Katie O. Orrico, Director
    AANS/CNS Washington Office
    725 15th Street, NW, Suite 500
    Washington, DC 20005
    Direct: 202-446-2024
    Email: korrico@neurosurgery.org

                                     ______

                 American Podiatric Medical Association (APMA)

                            9312 Old Georgetown Road

                          Bethesda, Maryland 20814-1621

                               Tel: 301-581-9200

                               Fax: 301-530-2752

                             https://www.apma.org/

                                January 11, 2017

    The Honorable Orrin Hatch
    Chairman
    Committee on Finance
    U.S. Senate
    219 Dirksen Senate Office Building
    Washington, DC 20510

    The Honorable Ron Wyden
    Ranking Member
    Committee on Finance
    U.S. Senate
    219 Dirksen Senate Office Building
    Washington, DC 20510

    Dear Chairman Hatch and Ranking Member Wyden:

    The American Podiatric Medical Association (APMA) respectfully requests
    your Committee affirmatively recommend Representative Thomas Price,
    M.D., to the full Senate for Secretary of Health and Human Services
    (HHS). Founded in 1912, the APMA is the leading organization and
    represents the majority of the estimated 15,000 podiatrists in the
    country.

    Dr. Price is highly qualified for this position and brings years of
    experience as a physician and the leading health policy expert in
    Congress. Dr. Price has been supportive of policies that will free
    providers of overly burdensome regulations which hinder the delivery of
    care to patients and has encouraged additional pathways for providers
    to play a more significant role in regulatory decision-making. He has
    consistently provided healthcare solutions that are patient-centered
    and emphasize consumer choice, which will be critical as Congress moves
    forward with changes to the Patient Protection and Affordable Care Act.

    Again, we support the nomination of Congressman Tom Price as HHS
    Secretary and ask for your favorable consideration.

    Sincerely,

    R. Dan Davis, DPM
    President

                                     ______

                             Corinthian Medical IPA

                            5030 Broadway, Suite 821

                               New York, NY 10034

                                 T 212-740-8294

                                 F 212-740-8246

                          www.corinthianmedicalipa.com

    January 16, 2017

    The Honorable Lamar Alexander
    Chairman,
    Committee on Health, Education, Labor, and Pensions
    U.S. Senate
    Washington, DC 20510

    Re: Letter in support of Dr. Tom Price

    Dear Honorable Lamar Alexander:

    I have practiced medicine in the United States for 25 years. Throughout
    that time, I have focused my practices exclusively on improving
    outcomes for lower-income communities, who face extreme health
    disparities in our current system. Many of my patients are immigrants;
    and I am proudly an immigrant myself.

    Today, I head a nonprofit network, Advocate Community Providers. We
    consist of over 2,000 physicians and healthcare providers and are
    responsible for over 700,000 lives across four boroughs in New York
    City. To put this population in perspective, this is larger than the
    populations of all but the seventeen largest cities in the country.
    Nearly all of our patients are Medicaid recipients; most are
    concentrated in the Hispanic and Asian communities. Our network came
    together as a result of New York's transformative Delivery System
    Reform Incentive Payment program, or DSRIP, which uses state and
    federal dollars to cut costs stemming from unnecessary hospital usage
    by lower-income patients by switching to a community-based preventative
    care system as opposed to one that depends on emergency room visits,
    and switching a value-based system instead of one based on exorbitant
    fee-for-service.

    I have had the opportunity to meet with Congressman Tom Price last year
    in New York; Dr. Price was particularly interested in knowing about
    health-care issues and care-enhancing, cost-saving methods that are
    showing promise in lower-income communities in New York, especially
    regarding the DSRIP initiative.

    I sincerely support his nomination and I hope that after his
    confirmation as Secretary of Health and Human Services, he will look
    closely at our work and this model and that we can work together to
    discuss support and scalability. The reforms that my network and the 24
    other similar networks in New York are pioneering can and should be
    thoughtfully considered in urban areas and rural states alike with
    heavy Medicaid populations. We stand ready to work with him.

    There is no question that a new Administration taking office presents a
    key opportunity. Hopefully, it will be a historic moment for a renewed
    national dialogue on health-care reform that is apolitical and places
    patients first. The eventual outcome is uncertain, but there is no
    doubt that the Affordable Care Act will undergo significant changes. No
    matter the changes, I hope that Dr. Price and President-Elect Trump
    will be as committed to raising outcomes and creating healthier,
    stronger and more prosperous communities through better quality care
    and lower expenditures as the previous administration. I trust that
    they share that goal, and as a doctor who has worked in the Medicaid
    network, I can confirm that using this system as the place to make
    change is where the strongest potential exists.

    I look forward to welcoming Dr. Price back to New York this year and
    convening a round table of providers who are leading on care-enhancing,
    cost-saving reforms that can flourish anywhere. I hope to serve as a
    laboratory for results that will have positive national implications
    and that Dr. Price and the Department of Health and Human Services will
    take every advantage of under his leadership.

    With regards,

    Dr. Ramon Tallaj
    Chairman, Corinthian Medical IPA (CMIPA) (ACP)

                                     ______

                                State of Georgia

                             Office of the Governor

                               Atlanta 30334-0090

    Nathan Deal
      Governor

    The Honorable Orrin Hatch           The Honorable Ron Wyden
    Chairman                            Ranking Member
    Committee on Finance                Committee on Finance
    U.S. Senate                         U.S. Senate
    Washington, DC 20510                Washington, DC 20510

                                January 23, 2017

    Dear Chairman Hatch and Senator Wyden:

        It is with great pride that I write to you to support the
    nomination of Congressman Tom Price, M.D. as the Secretary of Health
    and Human Services. As an orthopaedic surgeon, in private practice for
    twenty years, Rep. Price knows firsthand the intricacies of the
    healthcare landscape. Representative Price has served in both the State
    Senate and as a Representative for Georgia's 6th District. During this
    time, he has become a champion for healthcare. As such, he is uniquely
    situated to serve as the Secretary for Health and Human Services.
    Representative Price has been working for the past several years to
    craft a solution to the many woes of the Affordable Care Act, passed
    and signed into law in 2010.

        As a Governor, charged with balancing a state budget, I know the
    many challenges that the Affordable Care Act has brought to states like
    Georgia. Since taking office, we have seen the portion of our state
    budget consumed by health expenses continue to grow. Continued growth
    in healthcare expenses means that other critical spending areas like
    education, transportation, and public safety are put at risk.

        I look forward to the confirmation of Representative Price so that
    Georgia can craft a Medicaid program that is sustainable and best
    suited to fit the needs of our unique population.

                Sincerely,

                Nathan Deal

                                     ______

                              Grady Health System

                          80 Jesse Hill Jr. Drive, SE

                               Atlanta. GA 30303

                                 (404) 616-1000

                              www.gradyhealth.org

    January 20, 2017

    The Honorable Orrin Hatch
    Chairman
    Committee on Finance
    U.S. Senate
    Washington, DC 20510

    The Honorable Ron Wyden
    Ranking Member
    Committee on Finance
    U.S. Senate
    Washington, DC 20510

    Dear Chairman Hatch and Ranking Member Wyden:

    It is an honor to submit these comments as you deliberate the
    confirmation of Dr. Tom Price, M.D. as this country's next Secretary of
    Health and Human Services. I am Chairman of the Grady Health System
    Board of Directors (Grady Memorial Hospital) in Atlanta, Georgia, one
    of the largest, essential safety net health systems in the country.
    Grady has a vital stake in the future of this Nation's healthcare
    policy.

    Grady was founded with a mission to care for the underserved and is
    celebrating its 125th anniversary this year. Our health system consists
    of the 953-bed Grady Memorial Hospital, 6 neighborhood health centers,
    Crestview Health and Rehabilitation Center, and Children's Healthcare
    of Atlanta at Hughes Spalding, which is operated as a Children's
    affiliate. In 2016, Grady had over 620,000 patient visits, including
    more than 130,000 emergency room visits. Over 28% of our patients are
    uninsured, 28% are covered by Medicaid, and 24% are enrolled in
    Medicare. The remainder have other forms of coverage, including
    commercial insurance.

    With its nationally acclaimed emergency medical services, Grady has the
    premier level I trauma center in all of North Georgia and serves as the
    911 ambulance provider for the city of Atlanta and six rural counties.
    Grady's American Burn Association /American College of Surgeons
    verified Burn Center is one of only two in the State. And the Marcus
    Stroke and Neuroscience Center is a Joint Commission designated
    Advanced Comprehensive Stroke Center.

    Other key services include Grady's Regional Perinatal Center with its
    Neonatal Intensive Care Unit, Georgia's first Cancer Center for
    Excellence, The Avon Breast Health Center, the Georgia Comprehensive
    Sickle Cell Center, and the Ponce de Leon Center--one of the top three
    HIV/AIDS outpatient clinics in the country.

    As the cornerstone of healthcare in Atlanta, Grady serves Americans
    from every walk of life in every possible circumstance and does it with
    limited resources. Grady's funding, like other safety net hospitals in
    the country, is often determined by the changing priorities of
    government--local, State or Federal. And it's the place where changes
    in public policy can have an immediate and direct impact on the lives
    of our patients and the hospital's ability to meet the demand for
    services.

    Dr. Price completed his residency program in orthopedics at Grady and
    later returned to serve as Medical Director of the Orthopedics Clinic.
    We believe there is no better training or opportunity to gain personal
    perspective on the health-care needs of all Americans than working at a
    safety net institution like Grady. While at Grady, Dr. Price trained
    the next generation of clinicians and provided care to the vulnerable--
    particularly the uninsured and Georgia's Medicaid recipients.

    No clinician has been in charge of our Nation's health-care system
    since Dr. Louis Sullivan, a former board member of Grady. With so much
    change being contemplated and considered in both houses of Congress, it
    reassures us to know that Dr. Price will view changes in policy with
    Grady and the community we serve in mind.

    As our Nation continues to discuss how best to deliver health care to
    all Americans, but especially to the indigent and uninsured, we believe
    Dr. Price's experience as a physician at Grady will serve him well. We
    are grateful for Dr. Price's work with us throughout his time in public
    office. We look forward to working with him in this important role to
    improve access to care for all Americans.

    Sincerely,

    Francis S. Blake
    Chairman

                                     ______

                    National Confectioners Association (NCA)

                         1101 30th Street NW, Suite 200

                              Washington, DC 20007

                                 (202) 534-1440

                           https://www.candyusa.com/

    January 13, 2017

    The Honorable Orrin G. Hatch        The Honorable Ron Wyden
    Chairman                            Ranking Member
    Committee on Finance                Committee on Finance
    U.S. Senate                         U.S. Senate
    219 Dirksen Senate Office Building  219 Dirksen Senate Office Building
    Washington, DC 20510                Washington, DC 20510

    The Honorable Lamar Alexander       The Honorable Patty Murray
    Chairman                            Ranking Member
    Committee on Health, Education,
    Labor, and Pensions                 Committee on Health, Education,
                                        Labor, and Pensions
    U.S. Senate                         U.S. Senate
    428 Dirksen Senate Office Building  428 Dirksen Senate Office Building
    Washington, DC 20510                Washington, DC 20510

    Dear Chairmen Hatch and Alexander, Senator Wyden, and Senator Murray:

    I am writing to you to express support from the National Confectioners
    Association in regard to the nomination of Representative Tom Price as
    Secretary of the Department of Health and Human Services.

    The National Confectioners Association is the trade organization
    representing the $35 billion U.S. chocolate, candy, gum and mints
    industry. Confectionery is manufactured in all 50 states, directly
    employing 55,000 workers in more than 1,000 facilities. In addition to
    these jobs in manufacturing, the industry supports an additional
    410,000 U.S. jobs in fields like retail, transportation and
    agriculture. The confectionery industry generates more than $10 billion
    in U.S. taxes and more than $2 billion in exports annually.

    Dr. Price's experiences as a surgeon and his significant legislative
    background at the state and federal levels have uniquely positioned him
    to lead the Department. His considerable experience will also have a
    positive influence on the Food and Drug Administration, an agency with
    significant oversight on regulations that impact the confectionery
    industry. Dr. Price is a principled man and strong leader who will
    underscore the importance of making policy using the best science
    available after thorough and practical deliberation.

    NCA respectfully asks for Dr. Price's prompt consideration by both of
    your committees and confirmation by the United States Senate as our
    next Secretary of the Department of Health and Human Services.

    Sincerely,

    John H. Downs, Jr.
    President and CEO

                                     ______

           Small Business and Entrepreneurship Council (SBE Council)

                        301 Maple Avenue West, Suite 100

                                Vienna, VA 22180

                                 (703) 242-5840

    January 23, 2017

    The Honorable Orrin Hatch           The Honorable Ron Wyden
    Chairman                            Ranking Member
    Committee on Finance                Committee on Finance
    U.S. Senate                         U.S. Senate

    The Honorable Lamar Alexander       The Honorable Patty Murray
    Chairman                            Ranking Member
    Committee on Health, Education,
    Labor, and Pensions                 Committee on Health, Education,
                                        Labor, and Pensions
    U.S. Senate                         U.S. Senate

    Dear Chairmen Hatch and Alexander, and Ranking Members Wyden and
    Murray:

    On behalf of the Small Business and Entrepreneurship Council (SBE
    Council) and our more than 100,000 members nationwide, I am writing to
    express our strong support for the confirmation of U.S. Representative
    Tom Price, M.D. as Secretary of the U.S. Department of Health and Human
    Services (HHS).

    Congressman Price is a serious and successful physician, legislator,
    and policy thought leader who naturally transferred his Hippocratic
    Oath to policymaking and legislative initiatives across many areas.
    Over the course of his career in Congress, he has worked hard to
    propose and fight for policies that empower and help all Americans,
    while warning against those that do harm and undermine opportunity.

    Congressman Price is a great friend of entrepreneurs and small business
    America, and understands that government policies and actions--if not
    carefully thought through--can take a disproportionate toll on the
    ability of small businesses to compete, grow, innovate and create jobs.
    Regarding health care policy, his insights and experience have been
    invaluable in developing positive solutions, while also correctly
    warning about the unintended consequences of poor policy or actions.

    Congressman Price has been a leader on common sense reforms to lower
    health costs, improve quality, drive more choice and innovation in the
    market, and create true access for all health care consumers. His ``do
    no harm'' ethic is extraordinarily important now as the Congress and
    policymakers carefully unwind a health care law that has undermined
    people's health, access to health coverage, as well as their personal
    finances. Small businesses and the self-employed have especially been
    burdened by the higher costs and limited choices that have resulted
    from the Affordable Care Act.

    Congressman Price is the right person, with the precise set of skills,
    experience and temperament to guide us to a system where all people
    have access to high quality, affordable care, and a system that is
    innovating for the future. This is a system--a market--that desperately
    needs more entrepreneurial ideas, but excessive regulation and
    government control are barriers that prevent the type of rapid
    innovation we are benefitting from in other industries and sectors.

    SBE Council strongly supports Congressman Price's confirmation, and we
    urge the Senate to move quickly on a full vote to ensure HHS has the
    leadership it needs in many important areas, including navigating the
    type of reforms we need to make health coverage more affordable and
    competitive for the self-employed, small businesses and their
    employees. Please do not hesitate to contact me if you have questions
    about SBE Council's support for Congressman Price's confirmation as HHS
    Secretary.

    Sincerely,

    Karen Kerrigan
    President and CEO

                                     ______

                                  Scott Walker

                             Office of the Governor

                               State of Wisconsin

                                 P.O. Box 7863

                               Madison, WI 53707

                             www.wisgov.state.wi.us

                                 (608) 266-1212

                              Fax: (608) 267-8983

                                January 17, 2017

    The Honorable Orrin Hatch           The Honorable Ron Wyden
    Chairman                            Ranking Member
    Committee on Finance                Committee on Finance
    U.S. Senate                         U.S. Senate

    The Honorable Lamar Alexander       The Honorable Patty Murray
    Chairman                            Ranking Member
    Committee on Health, Education,
    Labor, and Pensions                 Committee on Health, Education,
                                        Labor, and Pensions
    U.S. Senate                         U.S. Senate

    Dear Chairmen Hatch and Alexander, and Ranking Members Wyden and
    Murray:

    I write today in support of President-elect Trump's nomination for
    Secretary of the U.S. Department of Health and Human Services, Dr. Tom
    Price.

    Secretary-designee Price is uniquely positioned to work with Wisconsin
    and other states to reform health care and help curb years of federal
    overreach. In addition to his leadership roles in congress, he spent
    more than 20 years caring for patients in Georgia as an orthopaedic
    surgeon and medical professional. If confirmed, Dr. Price will bring
    years of medical knowledge and federal lawmaking experience to the
    department.

    In Wisconsin, we share Dr. Price's commitment to quality healthcare as
    we rank one of the best states in the nation for health insurance
    coverage and our reforms allowed us to cover everyone living in poverty
    under Medicaid. His decades of medical knowledge and firsthand
    experience as a licensed physician and orthopaedic surgeon, combined
    with his years as a lawmaker make him the perfect candidate to begin
    tackling critical reforms to empower the states.

    Again, I strongly support the confirmation of Dr. Price as the next
    U.S. Health and Human Services Secretary. I look forward to working
    with him in this new role.

    Sincerely,

    Scott Walker
    Governor of Wisconsin

                                     ______

           Submitted by Hon. Dean Heller, a U.S. Senator From Nevada

                               Nevada Legislature

                                January 10, 2017

    The Honorable Dean Heller
    324 Hart Senate Office Building
    Washington, DC 20510

    Dear Senator Heller:

    We are writing to express our concern regarding plans to repeal the
    Affordable Care Act. Specifically, we are concerned that Republicans in
    Congress are pushing ahead with a repeal of the Affordable Care Act
    despite having no viable replacement legislation ready to enact.

    Failure to immediately enact replacement legislation risks creating
    uncertainty in the insurance marketplace. Such uncertainty will likely
    result in higher out-of-
    pocket costs and fewer insurance options for Nevada's families while
    simultaneously placing an increased burden on our State budget.

    As you are aware, Governor Sandoval worked closely with the Legislature
    and ultimately signed legislation creating the Silver State Health
    Exchange in 2011. Subsequently, more than 300,000 Nevadans have gained
    access to health care coverage, either by purchasing it on the exchange
    or by meeting the expanded Medicaid eligibility requirements.

    In light of these facts, we hope that you will address the following
    questions regarding the planned repeal of the Affordable Care Act:

        1.  What steps do you plan to take to ensure that the more than
    88,000 Nevadans who have purchased health insurance through the Silver
    State Health Exchange continue to have the ability to purchase health
    insurance with adequate coverage in a transparent marketplace?

        2.  What steps do you plan to take to ensure that the more than
    77,000 Nevadans who are eligible for Federal tax credits under the
    Affordable Care Act to help purchase private insurance will continue to
    have access to affordable health insurance options with adequate
    coverage?

        3.  What steps do you plan to take to ensure that the 217,000
    Nevadans who are receiving health care under the Medicaid expansion
    remain covered?

        4.  The Affordable Care Act guarantees coverage vital to
    preventative services for women, including cancer screenings and birth
    control. What steps do you plan to take to ensure that the Affordable
    Care Act's coverage guarantees remain intact for women's health?

        5.  The Affordable Care Act guarantees that Nevadans with pre-
    existing conditions will not be denied health care and ends lifetime
    minimums on coverage. It also allows younger people, many of whom are
    saddled with college debt and cannot afford insurance, to stay on their
    parents' insurance until they are 26. What steps do you plan to take to
    preserve those coverage guarantees?

    The lack of clarity regarding viable alternatives to the Affordable
    Care Act from the incoming administration and Republican congressional
    leadership is troubling. While Congress has expended considerable time
    and energy over the past several years talking about the law, hundreds
    of thousands of Nevadans have relied in good faith on the Affordable
    Care Act to obtain health insurance. Repealing the law without
    implementing an adequate replacement will put those Nevadans' health
    and well-being at risk.

    Further, any congressional action that creates a large gap in insurance
    coverage will likely result in more Nevadans relying on state-funded
    social service programs. Most of these programs are already under
    resourced. Nevada cannot afford to shoulder this new financial burden
    created by politicians in Washington failing to live up to guarantees
    that the Federal Government previously made to our citizens.

    We hope you will use your position as Nevada's senior U.S. Senator and
    a member of the majority party to protect the thousands of Nevada
    families who are now at risk of losing their health insurance. We also
    hope you will take steps to ensure that our State does not bear any
    unfair and unnecessary costs of caring for people who stand to lose
    that coverage in the near future.

    We look forward to your prompt reply.

    Sincerely,

    Aaron D. Ford                       Jason Frierson
    Majority Leader                     Speaker
    Nevada State Senate                 Nevada State Assembly

                                     ______

                                                Submitted by Hon. Claire McCaskill, a U.S. Senator From Missouri
                                                                         Table T16-0285
                                                         Repeal all ACA Taxes, Including Premium Credits
                                                                      Baseline: Current Law
                                           Distribution of Federal Tax Change by Expanded Cash Income Level, 2017 \1\
                                                                          Summary Table
                                                                 http://www.taxpolicycenter.org/
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                        Tax Units with Tax Increase or Cut \3\                                                     Average Federal Tax Rate
                               --------------------------------------------------------    Percent      Share of                              \5\
    Expanded Cash Income Level         With Tax Cut              With Tax Increase        Change in       Total        Average   ---------------------------
                \2\            --------------------------------------------------------   After-Tax    Federal Tax   Federal Tax
                                 Pct. of Tax                 Pct. of Tax    Avg. Tax     Income \4\      Change      Change ($)    Change  (%     Under the
                                    Units     Avg. Tax Cut      Units       Increase                                                 Points)      Proposal
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    Less than 10                         7.3        -1,150           0.0         7,140           1.6           3.5           -80          -1.5           5.3
    10-20                                6.6        -1,210           4.2         3,850          -0.5          -5.8            80           0.5           2.6
    20-30                                7.2          -960           9.9         4,020          -1.3         -22.1           320           1.3           4.4
    30-40                               41.6          -170           9.2         4,600          -1.1         -18.2           350           1.0           7.7
    40-50                               83.9           -90           6.1         5,630          -0.6         -11.2           260           0.6          10.4
    50-75                               93.6          -100           3.1         6,400          -0.2          -8.3           100           0.2          13.1
    75-100                              97.3          -140           1.3         5,840           0.1           3.1           -60          -0.1          15.6
    100-200                             98.8          -190           0.4         6,540           0.1          14.8          -160          -0.1          18.8
    200-500                             99.8          -540           0.0         8,320           0.2          18.0          -540          -0.2          23.0
    500-1,000                           99.9        -4,590           0.0             0           0.9          17.9        -4,580          -0.7          28.0
    More than 1,000                     99.9       -50,200           0.0             0           2.2         108.4       -50,130          -1.5          32.6
    All                                 60.0          -600           3.8         4,720           0.3         100.0          -180          -0.2          19.6
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    Source: Urban-Brookings Tax Policy Center Microsimulation Model (version 0516-2).
    Number of AMT taxpayers (millions). Baseline: 5.5; proposal: 5.5.
    * Non-zero value rounded to zero; **  Insufficient data.
    \1\ Calendar year. Baseline is current law. Proposal would repeal all ACA taxes: the 3.8 percent Net Invest Income Tax, the 0.9 percent additional HI
      tax, the Cadillac Tax, the excise tax on employers offering inadequate health insurance coverage, the excise tax on individuals without adequate
      health insurance, the increase in threshold for medical expense deductions, and the excise taxes on health insurance providers, pharmaceutical
      manufacturers and importers, and medical device manufacturers and importers. Analysis includes the Premium Tax Credit which is not treated as a tax in
      the TPC baseline due to its similarity to a spending program. Simulations of Premium Tax Credit calibrated to match results from Urban Institute's
      Health Insurance Policy Simulation Model (HIPSM). For a description of TPC's current law baseline,  see http://www.taxpolicycenter.org/taxtopics/
      Baseline-Definitions.cfm.
    \2\ Includes both filing and non-filing units but excludes those that are dependents of other tax units. Tax units with negative adjusted gross income
      are excluded from their respective income class but are included in the totals. For a description of expanded cash income, see http://
      www.taxpolicycenter.org/TaxModel/income.cfm.
    \3\ Includes tax units with a change in federal tax burden of $10 or more in absolute value.
    \4\ After-tax income is expanded cash income less: individual income tax net of refundable credits, corporate income tax, payroll taxes (Social Security
      and Medicare), estate tax, and excise taxes.
    \5\ Average federal tax (includes individual and corporate income tax, payroll taxes for Social Security and Medicare, the estate tax, and excise taxes)
      as a percentage of average expanded cash income.

           Submitted by Hon. Bill Nelson, a U.S. Senator From Florida
    _______________________________________________________________________
                                            Congressional Budget Office
                                                         September 2013

                    A Premium Support System for Medicare:
                        Analysis of Illustrative Options

    Summary

    Over the past two decades, numerous proposals have been advanced for
    the establishment of a premium support system for Medicare. Under such
    a program, beneficiaries would purchase health insurance from one of a
    number of competing plans, and the federal government would pay part of
    the cost of the coverage. The various proposals have differed in many
    respects, including the way in which the federal contribution would be
    set and how that contribution might change over time.

    This Congressional Budget Office (CBO) report presents a preliminary
    analysis of the ways two illustrative options for a premium support
    system would affect federal spending and beneficiaries' choices and
    payments. The agency has developed significant new tools to analyze
    such a system in greater depth than in the past; the specifications of
    the options examined here also differ from those CBO analyzed
    previously. As the agency refines its modeling approach and considers
    alternative options for a premium support system, its findings could
    change. CBO's analysis to date indicates the following:

      Both options for premium support considered here would reduce
    federal spending for Medicare net of beneficiaries' premiums and other
    offsetting receipts.

      Under the second-lowest-bid option, the option with the greater
    reduction in net federal spending, beneficiaries' premiums and total
    payments for Medicare's Part A and Part B benefits would each be higher
    on average than they would be under current law. (Total payments
    consist of premiums and out-of-pocket costs for deductibles,
    copayments, and coinsurance.) Under the average-bid option, the option
    with the smaller reduction in net federal spending, those amounts would
    each be lower on average than they would be under current law.
    ---------------------------------------------------------------------------
        Notes: Unless otherwise indicated, the years referred to in this
    report are calendar years. The estimates for the next 10 years were
    generated using the Congressional Budget Office's March 2012 baseline
    projections of Medicare spending, and the analysis of longer-term
    effects was based on the agency's June 2012 long-term projections of
    Medicare spending. (Those were the most recent projections available
    when much of the analysis was performed.)

        Numbers in the text, figures, and tables may not add up to totals
    because of rounding.

      Under both options, combined spending by the federal government
    and by beneficiaries (that is, premiums and out-of-pocket costs) would
    ---------------------------------------------------------------------------
    be less than that if current law remained in place.

      Under both options, effects on premiums and total payments for
    some beneficiaries would differ greatly from the national averages. In
    particular, in most regions, the premiums and total payments of
    beneficiaries enrolled in the fee-for-service (FFS) program would be
    higher than they would be under current law.

      Alternative specifications for key features of a premium support
    system would yield different results.

    What Premium Support Options Did CBO Analyze?

    The two premium support options analyzed in this report differ in terms
    of the formula by which the federal contribution would be determined.
    Otherwise, they are very similar. The nation would be divided into
    regions within which competing private insurers would submit bids
    indicating the amounts they would accept to provide Medicare benefits
    to a beneficiary of average health. The FFS program would be part of
    the system as a competing plan, and its ``bid'' would be based on the
    projected FFS spending for an enrollee of average health in a given
    region. Insurers would bid to provide a benefit package that would
    encompass the same services covered by Part A (Hospital Insurance) and
    Part B (Medical Insurance) of Medicare under current law and that would
    have the same actuarial value as Parts A and B combined (that is, each
    package would cover the same percentage of total expenses for a given
    population that Medicare's FFS program would cover under current law).
    Beneficiaries who were eligible for the premium support system would
    not be permitted to enroll in Part C (the current Medicare Advantage
    system, offered by private insurers that contract with Medicare to
    provide Part A and Part B benefits). Part D (Medicare's prescription
    drug benefit program), which is now delivered through a competitive
    system, would continue as it is under current law and would be
    administered separately from the new program.

    The federal government would pay insurers for each enrollee who was in
    average health an amount that was equal to a ``benchmark'' set for that
    region minus the standard premium paid by enrollees; insurers would
    receive larger or smaller government payments for beneficiaries whose
    health was worse or better than average. Beneficiaries who enrolled in
    a plan with a bid that equaled the benchmark would pay the plan a
    standard premium, which would equal one-quarter of the estimated cost
    of providing the Part B portion of benefits and would be the same
    across the nation (set by the same formula as that used under current
    law for the Part B premium). Beneficiaries who chose a plan with a bid
    less than the benchmark would pay a premium that was lower by the full
    amount of the difference between the bid and the benchmark, and those
    who chose a more expensive plan would pay a premium that was
    correspondingly higher.

    The benchmarks that would be used to set the federal contribution are
    the defining features of the two options CBO examined:

      Under the second-lowest-bid option, the benchmark in a region
    would be the lower of a pair of bids--the region's second-lowest bid
    submitted by a private insurer and Medicare's FFS bid.

      Under the average-bid option, the benchmark in a region would be
    the weighted average of all bids, including the FFS bid. Each bid would
    be weighted by the proportion of beneficiaries enrolled in that plan in
    the year immediately preceding.

    CBO assumed that no cap would be imposed on the amount or the rate of
    growth of the federal contribution and that insurers would be required
    to provide coverage to all beneficiaries who selected a particular
    plan.

    The agency made detailed assumptions about many other specifications of
    the premium support system. Some were chosen to illustrate the
    potential for savings from a highly competitive system; others were
    chosen for feasibility of implementation or to simplify the analytical
    process. The specifications adopted for this analysis are not
    recommendations, and many alternative specifications are possible.

    For this analysis, CBO assumed that dual-eligible beneficiaries--people
    who are simultaneously enrolled in Medicare and Medicaid--would be
    excluded from the premium support system and that federal spending for
    their health care would continue as it would under current law. Anyone
    else who was enrolled in Medicare when the premium support system was
    implemented (assumed to be 2018 for this report) would enter the system
    immediately, and anyone other than dual-eligible beneficiaries who
    became eligible subsequently would enroll in the new system. (See below
    for a brief discussion of policy alternatives that would exclude
    certain other Medicare beneficiaries from a premium support system.)
    The starting date of 2018 was chosen to allow for a period during which
    the federal government could develop the necessary administrative
    structures and beneficiaries and insurers could learn about and prepare
    for the new system.

     How Would the Premium Support Options Affect Federal Spending?

    CBO estimates that the second-lowest-bid option would reduce net
    federal spending for Medicare by about $45 billion in 2020 and that the
    average-bid option would reduce such spending in that year by about $15
    billion (see Table 1). For this analysis, CBO reports those effects as
    a percentage of two different measures of spending projected under
    current law: net federal spending on Medicare as a whole and net
    federal spending on Medicare's Part A and B benefits for beneficiaries
    who would be affected by the options (that is, everyone other than
    dual-eligible beneficiaries who would have enrolled in Medicare under
    current law).

      Net federal spending for Medicare is total Medicare spending,
    including spending on dual-eligible beneficiaries and prescription
    drugs covered by Part D, minus beneficiaries' premiums and other
    offsetting receipts. The second-lowest-bid option would reduce that
    spending in 2020 by 6 percent and the average-bid option would reduce
    that spending by 2 percent, CBO estimates.

      Net federal spending on Medicare Part A and B benefits for
    affected beneficiaries includes amounts that would be paid for hospital
    and medical benefits provided by the FFS program and private plans
    under current law and the premium support options, but excludes net
    spending for dual-eligible beneficiaries, Part D benefits, and certain
    items and services that are not covered by the bids of Medicare
    Advantage plans under current law. Beneficiaries' premiums and other
    offsetting receipts are subtracted from that amount to arrive at net
    spending. The second-lowest-bid option would reduce such spending in
    2020 by 11 percent and the average-bid option would reduce such
    spending by 4 percent, CBO estimates. Those percentages are larger than
    the percentages for total Medicare spending because the savings are
    measured relative to the portion of Medicare spending that would be for
    the beneficiaries who are directly affected by the premium support
    system rather than to total Medicare spending.

    Federal savings under either option would be substantially lower over
    an extended period if all current beneficiaries stayed in the existing
    Medicare system and only new enrollees participated in the premium
    support system.

    The savings to the federal government would stem, in part, from greater
    price competition. Because all plans would offer a basic benefit
    package covering the same services and having the same actuarial value
    and because the government's contribution within a region would not
    vary from plan to plan (except to adjust for differences in the health
    status of enrollees), the full difference between plans' bids would be
    reflected in the premiums that enrollees would pay. Thus, the two
    options would generate more price competition among private insurers
    than would be the case under current law, which would induce insurers
    to offer plans with lower premiums as a way to attract more enrollees.
    To reduce premiums, private insurers could, for example, strengthen
    utilization management (which insurers use to control costs by
    influencing the quantity and type of services provided) or tighten
    provider networks (that is, limit the number of providers to be covered
    by a plan). In most regions, the benchmark would be lower under the
    second-lowest-bid option than under the average-bid option, so the
    federal contribution for a plan with a given bid would be lower, and
    the premium would be higher under the second-
    lowest-bid option.

    Heightened price competition would probably restrain the growth of
    Medicare spending over the long term by curtailing demand for costly
    new technologies and treatments and by boosting demand for technologies
    that reduced costs--although the magnitude of any such changes is
    highly uncertain. Those effects on the growth of spending would be
    larger under the second-lowest-bid option than under the average-bid
    option, CBO anticipates, because the higher premiums under the second-
    lowest-bid option would cause a larger fraction of beneficiaries to
    choose private plans with lower bids.

    Under current law, the growth of Medicare spending will be restrained
    in other ways during the next two decades, thus limiting the potential
    for the government to realize further savings from a premium support
    system. For example, updates to Medicare's payment rates for most
    providers in the FFS program are generally scheduled to be smaller than
    the increases in the costs of their inputs (such as labor and
    equipment), and the federal government has broad authority under
    current law to make regulatory changes to expand demonstration projects
    that successfully reduce spending for Medicare. How effective the
    various incentives and possible administrative actions under current
    law ultimately will be at restraining growth in spending, however, is
    not known.

    CBO estimates that the rate of growth in Medicare spending in the 2020s
    under the two premium support options would be similar overall to the
    rate under current law. Thus, the estimated savings relative to current
    law would be roughly the same in percentage terms throughout that
    period as in 2020, although the dollar amount of the savings would
    increase. That estimate is subject to considerable uncertainty but, in
    CBO's judgment, lies in the middle of the distribution of possible
    outcomes. Beyond the next two decades, the federal savings from the
    premium support system would probably increase slightly in percentage
    terms, but CBO has not quantified the amounts because the uncertainties
    are even greater for that longer period.

    How Would the Premium Support Options Affect Beneficiaries' Premiums?

    CBO estimates that the premiums that affected beneficiaries would pay
    for Medicare Part A and B benefits under the second-lowest-bid option
    in 2020 would be about 30 percent higher, on average, than the current-
    law Part B premium projected for that year. CBO expects that much of
    the increase would occur because many beneficiaries would remain in the
    FFS program and pay much higher premiums than would be the case under
    current law. Two-fifths of the beneficiaries who chose the FFS program
    would spend at least 6 percent of their household income on premiums
    for each beneficiary, CBO estimates. (For comparison, CBO estimates
    that under current law about one-fifth of FFS enrollees would do so.)

    In contrast, under the average-bid option, affected beneficiaries would
    pay premiums that were 6 percent lower, on average, than the current-
    law Part B premium in 2020. Because of the higher federal contribution,
    premiums would be substantially lower under the average-bid option than
    they would be under the second-
    lowest-bid option. The impact of either option on premiums would vary
    geographically, depending on regional differences in plans' bids.

    Because CBO estimates that total Medicare spending would be reduced
    under either option, and the standard premium would equal the same
    share of spending that the Part B premium equals under current law, the
    standard premium under either premium support option would be lower
    than the current-law Part B premium. In each region, beneficiaries
    would be offered at least one plan at or below the standard premium
    (given the manner in which the regional benchmarks would be
    calculated), and in most cases, at least one plan with a premium that
    is below (not just at) the standard premium would be offered, CBO
    anticipates. Beneficiaries who chose such a low-cost plan would pay a
    lower premium than they would under current law. (Beneficiaries subject
    to the income-related premium under current law--that is, the
    additional Part B premium required of beneficiaries whose income
    exceeds specified thresholds--would still be required to pay that
    additional amount.)

    Under both options, most beneficiaries who wanted to remain in the FFS
    program would face higher premiums than they would for private plans.
    In addition, in many regions, the bid for the FFS program would exceed
    the benchmark, so beneficiaries who chose to remain in the FFS program
    would pay higher premiums than they would under current law. Although
    many beneficiaries would switch to lower-
    bidding private plans, CBO estimates, a substantial proportion of
    beneficiaries would still prefer to remain in the FFS program.

     How Would the Premium Support Options Affect Beneficiaries' Total
                        Payments for Medicare Services?

    CBO's analysis of beneficiaries' total payments focuses on premiums and
    out-of-pocket costs for deductibles, copayments, and coinsurance for
    Medicare's Part A and B benefits for affected beneficiaries. The
    analysis accounts for the loss of the federally subsidized supplemental
    benefits that enrollees in Medicare Advantage plans would receive under
    current law (projected to average about $400 per enrollee annually in
    2020), which would not be available under the options analyzed here. In
    2020, beneficiaries' total payments would be about 11 percent higher,
    on average, under the second-lowest-bid option and about 6 percent
    lower, on average, under the average-bid option than they would be
    under current law (see Table 2).

    Under the second-lowest-bid option, the premiums that beneficiaries
    would pay generally would be higher than current-law premiums, but out-
    of-pocket costs generally would be lower than under current law because
    more beneficiaries would enroll in lower-bidding private plans, which
    would tend to reduce the total costs of care while maintaining the
    required actuarial value. The lower out-of-pocket costs would offset
    part, but not all, of the increase in premiums. (On average, according
    to CBO's estimates, out-of-pocket costs would account for a higher
    share of beneficiaries' total payments than premiums would, but under
    the second-lowest-bid option, they would decline by a smaller
    percentage than premiums would increase relative to amounts under
    current law.)

    Under the average-bid option, the estimated reduction in beneficiaries'
    total payments results from the combination of lower average premiums
    and lower out-of-pocket costs. As with the second-lowest-bid option,
    the difference in out-of-pocket costs would be attributable primarily
    to increased enrollment in lower-bidding private plans.

    Under both options, the change in total payments for particular
    beneficiaries could differ markedly from the national average. For
    example, those who chose to remain in the FFS program would generally
    face higher premiums and would not see a reduction in out-of-pocket
    costs.

     How Would the Premium Support System Affect Combined Spending by the
                        Government and by Beneficiaries?

    The sum of net federal spending for Medicare and beneficiaries' total
    payments as discussed above would be about 5 percent lower in 2020
    under the second-lowest-bid option than under current law, CBO
    estimates. Under the average-bid option, combined payments would be
    about 4 percent lower than under current law. The estimated effects
    under both options are measured as a percentage of projected net
    federal spending and beneficiaries' total payments for benefits covered
    by Parts A and B, in each case focusing on the beneficiaries who would
    be affected by the premium support system. The second-lowest-bid option
    would yield slightly more savings overall than would accrue from the
    average-bid option because the smaller federal contribution under the
    second-lowest-bid option would increase competitive pressure. The
    federal savings under the second-lowest-bid option would be much larger
    than those under the average-bid option, but beneficiaries' payments
    would be higher.

     What Are the Implications of a ``Grandfathering'' Provision in a
                        Premium Support System?

    Under some premium support proposals, all beneficiaries who became
    eligible for Medicare before the system took effect would remain in the
    current-law Medicare program and only those who became eligible after
    that time would enroll in the premium support system. Such an
    arrangement would substantially reduce federal savings relative to a
    system without a grandfathering provision--for an extended period--
    because, in the early years, only a small portion of the Medicare
    population would be covered under the new system. Moreover, because
    newly eligible beneficiaries entering the system would have health care
    costs that were lower than the average for Medicare beneficiaries as a
    group, the potential savings would be limited even more.

    CBO estimates that if a premium support system began in 2018 and
    existing Medicare beneficiaries remained in the current system, only
    about 25 percent of the Medicare population would be covered under the
    new system after five years (assuming dual-eligible beneficiaries were
    excluded), and those beneficiaries would account for only about 15
    percent of net Medicare spending in total for that year under current
    law (including spending for dual-eligible beneficiaries and for Part
    D). After 10 years, about 45 percent of the Medicare population would
    be covered, accounting for about 30 percent of net Medicare spending in
    total.

    Although in order to simplify the modeling, CBO decided for this
    analysis not to consider grandfathering provisions, the agency expects
    to complete such a study soon. A very rough approximation (made on the
    basis of the estimated share of Medicare spending that would be covered
    each year) suggests that federal savings after five years of operation
    under a system with grandfathering would be about 15 percent of the
    savings achieved if all beneficiaries other than those with dual
    eligibility entered the new system in 2018; after a decade, about 30
    percent of those savings would be realized.

    Thus, the cumulative savings would be substantially less than would be
    possible if all beneficiaries entered a premium support system
    immediately. Grandfathering also would reduce, for an extended period,
    the incentives to modify the development and adoption of new
    technologies, so the restraint in the growth of Medicare spending that
    would probably occur under a premium support system would be
    substantially smaller for many years.

     What Key Specifications of a Premium Support System Would Affect
                        Federal Spending and Beneficiaries' Payments?

    On the basis of its preliminary analysis, CBO identified several
    important features of premium support proposals that would
    significantly affect federal spending and beneficiaries' payments:

      A smaller federal contribution would yield greater federal
    budgetary savings; on average, beneficiaries' premiums would be higher,
    however.

      Including the FFS program as a competing plan would boost
    federal savings, both because the rates the program pays providers
    (which generally are below rates paid by commercial plans) would serve
    to hold down the rates paid by competing private insurers and because
    in some regions the FFS program would be the
    lowest-bidding plan and therefore could lower the benchmark relative to
    what it would be otherwise.

      Excluding some groups of beneficiaries from the premium support
    system--say, people born before a particular year or dual-eligible
    beneficiaries--would reduce federal savings; however, including certain
    groups could pose additional challenges for administering the system
    and could have unintended consequences for members of those groups.
    (Dual-eligible beneficiaries, for example, might face limited provider
    networks and complex issues of care coordination.)

      Features that make beneficiaries more responsive to differences
    in premiums would boost enrollment in plans with lower bids and thus
    increase the incentive for plans to submit lower bids.

    Many other aspects of a premium support system also would significantly
    affect federal spending and enrollees' payments. CBO will continue to
    develop its capacity to estimate the effects of varying those features.

     Two Illustrative Options for a Premium Support System for Medicare

    In designing a premium support system for Medicare, lawmakers would
    confront many choices affecting federal costs, beneficiaries' payments,
    and, perhaps, beneficiaries' access to care and the quality and nature
    of the care that they would receive--both in the short term and over
    the longer term. To project the potential effects of such a system, CBO
    developed detailed illustrative specifications regarding eligibility
    for the program and the timing of its implementation, the structure of
    the market for Medicare benefits, and the determination of federal
    contributions and beneficiaries' payments.

    CBO analyzed two illustrative options, both of which would require
    insurers to submit bids specifying the payment they would accept to
    provide a basic package of Medicare benefits for an enrollee of average
    health. Under each option, the federal contribution toward
    beneficiaries' health care costs would be determined on the basis of a
    benchmark set for each region of the country. The two options differ in
    that under the first, determination of the benchmark would involve the
    second-
    lowest bid in each region; under the second, the benchmark would be set
    on the basis of a weighted average of bids in the region. For this
    analysis, CBO adopted a variant of the second-lowest-bid approach that
    is similar to those included in several recent proposals.\1\ Under such
    an approach, the benchmark would equal the lower of two bids: the
    second-lowest bid from a private insurer and Medicare's FFS bid. Thus,
    in any region, the benchmark could be no higher than the bid of the FFS
    program. (For a summary of the program's operations under the second-
    lowest-bid option, see Figure 1. The operations under the average-bid
    option would be the same except for the determination of the
    benchmark.)
    ---------------------------------------------------------------------------
        \1\ See House Committee on the Budget, The Path to Prosperity: A
    Responsible Balanced Budget: Fiscal Year 2014 Budget Resolution (March
    2013), http://go.usa.gov/bAAV (PDF, 7 MB); Pete Domenici and Alice
    Rivlin, Domenici-Rivlin Protect Medicare Act (Bipartisan Policy Center,
    June 2012), http://tinyurl.com/nherwb4; and Ron Wyden and Paul Ryan,
    Guaranteed Choices to Strengthen Medicare and Health Security for All:
    Bipartisan Options for the Future (House Committee on the Budget,
    December 15, 2011), http://go.usa.gov/bAsz.

    Medicare would continue to be divided into Parts A, B, and D under both
    options, and financing for federal outlays would come mostly from the
    ---------------------------------------------------------------------------
    same sources as under current law (see Box 1).

    The specifications outlined in this report are not recommendations.
    Some were chosen to illustrate the potential for savings from a premium
    support framework; others were chosen for feasibility of implementation
    or to simplify the modeling approach. Many other variants of these
    options are possible. (For additional discussion, see the section
    ``Implications of Key Specifications and Alternatives.'')

    Eligibility and Timing

    CBO assumed that dual-eligible beneficiaries would be excluded from the
    premium support system and that gross federal spending for their health
    care would continue as it would if current law remained in place. (In
    2009, those beneficiaries made up 19 percent of the Medicare population
    and accounted for 29 percent of total spending for Medicare's Part A
    and Part B benefits.) \2\ CBO made that assumption because of the
    additional complexity of specifying how the system would work if such
    beneficiaries were included, although alternative systems could be
    designed to include them. CBO did not make any explicit assumptions
    about the system of care that would be in place for dual-eligible
    beneficiaries, and it assumed that their exclusion from the premium
    support system would not affect the number of Medicare beneficiaries
    who enrolled simultaneously in Medicaid.
    ---------------------------------------------------------------------------
        \2\ See Congressional Budget Office, Dual-Eligible Beneficiaries of
    Medicare and Medicaid: Characteristics, Health Care Spending, and
    Evolving Policies (June 2013), www.cbo.gov/publication/44308.

    Everyone else who was enrolled in Medicare when the premium support
    program took effect in 2018 would enter the new system at once, and
    people who reached eligibility after 2018 (other than dual-eligible
    beneficiaries) would enter the new system when they became eligible.
    The Medicare Advantage program would not be available as an option
    after 2017 for beneficiaries in the premium support system.

    The Structure of the Market for Medicare Benefits

    CBO made several assumptions about the structure of the market for
    Medicare coverage, including the required scope of benefits, the
    bidding process, and the process by which beneficiaries would choose a
    plan.

    Scope of Benefits. Under each premium support option, insurers would
    offer a basic package of benefits with services and an actuarial value
    that matched those provided by Medicare's FFS program under Parts A and
    B. CBO assumed that hospice services and certain services provided to
    beneficiaries with end-stage renal disease would not be included in the
    basic benefit package and that spending for those services would
    continue as it would under current law. Those services were excluded so
    that the plans' benefits would be identical to those that are included
    in the bids of Medicare Advantage plans under current law. That
    assumption simplified CBO's modeling.

    Insurers would be permitted to offer an additional package with
    enhanced benefits, however, and would submit separate bids for
    providing prescription drug benefits through Medicare's Part D, as
    under current law. Enrollment in Part D would remain voluntary.

    Bids. To simplify the choices for beneficiaries (and thereby heighten
    competition based on differences in premiums), private insurers would
    be allowed to submit bids for just one or two plans for the basic
    Medicare package in each region. (The two plans could have different
    features--offering a larger or smaller provider network, for example--
    but both would need to have the same actuarial value.) Insurers would
    submit bids reflecting their costs for a combined package of Part A and
    Part B benefits (as insurers do for Medicare Advantage) and not
    separate bids for Parts A and B. Bids would be the amount that insurers
    would charge to provide care for a beneficiary of average health.
    Insurers also could offer one package of enhanced benefits (with a
    single, fixed higher actuarial value that would be the same for all
    insurers) to go along with each basic package offered. Enrollees would
    pay the full additional cost of the enhanced packages through higher
    premiums. Under such rules regarding packages with enhanced benefits,
    beneficiaries would find it easier to compare plans, and thus
    competition would be heightened.

    Bidding Regions. Regional boundaries would be determined by the
    government and designed to coincide with health care markets within
    states. Regions would be the same for all prospective bidders, and
    insurers would be required to serve the entire regions for which they
    submitted bids.

    Fee-for-Service Medicare. Medicare's FFS program would act as a
    competing plan. Its bid in each region would be based on the amount it
    would cost the program in that region to provide care for a beneficiary
    with average health as projected by the Medicare program. Support for
    disproportionate-share hospitals (whose share of low-income patients
    exceeds a specified threshold) and spending for medical education,
    hospice benefits, and certain benefits for patients with end-stage
    renal disease would be excluded from that projection. CBO assumed that
    such spending would continue outside the premium support system at the
    amounts projected under current law. The government's administrative
    costs for the FFS program, however, would be included in the bid. The
    FFS program would be required to maintain a contingency reserve fund
    equal to a specified percentage of projected expenses, and if the
    program's actual expenses differed from its projected expenses, future
    bids would be adjusted to maintain adequate reserves. CBO assumed that
    there would be no changes to current law concerning either the
    mechanisms for setting the rates paid to providers or the tools
    available to the FFS program to help it contain costs. As under current
    law, enrollees in the program could purchase supplemental (medigap)
    coverage from private insurers. CBO assumed that the same standard
    medigap plans that are currently available would be available under the
    two premium support options.

    Coverage for Retirees. CBO assumed that employers and unions that
    provide coverage for retirees who are Medicare beneficiaries would make
    cash payments to their retirees to be applied toward the purchase of a
    basic package offered in the bidding region, an enhanced-benefit
    package (on top of a basic package) from any of the private plans in
    that region, or supplemental coverage for the FFS program. In that way,
    the choices of beneficiaries with retiree coverage would be the same as
    those of other beneficiaries, and they would have no additional
    incentives to select a particular plan (as typically occurs now when
    employers pay part of the premium if retirees enroll in a plan offered
    by the employer). CBO assumed that the premium support system would be
    implemented so as to not affect the percentage of beneficiaries with
    retiree coverage. Those assumptions simplified CBO's modeling.

    Requirement Regarding Issuance. Insurers would be required to issue
    insurance to all Medicare beneficiaries who applied and to charge the
    same premium for all enrollees in a particular plan within a bidding
    region.

    Plan Selection. Beneficiaries would receive information about premiums,
    cost sharing, and other plan attributes to help them compare plans.
    Enrollees would choose a plan during an annual enrollment period and
    would be required to remain in that plan for a year. Once beneficiaries
    chose a plan, they would automatically remain in that plan in
    subsequent years unless they chose a different one.

    Initial Choice. Beneficiaries would not automatically remain in their
    current plan when the premium support system began in 2018. In 2018 and
    later years, beneficiaries who entered the premium support system and
    did not make an affirmative choice for enrollment would be assigned
    (with equal probability) to plans that presented bids at or below the
    benchmark, including the FFS program if it met that criterion. (If more
    than four plans in a region did so, beneficiaries would be assigned to
    one of the four lowest-bidding plans.) After their first year in the
    system, beneficiaries who were initially assigned to a plan would
    remain in that plan unless they chose a different plan during a future
    enrollment period or the plan to which they were assigned was no longer
    one of the lowest-bidding plans in their region (in that case, the
    beneficiaries would be assigned to one of the new low-bidding plans in
    their region). Beneficiaries who had been assigned to a plan and then
    subsequently chose another plan, as well as beneficiaries who
    affirmatively chose a plan when they entered the premium support
    system, would remain in that plan in subsequent years unless they chose
    a different one.

    Enrollment in Part A and Part B. For this analysis, CBO assumed that
    enrollment in Part B would remain voluntary and that beneficiaries with
    coverage under Part A or Part B (or both) could enroll in any plan
    within a bidding region. Federal payments to plans for enrollees with
    Part A coverage only would be reduced proportionately on the basis of
    the share of total Medicare spending nationally for Part A services,
    and federal payments to plans for people covered under Part B only
    would be reduced in a similar manner.\3\
    ---------------------------------------------------------------------------
        \3\ That approach to enrollment of beneficiaries who are not
    enrolled in both Parts A and B of Medicare was adopted to simplify the
    modeling for this analysis. In fact, including such beneficiaries in a
    premium support system would raise complex issues that are not
    addressed in this report.
    ---------------------------------------------------------------------------

    Federal Contributions and Beneficiaries' Payments

    CBO also made assumptions about the determination of the amounts the
    federal government would pay insurers for providing Medicare coverage
    and the amounts beneficiaries would pay for that coverage under the
    illustrative premium support options.

    Federal Contributions and Risk Adjustment. The benchmarks for setting
    the federal contribution would be based on the bids for the basic
    package of benefits. A benchmark would be calculated in each bidding
    region for a beneficiary of average expected health. For each enrollee
    of average health, the federal government would pay insurers an amount
    that was equal to the regional benchmark minus the standard premium. To
    compensate for a higher or lower cost implied by an individual
    beneficiary's ``risk score,'' insurers would receive a larger or
    smaller payment for a beneficiary whose health was worse or better than
    average--as is the case under current law for Medicare Advantage and
    Part D.\4\ Neither the amount nor the rate of growth in federal
    payments would be capped.
    ---------------------------------------------------------------------------
        \4\ CBO assumed that a risk adjustment mechanism comparable to that
    used for the Medicare Advantage program would be used for a premium
    support system. That mechanism assigns each beneficiary a risk score,
    based on the person's medical conditions and demographic
    characteristics, that represents the expected spending in the FFS
    program relative to the national average for the Medicare population. A
    beneficiary with a risk score of 1.0 has average expected spending. To
    simplify the discussion, this report refers to beneficiaries with risk
    scores that are less than or greater than 1 as being in better or worse
    than average health--although personal characteristics other than
    health also influence spending for Medicare services.

    Beneficiaries' Payments. Medicare beneficiaries who joined plans with
    bids that equaled the regional benchmark and were enrolled in Parts A
    and B would pay the insurer a standard premium, which would be set at
    25 percent of total costs for covered services in Part B (physicians'
    services, hospital outpatient care, durable medical equipment, and
    other services, including some home health care)--using the same
    formula as that for the standard Part B premium under current law. The
    premium for beneficiaries with Part A coverage only would be
    proportionately smaller than the standard premium based on the share of
    total Medicare spending nationally for Part A services (about half); a
    similar calculation would be used to set the premium for enrollees in
    ---------------------------------------------------------------------------
    Part B only.

    Beneficiaries who joined plans with bids that were higher than the
    benchmark would pay the insurers the standard premium plus the
    difference between the bid and the benchmark. Those who selected plans
    below the benchmark would pay the insurers the standard premium minus
    the difference between the benchmark and the bid. In contrast to the
    rules for the current Medicare Advantage program, insurers with bids
    below the benchmark could not use such differences to enhance benefits
    or reduce premiums for Part D prescription drug insurance and the
    result would be heightened competition based on differences in premiums
    for the basic benefit package.

    For the most part, premiums would be paid directly to insurers, as is
    generally the case for Part D, rather than withheld from Social
    Security benefits, as is generally the case under current law for Parts
    A and B. Income-related premiums for Part B specified in current law
    would continue and would be withheld from Social Security benefits.

    Hypothetical Examples of Determining Premiums

    Several examples show how premiums would be determined under the
    illustrative premium support options considered here. The hypothetical
    bids for regions with high and low levels of FFS spending per
    beneficiary are roughly consistent with the bids CBO has projected for
    such regions under the two options. In regions where FFS spending is
    high, premiums under the second-lowest-bid option would generally be
    higher than those under the average-bid option because the benchmark
    would be set at a low bid rather than at the average bid, and low bids
    would be much lower than the average bid. In regions where FFS spending
    is low, the low bids and the average bid would be closer and premiums
    under the two options would be more similar.

    The Second-Lowest-Bid Option. Consider a region with high FFS spending
    in which the FFS program's bid in 2020 was $14,000 and the bids from
    the region's five private plans were in the range of $11,000 to $11,800
    (see Table 3). Under the second-lowest-bid option, the regional
    benchmark would be $11,200, equal to the bid of the second-lowest-
    bidding private plan. The annual premium for enrollees in that plan
    would be $1,500, the standard premium nationwide. Premiums for the
    other plans would differ from that amount depending on how the bids
    compared with the benchmark. Because the FFS bid would be $2,800 more
    than the benchmark, the premium for FFS enrollees would be $4,300
    ($1,500 plus $2,800). The annual premium for the lowest-bidding private
    plan would be $1,300.

    Next, consider a low-spending region in which the FFS program's bid was
    $9,900 and the bids of the five private plans ranged from $9,300 to
    $10,100. The regional benchmark would equal that of the second-lowest-
    bidding private plan ($9,500), and enrollees in that plan would pay the
    standard premium of $1,500. Because the bid of the FFS program would be
    $400 more than the benchmark, FFS enrollees would pay an annual premium
    of $1,900.

    The Average-Bid Option. Consider again the high-spending region in
    which the FFS bid was $14,000. The private plans' bids would be
    slightly higher in this region--ranging from $11,200 to $12,000--
    because the share of income that beneficiaries would spend on premiums
    would be lower, on average, thus reducing the sensitivity of
    beneficiaries' choice to differences in premiums and reducing
    competition among plans to lower bids. As a simple example, assume
    that, in the previous year, 25 percent of the people in the region
    enrolled in the FFS program and 75 percent enrolled in private plans,
    with an equal number enrolled in each private plan. Then the benchmark
    (the enrollment-weighted average bid) would be $12,200. Under this
    option, the standard premium would be $1,500 nationwide. Because the
    FFS program's bid would be $1,800 more than the benchmark, the FFS
    premium would be $3,300. The annual premium for the lowest-bidding
    private plan would be $500 because that plan's bid would be $1,000 less
    than the benchmark.

    Finally, consider the low-spending region in which the FFS program's
    bid would be $9,900. The bids of private plans would be about the same
    as that for the second-lowest-bid option in this region, ranging from
    $9,500 to $10,300. Assume that, because FFS spending is low, in the
    previous year 75 percent of the region's beneficiaries enrolled in the
    FFS program and 25 percent enrolled in private plans, with an equal
    number enrolled in each private plan. The benchmark would be the
    enrollment-weighted average bid of $9,900. Because the FFS bid would be
    the same as the benchmark, the FFS premium would be the standard
    premium of $1,500. The annual premium for the lowest-bidding private
    plan would be $1,100.

    Comparison With the Current Medicare Program

    Although some aspects of a premium support system would make it similar
    to the current Medicare program, there also would be significant
    differences. Under both illustrative options analyzed here, insurers
    would be required to provide a benefit package that encompassed the
    same services that were covered under Parts A and B of Medicare (with
    the few exceptions noted above) and that had the same actuarial value
    as Parts A and B combined. However, under both options, the federal
    contribution per beneficiary in each bidding region would be determined
    prospectively each year on the basis of the bids submitted by
    participating insurers. In contrast, except for Part D, federal
    spending for Medicare under current law is either on a fee-for-service
    basis or, in the case of Medicare Advantage enrollees, is tied to
    spending in the FFS program.

    Under current law, the premium paid by enrollees in the FFS program is
    the same regardless of where a beneficiary lives. That premium has two
    components, both for enrollment in Part B: the standard amount
    (referred to in this report as the Part B premium), and the income-
    related amount. Under either illustrative option, by contrast, the FFS
    program would be one of the bidders, and its premium would vary by
    region depending on how its bid compared with the benchmark.

    Although the current Medicare Advantage program is similar in some ways
    to a premium support system, several features limit the extent of price
    competition among private insurers, and the FFS program is not a bidder
    in Medicare Advantage. For example, benchmarks for Medicare Advantage
    (which determine the maximum federal payment for an enrollee) are set
    by law as a specified percentage of the average FFS spending in a given
    county and are announced before insurers submit bids (see Box 1).\5\ In
    contrast, benchmarks for the premium support options would be
    determined from plans' bids. Another difference concerns the incentives
    offered to beneficiaries to enroll in plans with lower bids. Under
    Medicare Advantage, beneficiaries who enroll in a plan with a bid below
    the benchmark receive some of the difference between the two, generally
    in the form of additional benefits. Under the two premium support
    options, by contrast, beneficiaries who enrolled in a plan with a bid
    below the benchmark would receive the entire difference between the two
    in the form of a lower premium.
    ---------------------------------------------------------------------------
        \5\ This description reflects the method of determining Medicare
    Advantage benchmarks that will be fully phased in by 2017. The
    benchmark for each county will be set at a specified share (ranging
    from 95 percent to 115 percent) of local FFS costs.
    ---------------------------------------------------------------------------

    Effects on Federal Spending

    Projecting the effects of a premium support system in the first several
    years after implementation is difficult, given the substantial changes
    to the Medicare program that such a system would entail, the lack of
    historical experience with similar systems, the rapid evolution of
    health care and health insurance, and the significant changes in the
    Medicare program occurring under current law. (For additional details
    about the methods used in the analysis, see Appendix A.) Projections
    are even more uncertain for the period following the first several
    years of implementation. One reason is that growth in Medicare
    spending--and for health care more generally--has slowed markedly over
    the past several years, although it is not clear how much of the
    slowdown is attributable to persistent changes in the health care
    system.\6\ Moreover, spending for Medicare is projected to be
    restrained by provisions of the Affordable Care Act that will change
    the ways and amounts that health care providers and insurers are
    paid.\7\ The implications of those changes for long-term growth in
    Medicare spending are difficult to assess, thus adding to the
    uncertainty concerning the difference in spending that might occur as a
    result of policy changes--including the adoption of a premium support
    system.
    ---------------------------------------------------------------------------
        \6\ See Michael Levine and Melinda Buntin, Why Has Growth in
    Spending for Fee-for-Service Medicare Slowed? Working Paper 2013-06
    (Congressional Budget Office, August 2013), www.cbo.gov/publication/
    44513.
        \7\ The Affordable Care Act comprises the Patient Protection and
    Affordable Care Act and the health care provisions of the Health Care
    and Education Reconciliation Act of 2010.
    ---------------------------------------------------------------------------

    Effects in the First Several Years

    CBO assumed that the premium support system would be implemented in
    2018. This analysis reflects the assumption that dual-eligible
    beneficiaries would be excluded from the premium support system and
    that federal spending for their health care would continue as projected
    under current law. Everyone else enrolled in Medicare in 2018 would
    enter the new system in that year, and people who became eligible for
    Medicare subsequently (other than dual-eligible beneficiaries) would
    enter the new system. For this analysis, CBO chose 2020 as an
    illustrative year shortly after implementation for which to report
    results about federal spending. Additional information--both about the
    bids of private plans and about the uncertainty in the estimates--
    provides context for understanding those results.

    In 2020, the second-lowest-bid option would reduce net federal spending
    for Medicare by about $45 billion, or 6 percent, from the approximately
    $700 billion projected under current law, CBO estimates (see Figure 2).
    The average-bid option would reduce net spending in that year by about
    $15 billion, or 2 percent, the agency estimates.\8\ Those percentage
    savings were estimated relative to net federal spending on all services
    covered by Parts A, B, and D, including spending on benefits for dual-
    eligible beneficiaries. (The estimated savings in percentage terms were
    generated using CBO's March 2012 baseline projections of Medicare
    spending--because the agency's work on the estimates in this report
    began in earnest in early 2012--and the estimated savings in dollar
    terms were obtained by applying the percentages to the agency's latest
    baseline projections of Medicare spending, which were released in May
    2013.) \9\
    ---------------------------------------------------------------------------
        \8\ This analysis presents estimated changes in net federal
    spending because the allocation of financial flows to the budget
    categories of gross outlays and offsetting receipts would differ from
    those under current law in complicated ways. The two options would
    eliminate withholding of basic premiums from Social Security benefits;
    instead, beneficiaries would pay the basic premium directly to a plan.
    The reduction in gross spending attributable to that change in the way
    premiums were collected would be accompanied by a corresponding
    reduction in the government's collections of offsetting receipts.
    However, the proposals also would establish a new source of offsetting
    receipts consisting of the premiums paid by beneficiaries who enrolled
    in the FFS program--that is, the basic premiums plus the amount by
    which the FFS program's bid exceeded the benchmark (or minus the amount
    by which the benchmark exceeded the FFS program's bid).
        \9\ See Congressional Budget Office, ``Medicare--March 2012
    Baseline'' (March 13, 2012), www.cbo.gov/publication/43060, and
    ``Medicare--May 2013 Baseline'' (May 14, 2013), www.cbo.gov/
    publication/44205.

    The second-lowest-bid option would reduce net federal spending on Parts
    A and B of Medicare in 2020 by about 11 percent for beneficiaries who
    would be affected and the average-bid option would reduce such spending
    by about 4 percent, CBO estimates. Those savings are larger than the
    savings for net federal spending on all of Medicare because the amount
    of spending to which the savings are compared is restricted here to
    include only the beneficiaries and the portions of Medicare that would
    be covered by the new system. (The ratios of the two estimates for each
    premium support option are nearly identical, and the difference
    reported here is attributable primarily to rounding.) \10\
    ---------------------------------------------------------------------------
        \10\ The ratios also differ because of small effects on net
    spending for dual-eligible beneficiaries. Although CBO assumed that
    gross federal spending for dual-eligible beneficiaries would not
    change, net spending would increase by a small amount relative to that
    under current law because premiums for dual-eligible beneficiaries
    would decrease. Those premiums would be linked to total Part B spending
    in Medicare, which would decline under the premium support options.

    For either option, during the first several years of a premium support
    system, Medicare savings would be similar in percentage terms to the
    savings estimated for 2020, with one main exception. Under the average-
    bid option, the federal savings estimated for 2018 would be much
    smaller than the amount estimated for 2020 in percentage terms because
    the FFS bid would receive a greater weight in constructing benchmarks
    in the first year of the new system than it would in later years. (CBO
    assumed that the weight would equal the proportion of enrollment in the
    FFS program under current law in 2017.) Thus, under the average-bid
    option, most regions would have higher benchmarks in 2018 than they
    ---------------------------------------------------------------------------
    would later.

    Federal savings would be greater under the second-lowest-bid option
    than under the average-bid option because the benchmarks that determine
    the federal contribution would be lower. Under either option, CBO
    projects, the benchmarks in most regions would be lower than the FFS
    program's bid.

    Although federal costs would decrease if more people declined Medicare
    coverage under either option than did so under current law, CBO
    projects that few people would do so. Beneficiaries would have plans
    available that cost less than, or about the same as, Medicare under
    current law. Also, beneficiaries who did not actively choose a plan
    would be assigned to one, and CBO expects that few would choose to drop
    out of the Medicare program rather than remain in an assigned plan for
    the required one-year period.

    Effects on Private Plans' Bids. The options' effects on federal
    spending would be determined in part by how they influenced the bids of
    private plans. Various factors, such as competition and the reduced
    importance of the administratively determined payment rates of the FFS
    program, would affect the bids that determined the benchmarks. CBO used
    its projection of the bids that Medicare Advantage plans would submit
    under current law as a starting point in estimating the bids of private
    insurers under premium support. On net, CBO's analysis indicates that
    private insurers' bids in 2020 under the two options would be below the
    current-law bids for Medicare Advantage by about 4 percent, on average,
    and that the differences between those types of bids would vary
    regionally. That outcome would be the net result of different types of
    downward and upward pressures on bids.

    On the one hand, CBO expects, both options would create more
    competitive pressure than the Medicare Advantage program, encouraging
    insurers to reduce their costs (primarily by constraining the volume
    and intensity of health care services provided and to a lesser extent
    by reducing administrative costs and profits) and thus to be able to
    lower their bids. The greater competition relative to the current
    Medicare program would arise because insurers with lower bids would
    expect to achieve larger increases in enrollment, because more Medicare
    beneficiaries would choose plans affirmatively and those beneficiaries
    would face larger differences in premiums among different plans. The
    specification adopted for this report that insurers could submit no
    more than two bids for the basic benefit package per bidding region
    also would increase competitive pressure to submit lower bids, in CBO's
    view. (Under the Medicare Advantage program, insurers often submit more
    than two bids in their service areas.) Given the competitive structure
    of the two premium support options, CBO expects that restricting
    insurers to a maximum of two bids would cause insurers to eliminate
    some of the higher-bidding plans that would exist under the current-law
    Medicare Advantage program. Another smaller but notable force also
    would tend to lower private plans' bids: The enrollees in private plans
    would be healthier (on average, after accounting for characteristics
    included in the risk adjustment mechanism) than enrollees in the FFS
    program, and such ``favorable selection'' would occur to a greater
    extent in a premium support system than under current law, CBO expects.
    That relatively greater favorable selection would occur because private
    plans would face greater pressure under premium support to contain
    costs (for example, by narrowing provider networks), and as a result,
    they would be less attractive to beneficiaries who use more health care
    services than do other beneficiaries with the same risk score.

    On the other hand, reductions in the share of Medicare beneficiaries
    enrolled in the FFS program would cause private insurers participating
    in a premium support system to pay higher rates to health care
    providers. Two main mechanisms would be at work. First, although the
    rates private insurers pay now under the Medicare Advantage program are
    similar to those for Medicare's FFS program, CBO expects that a lower
    FFS market share would reduce the importance of the FFS program's rates
    in determining how much private insurers would pay providers for
    treating Medicare enrollees. Second, to accommodate an influx of
    enrollees, some private plans might need to expand their networks to
    include health care providers who would be more costly, on average.
    (CBO assumed in this preliminary analysis that all plans would be
    required to serve all beneficiaries who wished to enroll.) The
    resulting payment rates negotiated between insurers and health care
    providers would probably rise toward commercial rates for people under
    age 65 (which, adjusted for differences in average health status by
    age, are generally higher than Medicare's rates), especially where the
    market share of the FFS program declined substantially. However, even
    in areas where the FFS market share would be very low, CBO expects, the
    rates private insurers paid providers for their premium support
    enrollees would be somewhat lower than the rates they would pay for
    commercial enrollees under current law for several reasons: The FFS
    provider payment rates would serve as a reference point for
    negotiations, the competitive structure of a premium support system
    would tend to constrain rates, and the commercial rates existing
    alongside a premium support system would be lower because the extent to
    which relatively low Medicare FFS rates led providers to charge more to
    treat privately insured enrollees would abate as the FFS market share
    declined.

    Although CBO projects that bids would be similar under the two premium
    support options, the agency expects that they would be just slightly
    lower under the second-lowest-bid option than under the average-bid
    option because private insurers would have a stronger incentive to bid
    low under the former. However, factors that would tend to increase
    private plans' bids--the reduced importance of the provider payment
    rates in the FFS program and the broadening of provider networks--also
    would be stronger under the second-lowest-bid option than under the
    average-bid option and would partially offset the stronger incentive to
    bid low.

    Uncertainty in the Estimates. CBO's estimates of the effects on
    Medicare spending of the two illustrative premium support options
    depend on numerous parameters and other factors used in predicting the
    responses of insurers, health care providers, and beneficiaries--all of
    which are subject to considerable uncertainty. To characterize that
    uncertainty, the agency specified ranges of values for five key
    parameters in its analysis and determined the effects of varying those
    parameters, focusing on estimates for 2020.\11\ The ranges for the
    parameters' values were chosen to represent CBO's judgment that,
    accounting not only for uncertainty about those parameters but for many
    other sources of uncertainty, there would be about a two-thirds chance
    that the effect on federal spending would be within the range reported
    (under an assumption that the premium support system was implemented as
    specified here).
    ---------------------------------------------------------------------------
        \11\ CBO varied the following parameters to construct the ranges:
    bids of Medicare Advantage plans relative to FFS spending as projected
    under current law, the amount by which private insurers would reduce
    their bids relative to Medicare Advantage bids under current law in
    response to the increased competitive pressure created by the premium
    support system, the higher rates that private insurers would need to
    pay providers (with corresponding increases in bids) that CBO projects
    would result if the market share of the FFS program fell significantly,
    the responsiveness of beneficiaries to differences in premiums when
    choosing among plans, and the percentage of beneficiaries who would not
    actively choose a plan in the first year of premium support and that
    therefore would be assigned to a plan with a bid at or below the
    benchmark.

    The results indicate that for the second-lowest-bid option, net federal
    spending in 2020 on Parts A and B for beneficiaries who would be
    covered under the premium support system analyzed would probably be
    reduced by between 9 percent and 14 percent (CBO's central estimate is
    11 percent), and for the average-bid option, federal spending would
    probably be reduced by some amount between 1 percent and 7 percent (the
    central estimate is 4 percent). (See Table 2.) \12\ The range is
    smaller for the second-lowest-bid option mainly because a higher or
    lower proportion of beneficiaries enrolled in lower-bidding plans under
    that option would not directly affect the benchmarks that determined
    the federal contribution. By contrast, spending under the average-bid
    option would be directly sensitive to the fraction enrolled in lower-
    bidding plans, and the range of estimates incorporates the greater
    uncertainty from that additional factor. (For additional discussion of
    factors affecting the ranges, see Appendix B.)
    ---------------------------------------------------------------------------
        \12\ For the second-lowest-bid option, the reported range is not
    symmetric about the central estimate because of rounding.
    ---------------------------------------------------------------------------

    Effects After the First Several Years

    After the initial years of a premium support system, the percentage
    savings from either illustrative option would remain roughly constant
    for about a decade, CBO estimates. At that point, heightened price
    competition would probably reduce the growth of Medicare spending over
    the long term relative to that under current law, and that effect would
    probably be larger under the second-lowest-bid option than under the
    average-bid option. However, the longer-term effects are even more
    uncertain than are the short-term effects of a premium support system
    on Medicare spending. And if other health care or health insurance
    policies changed as well, the effects of such a system on spending
    could differ significantly from those presented here.

    Effects of the Two Illustrative Options. During the decade following
    the first several years of implementation, CBO expects that the growth
    in bids of private plans under either option would be close to the
    growth in per capita costs in the FFS program under current law,
    contributing to the roughly constant percentage savings over that
    period. Over the longer term, CBO expects that the growth in Medicare
    spending under the options would probably be somewhat less than the
    growth of Medicare spending under current law.

    The increased competition created by either option would tend to
    restrain growth in Medicare spending by reducing demand for costly new
    technologies and treatments and by increasing demand for cost-reducing
    technologies. A crucial factor underlying the rise in spending for
    health care in recent decades has been the emergence, adoption, and
    widespread diffusion of new medical technologies and services.\13\
    Although such advances can sometimes reduce costs, in medicine they and
    the accompanying changes in clinical practice have generally had the
    opposite effect. By strengthening price-based competition in Medicare,
    a premium support system could change that dynamic within the program
    and perhaps in the broader health care system. Moreover, relative to
    outcomes under current law, the potential for cost savings from
    managing utilization and limiting provider networks would be greater
    under a premium support system with a larger share of Medicare
    beneficiaries enrolled in private plans that have the flexibility to
    manage care. The magnitude of that effect is highly uncertain, however,
    and it would take a number of years before it became fully apparent.
    CBO anticipates that the effect on spending would be larger under the
    second-lowest-bid option--because of greater competitive pressure--than
    under the average-bid option.
    ---------------------------------------------------------------------------
        \13\ See Congressional Budget Office, Technological Change and the
    Growth of Health Care Spending (January 2008), www.cbo.gov/publication/
    41665.

    However, the provisions of current law that will restrain growth in
    Medicare spending limit the potential for additional savings to result
    from a premium support system. In particular, CBO anticipates, private
    insurers would not be able to hold down payments to health care
    providers to the extent required in the FFS program under the
    sustainable growth rate mechanism for physicians or under the
    provisions of the Affordable Care Act that apply to other providers
    (the consequences of those provisions are discussed below). More
    generally, current law offers incentives to providers and beneficiaries
    to help reduce growth in federal spending, and it allows some
    flexibility for the Centers for Medicare and Medicaid Services in
    managing the program. Beneficiaries' demand for Medicare services will
    be constrained as the program's premiums and cost sharing consume a
    larger portion of their income. For providers, whose updates to
    Medicare's payment rates are generally scheduled to be smaller than the
    increases in the costs of inputs, the pressure to adopt cost-reducing
    procedures and technologies will be significant. Other changes in the
    structure of Medicare payments to providers--such as financial
    incentives to reduce hospital-
    acquired infections and readmissions--also might help to constrain
    federal spending.\14\ The Centers for Medicare and Medicaid Innovation,
    like many state Medicaid agencies and private insurance companies and
    providers, is hoping to achieve cost savings by testing promising ideas
    for modifying rules and payment methods and by expanding the use of
    ideas that prove effective.\15\ Whether any of the several
    demonstrations currently in process will succeed and be applied more
    widely is still uncertain.
    ---------------------------------------------------------------------------
        \14\ For example, see Sarah L. Krein and others, ``Preventing
    Hospital-Acquired Infections: A National Survey of Practices Reported
    by U.S. Hospitals in 2005 and 2009,'' Journal of General Internal
    Medicine, vol. 27, no. 7 (July 2012), pp. 773-779, http://go.usa.gov/
    DbQC; and Centers for Medicare and Medicaid Services, ``Readmissions
    Reduction Program,'' http://go.usa.gov/DbQW.
        \15\ A list of ongoing demonstration projects is available at
    Centers for Medicare and Medicaid Services, ``Innovation Models,''
    http://go.usa.gov/DbQd.

    Another factor limiting the potential for cost savings under a premium
    support system is that the Medicare program is required by law to cover
    items and services that are judged to be medically necessary and
    reasonable. Private insurers participating in the premium support
    options analyzed for this report would be required to cover the same
    services as those covered by the FFS program. The options would cause
    less restraint on the development of costly new technologies than would
    be the case if private insurers (or the Medicare program as a whole)
    had the authority to refuse coverage for certain services if, for
    example, less costly alternatives were available that were at least as
    effective. Under the options analyzed in this report, however, private
    insurers would have some flexibility to reduce beneficiaries' use of
    costly services through tools such as utilization management, higher
    cost sharing, and exclusion of providers from an insurer's network on
    the basis of practice style. By contrast, the FFS program does not have
    the authority to apply such methods to influence beneficiaries' use of
    services but, rather, must pay for any services that are used as long
    as they meet Medicare's criteria for coverage. That feature of the FFS
    program would remain in place under the two premium support options and
    might limit the extent to which either option could reduce the growth
    in Medicare spending. (Removing the FFS program as a competitor in the
    premium support system would tend to push up Medicare spending in other
    ---------------------------------------------------------------------------
    ways, as discussed earlier.)

    In quantifying the effects of the illustrative premium support options
    relative to outcomes under current law, CBO recognized that current law
    provides for three approaches to restraining cost growth in Medicare
    that could be difficult to sustain over the long term: the ongoing
    reductions in payment updates for most providers in the FFS program,
    the sustainable growth rate mechanism for payment rates for physicians,
    and the process associated with the Independent Payment Advisory
    Board.\16\ It is unclear whether the long-term restraint of Medicare
    spending envisioned to occur through those provisions can be
    accomplished through greater efficiency in the delivery of health care
    or whether it would lead to reductions in beneficiaries' access to care
    or the quality of care they received. Accordingly, CBO's extended
    baseline reflects the assumption that the growth rate of Medicare
    spending after 2029 will not be affected by those provisions but that
    the percentage reduction in Medicare spending in 2029 achieved through
    those provisions will continue in later years.\17\ In the analysis in
    this report, CBO anticipates that beneficiaries will respond to
    concerns regarding access and quality in the FFS program by showing
    some additional preference for private plans relative to the FFS
    program when payment rates for providers in private plans increase
    relative to those paid by the FFS system.
    ---------------------------------------------------------------------------
        \16\ Before the enactment of the Affordable Care Act, payment
    updates for most providers (except for physicians, whose payments have
    been controlled by the sustainable growth rate mechanism since 1998)
    generally were set to equal the estimated percentage change in the
    average cost of providers' inputs. Under current law, however, the
    updates will equal those percentage changes in costs minus the 10-year
    moving average of growth in productivity in the economy overall--a
    measure that seeks to capture, for the economy as a whole, how much
    more output is produced from a given amount of inputs. Under current
    law, payment rates for physicians' services in Medicare will be reduced
    by about 25 percent in January 2014 and, CBO projects, will be
    increased by small amounts in most subsequent years. The Independent
    Payment Advisory Board will be required to submit a proposal to reduce
    Medicare spending in certain years if the rate of growth in spending
    per enrollee is projected to exceed specified targets.
        \17\ For more discussion, see Congressional Budget Office, The 2012
    Long-Term Budget Outlook (June 2012), pp. 56-57, www.cbo.gov/
    publication/43288.

    Under the assumptions of its extended baseline, CBO anticipates that
    growth in Medicare spending per beneficiary (after removing the effects
    of demographic changes on health care spending--in particular, changes
    in the population's age distribution) would exceed growth in spending
    per beneficiary for all forms of private health insurance combined
    because the private sector has more flexibility to respond to the
    pressures created by rising health care spending than administrators of
    Medicare have under current law. The growth rate of federal spending
    for Medicare under the two illustrative premium support options--which
    involve a mixture of features of Medicare and private health
    insurance--would probably be lower than that for the existing Medicare
    ---------------------------------------------------------------------------
    program but above that for private health insurance.

    Uncertainty in the Estimates. Estimates of the longer-term effects of
    the premium support options on Medicare spending are subject to the
    same sources of uncertainty that are described above for the shorter-
    term effects, but the magnitude of the uncertainty is increased by the
    longer time horizon. Uncertainty in projecting federal spending for
    Medicare over the long term under current law adds to the uncertainty
    of such estimates.

    In particular, CBO's assessment--that the growth rate of federal
    spending for Medicare under the two options would probably be lower
    than that for the existing Medicare program but above that for private
    health insurance--is highly uncertain. It is possible, for instance,
    that over the long term, the bargaining power of health care providers
    relative to private insurers could increase to such an extent that
    spending growth under the options would exceed that for the existing
    Medicare program. Alternatively, private health insurers could be more
    successful than CBO projects in developing processes for delivering
    care in ways that would reduce costs, in which case spending growth
    under the options could be further below that for the existing Medicare
    program than CBO anticipates.

    Effects of Modifying the Illustrative Premium Support Options or of
    Combining a Premium Support System With Other Changes to Medicare. The
    longer-term effects of the two illustrative options on Medicare
    spending could differ significantly from the estimates presented here
    if either option was modified or if policies for setting payment rates
    in the FFS program were revised. For example, imposing a cap on federal
    contributions under a premium support system could have an important
    effect on federal savings, and changes in the way provider payment
    rates in the FFS program were set could have complex interactions with
    a premium support system. Although CBO has not estimated the
    consequences of such policies, the following observations provide some
    relevant information.

    Effects of a Cap on Federal Contributions. The effects of a cap on
    federal contributions under a premium support system would depend in
    part on how the cap was specified. CBO expects that if a premium
    support system limited the growth rate of federal contributions per
    beneficiary to match the growth of gross domestic product (GDP) per
    capita plus, say, 1.5 percentage points per year, in most years such a
    cap probably would not be binding. Under last year's extended baseline,
    which largely follows current law and which CBO used for the analysis
    in this report, the agency projected that the growth rate of Medicare
    spending per beneficiary between 2020 and 2032 (after adjusting for
    demographic changes) would be, on average, 0.8 percentage points
    greater than the growth rate of GDP per capita.\18\ As a result of the
    offsetting factors just described, CBO estimates that the growth rate
    for Medicare spending during those years under both premium support
    options would be similar to that under current law.
    ---------------------------------------------------------------------------
        \18\ See Congressional Budget Office, The 2012 Long-Term Budget
    Outlook (June 2012), www.cbo.gov/publication/43288.

    A cap of per capita GDP plus 1.5 percentage points could be binding
    regularly, however, if CBO's long-term projection underestimates growth
    in Medicare spending. And that cap could be binding in some years but
    not in others even if the projection is generally accurate because of
    volatility in the growth of health care costs and GDP. Moreover, the
    prospect of a cap's taking effect could alter the behavior of insurers
    in any year, thus increasing or decreasing the likelihood that such a
    cap would take effect. The effects of a cap would also depend on the
    details of how it was specified and enforced. For the current report,
    CBO has not attempted to estimate the effects of imposing a cap on
    ---------------------------------------------------------------------------
    federal contributions.

    Effects of Alternative Policies for Setting Payment Rates for Providers
    in Fee-for-Service Medicare. Under CBO's extended alternative fiscal
    scenario (included in The 2012 Long-Term Budget Outlook), the reduced
    payment updates would expire and the Independent Payment Advisory Board
    process would cease to be effective after 2022, and payments to
    physicians would be maintained at 2012 rates rather than declining as
    scheduled. Under that scenario, CBO projected, net Medicare spending in
    2030 would be about 0.5 percent of GDP higher than it would be under
    CBO's extended baseline. CBO has not estimated the effects of combining
    a premium support system with the changes to current law that are
    assumed under its extended alternative fiscal scenario.

    Instead, if current-law policies restraining cost growth were retained
    through the 2030s or longer, then spending in the existing Medicare
    program would be below that projected under CBO's extended baseline.
    CBO has not estimated the long-term effects of a premium support system
    under such restraints either.

    Effects on Beneficiaries' Premiums

    The premiums that beneficiaries would pay under the two premium support
    options would depend on the premiums charged by the plans in their
    region and on the beneficiaries' choice of plan. Under each option, at
    least one plan would be available in every region that charged the
    standard premium or less, and in most regions other plans would be
    available that charged premiums that were higher or lower than that
    amount (depending on whether the bid was above or below the benchmark).
    For each option, CBO estimated the premiums that would be charged by
    the array of plans offered, and the agency summarized that information
    by estimating the average premiums charged by three plans--the second-
    lowest-bidding private plan in the region, the median-bidding private
    plan (that is, the plan with a bid in the middle of the distribution
    among private plans), and the FFS program. To arrive at the average
    premium charged by each plan, CBO computed a weighted average of
    region-specific premiums, with each region weighted by the proportion
    of affected beneficiaries.

    CBO next estimated the premiums that beneficiaries would pay under each
    option by estimating their choice of plan, based on the differences in
    the premiums charged and on beneficiaries' sensitivity to those
    differences. For that analysis, CBO computed a weighted average of the
    premiums charged, weighting plans by the number of beneficiaries each
    one enrolled. CBO compared average premiums charged by plans and
    average premiums paid by beneficiaries with the Part B premium under
    current law.

    Background on Premium Determination

    Under either premium support option analyzed in this report,
    beneficiaries would pay the standard premium if they chose a plan with
    a bid that was equal to the regional benchmark. That premium would be
    the same everywhere in the country and would be determined by the same
    formula used under current law for the Part B premium: The federal
    government allocates spending under Medicare Advantage to Parts A and B
    on the basis of the share of total spending in the FFS program for Part
    B services and then sets the Part B premium equal to 25 percent of all
    Part B spending, divided by the number of beneficiaries. In this
    report, the standard premium equals 25 percent of the estimated amount
    of total Medicare spending attributable to Part B services under a
    premium support system.

    Under current law, the Part B premium will be $1,600 in 2020, CBO
    projects. Because total Medicare spending would be slightly less than
    it would be under current law under either premium support option, CBO
    estimates, the standard premium for each would be slightly lower than
    the Part B premium under current law--$1,500 per year under either
    option. (All estimates of annual premiums in this report are rounded to
    the nearest $100; although CBO projects that the standard premium under
    the average-bid option would be higher than that under the second-
    lowest-bid option, those amounts round to the same number.)

    If a beneficiary chose a plan with a bid that differed from the
    regional benchmark, the premium would depend on the plan chosen.
    Someone who enrolled in a plan with a bid above the benchmark would pay
    the standard premium plus the amount by which the plan's bid exceeded
    the benchmark, and someone who enrolled in a plan with a bid below the
    benchmark would pay a correspondingly lower premium. CBO expects that,
    depending on how bidding regions were defined, there might be some
    sparsely populated regions in which no private plans would participate
    under either option. In those regions, the FFS program would be the
    only plan available, and beneficiaries who enrolled in the program
    would pay the standard premium.

    CBO focused on standard premium amounts that did not include income-
    related adjustments. In addition, the agency analyzed premiums only for
    the basic package of Medicare benefits, excluding additional amounts
    that enrollees in private plans might pay for enhanced benefits or that
    enrollees in the FFS program might pay for supplemental coverage.

    Enrollees in private plans under the options would forgo the federal
    subsidies for supplemental benefits that would be provided by many
    Medicare Advantage plans under current law. CBO estimates that the
    annual value of those supplemental benefits (under current law) will be
    about $400, on average, per Medicare Advantage enrollee in 2020. The
    loss of those subsidies would make private plans less attractive under
    the options, all else being equal. For this analysis, CBO compared
    premiums for both options with the $1,600 current-law premium projected
    for Part B. The agency did not make any adjustment in that analysis for
    the loss of supplemental benefits under the Medicare Advantage program.
    Those forgone benefits are included in the analysis presented below
    concerning the effects of the two options on beneficiaries' total
    payments.

    Premiums by Region. The range of premiums around the standard premium
    would vary geographically. CBO's analysis focused on four groups of
    regions--ranked from highest to lowest average FFS spending--with equal
    numbers of beneficiaries in each group. In regions with high FFS
    spending, CBO estimates, the bid for the FFS program would be higher
    than the private plans' bids and higher than the benchmark under either
    option. Medicare beneficiaries enrolled in the FFS program in such
    regions tend to use certain health care services at a higher-than-
    average rate, so private plans would have greater potential to achieve
    savings relative to the FFS program by reducing that use. In contrast,
    CBO estimates, the FFS program's bid would be similar to or lower than
    the bids of private plans in many regions with low FFS spending. People
    enrolled in the FFS program in those regions tend to use less care, so
    private plans would have less potential to achieve savings by reducing
    the quantity of care; savings from reducing the price of care also
    would be difficult to achieve because of the restraints in provider
    payment rates that are scheduled for the FFS system under current law.
    Thus, the range of premiums would be narrower in regions with low FFS
    spending.

    Premiums for Beneficiaries Who Do Not Actively Choose a Plan. CBO
    projects that many beneficiaries would not actively choose a plan in
    the first year of a premium support system--perhaps because they were
    unaware of the new system, did not understand how to enroll, were
    hampered by a health problem, or for some other reason. Under the
    options considered for this report, beneficiaries who did not choose a
    plan would be assigned to a plan with a bid at or below the benchmark.
    CBO projects that about 15 percent of beneficiaries would not choose a
    plan in the first year of premium support under the second-lowest-bid
    option and about 20 percent would not choose a plan in the first year
    under the average-bid option.\19\ Those beneficiaries would pay
    premiums less than or equal to the standard premium, but there would be
    no guarantee that the assigned plan would include all of their current
    providers.
    ---------------------------------------------------------------------------
        \19\ CBO expects that some beneficiaries who were assigned to a
    low-bidding plan in the first year would later switch to the FFS
    program or to another plan that would have, on average, a higher
    premium.

    Under an alternative approach, which CBO has not yet analyzed,
    beneficiaries who did not make a choice would remain in the plan most
    similar to their current plan (or be transferred to the FFS program if
    a similar plan was no longer available). In particular, beneficiaries
    who had been in the FFS program when the premium support system began
    would remain in that program unless they chose a private plan. In that
    sort of system, FFS beneficiaries would retain access to their current
    providers but, depending on the region, their premiums could be
    substantially higher. In addition, insurers would have less incentive
    to reduce their bids because they would anticipate that being a lower-
    bidding plan would result in a smaller gain in enrollment than they
    would achieve if all beneficiaries were required to affirmatively
    choose a plan.

    Premiums Charged by Plans in 2020

    Under either illustrative premium support option, CBO anticipates,
    beneficiaries would be offered at least one plan at or below the
    standard premium and most people would have access to at least one
    other plan with a premium below that amount. In most regions, the plans
    with premiums at or below the standard amount would be private.
    Overall, CBO estimates, the premiums charged by plans would generally
    be lower under the average-bid option than under the second-lowest-bid
    option because the benchmarks would be higher under the average-bid
    option, so the federal government would contribute more for each plan.

    The Second-Lowest-Bid Option. Under this option, CBO estimates, the
    average premium for the second-lowest-bidding private plan across all
    regions would be about $1,500 per year in 2020, or 6 percent below the
    Part B premium projected under current law for that year (see Table 4).
    In regions with low FFS spending, however, the premium for the second-
    lowest-bidding private plan would tend to be higher than in other
    regions because of the role of FFS spending in determining the
    benchmark. Specifically, in some regions with low FFS spending, the bid
    for the FFS program would be lower than that of the second-lowest-
    bidding private plan, so the FFS program's bid would become the
    benchmark, and the premium for the second-lowest-bidding private plan
    would be above the standard amount. CBO estimates that the average
    premium for the second-lowest-bidding private plan would be $1,600 in
    regions with the lowest FFS spending (see Figure 3).

    The average premium for the median-bidding private plan available would
    be $1,800 in 2020 under the second-lowest-bid option, CBO estimates.
    That amount would be 13 percent above the current-law Part B premium.

    The average premium for the FFS program under the second-lowest-bid
    option would be about $3,100, or almost twice the projected Part B
    premium under current law, CBO estimates. That increase would occur
    because, in most regions, the FFS program's bid would be substantially
    above that of the second-lowest-bidding private plan, and thus the bid
    for the latter would become the benchmark. The premium for the FFS
    program would be highest in regions with the highest average FFS
    spending. CBO estimates that in those regions, the average premium for
    the FFS program would be $4,600, or almost triple the projected
    current-law Part B premium. Even in regions with the lowest FFS
    spending, the average FFS premium would be $1,900, or almost 20 percent
    above the projected current-law Part B premium. (In some regions, the
    FFS program's bid would be lower than that of the second-lowest-bidding
    private plan, and the premium would equal the standard premium.)

    The Average-Bid Option. Premiums would generally be lower under the
    average-bid option than under the second-lowest-bid option. For the
    second-lowest-bidding private plan, the national average premium in
    2020 would be $900 under the average-bid option, CBO estimates--more
    than 40 percent below the projected current-law Part B premium for that
    year. That amount would be less than the premium for that plan under
    the second-lowest-bid option because, in most areas, the benchmark
    would be higher and the plan's bid would be below the benchmark, which
    determines the government's contribution. Under the average-bid option,
    the average premium of the second-lowest-bidding private plan would be
    the smallest (at $600) in regions with the highest FFS spending because
    that plan's bid would be lower relative to the benchmark (which would
    be influenced by the bids of the FFS program and the higher-bidding
    private plans). The average premium of the second-lowest-bidding
    private plan would be substantially greater (at $1,400) in regions
    where FFS spending is lowest because, in most of those areas, that
    plan's bid would be close to the bid of the FFS program.

    For the median-bidding private plan, CBO estimates that the average
    premium would be $1,200. That amount would be 25 percent below the
    current-law Part B premium in 2020.

    The FFS program's bid under the average-bid option would be above the
    benchmark in most areas. CBO estimates that the national average
    premium for the FFS program would be $2,400, 50 percent higher than the
    projected current-law Part B premium.

    Premiums Paid in 2020

    The average premiums that beneficiaries would pay under a premium
    support system would depend not only on the premiums charged by plans
    as just discussed, but also on the plans beneficiaries chose to enroll
    in. Under the second-lowest-bid option, CBO estimates, the average
    annual premium paid by beneficiaries in 2020 would be $2,100--about 30
    percent higher than the current-law Part B premium for that year (see
    Figure 4). Under the average-bid option, CBO estimates, the average
    premium paid by beneficiaries in 2020 would be $1,500, or 6 percent
    below the
    current-law Part B premium.

    The Second-Lowest-Bid Option. CBO estimates that about half of the
    beneficiaries included in the premium support system would enroll in
    private plans under the second-lowest-bid option and about half would
    enroll in the FFS program. The average premium paid by beneficiaries
    for private plans across all regions would be $1,800 and the average
    premium paid for the FFS program would be $2,500. The percentage of
    household income that beneficiaries would spend on the premium for the
    FFS program would vary substantially. The premium for the FFS program
    would amount to less than 2 percent of household income for about one-
    fourth of enrollees in that plan and to 6 percent or more for about
    two-fifths of the plan's enrollees. In comparison, under current law
    that premium would amount to less than 2 percent of household income
    for about two-fifths of beneficiaries in the FFS program and to 6
    percent or more of household income for about one-fifth of
    beneficiaries in that program. (Those estimates focus on the standard
    premium and, in the case of premium support, on any reduction or
    increase in that premium that would result when a beneficiary enrolled
    in a plan with a bid below or above the benchmark. The estimates do not
    include amounts paid for the income-related premium.)

    Under the second-lowest-bid option, average premiums would vary
    regionally. Beneficiaries in regions with the highest FFS spending
    would pay an average of $2,300 (compared with the nationwide average of
    $2,100). The higher average premium estimated for the regions with
    highest FFS spending is largely a reflection of CBO's estimate that
    about one-fifth of the beneficiaries would enroll in the FFS program.
    In those regions, roughly half of all beneficiaries enrolled in the FFS
    program would spend at least 6 percent of their household income on the
    FFS premium. Beneficiaries in regions with the lowest FFS spending
    would pay an average premium of $1,800, according to CBO's estimates.
    About 80 percent of beneficiaries in regions with the lowest FFS
    spending would enroll in the FFS program.

    The Average-Bid Option. CBO estimates that slightly fewer than half of
    all beneficiaries would enroll in private plans under the average-bid
    option in 2020 and slightly more than half would enroll in the FFS
    program--proportions that are similar to those CBO projects for the
    second-lowest-bid option.\20\ For all regions combined, the average
    premium paid by beneficiaries in the FFS program would be $2,000 and
    the average premium paid by enrollees in private plans would be $1,000,
    compared with $2,500 and $1,800, respectively, under the second-lowest-
    bid option.
    ---------------------------------------------------------------------------
        \20\ Two opposing considerations led CBO to project similar--but
    not identical--enrollment patterns for the two options. In most
    regions, the FFS premium would be higher relative to private plans'
    premiums under the second-lowest-bid option than under the average-bid
    option. That difference would arise because the second-lowest bid would
    be lower than the average bid, resulting in a larger gap between the
    federal contribution and FFS costs under the second-lowest-bid option.
    As a result, enrollment would tend to be higher in private plans under
    the second-lowest-bid option. CBO expects, however, that the prospect
    of paying higher premiums under the second-lowest-bid option would
    prompt more beneficiaries to choose a plan in the first year of the
    program. Thus, a smaller proportion of beneficiaries would be assigned
    to a plan at or below the benchmark, and that would tend to decrease
    enrollment in private plans under the second-lowest-bid option.

    Under the average-bid option, the average premium would be
    approximately equal for beneficiaries in all four groups of regions
    classified by FFS spending, CBO estimates. Where FFS spending is
    highest, the estimated $1,500 average premium reflects the anticipated
    choice of some beneficiaries to enroll in private plans with bids below
    the benchmark (about three-fourths of that group; their average premium
    would be less than $1,500) and of others to enroll in the higher-
    bidding FFS program (about one-fourth; their average premium would be
    more than $1,500). In areas with the lowest FFS spending, the $1,500
    average premium reflects much smaller differences between the bids of
    private plans and the FFS program. In those regions, about three-
    fourths of beneficiaries would enroll in the FFS program, by CBO's
    estimate.

    Effects on Beneficiaries' Total Payments

    CBO has estimated the effects of the two illustrative premium support
    options on beneficiaries' total payments for covered services. The
    total consists of premiums and out-of-pocket payments for deductibles,
    coinsurance, and copayments. In this analysis, out-of-pocket payments
    include all such obligations for beneficiaries, whether paid directly
    by beneficiaries or covered by supplemental insurance.\21\ The premiums
    included in CBO's estimates are the average premiums that beneficiaries
    would pay as presented above and are based on CBO's projections of the
    distribution of beneficiaries among plans. Income-related premiums for
    Part B also were included in the total payments the agency estimates
    under current law and for both options. In addition, the estimates
    account for the value of the forgone federally subsidized supplemental
    benefits that would have been available to enrollees in Medicare
    Advantage plans under current law but that would not be available under
    the two options. As discussed below, the estimated effects of the two
    premium support options on beneficiaries' total payments are subject to
    considerably greater uncertainty than are the estimated effects on
    federal spending and the premiums charged by plans.
    ---------------------------------------------------------------------------
        \21\ This report does not provide estimates of the total effects of
    the premium support options on beneficiaries' payments for Medicare
    services because the analysis did not include premiums that
    beneficiaries would pay for supplemental coverage. (CBO has not yet
    modeled such coverage as part of a premium support system.) However, by
    including total out-of-pocket costs for Medicare services, whether paid
    by the beneficiary or by supplemental insurance, the analysis captures,
    in the aggregate, most of the costs beneficiaries would incur for
    premiums for supplemental insurance.
    ---------------------------------------------------------------------------

    Effects in 2020

    CBO estimates that beneficiaries' total payments in 2020 would be about
    11 percent higher, on average, under the second-lowest-bid option than
    they would be under current law. The premiums paid by beneficiaries
    would be higher, on average, than under current law, but beneficiaries'
    out-of-pocket costs would be lower--even though the actuarial value of
    the Medicare benefit would be unchanged--because of a decline in the
    total cost of covered services, which would be a result primarily of
    greater enrollment in lower-bidding private plans.\22\ (On average, a
    larger share of beneficiaries' total payments is in out-of-pocket costs
    than in premiums, so, in the calculations of the change in total
    payments, the percentage change in out-of-pocket costs receives a
    greater weight than the corresponding change in premiums.) The
    projected savings in out-of-pocket costs would offset part, but not
    all, of the increase in premiums.
    ---------------------------------------------------------------------------
        \22\ CBO expects that lower-bidding plans would generally have
    lower rates of health care utilization. As a result, enrollees would
    pay less out of pocket than they would with higher-bidding plans. Under
    the options in this report, the actuarial value of all plans would
    match the value of current-law Medicare; that is, every plan would
    cover the same percentage of the total expenses of a given population
    that is covered by the current Medicare benefit package. For general
    information on the actuarial value of health plans, see Chris L.
    Peterson, Setting and Valuing Health Insurance Benefits, Report for
    Congress R40491 (Congressional Research Service, April 6, 2009).

    CBO's analysis implies that beneficiaries' total payments would be
    about 6 percent lower, on average, under the average-bid option than
    under current law. That reduction results from the combination of the
    lower average premiums paid discussed above and a reduction in average
    out-of-pocket costs, which would result primarily from higher
    ---------------------------------------------------------------------------
    enrollment in lower-bidding private plans.

    Under both options, the effect on total payments for particular
    beneficiaries could differ greatly from the nationwide average and
    would depend partly on the region and the choice of plan. In
    particular, beneficiaries who chose to remain in the FFS program would
    generally face higher premiums and would not experience a reduction in
    out-ofpocket costs.

    Uncertainty in the Estimates

    To characterize the uncertainty of the estimated effects of the options
    on beneficiaries' total payments, CBO applied the same type of analysis
    reported above for the effects of the premium support options on
    federal spending. Specifically, it varied the same five parameters,
    with ranges chosen to generate lower and higher estimates of the
    effects on beneficiaries' payments for each option. In CBO's judgment,
    there is a two-thirds chance under the second-lowest-bid option that
    beneficiaries' total payments in 2020 would, on average, be within a
    range extending from a reduction of 2 percent to an increase of 24
    percent relative to payments under current law (CBO's central estimate
    is that total payments would increase by 11 percent). For the average-
    bid option, the corresponding range of likely average effects on
    beneficiaries' total payments extends from no effect to a reduction of
    12 percent (the central estimate is a reduction of 6 percent.) (See
    Table 2.) The range under the average-bid option is narrower than that
    under the second-lowest-bid option mainly because the changes in
    beneficiaries' premiums from varying those parameters are smaller under
    the average-bid option and because the variation in responsiveness to
    smaller changes in premiums results in a smaller range of effects on
    total payments. (For additional discussion of factors affecting the
    ranges, see Appendix B.)

    Beneficiaries' total payments would be unlikely to rise, on average,
    under the
    average-bid option relative to those under current law, for two main
    reasons. First, because use of health care services tends to be higher
    for enrollees in the FFS program than for those in private plans, out-
    of-pocket costs would probably be lower under the average-bid option
    than they would be under current law as long as the percentage of
    beneficiaries in the FFS program did not increase. According to CBO's
    central estimates, the share of beneficiaries in private plans would be
    about 20 percentage points greater than under current law, and a
    reduction in that share would be unlikely. Second, average premiums
    paid under the option would be closely tied to the standard premium,
    which would be set using the same formula as the Part B premium under
    current law, so those average premiums would not differ greatly from
    the Part B premium. And even if premiums were slightly higher under the
    average-bid option than under current law, the effect probably would
    not offset the decline in out-of-pocket costs.

     Effects on Combined Federal Spending and Beneficiaries' Total Payments

    The combined payments of the federal government and beneficiaries
    constitute the total amount paid for health care services covered by
    Medicare. They consist of the federal government's payments to plans,
    beneficiaries' premiums, and beneficiaries' out-of-pocket payments. CBO
    estimates that those payments would be about 5 percent lower under the
    second-lowest-bid option and about 4 percent lower under the average-
    bid option than they would be under current law. Those percentages are
    a combination of the effects on net Medicare spending and on
    beneficiaries' total payments discussed above.

    CBO expects that the decrease in combined payments would probably be
    slightly larger under the second-lowest-bid option than under the
    average-bid option mainly because the former would result in lower bids
    by private plans and a larger share of beneficiaries enrolled in those
    plans. CBO did not quantify the uncertainty of those estimates but it
    did reach two conclusions about ranges that would cover two-thirds of
    the possible outcomes for the two options: First, such ranges would
    clearly overlap; that is, CBO is not confident that combined payments
    under the second-lowest-bid option would be lower than combined
    payments under the average-bid option. Second, based on the separate
    ranges for federal spending and for beneficiaries' total spending,
    ranges for combined payments would extend only over reductions in
    payments; that is, it is likely that either option would result in
    reductions in combined federal spending and beneficiaries' total
    payments.

    The sum of federal spending and beneficiaries' payments examined here
    is a significant component of total national spending on health care,
    and this analysis suggests that total national spending would probably
    decline under either of the two illustrative premium support options.
    However, a premium support system would interact with other parts of
    the health care system in complex ways that CBO has not quantified.

     Comparison With CBO's Previous Analyses of a Premium Support System

    CBO has previously estimated the budgetary effects of revamping
    Medicare as a premium support system.\23\ But those earlier analyses
    were limited in at least two key respects: They did not include
    detailed modeling of beneficiaries' choices among alternative insurance
    plans, and they did not include detailed modeling of insurers' behavior
    regarding bids or payments to health care providers. Thus, none of
    those analyses captured the full effects of a competitive system on
    federal spending or payments by beneficiaries. The analysis in this
    report incorporates such modeling. In addition, this report differs
    from some previous analyses by CBO in considering different
    illustrative options for a premium support system instead of a specific
    proposal.
    ---------------------------------------------------------------------------
        \23\ For example, see Congressional Budget Office, The Long-Term
    Budgetary Impact of Paths for Federal Revenues and Spending Specified
    by Chairman Ryan (March 2012), www.cbo.gov/publication/43023; Long-Term
    Analysis of a Budget Proposal by Chairman Ryan (attachment to a letter
    to the Honorable Paul Ryan, April 5, 2011), www.cbo.gov/publication/
    22085; Budget Options, Volume 1: Health Care (December 2008), pp. 120-
    121, www.cbo.gov/publication/41747; and Designing a Premium Support
    System for Medicare (December 2006), www.cbo.gov/publication/18258.

    The treatment in this report is substantially different from the rough
    analysis of a specific premium support proposal published by CBO in
    April 2011. Not only have there been substantial improvements in CBO's
    modeling of the behavior of beneficiaries and insurers, but the options
    examined in this report differ in important ways from that earlier
    proposal. For example, the earlier proposal included a grandfathering
    provision, and CBO estimated that only 4 percent of Medicare spending
    in 2022 would be accounted for by premium support payments under that
    proposal. The proposal also specified a federal contribution that was
    initially fixed (rather than determined through bidding) and that would
    keep pace with the consumer price index for all urban consumers (at a
    rate that CBO estimated would be substantially slower than the rate of
    growth in Medicare spending under current law). Moreover, because of
    the simple formula for determining federal spending in that proposal,
    CBO projected such spending over a longer period than it does in this
    ---------------------------------------------------------------------------
    report.

    CBO's estimates of the total payments by beneficiaries and of combined
    federal spending and beneficiaries' payments for the 2011 proposal were
    much higher than the estimates for the two options in this report
    primarily because CBO projected for that earlier report that health
    care spending covered by private plans would be much higher initially
    and would grow faster than the agency currently estimates. The
    difference arose from two main factors: First, the earlier proposal did
    not include the Medicare FFS program as a bidding plan in the premium
    support system. Because that program was not present to put downward
    pressure on the rates paid to providers by private insurers, CBO
    projected, the premiums of private plans would be substantially higher
    than they would be under the premium support options discussed in this
    report. Second, more recent information has led CBO to make a downward
    revision in its projections of the future growth rate of private health
    insurance premiums.\24\
    ---------------------------------------------------------------------------
        \24\ See Congressional Budget Office, Updated Estimates for the
    Insurance Coverage Provisions of the Affordable Care Act (March 2012),
    www.cbo.gov/publication/43076.
    ---------------------------------------------------------------------------

    Implications of Key Specifications and Alternatives

    Although policymakers would need to determine many specific
    characteristics of a premium support system, several choices would be
    particularly important from a federal budgetary perspective: setting
    the formula for the government's contributions, determining whether the
    traditional FFS program would be included as a competing plan, setting
    rules of eligibility for the system, delineating bidding regions, and
    designing the program features that would influence beneficiaries'
    choice of a plan. Policymakers would also need to address many other
    design and operational issues to implement such a system.

    Note again that the illustrative premium support options analyzed here
    are anchored in basic features of the current Medicare system: Both
    would guarantee insurance for all beneficiaries; adjust payments to
    private insurers to account for the health of their enrollees (that is,
    use risk adjustment); and, under what is called community rating,
    require that insurers charge everyone in a region the same premium for
    the same coverage. Changes to those features also could have important
    consequences for a premium support system.

    In addition, changes in the broader health care and health financing
    systems would affect a premium support system and change the way it
    affected federal spending and beneficiaries' payments. For example, if
    more people outside of the Medicare market purchased health insurance
    plans with narrower networks of providers and lower premiums than CBO
    expects under current law, the willingness of Medicare beneficiaries to
    purchase similar plans in a premium support system would probably
    increase--although the opposite could occur if people's experiences
    with those plans left them dissatisfied. Legislative changes affecting
    the broader health care market also could have consequences for the
    effects of a premium support system in Medicare. For instance,
    repealing the tax exclusion for employment-based health insurance would
    heighten pressure to restrain the growth of health care costs outside
    of Medicare. The resulting changes in practice patterns of health care
    providers would probably decrease private plans' bids under a premium
    support system, although CBO has no basis for estimating the magnitude
    of such an effect.

    Federal Contributions

    In this analysis, CBO focused on two possible approaches to determining
    federal contributions, but many other methods could be used. For
    example, capping the growth rate of federal contributions could
    generate additional federal savings relative to an uncapped proposal,
    although CBO has not yet estimated the effects of such a cap. In
    general, federal budgetary savings would increase as federal
    contributions declined, but beneficiaries' premiums would be higher.

    The Fee-for-Service Program

    CBO assumed that Medicare's FFS program would continue to be offered
    within the premium support options analyzed here. If, instead, the FFS
    program was eliminated, the savings produced for the government under a
    premium support system would be less (or federal spending could be even
    more than under current law) because the rates that private insurers
    would pay health care providers for treating Medicare enrollees would
    probably be higher than CBO estimates for either premium support
    option. In general, the rates that private insurers now pay providers
    for Medicare Advantage enrollees are similar to those Medicare pays
    under the FFS program but substantially below the rates paid for
    enrollees who are in commercial plans and are not Medicare
    beneficiaries.

    CBO anticipates that competition from the FFS program within a premium
    support system would constrain the rates that private insurers paid for
    premium support enrollees in the same way that the FFS program now
    appears to constrain the rates that insurers pay for Medicare Advantage
    enrollees. If a system did not offer the FFS program as a choice, the
    result probably would be higher payment rates, higher bids, and higher
    costs for the government. CBO also expects that, under the options
    analyzed here, in some regions the FFS program would submit the lowest
    bid, so eliminating the program would directly reduce federal savings
    by raising the benchmark in those regions.

    Eligibility

    If fewer people were included in a premium support system, federal
    savings generally would be lower, all else being equal. For this
    analysis, CBO assumed that the premium support systems would not
    include a grandfathering provision (thus including more beneficiaries
    than if such a provision were part of the system) and would exclude
    dual-eligible beneficiaries.

    A Grandfathering Provision. Under some premium support proposals, all
    beneficiaries who became eligible for Medicare before the system took
    effect would remain in the current-law Medicare program and only those
    who became eligible after that time would enroll in the premium support
    system. Several important questions would arise about the structure of
    such a program (see Box 2). Clearly, however, grandfathering some
    beneficiaries would limit the savings that could be achieved over an
    extended period because only a subset of the Medicare population would
    enroll in the new system and (because the grandfathered beneficiaries
    would be older) the cost of health care for the eligible population
    would tend to be lower than average.

    CBO estimates that if a premium support system implemented in 2018
    excluded beneficiaries who entered the program before 2018 and dual-
    eligible beneficiaries, only about 25 percent of the Medicare
    population would be covered under the new system after 5 years, and
    spending for those beneficiaries would represent only about 15 percent
    of net Medicare spending in total in that year under current law (where
    such spending includes that for dual-eligible beneficiaries and for
    Part D). After a decade, approximately 45 percent of the Medicare
    population would be covered, and spending for that group would
    represent about 30 percent of net Medicare spending in total under
    current law.

    Because the share of the Medicare population and the share of Medicare
    spending covered would rise gradually under a grandfathering provision,
    federal savings would be substantially smaller over an extended period
    than would be the case if all beneficiaries entered the new system
    immediately. A very rough approximation (made on the basis of the
    estimated share of Medicare spending covered each year) for a system
    that also excluded dual-eligible beneficiaries suggests that of the
    total savings achieved if all eligible beneficiaries entered in 2018,
    federal savings would be about 15 percent as much after 5 years and
    about 30 percent as much after 10 years.

    Moreover, the savings under a grandfathering provision could be
    slightly smaller than the rough estimates would suggest, for two
    reasons. First, CBO anticipates that the gradual rise in the proportion
    of Medicare beneficiaries and Medicare spending covered under such a
    system would give private insurers less incentive to reduce their bids,
    over an extended period, than would be the case if all eligible
    beneficiaries entered the system immediately. Second, the reduction in
    the growth of Medicare spending likely to occur under a premium support
    system as a result of changes in the demand for new technologies would
    be substantially smaller for many years if that system included a
    grandfathering provision.

    Dual-Eligible Beneficiaries. Medicare covers some services for dual-
    eligible beneficiaries and Medicaid covers others, thus creating
    conflicting financial incentives for the federal and state governments
    and for health care providers.\25\ Recent federal and state efforts
    have focused on integrating the Medicare and Medicaid funding streams
    and coordinating the often-complex care of many of those
    beneficiaries--and including that group in a premium support system
    would pose substantial additional challenges. For instance, it would be
    difficult to give dual-eligible beneficiaries incentives to choose low-
    bidding plans in a premium support system while also minimizing their
    total payments for medical services. Despite that, excluding such
    beneficiaries would reduce the potential savings that could be achieved
    from a premium support system. In addition, that exclusion might create
    incentives for private plans to encourage lower-income beneficiaries
    with higher health care costs than predicted by their risk scores to
    seek Medicaid eligibility and thereby leave the plan.\26\
    ---------------------------------------------------------------------------
        \25\ See Congressional Budget Office, Dual-Eligible Beneficiaries
    of Medicare and Medicaid: Characteristics, Health Care Spending, and
    Evolving Policies (June 2013), www.cbo.gov/publication/44308.
        \26\ Such effects are not included in CBO's estimates in this
    report.

    Bidding Regions

    CBO assumed that bidding regions for both options would reflect health
    care markets within states. The precise definition of those markets
    would involve trade-offs. For example, defining regions to include
    large numbers of beneficiaries would make insurers' projections of
    average spending within the region more reliable. However, regions that
    included areas that varied greatly in their spending would make it more
    difficult for insurers to project spending for their enrollees because
    those enrollees could be concentrated in certain areas within the
    region. As another example, because CBO assumed that a premium support
    system would require any insurer that submitted a bid for a region to
    serve the entire region, some local and regional insurers might decline
    to participate if a region included areas they could not serve
    effectively, thus reducing competition. And in some regions, those
    firms could be among the insurers offering the lowest-cost health care,
    the highest-quality health care, or both. However, if regions were
    small, some insurers might decline to participate even though they
    would have served those same areas if they had been included in larger
    regions. That result could occur, say, if the costs to carriers of
    developing networks of providers in those areas were higher than in
    nearby areas and if those costs would have been worth incurring to
    serve a larger region.

    Features of a System That Could Influence Enrollment

    Features of a premium support system that made beneficiaries more
    sensitive to differences in plans' premiums would tend to reward plans
    that bid low with higher enrollment and thus encourage more plans to
    submit lower bids.

    In the illustrative premium support options analyzed here, CBO assumed
    that differences in bids would be translated dollar for dollar into
    differences in premiums. If, instead, the government retained some of
    the difference between the benchmark and bids below that amount, two
    effects would occur: First, the government would reduce its spending by
    the amount retained, all else being equal. Second, however, by
    retaining some of the difference between the benchmark and the bids,
    the government would reduce the incentive for beneficiaries to enroll
    in low-bidding plans and thus reduce the incentive for plans to submit
    low bids--which would increase the benchmark and federal spending. The
    net effect of those two factors on government spending would depend
    partly on beneficiaries' responsiveness to premiums and partly on the
    extent to which private insurers raised their bids. Moreover, if the
    difference between the benchmark and bids below that amount was
    provided as additional benefits rather than as cash, beneficiaries
    would tend to have more difficulty comparing plans.

    CBO assumed that beneficiaries who did not choose a plan when they
    entered the premium support system would be assigned to a plan that
    submitted a bid that was at or below the benchmark (or assigned to one
    of the four lowest-bidding plans if more than four were at or below the
    benchmark). If, instead, beneficiaries were automatically placed into
    their original plan (if they had already been enrolled in Medicare) or
    into the FFS program, insurers would probably have less incentive to
    submit low bids, and beneficiaries' total payments would be higher
    because low-bidding plans would have lower enrollment. Conversely, if
    those beneficiaries were assigned to plans that had especially low bids
    (rather than being assigned equally to all plans bidding at or below
    the benchmark), insurers would probably have a greater incentive to
    submit low bids, and beneficiaries' total payments would be lower.
    Alternatively, if beneficiaries were required to choose a plan if they
    wished to enroll in the premium support system and thus to maintain or
    obtain Medicare coverage, some would not do so and the fraction of the
    eligible population not covered by Medicare would increase--
    particularly in the first few years after implementation.

    In this analysis, CBO assumed that the basic packages that plans would
    be required to offer would consist of health care services and an
    actuarial value that matched those provided by Medicare's FFS program
    under Parts A and B--although the plans could vary in other dimensions,
    such as the breadth of provider networks or the structure of
    coinsurance. If that basic package was only a minimum requirement and
    plans could supplement a package in unrestricted ways without offering
    the basic package itself, comparisons would be more difficult for
    beneficiaries, enrollment in low-bidding plans would be reduced, and
    plans' bids would rise. Conversely, if the deductibles and copayments
    of the basic package were made standard, comparisons would be simpler.
    The drawback of standardization, however, is that it could dampen the
    ability of insurers and providers to develop more cost-effective
    approaches to providing health care and for beneficiaries to choose
    those approaches rather than more expensive ones.

                                     ______

                                  Appendix A:
                            Basis for CBO's Findings

    The preliminary findings presented in this report regarding the effects
    of two illustrative options for a premium support system for Medicare
    (one called the second-lowest-bid option and the other called the
    average-bid option) are based on detailed modeling of the behavior of
    buyers and sellers of health insurance policies. In its analysis, the
    Congressional Budget Office (CBO) focused particular effort on
    estimating private insurers' bids under those options.

    CBO reviewed the research literature and consulted a variety of experts
    who represented a broad span of views about premium support systems. In
    addition, some insights about the potential responses of beneficiaries
    and insurers are possible from observing current experience with the
    Medicare Advantage program (which provides benefits through private
    insurance), Medicare Part D (the prescription drug program), the
    Federal Employees Health Benefits program, and various employment-based
    insurance plans. The usefulness of those systems to inform the analysis
    of a premium support system is limited, however, because the
    competitive structure of a premium support system would be quite
    different from that of Medicare Advantage or the federal employees'
    program, and the array of health care services covered would be broader
    than that under Part D. Moreover, information about the small number of
    employers whose experiences with similar systems have been studied in
    depth may not be broadly generalizable--particularly to the Medicare
    population, which is likely to be less responsive than the nonelderly
    population to differences in health insurance premiums. Finally, the
    changes that are occurring in private health care and in health
    insurance could affect federal spending on Medicare in complicated and
    unpredictable ways--either under current law or under a premium support
    system. And the adoption of a premium support system for Medicare could
    have spillover effects on private health care and health insurance
    systems.

    The current analysis incorporates a range of significant improvements
    in the modeling of a premium support system for Medicare compared with
    CBO's earlier analyses of such systems.\27\ The agency has devoted
    considerable time and effort to strengthening its analytical
    capabilities in this area. Nonetheless, it is extremely difficult to
    know how beneficiaries or insurers would respond to a premium support
    system for Medicare, and the actual outcomes would surely differ from
    the estimates presented in this report--which, according to CBO's
    current judgment, represent the middle of the distribution of possible
    outcomes. The agency's modeling effort is not complete; further
    analysis and additional consultation with outside experts may alter the
    findings, perhaps in significant ways. One potential area of inquiry
    that CBO has not analyzed concerns the ways a premium support system
    might affect the coordination of care or the quality of care that
    beneficiaries receive; the agency does not currently have the tools
    necessary to study such effects, nor does it anticipate having them in
    the near future.
    ---------------------------------------------------------------------------
        \27\ For examples of earlier analyses, see Congressional Budget
    Office, Long-Term Analysis of a Budget Proposal by Chairman Ryan
    (attachment to a letter to the Honorable Paul Ryan, April 5, 2011),
    www.cbo.gov/publication/22085, and Designing a Premium Support System
    for Medicare (December 2006), www.cbo.gov/publication/18258.
    ---------------------------------------------------------------------------

    Estimating Private Insurers' Bids

    To estimate the bids that private insurers would submit in 2020 under
    the two illustrative premium support options considered in this report,
    CBO analyzed insurers' 2012 bids for Medicare Advantage, projected
    those bids to 2020, and adjusted them to account for the differences in
    competition that CBO anticipates private insurers would face under the
    two options as compared with the current Medicare Advantage program.

    In adjusting the projected Medicare Advantage bids to develop estimates
    of what private insurers would bid under a premium support system, CBO
    concluded that some factors would tend to lower bids and others would
    tend to raise them (see Figure A-1). The net effect is that the
    projected bids under the two premium support options considered in this
    report are lower, by an average of about 4 percent under each option,
    than those projected for the current-law Medicare Advantage program.
    (Bids would be slightly lower under the second-lowest-bid option than
    under the average-bid option, but the differences relative to bids
    under the Medicare Advantage program are rounded to the nearest
    percentage point.) The difference between private insurers' bids under
    the two options and average spending in Medicare's fee-for-service
    (FFS) program would remain fairly constant in the decade after the
    first few years of implementation, CBO anticipates.

    Projecting Medicare Advantage Bids

    Under current law, each Medicare Advantage plan generally can define
    its service area as consisting of one or more counties.\28\ CBO based
    its estimates on the bids submitted by insurers for their service
    areas, using the county as the unit of analysis. The agency developed
    simulated distributions of bids for counties based on the view that
    insurers would participate in a premium support system and would offer
    insurance plans with a range of prices, just as is the case for the
    current Medicare Advantage program.
    ---------------------------------------------------------------------------
        \28\ This discussion applies to local Medicare Advantage plans,
    which account for the bulk of enrollment in the Medicare Advantage
    program. By contrast, the federal government defines service areas for
    regional preferred provider organizations--or PPOs--as consisting of
    one or more states; each PPO must serve one or more of those designated
    service areas.

    CBO estimated benchmarks for counties under the two premium support
    options on the basis of the agency's projected distributions of private
    insurers' bids, which were combined with projected per capita Medicare
    FFS spending for each county. The use of the county as the unit of
    analysis simplified the modeling and provides a foundation for
    subsequent analyses of a system with other types of bidding regions.
    The results of the analysis could change if different types of regions
    ---------------------------------------------------------------------------
    were specified.

    Under current law, Medicare Advantage insurers submit a bid for a
    beneficiary in average health (defined as a beneficiary with a risk
    score of 1.0). CBO projects that the average bid from current-law
    Medicare Advantage plans in 2020 will be 6 percent below the average
    FFS spending for a beneficiary with the same reported risk score. For
    the one-quarter of the nation's counties with the highest average FFS
    spending, CBO estimates, the average Medicare Advantage bid will be 12
    percent below that amount.\29\ For the one-quarter of counties with the
    lowest average FFS spending, CBO projects that the average Medicare
    Advantage bid will be 6 percent above that amount.\30\
    ---------------------------------------------------------------------------
        \29\ For this analysis, CBO divided counties into quartiles on the
    basis of average FFS spending in the county, with the same number of
    counties in each quartile. This differs from the approach elsewhere in
    the report for the analysis of beneficiaries' premiums, which divides
    groups of regions into quartiles constructed such that the same number
    of beneficiaries is in each quartile.
        \30\ Those estimates incorporate factors affecting bids that are
    related to the risk adjustment mechanism, discussed below. For this
    analysis, CBO excluded three types of Medicare Advantage plans that
    differ substantially from plans that would probably be offered under a
    premium support system: private FFS plans, special needs plans, and
    employment-based group plans. The FFS program's costs used for the
    comparisons in this report exclude certain types of spending because it
    is not covered by the bids that Medicare Advantage plans submit under
    current law--namely, the additional payments to disproportionate-share
    hospitals (whose share of low-income patients exceeds a specified
    threshold) and spending for medical education, hospice benefits, and
    certain benefits for patients with end-stage renal disease. CBO
    included in its calculations the government's cost of administering the
    FFS program. The analysis was based on CBO's projections of Medicare
    expenditures and Medicare Advantage enrollments in March 2012. See
    Congressional Budget Office, ``Medicare--March 2012 Baseline'' (March
    13, 2012), www.cbo.gov/publication/43060.

    CBO expects that Medicare Advantage bids will be higher relative to
    average FFS spending in the same areas in 2020 than in 2012 because
    Medicare Advantage plans will be able to achieve some--but not all--of
    the restraint in provider payment rates that is scheduled for the FFS
    system under current law. As a result, the agency projects higher
    growth in the bids of Medicare Advantage plans than it does for growth
    in per capita spending under the FFS system.

    Factors That Would Tend to Reduce Bids

    CBO anticipates that two main mechanisms would tend to lower bids under
    either option relative to Medicare Advantage bids under current law:
    increased competition that would result from stronger incentives for
    beneficiaries and insurers to focus on reducing health care costs and
    the slightly greater favorable selection for private plans than exists
    under the Medicare Advantage program.

    Increased Competition. Differences in the plans' bids under either
    option would translate directly into differences in beneficiaries'
    premiums. Under current law, a Medicare Advantage plan with a bid below
    the benchmark receives a federal payment that equals the bid plus a
    rebate that is a percentage of the difference between the bid and the
    benchmark. (Beginning in 2014, the rebate will range from 50 percent to
    70 percent, depending on the plan's performance on certain measures of
    quality.) Plans now return most of that difference in the form of
    supplemental benefits (rather than as reduced premiums), which
    consumers generally find harder to evaluate than a cash amount. Under
    the illustrative premium support options, plans with bids below the
    benchmark would return the entire difference between the two in the
    form of lower premiums. Beneficiaries would therefore be more sensitive
    to differences in plans' bids in deciding on a plan than they would be
    under the Medicare Advantage program, so the insurers would have more
    incentive to lower their bids under the two premium support options.

    Insurers also would face more competition under both options because of
    changes in market structure. Under the Medicare Advantage program, the
    benchmarks are announced before insurers submit their bids. Under the
    two premium support options, the benchmarks would be determined from
    the bids themselves. Some evidence suggesting that competition among
    Medicare Advantage plans is limited under the current approach comes
    from a study that concluded that a $1.00 increase in a benchmark, with
    all other factors (including health care costs) held constant, results
    in a $0.49 increase in the average bid.\31\ In a highly competitive
    system (for example, one in which each dollar that a bid was below the
    bid of another plan within a region would correspond to a dollar's
    difference in the premiums between the two plans), the insurers' bids
    would primarily reflect their costs rather than the benchmarks.
    ---------------------------------------------------------------------------
        \31\ Zirui Song, Mary Beth Landrum, and Michael E. Chernew,
    ``Competitive Bidding in Medicare: Who Benefits From Competition?''
    American Journal of Managed Care, vol. 18, no. 9 (September 2012), pp.
    546-552, http://tinyurl.com/odtwf87.

    Insurers would be expected to respond to increased competition by
    reducing their costs and lowering their bids.\32\ The reductions might
    occur partly as a result of reduced administrative costs or smaller
    profit margins. But they also could result from cuts in spending for
    services, perhaps made possible by insurers' combining improvements in
    management of care with development of more restrictive provider
    networks, slower adoption of expensive technological advances, faster
    adoption of methods to compensate providers that demonstrated cost-
    effective care, or changes in benefit design (for example, tying cost-
    sharing requirements to evidence of the cost-effectiveness of specific
    services).
    ---------------------------------------------------------------------------
        \32\ For related research, see Thomas C. Buchmueller, ``Consumer-
    Oriented Health Care Reform Strategies: A Review of the Evidence on
    Managed Competition and Consumer-Directed Health Insurance,'' Milbank
    Quarterly, vol. 87, no. 4 (December 2009), pp. 820-841, http://
    tinyurl.com/nsaff32, and ``Does a Fixed-Dollar Premium Contribution
    Lower Spending?'' Health Affairs, vol. 17, no. 6 (November 1998), pp.
    228-235, http://tinyurl.com/puwqjaz; David M. Cutler and Sarah J.
    Reber, ``Paying for Health Insurance: The Trade-Off Between Competition
    and Adverse Selection,'' Quarterly Journal of Economics, vol. 113, no.
    2 (May 1998), pp. 433-466, http://tinyurl.com/ mycqvem; and Steven C.
    Hill and Barbara L. Wolfe, ``Testing the HMO Competitive Strategy: An
    Analysis of Its Impact on Medical Care Resources,'' Journal of Health
    Economics, vol. 16, no. 3 (June 1997), pp. 261-286, http://tinyurl.com/
    nvvz76c.

    Under the specification of the two options that restricts insurers to
    submitting a maximum of two bids for the basic benefit package in any
    bidding region, CBO also expects that insurers would eliminate some of
    the higher-bidding plans that would exist under the Medicare Advantage
    program--reducing average bids. (Under the Medicare Advantage program,
    ---------------------------------------------------------------------------
    insurers often submit more than two bids in their service areas.)

    Increased Favorable Selection. Under both premium support options, all
    private insurers in a region would submit bids indicating the payment
    they would accept to provide Medicare benefits for a beneficiary of
    average health, and those standardized bids would be used to establish
    regional benchmarks. Payments to insurers would be adjusted to reflect
    the health status of their enrollees, using a risk adjustment mechanism
    that CBO assumed would be comparable to that of the Medicare Advantage
    program.

    It is difficult to adjust payments to reflect health status, and the
    system used for Medicare Advantage is unavoidably imperfect. Medicare
    beneficiaries in poor health tend to prefer to enroll in the FFS
    program because it generally places fewer restrictions on the use of
    health care services. That tendency is in evidence even among
    beneficiaries with the same risk scores because risk scores incorporate
    only limited information about health status. When a beneficiary who
    enrolls in a private plan is healthier than someone with the same risk
    score enrolled in the FFS program, the private plan experiences
    ``favorable selection'' beyond that captured by risk scores. Some
    research indicates that current Medicare Advantage enrollees who have a
    given risk score would have had lower costs, on average, under the FFS
    program than people enrolled in the FFS program with that same
    score.\33\
    ---------------------------------------------------------------------------
        \33\ Estimates of the difference vary considerably, however. For
    example, see Joseph P. Newhouse and others, ``Steps to Reduce Favorable
    Risk Selection in Medicare Advantage Largely Succeeded, Boding Well for
    Health Insurance Exchanges,'' Health Affairs, vol. 31, no. 12 (December
    2012), pp. 2,618-2,628, http://tinyurl.com/naps2jl; Medicare Payment
    Advisory Commission, Report to the Congress: Medicare and the Health
    Care Delivery System (June 2012), pp. 100-101, http://go.usa.gov/DXbF;
    Gerald F. Riley, ``Impact of Continued Biased Disenrollment From the
    Medicare Advantage Program to Fee-for-Service,'' Medicare and Medicaid
    Research Review, vol. 2, no. 4 (2012), pp. E1-E17, http://go.usa.gov/
    DXbd; and Jason Brown and others, How Does Risk Selection Respond to
    Risk Adjustment? Evidence From the Medicare Advantage Program, Working
    Paper 16977 (National Bureau of Economic Research, April 2011),
    www.nber.org/papers/w16977.

    CBO expects that, under either premium support option, private plans
    would experience greater favorable selection (beyond that captured by
    risk scores) than they will experience under the Medicare Advantage
    program. That is, people who enrolled in private plans--under either
    option--would use fewer health care services, on average, than people
    with the same risk score enrolled in Medicare Advantage. CBO
    anticipates that outcome because increased competition would prompt
    insurers to take more aggressive steps to control costs (by enhancing
    utilization management or using tighter provider networks, for
    example), thus rendering private insurers less attractive to
    beneficiaries who would, on average, use more health care services than
    ---------------------------------------------------------------------------
    would other beneficiaries with the same risk score.

    Because of the increased favorable selection, costs per enrollee would
    be lower for private plans under a premium support system than for
    Medicare Advantage plans under current law if the average risk scores
    in the two sets of plans were the same. Reflecting those lower costs,
    private plans competing for additional enrollees under either option
    would tend to reduce their bids for a beneficiary of average health
    relative to those of Medicare Advantage plans, CBO anticipates.

    Factors That Would Tend to Raise Bids

    CBO estimates that in most counties the percentage of beneficiaries
    enrolled in the FFS program would decline once either premium support
    option took effect. In CBO's assessment, the reduced market share of
    the FFS program would tend to boost the rates that private insurers
    paid to health care providers and thereby lead them to raise their
    bids. That reduction in market share, and thus the effect on private
    insurers' bids, would be greater in areas where average FFS spending
    was high. (CBO's methodology for estimating the proportion of
    beneficiaries who would select the FFS program is discussed below.)

    Declines in the FFS program's market share would affect payment rates
    for private insurers through two main mechanisms. First, the importance
    of payment rates from the FFS program would diminish as a determinant
    of the amounts private insurers would pay health care providers for
    treating Medicare enrollees (those FFS payment rates are generally a
    good deal lower than the rates private insurers pay to providers of
    health care for people with commercial insurance--that is, employment-
    based coverage). Second, some private insurers would need to broaden
    their provider networks to accommodate additional enrollees. Both
    mechanisms would cause insurers to raise their bids to cover additional
    costs, CBO projects.

    The Reduced Importance of FFS Provider Payment Rates. CBO's assessment
    of the importance to private plans of FFS payment rates is based on the
    observation that, on balance, the rates paid for Medicare Advantage
    enrollees are similar to or slightly above those that Medicare pays for
    FFS patients' care--even though providers receive substantially higher
    amounts when they offer the same services to patients in commercial
    plans focused on the under-65 population.\34\ The exact cause of the
    difference is not known, but it appears to arise in part because
    private insurers that offer Medicare Advantage plans can exclude from
    their networks any providers who are unwilling to accept Medicare's
    rates, thus reducing those providers' volume of Medicare patients;
    those same providers would generally end up being paid the lower rates
    for treating Medicare patients in the FFS system. Moreover, when
    Medicare Advantage enrollees go outside their plan's provider network
    to obtain care that the plan either must cover by law (emergency care,
    for example) or that it covers as a matter of choice (such as certain
    highly specialized services), federal law requires providers to accept
    Medicare's FFS rates as payment in full.\35\ Thus, a hospital that
    might anticipate providing a certain amount of emergency care to
    enrollees in a Medicare Advantage plan would not receive higher
    commercial rates for treating those patients simply because it refused
    to join the plan's network.
    ---------------------------------------------------------------------------
        \34\ Information about those rates is based on interviews conducted
    by CBO staff with industry sources and is consistent with reports in
    the research literature. See Robert A. Berenson and others, ``The
    Growing Power of Some Providers to Win Steep Payment Increases From
    Insurers Suggests Policy Remedies May Be Needed,'' Health Affairs, vol.
    31, no. 5 (May 2012), pp. 973-981, http://tinyurl.com/ntyyudv.
        \35\ Sections 1866(a)(1)(O) and 1876(i)(1) of the Social Security
    Act contain the relevant provisions for hospitals and physicians,
    respectively.

    The relationship between private insurers and providers is much
    different for plans that serve commercial enrollees. Although there are
    dominant insurers in many commercial markets, they appear to have less
    leverage than the Medicare FFS program has with providers--in part, at
    least, because FFS payment rates are established by law and are not
    subject to negotiation. If providers are unwilling to accept rates for
    their commercial enrollees that are similar to Medicare's rates, they
    can be reasonably confident that other insurers will pay them more--
    particularly because private insurers typically try to satisfy
    consumers' desire for broad provider networks. In addition, when
    enrollees in commercial plans go outside the plan's network to receive
    care, the providers who treat them generally charge more than they
    would have charged had they been in the plan's network. Insurers often
    limit their payments for such care to predetermined amounts, but
    patients are often responsible for some or all of the differences
    ---------------------------------------------------------------------------
    between those payments and the provider's charges.

    In regions where the role of the FFS program diminished under a premium
    support system, CBO expects, the relationship between private insurers
    and health care providers would become less similar to the relationship
    in Medicare Advantage under current law and more similar to the
    relationship in the commercial market for people under age 65.

    Broadening of Provider Networks. Another reason bids would increase as
    the share of beneficiaries in the FFS program fell is that private
    insurers, on average, would need to expand their networks to
    accommodate increased enrollment. As a result, private insurers would
    probably need either to pay higher rates or to contract with providers
    with higher-cost practice styles. Bids would rise as a result of
    including higher-cost health care providers that private insurers would
    tend to have excluded when their networks could be narrower. The
    expansion would be greater for lower-bidding plans, CBO projects,
    because those plans would experience greater increases in enrollment.

    The Magnitude of the Resulting Adjustments to Bids. CBO did not adjust
    its projections of private insurers' bids in counties in which it
    expects that the FFS program would maintain the share that it currently
    holds (or its nationwide market share, if that is lower). The agency
    anticipates that, in those counties, the forces that now allow private
    insurers to obtain payment rates for their Medicare Advantage plans
    that are similar to those for Medicare's FFS program would continue to
    prevail under a premium support system.\36\ However, where the market
    share of the FFS program is projected to fall below its current level--
    and where that share would be below the current national market share--
    CBO expects that private insurers would pay higher rates to providers
    for their premium support enrollees than they would pay under current
    law for Medicare Advantage enrollees. CBO adjusted its projections for
    insurers in those counties, and the adjustment was greater for counties
    where larger reductions are anticipated in the FFS program's market
    share. CBO also adjusted the bids upward slightly for plans at or near
    the bottom of the bid distribution to account for the expected
    broadening of provider networks.
    ---------------------------------------------------------------------------
        \36\ CBO expects that the rates private insurers will pay providers
    under Medicare Advantage plans will rise over time relative to
    Medicare's FFS rates because private insurers are not likely to obtain
    all of the reductions in payment updates that are scheduled for the FFS
    program under current law. The adjustments to bids discussed in this
    section were applied to projected Medicare Advantage bids, developed
    under the expectation that private insurers' payment rates would be
    higher relative to Medicare FFS rates than they are now.

    The size of the adjustment for private plans' bids was made partly on
    the basis of the agency's assessment of the average difference between
    the rates paid by Medicare and the rates paid by private insurers to
    hospitals, physicians, and other providers for enrollees in commercial
    plans. However, the adjustment was smaller than that average difference
    ---------------------------------------------------------------------------
    as a way to account for four main factors:

      The observed difference in payment rates now is more informative
    about the rise in rates that might occur under a premium support system
    in which the FFS program was eliminated; rates would generally rise
    much less under a system in which the FFS program was a competing
    plan--particularly in regions where the FFS program retained a
    significant market share.

      Medicare's FFS payment rates would be used as a reference point
    in negotiations between private plans and providers for their premium
    support enrollees, which would tend to keep those rates below
    commercial rates even in regions where the FFS program had a very low
    market share.

      The competitive structure of a premium support system would tend
    to push rates below commercial rates. In particular, current tax-based
    subsidies to health insurance for commercial enrollees result in less
    competitive pressure on provider payment rates than would occur under
    the premium support options analyzed here.

      A reduction in the FFS market share would lower commercial
    rates, reducing the difference between FFS rates and commercial rates.
    Because of the reduction in the FFS market share, fewer health care
    services would be paid for at relatively low Medicare FFS rates. As a
    result, fewer costs associated with Medicare beneficiaries would
    probably be shifted to private insurers through higher rates for
    hospital services, thus reducing commercial rates.

    After considering all of those factors, CBO made separate adjustments
    to its estimates of the bids in each county, depending on the projected
    changes in the FFS program's market share. The relationship between the
    FFS market share and private plans' bids is subject to considerable
    uncertainty, but CBO regards its estimates as being in the middle of
    the distribution of possible outcomes.

    Differences Between the Options' Effects on Bids

    The combined effects of the factors that would tend to lower bids would
    be slightly larger under the second-lowest-bid option than under the
    average-bid option. In 2020, those effects would reduce bids by about 7
    percent, on average, under the
    second-lowest-bid option and by about 6 percent under the average-bid
    option. In either case, the amount by which bids were reduced would
    vary considerably from one region to another.

    The effects of the factors that tended to increase bids also would be
    slightly larger under the second-lowest-bid option than under the
    average-bid option because the increased competition, and the resulting
    changes in enrollment among the plans, would be greater. In 2020, that
    effect would boost bids by about 3 percent, on average, under the
    second-lowest-bid option and by about 2 percent under the average-bid
    option.

    The largest difference in the effects of the two options on bids by
    private insurers would result from a difference in the degree of
    competition. That difference would occur for two main reasons.

    First, and more important, the benchmark would be lower under the
    second-lowest-bid option than under the average-bid option in most
    regions, so the premiums for a plan with a given bid would be higher.
    In CBO's judgment, insurers would expect those higher premiums to
    increase beneficiaries' sensitivity to differences in costs because
    premiums would consume a greater share of enrollees' discretionary
    income.

    Second, bids for plans that wanted to attract automatically assigned
    beneficiaries would tend to be lower under the second-lowest-bid option
    than under the average-bid option. Under either option, according to
    specifications outlined in this report, beneficiaries who made no
    affirmative choice would be assigned with equal probability to an
    available plan that had submitted a bid that was at or below the
    regional benchmark (or to one of the four lowest-bidding plans if more
    than four met that criterion). Although such beneficiaries would be
    comparatively less attractive to plans than those who made an active
    enrollment choice, some plans would nevertheless seek to obtain them
    through assignment. Because no more than two plans would receive
    automatically assigned beneficiaries under the second-lowest-bid option
    in most instances, compared with as many as four under the average-bid
    option, the plans that wanted to enroll such beneficiaries would have
    greater incentives to submit lower bids under the second-lowest-bid
    option.

    Changes Over Time in Effects on Bids

    Under either option, the combined effects of the factors that tended to
    reduce bids would increase over time, as would the combined effects of
    the factors that tended to increase bids. On balance, CBO anticipates,
    the difference between private insurers' bids under the two options and
    average FFS costs would remain fairly constant for the decade following
    the first few years of implementation.

    CBO expects that the increased competition in particular would lead
    insurers to reduce costs even more after 2020 so they could keep their
    bids as low as possible in subsequent years. However, for three
    reasons, the incremental reductions would probably be smaller than the
    initial drop: First, one assumption of this analysis is that the
    legislation that created a new premium support system would provide
    private insurers with several years to determine how to reduce their
    costs before the system was implemented with the result that many
    changes would probably be undertaken in the first few years. Second,
    because many beneficiaries would probably remain in the first plan they
    chose without thoroughly evaluating their options in subsequent years,
    insurers would have an especially strong incentive to submit low bids
    in the first year of the new system. Third, insurers would tend to
    undertake the easier reductions first, and additional reductions would
    probably involve more difficult actions.

    However, CBO also projects that Medicare Advantage bids under current
    law will rise more rapidly than average spending in the FFS program. As
    a result, greater cost reduction under the premium support options
    would be necessary in future years to maintain the percentage savings
    relative to FFS spending projected for 2020. By CBO's estimate, the
    additional cost reductions would roughly offset the trends in Medicare
    Advantage bids projected under current law through the 2020s.

     Estimating Federal Spending for Medicare and Beneficiaries' Total
                        Payments

    The methods for estimating combined federal spending and beneficiaries'
    total payments were similar for both options CBO analyzed. CBO
    projected bids for a given year as described in the previous section.
    The agency used those bids (and, for the average-bid option, past
    enrollment) to estimate benchmarks in each county and premiums for each
    plan in each county. It then simulated the enrollment of a large sample
    of beneficiaries in different plans on the basis of premiums and
    previous patterns of enrollment, calculated federal spending as the sum
    of the risk-adjusted federal contribution for each beneficiary, and
    compared total federal spending with the baseline projection. To
    project beneficiaries' total payments, CBO used claims data to estimate
    cost-sharing payments by each beneficiary for the services covered by
    Medicare and combined those estimates with the plans' premiums.

    The estimates incorporated data from administrative records for a
    sample of about 600,000 Medicare beneficiaries, along with county-level
    projections of the FFS program's bid and the bids of private plans. CBO
    adjusted the estimates of out-of-pocket spending to match the actuarial
    value of the plans and current distributions of health spending by age,
    health risk, and other factors.

    The enrollment simulations were based in part on estimates of two
    especially important aspects of beneficiaries' choices of plans: their
    sensitivity to premiums and the likelihood that they would actively
    choose to enroll in a plan. The analysis also incorporated the effects
    of CBO's expectation that patients who enrolled in private plans would
    have their diagnoses coded more intensively than would patients in the
    FFS program. Possible spillover effects on Medicare FFS spending from
    increased enrollment in private plans were not considered in the
    estimates.

    Sensitivity to Premiums

    To develop its projections of the plans that Medicare beneficiaries
    would choose under different premium support proposals, CBO conducted
    its own analysis and it examined findings from the research literature
    concerning beneficiaries' sensitivity to premiums in selecting health
    plans.\37\ In the agency's judgment, there are two main reasons that
    beneficiaries' sensitivity under either option would be greater than is
    generally reported in the literature for the Medicare population.
    First, they would face larger differences in premiums under the options
    than those that have been studied previously. Second, beneficiaries
    would receive information on the features of available plans--including
    premiums--in ways that would make comparison among plans simpler than
    is generally the case under current law. Moreover, CBO anticipates,
    beneficiaries who are new Medicare enrollees in the future will be more
    sensitive, on average, than current beneficiaries are to differences in
    premiums. CBO expects those beneficiaries to be healthier generally
    (and thus less likely to have strong ties to providers who might not be
    in some plans' networks) and, because of their experience in the health
    insurance marketplace, to be more conversant than many current
    enrollees are with the process of choosing among plans that offer
    different premiums and packages of benefits.
    ---------------------------------------------------------------------------
        \37\ See, for example, Thomas C. Buchmueller and others, ``The
    Price Sensitivity of Medicare Beneficiaries: A Regression Discontinuity
    Approach,'' Health Economics, vol. 22, no. 1 (January 2013), pp. 35-51,
    http://tinyurl.com/oo2rrk4; Steven D. Pizer, Austin B. Frakt, and Roger
    Feldman, ``Nothing for Something? Estimating Cost and Value for
    Beneficiaries From Recent Medicare Spending Increases on HMO Payments
    and Drug Benefits,'' International Journal of Health Care Finance and
    Economics, vol. 9, no. 1 (March 2009), pp. 59-81, http://tinyurl.com/
    p7xjtvh; Thomas C. Buchmueller, ``Price and the Health Plan Choices of
    Retirees,'' Journal of Health Economics, vol. 25, no. 1 (January 2006),
    pp. 81-101, http://tinyurl.com/m6p93dz; Adam Atherly, Bryan E. Dowd,
    and Roger Feldman, ``The Effect of Benefits, Premiums, and Health Risk
    on Health Plan Choice in the Medicare Program,'' Health Services
    Research, vol. 39, no. 4 (August 2004), pp. 847-864, http://
    tinyurl.com/o4wl339; Bryan E. Dowd, Roger Feldman, and Robert Coulam,
    ``The Effect of Health Plan Characteristics on Medicare+Choice
    Enrollment,'' Health Services Research, vol. 38, no. 1, part 1
    (February 2003), pp. 113-135, http://tinyurl.com/p34m69r; Anne Beeson
    Royalty and Neil Solomon, ``Health Plan Choice: Price Elasticities in a
    Managed Competition Setting,'' Journal of Human Resources, vol. 34, no.
    1 (Winter 1999), pp. 1-41, http://tinyurl.com/o2m3br7; David M. Cutler
    and Sarah J. Reber, ``Paying for Health Insurance: The Trade-Off
    Between Competition and Adverse Selection,'' Quarterly Journal of
    Economics, vol. 113, no. 2 (May 1998), pp. 433-466, http://tinyurl.com/
    mycqvem; and Thomas C. Buchmueller, ``The Health Plan Choices of
    Retirees Under Managed Competition,'' Health Services Research, vol.
    35, no. 5, part 1 (December 2000), pp. 949-976, http://tinyurl.com/
    lajxa4w.

    In most regions, under either option, beneficiaries would be able to
    choose from several private plans that are likely to be more similar to
    one another than to the FFS program in terms of the size of provider
    networks and approaches to utilization management. Therefore, CBO
    anticipates, beneficiaries would be more sensitive to premiums when
    choosing among private plans than they would be when choosing between
    any private plan and the FFS program. Additionally, CBO expects,
    beneficiaries would become somewhat less sensitive to the cost of
    premiums after the first few years; once beneficiaries are in a plan,
    they generally do not seem to switch readily.\38\ Nevertheless, the
    possibilities of attracting new enrollees each year and of losing
    existing enrollees to competitors would provide incentives for private
    plans to continue to keep bids low.
    ---------------------------------------------------------------------------
        \38\ For related discussion, see Benjamin R. Handel, ``Adverse
    Selection and Inertia in Health Insurance Markets: When Nudging
    Hurts,'' working paper (University of California at Berkeley, March
    2013, http://emlab.berkeley.edu/bhandel/index.shtml; Peter J.
    Cunningham, Few Americans Switch Employer Health Plans for Better
    Quality, Lower Costs, Research Brief 12 (National Institute for Health
    Care Reform, January 2013), www.nihcr.org/Health-Plan-Switching;
    Jonathan D. Ketcham and others, ``Sinking, Swimming, or Learning to
    Swim in Medicare Part D,'' American Economic Review, vol. 102, no. 6
    (October 2012), pp. 2639-2673, http://tinyurl.com/ow8luxd; Keith M.
    Marzilli Ericson, Consumer Inertia and Firm Pricing in the Medicare
    Part D Prescription Drug Insurance Exchange, Working Paper 18359
    (National Bureau of Economic Research, September 2012), www.nber.org/
    papers/w18359; and Kathleen Nosal, ``Estimating Switching Costs for
    Medicare Advantage Plans,'' working paper (University of Arizona, June
    2012), www.u.arizona.edu/nosal/research.html.

    The constraints on Medicare payment rates for providers embodied in
    current law may result in diminished access to care and in reduced
    quality of care for beneficiaries in the FFS program, although the
    timing and extent of such changes are very difficult to predict. In
    this analysis, CBO anticipates that beneficiaries would respond to the
    possibility of reduced access or quality by being somewhat more
    inclined to choose a private plan than to choose the FFS program when
    the FFS rates for health care providers fell relative to those of
    private plans.

    Active Choice of a Plan

    In CBO's assessment, a significant proportion of beneficiaries would
    not actively choose a plan in the first year that a premium support
    system was implemented. Under the specifications adopted for this
    report, beneficiaries who did not make a choice would be assigned
    randomly to a plan with a bid at or below the benchmark (or to one
    among the four lowest-bidding plans, if more than four bid at or below
    the benchmark). To project that share of beneficiaries, CBO analyzed
    the behavior of Medicare Advantage enrollees whose plans had left the
    market, and it reviewed research on enrollment in the Part D program.

    CBO expects that a higher percentage of beneficiaries would choose a
    plan under the second-lowest-bid option than under the average-bid
    option because the higher average premiums would be more likely to
    impel beneficiaries to learn about the new program and choose a plan.
    CBO projects that, on average, about 15 percent of beneficiaries would
    not choose a plan in the first year of premium support under the
    second-lowest-bid option and about 20 percent would not choose a plan
    in the first year under the average-bid option. The percentages would
    be expected to vary according to certain demographic characteristics
    and health status identified in CBO's analyses and in its review of
    related research. The agency also projects that most beneficiaries who
    were assigned to a plan in 2018 would still be in that plan by 2020
    (the reference year for the analysis of beneficiaries' premiums) but
    that some beneficiaries who did not choose a plan in the first year
    would switch from the low-bidding plan to which they were assigned to a
    higher-bidding plan later.

    More Intensive Diagnostic Coding by Private Insurers

    Evidence suggests that private insurers in the Medicare Advantage
    program record a larger number of diagnoses than FFS providers do, so a
    given beneficiary would be expected to have a higher risk score in a
    Medicare Advantage plan than in the FFS program. Because higher risk
    scores result in larger payments, private insurers have a financial
    incentive to ensure that every appropriate diagnosis is coded for each
    enrollee; such an incentive does not generally exist in the FFS sector.
    Although the Medicare program adjusts the risk scores of Medicare
    Advantage enrollees downward to attempt to account for the difference--
    and that adjustment was incorporated in the risk scores used in this
    analysis--there is recent evidence that the adjustment is probably
    insufficient.\39\ CBO expects that under the two options private
    insurers would code diagnoses more intensively than providers treating
    FFS patients to the same extent that they would do so in the Medicare
    Advantage program under current law and that the Medicare program would
    adjust the risk scores of enrollees in private plans to the same extent
    that is projected for Medicare Advantage under current law. Thus, no
    adjustments to plans' projected bids in Medicare Advantage were needed
    to account for those practices.
    ---------------------------------------------------------------------------
        \39\ The Centers for Medicare and Medicaid Services has estimated
    that reported risk scores for Medicare Advantage enrollees are 3.4
    percent higher than they would have been in the FFS sector, and the
    agency adjusts the reported risk scores downward by 3.4 percent when it
    calculates payments to the plans. Under current law, beginning in 2014
    and continuing until 2018, the agency must increase the adjustment
    until the downward adjustment reaches at least 5.9 percent. The
    Government Accountability Office has estimated that the difference in
    coding boosts risk scores for Medicare Advantage enrollees by between 5
    percent and 6 percent relative to likely scores in the FFS system and
    that the difference has widened over time. See Government
    Accountability Office, Substantial Excess Payments Underscore Need for
    CMS to Improve Accuracy of Risk Score Adjustments, GAO-13-206 (January
    2013), www.gao.gov/products/GAO-13-206.

    However, CBO expects that the more intensive coding of diagnoses would
    affect federal spending under a premium support system even though it
    would not affect the bids of private plans relative to those under
    current law. In particular, under both options, a larger fraction of
    the Medicare population would be covered by private plans, and thus
    more of the population would be subject to more intensive coding, on
    average, than is the case under current law. Therefore, CBO accounted
    for differences in coding in its projections of payments to insurers.
    CBO expects that beneficiaries who switched from the FFS program to a
    private plan would end up with higher risk scores and that the Medicare
    program would adjust for only part of that difference in calculating
    payment amounts for the insurers. As a result, the federal government
    would pay more for such beneficiaries under a premium support system,
    all else being equal, than it would if there was no difference in
    coding or if the Medicare program adjusted the risk scores of private
    plans to completely remove the effects of coding differences.

    Possible Spillover Effects on Medicare FFS Spending

    There is evidence that increases in the proportion of beneficiaries
    enrolled in Medicare Advantage plans lead to lower federal spending for
    beneficiaries in the FFS program and in a lower intensity of their
    treatment.\40\ Such spillover effects could occur through at least two
    pathways: Increased managed care penetration could change the way
    physicians treat all of their patients, not just those enrolled in
    managed care plans, and it could influence investment decisions and the
    adoption of new technology in local markets. For this report, CBO did
    not incorporate such spillover effects on the FFS program.
    ---------------------------------------------------------------------------
        \40\ See Katherine Baicker, Michael Chernew, and Jacob Robbins, The
    Spillover Effects of Medicare Managed Care: Medicare Advantage and
    Hospital Utilization, Working Paper 19070 (National Bureau of Economic
    Research, May 2013), www.nber.org/papers/w19070; Michael Chernew,
    Philip DeCicca, and Robert Town, ``Managed Care and Medical
    Expenditures of Medicare Beneficiaries,'' Journal of Health Economics,
    vol. 27, no. 6 (December 2008), pp. 1,451-1,461, http://tinyurl.com/
    qxfh4h9; and Laurence C. Baker, ``The Effect of HMOs on Fee-for-Service
    Health Care Expenditures: Evidence From Medicare,'' Journal of Health
    Economics, vol. 16, no. 4 (July 1997), pp. 453-481, http://tinyurl.com/
    kf28hus. The study of Baicker and others presented estimates of the
    effects of Medicare Advantage plans' market share on hospitals'
    resource costs of treating Medicare beneficiaries, which do not
    directly determine Medicare's payments for FFS beneficiaries under the
    prospective payment system. The two other studies estimated the effects
    of Medicare Advantage plans' market share on Medicare spending for FFS
    beneficiaries.

    In CBO's estimation, such effects would be very small or even
    negligible in 2020, although the agency will explore the issue more in
    future analyses. The sustainable growth rate mechanism for physicians
    and the provisions of the Affordable Care Act that restrain payment
    updates for most other FFS providers also will restrain federal
    spending in Medicare's FFS program, suggesting that any additional
    reductions in Medicare spending on the FFS program that might result
    from a spillover effect would be smaller than has been estimated in the
    past.\41\
    ---------------------------------------------------------------------------
        \41\ The Affordable Care Act comprises the Patient Protection and
    Affordable Care Act and the health care provisions of the Health Care
    and Education Reconciliation Act of 2010.

    Over the longer term, the size of spillover effects would depend in
    part on whether the restraints on payment updates in the FFS program
    specified under current law are maintained. However, as discussed in
    the section of the text on ``Effects After the First Several Years,''
    stronger price-based competition under a premium support system would
    probably affect the emergence and diffusion of new technology and
    services in ways that might reduce FFS spending (for a beneficiary of
    ---------------------------------------------------------------------------
    average health, relative to that under current law) in the longer term.

                                     ______

                                  Appendix B:
                    Analysis of Uncertainty in the Estimates

    To characterize uncertainty in the estimated effects of the two
    illustrative options for a premium support system (one called the
    second-lowest-bid option and the other called the average-bid option)
    on federal spending for Medicare and on beneficiaries' total payments,
    the Congressional Budget Office (CBO) determined ranges of values for
    five key parameters and estimated the effects of varying those
    parameters. Those estimates focused on results for 2020, which CBO used
    as a reference year in the analysis. The ranges for the parameters'
    values were chosen to represent CBO's judgment that, accounting not
    only for uncertainty about those parameters but also about most of the
    sources of uncertainty in the analysis (assuming that a premium support
    system was implemented as specified here), there would be about a two-
    thirds chance that CBO's central estimate for the effect on federal
    spending would be within the range reported.

    CBO varied the following parameters to construct the ranges:

      Bids of Medicare Advantage plans relative to Medicare fee-for-
    service (FFS) spending as projected under current law,

      The amount by which private insurers would reduce their bids
    relative to Medicare Advantage bids under current law in response to
    the increased competitive pressure created by the premium support
    system and other factors,

      The higher rates that private insurers would need to pay
    providers (with corresponding increases in bids) that CBO projects
    would result if the market share of the FFS program fell significantly,

      The responsiveness of beneficiaries to differences in premiums
    when choosing among plans, and

      The percentage of beneficiaries who would not actively choose a
    plan in the first year of premium support and who therefore would be
    assigned to a plan with a bid at or below the benchmark.

    Effects on Federal Spending

    CBO estimated a range of effects on federal spending by simultaneously
    varying all five key parameters in ways that would result in higher or
    lower spending under the premium support options. To do so, the agency
    examined how varying each parameter would affect spending.

     Bids by Medicare Advantage Plans Relative to Fee-for-Service Spending

    If Medicare Advantage bids under current law were lower than those in
    CBO's projections and FFS spending was as CBO projects, then federal
    savings under both options would be greater, according to CBO's
    estimates, because the benchmarks under the options would be lower than
    projected. Conversely, if Medicare Advantage bids under current law
    were higher than those in CBO's projections and FFS spending was as CBO
    projects, federal savings would be smaller than projected. Although
    CBO's estimates of the effects of a premium support system are
    sensitive to changes in the bids of Medicare Advantage plans relative
    to FFS spending, those estimates are not directly sensitive to equal
    percentage changes in Medicare Advantage bids and FFS spending--that
    is, to an across-the-board increase or decrease in Medicare spending
    relative to the amounts that CBO projects--because the difference
    between the benchmarks under the options and federal spending for
    Medicare under current law would not be affected. However, if such an
    across-the-board change occurred, it could affect the amount by which
    private insurers under a premium support system reduced their bids
    relative to Medicare Advantage bids (as discussed below).

     Reduction of Bids of Private Plans in Response to Increased
                        Competitive Pressure and Other Factors

    If private insurers responded to increased competitive pressure by
    reducing their bids by more than the amounts in CBO's central
    estimates, federal savings would be correspondingly greater under both
    options because the benchmarks would be lower than estimated. But
    federal savings would be lower if private insurers reduced their bids
    by less than the central estimates.

    In addition, if FFS and Medicare Advantage costs were higher across the
    board (because of greater systemwide growth in costs), there might be
    more opportunity for cost savings, depending on the underlying drivers
    of that growth, and the amounts by which private insurers reduced their
    bids under the premium support options would probably be greater than
    they are in the agency's central estimates. Similarly, if costs were
    lower across the board, the amounts by which private insurers reduced
    their bids under the premium support options would probably be smaller
    than they are in the agency's central estimates.

    Rates That Private Insurers Would Pay to Providers

    If the decline in the market share of the FFS program under a premium
    support system resulted in higher payment rates for health care
    providers and therefore in higher bids from private insurers than in
    CBO's central estimates, federal savings would be correspondingly
    smaller because both those bids and the benchmarks would be higher, all
    else being equal. If that effect was smaller than in the central
    estimates, however, federal savings would be correspondingly greater.

    Beneficiaries' Sensitivity to Premiums

    Departures from the central estimates in beneficiaries' responsiveness
    to differences in premiums would influence federal spending both
    through the effects on plans' bids and through the effects on the share
    of beneficiaries enrolled in private plans. If beneficiaries were more
    responsive to differences in premiums than is predicted in CBO's
    central estimates, private insurers' bids would be lower than they are
    in those estimates (because insurers would have a stronger incentive to
    reduce their bids if such reductions led to larger increases in
    enrollment); those lower bids would result in greater federal savings.
    Conversely, if beneficiaries were less responsive to differences in
    premiums than in the central estimates, the private insurers' bids
    would be higher and federal savings would be lower. Regarding
    enrollment shares, if beneficiaries were more responsive to differences
    in premiums than in the central estimates, a larger proportion would
    switch to lower-bidding plans under premium support, causing several
    indirect effects on federal savings (as discussed below). If they were
    less responsive, the opposite would occur.

    Active Choice of a Plan

    If a larger percentage of beneficiaries did not actively choose a plan
    in the first year of premium support than is predicted in CBO's central
    estimates and if those beneficiaries were assigned to plans with bids
    at or below the benchmark, a larger percentage of beneficiaries would
    be enrolled in low-bidding plans, all else being equal. Conversely, if
    a smaller percentage of beneficiaries did not actively choose a plan, a
    smaller percentage would be enrolled in low-bidding plans. The
    implications for federal savings under the two premium support options
    would be similar to the indirect effects (discussed below) that would
    occur through changes in the shares of enrollment in private plans when
    beneficiaries were more, or less, sensitive to differences in premiums
    than is predicted in the central estimates. (Although one might expect
    that having a higher share of beneficiaries not actively choosing a
    plan would have effects similar to beneficiaries' being less sensitive
    to premiums, that is not the case because the beneficiaries who did not
    choose a plan would be assigned to a low-bidding plan.)

     Effects of Changes in the Proportion of Beneficiaries in Lower-Bidding
                        Plans

    A greater responsiveness of beneficiaries to differences in premiums
    when choosing among plans and a larger percentage of beneficiaries not
    actively choosing a plan in the first year would both lead to a larger
    proportion of beneficiaries being enrolled in lower-bidding plans.
    Similarly, less responsiveness to differences in premiums and a smaller
    percentage of beneficiaries not actively choosing a plan would lead to
    a smaller proportion of beneficiaries being enrolled in lower-bidding
    plans. Those differences in enrollment would have indirect effects on
    federal savings through three main mechanisms:

      Under the average-bid option, having a greater proportion of
    beneficiaries in lower-bidding plans would result in lower benchmarks
    (because benchmarks are constructed by weighting each plan's bid by its
    enrollment in the prior year) and thus would result in greater federal
    savings. And if a smaller proportion were enrolled in lower-bidding
    plans, higher benchmarks and lower federal savings would result. Under
    the second-lowest-bid option, however, having a higher or lower
    proportion of beneficiaries enrolled in lower-bidding plans would not
    directly affect benchmarks.

      In most regions, the lower-bidding plans would be private plans,
    and higher enrollment in those plans would be accompanied by a lower
    market share for the FFS program, which would increase bids of private
    plans for reasons discussed above, all else being equal. Lower
    enrollment in private plans would have the opposite effect.

      For any given set of bids, CBO expects, greater enrollment in
    private plans would result in smaller federal savings because
    diagnostic coding by private insurers would be more intensive than that
    by FFS providers under a premium support system (as is now the case
    under the Medicare Advantage program) and federal payments to private
    plans would be adjusted to account for only part of that difference in
    coding. Again, lower enrollment in private plans would have the
    opposite effect.

    Effects on Beneficiaries' Total Payments

    CBO estimated a range of effects on beneficiaries' total payments by
    simultaneously varying all five key parameters in ways that would
    result in higher and lower payments under the premium support options.
    In CBO's assessment, the uncertainty of the estimated effects on
    beneficiaries' total payments is greater than that concerning the
    estimated effects on federal spending because there are especially
    broad ranges of plausible values for the two parameters that would
    affect beneficiaries' payments the most: their sensitivity to premiums
    and the percentage who would not initially choose a plan. Varying other
    parameters also affects the estimates.

    If beneficiaries were more sensitive to premiums than CBO's central
    estimates indicate, more of them would enroll in lower-bidding plans,
    and their total payments would be lower, on average, than the central
    estimates indicate (because enrollees in low-bidding plans would pay
    lower premiums and use fewer medical services and therefore pay less
    out of pocket for services). The opposite also is true: If
    beneficiaries are less sensitive to premiums, fewer would enroll in
    lower-bidding plans, and their total payments would be higher, on
    average.

    By the same logic, if the proportion of beneficiaries who did not
    choose a plan in the first year of a premium support system was larger
    than that indicated by the central estimates, their total payments
    would be lower, on average, than predicted (because those who did not
    choose a plan would be assigned to one with a bid at or below the
    benchmark). And if the proportion of beneficiaries who did not choose a
    plan was smaller than in the central estimates, their total payments
    would be higher, on average.

    Beneficiaries' payments under the premium support options also would
    depend on other factors that contribute to the uncertainty of CBO's
    estimates. Private plans' bids could differ from the agency's central
    estimates if the current-law bids for Medicare Advantage were higher or
    lower than they are in CBO's estimates, if private insurers reduced
    their bids under a premium support system by more or less than the
    amounts in those estimates, or if the adjustment to plans' provider
    payment rates (and thus their bids) reflected a decline in the FFS
    market share that was smaller or larger than that in the estimates. For
    example, if the bids of private plans were below the central estimates,
    then payments would be lower for enrollees in those plans (because of
    lower premiums and reduced cost sharing) and higher for those who
    enrolled in the FFS program (because the lower cost of private plans
    would reduce benchmarks and raise FFS premiums). As a result,
    beneficiaries would have a greater incentive to switch from the FFS
    program to private plans, and beneficiaries' total payments would be
    lower than CBO's central estimates would indicate (assuming that the
    number of beneficiaries enrolled in the FFS program was not so large
    that the increase in payments for those beneficiaries outweighed the
    reduction in payments for enrollees in private plans and the reduction
    in the standard premium for all beneficiaries as a result of the lower
    benchmarks). If private plans' bids were higher than predicted by the
    central estimates, beneficiaries' total payments would rise relative to
    the central estimates.

                                     ______

                              About This Document

    This Congressional Budget Office (CBO) report was prepared in response
    to interest expressed by Members of Congress. In keeping with CBO's
    mandate to provide objective, impartial analysis, the report makes no
    recommendations.

    Jessica Banthin, James Baumgardner, Tom Bradley, Melinda Buntin
    (formerly of CBO), Holly Harvey, Paul Jacobs, Jeffrey Kling, Paul Masi,
    Eamon Molloy, Lyle Nelson, Romain Parsad, and Andrew Stocking
    contributed to the analysis and prepared the report with guidance from
    Linda Bilheimer and Peter Fontaine. Additional assistance was provided
    by numerous analysts in CBO's Budget Analysis Division and in its
    Health, Retirement, and Long-Term Analysis Division.

    Henry Aaron of the Brookings Institution, Joseph Antos of the American
    Enterprise Institute, Thomas Buchmueller of the University of Michigan,
    Michael Chernew of Harvard University, Mark Duggan of the University of
    Pennsylvania, Alain Enthoven of Stanford University, Roger Feldman of
    the University of Minnesota, Amy Finkelstein of the Massachusetts
    Institute of Technology, Paul Ginsburg of the Center for Studying
    Health System Change, Mark McClellan of the Brookings Institution, Mark
    Miller of the Medicare Payment Advisory Commission, Joseph Newhouse of
    Harvard University, Patricia Neuman of the Kaiser Family Foundation,
    and Robert Reischauer of the Urban Institute provided comments about
    CBO's analytical approach. (The assistance of external experts implies
    no responsibility for the final product, which rests solely with CBO.)

    Kate Kelly edited the report, and Maureen Costantino and Jeanine Rees
    prepared it for publication. An electronic version is available on
    CBO's website (www.cbo.gov/publications/44581).

    Douglas W. Elmendorf
    Director

    September 2013

                                     ______

                                    Table 1.
     Change in Net Federal Spending for Medicare Under Illustrative Premium
            Support Options, Relative to That Under Current Law, 2020
    ------------------------------------------------------------------------
                          Second-Lowest-Bid Option     Average-Bid Option
    ------------------------------------------------------------------------
    In Billions of                            -45                       -15
     Dollars a

    As a Percentage of                         -6                        -2
     Net Federal
     Spending for
     Medicare

    As a Percentage of                        -11                        -4
     Net Federal
     Spending for Parts
     A and B for
     PAffected
     Beneficiaries b
    ------------------------------------------------------------------------
    Source: Congressional Budget Office.

    Note: Although estimates of percentage changes are based on CBO's March
      2012 baseline projections (which are the projections underlying the
      analysis in this report), the dollar savings are based on applying
      those percentages to CBO's most recent projections (see Updated Budget
      Projections: Fiscal Years 2013 to 2023, May 2013, www.cbo.gov/
      publication/44172).

    a Rounded to the nearest $5 billion.

    b Affected beneficiaries include everyone who would have enrolled in
      Medicare under current law, except dual-eligible beneficiaries (people
      who are simultaneously enrolled in Medicare and Medicaid). Spending
      for affected beneficiaries includes all spending for Part A (Hospital
      Insurance) and Part B (Medical Insurance) except spending that was
      excluded because it is not covered by the bids that Medicare Advantage
      plans submit under current law--namely, the additional payments to
      disproportionate-share hospitals (whose share of low-income patients
      exceeds a specified threshold) and spending for medical education,
      hospice benefits, and certain benefits for patients with end-stage
      renal disease. Spending for Part D prescription drug insurance is
      excluded.

                                    Table 2.
        Change in Net Federal Spending for Medicare and in Beneficiaries'
    Payments Under Illustrative Premium Support Options, Relative to Amounts
                             Under Current Law, 2020
    ------------------------------------------------------------------------
          (Percent)       Second-Lowest-Bid Option     Average-Bid Option
    ------------------------------------------------------------------------
    Net Federal Spending
     for Parts A and B
     for Affected
     Beneficiaries a
        Central Estimate                      -11                        -4
        Range                           -9 to -14                  -1 to -7

    Total Payments by
     Affected
     Beneficiaries b
        Central Estimate                       11                        -6
        Range                            -2 to 24                  0 to -12

    Net Federal Spending
     for Parts A and B
     for Affected
    Beneficiaries Plus
     Total Payments by
     Affected
     Beneficiaries a, b,
      c
        Central Estimate                       -5                        -4

    Memorandum:
    Premiums Paid by
     Affected
     Beneficiaries c, d
        Central Estimate                       31                        -6
    ------------------------------------------------------------------------
    Source: Congressional Budget Office.

    Note: Affected beneficiaries include everyone who would have enrolled in
      Medicare under current law, except dual-eligible beneficiaries (people
      who are simultaneously enrolled in Medicare and Medicaid).

    a The reported range for the second-lowest-bid option is not symmetric
      around the central estimate because of rounding. Spending for affected
      beneficiaries includes all spending for Part A (Hospital Insurance)
      and Part B (Medical Insurance) except spending that was excluded
      because it is not covered by the bids that Medicare Advantage plans
      submit under current law--namely, the additional payments to
      disproportionate-share hospitals (whose share of low-income patients
      exceeds a specified threshold) and spending for medical education,
      hospice benefits, and certain benefits for patients with end-stage
      renal disease. Spending for Part D prescription drug insurance is
      excluded.

    b Payments include premiums and out-of-pocket costs for deductibles,
      copayments, and coinsurance for services and supplies covered by Part
      A and Part B. Payments include the standard Part B premium and the
      income-related premium (applicable for beneficiaries whose income
      exceeds specified threholds) but exclude any additional amounts paid
      for enhanced benefits or supplemental (medigap) coverage.

    c Range has not yet been estimated.

    d Under current law and under the options, premiums are for the basic
      package of Medicare benefits covered under Parts A and B. They exclude
      any additional amounts paid for enhanced benefits or supplemental
      (medigap) coverage and any amounts paid for the incomerelatedpremium.

      [GRAPHIC] [TIFF OMITTED] T12417.001

      [GRAPHIC] [TIFF OMITTED] T12417.002

                                     Box 1.
    ------------------------------------------------------------------------

    -------------------------------------------------------------------------
    The Medicare Program
    ------------------------------------------------------------------------
    In 2013, Medicare will provide federal health insurance for 52 million
     people who are elderly (age 65 or older) or disabled or who have end-
     stage renal disease. Of that group, about 85 percent are elderly.
     Medicare's Part A (Hospital Insurance) primarily covers inpatient
     hospital, skilled nursing facility, and hospice care. Part B (Medical
     Insurance) mainly covers services provided by physicians and other
     practitioners and by hospital outpatient departments. Home health care
     may be covered by Part A or by Part B. Medicare's Part D is the
     prescription drug program. Nearly 30 percent of Medicare beneficiaries
     receive care through the Medicare Advantage program, or Part C, in
     which private health insurers assume responsibility for, and the
     financial risk of, providing Medicare benefits. Almost all of the
     remaining beneficiaries receive care in the traditional fee-for-service
     (FFS) program. In 2012, gross spending for Medicare was $557 billion.
     Net of offsetting receipts (mostly premiums paid by beneficiaries),
     federal spending for the program was $472 billion.

    Medicare's Financing
    The various parts of Medicare are financed in different ways. Part A is
     financed primarily by a payroll tax. Beneficiaries' premiums (including
     income-related adjustments paid by higher-income beneficiaries) cover
     just over one-quarter of the outlays for Part B, and general funds from
     the U.S. Treasury cover nearly all of the rest. The government's
     payments to Medicare Advantage plans are financed by funds from Parts A
     and B. For Part D, enrollees' premiums cover about one-quarter of the
     cost of the basic prescription drug benefit, the federal government
     receives payments from states for dual-eligible beneficiaries (who are
     enrolled simultaneously in Medicare and Medicaid), and general funds
     cover most of the remaining cost. In fiscal year 2012, payroll taxes
     financed about 37 percent of Medicare outlays, beneficiaries' premiums
     covered about 13 percent, and most of the rest came from general funds
     of the Treasury.

    Medicare's Traditional Fee-for-Service Program
    Enrollees in the traditional FFS program are covered for services
     delivered by any participating provider, and both the package of
     benefits and the rates paid to providers are set by law. Medicare
     beneficiaries share those costs through deductibles and coinsurance,
     but because cost-sharing liabilities can be substantial (in part
     because traditional Medicare does not include an annual cap on what
     beneficiaries spend), about 90 percent of beneficiaries in the FFS
     program have supplemental insurance that covers most or all of their
     cost sharing, often through retiree plans offered by former employers
     or through individual insurance policies (known as medigap plans) or
     Medicaid.

    Medicare Advantage
    In most places in the United States, Medicare beneficiaries may choose
     among competing private insurers--through the Medicare Advantage
     program--instead of the traditional FFS program. Participating
     insurance companies submit bids indicating the per capita payment they
     are willing to accept for providing Part A and B benefits to a
     beneficiary of average health. (A separate bidding process determines
     payments for Part D.) The federal payment per enrollee then depends on
     what the insurance company bids and on how that amount compares with a
     ``benchmark'' that is announced by the federal government before those
     bids are submitted. Under a system set to be fully phased in by 2017,
     benchmarks will be based on per capita spending in the FFS program at
     the county level, and they will range from 95 percent of FFS spending
     per capita in the one-quarter of counties where such spending is
     highest to 115 percent of FFS spending per capita in the one-quarter of
     counties where such spending is lowest. Plans with quality ratings
     above a specified threshold will have bonus amounts added to their
     benchmarks.

    Plans that submit a bid below the benchmark for a service area receive
     federal payments that equal their bid plus a rebate that is a
     percentage of the difference between the bid and the benchmark.
     (Beginning in 2014, the rebate will range from 50 percent to 70
     percent, depending on the plan's performance on certain quality
     measures.) Plans must return the rebate to enrollees in the form of
     reduced cost sharing for benefits, coverage for items not covered by
     Medicare, or reduced Part B or Part D premiums. Plans with a bid that
     equals or exceeds the benchmark receive federal payments that equal the
     benchmark and must charge enrollees a premium for their Medicare
     coverage equal to the amount by which their bid exceeds the benchmark.
     Plans' payments from Medicare are larger or smaller, respectively, for
     enrollees who are in worse- or better-than-average health.
    ------------------------------------------------------------------------

                                                        Table 3.
        Examples of Determining Premiums Under Illustrative Premium Support Options, Using Hypothetical Bids and
                                                       Enrollment
    ----------------------------------------------------------------------------------------------------------------
                                      Region With High Fee-for-Service      Region With Low Fee-for-Service Spending
                                                  Spending                 -----------------------------------------
                                 ------------------------------------------
                                                   Annual      Proportion        Bid         Annual      Proportion
                                       Bid         Premium      Enrolled                     Premium      Enrolled
    ----------------------------------------------------------------------------------------------------------------
                                                Second-Lowest-Bid Option

    Fee-for-Service Program            14,000         4,300          0.25         9,900         1,900          0.75

    Private Plans
        A                              11,800         2,100          0.15        10,100         2,100          0.05
        B                              11,600         1,900          0.15         9,900         1,900          0.05
        C                              11,400         1,700          0.15         9,700         1,700          0.05
        D                              11,200         1,500          0.15         9,500         1,500          0.05
        E                              11,000         1,300          0.15         9,300         1,300          0.05

    Benchmark                          11,200          n.a.          n.a.         9,500          n.a.          n.a.
    Standard Premium                     n.a.         1,500          n.a.          n.a.         1,500          n.a.

                                                   Average-Bid Option

    Fee-for-Service Program            14,000         3,300          0.25         9,900         1,500          0.75

    Private Plans
        A                              12,000         1,300          0.15        10,300         1,900          0.05
        B                              11,800         1,100          0.15        10,100         1,700          0.05
        C                              11,600           900          0.15         9,900         1,500          0.05
        D                              11,400           700          0.15         9,700         1,300          0.05
        E                              11,200           500          0.15         9,500         1,100          0.05

    Benchmark                          12,200          n.a.          n.a.         9,900          n.a.          n.a.
    Standard Premium                     n.a.         1,500          n.a.          n.a.         1,500          n.a.
    Enrollment-Weighted Average        12,200         1,500          n.a.         9,900         1,500         n.a.
    ----------------------------------------------------------------------------------------------------------------
    Source: Congressional Budget Office.

    Notes: Under the second-lowest-bid option, the benchmark would equal the lower of the second-lowest bid from a
      private plan and the bid of the fee-for-service program. Under the average-bid option, the benchmark would
      equal the enrollment-weighted-average bid among all plans, including the fee-for-service program.

          Proportion enrolled is for the previous year. Equal proportions among private plans are used to simplify
      the example. (According to CBO's estimates, enrollment would be higher in low-bidding plans.)

          Under both options, premiums would equal the standard premium plus the bid minus the benchmark, and
      federal contributions for a beneficiary of average health would equal the benchmark minus the standard
      premium. Those federal contributions would be $9,700 and $8,000 under the second-lowest-bid option in regions
      with high and low fee-for-service spending, respectively, and $10,700 and $8,400 under the average-bid option
      in such regions, respectively.

          n.a. = not applicable.

    [GRAPHIC] [TIFF OMITTED] T12417.003

                                                        Table 4.
     Average Annual Premiums Charged by Plans for Medicare Part A and B Benefits Under Illustrative Premium Support
                                          Options, Weighted by Population, 2020
    ----------------------------------------------------------------------------------------------------------------
                                             Second-Lowest-Bid Option                   Average-Bid Option
                                     -------------------------------------------------------------------------------
                                                           Change From  Part                       Change From  Part
                                        Annual Premium     B Premium  Under     Annual Premium     B Premium  Under
                                           (Dollars)          Current Law          (Dollars)          Current Law
                                                               (Percent)                               (Percent)
    ----------------------------------------------------------------------------------------------------------------
    Second-Lowest-Bidding Private                 1,500                  -6                 900                 -44
     Plan

    Median-Bidding Private Plan                   1,800                  13               1,200                 -25

    Fee-for-Service Program                       3,100                  94               2,400                 50
    ----------------------------------------------------------------------------------------------------------------
    Source: Congressional Budget Office.

    Note: Premiums charged by plans are averages weighted by the Medicare population in each region. (Those averages
      differ from the average premiums paid by beneficiaries, which are based on CBO's projections of enrollment in
      plans.) Under current law and under the options, premiums are for the basic package of Medicare benefits
      covered under Part A (Hospital Insurance) and Part B (Medical Insurance). They exclude any additional amounts
      paid for enhanced benefits or supplemental (medigap) coverage and any amounts paid for the income-related
      premium (applicable for beneficiaries whose income exceeds specified threholds). Under current law, for most
      beneficiaries, Part A will have no premium and the premium for Part B (excluding income-related adjustments)
      will be $1,600 in 2020, CBO projects. Amounts are rounded to the nearest $100.

      [GRAPHIC] [TIFF OMITTED] T12417.004

      [GRAPHIC] [TIFF OMITTED] T12417.005

                                     Box 2.
    ------------------------------------------------------------------------

    -------------------------------------------------------------------------
    Grandfathering of Beneficiaries Under a Premium Support System
    ------------------------------------------------------------------------
    Under one type of proposal for a premium support system, current
     beneficiaries and those who became eligible for Medicare before the new
     system took effect would continue to receive coverage under the
     existing Medicare program; only those beneficiaries who became newly
     eligible on or after a specified date would enroll in the premium
     support system. Such an arrangement would require the federal
     government to address several important design questions-some are
     unique to such a system and others are relevant for any premium support
     system but have added significance if grandfathering is part of the
     design. Although policymakers might also consider changing the existing
     Medicare program if it remained in operation, this discussion focuses
     on design issues specifically related to a grandfathering provision in
     a premium support system, and it assumes that beneficiaries who
     remained in the existing system could choose Medicare's fee-for-service
     (FFS) program or a Medicare Advantage plan and that private insurers
     could participate in the premium support system, the Medicare Advantage
     program, or both.

    Enrollment in Part B
    An important question for any premium support system is whether
     enrollment in Medicare's Part B (Medical Insurance) would remain
     voluntary, and if so, how beneficiaries who declined that coverage
     would be treated by the system. About 8 percent of Medicare
     beneficiaries are not enrolled in Part B currently, generally because
     either they or a spouse are still working and have employment-based
     coverage as primary insurance with Medicare as a secondary insurer.

    Among the Medicare population age 65 or older, younger beneficiaries are
     more likely to decline Part B coverage, and the percentage that does so
     has increased as more people have stayed in the workforce past age 65.
     (The late-enrollment penalty for Part B is waived for active workers in
     larger companies that offer employment-based coverage. If such workers
     were to enroll, Medicare would be a secondary payer for their health
     care costs, which would reduce the value of the coverage.) Some 19
     percent of 65-year-old Medicare beneficiaries were not enrolled in Part
     B in 2011, up from 15 percent in 1999. If a premium support program
     included grandfathering, the question of whether Part B enrollment
     would remain voluntary would be especially important because the
     younger segment of the retirement-age population would constitute a
     substantial fraction of the beneficiaries covered in the first few
     years.

    Bidding Regions
    Depending on how the regions were defined, in many regions the number of
     beneficiaries in a premium support system with a grandfathering
     provision could initially be very small. If dual-eligible beneficiaries
     also were excluded from the new system, the Congressional Budget Office
     (CBO) projects, just 5 percent of the Medicare population would be
     covered by the system after the first year, and only 25 percent would
     be covered after the fifth year.

    Some proposals would have bidding regions correspond to health care
     markets within states. In that case, grandfathering would result in
     some regions' enrolling very small numbers of people in the new system
     in the first few years. Because personal health care expenditures vary
     widely, the actual costs of enrollees in private plans and the FFS
     program could differ greatly from those plans' bids for their regions.
     That uncertainty could make participation less attractive to private
     insurers, cause them to raise their bids if they chose to participate,
     and create significant year-to-year variation in the amounts of the
     bids. In regions with few beneficiaries, private insurers also would
     have less incentive to modify health care plans to contain costs.

    Bids and Risk Adjustment
    Under the illustrative premium support options analyzed for this report,
     insurers would submit a bid for a beneficiary with average expected
     health care costs (that is, a beneficiary with a risk score of 1.0),
     and federal payments to insurers would be adjusted to account for
     differences between their enrollees' expected costs and those of the
     average beneficiary. CBO assumed that the risk adjustment would be
     comparable to that for the Medicare Advantage program, in which federal
     payments to insurers are adjusted on the basis of enrollees' medical
     conditions and demographic characteristics.

    In the initial years of a system with grandfathering, a substantial
     proportion of covered beneficiaries would not have the history of past
     Medicare claims data necessary to compute a risk score. For those
     beneficiaries, payments to plans could be adjusted using a version of
     the risk adjuster based entirely on demographic characteristics. That
     approach lacks the completeness of the standard risk adjuster, which
     includes information on medical conditions, so pursuing it would raise
     questions about the adequacy of risk adjustment in the first few years.

    Under a grandfathering provision, the bidding and risk adjustment
     mechanism could reflect average expected costs for a beneficiary in the
     premium support system. That approach would necessitate ``rescaling''
     the risk adjustment factors to correspond to the segment of the
     Medicare population enrolled in the premium support system or
     reestimating those factors (because particular risks are associated
     with costs in ways that would differ between that segment and the
     Medicare population as a whole). If the existing risk adjustment
     mechanism was used instead, insurers would base their bids on a
     population that differed from the population served under the premium
     support system. An analogous set of issues would confront the Medicare
     Advantage program. Once the premium support system began, the
     proportion of beneficiaries eligible to enroll in a Medicare Advantage
     plan would decline each year as new people entered the premium support
     system.

    Beneficiaries' Premiums
    For both illustrative options, CBO assumed that beneficiaries who
     enrolled in a plan with a bid equal to the benchmark would pay a
     standard premium determined using the same formula used to calculate
     the Part B premium under current law. With grandfathering, that premium
     could be determined in various ways. One approach would be to compute a
     single standard premium for the entire Medicare population that would
     apply both to beneficiaries in the premium support system and to those
     who were grandfathered into Medicare in its current-law form. In a
     second approach, separate computations could be made for a standard
     premium under the premium support system and for the Part B premium
     that would apply to the grandfathered population; a standard premium
     could be computed as one amount, or standard premiums could differ by
     beneficiaries' age. Each approach would involve a different
     distribution of health care costs and of potential savings from a
     premium support system among age groups.
    ------------------------------------------------------------------------

     [GRAPHIC] [TIFF OMITTED] T12417.006

                                     ______

                            Politico, April 30, 2012

                       GOP Split on Reforming Health Care
                             By Jennifer Haberkorn
    Ask the 242 House Republicans what kind of health policy they'd like to
    enact instead of President Barack Obama's health care reform law and
    you might get 242 different answers.

    Even after 3 years of railing against Obama's plan, Republicans have
    coalesced around only a few basic tenets of health policy--let alone a
    full replacement plan.

    They are even divided over whether some of the popular pieces of
    Obama's health law are a good idea. For example, most Republicans
    support the health law's requirement that insurance companies accept
    all applicants--but the replacement plan put forward by the most
    prominent Republican ignores that idea.

    ``It's a terrible idea,'' Rep. Tom Price (R-GA), the sponsor of the
    plan, told Politico. He said Democrats only enacted the provision in
    order to require exactly what kinds of insurance Americans must have.
    He would rather expand coverage voluntarily.

    The wide range of GOP opinions could make it hard for the party to come
    together behind a single plan to replace Obama's health care law if
    it's overturned by the Supreme Court this summer.

    A ruling against all or part of the legislation has the potential to
    reopen the health care wars of 2009, putting the differences among
    Republicans on full display. It's a divide Democrats would try to
    exploit as they press Republicans on how they're going to solve the
    country's health care problems.

    ``If the Supreme Court throws out the president's plan, we're going to
    have to have something on the table,'' said Rep. Paul Broun (R-GA), a
    physician.

    House Republicans won't be the only ones with replacement plans. Gov.
    Mitt Romney's health agenda relies more on state-level reforms and
    private competition than Obama's law.

    On Capitol Hill, there are a handful of pending Republican health
    bills.

    Days before the Supreme Court heard oral arguments over the health law,
    Broun introduced a plan that allows Americans to deduct all of their
    health care costs; encourages the use of health savings accounts;
    converts Medicare to a ``premium support'' model that subsidizes
    private coverage; allows consumers to buy insurance across state lines;
    and encourages the use of association health plans, which allow groups
    of people or co-workers to buy health care together.

    Broun said he's trying to drum up support among lawmakers and outside
    groups and already has the backing of FreedomWorks, the conservative
    group led by Dick Armey.

    The plan that's likely to get the closest look from Republicans is
    sponsored by Price, an orthopedic surgeon and one of the House's
    leading voices on health care. He released a video on Wednesday touting
    the plan, which he originally introduced in 2009.

                                     ______

        Prepared Statement of Hon. Thomas Price, M.D., Nominated to be
               Secretary, Department of Health and Human Services
        Thank you, Chairman Hatch, Ranking Member Wyden, and all the
    members of this committee, for the opportunity to speak with you today
    and engage in a discussion about the road ahead for our great Nation.
    These proceedings, and this entire process, would not be possible
    without the work of your staff, and so I want to extend my appreciation
    to them as well for the great service they provide. Thanks so much to
    Senator Johnny Isakson for his generous introduction. We've known each
    other for nearly 30 years--and I'm so grateful for his friendship and
    kindness, and our State is blessed to have had his service and
    leadership. I wish also to especially thank my wife of 33 years, Betty.
    Her support, encouragement and advice (which is always correct) mean
    more than I could ever say.

        Over the past few weeks, I have had the chance to meet with many of
    you individually and have gained a real appreciation for the passion
    you all have about the critical work of the Department of Health and
    Human Services. Please know that I share that passion. That is why I am
    here today--and why I'm honored to have been nominated by the President
    to serve as the next Secretary of HHS.

        We all come to public service in our own unique ways that inform
    who we are and why we serve. My first professional calling was to care
    for patients. That experience as a physician and later as a legislator
    has provided a holistic view of the complex interactions that take
    place every day across our communities and across this country that,
    when done correctly, are in service to the greater good we seek to
    achieve. Today, I hope to share with you how my experience has helped
    shape my understanding of and appreciation for the work of the
    department and its team, which I hope to lead.

        From an early age, I had an interest in medicine. My earliest
    memories are of a farm in Michigan where my family and I lived before
    moving to suburban Detroit at the age of five. I spent most of my
    formative years being raised by a single mom--and I assumed a lot of
    responsibility since there were 5 of us. Some of my fondest memories
    were spending time with my grandfather--a physician--as he made house
    calls to see patients. Having both a father and grandfather as
    physicians surely influenced my path toward medicine. And it was very
    likely that the orthopedist who treated my many broken bones in my
    youth gave me a particular fascination for fixing things--and not just
    broken bones.

        After graduating with a medical degree from the University of
    Michigan, I went south to Atlanta, GA--which I've called home for
    nearly 40 years. It's where I met my wife Betty and where we raised our
    son. I did my residency at Emory University and Grady Memorial Hospital
    in downtown Atlanta. I would return to Grady later in my career to
    serve as Medical Director of the Orthopedic Clinic. Throughout my
    professional career I treated patients of every age--from all walks of
    life--including many children. Anyone who has ever treated a child
    knows how fulfilling it is to look into the eyes of a parent and tell
    them our team has helped heal their son or daughter--to give them peace
    of mind. My memories of Grady are filled with the gracious comments
    from parents and patients for the team of health care specialists with
    whom I had the privilege of working. I cherished my time there.

        After 25 years of school and training, I hung out my shingle to
    start a solo private orthopedic practice. Over the years, this practice
    grew and eventually became one of the largest, non-academic orthopedic
    groups in the country--a group I would eventually serve as Chairman of
    the Board. Whether as part of that team or on staff at a hospital, it
    was apparent early on that every person involved in the delivery of
    care, no matter their role--doctors, nurses, lab techs, orderlies--all
    had one goal in mind--and that was to get our patients well again, to
    heal them. It was always a team effort and wherever you fit into that
    team, you appreciated the value of those working with you.

        During 20 years as a practicing physician--both in office and
    hospital setting--I learned a good bit about not just treating patients
    but about the broader health care system and where it intersects with
    government--local, State and Federal. A couple of lessons stand out.
    One--many patients I knew or treated were never more angry and
    frustrated than when they realized that there was someone other than
    themselves and /or their physician making medical decisions on their
    behalf--when there was someone not involved in the actual delivery of
    care that was standing between them and their doctor or treatment.

        Another lesson came the day I noticed that there were more
    individuals within our office who were dealing with paperwork,
    insurance filings, and government regulations than there were
    individuals actually seeing and treating patients. It was in those
    moments that it became crystal clear that our health care system was
    losing focus on the number one priority--the individual patient. Having
    had no greater joy than taking care of patients, I felt compelled to
    broaden my role in public service, and help solve the issues harming
    the delivery of medicine--so I ran for the State Senate in Georgia.

        Anyone here who has ever served at the State level knows that State
    government has a different feel to it--a different pace. In Georgia, I
    found the State Senate to be a remarkably bipartisan place where
    collegial relationships were the norm. This is the environment in which
    I learned to legislate--reaching across the aisle to get the work
    done--needing the buy-in and the support of more than just one party. I
    worked with Democrats including then State senator, now-Atlanta Mayor,
    Kasim Reed. He and I did not see eye to eye on everything, for sure,
    but we were successful in finding our way together through some really
    challenging issues for our State.

        In Congress, I have been fortunate to have been a part of
    collaborations that broke through party lines to solve problems
    including those pertaining to health care. Early in my congressional
    career, I was privileged to work alongside then-
    representative, now Senator, Tammy Baldwin to introduce legislation
    that would have empowered States to come up with new ideas to provide
    health care coverage to their uninsured populations. Just this past
    Congress, it was a bipartisan, bicameral effort that actually succeeded
    in ridding Medicare of a broken physician payment system and which has
    now begun the creation of a new system that, if implemented properly,
    will help ensure that seniors have better access to higher quality
    care.

        If confirmed, my obligation will be to carry to the Department of
    Health and Human Services both an appreciation for bipartisan, team-
    driven policymaking and what has been a lifetime commitment to work to
    improve the health and well-being of the American people. That
    commitment extends to what I call the six principles of health care--
    six principles that, if you think about it, all of us hold dear:
    affordability, accessibility, quality, choices, innovation, and
    responsiveness. We all want a health care system that's affordable,
    that's accessible to all, of the highest quality, with the greatest
    number of choices, driven by world-leading innovations, and responsive
    to the needs of the individual patient.

        But HHS is more than just health care. There are real heroes at
    this department doing incredible work to keep our food safe, to develop
    new drugs and treatment options--driven by scientists conducting truly
    remarkable research. The Centers for Disease Control and Prevention--
    which we in Atlanta are proud to have headquartered in our city--is the
    first place the world turns to when there's a health care threat that
    requires the greatest, most capable minds to solve.

        There are heroes among the talented, dedicated men and women
    working to provide critical social services--helping families and,
    particularly, children have a higher quality of living and the
    opportunity to rise up and strive to achieve their American Dream--
    something we all want for ourselves and our loved ones.

        The role of HHS in improving lives means it must carry out its
    responsibilities with compassion. It also must be efficient, effective
    and accountable, as well as being willing to partner with those in our
    communities already doing remarkable work. In every aspect of the
    department, across the spectrum of issues and services it handles,
    there is embedded a promise that has been made to the American people.
    Governor Michael Leavitt, during his confirmation hearing in 2004 to
    take on this task, spoke of our highly regarded ``brands''--the CDC,
    FDA, NIH, and others--and how they must be preserved and strengthened
    because they guarantee that those promises are kept.

        Today's challenges make it even more important that we strengthen
    our resolve to keep the promises we, as a society, have made to our
    senior citizens and to those among us who are most in need of care and
    support. That means saving, strengthening, and securing Medicare for
    today's beneficiaries and future generations. It means ensuring that
    our Nation's Medicaid population has access to quality care. It means
    maintaining, and expanding, America's leading role in medical
    innovation and the treatment and eradication of disease.

        As I noted at the outset, I share your passion for these issues--
    having spent my life in service to them. And yet, there's no doubt that
    we do not all share the same point of view when it comes to addressing
    each and every one of them. Our approaches to policies may differ, but
    there surely exists a common commitment to public service and
    compassion for those we serve. We all hope, by our actions, to help
    improve the lives of the American people, to help heal individuals and
    whole communities. With a healthy dose of humility and appreciation for
    the scope of the challenges before us, with your assistance and with
    God's will, we can make it happen. I look forward to working with you
    to do just that.

        Thank you very much for the privilege of appearing before you
    today.

                                     ______

                            SENATE FINANCE COMMITTEE

                      STATEMENT OF INFORMATION REQUESTED
                                   OF NOMINEE

                          A. BIOGRAPHICAL INFORMATION

     1.  Name (include any former names used): Thomas Edmunds Price, M.D.

     2.  Position to which nominated: Secretary of the Department of Health
    and Human Services.

     3.  Date of nomination: January 20, 2017.

     4.  Address (list current residence, office, and mailing addresses):

     5.  Date and place of birth: October 8, 1954, Lansing, Michigan.

     6.  Marital status (include maiden name of wife or husband's name):

     7.  Names and ages of children:

     8.  Education (list secondary and higher education institutions, dates
    attended, degree received, and date degree granted): Dearborn High
    School, 1969-1972, Diploma; University of Michigan, 1972-1979,
    Bachelor's Degree and Doctor of Medicine.

     9.  Employment record (list all jobs held since college, including the
    title or description of job, name of employer, location of work, and
    dates of employment): Surgical Intern, Emory University School of
    Medicine/Grady Health System, Atlanta, GA, 1979-1980; Orthopaedic
    Surgical Resident, Emory University School of Medicine/Grady Health
    System, Atlanta, GA, 1980-1984; Orthopaedic Surgeon, solo and group
    practice (North Fulton Orthopaedic Clinic, Compass Orthopaedics,
    Resurgens Orthopaedics), Roswell/Atlanta, GA, 1984-2002; Assistant
    Professor, Orthopaedic Surgery, Emory University School of Medicine/
    Grady Health System, Atlanta, GA 2002-2004; Georgia State Senator,
    State of Georgia, Atlanta, GA, 1997-2005; Member of Congress, GA06,
    House of Representatives, Washington DC, 2006-present.

    10.  Government experience (list any advisory, consultative, honorary,
    or other part- time service or positions with Federal, State, or local
    governments, other than those listed above): See Appendix A.

    11.  Business relationships (list all positions held as an officer,
    director, trustee, partner, proprietor, agent, representative, or
    consultant of any corporation, company, firm, partnership, other
    business enterprise, or educational or other institution): Founder/
    owner, North Fulton Orthopaedic Clinic, Roswell, GA; co-
    founder/president, Compass Orthopaedics, Roswell, GA; Director/chairman
    of board, Resurgens Orthopaedics, Atlanta/Roswell, GA; managing
    partner, Chattahoochee Associates, Roswell, GA (owns medical office
    building); member and co-owner, Diagnostic Ventures of Roswell, LLC,
    Roswell, GA (owns medical office building); member and co-owner, RMC3,
    LLC, Roswell, GA (owns stake in Diagnostic Ventures of Roswell, LLC,
    which owns medical office building); limited partner, Carolina
    Properties, Ltd., (owns apartment buildings in North Carolina, South
    Carolina, and Virginia).

    12.  Memberships (list all memberships and offices held in
    professional, fraternal, scholarly, civic, business, charitable, and
    other organizations): Roswell Rotary Club, 1985-present, president
    1996-1997; American Academy of Orthopaedic Surgeons; American Medical
    Association; Medical Association of Georgia; Medical Association of
    Atlanta; Atlanta Orthopaedic Society; Kelly Orthopaedic Society;
    Georgia Orthopaedic Society; American College of Surgeons;
    Chattahoochee Nature Center; Georgia Ensemble Theatre; Georgia
    Arthritis Foundation.

    13.  Political affiliations and activities:

        a.  List all public offices for which you have been a candidate.

          Georgia State Senate District 56; U.S. House of Representatives
    GA06.

        b.  List all memberships and offices held in and services rendered
    to all political parties or election committees during the last 10
    years.

          Member of Congress, GA06, Republican.

        c.  Itemize all political contributions to any individual, campaign
    organization, political party, political action committee, or similar
    entity of $50 or more for the past 10 years.

          See Appendix B.

    14.  Honors and awards (list all scholarships, fellowships, honorary
    degrees, honorary society memberships, military medals, and any other
    special recognitions for outstanding service or achievement):

         See Appendix C.

    15.  Published writings (list the titles, publishers, and dates of all
    books, articles, reports, or other published materials you have
    written):

         Saving the American Miracle: The Destruction and Restoration of
    American Values. Paperback--self-published, January 20, 2011.

         In addition, a listing of all requested Op-Eds authored by Dr.
    Price has been attached as Appendix D.

    16.  Speeches (list all formal speeches you have delivered during the
    past 5 years which are on topics relevant to the position for which you
    have been nominated):

         See Appendix E.

    17.  Qualifications (state what, in your opinion, qualifies you to
    serve in the position to which you have been nominated):

         My strengths are commitment, passion, and expertise. My entire
    adult life has been dedicated to service--professionally as an
    orthopaedic surgeon, politically as a State Senator and member of
    Congress, and in our community through numerous volunteer and charity
    activities. As a third-generation physician, I am well aware of the
    challenges of caring for patients and the societal needs of
    populations. For over 20 years, I had the privilege of practicing
    orthopaedic surgery in both private and public settings, training in an
    urban medical center including service in a veterans hospital, and
    treating folks of all ages and all walks of life. I founded North
    Fulton Orthopaedic Clinic and over time co-founded Resurgens
    Orthopaedics--reputed to be the largest private group practice of
    orthopaedic surgeons in the country. While serving as a Georgia State
    Senator, I was responsible for training students, interns, and
    residents in a large, major urban hospital in Atlanta. Those
    experiences coupled with being a legislator at both the State and
    Federal levels has given me a comprehensive understanding of the
    complex interactions taking place every day between patients and their
    families, physicians, providers, insurers, as well as local, State, and
    Federal Governments. It is a perspective that has reinforced my belief
    that the individual patient must always be at the center of health-care
    policy decisions. Having examined many systems and collaborated with
    many individuals and groups to bring improvements to our health-care
    financing and delivery, my breadth of experience and understanding has
    uniquely qualified me for this post. I have a deep passion for finding
    positive solutions to improve the human condition and allowing each
    member of our society to realize their full potential. I am not daunted
    by the challenge before us and have confidence in the promise that HHS
    may bring with its many agencies and broad jurisdiction to assist our
    communities and citizens. As a student of scientific principles, I have
    a profound appreciation for the role of basic scientific research, for
    the development of innovative treatments and cures, and for the
    imperative that America remains a leader in those pursuits.

                       B. FUTURE EMPLOYMENT RELATIONSHIPS

     1.  Will you sever all connections with your present employers,
    business firms, associations, or organizations if you are confirmed by
    the Senate? If not, provide details.

        Yes, any and all necessary.

     2.  Do you have any plans, commitments, or agreements to pursue
    outside employment, with or without compensation, during your service
    with the government? If so, provide details.

        No.

     3.  Has any person or entity made a commitment or agreement to employ
    your services in any capacity after you leave government service? If
    so, provide details.

        No.

     4.  If you are confirmed by the Senate, do you expect to serve out
    your full term or until the next presidential election, whichever is
    applicable? If not, explain.

        Yes.

                       C. POTENTIAL CONFLICTS OF INTEREST

     1.  Indicate any investments, obligations, liabilities, or other
    relationships which could involve potential conflicts of interest in
    the position to which you have been nominated.

         None. The nominee will comply with all Office of Government Ethics
    recommendations for current and future personal investment holdings.

     2.  Describe any business relationship, dealing or financial
    transaction which you have had during the last 10 years, whether for
    yourself, on behalf of a client, or acting as an agent, that could in
    any way constitute or result in a possible conflict of interest in the
    position to which you have been nominated.

         None. The nominee will comply with all Office of Government Ethics
    recommendations for personal business relationships, dealings, and
    financial transactions.

     3.  Describe any activity during the past 10 years in which you have
    engaged for the purpose of directly or indirectly influencing the
    passage, defeat, or modification of any legislation or affecting the
    administration and execution of law or public policy. Activities
    performed as an employee of the Federal Government need not be listed.

         Only as a member of Congress.

     4.  Explain how you will resolve any potential conflict of interest,
    including any that may be disclosed by your responses to the above
    items.

         I intend to operate as I always have during all of my years in
    public service: by making ethical compliance a cornerstone of my public
    service and operating without reproach. Any personal holdings or
    positions which could conceivably present a potential conflict of
    interest have been disclosed to the Office of Government Ethics, and
    appropriate resolution of any potential conflict of interest will be
    resolved prior to my confirmation.

     5.  Two copies of written opinions should be provided directly to the
    committee by the designated agency ethics officer of the agency to
    which you have been nominated and by the Office of Government Ethics
    concerning potential conflicts of interest or any legal impediments to
    your serving in this position.

     6.  The following information is to be provided only by nominees to
    the positions of United States Trade Representative and Deputy United
    States Trade Representative:

         Have you ever represented, advised, or otherwise aided a foreign
    government or a foreign political organization with respect to any
    international trade matter? If so, provide the name of the foreign
    entity, a description of the work performed (including any work you
    supervised), the time frame of the work (e.g., March to December 1995),
    and the number of hours spent on the representation.

        N/A.

                           D. LEGAL AND OTHER MATTERS

     1.  Have you ever been the subject of a complaint or been
    investigated, disciplined, or otherwise cited for a breach of ethics
    for unprofessional conduct before any court, administrative agency,
    professional association, disciplinary committee, or other professional
    group? If so, provide details.

         The nominee was the subject of an investigation by the Office of
    Congressional Ethics in 2010 for matters involving fundraising
    activities associated with his principal campaign committee. Although
    the matter was referred for further consideration by the House
    Committee on Standards of Official Conduct, the committee dismissed the
    matter finding no wrongdoing and recommending that no further action
    was necessary. The public record associated with this investigation is
    available at the following link: https://oce.house.gov/january-26-2011-
    oce-referral-regarding-rep-tom-price/.

     2.  Have you ever been investigated, arrested, charged, or held by any
    Federal, State, or other law enforcement authority for a violation of
    any Federal, State, county or municipal law, regulation, or ordinance,
    other than a minor traffic offense? If so, provide details.

        No.

     3.  Have you ever been involved as a party in interest in any
    administrative agency proceeding or civil litigation? If so, provide
    details.

        No.

     4.  Have you ever been convicted (including pleas of guilty or nolo
    contendere) of any criminal violation other than a minor traffic
    offense? If so, provide details.

        No.

     5.  Please advise the committee of any additional information
    favorable or unfavorable, which you feel should be considered in
    connection with your nomination.

        N/A.

                         E. TESTIFYING BEFORE CONGRESS

     1.  If you are confirmed by the Senate, are you willing to appear and
    testify before any duly constituted committee of the Congress on such
    occasions as you may be reasonably requested to do so?

        Yes.

     2.  If you are confirmed by the Senate, are you willing to provide
    such information as is requested by such committees?

        Yes.

                                   APPENDIX A

            Leadership Positions and Standing Committee Assignments

    1997-1998--Georgia Senate
         Health and Human Services
         Insurance and Labor
         Reapportionment
         Special Judiciary
         Youth, Aging, and Human Ecology

    1999-2000--Georgia Senate
         Minority Whip
         Consumer Affairs
         Education
         Health and Human Services
         Reapportionment
         Special Judiciary

    2001-2002--Georgia Senate
         Minority Whip
         Education
         Health and Human Services
         Reapportionment
         Rules
         Veterans and Consumer Affairs

    2003-2004--Georgia Senate
         Majority Leader
         Appropriations
         Economic Development and Tourism, Vice-chair
         Education, ex-officio
         Ethics
         Health and Human Services
         Insurance and Labor ex-officio
         Reapportionment and Redistricting, Secretary
         Rules, Secretary

    2005-2009--U.S. House of Representatives
         Financial Services
         Education and Workforce/Labor

    2009-2011--U.S. House of Representatives
         Chair--Republican Study Committee
         Financial Services
         Education and Labor
         Ranking Member--Workforce Protections Subcommittee
         Ranking Member--HELP Subcommittee
         Franking Commission

    2011-2013--U.S. House of Representatives
         Chair--Republican Policy Committee
         Ways and Means
         Budget
         Franking Commission

    2013-2015--U.S. House of Representatives
         Ways and Means
         Vice-Chair--Budget Committee
         Education and Workforce
         Franking Commission

    2015-2017--U.S. House of Representatives
         Chair--Budget Committee
         Ways and Means

                                   APPENDIX B

                Contributions Made By Thomas and Elizabeth Price
    ------------------------------------------------------------------------
      Contributor Name    Committee Name     Transaction Date       Amount
    ------------------------------------------------------------------------
    Clark-Price,         Norwood, Charlie       August 23, 2000         $250
     Elizabeth            via Norwood for
                          Congress
    ------------------------------------------------------------------------
    Clark-Price,         Gingrey, J.              July 27, 2002       $1,000
     Elizabeth            Phillip via
                          Gingrey for
                          Senate Inc.
    ------------------------------------------------------------------------
    Clark-Price,         Isakson, John             June 6, 2003         $200
     Elizabeth            Hardy via
                          Georgians for
                          Isakson
    ------------------------------------------------------------------------
    Price, Elizabeth     Handel, Karen            June 29, 2013       $1,000
                          Christine via
                          Handel for
                          Senate Inc.
    ------------------------------------------------------------------------
    Price, Elizabeth     Handel, Karen        December 18, 2013       $1,000
                          Christine via
                          Handel for
                          Senate Inc.
    ------------------------------------------------------------------------
    Price, Elizabeth     Georgia                 March 21, 2013         $250
                          Republican
                          Party, Inc.
    ------------------------------------------------------------------------
    Price, Elizabeth     Georgia                 March 10, 1999         $200
                          Republican
                          Party, Inc.
    ------------------------------------------------------------------------
    Price, Elizabeth     Georgia                   June 9, 1997         $500
                          Republican
                          Party, Inc.
    ------------------------------------------------------------------------
    Price, Elizabeth     Gingrey, J.            August 28, 2002       $1,000
                          Phillip via
                          Gingrey for
                          Senate, Inc.
    ------------------------------------------------------------------------
    Clark-Price,         Romney, Mitt/            June 28, 2012       $1,000
     Elizabeth            Paul D. Ryan
                          via Romney for
                          President, Inc.
    ------------------------------------------------------------------------
    Price, Thomas E.,    Georgia                    May 4, 1999         $295
     M.D.                 Republican
                          Party, Inc.
    ------------------------------------------------------------------------
    Price, Thomas E.,    Gingrey, J.              July 27, 2002       $1,000
     M.D.                 Phillip via
                          Gingrey for
                          Senate, Inc.
    ------------------------------------------------------------------------
    Price, Thomas E.,    Gingrey, J.            August 28, 2002       $1,000
     M.D.                 Phillip via
                          Gingrey for
                          Senate, Inc.
    ------------------------------------------------------------------------
    Price, Thomas E.,    Republican            October 23, 2000         $250
     M.D.                 National
                          Committee
    ------------------------------------------------------------------------
    Price, Thomas E.,    Bush, George W.       January 22, 2004       $2,000
     M.D.                 via Bush-Cheney
                          '04 (Primary)
                          Inc.
    ------------------------------------------------------------------------
    Price, Thomas E.,    Republican            October 23, 2000         $250
     Mrs.                 National
                          Committee
    ------------------------------------------------------------------------
    Price, Thomas E.,    Political Action          June 6, 2002         $250
     M.D.                 Committee of
                          the American
                          Association of
                          Orthopaedic
                          Surgeons--PAC
                          of AAO
    ------------------------------------------------------------------------
    Price, Thomas E.,    Dole, Elizabeth        August 24, 1999       $1,000
     M.D.                 via Elizabeth
                          Dole for
                          President
                          Exploratory
                          Committee Inc.
    ------------------------------------------------------------------------
    Price, Thomas E.,    Georgia                   May 24, 2000         $300
     M.D.                 Republican
                          Party, Inc.
    ------------------------------------------------------------------------
    Price, Thomas E.,    Biggert, Judy       September 23, 2012       $2,000
     M.D.                 via Judy
                          Biggert for
                          Congress
    ------------------------------------------------------------------------
    Price, Thomas E.,    NRCC                 December 11, 2008         $220
     M.D.
    ------------------------------------------------------------------------
    Price, Thomas E.,    Gingrich, Newton      January 22, 1998       $1,000
     M.D.                 L., via Friends
                          of Newt
                          Gingrich
    ------------------------------------------------------------------------
    Price, Thomas E.,    Price, Thomas            July 28, 2004      $99,000
     M.D.                 Edmunds via
                          Price for
                          Congress--Loan,
                          since repaid
    ------------------------------------------------------------------------
    Price, Thomas E.,    Price, Thomas           August 6, 2004     $150,000
     M.D.                 Edmunds via
                          Price for
                          Congress--Loan,
                          since repaid
    ------------------------------------------------------------------------

                         Joint Fundraising Contributions
        These are contributions to committees who are raising funds to be
                        distributed to other committees.
       The breakdown of these contributions to their final recipients may
                                  appear below.
    ------------------------------------------------------------------------
      Contributor Name    Committee Name     Transaction Date       Amount
    ------------------------------------------------------------------------
    Price, Mrs.          Trump Make          September 15, 2016       $1,000
     Elizabeth            America Great
                          Again Committee
    ------------------------------------------------------------------------

                   Recipient of Joint Fundraiser Contributions
       These are the Final Recipients of Joint Fundraising Contributions.
    ------------------------------------------------------------------------
      Contributor Name    Committee Name     Transaction Date       Amount
    ------------------------------------------------------------------------
    Price, Mrs.          Trump, Donald J./   September 15, 2016         $800
     Elizabeth            Michael R.
                          Pence via
                          Donald J. Trump
                          for President,
                          Inc.
    ------------------------------------------------------------------------

                              Georgia Contributions
    ------------------------------------------------------------------------
                                        PAC
                  Contributor's    Affiliation/      Date
     Recipient         Name         Occupation/    Received    Type   Amount
                                     Employer
    ------------------------------------------------------------------------
    Georgia      Hon. Thomas E.   Physician Self- April 25,   Monet   $4,863
     Republican   Price            Employed        2006        ary
     Party,                                                    Gene
     Inc.                                                      ral
    ------------------------------------------------------------------------
    Georgia      Hon. Thomas E.   Physician Self- April 25,   Monet   $4,956
     Republican   Price            Employed        2008        ary
     Party,                                                    Gene
     Inc.                                                      ral
    ------------------------------------------------------------------------
    Georgia      Hon. Thomas E.   Physician Self- April 27,   Monet   $5,220
     Republican   Price            Employed        2010        ary
     Party,                                                    Gene
     Inc.                                                      ral
    ------------------------------------------------------------------------
    Georgia      Hon. Thomas E.   Physician Self- January 5,  Monet   $5,220
     Republican   Price            Employed        2010        ary
     Party,                                                    Gene
     Inc.                                                      ral
    ------------------------------------------------------------------------
    Karen        Elizabeth Price  Councilwoman,   January 5,  Monet   $1,000
     Handel for                    City of         2010        ary
     Governor,                     Roswell                     Prim
     Inc.                                                      ary
    ------------------------------------------------------------------------
    Georgia      Elizabeth Price  Physician       March 21,   Monet     $250
     Republican                    Compass         2013        ary
     Party,                        Orthopedics                 Gene
     Inc.                                                      ral
    ------------------------------------------------------------------------
    Keep Judge   Elizabeth Price  Physician       April 16,   Monet     $500
     Tom                           Compass         2014        ary
     Campbell;                     Orthopedics                 Gene
    Thomas                                                     ral
     Ralph
     Campbell
     Jr.
    ------------------------------------------------------------------------
    Fulton       Elizabeth Price  Homemaker  N/A  January     Monet     $150
     County                                        22, 2009    ary
     Republican                                                Gene
     Party,                                                    ral
     Inc.
    ------------------------------------------------------------------------
    Fulton       Elizabeth Price  Homemaker  N/A  February    Monet      $50
     County                                        13, 2009    ary
     Republican                                                Gene
     Party,                                                    ral
     Inc.
    ------------------------------------------------------------------------
    Fulton       Elizabeth Price  Homemaker  N/A  April 29,   Monet     $150
     County                                        2010        ary
     Republican                                                Gene
     Party,                                                    ral
     Inc.
    ------------------------------------------------------------------------
    Fulton       Elizabeth Price  City            October 7,  Monet      $10
     County                        Councilman,     2011        ary
     Republican                    City of
     Party,                        Roswell
     Inc.
    ------------------------------------------------------------------------
    Fulton       Elizabeth Price  City            October 7,  Monet     $180
     County                        Councilman,     2011        ary
     Republican                    City of
     Party,                        Roswell
     Inc.
    ------------------------------------------------------------------------
    Friends to   Thomas E.        Congressman     October     Monet   $1,000
     Elect Todd   Price, MD        United States   25, 2013    ary
     Tyson,                                                    Spec
     Inc., Todd                                                ial
     Tyson
    ------------------------------------------------------------------------
    Georgia      Thomas E.        Physician Self- December    Monet     $250
     Medical      Price, MD        Employed        3, 2014     ary
     Political                                                 Prim
     Action                                                    ary
     Couunittee
     (GAMPAC)
    ------------------------------------------------------------------------

                                   APPENDIX C

                      Awards Received by Dr. Thomas Price

    1988  In  Appreciation--Chairman, Bylaws Committee--North Fulton
    Regional Hospital 1988
           In Appreciation--American Cancer Society

    1990  In  Appreciation--Chairman, Department of Surgery--North Fulton
    Regional Hospital

    1993   President's Award--``Rx for Georgia''--Medical Association of
    Georgia
          Pr esident's Award--Medical Association of Atlanta--Chairman,
    Health Care Reform Committee

    1994  Pr esident's Award--Medical Association of Atlanta--Chairman,
    Health Systems Reform Committee
          Pr esident's Award--Medical Association of Atlanta--Chairman,
    Health Care Reform Committee

    1996   Partners in Education--Fulton County Schools
           In Appreciation--1st Vice President--Medical Association of
    Georgia

    1997   In Appreciation--Northside Alliance for Mentally Ill
          Re cognition--Support of Georgia Rotary Student Program--Georgia
    Rotary Student Endowment
           Distinguished Service Award--Medical Association of Atlanta

    1998   Rotarian of the Year--Roswell Rotary Club
          Outstanding Rotarian--Past Service--Roswell Rotary Club
          Legislative Service Award--Association of County Commissioners of
    Georgia
          Certificate of Achievement--Georgia Emergency Management Agency

    1999  Ou tstanding work as a friend of medicine and demonstrating
    dedication to patients of Georgia--Medical Association of Georgia
           In Appreciation--Kiwanis Club of Historic Roswell
           Senator of the Year--Georgia Republican Party
           Legislative Leadership Award--Georgia Hospital Association
          In  Appreciation--Honorable and Holy Calling to Public Service--
    Presbytery of Greater Atlanta

    2000   Will Watt Fellow--Rotary International
          In  Appreciation--Member of Governing Council--Organized Medical
    Staff Section, American Medical Association
           In Appreciation--Medical Team--Roswell High School
           Legislative Leadership Award--Georgia Hospital Association

    2001   In Appreciation--Georgia Alcohol Policy Partnership
           In Appreciation--North Georgia Community Action, Inc.
           In Appreciation--Coalition for Hospital Choice
           In Appreciation--Friends of Scouting, North Fulton Team
          Fa mily Practice Legislator of the Year--Leadership in Health
    Care--Georgia Academy of Family Physicians

    2002   Aven Citizenship Cup--Medical Association of Atlanta
          Na than Davis Award--Outstanding State Senator--American Medical
    Association
           In Appreciation--Keep Roswell Beautiful

    2003   President's Award--National Republican Legislators Association
          Ch ampion of 2003 Legislative Session--Perimeter Community
    Improvement Districts
           Cottage School--commencement speaker
           In Appreciation--Northside Baptist Church dedication

    2005   NWYC Constituent Communication Award
           Rotary Club of Roswell East
           Civil Air Patrol
           University of Phoenix Award
           Consulate General of Israel--Friend of Israel Award
           New South Energy Award
           Governor's Office of Highway Safety
           National Health Museum Charter Membership Award
           College of American Pathologists Award
           Americans for Tax Reform--2005 Hero of the Taxpayer Award
           Spirit of Enterprise Award--U.S. Chamber of Commerce

    2006   U.S. Chamber--Spirit of Enterprise Award
           Tommy Nobis Center--Award Presentation
           Adopt a Road Award
           ATR Hero of the Taxpayer Award
           60 Plus Association of the Guardian of Senior's Rights Award
           Association of Builders and Contractors--Champion of Merit Shop
           JWOD Congressional Champion Award
           Club for Growth Defender of Economic Freedom Award
           National Tax Limitation Committee Tax Fighter Award
           National Museum of Patriotism--Patriotism Award
           All Saints Catholic Church--Community Fellowship Award
           Cobb Chamber Award
           National Society of Sons of the American Revolution
           Armor Troops Foundation, Inc. Award
           National Hemophilia Foundation Award
           National Taxpayers Union--Taxpayers' Friend
           International Foodservice Distributors Association--Thomas
    Jefferson Award

    2007   U.S. Chamber--Spirit of Enterprise Award
           Georgia Ensemble Theater--Legacy Award
           National Taxpayers Union--Taxpayers' Friend
           NAPUS Georgia Chapter Award

    2008   North Fulton Chamber of Commerce Pioneer Award
            U.S. Chamber of Commerce Spirit of Enterprise Award
           U.S. English Award
           Medicare Choices Award
            A in English Award
           Americans for Tax Reform Award--Hero of the Taxpayer
          Na tional Association of Mutual Insurance Companies--Benjamin
    Franklin Public Policy Award
           Club for Growth's Defender of Economic Freedom Award
           American Legion--Certificate of Appreciation
           Oglethorpe Student Body and Phi Delta Epsilon's Thank You Award
           GA Civilian Aide to Secretary of Army--Appreciation Award
           Coalition for Medicare Choices--The Medicare Choices Leadership
    Award
           IFDA--Thomas Jefferson Award
           National Taxpayers Union Taxpayers' Friend

    2009  Na tional Association of Manufacturers--Manufacturing Legislative
    Excellence
          Na tional Orthopedic Leadership Conference--leadership on
    musculoskeletal diseases and conditions
           American Conservative Union Defenders of Liberty Award
           National Taxpayers Union--2008 Taxpayers' Friend Award
          60  Plus Association--Ben Franklin Award to thank you for working
    against the death tax
           AAOS--Congressional Leadership Award
           Club for Growth Defender of Economic Freedom Award
           Weyrich Awards Reception--You are receiving an award
           U.S. Chamber--Spirit of Enterprise Award
           Fulton County Republican Party--Leadership and Service Award
           Cherokee County Volunteer Aging Council Award
           FHL Bank--Key to Homeownership Award
          Am erican Academy of Orthopedic Surgeons--Congressional
    Leadership Award
           Doctors for Patient Freedom--Ed Annis Award for Medical
    Leadership
           Logisticare Appreciation Award for Presentation to Logisticare
    Operations

    2010   National Taxpayers Union--Friend of the Taxpayer Award
           U.S. Chamber of Commerce Spirit of Enterprise Award
           AAOS Advocacy Communications Award
          Na tional Association of Mutual Insurance Companies--Benjamin
    Franklin Public Policy Award
           American Conservative Union Defenders of Liberty Award
           U.S. English Award
           ProEnglish--American Unity Award
           GM Executive Retirees Club of GA
           GA GOP 6th District--Ronald Reagan Freedom Fighter Award
          Am erican Academy of Orthopedic Surgeons Advocacy--Communications
    Award
          International Foodservice Distributors Association--Thomas
    Jefferson Award
           Club for Growth's Defender of Economic Liberty Award

    2011   Institute for e-Health Policy--leadership award on HIT policy
    issues
          Na tional Association of Manufacturers--Manufacturing Legislative
    Excellence
           National Taxpayers Union's--Taxpayers' Friend Award
           Emory Board of Trustees--GA Delegation Award
           60 Plus Association's Guardian of Seniors' Rights Award
           American Conservative Union Defender of Liberty Award
           Club for Growth's Defender of Economic Liberty Award
           Health Care Leadership Council--Champion of Healthcare
    Innovation
           GA Association of Physicians of Indian Heritage Award

    2012   Cobb County Republican Women--Trumpet Award
           U.S. Chamber of Commerce Spirit of Enterprise Award
           Rotary International's Polio Eradication Champion Award
           Healthcare Leadership Council--Champion of Healthcare Innovation
           Small Business Council of America's 2012 Congressional Award
           IFDA--Thomas Jefferson Award
           RetireSafe--2012 Standing Up for America's Seniors Award
           Freedomworks Award
           NFIB Guardian of Small Business Award
           Fulton County JRTOC's Coin of Excellence Award
           National Society of Daughters of the American Revolution
           NASA-Space Shuttle Discovery GA flag
           American Congress of Obstetricians and Gynecologists--Public
    Service Award

    2013   National Association of Manufacturers--Award for Excellence
           American Conservative Union Foundation Award
           American Congress of Obstetricians and Gynecologists--Public
    Service Award
           U.S. Chamber of Commerce Spirit of Enterprise Award
           Dearborn High School Hall of Fame
           Senior Connections--Summer 2013 Champion of Senior Award
           America's Essential Hospitals Essential Physician Leader Award
           National Taxpayers Union--2012 Taxpayers' Friend Award
           Doctors for Patient Freedom--Ed Annis Award for Medical
    Leadership
           Southern Ortho Association's Award
           American Urological Association--Presidential Lecturer Award

    2014   U.S. Chamber of Commerce Spirit of Enterprise Award
           America's Essential Hospital Essential Physician Leader Award
           ACU Annual Award
           Association of Builders and Contractors--Champion of Merit Shop
           National Retail Federation--Hero of Main Street Award
           International Foodservice Distributors Association--Thomas
    Jefferson Award
           Virginians for Quality Healthcare--Healthcare Freedom Guardian
    Award
           National Association of Manufacturers--Award for Excellence
          Na tional Taxpayer Union--National Taxpayers Union's Taxpayers'
    Friend Award for 2013
           Association of Mature American Citizens--Friend of AMAC Award
           National Active and Retired Federal Employees Award
           Rx Drug Abuse Summit
          Am erican College of Cardiology--President's Award for
    Distinguished Public Service Award
           ACC President's Award for Distinguished Public Service
           International Foodservice Distributors Association--Thomas
    Jefferson Award

    2015   FRC Action True Blue Award
           National Association of Manufacturers--Award for Excellence
          Am erican Society of Transplantation--Organ Transplantation and
    Donation Legislative Leaders of the Year Award
           American Academy of Ophthalmology--Academy's Visionary Award
           American Conservative Union--Award for Conservative Excellence
           60 Plus Association--Member Tax Reform Award
           U.S. Chamber of Commerce Spirit of Enterprise Award
          Al liance for Patient Access and National Association of
    Nutrition and Aging Services Programs--2015 Medicare Part D Patient
    Access Champion Award
           ACU Annual Award
           Rotary Club of Dunwoody--Certificate of Appreciation
           GA Ortho Society--James Funk Distinguished Service Award
           GA Association of College Republicans--Order of Reagan
           FRC Action True Blue Award

    2016   AMRPA Chairman's Award
           ACU--Award for Congressional Excellence
           American Medical Rehab Providers Association--Chairmen's Award
           American Transaction Processor Coalition--Legislative Champion
    Award
           ATPC Friend of Industry Award
           U.S. Chamber of Commerce Spirit of Enterprise Award
          He althcare Leadership Council--Champion of Healthcare Innovation
    IFDA--Thomas Jefferson Award
           Campaign to Fix the Debt--Fiscal Hero Award
           National Retail Federation--Heroes of Main Street Award
           GA Life Alliance--Advocate for Life Award
           HME--Congressional Leadership Award
           World Harvest Church Award
           Campaign to Fix the Debt Fiscal Hero Award
           National Retail Federation--Heroes of Main Street Award

    No Year   Coalition for Medicare Choices--Leadership Award
           SIRPAC
          Al liance for Patient Access Medicare Part D--Patient Access
    Champion Award
           Veterans Issues--William Cobb VFW of Roswell Award
           Republic of Korea
           Naval Academy--Certificate of Appreciation
           American's Essential Hospital--Essential Physician Leader
           NFIB Guardian of Small Business (111th Congress)
           NFIB Guardian of Small Business (113th Congress)
           NFIB Guardian of Small Business (114th Congress)
          As sociated Builders and Contractors Champion of the Merit Shop
    (111th Congress)
           Theodore Roosevelt American Unity Award (111th Congress)
          As sociated Builders and Contractors Champion of the Merit Shop
    (110th Congress)
           NFIB Guardian of Small Business (112th Congress)
          As sociated Builders and Contractors Champion of the Merit Shop
    (112th Congress)

                                   APPENDIX D

           Op-Eds Authored by Dr. Tom Price--May 2011 to the Present

            The listing of pertinent Op-Eds begins on the table below and
            contains website addresses for direct access to the specified
            publications. In instances where a particular Op-Ed is not
            available via an internet source, a copy of the actual
            publication is attached for the committee's reference.

    ------------------------------------------------------------------------
        Date         Publication        Title                 Link
    ------------------------------------------------------------------------
    May 13, 2011  Health Reform     Empowering     http://tomprice.house.gov/
                   Report            America's      op-ed/empowering-
                                     Seniors        americas-seniors
    ------------------------------------------------------------------------
    May 14, 2011  The Daily Caller  Debt Limit     http://tomprice.house.gov/
                                     and Spending   op-ed/debt-limit-nnd-
                                     Reforms are    spending-reforms-are-
                                     Inextricably   inextricably-linked
                                     Linked
    ------------------------------------------------------------------------
    June 28,      TownHall.com      Cutting What   http://tomprice.house.gov/
     2011                            Washington     op-ed/cutting-what-
                                     Has Yet to     washington-has-yet-spend-
                                     Spend and      and-cannot-afford
                                     Cannot
                                     Afford
    ------------------------------------------------------------------------
    October 10,   Human Events      Empowering     http://tomprice.house.gov/
     2011                            Patients       op-ed/empowering-
                                     First Act:     patients-first-act-
                                     The Solution   solution-obamacare
                                     to Obamacare
    ------------------------------------------------------------------------
    November 15,  Cobb Medical      H.R. 3000--    Attached
     2011          Society           Empowering
                                     Patients Not
                                     Government
    ------------------------------------------------------------------------
    November 16,  Big Government    Patient        http://tomprice.house.gov/
     2011                            Centered       op-ed/patient-centered-
                                     Healthcare     healthcare-possible
                                     is Possible
    ------------------------------------------------------------------------
    November 26,  The Washington    PRICE:         http://tomprice.house.gov/
     2011          Times             Preserving     op-ed/price-preserving-
                                     the promise    promise-patients
                                     to patients
    ------------------------------------------------------------------------
    December 1,   Reporter          Republicans,   http://tomprice.house.gov/
     2011          Newspapers        Democrats      op-ed/republicans-
                                     see            democrats-see-different-
                                     different      fixes-fiscal-stalemate
                                     fixes to
                                     fiscal
                                     stalemate
    ------------------------------------------------------------------------
    December 12,  Chicago Tribune   Getting        http://tomprice.house.gov/
     2011                            America out    op-ed/getting-america-
                                     of deep debt   out-deep-debt
    ------------------------------------------------------------------------
    December 16,  The Oregonian/    Medicare pro:  http://www.oregonlive.com/
     2011          McClatchy         Reasonable     opinion/inPdex.ssf/2011/
                                     reforms can    12/
                                     provide fair   medicare_pro_reaPsonable
                                     fees for       _reform.html
                                     physicians
                                     and ensure
                                     patients
                                     receive
                                     quality
                                     treatment
    ------------------------------------------------------------------------
    February 15,  The Hill          President      http://tomprice.house.gov/
     2012                            obviously      op-ed/president-
                                     doesn't        obviously-
                                     grasp the      doesn%E2%80%99t-grasp-
                                     seriousness    seriousness-fiscal-
                                     of fiscal      situation
                                     situation
    ------------------------------------------------------------------------
    May 31, 2012  The Daily Caller  Obamacare      http://tomprice.housc.gov/
                                     Medical        op-ed/obamacare-medical-
                                     Device Tax:    device-tax-hazardous-
                                     Hazardous to   america%E2%80%99s-health
                                     America's
                                     Health
    ------------------------------------------------------------------------
    June 5, 2012  The Hill          IPAB is not    http://tomprice.house.gov/
                                     the way to     op-ed/ipab-not-way-lower-
                                     lower          medicare-costs
                                     Medicare
                                     costs
    ------------------------------------------------------------------------
    July 1, 2012  Marietta Daily    Try            http://tomprice.house.gov/
                   Journal           Principled     op-ed/try-principled-
                                     Solutions to   solutions-health-care-
                                     Health Care    fix
                                     Fix
    ------------------------------------------------------------------------
    July 26,      USA Today         Plenty of      http://tomprice.house.gov/
     2012                            Alternatives   op-ed/plenty-
                                     to             alternatives-government-
                                     Government     health-care
                                     Health Care
    ------------------------------------------------------------------------
    Fall 2012     Jewish Policy     A Principled   https://
                   Center            Health Care    www.jewishpolicycenter.o
                                                    rg/2012/08/31/health-
                                                    care-empower-patients/
    ------------------------------------------------------------------------
    July 30,      The Washington    Regulations    http://tomprice.house.gov/
     2012          Times             Are Choking    op-ed/regulations-are-
                                     Small          choking-small-business-
                                     Business       engine-growth
                                     Engine of
                                     Growth
    ------------------------------------------------------------------------
    December 6,   AJC               House          http://tomprice.house.gov/
     2012                            Republicans    op-ed/house-republicans-
                                     Stand by       stand-taxpayers
                                     Taxpayers
    ------------------------------------------------------------------------
    February 6,   Red State         Require A      http://tomprice.house.gov/
     2013                            Plan           op-ed/require-plan
    ------------------------------------------------------------------------
    March 12,     FoxNews.com       Introducing a  http://tomprice.house.gov/
     2013                            responsible,   op-ed/introducing-
                                     reasonable     responsible-reasonable-
                                     plan to        plan-balance-federal-
                                     balance the    budget
                                     federal
                                     budget
    ------------------------------------------------------------------------
    April 19,     The Hill          President's    http://origin-
     2013                            budget         nyi.thehill.com/blogs/
                                     ignores the    congress-blog/economy-a-
                                     will of the    budget/295025-presidents-
                                     people         budget-ignores-the-will-
                                                    of-the-people
    ------------------------------------------------------------------------
    May 20, 2013  Real Clear        The Unserious  http://tomprice.house.gov/
                   Politics          Senate         op-ed/unserious-senate-
                                     Budget         budget
    ------------------------------------------------------------------------
    May 30, 2013  Washington        President      http://tomprice.house.gov/
                   Examiner          Obama is       op-ed/president-obama-
                                     Responsible    responsible-his-
                                     for His        administration
                                     Administrati
                                     on
    ------------------------------------------------------------------------
    May 31, 2013  AJC               Stop the       http://tomprice.house.gov/
                                     Obamacare      op-ed/stop-obamacare-
                                     train wreck    train-wreck
    ------------------------------------------------------------------------
    July 17,      The Hill          How to         http://tomprice.house.gov/
     2013                            Replace        op-ed/how-replace-
                                     Obamacare      obamacare
    ------------------------------------------------------------------------
    July 31,      The Daily Caller  We can't       http://tomprice.house.gov/
     2013                            trust the      op-ed/we-can%E2%80%99t-
                                     IRS to         trust-irs-enforce-
                                     enforce        obamacare
                                     Obamacare
    ------------------------------------------------------------------------
    October 8,    Marietta Daily    All            http://tomprice.house.gov/
     2013          Journal           Republicans    op-ed/all-republicans-
                                     want is        want-fairness-all-
                                     fairness for   americans-and-thats-why-
                                     all            we-fight
                                     Americans,
                                     and that's
                                     why we fight
    ------------------------------------------------------------------------
    December 5,   National Review   Empowering     http://tomprice.house.gov/
     2013                            Patients       op-ed/empowering-
                                     First          patients-first
    ------------------------------------------------------------------------
    February 10,  ConservantiveUSA  Let's Begin    http://
     2014          .org              Again--Patie   www.conservativeusa.org/
                                     nts First      updates/lets-begin-again-
                                                    patients-first-rep-tom-
                                                    price-md-ga-06-
                                                    reptomprice-feb-10-2014
    ------------------------------------------------------------------------
    February 19,  Red Alert         A Better       http://tomprice.house.gov/
     2014          Politics          Prescription   op-ed/better-
                                     for            prescription-millenials
                                     Millenials
    ------------------------------------------------------------------------
    March 7,      Maryland State    There's No     Attached
     2014          Medical Journal   Code for
                                     Quality Care
    ------------------------------------------------------------------------
    March 20,     AMA SE            New            Attached
     2014                            Challenges
                                     Mean New
                                     Opportunitie
                                     s
    ------------------------------------------------------------------------
    March 24,     Medical           Modernizing    Attached
     2014          Association of    Medicare to
                   Georgia E-        Protect
                   Newsletter        Seniors
    ------------------------------------------------------------------------
    August 11,    Roll Call         Save           http://tomprice.house.gov/
     2014                            Medicare's     op-ed/save-medicares-
                                     Home Health    home-health-benefit
                                     Benefit
    ------------------------------------------------------------------------
    January 23,   Real Clear        A Healthy      http://tomprice.house.gov/
     2015          Politics          Economy for    op-ed/healthy-economy-
                                     All            all
    ------------------------------------------------------------------------
    March 17,     USA Today         Balance the    http://tomprice.house.gov/
     2015                            budget for a   op-ed/balance-budget-
                                     prosperous     prosperous-america
                                     America
    ------------------------------------------------------------------------
    April 1,      AMA SE            Prepared to    Attached
     2015                            Act on
                                     Patient-
                                     Centered
                                     Reform
    ------------------------------------------------------------------------
    April 6,      SC Times          House budget   http://www.sctimes.com/
     2015                            plan would     story/opinion/2015/04/05/
                                     set U.S. on    house-budget-plan-set-us-
                                     right fiscal   right-fiscal-path/
                                     path           25277905/
    ------------------------------------------------------------------------
    July 30,      Independent       Medicare and   http://tomprice.house.gov/
     2015          Journal PReview   Medicaid       op-ed/medicare-and-
                                     Turn 50        medicaid-turn-50-today-
                                     Today. Let's   let%E2%80%99s-keep-them-
                                     Keep Them      healthy
                                     Healthy
    ------------------------------------------------------------------------
    February 2,   Medical           A Step in the  Attached
     2016          Association of    Right
                   Georgia E-        Direction
                   Newsletter
    ------------------------------------------------------------------------
    March 10,     Medical           Keep the       Attached
     2016          Association of    focus on the
                   Georgia E-        patient
                   Newsletter
    ------------------------------------------------------------------------
    April 5,      AMA SE            Focused on     Attached
     2016                            Solutions
    ------------------------------------------------------------------------
    April, 13,    Real Clear        How and Why    http://tomprice.house.gov/
     2016          Politics          We Budget      op-ed/how-and-why-we-
                                                    budget
    ------------------------------------------------------------------------
    September 7,  Roll Call         Obamacare      http://tomprice.house.gov/
     2016                            Agency         op-ed/obamacare-agency-
                                     Escapes        escapes-congressional-
                                     Congressiona   oversight
                                     l Oversight
    ------------------------------------------------------------------------
    October 13,   JAMA Forum        Three          http://tomprice.house.gov/
     2016                            Congressmen'   op-ed/3-
                                     s Views on     congressmen%E2%80%99s-
                                     ACA's Flaws,   views-aca%E2%80%99s-
                                     Alternatives   flaws-alternatives-
                                     for Health     health-system-reform
                                     System
                                     Reform
    ------------------------------------------------------------------------
    October 17,   FoxNews.com       Reps.          http://www.foxnews.com/
     2016                            Burgess,       opinion/2016/10/17/reps-
                                     Price, Roe:    burgess-price-roe-our-
                                     Our            diagnosis-as-doctors-
                                     diagnosis as   obamacare-is-about-to-
                                     doctors--Oba   collapse.html
                                     maCare is
                                     about to
                                     collapse
    ------------------------------------------------------------------------
    November 1,   TownHall.com      Obamacare is   http://tomprice.house.gov/
     2016                            failing.       op-ed/obamacare-failing-
                                     Let's try a    let%E2%80%99s-try-better-
                                     Better Way     way
    ------------------------------------------------------------------------

                                     ______

                         A Step in the Right Direction
                     By Congressman Tom Price, M.D. (GA-06)
    On December 28th of last year, President Obama signed into law the
    Patient Access and Medicare Protection Act (S. 2425)--legislation that
    included several health-care reforms that had bipartisan support in
    Congress. Included in that package of reforms was a provision
    addressing electronic health record (EHR) meaningful use requirements--
    specifically hardship exceptions for physicians who would be unable to
    comply with the Centers for Medicare and Medicaid Services' (CMS) final
    Stage 2 modification rule. At issue was the fact that CMS released its
    rule with less than the requisite 90 days left to comply in 2015.

    The hardship exceptions provisions in S. 2425 are based on a bill that
    I had introduced, the Meaningful Use Hardship Relief Act (H.R. 3940),
    almost 2 months prior. We acted because it was clear that many
    physicians would likely be unfairly penalized due to CMS's failure to
    offer health-care providers adequate time to comply with new
    requirements pertaining to the electronic health records program. Under
    the new law, physicians are able to more easily obtain a hardship
    exception due to insufficient time in the 2015 reporting period.
    Additionally, CMS is now also able to batch process hardship exception
    applications for groups of physicians, rather than strictly on a more
    burdensome individual case-by-case basis.

    On January 22nd, CMS released guidance on the updated hardship
    exception application, and our office is continuing to closely monitor
    this issue as well as the meaningful use and electronic health records
    program. We would encourage you to apply for the hardship exemption.
    You can do so by going to CMS.gov. This is a small step but a step
    nonetheless toward protecting the critical doctor-patient relationship.
    Patients and physicians face many challenges in today's health-care
    system. Anything that can be done to allow physicians to focus more of
    their time and energy on the practice of medicine ought to be done so
    that we can further improve the quality and responsiveness of care.

                                     ______

                        There's No Code for Quality Care
                     By Congressman Tom Price, M.D. (GA-06)
    Physicians are used to dealing with complex systems--the human body
    being the most obvious example. They devote their years of education
    and their craft to finding answers to tough questions, solutions to
    difficult and--for patients and their families--very personal
    challenges. The eagerness of physicians, scientists, and other health-
    care providers to tackle the complex and at times unknown is driven by
    the knowledge that their time and commitment is in service to the
    health and well-being of others. Providing the best care for patients
    is the motivation.

    So it is with particular concern and consternation that today
    physicians are being inundated with a new set of complex problems to
    solve. The purveyor of these new challenges is, generally speaking, the
    regulatory state. It's the folks who are not so much in charge of
    actually caring for patients but the ones who have taken it upon
    themselves to be in charge of telling physicians more and more how to
    care for patients.

    Their more widely known mandates and regulations center most recently
    on the implementation of electronic health records (EHRs) and
    meaningful use requirements. The sorts of items that can justifiably be
    applied to improving quality care if physicians have the flexibility,
    the time and the resources to comply in an orderly fashion. That's a
    big ``if.''

    But then you have the complexities being handed down from upon high
    that have at best a tangential relationship to serving the needs of
    patients. Perhaps none will be more frustrating and costly to the
    delivery of care than the new ICD-10 diagnosis coding system that
    American physicians, hospitals, and other health-care providers are
    being told to adopt.

    The ICD-10 system has already earned a reputation as a bridge a bit too
    far--a sign that the regulatory state has become far too prescriptive
    to the point of being comical. You've likely heard of some of the more
    humorous new diagnosis codes. ICD-10 applies specific codes to injuries
    related to burning water skis, injuries sustained through an accident
    with a military vehicle while riding an animal, or being struck by any
    number of different animals for example, an orca.

    Could those examples and any of the others listed in the ICD-10 system
    occur? One supposes almost anything is possible. But the ``more is
    better'' mentality that sits behind the drafting and implementation of
    this system portends a very arduous and in many cases financially
    perilous environment for physicians and their practice.

    Resources that might be applied to new innovative technologies,
    expanded capacity to serve new patients, or even charitable payment
    scenarios will be diverted to pay for the adoption and implementation
    of ICD-10. Those most likely to be squeezed are the private practices--
    particularly those caring for patients in rural or under-served
    communities--that operate on narrow margins. That shifts the delivery
    of care to hospitals where the quality can be equal but the costs
    disproportionately higher.

    As an orthopaedic surgeon who practiced medicine for over 20 years in
    the Metro Atlanta area, I know firsthand about practicing medicine both
    in a private and hospital setting. There are benefits and drawbacks to
    both. But what makes our health-care system most beneficial to patients
    is the flexibility and diversity of care. The regulators are on
    schedule to continue destroying that flexibility and diversity of care.

    We see it in the manner in which the Affordable Care Act (ACA) is
    defining quality care based on a Washington-centric point of view. And,
    we see it with the unwillingness on the part of the Centers for
    Medicare and Medicaid Services (CMS) to consider a delay in the
    implementation of ICD-10 coding requirements. CMS Director Marilyn
    Tavenner recently confirmed that Washington would consider no more
    delays and that it was ``time to move on.''

    Thankfully, Congress has taken action--albeit in a limited capacity.
    Legislation recently signed into law included a 1-year delay of the
    ICD-10 deadline. It pushes back the date at which medical providers
    must adopt the new coding system from October 1st of this year to
    October 1, 2015.

    So where does that leave physicians trying to practice their profession
    and care for patients? According to a February 2014 report commissioned
    by the American Medical Association (AMA), a small medical practice
    will be on the hook for anywhere between $56,639 to over $226,000 in
    costs associated with the transition. For a medium size practice, AMA
    estimates pre- and post-implementation costs rising to as high as
    $824,735. And, the ``typical large practice'' can expect to pay
    anywhere in the range of $2 million to $8 million.

    Perhaps in Washington that's not considered a lot of money. But in the
    real world where the cost of health-care delivery is already rising due
    to any number of other forces--including innovation and other
    regulations--adding hundreds of thousands to millions of dollars to the
    cost of care is incredibly troubling.

    It should come as no surprise that an overwhelming majority of
    physicians were not ready for this year's October 1st deadline. A
    survey by the Medical Group Management Association found that slightly
    fewer than 10 percent of medical practices claim to have made
    significant progress on implementing the overhaul of the ICD system. In
    other words, if you were to put aside the argument about whether or not
    shifting to the new coding system was wise or necessary, folks still
    are not ready.

    In Congress, there's a broader effort underway to avoid this coming
    train wreck altogether. H.R. 1701, the Cutting Costly Codes Act of
    2013--of which I'm a co-
    sponsor--would prohibit the Secretary of Health and Human Services from
    moving forward with the ICD-10 implementation.

    What happens if a year passes, no action is taken to prohibit the
    implementation, and further delays are not forthcoming? If Washington
    ignores the facts and the frustration shared by many in the medical
    community? The initial costs associated with adopting ICD-10 will
    likely seem like a drop in the bucket over the longer term as medical
    practices struggle to familiarize themselves with the new litany of
    codes. It is expected that the number of codes will grow from roughly
    20,000 to over 150,000.

    Any failures to properly apply the right diagnostic label may be met
    with rejection or withholding of payment for services already rendered.
    Furthermore, fines and other costly legal proceedings could be incurred
    by physicians and medical practices whose only crime may be that they
    had unwittingly failed to comply properly with this complex new system.

    Were the new ICD-10 diagnosis codes coming online in otherwise
    relatively calm waters in the Nation's health-care system, the
    disruption could perhaps have been contained. But that's not the
    reality physician's face today. With the implementation of the
    Affordable Care Act, America's health-care system and those
    participating in it have been thrown one curve ball after another--told
    to get on board or get out of the way.

    Far too often that's how a bureaucracy functions, and it is the
    strongest argument against endowing regulators with the type of
    prescriptive power they are now preparing to wield. For the sake of
    patient access to quality, affordable care, we must continue to search
    for solutions that will let physicians do what they are trained to do--
    care for those in need. To be successful, physicians must engage in the
    public debate.

                                     ______

                     New Challenges Mean New Opportunities
                     By Congressman Tom Price, M.D. (GA-06)
    There is no shortage of issues these days competing for our attention.
    We have turmoil and upheaval around the world. There are long-running
    disagreements and troubles here at home. And while it can all be a tad
    overwhelming, it's important to find within these challenges the
    opportunity to affect positive change. Of note right now are five key
    areas that do deserve our focus--all of which, coincidentally, have
    emerged either from action or inaction on the part of your government.

    As a physician, I have watched with particular concern the troubled
    rollout or unraveling of the President's health-care law. Frankly, what
    we have is the expected outcome of truly disastrous policymaking. The
    law is not working--at least not as advertised. It is not working for
    patients, families or physicians. And, its failures are not merely the
    result of incompetence on the part of the Obama administration. They
    are the product of a fundamental conflict between the law and those
    principles of health care we hold dear: affordability, accessibility,
    choices, innovation, quality, and responsiveness.

    Premiums are rising. Provider networks made available through the new
    exchange plans are smaller. Folks are losing the coverage they had and
    access to the doctors they trusted. Less access and less affordability
    mean choices are being taken away from Americans. The law taxes
    innovation--literally a tax on life-saving medical devices. All of this
    will contribute to diminished quality of care as the system becomes
    more responsive to the needs of bureaucrats and less so to the needs of
    patients, families and doctors.

    So what can be done? Anyone who has taken care of patients knows that
    the status quo that existed prior to the passage of Obamacare was not
    working either. So no one should pretend we can simply uproot the
    current law and that will solve everything. We need a set of reforms
    that serve patients and those who care for them. Patient-centered
    solutions--like those I've introduced in H.R. 2300, the Empowering
    Patients First Act--would expand access to more health care choices by
    making it financially feasible for folks to purchase the coverage they
    want.

    We'd solve the insurance challenges of portability and pre-existing
    conditions by allowing folks to own their coverage no matter who's
    paying for it and to pool together and gain the purchasing power of
    millions. That way we can make sure no one is priced out of the
    insurance market due to a pre-existing injury or illness.

    To go after the rising costs of care in America, H.R. 2300 would enact
    medical malpractice reforms. Our plan would deter the practice of
    defensive medicine by giving physicians an affirmative defense in a
    court of law built on standards agreed upon and established by
    physicians--not Washington.

    Just as we need broader health-care reform, we also need to once and
    for all rid Medicare of its current payment formula. The sustainable
    growth rate (SGR) formula is not working for patients or doctors. The
    effort to repeal and replace it with one that does work has gone on too
    long. Thankfully, some encouraging steps have been taken in recent
    weeks.

    In the House of Representatives, we have passed a bill to repeal the
    SGR and modernize the payment system--giving physicians time to adjust
    to new rules that will hopefully provide the type of certainty and
    flexibility needed to increase the quality of care. The ball is now in
    the Senate's court. Our hope is that they will work with us so that
    there is a credible plan to move forward. We need to get this specific
    issue resolved in a way that protects seniors and respects American
    taxpayers.

    It is out of respect for American taxpayers that we must also keep our
    eye on the tremendous fiscal challenges we are facing as a Nation right
    now. As vice-chairman of the House Budget Committee, I've had the
    opportunity to work with many of my colleagues on different budget
    proposals over the years--plans that would balance the Federal
    Government's books, save and strengthen critical programs like Medicare
    and Social Security, and enact pro-growth policies like fundamental tax
    reform to get this economy moving. A budget is a blueprint for the
    positive direction we can take our Nation if we have the courage to
    make real, tough decisions on behalf of this generation and the next.
    Right now the committee is working on the next budget for fiscal year
    2015. With the President offering his plan that taxes more in order to
    spend more, there's a real opportunity and obligation to provide that
    better, alternative vision.

    Another pro-growth area we ought to be focused on is America's ongoing
    energy revolution. Whether one is talking about the growth in our
    ability to safely harvest more and more of America's abundant natural
    resources or the growth in new energy technologies, there are exciting
    opportunities here that will truly benefit our Nation. A robust energy
    market means more direct and indirect jobs and economic freedom.
    Internationally, a lessening of dependence on foreign sources of energy
    and a growing of America's impact on the global energy markets means we
    have greater influence in diplomatic and national security affairs.

    One doesn't have to look farther than the recent events in Ukraine to
    see an opportunity to leverage an all of the above energy strategy.
    With Russia exercising power in that part of the world thanks to their
    prolific energy production and distribution we can directly undermine
    their coercive powers by expanding our production and sale of energy
    resources to allies in the region.

    Lastly, what contributes to the disgust many feel watching Russia
    invade and annex a piece of another country is that this action flies
    in the face of democratic values we hold sacred here in America. Those
    values were written into our Constitution and made explicit when our
    founders declared our rights came from God, not man. Chief among them
    is the First Amendment's right to freedom of speech.

    Unfortunately, that fundamental freedom has been under assault from an
    overactive regulatory environment in Washington. We know that the IRS
    unfairly targeted and abused certain Americans whose only crime was
    attempting to speak up for their beliefs. Now, the IRS is attempting to
    codify that level of abuse through new regulations affecting groups--
    including veterans' organizations and those engaged in civic
    education--that file as nonprofits under the tax code's 501(c)(4)
    designation.

    Under that section of the code, activities by these nonprofits that are
    for the purposes of ``social welfare'' are tax exempt. The IRS wants to
    rewrite the rules after 55 years to essentially force these
    nonprofits--many of which hold political views in conflict with the
    current administration--to re-classify under a different section of the
    code or become subject to taxation. Either way, the end result would be
    to silence voices and expose more Americans to further abuse and unfair
    treatment.

    All of these issues--whether foreign, domestic or both--impact our
    lives in some form or another. We should not shy away from these
    challenges because with them comes opportunity to improve our lives and
    that of our families, friends, and neighbors. If we can find a way to
    bridge differences, reinforce time-honored principles, and show
    leadership, I'm confident we will find positive solutions that build a
    stronger future for our Nation.

                                     ______

                    Modernizing Medicare to Protect Seniors
                     By Congressman Tom Price, M.D. (GA-06)
    The Medicare program is a vital life-line for millions of American
    seniors. Unfortunately, the current program is not working as well as
    it should for either those in retirement or the physicians who care for
    them. In addition to the real financial challenges the program as a
    whole faces in the next few years--challenges that ought to be
    addressed with broader reforms to Medicare--we have an even more
    immediate concern as it relates to Medicare's current payment formula.

    Efforts to address the broken sustainable growth rate formula (SGR)
    have been underway for years. In the meantime, Congress has acted to
    avoid the SGR's looming large cuts in physician reimbursements by
    enacting a series of delays--some longer than others. This has been
    done to buy time for policymakers to coalesce around a responsible
    solution that will repeal the SGR permanently and replace it with a
    system that makes sense. The cost of those delays has been substantial,
    but it has also been necessary in order to protect access to care for
    seniors.

    Thankfully, promising steps have been made in the last several months
    to forge a consensus on a real plan to modernize the Medicare payment
    system. Introduced in February, the SGR Repeal and Medicare Provider
    Payment Modernization Act of 2014 (H.R. 4015) enjoys bipartisan,
    bicameral support. On March 14th the House of Representatives passed
    the bill and sent it to the Senate for its consideration.

    In order to ensure these solutions both protect seniors and respect
    taxpayers, the legislation endorsed by the House of Representatives
    included a delay in the Affordable Care Act's individual mandate to
    offset the costs associated with a repeal of the SGR. The Obama
    administration has already implemented a de facto delay to this
    provision of the President's health-care law through executive fiat. We
    thought it better to do so through the normal and constitutional
    lawmaking process.

    The latest projections show cuts to physician reimbursement rates in
    the range of 24% if nothing is done. Temporary patches will continue to
    buy more time but in the aggregate over the years they also prove more
    costly than a full repeal and replace scenario. More importantly, the
    level of uncertainty and anxiety that will persist so long as this
    issue remains unresolved exacts its own costs on physicians and seniors
    that cannot be measured in dollars and cents.

    It is rare in Washington these days that you can find an issue that
    secures both bipartisan support and action. We should not miss this
    opportunity to enact a positive set of solutions that will modernize
    Medicare's payment system. Our hope is that the Senate will come to the
    table with the House of Representatives so we can work together to
    protect seniors' access to health care.

                                     ______

                   Prepared to Act on Patient-Centered Reform
                     By Congressman Tom Price, M.D. (GA-06)
    This summer the Supreme Court of the United States will render a
    verdict in the case of King v. Burwell, which could have a lasting
    impact on whether the Affordable Care Act or ``Obamacare'' remains the
    law of the land. The fundamentals of the case are fairly
    straightforward: should the Obama administration be allowed to offer
    subsidies to help Americans purchase health-care coverage through
    Obamacare exchanges established by the Federal Government? The text of
    the law states that subsidies are to be made available to those who
    have enrolled in an insurance plan through an exchange established by
    the State. Since the enactment of Obamacare, 37 States have chosen not
    to establish their own exchanges or have partnered with the Federal
    Government in some fashion--meaning millions of Americans have gained
    health-care coverage with the help of subsidies through a Federal
    exchange.

    If the Court rules in favor of the actual text of the law, which does
    not explicitly provide financial assistance to those purchasing
    coverage through the Federal exchange, those millions of Americans who
    purchased that insurance coverage would lose access to subsidies and
    face even higher health-care costs. For its part, the Obama
    administration has claimed it has no strategy in place to handle the
    aftermath of such a ruling--despite being complicit in the creation of
    the law itself and its, quite possibly soon to be ruled illegal,
    interpretation.

    Conversely, in March, I introduced the Medical Freedom Act (H.R.
    1234)--legislation to allow States the freedom to offer within their
    jurisdiction health plans, health savings accounts, and other
    arrangements that are currently restricted under Obamacare, and the
    Medicare Patient Empowerment Act (H.R. 1650)--allowing patients and
    physicians to voluntarily contract for a service outside of the
    dictates from CMS. This type of flexibility within States to regulate
    their markets and ensuring doctors may practice as they see most
    appropriate would be strong first steps toward mitigating the fallout
    from the King v. Burwell ruling. At the same time, committees of
    jurisdiction in the House of Representatives and the Senate have been
    hard at work putting together policy proposals of their own that would
    be needed to respond should the court rule that the Federal exchange
    subsidies are indeed illegal. No matter the makeup of our response,
    Congress is aiming to be prepared so that the American people are not
    made to suffer any more than they already have from Obamacare.

    Even if the Court rules in favor of the Obama administration's
    interpretation and keeps the subsidies flowing on the Federal
    exchanges, there still remains real, fundamental concerns with how this
    law has been implemented, the impact it is having on the quality and
    affordability of health care in America, on access to physicians and on
    innovation.

    Those of us who believe we ought to have a health-care system less
    geared toward Washington and more in the hands of patients, families
    and physicians have to continue to push our colleagues and Congress and
    take our case to the American people. We have to keep the conversation
    going, and make clear that there are positive, patient-centered
    solutions out there that are far better for the health of our Nation
    than what Obamacare has to offer.

    For several years now, I have introduced legislation each Congress
    called the Empowering Patients First Act--a set of solutions that would
    expand access to quality affordable health-care choices and put
    patients, families and doctors in charge of health-care decisions, not
    Washington, DC. We have offered patient-centered reforms like
    Individual Member Associations so folks can pool together for the
    purpose of purchasing affordable coverage; lawsuit abuse reform to end
    the practice of defense medicine that adds hundreds of billions of
    dollars to America's health-care bill each year; health-care tax
    credits so folks have the financial wherewithal and incentive to
    purchase the sort of coverage that meets their individual needs.

    There are many other aspects of the Empowering Patients First Act that
    would enhance the quality, affordability and accessibility of care in
    our country. Indeed, there are a myriad of positive, promising ideas
    that my colleagues in Congress have put forward and each of those ideas
    should continue to be a part of an honest and open debate on a broader
    reform effort.

    Depending on its decision, the Supreme Court's ruling later this year
    may initiate an unraveling of Obamacare or it may have no real impact.
    Either way, policymakers need to be prepared to respond. Physicians and
    other health-care practitioners across the country need to be ready as
    well to play a constructive role in ensuring that not only in the near
    term but in the long run, we protect and preserve the sanctity of the
    doctor-patient relationship.

                                     ______

                              Focused on Solutions
                     By Congressman Tom Price, M.D. (GA-06)
    America's Founding Fathers wisely chose to give Congress--the branch of
    government closest and most accountable to the people--the power to
    write laws, determine how many hard-earned tax dollars are necessary to
    administer those laws, and to ensure the executive branch is faithfully
    carrying out those laws. For our Nation's experiment in self-government
    to work, those roles and responsibilities must be respected.

    At the Committee on the Budget in the U.S. House of Representatives--on
    which I am honored to serve as chairman--we have been hard at work
    doing just that. The House Budget Committee is tasked with putting
    together an annual budget. We provide lawmakers a blueprint for how
    Congress can assert the spending and oversight authorities given it
    under the Constitution and do so in a responsible, responsive manner.

    In March, the House Budget Committee introduced and approved our fiscal
    year 2017 budget resolution which we call A Balanced Budget for a
    Stronger America. This proposal would balance the Federal budget within
    10 years without raising anyone's taxes. It keeps the Federal
    Government's books in balance beyond the coming decade which puts us on
    a path to pay off the national debt. If the policies we advocate were
    enacted, we would achieve over $7 trillion in deficit reduction through
    a combination of savings and economic growth. Those savings come from
    common sense reforms we propose to make government more efficient,
    effective, and accountable.

    Some of the more critical reforms are in the area of health care. We
    put forward a plan to save and strengthen the Medicare program. We
    advocate for an improved system that enhances quality, gives seniors
    more choices, and ensures that traditional Medicare is always available
    to Americans when they reach retirement age.

    Under current law, if nothing is done, Medicare will go insolvent in
    2030. This will result in a significant reduction in benefits for
    seniors' health care. We believe this would be irresponsible. Our plan
    would prevent this from happening with patient-centered reforms, and
    ensure this program, which millions have paid into, will be there for
    them when they need it.

    For the brave men and women of our armed forces, for our veterans, and
    for our military families, our budget encourages additional health-care
    reforms at both the Department of Veterans Affairs (VA) and the
    Department of Defense (DoD). Those who protect and defend our Nation
    must have access to the care they need when they need it.

    For those Americans who are struggling to afford health-care coverage,
    our budget rejects the broken status quo and calls for innovative
    solutions. We would give States the flexibility to design and implement
    their Medicaid programs to meet the unique needs of their communities.
    At the same time, we would get rid of the top-down, Washington-knows-
    best model that is currently in place in private-sector health care and
    implement patient-centered solutions to ensure every American has
    access to the health coverage they want, not the one Washington forces
    them to buy.

    What these solutions ultimately comprise is part of a conversation
    currently being held in Congress and, specifically, among those of us
    on the House Task Force on Health Care Reform. We are developing a
    package of reforms that would create a patient-centered health-care
    system where Americans have access to quality, affordable choices, the
    doctor-patient relationship is respected, and real insurance challenges
    like pre-existing conditions are solved through policies that protect
    and empower individuals, not government mandates.

    The task force is committed to building these solutions from the ground
    up. However, we do not come to this challenge empty handed. Numerous
    health care policy ideas--including H.R. 2300, the Empowering Patients
    First Act which I have introduced for the past several congresses--have
    been circulating for years, both before and after passage of the
    President's health-care law.

    The Task Force on Health Care Reform is one pillar of a larger effort
    to advance a positive, proactive agenda. A perfect partner in that
    effort is the annual budget resolution which is why the House Budget
    Committee has been committed to bringing this positive proposal
    forward. We are focused on getting results and solving the numerous
    challenges facing our country--from the economy to national security--
    so we have a more secure and more prosperous Nation.
                                     ______

                       Empowering Patients Not Government
                     By Congressman Tom Price, M.D. (GA-06)
    While practicing orthopaedic surgery for over 20 years, my focus was,
    as it should be, on the patients and serving their needs to the best of
    my ability. Unfortunately, during the early 1990s under then-President
    Clinton's attempt to overhaul America's health-care system, it became
    clear that policy decisions were continuing to be made in Washington
    that would have a profound, and oftentimes, negative impact on the
    practice of medicine. Many of those decisions were being made by
    individuals, probably with good intentions, but who knew little to
    nothing about the practice of medicine--who had never cared for
    patients or understood what it took to do so.

    While President Clinton's efforts were unsuccessful, last year
    President Obama signed into law a massive health reform law that is
    destructive and fails to protect and promote the principles of health
    care we cherish, including affordability, accessibility, quality,
    responsiveness, innovation, and choices. The challenge to improve our
    health-care system and make it accessible to more Americans still
    stands; i.e., the status quo is unacceptable, which makes it incumbent
    upon those of us who disagree with the overhaul enacted in the previous
    congress to propose positive solutions in line with health-care
    principles that protect the rights of patients and doctors.

    In order to ensure health-care choices in America, Congress must repeal
    the President's health-care law first and foremost and then reform the
    system in a common sense manner. As one of a growing number of
    physicians in the House of Representatives, we understand that changes
    must be made. In order to move the debate forward, I recently
    introduced legislation to repeal and replace the President's health-
    care law.

    The Empowering Patients First Act (H.R. 3000) encourages individuals to
    obtain health coverage and makes it financially feasible for
    individuals and families to do so. It addresses the issue of lawsuit
    abuse and defensive medicine, which was completely ignored in last
    year's health-care law, and it keeps Washington out of the way of
    health-care decisions. At its core, it advances patient-centered
    solutions to the challenges we face.

    Many of us in the medical profession have seen firsthand the
    distortions and disruptions that defensive medicine and excessive
    bureaucracy have on the practice of medicine. Inserting misguided
    government controls and regulations will lead to the denial of care and
    the elimination of health-care choices and personal decision-
    making. Under current law, there is even an unaccountable, unelected
    board of 15 bureaucrats--the Independent Payment Advisory Board
    (IPAB)--that will have the power to deny health care to America's
    seniors. That is wrong and does not have to happen in order to make our
    health-care system stronger. It will only weaken the quality of
    medicine for seniors and all Americans.

    Since physicians know the best care for their patients, the Empowering
    Patients First Act establishes doctor-led quality measures. And we
    encourage healthier lifestyles by allowing employers more flexibility
    in offering discounts to their employees through wellness and
    prevention programs.

    The health-care system in America needs to be reformed and improved--
    there is no doubt about that--but this must be done without handing
    over greater authority to the Federal Government. As a physician and
    someone who spent years caring for patients, the damage that can be
    done to the health of our great Nation by government interference is
    clear and unacceptable. The current situation demands that we advance a
    plan not only to halt that interference, but also one to improve access
    to quality, affordable health care. That solution is H.R. 3000!

                                     ______

                         Keep the Focus on the Patient
                     By Congressman Tom Price, M.D. (GA-06)
    A patient-centered health-care system is built upon six principles:
    accessibility, affordability, quality choices, responsiveness, and
    innovation. Today, there are many instances where those principles are
    being violated--more often than not through rules and regulations
    handed down from bureaucratic agencies in Washington, DC. For an
    example, we need only look at how physicians and hospitals have had to
    go about adopting electronic health records (EHR).

    As part of the economic stimulus package that became law in the early
    days of the Obama administration, there was a concerted effort to help
    spur adoption of EHR among physicians and hospitals. The law states
    ``the Secretary [of Health and Human Services] shall seek to improve
    the use of electronic health records and health-care quality over time
    by requiring more stringent measures of meaningful use.''

    From this text was born a complex and burdensome set of requirements
    known as Meaningful Use (MU) Stage 1, 2, and 3. Although well-
    intentioned, the MU requirements have chiefly missed the mark by
    focusing more on data entry and less on patients and their doctors.

    Physicians face a number of impediments to meeting the MU requirements,
    many of which are outside of their control. These include the lack of
    usability and interoperability among EHR, significant data exchange
    fees, interference with face-to-face patient care, time-consuming data
    entry, the degradation of clinical documentation, and in inflexible
    metrics.

    A total of 209,000 physicians will face penalties in 2016 for failing
    to meet EHR MU criteria. While 80 percent of physicians have adopted
    EHR in their practices, less than 10 percent of physicians have
    successfully participated in MU Stage 2 so far. If we want higher
    quality care, healthier patients, and a more efficient use of time and
    resources, then the MV program needs to be reevaluated so it moves in
    the direction of our health-care principles.

    This past October, the Centers for Medicare and Medicaid Services (CMS)
    released its modified Stage 2 rule of the MU program. CMS issued its
    directive with less than the requisite 90 days remaining in the 2015
    program year. That meant it was virtually impossible for doctors to
    meet the requirement deadlines.

    Anticipating this challenge, I introduced H.R. 3940--the Meaningful Use
    Hardship Relief Act--to provide physicians with much-needed relief by
    ensuring they would be granted a hardship exception to avoid penalties
    stemming from the delayed rulemaking. Working with colleagues in
    Congress, physicians and various stakeholders, we were able to get
    language based on the solutions that we introduced included in a larger
    package of reforms--S. 2425, the Patient Access and Medicare Protection
    Act--which was signed into law just prior to the new year.

    On January 22, CMS released a hardship application for physicians and
    hospitals to use when filing an exception to the MU penalty for the
    2015 program year. In the past, providers and hospitals had separate
    application forms. Under the new law, the application is now
    streamlined and can be used by both. Providers may file as individuals
    or in groups--while before each individual provider would have had to
    submit a separate application to be considered by CMS on a case-by-case
    basis. This new streamlined process also allows CMS to process hardship
    applications more efficiently in batches.

    All physicians are encouraged to go to CMS.gov and apply for a hardship
    exception under the category ``EHR Certification/Vendor Issue (CEHRT
    Issues),'' which references ``insufficient time'' in accordance with
    CMS's delayed rulemaking. Applications must be submitted to CMS by
    March 15.

    Sadly physicians know all too well that the work of defending the
    principles of patient-centered care never ends. While MU penalties
    affect physicians and hospitals nationwide, here in Georgia our
    laboratories and physician groups were facing a more unique threat at
    the beginning of this year. Under a blatantly prejudiced reimbursement
    policy related to new codes for drug testing. CMS was threatening a 33
    percent cut from the national payment rate for Georgia labs and
    doctors. Thanks to the Medical Association of Georgia and others, we
    were able to get this serious discrepancy repaired and ensure that
    Georgia health-care providers were treated fairly.

    With solutions to improve our health-care system that adhere to our
    principles, we can protect the doctor-patient relationship from undue
    influence and interference, and put patients, families, and doctors in
    charge.

                                     ______

                                   APPENDIX E

        Speeches and Remarks Made by Dr. Tom Price--2012 to the Present

    ------------------------------------------------------------------------
         Date              Name              Topic             Location
    ------------------------------------------------------------------------
                   2016 Speeches and Remarks by Dr. Tom Price

    January 13,     REMARKS:           What, If Anything  DC
     2016            Brookings Event    Congress is
                                        Likely to
                                        Accomplish in
                                        This Election
                                        Year

    January 23,      REMARKS: Georgia  Washington Update  GA
     2016            Medical
                     Directors
                     Association
                     Winter Symposium

    January 30,     REMARKS:           Healthcare         GA
     2016            Conservative       Update, Emphasis
                     Policy             on H.R. 2300
                     Leadership
                     Institute

    February 24,    REMARKS: NAHU      Health Care--ACA   DC
     2016            Meeting            replacement

    March 1, 2016   REMARKS: AMRPA     Congressional      DC
                     Leadership Forum   Update and
                                        Gratitude for
                                        the AMRPA
                                        Chairman's Award

    March 22, 2016  REMARKS: Pete      General            DC
                     Sessions Medical   Healthcare
                     Professionals      Overview
                     Fly-in

    March 24, 2016  REMARKS: Emory     The State of the   GA
                     College            GOP and H.R.
                     Republicans        2300

    April 11, 2O16  REMARKS:           Issues of          GA
                     Healthcare         Healthcare
                     Symposium with     Economics and
                     Berry College      Policy in the
                                        U.S.

    April 13, 2016  REMARKS: Idea      No topics listed   DC
                     Forum on
                     Healthcare
                     Reform

    April 14, 2016  REMARKS: Georgia   Washington Update  DC
                     Society of
                     Ophthalmology
                     Breakfast

    April 19, 2016  REMARKS: NASS      General/Broad      DC
                     Event              Update on
                                        Healthcare as it
                                        Stands in the
                                        House and From
                                        his Perspective
                                        as Chairman of
                                        the Budget
                                        Committee

    May 4, 2016     REMARKS: Emory     Federal Funding    GA
                     Science Advocacy   for Biomedical
                     Network            Research,
                                        Particularly for
                                        the National
                                        Institutes of
                                        Health (NIH) and
                                        National Science
                                        Foundation (NSF)

    June 27, 2016   REMARKS:           Washington Update  NY
                     Roundtable Lunch   With a Focus on
                     Event with         Budget Committee
                     Market News        Activity and Dr.
                     International      Price's Work on
                     Connect            Health Care

    July 13, 2016   REMARKS: Health    Your Perspective   DC
                     on Wednesday       as a Leader in
                                        the House on
                                        Finalizing
                                        Health
                                        Initiatives in
                                        the 2nd Session
                                        of Congress;
                                        Standard
                                        Healthcare
                                        Speech

    July 21, 2016   REMARKS:           Future of Health   OH
                     Washington Post    Care and Health
                     Panel on           Policy Issues
                     Healthcare         the Next
                                        President Will
                                        Face

    August 7, 2016  REMARKS: GPLA;     Perspectives on    GA
                     Perspectives on    Physician
                     Physician          Leadership
                     Leadership         Communication
                     Communication

    August 13,      REMARKS:           The Current State  GA
     2016            Concierge          of Healthcare
                     Medicine           and Emerging
                     Conference         Entrepreneurial
                                        Forms of
                                        Healthcare
                                        Delivery in
                                        America

    August 25,      REMARKS: MVP Vets  Your Work in       GA
     2016            Event With         Washington and
                     Elekta and         How It's
                     AdvaMed            Essential to the
                                        Medical
                                        Technology
                                        Community
                                        (Medical Device
                                        Tax or Even the
                                        Breakthrough
                                        Pathways
                                        legislation,
                                        e.g.)

    August 25,      REMARKS: AARP      Social Security    GA
     2016            Financial Forum    (Challenges to,
                     With Senator       the Future of,
                     Isakson            Possible
                                        Solutions) and
                                        any Other
                                        Financial
                                        Initiatives at
                                        the Federal
                                        Level You Would
                                        Like to
                                        Highlight

    September 10,   REMARKS: AKSM      Washington/        GA
     2016            Medical Director   Healthcare
                     Meeting            Update

    September 13,   REMARKS: PhRMA     CMMI and 2017      DC
     2016            Board              Agenda

    September 20,   REMARKS: AAMC      Present            DC
     2016                               Information
                                        About Mr.
                                        Trump's
                                        Platform,
                                        Especially as it
                                        Related to
                                        Health Care

    September 28,   REMARKS: U.S.      Better Way Health  DC
     2016            Chamber's E8       Care Plan
                     Committee

    October 10,     REMARKS: Emory     Future of Health,  GA
     2016            School of          Healthcare, and
                     Business's         Congressional
                     Speaker Series:    Roll
                     Medical
                     Technology
                     (Health IT and
                     Medical Devices)

    October 17,     REMARKS: Seniors   Senior's           Call
     2016            for Trump          Healthcare
                     Conference Call    (Medical and
                                        Supplementary
                                        Coverage)

    October 20,     REMARKS: Eastern   Federal            LA
     2016            Orthopedic         Healthcare and
                     Society            How it Affects
                                        Orthopaedic
                                        Surgeons

    November 1,     REMARKS:           Healthcare         PA
     2016            Healthcare Event
                     With Trump

    November 2,     REMARKS: Medtrade  AAHomecare         GA
     2016            Conference         Washington
                                        Update

    November 12,    REMARKS: RIPON:    National Health    DC
     2016            PANEL 4            Service vs.
                                        Obamacare

    November 21,    REMARKS: Panel     Importance of      GA
     2016            Discussion With    U.S. Global
                     U.S. Global        Leadership and
                     Leadership         to Highlight the
                     Coalition          Positive Impacts
                                        America's
                                        Development and
                                        Diplomatic
                                        Programs Have on
                                        Georgia

                    2015 Speeches and Remarks by Dr.Tom Price

    January 12,     REMARKS: Heritage  Vision for the     DC
     2015            Action Policy      House Budget
                     Summit             Committee +
                                        Upcoming Fiscal/
                                        Economic
                                        Deadlines (ex:
                                        SGR)

    January 30,     REMARKS: American  Affordable Care    DC
     2015            Society of         Act Update
                     General Surgeons
                     Conference

    January 31,     REMARKS:           Empowering         GA
     2015            Conservative       Patients First
                     Policy             Act
                     Leadership
                     Institute

    February 9,     REMARKS: MASA      SGR, ICD-10 and    DC
     2015            Conference         How the Doctor's
                                        Caucus Can Have
                                        More Influence
                                        in Congress as
                                        Far as Medical
                                        Issues

    February 12,    REMARKS: ASCO      SGR Reform and     DC
     2015            Oncology Meeting   How it is
                                        Impacted by the
                                        Budget Process

    February 18,    REMARKS: Panel     Obamacare/         GA
     2015            Discussion With    Healthcare
                     Senator Isakson:   Reform
                     NFIB/GA Small
                     Business Day

    February 24,    REMARKS: AMA       Budget, Medicare,  DC
     2015            National           etc.
                     Advocacy
                     Conference

    February 28,    REMARKS: CPAC      What Have His      MD
     2015                               Former
                                        Colleagues in
                                        Medicine Told
                                        Him About How
                                        Obamacare is
                                        Affecting Their
                                        Practices, and
                                        What Effect
                                        Might This Have
                                        on Federal
                                        Spending?

    March 2, 2015   REMARKS: American  General Update on  DC
                     Academy of         Healthcare
                     Neurology
                     Reception

    April 16, 2015  REMARKS: American  Medicare Payment   DC
                     Academy of         Outlook
                     Ophthalmology

    April 27, 2015  REMARKS: GNFCC's   Your Health Care   GA
                     Healthcare         Plan and
                     Technology         Obamacare Repeal
                     Roundtable         and Replacement

    April 27, 2015  REMARKS:           Repeal of the SGR  FL
                     Emergency          and Interested
                     Department         in What Will
                     Practice           Happen Moving
                     Management         Forward
                     Association's
                     Solutions Summit

    April 28, 2015  REMARKS: Big       Opening Remarks--  DC
                     Cities Health      Share Your
                     Coalition          Personal Story
                     Breakfast
                     Briefing With
                     John Lewis

    April 30, 2015  REMARKS: Laffar    Discuss What Your  DC
                     Associates 55th    View Is as to
                     Washington         the Most
                     Conference         Important
                                        Economic
                                        Legislative
                                        Agenda Items and
                                        Current Events

    May 1, 2015     REMARKS: American  What It's Like to  DC
                     Association of     Be a Member of
                     Orthopaedic        Congress and
                     Surgeons           Former Surgeon;
                                        Budget Outlook;
                                        Healthcare
                                        Landscape--Post-
                                        SGR

    May 6, 2015     REMARKS: Lecture   A Balanced Budget  NJ
                     With the           for a Stronger
                     Princeton Tory     America: Federal
                                        Spending,
                                        Obamacare, and
                                        Other Washington
                                        Updates

    May 13, 2015    REMARKS: American  H.R. 23OO          DC
                     Tax Reform
                     Meeting

    May 19, 2015    REMARKS: National  Primary Focus:     DC
                     Association of     Dr. Price's
                     Spine              Patient Shared
                     Specialists:       Billing
                     (NASS) Capitol     Legislation--H.R
                     Hill Day 2015      . 1650, Medicare
                                        Patient
                                        Empowerment Act

    June 8, 2015    REMARKS: SE        Healthcare         IL
                     Breakfast at AMA

    June 15, 2015   REMARKS: American  H.R. 2300          GA
                     Society of
                     Actuaries

    June 23, 2015   REMARKS:           Brief Overview of  DC
                     Healthcare         Work in the Ways
                     Leadership         and Means
                     Council Luncheon   Committee

    July 20, 2015   REMARKS: Town      Meaningful Use--   GA
                     Hall Meeting       Town Hall Is
                     With AMA           Focused on
                     President Stack    Electronic
                                        Health Records
                                        and Looming
                                        Regulations

    August 1, 2015  REMARKS:           Current State of   GA
                     Concierge          Healthcare and
                     Medicine           Emerging
                     Conference         Entrepreneurial
                                        Forms of
                                        Healthcare
                                        Delivery in
                                        America

    August 9, 2015  REMARKS: GPLA      Perspectives on    GA
                                        Physician
                                        Leadership

    August 14,      REMARKS: South     Policy and the     GA
     2015            Atlantic Region    Impact on
                     Architecture for   Healthcare
                     Health Annual      Delivery
                     Conference

    August 17,      REMARKS: UCB       Healthcare         GA
     2015            Politics and       Related Topics--
                     Pizza Luncheon     Vision for the
                                        U.S. Healthcare
                                        System--FDA
                                        Reform, etc.

    August 21,      REMARKS: WellStar  Healthcare/Budget  GA
     2015            Board Meeting--    Update
                     Reception and
                     Dinner

    September 24,   REMARKS:           Your Specialty in  MI
     2015            University of      Medicine and
                     Michigan Young     Perhaps Touch on
                     Americans for      Some Important
                     Freedom            Legislative
                                        Issues
                                        (Obamacare)

    September 28,   REMARKS:           Health Reform and  DC
     2015            Chairman's         Budget
                     Council Policy
                     Conference

    October 3,      REMARKS: GOS       No topics listed   GA
     2015

    November 16,    REMARKS: AMA       Personal           GA
     2015            Southeastern       Experience in
                     Delegation         Medicine and
                     Breakfast          Transition to
                                        Government

    December 3,     REMARKS: First     Health Policy and  DC
     2015            Quality Forum      Related Budget
                                        Issues

    December 9,     REMARKS: AEI       No topics listed   DC
     2015            Speech

                   2014 Speeches and Remarks by Dr. Tom Price

    January 15,     REMARKS:           MMP Bill           DC
     2014            Healthcare         Completive
                     Policy Briefing    Bidding (They
                                        May Bring Up
                                        SGR, ACA, etc.)

    February 10,    REMARKS: Heritage  H.R. 2300          DC
     2014            Action Panel

    February 22,    REMARKS: Tea       Healthcare         GA
     2014            Party Patriots     Update--H.R.
                     Healthcare Event   2300

    February 27,    REMARKS: Lone      Healthcare         DC
     2014            Star Leadership    Roundtable--E&C,
                     PAC Breakfast      W&M Perspective

    February 27,    REMARKS: Galen     Healthcare Reform  DC
     2014            Institute Health   Proposals
                     Solutions
                     Conference

    February 28,    REMARKS: AEI       Healthcare Reform  DC
     2014            Symposium

    March 6, 2014   REMARKS: CPAC      The New Medical    MD
                     Panel              Realities We All
                                        Face: Rationing,
                                        Denial of Care,
                                        Doctor Shortages
                                        and a Loss of
                                        Religious
                                        Liberty Under
                                        Obamacare

    March 7, 2014   REMARKS: AEI       The Health of      DC
                     Panel              America's Health
                                        Policy

    March 9, 2014   REMARKS: RJC--     Healthcare         GA
                     Atlanta            Update, Emphasis
                                        on H.R. 2300

    March 12, 2014  REMARKS: The       Affordable Care    DC
                     Commonwealth       Act, its
                     Fund's Harkness    Prospects for
                     Fellows            Expanding
                                        Coverage,
                                        Transforming the
                                        U.S. Health Care
                                        System and
                                        Containing Costs

    March 24, 2014  REMARKS: American  Current Major      DC
                     Psychiatric        Healthcare
                     Association        Issues in
                     Advocacy           Congress
                     Leadership
                     Conference
                     (annual fly-in)

    March 27, 2014  REMARKS: American  Healthcare: SGR,   DC
                     Association of     ACA, etc.
                     Physicians of
                     Indian Origin
                     (AAPI)

    March 27, 2014  REMARKS: NASS      Importance of      DC
                     Washington         Physician
                     Conference         Advocacy and
                                        Visiting
                                        Washington, DC,
                                        to SGR

    April 1, 2014   REMARKS:           Health Care and    DC
                     Obamacare: What    the Economy
                     to Watch in 2014   Between Now and
                                        November

    April 3, 2014   REMARKS: Tax       Your Thoughts on   DC
                     Council            the
                                        Comprehensive
                                        Reform Process,
                                        SGR, Highways,
                                        and Other Items.

    April 9, 2014   REMARKS: Las       Healthcare and     DC
                     Vegas              the Impact on
                     Metropolitan       American
                     Chamber of         Employers Both
                     Commerce           Large and Small
                     Conference

    April 10, 2014  REMARKS: PDMA      Healthcare in      MD
                                        2014 and Beyond

    April 11, 2014  REMARKS: Heritage  If You Like This   DC
                     Conference         Session, You Can
                                        Keep it--Real
                                        Health Care
                                        Solutions As
                                        Obamacare
                                        Unravels

    April 14, 2014  REMARKS: Forsyth   The Un-Affordable  GA
                     County Tea Party   Care Act/
                     Tax Day Rally      Obamacare--``0ne
                                        Giant Tax''

    April 23, 2014  REMARKS: National  Drug-Related       GA
                     Rx Abuse Summit    Legislation He
                                        Has Supported
                                        and any Stories
                                        He Could Tell
                                        About the
                                        Epidemic in
                                        Georgia

    April 23, 2014  REMARKS: St.       The Future of      MO
                     Louis              Health Care
                     Orthopaedic        Reform: A
                     Society Dinner     Physician's
                                        Perspective on
                                        Policy Making

    April 26, 2014  REMARKS: Alabama   Navigating the     AL
                     Orthopaedic        ACA and the
                     Society Meeting    Battle for
                                        PPatient-
                                        Centered
                                        Solutions

    May 8, 2014     REMARKS:           Concern That is    VA
                     Virginians for     Percolating
                     Quality            Among the
                     Healthcare Forum   Republican Base
                                        and the Media
                                        That the
                                        Leadership
                                        Actually Has no
                                        Intention to
                                        ``Repeal and
                                        Replace''

    May 12, 2014    REMARKS: St.       Healthcare Update  GA
                     Joe's General
                     Medical Staff
                     Meeting

    May 17, 2014    REMARKS: Atlanta   Healthcare Update  GA
                     International      from DC--
                     Trauma Symposium   Emphasis on
                                        Reform

    June 17, 2014   REMARKS:           Crafting Health    DC
                     Government         Innovation That
                     Health             Works for
                     Information        Patients and
                     Technology         Doctors
                     Conference

    June 17, 2014   REMARKS: ASCA      An Update on       DC
                     Dinner             Healthcare

    August 12,      REMARKS: Medical   Healthcare         NC
     2014            Forum: ``Federal   Problems
                     Issues Facing      Confronting
                     the Medical        Doctors, Nurses,
                     Community in       Administrators,
                     NC's 3rd           and Patients
                     Congressional
                     District''

    August 13,      REMARKS:           Federal Issues     NC
     2014            Roundtable Lunch   that Will Affect
                     with Congressman   Eastern NC's
                     Walter Jones and   Medical
                     Special Guest      Community
                     Congressman Tom
                     Price

    August 17,      REMARKS:           Perspectives on    GA
     2014            Leadership         Physician
                     Session--GPLA      Leadership

    September 30,   REMARKS: Keynote   Sustaining         DC
     2014            Speaker, AHIP      Medicare for
                     Medicare and       Future
                     Medicaid           Generations:
                     Conference         Views From the
                                        Hill

    November 20,    REMARKS: Speech/   General            DC
     2014            Panel With         Discussion on
                     Benjamin Rush      How One Goes
                     Institute,         From Medicine to
                     Georgetown         Congress
                     Chapter

                   2013 Speeches and Remarks by Dr. Tom Price

    January 10,     REMARKS: Florida   Update on What is  FL
     2013            Healthcare         Happening in DC
                     Reception          on the Health
                                        Care Front Since
                                        Election Day--
                                        Federal
                                        Viewpoint

    February 27,    REMARKS: Call      Reintroduction of  Call
     2013            With Coalition     the Medicare
                     or State Medical   Patient
                     and National       Empowerment Act.
                     Specialty          (Dr. Price)--
                     Societies          Medicare Patient
                                        Empowerment Act
                                        in the New
                                        Congress and
                                        Strategies to
                                        Get it Passed

    March 4, 2013   REMARKS: AWARD     Physician          DC
                     American           Payments: Cuts,
                     Congress of        Bumps, and
                     Obstetricians      Bruises
                     and
                     Gynecologists
                     (ACOG) 31st
                     Annual
                     Congressional
                     Leadership
                     Conference

    March 4, 2013   REMARKS: AAMC      Current Climate    DC
                     Government         on Capitol Hill
                     Relations          as it Relates to
                     Conference         Federal Health
                                        Care Spending
                                        (Particularly,
                                        Medicare,
                                        Medicaid, Public
                                        Health Service
                                        Programs Like
                                        the National
                                        Health Service
                                        Corps, and the
                                        NIH)

    March 6, 2013   REMARKS: Meeting   U.S. Health        DC
                     With               Reform and the
                     Commonwealth       Sustainability
                     Fund's Fellows     of Medicare and
                                        Medicaid, the
                                        Challenge of
                                        Improving the
                                        Quality of Care
                                        and Access to
                                        the Latest
                                        Technologies and
                                        Medications
                                        While Containing
                                        Spiraling Health
                                        Care Costs

    March 17, 2013  REMARKS: American  Impact of the      VA
                     Urological         Affordable Care
                     Association        Act on
                                        Physicians

    April 7, 2013   REMARKS: Self-     Perspectives on    DC
                     Insurance          Implementation
                     Institute of       of the ACA and
                     America, Inc.      any Future
                     (SIIA)             Actions Being
                                        Taken by the
                                        House Affecting
                                        Healthcare
                                        Reform

    May 3, 2013     REMARKS: National  Entitlement        DC
                     Orthopaedic        Reform: Long-
                     Leadership         Term Economic
                     Conference         Projections and
                     (AAOS)             the Outlook for
                                        Medicare Reform

    May 6, 2013     REMARKS: RADPAC    Specifics on       DC
                                        Healthcare and
                                        Comments on
                                        Radiology Bill--
                                        H.R. 846--and
                                        H.R. 3269 Last
                                        Congress That
                                        Had More Than
                                        270 Co-Sponsers

    May 15, 2013    REMARKS: PPO       Impact of          DC
                     Capital Caucus     Obamacare and
                                        the Next Steps
                                        as We Look Ahead
                                        to 2014

    May 22, 2013    REMARKS: American  Problems With      DC
                     Association for    Medicare's
                     Homecare           Competitive
                     Washington         Bidding Program
                     Legislative        and Benefits of
                     Conference         the Market
                                        Pricing Program
                                        (MPP) HME
                                        Provider
                                        Compliance and
                                        Audit Issues;
                                        Power Mobility
                                        Issues; and
                                        Efforts to
                                        Eliminate
                                        Medicare Fraud
                                        and Abuse

    June 15, 2013   REMARKS: Becker's  Orthopaedic,       IL
                     ASC Review Panel   Spine, and Pain
                                        Management
                                        Practices and
                                        ASCs--6 Defining
                                        Issues

    June 17, 2013   REMARKS: AMA SE    Status of          IL
                     Delegation         Obamacare
                     Breakfast

    June 24, 2013   REMARKS: National  Obamacare and      GA
                     Association of     Your Plan on
                     Health             Reducing Costs,
                     Underwriters'      From the
                     Annual             Provider Side of
                     Convention         Business

    July 9, 2013    REMARKS: Alliance  Healthcare         DC
                     of Specialty
                     Medicine

    July 16, 2013   REMARKS: 2013      What               DC
                     Health Care        Representative
                     Payments and       Price Thinks
                     Policy             About Emerging
                     Conference         Health Reform
                                        Issues in the
                                        113th Congress

    July 20, 2013   REMARKS: Southern  Obamacare Current  ..................
                     Orthopaedic        Perspective
                     Association

    August 10,      REMARKS: GA        Perspectives on    GA
     2013            Physicians         Physician
                     Leadership         Leadership
                     Academy

    August 17,      REMARKS: American  How Will The       MD
     2013            Society of         Affordable Care
                     General Surgeons   Act Influence
                                        the Practice of
                                        Surgery in the
                                        Near Future?

    August 20,      REMARKS: GNFCC's   ACA                GA
     2013            Healthcare Panel

    September 23,   REMARKS: Elekta    Importance of      GA
     2013            Learning and       Elekta to
                     Innovation         Georgia and the
                     Center (LINC)      Health Care
                     Grand Opening/     Industry
                     Ribbon Cutting

    October 9,      SPECIAL GUEST:     Talk About SGR,    DC
     2013            U.S. Oncology      Government
                     Network PAC        Shutdown, and
                     Board              Thoughts of What
                                        Happens Over the
                                        Next Couple of
                                        Months; Anything
                                        Physician
                                        Related

    October 21,     REMARKS: GA/Cobb   Affordable Care    GA
     2013            Chamber            Act--The Story,
                     Healthcare         The Politics and
                     Summit             Policy, and the
                                        Future

    October 24,     REMARKS: CA        Panel of GOP       ..................
     2013            Lincoln Club Fly-  members Who Are
                     in                 Working on a GOP
                                        Plan/Alternative
                                        to Obamacare--
                                        Very Casual/
                                        Informal
                                        Discussion

    November 16,    REMARKS: Keynote   As the Largest     DC
     2013            address Medical    Medical Student
                     Student Section    Organization in
                     at the AMA-MSS     the Country the
                     Interim Assembly   AMA-MSS is
                     Meeting            Dedicated to
                                        Representing
                                        Medical
                                        Students,
                                        Improving
                                        Medical
                                        Education,
                                        Developing
                                        Leadership, and
                                        Promoting
                                        Activism for the
                                        Health of
                                        America

    November 16,    REMARKS: 4th       Current            MD
     2013            Edward Annis       Republican
                     Medical Freedom    Health Reform
                     Awards Dinner/     Proposals
                     Give Award to
                     Dr. Carson

    November 17,    REMARKS:           Physicians as      MD
     2013            International      Leaders and
                     Medical            Legislators
                     Graduates
                     Section

    November 18,    REMARKS: AMA SE    Developments on    DC
     2013            Delegation         ACA and Some on
                     Breakfast          SGR

    December 4,     REMARKS: Ripon     The Health Care    DC
     2013            Society            Debate: Reform
                     Breakfast          vs. Reality

    December 11,    REMARKS: ATR       H.R. 2300          DC
     2013            Wednesday
                     Meeting to Roll
                     Out H.R. 2300
                     Score

                   2012 Speeches and Remarks by Dr. Tom Price

    January 23,     REMARKS: 39th      March for Life     DC
     2012            Annual March for
                     Life

    February 21,    REMARKS: Cushman   Healthcare Update  GA
     2012            and Wakefield
                     Healthcare CFO
                     Roundtable

    February 23,    REMARKS:           Healthcare         GA
     2012            Southeast          Update,
                     Permanente         Including the
                     Medical Group      Revolving Status
                     Board of           of the ACA
                     Directors          Legislation and
                     Meeting            What SPMG Can Do
                                        to Best Position
                                        Itself for the
                                        Future

    February 29,    REMARKS: Luncheon  Physician Payment  DC
     2012            for the American   Reform and the
                     Association of     Prospects of
                     Clinical           Passing H.R.
                     Endocrinologists   1700 Given the
                                        Inability of
                                        Congress Thus
                                        Far to Enact
                                        Permanent
                                        Medicare
                                        Physician
                                        Payment Reform

    March 5, 2012   REMARKS: American  Perspective on     DC
                     Urological         Where Medicine
                     Association        is Going,
                                        Implementation
                                        of the Health
                                        Reform Bill,
                                        etc.

    March 7, 2012   REMARKS: Academic  Conference         DC
                     Health Centers     Committee
                     Fly-in             Outcome; What
                                        Will the 2012
                                        Election Mean
                                        for Teaching
                                        Hospitals,
                                        Payroll Tax
                                        Conference, and
                                        SGR?

    March 13, 2012  REMARKS: Colorado  The Nexus of       CO
                     School of          Medicine and
                     Medicine           Politics . . .
                     Benjamin Rush      Closer Than you
                     Society            Think!

    March 16, 2012  REMARKS: RPA       Future of          DC
                     Reception          Healthcare

    March 22, 2012  REMARKS: Townhall  Athena's           DC
                     Meeting With       Innovative
                     Athena Health      Approach to
                                        Incentivizing
                                        Meaningful
                                        Health
                                        Information
                                        Exchange and a
                                        Recent OIG
                                        Opinion the
                                        Company
                                        Successfully
                                        Obtained That
                                        Has the
                                        Potential to at
                                        Last Unleash the
                                        Technological
                                        Innovation in
                                        the Health Care
                                        Sector That Has
                                        Eluded Policy
                                        Makers for
                                        Decades

    March 22, 2012  REMARKS: National  Medication         DC
                     Association of     Adherence: How
                     Chain Drug         Important it Is
                     Stores             for Patients to
                                        Take Their
                                        Medications, and
                                        Take Them
                                        Correctly; One
                                        of the Items in
                                        our MTM Bill
                                        That We Stress
                                        is That Patients
                                        in Transition of
                                        Care Need Extra
                                        Help to Make
                                        Sure They Take
                                        Their Meds, Take
                                        Them Properly,
                                        and Continue to
                                        Take Them Until
                                        the Physician
                                        Has Determined
                                        They Stop

    March 27, 2012  REMARKS: Hands     Hands Off My       DC
                     Off My             Healthcare
                     Healthcare Rally

    April 12, 2012  REMARKS: Lunch     Health Care        DC
                     With AMA           Reform From the
                     Students           Perspective of a
                                        Physician in
                                        Congress

    April 12, 2012  REMARKS: Speaking  Healthcare in      DC
                     at the Commons     America: Where
                     Seminar            Have We Come
                                        From and Where
                                        Are We Going?

    April 13, 2012  REMARKS: Medical   Physician          AL
                     Association for    Leadership:
                     State of Alabama   Critical for
                     Annual Meeting     Preserving the
                                        Profession; Why
                                        Physicians
                                        Should be More
                                        Involved in the
                                        Political
                                        Process

    April 23, 2012  REMARKS: North     A Washington/      GA
                     Fulton Hospital    Healthcare
                     (Semi- Annual      Update
                     Medical Staff
                     Meeting)

    April 26, 2012  REMARKS: National  Discussion on How  DC
                     Journal Keynote    Congress Can Act
                     Interview          in the Interest
                                        of the American
                                        Public and the
                                        Policy Issues
                                        Americans Want
                                        Their Elected
                                        Officials to
                                        Focus on for the
                                        Remainder of the
                                        112th Congress

    April 26, 2012  REMARKS: American  No Topic Listed    DC
                     Association of
                     Orthopaedic
                     Surgeons

    April 30, 2012  REMARKS: To        A Principled       ..................
                     Hilldale           Prescription for
                     Students           America's
                                        Health: The
                                        Perspective of
                                        Doctor-Turned-
                                        Lawmaker

    May 8, 2012     REMARKS: College   Outlook in         DC
                     of American        Congress for the
                     Pathologists       Rest of the
                     Breakfast          Year; What's the
                                        GOP View on
                                        Health Care and
                                        Medicare Reform?
                                        What Happens
                                        Next in Health
                                        Care if ACA is
                                        Repealed or is
                                        Not Repealed?

    May 21, 2012    REMARKS:           Health Care        MO
                     University of      Financing in
                     Missouri Medical   General and
                     School             Financing of
                                        Graduate Medical
                                        Education

    May 22, 2012    REMARKS: Richmond  Healthcare         GA
                     County Medical     Update; Status
                     Society            of Healthcare
                                        Reform
                                        Legislation

    June 3, 2012    REMARKS: GA/SC     Our Bill, H.R.     SC
                     Radiology          3269; How We Can
                     Societies Joint    Get it Into End
                     Chapter Meeting    of Year Package,
                                        etc.; SGR; Your
                                        Bill to Repeal
                                        and Replace ACA

    June 15, 2012   REMARKS: Faith     Panel: Obamacare:  DC
                     and Freedom        Repeal, Replace,
                     Coalition          and Reform

    June 18, 2012   REMARKS: AMA       No topic listed    IL
                     Southeastern
                     Breakfast

    June 22, 2012   REMARKS: Stand Up  Your/House         GA
                     for Religious      Perspective on
                     Liberty Rally      HSS Mandate;
                                        Role the Federal
                                        Government is
                                        Playing to
                                        Infringe on the
                                        Rights of
                                        Religious
                                        Organizations;
                                        Any Updates From
                                        the House on
                                        These Issues

    June 26, 2012   REMARKS: American  Personal Story of  MD
                     Orthopaedic        How You Got
                     Association        Involved in
                                        Politics

    July 10, 2012   REMARKS: American  Repealing and      DC
                     Action Network     Replacing
                     and Crossroads     Obamacare
                     GPS Healthcare
                     Panel

    July 10, 2012   REMARKS: American  Price/Boustany     DC
                     Association of     Medicare
                     Neurological       Physician
                     Surgeons Fly-in    Payment Bill and
                                        Private
                                        Contracting

    July 20, 2012   REMARKS: Smart     Healthcare, Next   VA
                     Girl Politics      Steps

    July 27, 2012   REMARKS: Lincoln   Obamacare          FL
                     Day Dinner with
                     Ross

    July 31, 2012   REMARKS: B26       Healthcare         NC
                     Romney Breakfast

    August 3, 2012  REMARKS: ASCRS/    Medicare           Call
                     ASOA Retreat       Physician
                     (via               Payment Reform,
                     teleconference)    the SGR, IPAB
                                        Repeal

    August 7, 2012  REMARKS: GAMES     Healthcare: Home   GA
                     Legislative        Health Care:
                     Breakfast          Medicare
                                        Competitive
                                        Bidding and the
                                        Current Audit
                                        Environment

    August 7, 2012  REMARKS:           Healthcare/        GA
                     Brunswick          Washington
                     Medical            Update
                     Community Event

    August 12,      REMARKS: Georgia   Perspective on     GA
     2012            Physicians         Physician
                     Leadership         Leadership
                     Academy

    August 24,      REMARKS:           The Opportunity    CA
     2012            Strathspey         for Reforms to
                     Crown: A New       the ACA
                     Model for
                     Healthcare

    August 25,      REMARKS:           No topic listed    CA
     2012            Government
                     Affairs Panel:
                     Creating a New
                     Era in
                     Healthcare

    August 28,      REMARKS:           Healthcare Panel   FL
     2012            Bipartisan
                     Conversation on
                     Healthcare

    August 29,      REMARKS: The Hill  No topic listed    FL
     2012            Healthcare Panel

    September 9,    REMARKS: Docs 4    U.S.               VA
     2012            Patient Care       Congressional
                                        Solutions for
                                        Obamacare

    September 10,   REMARKS: American  The Outlook for    DC
     2012            Academy of         Health Care
                     Dermatology        Legislation and
                                        Legislation
                                        Impacting
                                        Physicians
                                        Broadly and,
                                        More
                                        Specifically,
                                        Dermatologists

    September 13,   REMARKS: American  Providing an       Call
     2012            Congress of        Assessment of
                     Obstetricians      the Post-SCOTUS
                     and                Health Reform
                     Gynecologists      Landscape
                     Government
                     Relations
                     Committee

    September 13,   REMARKS: SC-04     Healthcare,        DC
     2012            Chambers of        General Ideas
                     Commerce           and Thoughts
                     National Issues    About PPACA, the
                     Fly-in             Supreme Court
                                        Ruling on PPACA,
                                        and Healthcare
                                        Issues in
                                        General as it
                                        Relates to the
                                        Business
                                        Community

    November 10,    REMARKS: Mount     Obamacare's        GA
     2012            Vernon Towers      Impact on
                     Retirement         Seniors
                     Facility

    November 11,    REMARKS: Emory     Healthcare         GA
     2012            Johns Creek        Update; H.R.
                     Hospital           3000

    November 16,    REMARKS: Medtrade  H.R. 6490--Why     GA
     2012            Expo (Power for    That Would be
                     Funding Welcome    Better Than the
                     Reception)         Current
                                        Competitive
                                        Bidding
                                        Methodology

    November 22,    REMARKS: SCI       Healthcare Update/ GA
     2012            Solutions          Legislative
                     Healthcare         Trends in
                     Meeting            Healthcare
                                        Policy

    November 24,    REMARKS: National  Health Policy      TX
     2012            Association of     Issues Facing
                     Spine              Congress
                     Specialists
    ------------------------------------------------------------------------

                                     ______

         Questions Submitted for the Record to Hon. Thomas Price, M.D.
                     Questions Submitted by Hon. Ron Wyden
                        brokerage account documentation
        Question. In the hearing, you were asked to reaffirm that trades in
    your brokerage accounts were controlled by your stock broker and not by
    yourself.

        Please provide the management and brokerage agreements for all
    accounts that hold individual health-care stocks including but not
    limited to the Morgan Stanley account labeled Morgan Stanley #1 in your
    2015 House of Representatives Financial Disclosure and the Morgan
    Stanley account labeled Morgan Stanley #2 in your 2015 House of
    Representatives Financial Disclosure.

        Answer. I previously provided the Senate Finance Committee
    (``SFC'') with substantial information regarding the nature of the
    brokerage accounts described in this inquiry and have no further
    information to provide at this time. Additional information regarding
    Morgan Stanley's management and brokerage policies is also readily
    available in the public domain.
               management of shares in innate immunotherapeutics
        Question. As discussed in the disclosure memo, which was made part
    of the record of the hearing, you purchased shares in Innate
    Immunotherapeutics in private placements in 2016.

        In what account and in what form were those shares held at the time
    you filed your financial disclosures, as a nominee, with Federal ethics
    officials and your response to the committee's questionnaire? In what
    account and in what form are those shares currently held? If shares
    were transferred between accounts, when were they transferred and at
    whose direction?

        Answer. I previously provided the SFC with substantial information
    regarding the issues raised in this question. As the committee is fully
    aware, the shares of Innate Immunotherapeutics (``Innate'') purchased
    in 2016 through private placement were held with the company in
    electronic certificate format up until recently. In the process of
    gathering information to respond to committee questions (posed on
    January 17, 2017) in the wake of due diligence meetings with committee
    staff, I learned that these electronic certificate holdings have now
    been transferred to his Wells Fargo Joint Brokerage Account #1. The
    desire to transfer this holding from electronic certificate form to a
    brokerage account was discussed during the due diligence meeting with
    SFC staff. Both the SFC and OGE were appropriately notified of the
    transfer upon its completion.
                                brokerage trades
        Question. In testimony to the Senate HELP Committee, you stated
    that you directed your broker to purchase shares in Innate
    Immunotherapeutics.

        During your time in Congress, have you ever directed your broker to
    make any other transactions in stock of specific companies? If so,
    please identify the companies, the date, and volume of the transaction.

        Answer. To the best of my knowledge, I have not undertaken such
    actions. Throughout my time as a member of the U.S. House of
    Representatives, I have abided by and adhered to all ethics and
    conflict of interest rules applicable to me.
                     trans-pacific partnership negotiations
        Question. Did you or your staff consult with the House Ethics
    Committee at any time concerning the possibility or appearance of a
    conflict of interest or other ethics concern arising from your
    ownership of shares in Innate Immunotherapeutics and your role as a
    member of the House Ways and Means Committee concerning negotiations
    related to the Trans-Pacific Partnership, or the receipt of any
    information that you received in that capacity or as a member of the
    House concerning such negotiations?

        Answer. To the best of my knowledge, neither I nor my staff has had
    such consultations. Throughout my time as a member of the U.S. House of
    Representatives, I have abided by and adhered to all ethics and
    conflict of interest rules applicable to me.
                      innate immunotherapeutics purchases
        Question. The nominee owns 461,238 shares of Innate
    Immunotherapeutics Ltd. (``Innate''), a small Australian
    biopharmaceutical firm developing a multiple sclerosis therapy. The
    nominee acquired the stock in four separate purchases on January 8, 9
    and 23 of 2015 (``2015 tranche''), and in a pair of private stock
    placements on August 31, 2016 (``2016 tranche''). Regarding Innate:

        Please describe how and when the nominee first learned about
    Innate.

        Answer. I previously answered this question for the SFC. I learned
    about Innate during the course of a conversation in the fall of 2014
    with Representative Chris Collins regarding their respective personal
    backgrounds. I cannot recall the specific date of that conversation.
    During that exchange, Representative Collins told me that he sat on a
    number of public company boards including Innate, which was developing
    a treatment for multiple sclerosis (MS).

        Question. Did the nominee or his staff ever meet or otherwise
    communicate with current or former employees, directors, consultants,
    or other officials affiliated with Innate? If so, please describe the
    communication, including who it involved, the date, subject, place and
    form (e.g., in person, by phone) of communication.

        Answer. I previously answered this question for the SFC.

        I communicated with Representative Collins, who is a director of
    Innate. As noted above, I learned about Innate through a general
    conversation with him in the fall of 2014. I also communicated with
    Simon Wilkinson of Innate regarding my interest in participating in the
    2016 private placement of company stock. According to Innate's website,
    Mr. Wilkinson is currently the Managing Director and CEO of Innate.

        My congressional staff has not met or otherwise communicated with
    current or former employees, directors, consultants or other officials
    affiliated with Innate.

        Question. Please describe any communication between the nominee and
    Congressman Collins regarding Innate Immunotherapy, including the date,
    subject, place and form.

        Answer. I previously answered this question for the SFC.

        I had a conversation with Representative Collins in the fall of
    2014 that brought Innate, as a company, to my attention. The nature of
    that conversation did not, however, influence my decision to invest in
    the company in either 2015 or 2016.

        I believe I had subsequent general communications with
    Representative Collins regarding Innate. I do not have a specific
    recollection of when those conversations occurred or their substance.
    Any such communications did not impact my investment decisions,
    however, because my purchases of Innate stock were based solely on my
    own research.

        Question. The nominee bought 400,316 shares in the 2016 tranche in
    a private stock sale that included two placements at two prices. Please
    provide the number of shares bought in each placement, and the price at
    which the shares were bought.

        Answer. I previously answered this question for the SFC. I
    purchased 250,000 shares of Innate in Private Placement 1 at US$0.18/
    share--the same price offered all participants in this private
    placement. I purchased 150,613 shares of Innate in Private Placement 2
    at US$0.26/share--the same price offered all participants in this
    private placement.
                          zimmer biomet stock holding
        Question. Did you or your staff meet with Zimmer Biomet employees
    or representatives, including but not limited to lobbyists, executives,
    or board members, between July 14, 2015 and April 1, 2016? If so,
    please describe the communication, including who it involved, the date,
    subject, place and form (e.g., in person, by phone) of communication.

        Answer. To the best of my knowledge, neither I nor any members of
    my staff met with or attended an event with a lobbyist or
    representative from Zimmer Biomet during the specified dates.
                      house ethics committee consultation
        Question. House rule 3, clause 1, provides that members of the
    House ``shall vote on each question put, unless having a direct
    personal or pecuniary interest in the event of such question.''
    However, the House Ethics Manual (House Ethics Manual, U.S. House of
    Representatives Committee on Standards of Official Conduct, 110th Cong,
    2d Sess. (2008), pp. 233-37) makes a sharp distinction between, on one
    hand, voting on the House floor, and, on the other, more active
    advocacy. The House Ethics Manual states:

            The provisions of House Rule 3, clause 1, as discussed in this
            section apply only to members voting on the House floor. They
            do not apply to other actions that members may normally take on
            particular matters in connection with their official duties,
            such as sponsoring legislation, advocating or participating in
            an action by a House committee, or contacting an executive
            branch agency. Such actions entail a degree of advocacy above
            and beyond that involved in voting, and thus a member's
            decision on whether to take any such action on a matter that
            may affect his or her personal financial interests requires
            added circumspection. Moreover, such actions may implicate the
            rules and standards, discussed above, that prohibit the use of
            one's official position for personal gain. Whenever a member is
            considering taking any such action on a matter that may affect
            his or her personal financial interests, the member should
            first contact the [Ethics] Committee for guidance.

        Before, or any time after, you introduced H.R. 4848, the Healthy
    Inpatient Procedures Act of 2016 (HIP Act) in the 114th Congress, did
    you consult with the House Ethics Committee concerning the possibility
    of, or appearance of, a conflict of interest or other ethics concern
    arising from your ownership of shares in ZimmerBiomet? If so, when?

        Answer. My investment accounts, particularly the Morgan Stanley
    Portfolio Management Program account wherein the noted stock
    transaction occurred, were established so as to place trading
    discretion in the hands of my broker/financial advisor. No conflict of
    interest existed and no consultation was necessary. Throughout my time
    as a member of the U.S. House of Representatives, I have abided by and
    adhered to all ethics and conflict of interest rules applicable to me.

        Question. Before, or at any time after, you introduced H.R. 4185,
    the Protecting Access through Competitive-pricing Transition Act of
    2015 (the PACT Act) in the 114th Congress, did you consult with the
    House Ethics Committee concerning the possibility of, or appearance of,
    a conflict of interest or other ethics concern arising from your
    ownership of shares in health-care stocks? If so, when?

        Answer. My investment accounts, particularly the Morgan Stanley
    Portfolio Management Program account wherein the noted stock
    transactions occurred, were established so as to place trading
    discretion in the hands of my broker/financial advisor. No conflict of
    interest existed and no consultation was necessary. Throughout my time
    as a member of the U.S. House of Representatives, I have abided by and
    adhered to all ethics and conflict of interest rules applicable to me.

        Question. Before, or at any time after, you introduced H.R. 5400,
    an Act to amend the Internal Revenue Code of 1986 to make permanent the
    deduction for income attributable to domestic production activities in
    Puerto Rico in the 114th Congress, did you consult with the House
    Ethics Committee concerning the possibility of, or appearance of, a
    conflict of interest or other ethics concern arising from your
    ownership of shares in Eli Lilly, Bristol Myers Squibb, and Amgen? If
    so when?

        Answer. My investment accounts, particularly the Morgan Stanley
    Portfolio Management Program account wherein the noted stock
    transactions occurred, were established so as to place trading
    discretion in the hands of my broker/financial advisor. No conflict of
    interest existed and no consultation was necessary. Throughout my time
    as a member of the U.S. House of Representatives, I have abided by and
    adhered to all ethics and conflict of interest rules applicable to me.

        Question. Before, or at any time after, you introduced H.R. 5210,
    the Patient Access to Durable Medical Equipment (PADME) Act of 2016 in
    the 114th Congress, did you consult with the House Ethics Committee
    concerning the possibility of, or appearance of, a conflict of interest
    or other ethics concern arising from your ownership of shares in
    Blackstone, Inc. or any other company that markets or manufacturers
    durable medical equipment? If so, when?

        Answer. My investment accounts were established so as to place
    trading discretion in the hands of my broker/financial advisor. No
    conflict of interest existed and no consultation was necessary.
    Throughout my time as a member of the U.S. House of Representatives, I
    have abided by and adhered to all ethics and conflict of interest rules
    applicable to me.
                             resurgens orthopaedics
        Question. Do you have any financial or business relationship
    including an equity or ownership stake in Resurgens Orthopaedics, and/
    or do you derive any financial interest or benefit from the company? If
    so, please detail the type of financial or business relationship you
    have, and any income you do or may derive related to Resurgens. In
    addition, if you answered ``yes,'' please describe your plan to divest
    your financial interest in the company.

        Answer. I have no current financial stake or interest in Resurgens
    Orthopaedics.
                               lgbtq health care
        Question. LGBTQ individuals often experience exceptional barriers
    to care; health disparities associated with gender identity are
    partially driven by lower rates of insurance. Under the ACA, the LGBTQ
    population cannot be excluded from health plans due to pre-existing
    conditions such as HIV. Discrimination based on sex and gender identity
    is also prohibited for programs receiving Federal funds. Additionally,
    all insurance plans must offer the same coverage to married same-sex
    couples as is offered to opposite-sex couples. In terms of national
    health surveys, the ACA changed data collection requirements to include
    sexual orientation and gender identity, which supports future advocacy
    and research.

        Will you maintain health-care protections for the LGBTQ community?
    Please explain.

        Answer. It is essential that health-care services be available to
    all people with the highest level of quality, affordability, and
    respect for their human dignity. If confirmed, I will ensure that HHS
    follows Congress's lead in defining and enforcing nondiscrimination
    laws, and that HHS will comply with all statutory and judicial
    requirements in doing so.
                        medicaid and disability services
        Question. Medicaid serves as the primary health insurance program
    for Americans with disabilities, especially those with limited income.
    A lack of adequate health and long-term care coverage is often cited as
    a primary barrier to the ability to live in the community and the
    ability to succeed in employment. Many of the most important Medicaid-
    funded services for people with disabilities can be the most expensive.
    States must offer three of these services: inpatient hospital care,
    home health care, and Early and Periodic Screening, Diagnostic, and
    Treatment (EPSDT). State Medicaid programs currently have the option to
    cover the remaining services important to Americans with disabilities
    including: many home-and-community based services; prescription drugs;
    private duty nursing, physical therapy, occupational therapy; speech,
    hearing, and language therapy; prosthetic devices; intermediate care
    facilities; and personal care services.

        Since the enactment of the Americans with Disabilities Act (ADA) in
    1990, there has been a concerted effort at the State, Federal, and
    community levels to transform the Medicaid program from institutional-
    care focused financing mechanism into a comprehensive and flexible
    community-based long-term services and supports program. Examples of
    such congressional efforts can be seen in the Affordable Care Act,
    which strengthened and expanded the Money Follows the Person program
    and created the State Balancing Incentive Program and Community First
    Choice Option.

        How will the administration ensure Medicaid supports the
    protections of the Americans with Disabilities Act?

        Answer. The coordination of two complex laws such as Medicaid and
    the Americans with Disabilities Act requires the close interaction of
    those who are expert in each. At some level the protections referred to
    are best supported by allowing States the flexibility to approach them
    in a way that makes sense for their program, so long as Federal
    requirements are met. As to those Federal requirements, there may be a
    need for close coordination with the Department of Justice or the Equal
    Employment Opportunity Commission as well as the Department's own
    Office for Civil Rights.

        Question. How will you ensure that Federal dollars are not used in
    a way that promotes unnecessary institutionalization of individuals
    with disabilities?

        Answer. Community integration, beneficiary autonomy in decision
    making, and person-centered planning are central tenets articulated in
    CMS' approach to Home and Community Based Services and the HCBS
    Settings Rule with a compliance date in March 2019, and I support each
    of those principles. It is also important to note that many
    residential, disability-specific settings have long provided a safe and
    integrated community alternative to institutional placement for
    individuals with disabilities, and appropriate weight should be given
    to the preferences of families and individuals with disabilities
    because they are in the best position to decide what type of setting
    best meets their individualized needs and circumstances.

        Question. How will you work to ensure States have sufficient
    resources to fund home- and community-based services?

        Answer. As with any program or initiative relying on States, the
    central question for the State is often one of funding. If confirmed, I
    would work to see that the Department is a helpful resource to the
    States with respect to these services at least by providing clarity
    regarding their flexibility, technical assistance and support as
    needed, and sharing best practices.

        Question. Will you direct CMS in its approval of waivers to
    encourage States to expand home- and community-based services and shift
    away from waiting lists and institutional care?

        Answer. Every State is unique in their specific approach to the
    provision of services for the population eligible to receive HCBS, and
    we stand ready to assist States as they develop strategies to meet
    their particular goals.
                           medicaid equal access rule
        Question. Congressman Price, as you have previously stated, some
    providers do not accept Medicaid. Studies show that provider payment
    rates are a leading reason that some providers choose not to
    participate in Medicaid.

        Recently, the Centers for Medicare and Medicaid Services (CMS) has
    finalized two major rules to help address this issue--the ``equal
    access'' rule and the Medicaid managed care rule.

        Congressman Price, given that this is an issue you seem
    particularly concerned about, will you commit to ensuring successful
    enforcement of the Medicaid Equal Access rule, the Medicaid managed
    care rule, and other Federal standards that help ensure States set
    appropriate payment rates as required under the Medicaid statute's
    equal access provision?

        Answer. If confirmed as Secretary, I will faithfully implement laws
    written by Congress and the regulations issued by the Department. This
    includes enforcement action as appropriate. As a doctor who has
    actually treated thousands of Medicaid patients, I do care deeply about
    the Medicaid program and the access of Medicaid patients to actual
    care, not just a card they can carry with them.
                            medicare balance billing
        Question. Congressman Price, you have championed legislation to
    allow providers participating in Medicare to enter into private
    contracts with Medicare beneficiaries, meaning that those providers
    would be permitted to balance bill seniors and other Medicare
    beneficiaries for the difference between what Medicare pays and what
    the provider decides to charge--potentially putting seniors and other
    Medicare beneficiaries on the hook for high medical bills. More than 30
    years ago, Congress passed legislation to protect against exactly that
    situation. One study found that out-of-pocket medical spending declined
    by 9% in Medicare households as a result of these protections.

        Those who want balance billing in Medicare often claim that doctors
    are fleeing the Medicare program, but evidence demonstrates this is
    simply not true. Provider participation in Medicare remains strong. In
    fact, 9 in 10 primary care physicians accept Medicare, and 96 percent
    of people with Medicare report having regular access to a physician's
    care. Allowing balance billing would essentially create two tiers of
    Medicare beneficiaries--those who can afford to access needed care and
    those who cannot.

        Will you commit to the more than 55 million Americans who rely on
    Medicare that, if confirmed as HHS Secretary, you will advise the
    President to veto any legislation that would undermine these decades-
    old protections and allow providers participating in Medicare to
    balance bill seniors and other Medicare beneficiaries?

        Answer. In considering Medicare, it is important to appreciate that
    the bipartisan Medicare Trustees have told everyone that Medicare, in
    less than 10 years, is going to be out of the kind of resources that
    will allow us as a society to keep the promise to beneficiaries of the
    Medicare program. My goal, if confirmed, is to work with Congress to
    make certain that we save and strengthen Medicare. It is irresponsible
    for us to do anything else. If I am confirmed, my role will be one of
    carrying out the laws Congress passes and as to that I would convey to
    the Medicare population that we look forward to assisting them in
    getting the care they need.

        Question. Do you believe low- and middle-income seniors can afford
    to pay more for Medicare services than they currently do?

        Answer. In previous legislation, I have proposed giving our seniors
    more flexibility within the Medicare Program and providing the
    opportunity to make decisions with their physicians without
    interference from Washington. The measure would help ensure that
    Medicare beneficiaries maintain adequate access to health-care
    professionals by increasing the number of physicians who will accept
    Medicare patients and addressing physician shortages by attracting new
    professionals to the field of medicine. In addition, the bill provides
    safeguards to Medicare beneficiaries. More importantly, it would allow
    a provider to see a Medicare patient pro-bono or charge minimal cost
    (below the standard fee schedule) without prosecution.
                      raising the medicare eligibility age
        Question. Congressional Republicans support increasing the Medicare
    eligibility age from 65 to 67 to generate savings for the Federal
    Government. It is well documented that these savings ultimately shift
    costs to the American people, States, and employers. According to 2014
    estimates, increasing the Medicare eligibility age would result in a
    $11.4 billion shift to individuals, States, and employers. The Federal
    savings would amount to only half of this cost, or $5.7 billion.

        Most Americans retire well before age 67. By age 63, nearly half of
    the population is no longer working. Advocacy groups argue that
    increasing the Medicare eligibility age is an across the board benefit
    cut that undercuts a promise made to working families and seniors more
    than 50 years ago.

        Would you recommend President Trump veto legislation that would
    increase the Medicare eligibility age?

        Answer. In considering Medicare, it is important to appreciate that
    the bipartisan Medicare Trustees have told everyone that Medicare, in
    less than 10 years, is going to be out of the kind of resources that
    will allow us as a society to keep the promise to beneficiaries of the
    Medicare program. My goal, if confirmed, is to work with Congress to
    make certain that we save and strengthen Medicare. It is irresponsible
    for us to do anything else. If am confirmed, my role will be one of
    carrying out the laws Congress passes and as to that I would convey to
    the Medicare population that we look forward to assisting them in
    getting the care they need.

        Question. If implemented, would Federal savings from a higher
    eligibility age be shifted onto Medicare beneficiaries, States, or
    employers instead?

        Answer. If such a change is made and the savings do not accrue to
    beneficiaries and the Trust Fund, then we may be right back where we
    started without the change. However, the allocation of savings from
    such a change, whether to the Medicare Trust Fund or to other budgetary
    priorities, will be a decision for the Congress.
                                 mental health
        Question. As you must know, mental illness is highly prevalent in
    the United States. Over 43 million adults, just over 18 percent of the
    population, had any mental illness in 2014. In the past year, over 68
    million Americans, representing 20 percent of the population,
    experienced a psychiatric or substance use disorder.

        Medicaid is the country's primary payer for all mental health
    services and is an important source of funding for mental health
    services that would otherwise be out of reach for low-income people.
    Under Medicaid, children and adults with mental illness receive vital
    services and supports that are not typically covered by private
    insurance. Medicaid accounted for 25% of all mental health spending in
    the United States in 2014.

        Thanks to Medicaid expansion under the Affordable Care Act (ACA),
    an additional 3.8 million Americans have access to mental health
    coverage. Furthermore, due to consumer protections under the ACA, it is
    now required that health insurers provide mental health and substance
    use disorder services as an essential health benefit.

        In your 2017 budget and 2015 reconciliation bill, you call for a
    full-out repeal of the Medicaid expansion; do you still support full
    repeal?

        Answer. This is a matter for the legislative branch to consider. If
    confirmed, I will work to ensure that HHS (appropriately) implements
    the statutes within its purview.

        Question. In 2015 you voted to eliminate important coverage
    protections for Medicaid beneficiaries in alternative benefit plans so
    they can access the treatment they need.

        Do you still support eliminating these protections?

        Answer. This is a matter for the legislative branch. I remain
    committed to making sure health care is affordable and accessible for
    all Americans. And if confirmed, I will work to ensure that HHS
    (appropriately) implements the statutes within its purview.

        Question. In your Empowering Patients First Act you call for full
    repeal of the ACA including important protections such as mental health
    parity that help to ensure that a person receives the same level of
    mental health coverage that they would for any physical illness.

        Do you still support repeal of these protections?

        Answer. I believe it is important that we as a nation make sure
    that every American has access to the kind of mental health and
    substance abuse care that they need. This is a matter for the
    legislative branch, however, and if confirmed, I will work to ensure
    that HHS (appropriately) implements the statutes within its purview.

        Question. The Office of the Assistant Secretary for Planning and
    Evaluation (ASPE), which will be your principal advisor as HHS
    Secretary should you be confirmed, reported that in States that didn't
    expand Medicaid nearly 2 million low-income adults with mental health
    and substance use disorders are uninsured.

        How do you plan to work with States to expand Medicaid coverage to
    these individuals?

        Answer. Every State has different demographic, budgetary, and
    policy concerns that shape their approach to Medicaid and Medicaid
    expansion. That is one of the reasons I devoted so much time working to
    help identify creative solutions, and why I believe a one-size-fits-all
    approach is not workable for a country as diverse as the United States.
    If I am confirmed, I will work with CMS and SAMHSA to help the
    population of uninsured low-income adults with mental health and
    substance use disorders.

        I note that the conversation and focus in these topics has been the
    question of coverage rather than true access to care. For many
    Americans, they might have an insurance card and yet not be able to
    afford care or it might not be available to them for other reasons.
                         opioids and medicaid expansion
        Question. In November, I released a report describing the
    consequences of not adequately funding treatment and prevention
    services for opioid addiction. However, as we both know, the effects of
    opioid crisis go far beyond mere statistics. People all across the
    country end up struggling with opioid addiction simply because they got
    into a car accident, or had a painful surgery. Medicaid expansion has
    provided millions of Americans an opportunity to get the treatment they
    need to get back on their feet.

        Congressman Price, in your 2017 budget you call for ending the
    Medicaid expansion, can you confirm whether you still support getting
    rid of the Medicaid expansion?

        Answer. This is a matter for the legislative branch. If confirmed,
    I will work to ensure that HHS (appropriately) implements the statutes
    within its purview.

        Question. In your role as a cabinet Secretary, would you advise the
    President to veto a bill that repeals the Medicaid expansion?

        Answer. I am committed to making sure all Americans have access to
    affordable health care that is of the highest quality. Every State has
    different demographic, budgetary, and policy concerns that shape their
    approach to Medicaid. That is one of the reasons I devoted so much time
    to working with States to help them to identify creative solutions, and
    why I believe a one-size-fits-all approach is not workable for a
    country as diverse as the United States. I would encourage anyone to
    keep this principle front and center in considering any changes to
    Medicaid, which themselves might well be part of a greater context that
    further informs the best approach. In the meantime, I look forward to
    faithfully executing whatever law that Congress passes and the
    President signs, if I am confirmed. I will promise you this: Regardless
    of the final legislative outcome, I would work as HHS Secretary to
    ensure that the Medicaid program is well administered, effective, and
    available for eligible beneficiaries and that the States/Governors are
    given the flexibility to pursue innovative approaches that fits the
    needs of their States.

        Question. Would you advise the President to support ending coverage
    for the 1.6 million Americans struggling with substance use disorders
    who gained access to coverage for treatment under the Medicaid
    expansion?

        Answer. It is important that we as a nation make sure that every
    American has access to the kind of mental health and substance abuse
    care that they need. If I am confirmed, I am committed to ensure that
    access is not diminished.

        Question. Will you promise that people dealing with opioid
    addiction will not lose their Medicaid expansion coverage that has
    provided them with the treatment they need and deserve?

        Answer. Opioid addiction has had a severe and devastating impact to
    communities and families across the country. If I am confirmed, I am
    committed to ensure that access to treatments is not diminished and
    will work with CMS and SAMHSA to help low-income adults with mental
    health and substance use disorders.
                network adequacy rules for specialty pharmacies
        Question. Pharmacy Benefit Managers (PBMs) may or may not own the
    pharmacies in their pharmacy networks. Recently, PBMs have been
    criticized for using aggressive tactics to restrict access to
    pharmacies that they do not own. If pharmacy networks are narrowed,
    then individuals will have limited access to pharmacies and necessary
    medications.

        I have heard from Oregon pharmacies that pharmacy benefit managers
    (PBMs) are using aggressive tactics to, in the pharmacies' opinion,
    restrict access to pharmacies not owned by the PBM.

        This issue was described in a January 9, 2017 New York Times
    article: (https://mobile.nytimes.com/2017/01/09/business/specialty-
    pharmacies-say-benefit-manag
    ers-are-squeezing-
    themout.html?_r=0&referer=https%3A%2F%2Fwww.google.com%
    2F).

        I am concerned that if pharmacy networks are narrowed, access to
    needed medications will be limited.

        Can you explain if practices described in the New York Times
    article are permitted under Medicare Part D and the Exchanges
    established under the Affordable Care Act (ACA)?

        Answer. Part D plans are required to accept any pharmacy willing to
    participate in the plan under the terms of its standard contract.
    Qualified health plans do not have such a requirement though State
    insurance commissioners may consider such practices in their regulatory
    oversight.

        Question. What minimum standards regarding network adequacy for
    specialty pharmacies exist for both Part D plans and plans offered on
    the ACA Exchanges?

        Question. For Part D plans, network adequacy requirements are set
    forth in 42 CFR 423.120 and in subregulatory guidance. The requirements
    vary by the type of drug. For home infusion drugs, they vary by State.
    See https://www.cms.gov/Medicare/Prescription-Drug-Coverage/
    PrescriptionDrugCovContra/Downloads/Adequate-Access-to-HI-Pharmacies-
    Rewrite-012610.pdf.

        For Qualified Health Plans, network adequacy requirements are set
    forth at 45 CFR 156.230, 45 CFR 156.122(e), and QHP application and
    attestation materials, as well as in State laws.
                                preventive care
        Question. Countless studies have proven that early detection of
    disease saves lives and improves quality of life. Early detection,
    through preventive screenings, can save the health-care system the
    expense of more costly treatments that may be necessary with a later
    stage diagnosis. However, early detection of disease is often not
    possible without preventive screenings, for both acute conditions like
    cancer and chronic conditions like diabetes. High copays and high
    deductibles can be a deterrent to patients utilizing these preventive
    screenings, regardless of socioeconomic status.

        The ACA included a provision requiring private health plans to
    cover recommended preventive services without any co-payments or cost-
    sharing. It also added coverage of an annual wellness visit and
    eliminated cost-sharing for recommended preventive services under the
    Medicare program.

        As HHS Secretary, how will you guarantee that Americans will retain
    their current level of coverage for preventive screenings and ensure
    early detection screenings are preserved?

        Answer. I would convey to the Medicare population that we look
    forward to assisting them in getting the care they need and the
    caregivers that they need too.

        As we consider what to do with regards to the Affordable Care Act,
    my hope is to move in a direction where insurers can offer products
    people want and give them the coverage they want. Getting to that kind
    of system requires changes that will inevitably involve working with
    Congress and considering the tradeoffs of various proposals to achieve
    our shared objective of the best and highest quality care being
    available to Americans.
                       spousal impoverishment protections
        Question. In the 1980s, married couples commonly were driven into
    complete poverty when one spouse developed a need for nursing home
    care. The couple often had to spend down their joint resources to just
    a few thousand dollars before Medicaid could provide assistance.
    Congress addressed this problem in 1988 legislation signed by President
    Reagan. Beginning in October 1989, the spouse of a nursing home
    resident has been allowed allocations of income and resources in
    determining the resident's Medicaid eligibility. These allocations
    allow the at-home spouse to retain adequate but not lavish amounts of
    income and savings. To allow for State flexibility, the Federal
    Government sets a range for these allocations, and indexes those ranges
    to inflation. Each State sets its own income allocation and resource
    allocation, as long as the allocation falls within the Federal range.

        Spousal impoverishment protections are mandatory for nursing home
    residents and were optional for people receiving home and community-
    based services (HCBS). Due to the Affordable Care Act, people receiving
    HCBS are also entitled to spousal impoverishment protections.

        Do you support the requirement for State spousal impoverishment
    protections?

        Answer. I support the flexibility of States to make decisions about
    eligibility so that they can ensure the broadest set of people get
    access to the highest quality care on the budget available to the
    State. Spousal impoverishment protections allow States to delay or
    prevent the impoverishment of spouses lest they too need to be added to
    the Medicaid rolls.

        Question. Should a person be required to receive long-term care in
    a nursing home in order to protect a spouse from poverty?

        Answer. My hope is that we can move to a system where States can
    make decisions like this with their population, values, dynamics, and
    funding in mind.

        Question. How will HHS ensure spouses are protected from living in
    poverty when a loved one reaches a stage of fragility that requires
    long-term care?

        Answer. I have seen that the best solutions to seemingly
    intractable problems like this rely on States to find the right
    approach for that State. If confirmed, I look forward to working with
    Governors (and Congress) to help States chart their course in this
    regard.
                                 women's health
        Question. Congressman Price, in the past, when asked whether birth
    control should have to be covered, you've stated that not a single
    woman has been left behind.

        Will you reject any proposals that limit a women's access to
    contraceptive care or make it cost more for her?

        Answer. Women should have the health care that they need and want.
    The system we ought to have in place is one that equips women and men
    to obtain the health care that they need at an affordable price.

        Question. As a cabinet adviser to the President, will you advise
    the President to veto any bill that reduces guaranteed access to
    affordable contraceptive coverage?

        Answer. As we consider what to do with regards to the Affordable
    Care Act, my hope is to move in a direction where insurers offer
    products people want and give them the coverage they want. Getting to
    that kind of system requires changes that will inevitably involve
    working with Congress and considering the tradeoffs of various
    proposals to achieve our shared objective of the best and highest
    quality care being available to Americans.

        Question. In your hearing last week, you were asked about your vote
    against the DC Council's efforts to protect employees from being fired
    for taking birth control. Congressman Price, to clarify for the record,
    do you or do you not think an employer should be able to fire or
    discriminate against an employee for taking birth control?

        Answer. I do not believe so. My vote regarding the DC Council law
    you mentioned does not relate to this particular issue or question.

        Question. Will you advise the President to veto any bill that rips
    access to care away from hundreds of thousands of women by defunding
    Planned Parenthood?

        Answer. Deciding whether to sign any particular law, particularly
    one that involves as many different moving parts as one to replace the
    Affordable Care Act, inevitably involves considering many competing,
    complementary, or countervailing issues. If Congress passes a law that
    makes certain that every single American has access to the coverage
    they want for themselves and ensures the individuals who lost coverage
    under the Affordable Care Act get or maintain coverage, that is
    something I would hope would be strongly considered for signature.

        Question. You sponsored the 2015 reconciliation bill (H.R. 3762)
    that would repeal key components of the Affordable Care Act (ACA) and
    rescind Federal funding for Planned Parenthood for 1 year. Please
    provide the names of providers other than Planned Parenthood health
    centers that H.R. 3762 would prohibit from participating in Medicaid?

        Answer. H.R. 3762 restricts the availability of Federal funding to
    a State for payments to any entity that is a 501(c)(3) tax-exempt
    organization, is an essential community provider primarily engaged in
    family planning services and reproductive health; provides abortions
    other than in cases of rape, incest or life of the mother, and receive
    a total of more than $350 million under Medicaid in FY 2014.

        It should also be noted that H.R. 3762 would increase funding
    available to the Community Health Center Program (CHC) by $470 million
    over 2 years. As I said in my hearing before the Senate Health,
    Education, Labor, and Pensions (HELP) Committee last week, community
    health centers are a vital part of the health care delivery system,
    filling a void in so many areas across the county. We need to do all we
    can to strengthen them, ensuring they are staffed with the highest
    quality providers and providing the highest quality care, and look
    forward to working with you on this if confirmed.
                    work requirements for medicaid services
        Question. Your Budget Plan for 2017 proposes work requirements for
    so called ``able-bodied'' adults in order to qualify for Medicaid
    coverage. Specifically, these individuals must be actively seeking
    employment or participating in an education or training program in
    order to qualify for health-care coverage under Medicaid.

        According to independent evaluations of programs that have imposed
    work requirements, imposition of work requirements found only modest,
    short-term increases in employment with families living in deep poverty
    rising under such programs. The evidence also shows that over the long-
    term, those in programs with work requirements were as likely to find
    employment as enrollees in Medicaid programs that did not have strict
    work requirements.

        How do you define an ``able-bodied'' adult?

        Do you support work requirements in order for these ``able-bodied''
    adults to qualify for Medicaid?

        Given you're interest in employment, how do you plan on working to
    support local economies to ensure that those looking for work
    regardless of income are actually able to obtain jobs?

        Answer. One major lesson learned from welfare reform signed into
    law by President Clinton is that the American people, when given the
    opportunity, work exceptionally hard. This view is also shared by
    President Trump and reflected in his commitment to job creation and the
    dignity of work. Encouraging work allows more families to realize the
    American dream, earn their success and rise out of poverty. I will
    faithfully execute any laws passed by Congress to institute work
    requirements and if given the opportunity to serve I will allow States
    greater flexibility for determining how to care for their most needy
    citizens.
                                  ama recusal
        Question. Congressman Price, in your January 11th letter to the
    Associate General Counsel for Ethics at HHS, you said you would resign
    from your position as a Delegate of the American Medical Association
    (AMA) if confirmed as HHS Secretary. You also promised that--for 1 year
    after your AMA resignation--you would ``not participate personally and
    substantially in any particular matter involving specific parties in
    which (you know) the American Medical Association is a party or
    represents a party, unless (you are) first authorized to participate.''

        In 2016 alone, the AMA submitted 21 formal comment letters to HHS
    and CMS--almost two per month on average--covering a wide range of
    issues, including, for example, the implementation of the Medicare
    physician payment reforms in MACRA (the Medicare Access and CHIP
    Reauthorization Act) and key provisions of last year's Comprehensive
    Addiction and Recovery Act (CARA).

        In this context, what criteria would you use to determine what
    constitutes participating ``personally and substantially'' in a matter?

        Answer. I view the term ``personally and substantially'' in the
    context of its statutory and regulatory definitions. To the extent
    necessary, I will seek advice from his designated agency ethics
    official and other appropriate parties when assessing whether
    participation in a matter is indeed personal and substantial.

        Question. In this context, what criteria would you use to determine
    whether the level of AMA's involvement means that it is a party or
    represents a party in a particular matter?

        Answer. I will abide by the actions agreed to in my publicly
    available ethics agreement with the Office of Government Ethics, and
    seek advice (when necessary) from the designated agency ethics official
    and other appropriate persons.

        Question. Will you recuse yourself from any matter in which the AMA
    has submitted formal comments to HHS or CMS?

        Answer. This matter has already been addressed with the OGE and
    designated agency ethics official, and I will abide by the obligations
    agreed to in my publicly available ethics agreement.

        Question. For example, will you recuse yourself from any decision-
    making regarding the implementation of the physician payment reforms in
    MACRA--given how actively engaged AMA has been with HHS and CMS on that
    issue?

        Answer. This matter has already been addressed with the OGE and
    designated agency ethics official, and I will abide by the obligations
    agreed to in my publicly available ethics agreement.

        Question. Will you also recuse yourself from any matter about which
    the AMA sent correspondence to HHS or CMS?

        Answer. This matter has already been addressed with the OGE and
    designated agency ethics official, and I will abide by the obligations
    agreed to in my publicly available ethics agreement.

        Question. Do you think an HHS Secretary can effectively do his job
    if he cannot participate in any of the above described matters?

        Answer. Adherence to all applicable ethics and conflict of interest
    obligations under Federal law is an essential component of being an
    effective HHS Secretary, and in no way limits the ability of an
    individual to successfully carry out his or her responsibilities within
    the Department.
                         automatic cuts to entitlements
        Question. The day after you were nominated for HHS Secretary, you
    rolled out a set of budget process changes that would force automatic
    cuts to almost all Federal programs--including Social Security,
    Medicare, and Medicaid--if the national debt exceeds targets specified
    by Congress. If the Trump tax plan is signed into law, but Congress
    cannot agree on how to pay for its cost of more than $6 trillion over
    10 years, your budget process would automatically cut Social Security
    by $1.7 trillion and Medicare by $1.1 trillion over 10 years. This
    would cut the average Social Security benefit by $168 per month.
    President Trump has pledged not to cut Social Security, Medicare, and
    Medicaid; but your budget process seems to provide a way to cut these
    programs without President Trump having to sign any specific cuts into
    law.

        If Congress passed your budget changes today, would you recommend
    he veto that legislation?

        Answer. Should the budget pass, I will carefully review the
    legislation and communicate the health-care implications of that budget
    to the President.

        Question. The sequester, under current law, shields vulnerable
    populations from across the board cuts. Why do you believe the
    sequester should be expanded to programs that serve the most vulnerable
    Americans?

        Answer. It is my belief that the Federal Government needs to
    strengthen mandatory programs if we are going to ensure future
    generations have access to the programs.
                           children's health coverage
        Question. Congressman Price, you once remarked that low-income
    children already have access to all the health care they need. You've
    publicly said that you, ``know of no study that shows these individuals
    have no access,'' and that uninsured children are already treated by
    doctors and hospitals even though they often do not pay for the care
    they receive.

        Do you still believe that all children had adequate access to
    health care before the ACA?

        Answer. Though programs like CHIP have made substantial progress in
    the availability of health-care coverage to children, there has always
    been more work to do in this regard. I should add that what is most
    important in this regard is not just that children have coverage but
    also actual access to care that is affordable and available to them.

        Question. Do you agree that maintaining these coverage gains and
    not taking a step back on children's health is vitally important?

        Answer. With regards to health care for children, our goal is to
    make certain that every single American has access to the coverage they
    want for themselves and their children and ensures the individuals and
    children who lost coverage under the Affordable Care Act get or
    maintain coverage.

        Question. Congressman Price, according to independent reports,
    repeal of the ACA would mean over 4 million children would become
    uninsured. As advisor to the President, will you advise the President
    to veto any bill if the result is fewer children have coverage?

        Answer. Deciding whether to sign any particular law, particularly
    one that involves as many different moving parts as one to replace the
    Affordable Care Act, inevitably involves considering many competing,
    complementary, or countervailing issues. I look forward to working with
    the Congress to ensure that fewer children having coverage is not one
    of those tradeoffs, but rather that every single American has access to
    the coverage they want for themselves and their children and ensures
    the individuals and children who lost coverage under the Affordable
    Care Act get or maintain coverage.
                   children's health insurance program (chip)
        Question. Today, the bipartisan Children's Health Insurance Program
    provides 8 million children with access to comprehensive, affordable
    health care including thousands of children in Oregon's Healthy Kids
    program. Yet you've publicly referred to CHIP as ``government-run
    socialized medicine'' and put forth proposals that would have denied
    families with access to more affordable care for their children through
    this successful bipartisan health program.

        Congressman Price, in your role as a cabinet Secretary, would you
    advise the President to support an extension of the Children's Health
    Insurance Program?

        Answer. It is important that every child has access to high-quality
    health coverage, and CHIP plays an important role in accomplishing this
    objective.

        Question. Will you commit to ensuring that not a single child under
    Oregon's Healthy Kids program gets left behind under any CHIP
    extension?

        Answer. If confirmed as Secretary, my goal would be to ensure that
    no child in Oregon or anywhere else is left behind. CHIP plays a major
    role in this, but there is also a need for coordinated family coverage
    in the private market and employer plans, and giving States the needed
    flexibility to accomplish this.

        Question. As a cabinet-level advisor to the President, will you
    advise the President to veto any bill that results in coverage being
    stripped away from a single child in Oregon benefiting from our Healthy
    Kids program?

        Answer. Deciding whether to sign any particular law inevitably
    involves considering many competing, complementary, or countervailing
    issues. I look forward to working with the Congress to ensure that
    fewer children having coverage is not one of those tradeoffs, but
    rather that every single child in Oregon and America has access to
    high-quality care. That means not just having a card, but being able to
    access the care it covers.
                            cost sharing in medicaid
        Question. Your 2017 budget used the Healthy Indiana Plan as an
    example of an innovative State program that is reducing State Medicaid
    costs. However, the Healthy Indiana Plan has not worked as intended in
    some important ways and has created access barriers for some. In fact,
    studies show that the required premiums for many low-income people
    depress participation and make it harder for people to access the
    coverage they need. According to an independent evaluation of the
    program, thousands of individuals in the program were penalized or
    kicked off and locked out of coverage under the complicated structure.

        If these types of complicated structures used in a State's Medicaid
    program is shown to keep eligible people from getting the health care
    they need, will you disallow it as not meeting the objectives of the
    Medicaid statute?

        Answer. The Healthy Indiana Plan has long been and continues to be
    a national model for State-led Medicaid reforms pertaining to the low-
    income, able-bodied adult population. It is important that Medicaid's
    design helps its members to transition successfully from the program
    into commercial health insurance plans, as HIP's
    consumer-driven approach and underlying incentive structures encourage.
    HIP members are more engaged with their providers, less reliant on the
    emergency room, and more satisfied with their coverage than traditional
    Medicaid members. HIP is achieving Indiana's objective to increase
    access to consumer-driven coverage as well as the broader objectives of
    the Medicaid program, and I support the use of HIP's reforms in future
    1115 demonstration requests by other States.
                             delivery system reform
        Question. Congressman Price, you have been an outspoken critic of
    the delivery system reforms included in the Affordable Care Act (ACA),
    particularly the Center for Medicare and Medicaid Innovation (CMMI) and
    the movement away from traditional fee-for-service payments for
    providers and toward value-based payment models such as bundled
    payments.

        Do you agree that the traditional fee-for-service payment system--
    in which providers are paid based on volume instead of value--creates
    incentives for overutilization of health-care services?

        Answer. Our health-care system is complex, and we cannot attribute
    overutilization trends to a single cause. For instance, efforts to curb
    overutilization in emergency rooms have been unsuccessful.
    Overutilization is a complex issue that needs to be carefully
    addressed.

        Question. Do you also agree that the successful implementation of
    the bipartisan Medicare Access and CHIP Reauthorization Act (MACRA)
    will require the continued development of value-based payment models?

        Answer. The Medicare Access and CHIP Reauthorization Act of 2015
    (MACRA) is built on the principle of encouraging providers to develop
    Alternative Payment Models (APMs) that can ultimately be adopted by CMS
    and commercial payers.

        Question. Will you commit to supporting the continued development
    of value-based payment models in Medicare and increasing the percentage
    of provider payments made through those models?

        Answer. We share the goal of improving Medicare by empowering
    providers to be creative and develop payment models that best suit the
    unique needs of their patients to ultimately improve patient care.
                     medicare-medicaid coordination office
        Question. ``Dual eligibles'' receive benefits under the Medicare
    and Medicaid programs. Full benefit dual eligibles suffer from serious
    health care needs including debilitating physical and mental
    disabilities, often requiring complicated and expensive long-term
    services and supports. The ACA created the Medicare-Medicaid
    Coordination Office, also called the Medicare-Medicaid Coordination
    Office, to coordinate and address the needs of dual eligibles. The
    office has led Federal efforts to improve how programs are delivered to
    this high need, high cost population.

        Will the administration continue to support the Medicare-Medicaid
    Coordination Office?

        Answer. If confirmed as Secretary, and if legislation regarding
    this Office changes, I will work with the CMS Administrator to consider
    how best to deploy the tremendous resources of CMS against the enormous
    challenge of ensuring access to the highest quality care for dual
    beneficiaries. In the meantime, I will implement the law as passed by
    Congress.

        Question. Does the administration plan to continue the financial
    alignment demonstration currently underway in several States?

        Answer. Commenting on specific potential models is premature at
    this point. These models go through a lengthy development and modeling
    process, as well as internal review and approval at CMMI and OMB. If
    confirmed, as HHS Secretary, I plan to work closely with CMS to ensure
    that CMMI--after appropriate consultation with Congress, the States,
    health-care stakeholders, and Innovation Center staff--tests innovative
    models that reduce costs and improve quality for Medicare and Medicaid
    beneficiaries.
                            federal data collection
        Question. The Department of Health and Human Services (HHS)
    collected valuable data related to the Affordable Care Act (ACA). This
    includes rate filings, enrollment data, and analytical reports on the
    efficacy of the law in different sectors of the health system.
    Additionally, the ACA invested in the implementation of a new health
    data collection and analysis strategy. Section 4302 of the Affordable
    Care Act contains provisions requiring all national Federal data
    collection efforts collect information on race, ethnicity, sex, primary
    language and disability status. The law also provides HHS the
    opportunity to collect additional demographic data to further improve
    our understanding of health-care disparities.

        Will health-care data collected by the government continue to be
    publicly available to promote government transparency?

        Answer. If confirmed as Secretary, I would implement the law
    regarding these topics as written and passed by the Congress.

        Question. Will health-care data continue to require the collection
    of information on race, ethnicity, sex, primary language, and
    disability status?

        Answer. If confirmed as Secretary, I would implement the law
    regarding these topics as written and passed by the Congress, including
    with respect to the data points required to be collected.

        Question. How does CMS plan to leverage this data to address health
    disparities?

        Answer. Any data that can inform CMS's approach to understanding
    where people's needs are not being met will help us understand how best
    to move towards a system where every single American has access to the
    coverage they want for themselves.
                      ban on health agency communications
        Question. News reports on January 24th indicate that Trump
    administration officials have issued what amounts to a gag order
    essentially muzzling external communications by employees of the
    Department of Health and Human Services (HHS) and the National
    Institutes of Health between now and February 3. This ban on external
    communications reportedly includes correspondence with public officials
    including members of Congress as well as press releases and social
    media posts.

        What communications are covered by the Trump administration's
    restriction of external communications?

        Are there any exceptions allowed for releases of information about
    matters of public health or safety?

        If a public health or safety matter arises between now and February
    3rd, will the agencies be prevented from communicating with public
    officials or the general public about these matters?

        Under what circumstances would external communications be allowed?

        Who within the Department is authorized to allow communications in
    a public health or safety situation or otherwise? Please provide the
    criteria that has been developed to determine if and when external
    communications are permitted.

        What impact will this restriction have on whistleblowers who are
    exercising rights protected by law?

        What is the reason for this action?

        Is it possible the restriction will be extended beyond February
    3rd? Under what circumstances could it be extended?

        Does the restriction apply to Federal employees' personal use of
    social media or only use of official agency accounts?

        Will the restriction prevent HHS employees from responding to
    outstanding questions from members of Congress including letters or
    other communications awaiting answers? If so, when will such questions
    be answered?

        Will questions submitted by members of the Finance Committee be
    answered in a timely manner and in any case before February 3rd
    notwithstanding the restriction on external communications?

        Answer. The Acting Secretary Memo to Department of Health and Human
    Services operating and staff division heads is straightforward and
    consistent with Chief of Staff Memo issued on behalf of President Trump
    with regard to regulatory review of new or pending regulations and
    guidance. As noted in the HHS memo, the purpose of the directive is to
    ensure ``President Trump's appointees and designees have the
    opportunity to review and approve any new or pending regulations or
    guidance documents.'' Furthermore, the Chief of Staff memo provides
    explicit exceptions for ``emergency situations or other urgent
    circumstances relating to health, safety, financial, or national
    security matter. . . .'' This request is standard for a new
    administration. With regard to correspondence to public officials, such
    as members of Congress, the memo outlines a clear and expedited process
    for adequate review and is by no means intended to impede the agencies
    or staff divisions from continuing their important work on behalf of
    the American people, including routine constituent service
    communications.
                            cost-sharing reductions
        Question. Under the Affordable Care Act, individuals and families
    with incomes between the Federal poverty level and 250 percent of the
    poverty level are eligible for cost-sharing reductions (CSRs) if they
    are eligible for a premium tax credit and purchase a silver plan
    through the health insurance exchange. The cost-sharing reductions
    reduce the deductibles, copayments, and other out-of-pocket costs for
    these lower- and moderate-income Americans.

        In House v. Burwell, House Republicans challenged the legality of
    Federal funding of CSR subsidies. In a May 2016 ruling, U.S. District
    Judge Rosemary Collyer ruled in favor of the House Republicans,
    although she stayed implementation of the ruling. The previous
    administration appealed the decision, but the case was stayed until
    after the 2016 presidential election.

        If confirmed as HHS Secretary, will you recommend that the
    administration continue to reimburse insurers for the cost-sharing
    reductions that reduce deductibles, copayments and other out-of-pocket
    costs for lower- and moderate-income Americans?

        Answer. The agency is currently involved in litigation related to
    this matter, and it would be inappropriate for me to comment at this
    time.

        Question. If confirmed as HHS Secretary, will you recommend that
    the administration protect the Federal Government's authority to make
    payments for cost-sharing reductions, which was challenged in House v.
    Burwell, and move forward with its appeal of the lower court's ruling?

        Answer. The agency is currently involved in litigation related to
    this matter, and it would be inappropriate for me to comment at this
    time.

        Question. If confirmed as HHS Secretary, will you recommend that
    the administration seek an appropriation from Congress for the cost-
    sharing reductions?

        Answer. It will be up to the President and Congress to determine
    the appropriate policy on this issue. My job, if confirmed, would be to
    faithfully execute that law.
                             risk corridor payments
        Question. The Affordable Care Act's temporary risk corridor program
    was intended to promote accurate premiums in the early years of the
    exchanges (2014 through 2016) by cushioning insurers from extreme gains
    and losses. It was modeled after the Medicare Part D prescription drug
    program's successful risk corridor program. The Federal Government
    currently owes insurers approximately $8.3 billion under the risk
    corridor program to offset losses from 2014 and 2015. This is largely
    due to a rider attached to the 2015 and 2016 appropriations bills
    requiring the risk corridor program to be revenue neutral, meaning that
    the Centers for Medicare and Medicaid Services (CMS) can only pay out
    funds under the program that it collected under the program.

        Under the previous administration, HHS and CMS acknowledged that
    risk corridor payments are an obligation of the government and that
    full payment must be made to insurers. The Department of Justice
    defended the lawsuits brought by insurers for the full risk corridor
    payments, but also expressed a willingness to engage in settlement
    discussions.

        If confirmed as HHS Secretary, will you also acknowledge that risk
    corridor payments are an obligation of the government and that full
    payment must be made to insurers?

        Answer. The agency is currently involved in litigation related to
    this matter, and it would be inappropriate for me to comment at this
    time.

        Question. If confirmed as HHS Secretary, will you recommend that
    the administration engage in settlement discussions with insurers on
    overdue risk corridor payments?

        Answer. The agency is currently involved in litigation related to
    this matter, and it would be inappropriate for me to comment at this
    time.
                                 gender rating
        Question. Before the Affordable Care Act, insurance companies were
    able to charge women more for their health insurance compared to men.
    This practice was widespread, as 92 percent of the best-selling plans
    on the individual market used gender rating in setting their premiums.
    This cost women approximately $1 billion in additional costs each year
    that men did not have to pay.

        Do you believe that insurance companies should be required to
    charge men and women the same rate for premiums?

        Answer. The setting of premiums is something that has historically
    been a matter of State law and regulation, so that the dynamics of that
    State and its population and risk pool and consumer behavior can be
    taken into account. Nevertheless, of course, if confirmed as HHS
    Secretary, my role would be to implement the law as it is now written.
                                  1332 waivers
        Question. The ACA included a provision known as the State
    Innovation Waiver (SIW), or 1332, that provides States the opportunity
    to tailor their own health care system in a way that best aligns with
    the individual State's needs. This waiver was written to give States a
    chance to implement the ACA better; it was not written as a tool to
    undermine the law. States may apply to use these waivers beginning
    January 1, 2017.

        As a reminder, a waiver must meet the following requirements:

            Ensure that individuals get insurance coverage that is at
    least as comprehensive as provided under the ACA.
            Ensure that insurance coverage offered to individuals is at
    least as affordable as it would be under the ACA.
            Ensure that as many people are covered as would be under the
    ACA.
            Not increase the Federal deficit.

        Please respond to the following questions.

        What opportunities do you see for States to use the SIW? Are there
    particular reforms that you think would enhance access to affordable,
    quality coverage?

        Answer. These waivers present an opportunity for CMS to encourage
    State innovation and allow for adaptation of national requirements to
    the needs of individual States. If confirmed, I would work with CMS to
    enable States to utilize this--and other--authority provided by
    Congress to ensure access to high-quality, affordable health insurance.

        Question. How do you envision the SIW working in conjunction with
    Medicaid and any corresponding Medicaid waivers? What checks would you
    put in place to ensure that those individuals entitled to Medicaid
    receive the full benefits and protections afforded them under title
    XIX?

        Answer. There is a tremendous opportunity to allow States to
    innovate with respect to the intersection of their Medicaid programs
    and qualified health plans and the risk pools within each. State fair
    hearing processes (as well as the Medicaid waiver process and CMS
    oversight) provide substantial procedural and other protections that
    would address concerns regarding Medicaid beneficiaries not getting
    benefits due to them.

        Question. What precautions would you put in place to ensure
    consumers are protected in States that choose to move forward with a
    1332 waiver application?

        Answer. The statute itself has protections in place relating to the
    findings that must be made that would protect consumers in States that
    move forward with a 1332 waiver application. Furthermore, the
    democratic process in each State, where government is even closer to
    the people, provides substantial protection with regards to any 1332
    waiver application and its implementation. Such protection may well be
    even more effective than that available to consumers vis-a-vis the
    Federal Government.

        Question. What steps would you take, as Secretary of HHS, to
    implement this provision, as intended by congressional drafters, to
    ensure it is not used to undermine the ACA?

        Answer. As part of the ACA, the use of section 1332 to allow States
    to innovate would not undermine the ACA. In fact, failing to
    successfully use this important tool to allow States flexibility with
    regards to the ACA as allowed by the law would undermine the ACA.
                                  rural health
        Question. Americans living in rural areas often have difficulty
    accessing quality care due to physical and economic barriers. The
    Health Resources and Services Administration estimates that 65 percent
    of primary care health professional shortage areas are in rural areas.
    These challenges translate into significant health disparities for
    rural populations, including higher rates of chronic disease and
    disability as well as lower life expectancy. Rural Americans have also
    historically experienced lower rates of insurance. The Affordable Care
    Act provided new access to coverage for people living in rural areas
    through the Health Insurance Marketplaces and Medicaid expansions, as
    well as critical consumer protections.

        If confirmed how will you protect access to quality health care in
    rural areas?

        Answer. Too often rural health care is overlooked in the broader
    discussion of national health-care issues. Significant health
    disparities exist for rural populations for a variety of reasons,
    including challenges with access to affordable coverage and health-care
    services. Rural Americans are acutely aware of the dire need for
    expanded health insurance options. If confirmed, I will work tirelessly
    to address the health-care needs of all Americans, rural or urban.
          pre-existing conditions and continuous coverage requirement
        Question. The Affordable Care Act prohibits insurers from denying
    coverage to individuals with pre-existing conditions, charging them
    higher premiums, or refusing to cover benefits related to a pre-
    existing conditions.

        Your Empowering Patients First Act (H.R. 2300 in the 114th
    Congress) repeals the Affordable Care Act in its entirety (including
    the protections for those with pre-existing conditions) and instead
    puts in place a ``continuous coverage requirement,'' meaning that
    individuals with pre-existing conditions must maintain continuous
    health insurance coverage for at least 18 months in order to qualify
    for protections against discrimination by insurers. Under your
    legislation, insurers would once again be allowed to exclude coverage
    of a pre-existing condition for lengthy periods of time or charge much
    higher premiums unless individuals had maintained continuous coverage
    for at least 18 months.

        According to a recent report from the HHS Office of the Assistant
    Secretary for Planning and Evaluation (ASPE), up to 133 million non-
    elderly Americans may have a pre-existing condition, and nearly one-
    third (44 million) went uninsured for at least 1 month during the 2-
    year period beginning in 2013.

        If any of these individuals were to face difficult circumstances
    that resulted in a temporary loss of coverage--such as losing a job or
    being unable to work due to serious illness--your legislation would
    allow insurers to refuse to cover services related to the pre-existing
    condition or charge a much higher premium than many of these
    individuals would likely be able to afford.

        Do you agree that individuals with pre-existing conditions who
    experience a loss of coverage--for example, due to the loss of a job or
    being unable to work due to a serious illness--should not be denied
    coverage for their condition or charged high, unaffordable premiums as
    a result of that temporary loss of coverage?

        Under the continuous coverage requirement included in your
    Empowering Patients First Act, what would prevent insurers from doing
    exactly that to any individual with a pre-existing condition who
    experiences a temporary loss of coverage?

        Answer. I believe it is important that we as a nation make sure
    that every American has access to the kind of mental health care and
    health coverage that best meets their need. Additionally, it is
    imperative that all Americans have access to affordable coverage and
    that no one is priced out of the market due to a bad diagnosis. This is
    a matter for the legislative branch, however, and if confirmed, I will
    work to ensure that HHS appropriately implements the statutes within
    its purview.
                            human services programs
        Question. In recent years, there has been an increasing focus on
    using evidence to make policy decisions.

        What is your view on this?

        Answer. There is no question we must use available evidence when
    making governmental decisions.

        Question. What evidence would you use to decide whether policies or
    program changes that you have championed are successful?

        Answer. When championing policy or program changes, outcomes should
    always be a top indicator when determining whether or not those changes
    are successful.

        Question. What evidence leads you to believe that TANF was a
    success?

        Answer. Since the passage of TANF, we have seen employment rates of
    single mothers increase, lower poverty rates among female-headed
    households with children and African-American households, a reduction
    in child poverty overall, and a sharp decline in the number of families
    receiving cash assistance.

        Question. The annual data from HHS through the Adoption and Foster
    Care Analysis Reporting Systems (AFCARS) released in fall 2016 show a
    third consecutive annual increase in foster care to 427,910 children.
    This represents an 8-percent increase since 2012. Your home State is no
    exception. A recent AP story stated that, ``the most dramatic increase
    has been in Georgia, where the foster-care population skyrocketed from
    about 7,600 in September 2013 to 13,266 last month. The State is
    struggling to provide enough foster homes for these children and keep
    caseloads at a manageable level for child-protection workers.'' \1\ HHS
    recently indicated that:
    ---------------------------------------------------------------------------
        \1\ http://www.bigstory.ap.org/article/
    12658e69b70148fc8d4743fa631fa9f9/5-states-struggle-surging-numbers-
    foster-children.

            A rise in parental substance use is likely a major factor
            driving up the number of children in foster homes. Citing
            opioid and methamphetamine use as the most debilitating and
            prevalent substances used, some State officials expressed
            concern that the problem of substance use is straining their
            child welfare agencies.\2\
    ---------------------------------------------------------------------------
        \2\ https://www.acf.hhs.gov/media/press/2016-number-of-children-in-
    foster-care-increases-for-the-third-consecutive-year.

        Clearly, substance use is having a big impact on children,
    families, and child welfare systems. I am particularly concerned about
    the strain the epidemic is placing on grandparents and other relatives
    who often unexpectedly take on the role of caretaker for children in
    foster care and at risk of entering foster care. Thankfully, there are
    programs that work and can even save taxpayer dollars over the long
    run. For example, research shows that when parents are able to get into
    substance use treatment programs that permit them to live with their
    children, two-thirds of these parents successfully complete the
    program. That compares with only one-fifth of parents when their
    children aren't allowed to stay in the treatment facility with them.\3\
    The results achieved by these model programs have saved millions of
    dollars every year in the costs of keeping kids in foster care.
    ---------------------------------------------------------------------------
        \3\ https://www.ncbi.nlm.nih.gov/pubmed/11291901 and https://
    www.ncbi.nlm.nih.gov/pubmed/11291900.

        What will you do to ensure that drug treatment and services will be
    both maintained and coordinated to target these families that need
    treatment and whose children could end up in foster care without the
    ---------------------------------------------------------------------------
    appropriate services?

        Answer. There needs to be better coordination between Federal
    departments, State governments, and local governments to ensure we are
    meeting the challenges of one of the great crises of our times: the
    opioid epidemic. A top agenda of all levels of government is to ensure
    innocent children, including those in foster homes, are protected from
    the scourge of this epidemic. As a strong proponent of the
    Comprehensive Addiction and Recovery Act of 2016, I will do all I can
    to effectively administer and implement this law should I be confirmed
    as Secretary.

        Question. How will you help grandparents and other family members
    receive the supportive services they need in the event that parents
    cannot safely retain custody of their children?

        Answer. Should I be confirmed as HHS Secretary, I will do all
    within my power, under the laws passed by Congress, to help
    grandparents and other family members receive supportive services.

        Question. Will you pledge to me that, if confirmed, you will work
    with me to provide Federal support for effective programs, and to
    ensure that the children and grandparents caught up in the opioid
    epidemic get support from your Department?

        Answer. I absolutely pledge to work with you to ensure support for
    effective programs and to see that children and grandparents get
    appropriate support from HHS to deal with the tragic opioid epidemic.

        Question. As part of the Comprehensive Addiction and Recovery Act
    of 2016, Congress required States to have plans of ``safe care'' for
    infants born exposed to substances.\4\ This requirement, along with
    numerous existing requirements, is a condition of State receipt of
    grants under the Child Abuse Prevention and Treatment Act, or CAPTA.
    Grants to States under CAPTA total $26 million per year. Discretionary
    spending for child welfare services under CAPTA, the Adoption/Kinship
    Incentives Program, the Promoting Safe and Stable Families Program and
    Child Welfare Services have all faced significant reductions in
    appropriations over the past 5 years.
    ---------------------------------------------------------------------------
        \4\ http://www.cwla.org/discussion-on-plans-of-safe-care/.

        What is your position on proposals that would move mandatory
    funding to discretionary funding (thus limiting the committee's ability
    ---------------------------------------------------------------------------
    to fund both child welfare and other vital services)?

        Answer. This is a legislative matter. Should I be confirmed as HHS
    Secretary, I will implement the laws passed by Congress.

        Question. How will you ensure adequate funding for these services
    that have suffered significant reductions over the recent past despite
    a backdrop of increasing foster care numbers?

        Answer. Should I be confirmed as HHS Secretary, I will strive to
    make effective use of all dollars appropriated by Congress in order to
    provide the most effective services possible.

        Question. The United States is the only industrialized country
    without paid maternity leave.\5\ The President has endorsed such leave
    for new mothers.
    ---------------------------------------------------------------------------
        \5\ http://www.oecd.org/els/family/
    PF2_5_Trends_in_leave_entitlements_around_childbirth.
    pdf.

        If confirmed, how might you lead the Department to help support
    this goal? Please be specific about resources and expertise that may be
    available at HHS, including in such areas as benefit design,
    ---------------------------------------------------------------------------
    eligibility determination, IT systems, and program access.

        Answer. If I am so honored as to be confirmed as HHS Secretary, I
    will implement the laws passed by Congress and support the President's
    initiatives as they fall within HHS's authorities. I will do so in a
    way that is as effective and as efficient as possible, drawing on the
    expertise and experience of the fine men and women currently working at
    HHS.

        Question. Access to high-quality child care is fundamental to the
    economic security of families and too many parents cite lack of
    dependable child care as a key barrier to finding and maintaining
    employment. The President's child care tax proposals would primarily
    benefit high-income families through tax deductions, while providing
    little or no help to low- and middle-income families.\6\ The most
    significant Federal child care program for families of modest means is
    the Federal Child Care and Development Block Grant (CCDBG) which
    provides funds to States to help low-income families afford child care
    of their choice. Yet the CCDBG serves only one out of seven children
    eligible for assistance.
    ---------------------------------------------------------------------------
        \6\ https://papers.ssrn.com/sol3/
    papers.cfm?abstract_id=2842802&download=yes.

        If confirmed, under your leadership how might the Department
    improve access to high quality child care? Please be specific about
    resources and expertise that may be available at HHS, including in such
    areas as benefit design, eligibility determination, IT systems, and
    ---------------------------------------------------------------------------
    program access.

        Answer. Should I be confirmed as HHS Secretary, I will implement
    the laws passed by Congress. I will do so in a way that is as effective
    and as efficient as possible, utilizing the ample and exemplary
    expertise available by the fine men and women currently working at HHS.

        Question. As Budget Chairman, you proposed eliminating funding for
    the Social Services Block Grant (SSBG), a flexible funding stream for
    social services programs such as substance use disorder treatment
    services, child protection, elder protection, services for the elderly
    like Meals on Wheels, and other critical safety net programs. It also
    helps fill in financial gaps for overburdened State foster care systems
    which are facing an increased strain in light of the opioid epidemic.

        In light of increased demands on State human services programs
    brought on by the opioid epidemic, has your position on the SSBG
    changed?

        Answer. During my time in Congress, I have been acutely aware of
    the need to eliminate duplicative programs and strengthen those
    programs that work. However, as SSBG continues to be a program
    authorized by Congress, I will do all I can to effectively administer
    this law should I be so honored as to be confirmed as HHS Secretary.

        Question. If not, where do you suggest States turn to make up for
    the loss of these flexible SSBG dollars if funding is eliminated?
    Please be specific in terms of which programs you believe would fill
    the void left by SSBG.

        Answer. Given the nature of our Federal system, there is not a one-
    size fits all approach to how States might react should there be an
    elimination of any Federal program.

        Question. Can you explain what makes the flexibility in the Social
    Services Block Grant inherently different and worse than either
    existing or proposed block grants (such as TANF as it exists or
    Medicaid as you have proposed)? I'd be especially interested in why you
    consider SSBG to be a failure while you consider TANF to be a success.

        Answer. As a 2011 GAO report pointed out, SSBG is a program of
    fragmentation, overlap, and duplication. SSBG essentially offers a no-
    strings-attached approach whereas TANF, while maintaining a great deal
    of flexibility for the States, has been successful in moving recipients
    off of welfare and on to work. That being said, SSBG continues to be a
    program authorized by Congress, I will do all I can to effectively
    administer this law should I be confirmed as HHS Secretary.

        Question. One of the most significant sources of assistance on the
    human services side of the Department of Health and Human Services is
    Temporary Assistance for Needy Families, or TANF. During the hearing,
    in your response to Senator McCaskill, you touted the success of TANF.
    However, according to HHS data, between 1996--when the welfare reform
    law was enacted--and 2015, the number of poor families in Georgia
    receiving support through TANF dropped from 82 per 100 to just 5
    families per 100 while the population of poor Georgia families
    increased by over 50 percent.\7\ While Georgia is one of the most
    drastic examples, this overall trend is not unique to your home State.
    Nationally, TANF reached 68 percent of poor families when the 1996 law
    passed. It now reaches just 23 percent of such families, despite the
    fact that extreme poverty has more than doubled.\8\ Moreover, TANF has
    faced effective cuts of over 30 percent since its creation in 1996 and
    benefit levels have also declined.\9\
    ---------------------------------------------------------------------------
        \7\ http://www.cbpp.org/sites/default/files/atoms/files/
    tanf_trends_ga.pdf and http://www.
    cbpp.org/research/family-income-support/how-states-use-funds-under-the-
    tanf-block-grant.
        \8\ http://www.cbpp.org/research/family-income-support/tanf-
    continues-to-weaken-as-a-safety-net and http://poverty.ucdavis.edu/faq/
    what-deep-poverty.
        \9\ http://www.cbpp.org/research/family-income-support/tanf-cash-
    benefits-have-fallen-by-more-than-20-percent-in-most-states and https:/
    /fas.org/sgp/crs/misc/RL32760.pdf.

        Do you believe TANF has been a success both across the Nation and
    ---------------------------------------------------------------------------
    in your home State of Georgia?

        Answer. Yes. Since the passage of TANF, we have seen employment
    rates of single mothers increase, lower poverty rates among female-
    headed households with children and African-American households, a
    reduction in child poverty overall, and a sharp decline in the number
    of families receiving cash assistance.

        Question. What metrics do you use in making this determination?
    Please specifically address time periods beyond 2005 in describing your
    views.

        Answer. I think the best way to measure the success of the law is
    to see where the Nation was prior to its passage and where we are now.
    As I've pointed out, since passage of TANF, we have seen employment
    rates of single mothers increase, lower poverty rates among female-
    headed households with children and African-American households, a
    reduction in child poverty overall, and a sharp decline in the number
    of families receiving cash assistance.

        Question. Can you provide a commitment that Medicaid will not see
    cuts like what you've proposed in your budget and what has happened to
    TANF?

        Answer. I will provide a commitment that if I am honored to be
    confirmed as HHS Secretary, I will faithfully implement and administer
    all the laws passed by Congress.

        Question. President George H.W. Bush's welfare advisor and one of
    the conservative architects of the 1996 law, Ron Haskins, has said,
    ``States did not uphold their end of the bargain,'' and argued that
    TANF is not a model for other programs, asking ``So why do something
    like this again?'' \10\ A recent piece published by the conservative
    think-tank, American Enterprise Institute came to a similar conclusion
    noting that unfortunately, ``some States have abandoned their
    responsibility to provide support to poor families and help them get
    jobs,''and that enough States have stopped spending money on core
    services that, ``it tarnishes the entire program.'' \11\
    ---------------------------------------------------------------------------
        \10\ http://www.cbpp.org/blog/tanfs-worsening-track-record-shows-
    why-its-not-a-model.
        \11\ https://www.aei.org/publication/welfare-reform-progress-
    states-step-up/.

        However, you resisted recent Republican-authored legislation that
    aimed to ensure States met even the most basic TANF spending
    obligations.\12\ You insisted on changes that essentially would
    grandfather in practices that let Georgia and other States continue to,
    to use the AEI publication's words, ``abandon their responsibility to
    provide support to poor families and help get them jobs.''
    ---------------------------------------------------------------------------
        \12\ https://waysandmeans.house.gov/event/39841647/ and http://
    mlwiseman.com/wp-content/uploads/2016/05/Profiles-in-
    Courage.052216.pdf.

        If confirmed, will you continue to oppose efforts to ensure States
    hold up their end of the bargain with respect to investing their own
    ---------------------------------------------------------------------------
    dollars into the TANF program?

        Answer. States should contribute their part in State-Federal human
    services programs, even if we don't always agree on the method for
    getting there. I have an open mind and welcome proposals to improve
    State-Federal human services programs to achieve the goal to reduce
    low-income families' dependence on government aid through high levels
    of paid work, especially those that are well supported by evidence. We
    have a duty to the American taxpayers, and the people these programs
    were created to help, to find workable solutions to problems within
    these programs. If I am privileged to serve as the HHS Secretary, I
    will follow the policies adopted by the Congress and signed into law by
    the President that reform State-Federal human services programs.

        Question. Specifically, will you advise the President to oppose
    legislation, like H.R. 2959 as introduced in the 114th Congress, that
    would phase out the practice of States being able to count third party
    spending towards their TANF maintenance of effort requirements? \13\
    ---------------------------------------------------------------------------
        \13\ https://www.gpo.gov/fdsys/pkg/BILLS-114hr2959ih/pdf/BILLS-
    114hr2959ih.pdf.

        Answer. The ultimate objective of human services programs is to
    help people stand on their own again after they have fallen down.
    Certain interpretations cut against this objective by keeping people
    down even when they want to stand up. I have a broad and open mind and
    welcome proposals to improve programs like TANF that would help people
    stand on their own again, especially those that are well-supported by
    evidence. If I am privileged to serve as the HHS Secretary, I will
    follow the policies adopted by the Congress and signed into law by the
    ---------------------------------------------------------------------------
    President.

        Question. In your testimony and meetings with committee staff, you
    stressed the need to establish better measures by which to evaluate the
    effectiveness of Federal human services programs. As you know, timely,
    accurate and relevant evaluations rely on: modern, efficient and
    integrated State and Federal data systems; effective data use
    agreements; and transparent and strong privacy and data security
    measures. Moreover, system modernization cannot only improve client
    services but reduce waste, fraud, and abuse. However, much of the
    funding currently being used to modernize and integrate systems comes
    through ACA and the OMB A-87 waiver.

        Will you commit to working, if confirmed, with Congress and the
    administration to sustain the current efforts to improve State and
    Federal health and human services data systems?

        Answer. Good data is an essential element for ensuring that we have
    accurate information and are able to effectively manage the programs
    under our charge. While funding decisions ultimately rest with
    Congress, if I am privileged to serve as the HHS Secretary, I will
    follow the policies adopted by the Congress and signed into law by the
    President to modernize State and Federal human services data systems.

        Question. The Maternal, Infant, and Early Childhood Visitation
    program (MIECHV) is a program that members on both sides of the aisle
    have championed due to the demonstrated success of its models in
    improving the health and well-being mothers and children. MIECHV's
    innovative model has well-established goals, outcomes and metrics.

        MIECHV is due for reauthorization this year. At current funding
    levels ($400M/year), the Department of Health and Human Services (HHS)
    estimates that only 3% of the eligible population receives MIECHV
    services. To me, reauthorization represents an opportunity to increase
    access to the program and improve the life course of children born into
    low-income households, while also reducing preventable government
    spending in the short and long term.

        In your home State of Georgia, the Great Start Georgia program
    receives MIECHV funds. The program's aim is to provide evidence-based
    home visiting services to those families who are most in need of
    support and has met all 6 program benchmarks, including maternal and
    newborn health, family economic self-sufficiency, improving at-risk
    students' school readiness, and reducing crime and domestic violence.

        If confirmed, how do you plan on continuing the successful MIECHV
    program?

        Answer. I share your goal of increasing access to affordable,
    quality health coverage. While I cannot comment specifically on
    legislation that would reauthorize MIECHV, I look forward to working
    with you on examining this program's funding and working on ways to
    improve rural and child health using evidence-based approaches.

                                     ______

                    Questions Submitted by Hon. Bill Nelson
        Question. Your health proposal would remove protections for
    individuals with pre-existing conditions, allowing insurers to charge
    them higher premiums or denying them coverage altogether, unless an
    individual has maintained coverage for 18 months. Your bill would
    expand high-risk pools as an option to individuals with pre-existing
    conditions. In Florida, more than 7.8 million people have pre-existing
    conditions.

        Please explain how you believe high-risk pools will provide quality
    coverage to the 7.8 million people in my State who have pre-existing
    conditions.

        Answer. Pooling mechanisms that allow individuals to come together
    for the purchase of coverage, like the traditional Blue Cross Blue
    Shield Plan, have been successful in bringing down the cost of
    insurance for Americans. I believe this same concept could be
    successful in pooling the risk among those Americans with pre-
    existing conditions.

        Question. Have high-risk pools been successful in providing
    adequate and affordable coverage in populous, high-costs States like
    New York or Florida?

        Answer. If confirmed, I look forward to working with you to
    implement commonsense solutions that prioritize flexibility for States
    like New York and Florida to design and operate their own high-risk
    pools or other risk-mitigation programs that suit their citizens'
    unique needs.

        Question. You introduced the 2015 reconciliation bill, which would
    have repealed key parts of the Affordable Care Act, had it not been
    vetoed. The nonpartisan Congressional Budget Office released a report
    on the effects of your bill, including increased numbers of uninsured
    Americans and increased premiums.

        Last week, President Trump said the Republican replacement plan is
    ``coming down to the final strokes.'' He said that as soon as the HHS
    Secretary is confirmed, a repeal and replace plan will be submitted,
    ``essentially simultaneously.''

        Is there a nearly fully formed replacement plan?

        If yes, what's in the replacement plan?

        Does it provide insurance coverage for everyone as President Trump
    said?

        Does it protect individuals with pre-existing conditions from
    paying higher premiums or being denied coverage altogether?

        Does it allow children to stay on their parents' insurance until
    age 26?

        Does it ensure that individuals struggling with substance use
    disorders or diagnosed with behavioral health conditions have adequate
    access to quality treatment?

        Answer. Plans for real health-care reform are a work in progress,
    but the President and I share the same goal: to provide relief to all
    Americans from Obamacare. Obamacare has raised premiums and
    deductibles, narrowed doctor networks, reduced choices of plans,
    limited Americans' liberty, and undermined the doctor patient
    relationship. The goal is to make certain that every single American
    has access to the coverage they want for themselves.

        Question. What will you do to provide coverage to the more than
    800,000 Floridians that could have been covered by Medicaid expansion?

        Answer. I look forward to faithfully executing whatever law that
    Congress passes and the President signs, if I am confirmed. I will
    promise you this: Regardless of the final legislative outcome, I would
    work as HHS Secretary to ensure that the Medicaid program is well
    administered, effective, and available for eligible beneficiaries and
    that the States/Governors are given the flexibility to pursue
    innovative approaches that fit the needs of their States.

        Question. Can you explain how, under a Medicaid block grant
    program, States like Florida would cover the unforeseen costs
    associated with public health crises, like Zika virus, or high cost
    prescription drugs, or unexpected sudden changes in demographics
    without harming another population?

        Answer. My work in the Congress has been focused on how to improve
    Medicaid and provide additional flexibility. If I have the privilege of
    being confirmed as Secretary, I would look forward to the opportunity
    to work with States and Congress using the tools and authorities given
    by Congress in legislation. The mechanics of any new Medicaid program
    along the lines described would be a legislative decision that would
    need to account for how to encourage States to save for such
    eventualities or how the Federal and State governments do so together.

        Question. Florida is currently in the process of renegotiating its
    section 1115 Medicaid managed care waiver.

        What safeguards and beneficiary protections do you believe HHS
    should keep in place when reviewing Medicaid waivers?

        Answer. The 1115 waivers are an important tool for States to
    innovate within the Medicaid program, as they have for many years prior
    to the ACA becoming law. The statute itself has requirements for
    certain procedures. Furthermore, the democratic process in each State,
    where government is even closer to the people, provides substantial
    protection with regards to any 1115 waiver application and its
    implementation.

        Question. You introduced a bill to allow practitioners to enter
    into private contracts with their Medicare patients and charge higher
    fees than what is currently allowed under the Medicare program.
    Currently, when seniors in Medicare see their doctors, they are
    responsible for a set amount of costs and don't encounter any surprise
    bills. Under current law, physicians who choose to participate in
    Medicare are not allowed to bill their patients for any costs that
    remain once Medicare pays their share of the bill, a practice that is
    commonly known as balance billing.

        Did you know that half of all Medicare beneficiaries had incomes of
    less than about $24,000 and savings below $63,350 in 2014? Is this the
    population that your bill targets?

        Answer. The Medicare Patient Empowerment Act is one approach to
    giving our seniors more flexibility within the Medicare Program and
    providing the opportunity to make decisions with their physicians
    without interference from Washington. The measure would help ensure
    that Medicare beneficiaries maintain adequate access to health-care
    professionals by increasing the number of physicians who will accept
    Medicare patients and addressing physician shortages by attracting new
    professionals to the field of medicine. In addition, the bill provides
    safeguards to Medicare beneficiaries. More importantly, my legislation
    would allow a provider to see a Medicare patient pro-bono or charge
    minimal cost (below the standard fee schedule) without prosecution.
    Without this legislation, a physician can be charged with fraud for
    failure to attempt to collect the full coinsurance amount under
    Medicare.

        Question. The Medicare Advantage program provides quality care to
    over 1.6 million Floridians and over 18 million seniors across the
    United States.

        Do you have any ideas about how to strengthen and build upon this
    vital and proven part of the Medicare program? In your role as
    Secretary of HHS, will you commit to supporting Medicare Advantage and
    protecting the Nation's seniors as they age?

        Answer. Medicare Advantage provides an important option for
    Medicare beneficiaries to access coordinated care and greater benefits.
    If confirmed as Secretary, I would seek to ensure Medicare Advantage
    remains a stable option for beneficiaries and that Medicare Advantage
    plans are afforded the flexibility to design plans that beneficiaries
    want and give them the coverage they want.

        Question. Today, I joined a bipartisan group of Senators in
    reintroducing the Public Health Emergency Response and Accountability
    Act, which would fund the nearly empty Public Health Emergency Fund
    through mandatory appropriations designated as emergency spending, a
    proposal modeled after FEMA's disaster relief fund.

        As HHS Secretary, would you work with me to protect my constituents
    from the Zika virus and other public health emergencies? Do you support
    the creation of an emergency health fund to provide mandatory
    appropriations to fight Zika and other infectious diseases?

        Answer. If confirmed as HHS Secretary, I give you my word I will do
    all within my power to protect your constituents, and the constituents
    of every Senator, from the Zika virus and other public health
    emergencies. Should Congress create a new program or alter an existing
    program, I will work to ensure the program is as effective as it can be
    in fighting Zika and other infectious diseases.

        Question. The increased use of generic drugs results in real
    savings due to their lower costs as compared to brand name drugs.
    Senator Collins and I asked GAO to examine the factors behind recent
    spikes in some generic drugs. GAO found that Part D generic drug prices
    declined overall since 2010--they fell about 59 percent. Additionally,
    GAO found that 300 of the more than 1,400 established generic drugs
    analyzed had at least one price increase of 100 percent or more between
    2010 and 2015.

        What do you believe should be done to keep generic drugs
    affordable?

        Answer. I appreciate that generic drugs play an important role in
    meeting many American's health-care needs. If confirmed, I look forward
    to focusing on how we can make health care more affordable, including
    prescription drugs, and build on policies that have helped to empower
    patients in meeting their health-care needs.

        Question. Amyotrophic lateral sclerosis (ALS) usually strikes
    people between the ages of 40 and 70, and for unknown reasons, military
    veterans are approximately twice as likely to be diagnosed with ALS.
    There is currently one FDA approved drug that modestly slows the
    progression of ALS in some people. While there is no cure or treatment
    that that halts or reverses ALS, scientists have made significant
    progress in learning more about this disease.

        The Centers for Disease Control and Prevention operate a National
    ALS Registry, which is a critical resource for (1) providing data to
    researchers focused on developing treatments and prevention strategies;
    and (2) matching patients to potential clinical trials.

        Please advise how the administration will support this work in
    fiscal year 2018 and work with Congress to make the registry even more
    effective at confronting ALS.

        Answer. ALS is a devastating disease with far-reaching consequences
    for both those afflicted and their families, and as a physician I
    understand the hardships these individuals must endure. If confirmed, I
    plan to work to advance patient-
    focused health care, which will support efforts to better serve those
    suffering from ALS.

        Question. The ACA reauthorized the Minority Centers of Excellence
    (COE) program, housed within the Department of Health and Human
    Services. The Florida Agricultural and Mechanical University (FAMU)
    Pharmacy, located in Florida, is a grantee. COE supports curriculum-
    based initiatives for increasing minority and underrepresented
    individuals to become health professionals.

        Do you support preserving important programs like COE, Health
    Careers Opportunities Program, and Area Health Education Centers?

        Answer. As a physician, I understand the critical importance of
    diversity among health-care practitioners in order to meet the varied
    health-care needs of the American people. If confirmed, I look forward
    to working with you and others to ensure that we are supporting efforts
    to increase diversity within our Nation's health-care workforce as part
    of advancing patient-focused health care.

        Question. CT colonography (CTC), also known as virtual colonoscopy,
    are diagnostic medical tests, which produce detailed images of the
    colon by using a combination of 2-dimensional x-rays and a 3-
    dimensional computer views. They have the ability to identify lesions
    and tumors on the kidneys and other organs and blockages in the
    coronary arteries.

        Currently, Tricare and private payers in 21 States and the District
    of Columbia cover virtual colonoscopies for colorectal cancer
    screening, but Medicare does not.

        Will you use your authority as Secretary to consider the addition
    of virtual colonoscopies as a colon cancer screening option for
    Medicare beneficiaries?

        Answer. As you know, CMS has a detailed process for making
    determinations regarding whether items and services are reasonable and
    necessary, if they can be considered eligible for Medicare coverage
    given other restrictions and prohibitions. I understand CMS's decision
    to cover CT colonography only for diagnostic testing but not screening
    was based on the state of the technology at the time and the possible
    need for a confirmation colonoscopy in so many cases. If confirmed as
    Secretary, I would look forward to working with you to understand if
    revisiting this issue is appropriate and warranted.

        Question. On July 16, 2015, Proposed/Draft Local Coverage
    Determination for Lower Limb Prostheses (DL33787) (Draft LCD) was
    published by the four Durable Medical Equipment Medicare Administrators
    (``DME MACS''). Last year, the Coverage and Analysis Group, headed by
    CMS, was created to review the DME MAC recommendations. That Group
    continues to deliberate.

        Can you speak to what actions as an administrator you would take on
    finalizing this Draft LCD?

        Answer. Medicare coverage for prostheses can be a particularly
    challenging topic given the role this durable medical equipment plays
    in the lives of many Medicare beneficiaries. I understand CMS has
    stated it is committed to providing high quality care to Medicare
    beneficiaries in need of a prosthesis, that it has committed to a
    Workgroup the task of making recommendations concerning the best and
    most relevant measures in this realm, and that CMS will ensure there is
    opportunity for public comment and engagement. If confirmed as
    Secretary, I would be pleased to work with you to look into the timing
    of this matter and see what can be done to either expedite it or
    further support the work so there is assurance of its comprehensiveness
    and objectivity.

        Question. Representative Price, I know you are very familiar with
    the Centers for Medicare and Medicaid Service's (CMS) Home Health pilot
    program known as the ``Pre-Claim Review Demonstration (PCRD)'' which
    affects five States, including Florida. I am concerned that the PCRD
    may restrict beneficiary access to timely services, divert clinical
    resources to paperwork management, and incur high administrative costs.
    These concerns were amplified after hearing what the State of Illinois
    had been dealing with when PCRD began there in August 2016.

        In response to my concerns, CMS delayed PCRD in Florida until April
    2017. While I understand the concern, CMS has with needing to tackle
    the improper payment rates, PCRD may not get to the root of the
    problem.

        As Secretary, how do you plan to tackle the problem of improper
    payments? Do I have your commitment that you will work with me to
    alleviate the concerns raised by the PCRD?

        Answer. The topic of improper payments is one of concern in the
    Medicare program--both overpayments and in some cases underpayments.
    Tackling them requires close support for the payment integrity team
    within CMS and close cooperation with the Office of the Inspector
    General and the Department of Justice. But it also involves a
    definition of scope and a prioritization--which improper payments are
    ones that reflect services not rendered and which involve a missing
    signature on a form. With that prioritization in mind, I am hopeful we
    can align resources to those areas of highest risk.

        As to the Pre-Claim Review Demonstration (PCRD), if confirmed, I
    would be pleased to work with you to address your concerns. For
    example, we may want to explore the experience of the Prior
    Authorization of Repetitive Scheduled Non-
    Emergent Ambulance Transport demonstration to understand if there are
    applicable lessons for PCRD or vice-verse.

        Question. During the public comment period for the FDA's tobacco
    deeming rule, the Small Business Administration's Office of Advocacy
    filed concerns that the economic impact analysis conducted by FDA was
    ``deficient'' and should be recalculated. Small business premium cigar
    retailers and manufacturers in my State have expressed the same concern
    to me. Unfortunately, FDA took no action to address these concerns.

        Do you believe additional review of the costs of this regulation
    should be conducted before any additional implementation?

        Answer. Whenever the Federal Government implements its regulatory
    responsibilities, it is important to consider the costs, especially
    those imposed on small businesses. Any time economic impact analyses
    are conducted, I believe they must be fact-based. If I am confirmed, I
    would seek to better understand the SBA's views of the regulation in
    question, which is consistent with the President's commitment to reduce
    the overall regulatory burden on American businesses.

                                     ______

                  Questions Submitted by Hon. Thomas R. Carper
        Question. The number one concern I hear from my constituents about
    health care is affordability. I was pleased to hear the President say
    that under his plan, health insurance will be better and less expensive
    for all Americans. Americans cannot afford to pay more for their health
    care. Even supporters of the President value the health benefits they
    have gained through the Affordable Care Act and could not bear the
    higher deductibles and decreased benefits that your earlier plans have
    called for.

        Can you ensure that under the President's health-care plans, health
    insurance premiums, deductibles, and co-pays will decrease for all
    Americans? How exactly will you do this?

        Answer. President Trump and I have the same goals for health-care
    reform and the same general approach to meeting those goals. Neither
    one of us is wedded to a particular plan to the exclusion of all
    others. We see eye-to-eye on this, and are looking forward to giving
    the American people what they've been longing for, for 7 long years:
    real health-care reform. But they have never wanted Obamacare: It has
    raised premiums and deductibles, narrowed doctor networks, reduced
    choices of plans, limited Americans' liberty, and undermined the doctor
    patient relationship.

        Question. The Congressional Budget Office (CBO) has found that
    repealing the ACA will cause more than 30 million Americans to lose
    their insurance and increase premiums by more than 20 percent.

        Do you agree that the President's executive order to begin
    repealing the Affordable Care Act while there is no alternative plan
    creates instability and uncertainty that will only drive up costs in
    our health-care system?

        Answer. The insurers are deciding right now as they come forward in
    March and April what the premium levels will be for 2018. What they
    need to hear from us is a level of support and stability in the market,
    the kinds of things that are able to provide stability. There are
    counties in the State where there is only on provider. We must, as
    policymakers, ask what is going on. Where are the problems out there?
    The President's Executive order is directed towards exactly that--
    reducing costs and the other burdens on the American people imposed by
    Obamacare. The initial reactions to the order from plans and others
    indicate this is something they anticipated based on the President's
    promises and that the recent and current discussions regarding how to
    address the issue of costs have been productive. In fact, it is the
    costs of inaction which are not acceptable.

        Question. Do you believe that all Americans, regardless of income,
    should have health insurance and does the President share your views on
    this? Have you told the President that repealing the ACA without a
    replacement means 32 million Americans will lose their health insurance
    and add $9 trillion to our national debt? Have you had direct
    discussions with members of the Transition Team or the President's
    current health-care advisers since your nomination? Would you insist
    that Congress hold multiple bipartisan hearings on the President's
    health care proposal? Will you commit to, should you be confirmed, to
    answer our questions when such a proposal is sent to Congress and
    evaluated by the non-partisan, independent Congressional Budget Office?

        Answer. I think the conversation and focus in these topics has been
    the question of coverage rather than true access for too long. By that
    I mean that Americans might have an insurance card and yet not be able
    to afford care or it might not be available to them for other reasons.
    And so when we talk about coverage we ought to make clear what we
    really mean and want to have happen. In any case, the President has
    made clear his hope and plan for a replacement to Obamacare. The goal
    is to make certain that every single American has access to the
    coverage they want for themselves.

        Question. Sixty percent of the children born outside of marriage
    are from unplanned pregnancies. This is a major public health
    challenge, as children born from unintended pregnancies and raised in
    single parent households have a higher rate of mental health problems,
    a lower rate of high school graduation, earn less income than their
    peers, and cost more to taxpayers. Because of the Affordable Care Act,
    millions of American women can now afford contraception, without co-pay
    or cost-sharing, and the rate of unplanned pregnancies has dropped.

        Will the President's plan to replace the ACA ensure these women
    will not have to pay more for contraception and put birth control out
    of reach for millions of young women and families?

        Answer. Women should have the health care that they need and want.
    The system we ought to have in place is one that equips women and men
    to obtain the health care that they need at an affordable price.

        Question. Health-care experts have found that obesity, smoking, and
    mental health challenges are the ``root causes'' of our country's most
    persistent public health challenges. Together, tobacco, obesity, and
    mental health lead to more than a million deaths and cost us more than
    half a trillion dollars each year. It's critical that all health
    insurance plans fully cover the treatment for these conditions. If the
    ACA is repealed, Americans would lose access to treatment for mental
    health care, smoking cessation, and obesity treatment.

        Under the bills and proposals you have championed, would the
    treatment and cost of insurance coverage for obesity, smoking
    cessation, and mental health care remain the same or decrease?

        Answer. It has been the goal, for any legislation I have
    championed, for the treatment and cost of insurance coverage for all
    Americans to decrease.

        Question. The obesity epidemic has had a devastating impact on our
    health-care system, increasing the prevalence of nearly every major
    chronic condition, including heart disease, hypertension, diabetes, and
    cancer, and costing our country hundreds of billions of dollars every
    year to treat the variety of conditions attributable to this
    increasingly prevalent disease. A critical step in combating obesity
    was the decision by the AMA in 2013 to designate obesity as a disease.
    This designation is an important step towards ensuring the best medical
    care is provided to those suffering from this disease.

        Will you, as Secretary of Health and Human Services, follow the
    leading medical association and declare obesity as a disease and will
    you assist us in maximizing the use of all the medical interventions
    currently available to combat this crisis?

        Answer. Obesity is a chronic condition that takes its toll over
    many years and in many quiet ways. I agree it is an important priority
    for all involved in the health-care system to address this toll. This
    is particularly the case because obesity is generally a preventable
    condition and can be controlled through changes in behavior.
    Fundamental to that is the relationship between patient and doctor
    which our current system has undermined in many ways. I can tell you
    that I will consider the legal framework within which any decision
    regarding the formal designation of any disease ought to take place and
    come to any decision with these considerations in mind.

        Question. Have you ever been a member of the Association of
    American Physicians and Surgeons? This group has said that the
    government poses a greater threat to patients than tobacco use, drug
    addiction, and excessive alcohol intake, and that patients should seek
    doctors who do not participate with Medicare, Medicaid, and private
    health insurers. When you were a member of this group, did you agree
    with this position? Do you agree with this position now? This group has
    also compared the use of advance directives--the process by which
    patients and their health-care providers plan for end of life care
    decisions in advance and when they are of sound mind and body--as
    ``population control.'' Do you agree with this comparison?

        Answer. My work has been focused on making sure that physicians and
    patients are ones making medical decisions, rather than the government.
    Once that relationship is undermined and patients do not trust their
    doctors or doctors do not think first about their patients then no
    other medical or public health goal can be achieved. This is important
    when it comes to chronic disease, preventive care and healthy choices,
    and life and death decision-making. For all these reasons, I have
    fought alongside many to ensure patients have these choices to make for
    themselves and with their doctors.

        Question. As you know, the Affordable Care Act prohibits health
    insurance companies from limiting coverage to individuals on the basis
    of sexual orientation and gender identity. But a number of your
    previous statements regarding lesbian, gay, bisexual, and transgender
    people indicate that you don't support these consumer protections.

        As HHS Secretary would you support reversing these protections and
    jeopardizing the LGBT population's access to health care? As Secretary
    of Health and Human Services, would you uphold the department's efforts
    to ensure that health insurance companies do not deny or limit health-
    care coverage to LGBT people?

        Answer. If confirmed, my efforts and work as Secretary will be to
    seek the availability of the highest quality care for all Americans.
    The goal is to make certain that every single American has access to
    the coverage they want for themselves. Of course, consumer protections
    at Federal and State levels ought to be available to all consumers, not
    just certain ones who meet certain criteria.

        Question. Data has shown repeatedly that Federal resources devoted
    to fighting health-care fraud is well worth the investment. The Health
    and Human Services Department has found that for every dollar that is
    invested to fight fraud, the government recovers $5. On January 23,
    2017, the President announced a hiring freeze on government workers,
    which would include a freeze on hiring investigators and attorneys
    devoted to protecting Medicare and Medicaid from criminals. The GAO has
    repeatedly listed Medicare and Medicaid as two of the Federal
    Government programs most vulnerable to fraud, waste, and improper
    payments. Unfortunately, this freeze only leaves Medicare and Medicaid
    more vulnerable to fraud.

        Do you agree with these concerns and if confirmed, will you
    recommend to the President that the hiring freeze should be lifted for
    Federal workers fighting criminal activity, waste, and fraud in
    Medicare and Medicaid?

        Answer. The President's memorandum is not for time immemorial. It
    provides that within 90 days of its issuance, the Director of OMB, in
    consultation with the Director of OPM, shall recommend a long-term plan
    to reduce the size of the Federal Government's workforce through
    attrition and that the ``freeze'' will expire upon implementation of
    the OMB plan. If confirmed as Secretary, I will take into account in
    weighing in with OMB and OPM the clearly important role our fraud
    fighters play which you outline.

        Question. During your time in Congress, you have supported
    proposals that would block grant Medicaid or put a per capita cap on
    Medicaid spending. The Congressional Budget Office has found that
    reversing the Medicaid expansion under the Affordable Care Act would
    lead to the loss of health care for millions of Americans and would
    lead to State funding shortfalls of $1 to $2 trillion.

        Do you support proposals to block grant or cap Medicaid? Do you
    agree that block granting or capping Medicaid would save the Federal
    Government as much as $1 to $2 trillion?

        Answer. Every State has different demographic, budgetary, and
    policy concerns that shape their approach to Medicaid. That is one of
    the reasons I devoted so much time to working with States to help them
    to identify creative solutions, and why I believe a one-size-fits-all
    approach is not workable for a country as diverse as the United States.
    Of course, the specifics of any particular proposal to provide more
    flexibility to States will determine its budgetary consequence.

        Question. The American Association of Actuaries has pointed to risk
    corridors and other risk mitigation programs as important mechanisms
    for stabilizing our insurance markets. These programs were also
    included in the Medicare Part D program and remain in place today.
    Please just give us a yes or no answer to the following questions.

        Do you support the use of these programs in Medicare Part D? Did
    you support these programs as a part of the State insurance
    marketplaces created by the Affordable Care Act? Do you think these
    types of programs should be included in any plan to improve on the ACA
    or to replace the ACA?

        Answer. Risk adjustment is used to adjust payments to health plans
    based on the relative risk of plan participants. Reinsurance has been
    used to reimburse insurers for the cost of individuals who have
    unusually high claims. And risk corridors are used to mitigate the
    pricing risk that insurers face when they lack data on health spending
    for potential enrollees. Part D has successfully deployed these
    mechanisms consistent with the underlying direction of Congress. The
    issue with any of these programs is often in the way they are
    implemented and the direction Congress gives with respect to them. In
    any current or future legislation, it would be important to consider
    these issues closely.

        Question. You have expressed concerns with delivery system reforms
    and in particular, bundled payments.

        Please talk about your recommendations for how we can move away
    from fee for service reimbursement to a health care payment system that
    rewards better health outcomes and reduced costs.

        Answer. For certain populations, bundled payments make a lot of
    sense. And they can often lead to both better health outcomes and
    reduced costs. But it is important we not get fixated on one of those
    two outcomes. That is, I support making certain that we deliver care in
    a cost-effective manner but we absolutely must not do things that harm
    the quality of care being provided to patients. What we ought to do is
    allow for all sorts of innovation. Not just in this area. There are
    things that haven't been thought up yet that would actually improve
    health-care delivery in our country and we ought to be incentivizing
    that kind of innovation. And in finding our way to those innovations,
    we ought to remember we are not talking about science experiments in a
    lab or a computer simulation, but about experiments involving real
    patients' lives.

        Question. During your time in Congress, how have you worked to
    strengthen and improve community health centers in your district and in
    the country? Do you think we should increase the presence of community
    health centers to increase Americans' access to health care?

        Answer. Community health centers are a vital part of our medical
    infrastructure. They fill a void in so many States and are often times
    the entry point if not the main source of health care. I have sought to
    support them to make sure they can provide the highest quality care and
    will continue to do so if confirmed.

        Question. I have always felt that we can't manage what we can't
    measure. You point to having good metrics as an important tool for
    ensuring we've made good progress. I agree with you wholeheartedly.

        With your wealth of experience as a physician, a State legislator,
    a Congressman, and the chairman of a major House committee writing
    major legislation, please share with me the metrics we should use to
    measure our progress towards a more just and equal health-care system
    that ensures affordable and high quality health care for all Americans.
    If you cannot name any specific metrics, can you outline the process by
    which we should determine what metrics we should use to measure
    progress towards increasing access to health care?

        Answer. The fundamental metric for knowing that our system is on
    the right track is the centrality of the patient in the system and
    their ability to make choices about their care in consultation with
    their doctor. Without that, the most impressive facilities and
    technology are not serving our people's needs, nor is the most
    efficient system doing what is most important. With the patient at the
    center of the system as a foundation, all else is possible and
    achievable.

        Question. During the debate over the Affordable Care Act, Congress
    held more than 100 bipartisan hearings, roundtable discussions, and
    negotiations, which were predominantly open and transparent to the
    public. The legislation was open to amendment by both parties in
    lengthy committee markups and by the full Senate, completely evaluated
    by the Congressional Budget Office, and reported on extensively by the
    news media before Congress voted on final passage. I understand that
    you place a high premium on transparency and honesty.

        Will you commit to having the same level of bipartisan discussion,
    transparency, and honesty in putting together the President's proposal
    for reforming our country's health-care system and ensuring that all
    Americans will have affordable and high quality health care?

        Answer. The President has made clear his hope and plan for a
    replacement to Obamacare. At the same time, many in Congress have their
    own ideas. And the conversation about how those will play out is
    ongoing. That is the nature of our democracy. I certainly hope we will
    have bipartisan support for any approach to fixing the current system,
    which we must all agree is broken. If confirmed, I look forward to
    working with anyone in Congress willing to work with me and the
    administration generally to come up with the best replacement plan
    under the procedures and involving the processes the Congress considers
    appropriate so as to make available the highest quality care to all
    Americans.

        Question. Do you agree with the President that the sale of health
    insurance over State lines will increase competition and lower the cost
    of health insurance? Section 1333 of the Affordable Care Act already
    allows States to form interstate compacts to allow for the sale of
    health insurance over States lines? The States of Georgia, Maine,
    Kentucky, and Wyoming allow for out-of-state insurance sales, but
    virtually no out-of-state insurers have tried to sell insurance in
    these States. How would you increase the sale of insurance over State
    lines while maintaining consumer protections such as insurance coverage
    for contraception, preventive screenings, maternity care, and mental
    health treatment?

        Answer. The idea of allowing interstate sale of insurance may take
    many different forms. I agree with the President that it is an
    important option to increase competition and lower the cost of
    insurance. While the details of any such proposal would have to
    consider the extent to which benefit design varies among States, it is
    important that individuals be able to purchase the coverage that they
    want and there has to be a floor of creditable coverage.

                                     ______

                   Questions Submitted by Hon. Chuck Grassley
        Question. As someone who is being considered to lead the Department
    of Health and Human Services, and as a physician, do you have any
    doubts about safety and effectiveness of vaccines?

        Answer. I understand the significant impact vaccines have had on
    our Nation's public health, as well as the importance of patients
    having confidence in the therapies they receive as part of their care.

        Question. As a physician would you recommend that families follow
    the recommended vaccine schedule that has been established by experts
    and is constantly reviewed?

        Answer. As a physician, I encourage individuals and families to
    consult with their physician on the most appropriate care for them and
    their loved ones.

                                     ______

                  Questions Submitted by Hon. Robert Menendez
            clampdown on communications with the public and congress
        Question. Shortly after your hearing concluded, press reports came
    out that a memo was issued to employees of the Department of Health and
    Human Services and the National Institutes of Health prohibiting any
    external communication throughout the entire Department. Specifically,
    the press accounts quote the memo as stating ``[f]or your additional
    awareness, please note that (HHS employees) have been directed not to
    send any correspondence to public officials (to include Members of
    Congress and State and local officials) between now and February 3,
    unless specifically authorized by the Department[.]''

        I find this to be an unconscionable clampdown of information and a
    rejection of basic transparency and accountability standards that
    should seriously concern all Americans. This is made all the more
    concerning given the health-care, public safety, research, and
    biodefense programs that operate within HHS.

        Do you support this directive or any other department-wide order to
    suppress the flow of information between the Department of Health and
    Human Services, the public and Congress?

        If confirmed, do you commit to never imposing such restrictions on
    any agency, office, or employee at HHS that limits their ability to
    communicate with the public and Congress?

        During your hearing today you agreed ``to provide a prompt response
    in writing to any questions that may be submitted to you or addressed
    to you by any Senator of this committee[.]'' Do you believe this
    directive prohibits you from fulfilling that commitment to the
    committee?

        Were you aware this directive was going to be issued prior to the
    time of your hearing on January 24, 2017?

        Answer. The Acting Secretary Memo to Department of Health and Human
    Services operating and staff division heads is straightforward and
    consistent with the Chief of Staff Memo issued on behalf of President
    Trump with regard to regulatory review of new or pending regulations
    and guidance. As noted in the HHS memo, the purpose of the directive is
    to ensure ``President Trump's appointees and designees have the
    opportunity to review and approve any new or pending regulations or
    guidance documents.'' Furthermore, the Chief of Staff memo provides
    explicit exceptions for ``emergency situations or other urgent
    circumstances relating to health, safety, financial, or national
    security matters. . . .'' This request is standard for a new
    administration. With regard to correspondence to public officials, such
    as members of Congress, the memo outlines a clear and expedited process
    for adequate review and is by no means intended to impede the agencies
    or staff divisions from continuing their important work on behalf of
    the American people, including routine constituent service
    communications.
           fidelity to science and to debunking dangerous falsehoods
        Question. During the hearing I raised a series of debunked and fake
    health and science claims, all of which have been perpetrated and
    advanced by the Association of American Physicians and Surgeons, a
    group to which you currently, or previously, have been a member. These
    debunked and factually inaccurate claims include linking undocumented
    immigrants to a spike in leprosy, connecting abortions to breast
    cancer, and claiming that the HIV virus doesn't lead to AIDS. This
    group has also promoted widely debunked and untrue claims that
    vaccinations lead to the development of autism spectrum disorder. These
    are dangerous claims made all the more toxic for being promoted by a
    group comprised of medical professionals. What's even more dangerous is
    that the President himself has a long history of promoting falsehoods
    linking vaccinations to autism.

        Will you state unequivocally that vaccines do not have any link to
    the development of an autism spectrum disorder and confirm that such
    all claims are fraudulent and have been widely debunked?

        Answer. General scientific consensus at this time is that vaccines
    do not lead to autism spectrum disorder. As always, this is an area
    where patients and the parents of patients should consult with their
    doctor.

        Question. Will you, if confirmed to be the Nation's highest ranking
    health care official, actively work to debunk these types of false
    health-care and scientific claims?

        Answer. If confirmed, I will work to hold HHS to the highest
    scientific standards.

        Question. Do you ensure that no political appointee within any
    agency, department or office in the Department of Health and Human
    Services believes in, or has promoted, demonstrably false statements
    about health-care practices or debunked scientific claims?

        Answer. As a physician, I understand the importance of patients
    having confidence in the therapies they receive as part of their care.
    When confirmed, I commit to conducting the due diligence HHS must to
    ensure that factual, science-based information is clearly communicated
    to the American people.

        Question. Will you advise that the President not appoint anyone to
    the staff of the Executive Office of the President who believes in, or
    has promoted, demonstrably false statements about health-care practices
    or debunked scientific claims?

        Answer. As a physician, I understand the importance of patients
    having confidence in the therapies they receive as part of their care.
    When confirmed, I commit to conducting the due diligence HHS must to
    ensure that factual, science-based information is clearly communicated
    to the American people.
                                 autism policy
        Question. Since I first learned that New Jersey has the highest
    incidence of autism in the country, I have been Congress's leading
    advocate for advancing Federal policy to help individuals and families
    with autism and other developmental disabilities. Recently, the CDC
    released updated numbers showing that 1 in just 41 children in New
    Jersey are diagnosed with an autism spectrum disorder by the age of 8.
    This is the highest rate in the Nation.

        In 2014, I authored the Autism Collaboration, Accountability,
    Research, Education, and Support Act of 2014, known as Autism CARES.
    Among the several key policies included in this law was the
    continuation of the Interagency Autism Coordinating Committee and the
    elevation of a senior Health and Human Service official to serve as the
    HHS Autism Coordinator.

        Do you commit to ensuring individuals appointed to these key
    positions maintain a fidelity to science, and will you ensure that they
    will have the ability and freedom to debunk false claims linking autism
    to vaccines (or any other similar demonstrable falsehoods) without fear
    of retribution from you or the White House?

        Do you commit to promoting, through your capacity as Secretary and
    through the President's annual budget, increased funding for autism
    research and supports and services programs?

        What specific steps will you take as Secretary to promote and
    support a robust environment throughout the Department that focuses on
    research into diagnosis, treatments, supports and services,
    specifically those targeting adolescents and adults with autism and
    other developmental disabilities?

        The Centers for Disease Control and Prevention report that a child
    with an autism spectrum disorder can be diagnosed as early as age 2,
    yet children are frequently much older at the time of diagnosis. List
    the specific steps will you take to promote early diagnosis and early
    intervention?

        Answer. As a physician, I understand the importance of patients
    having confidence in the therapies they receive as part of their care.
    If confirmed, I commit to conducting the due diligence HHS must to
    ensure that factual, science-based information is clearly communicated
    to the American people. HHS is involved in a number of autism-related
    initiatives with the important goal of helping the individuals and
    families living with autism. When confirmed, I look forward to
    continuing this important work on behalf of these individuals and
    families.

        Question. The Affordable Care Act, as part of the Essential Health
    Benefit Package for plans sold on the Marketplace, requires that all
    carriers provide coverage for behavioral health-care services,
    including those for autism. This was an amendment that I had included
    into the ACA, and it has provided families across the Nation with
    assurances that their children's coverage will provide them with the
    care they need.

        Do you commit to maintaining nationwide access to behavioral health
    care by preserving the Essential Health Benefits package?

        Answer. My hope is to move in a direction where insurers offer
    products people want and give them the coverage they want. And in so
    doing, we want to not lose sight of our shared objective of the best
    and highest quality care being available to every American. I refer to
    care because ultimately, having maternity or other coverage is not
    meaningful if one cannot access the care they need or the quality of
    care leaves them worse off. So we must work towards both coverage and
    care.

        Question. Do you strongly disavow any attempt to weaken this
    coverage standard or any attempt at the Federal level to preempt
    States, like New Jersey, that have a long-standing State requirement
    that insurance provides benefits that cover services for autism?

        Answer. I am respectful of the role of States and, if confirmed as
    Secretary, will work to provide States with flexibility along the lines
    described and consistent with President Trump's Executive order
    Minimizing the Economic Burden of the Patient Protection and Affordable
    Care Act Pending Repeal.

        Question. Medicaid is a literal lifeline to those with autism and
    other developmental disabilities. Every year, 50,000 of these
    individuals age out of school-based services and need access to home
    and community-based care to ensure they live as active and integrated a
    life as possible. This is largely accomplished through Medicaid.

        List the specific policies will you promote as Secretary to expand
    access to home and community-based services for individuals with autism
    and other developmental disabilities?

        Answer. Every State is unique in their specific approach to the
    provision of services for the population eligible to receive HCBS, and
    we stand ready to assist States as they develop strategies to meet
    their particular goals.

        Question. List the specific steps will you take to improve outcomes
    for transition-aged youth and ensure that they maintain access to
    services and supports?

        Answer. If confirmed, I would work as HHS Secretary to ensure that
    the Medicaid program is well administered, effective, and available for
    eligible beneficiaries and that the States/Governors are given the
    flexibility to pursue approaches that fit the needs of their States.

        Question. The Autism CARES Act of 2014 requires the Secretary of
    Health and Human Services to submit to this committee a report
    concerning young adults with autism and the challenges related to the
    transition from existing school-based services to those services
    available during adulthood. This report is long overdue.

        When will this report be finalized? Will you prioritize the
    finalization and submission of this report to Congress before March 31,
    2017?

        Answer. If confirmed, I would be pleased to work with you on the
    status and finalization of this report.
                            community health centers
        Question. Federally Qualified Health Centers (FQHCs) are the
    health-care home for more than 25 million patients nationwide with
    494,912 Community Health Center patients in New Jersey. In New Jersey,
    FQHCs save the State and hospitals millions of dollars when patients
    are seen at health centers rather than in emergency rooms. FQHCs cost
    of care is substantially lower than other types of providers, even
    though they provide a wide range of ancillary services not offered in
    other health-care settings. As an example, FQHCs in New Jersey have a
    lower average per-
    episode cost than health centers nationally, and almost half that of
    hospitals.

        Further, community health centers are essentially one-stop shops
    for health care, providing medical, oral health, mental health,
    substance abuse, and other critical services at the same location. The
    23 New Jersey Community Health Centers make up the largest primary care
    network in the State, providing care to almost half a million patients
    in over 131 sites of care including in schools, homeless centers, and
    public housing. Beyond just providing health care, our State's FQHCs
    employ more than 180,000 individuals, and generate over $26 billion
    annually in economic impact to some of the Nation's most distressed
    communities.

        What is the specific dollar amount that Community Health Centers
    stand to lose as a result of ACA repeal and the repeal of Medicaid
    expansion funding?

        Answer. I am not aware of the specific dollar amount.

        Question. How many fewer patients will not get health-care services
    at Community Health Centers as a result of ACA repeal and the repeal of
    Medicaid expansion funding?

        Answer. I do not have this figure.

        Question. What will be the impact on any ongoing Community Health
    Center expansion project that will be halted as a result of ACA repeal
    and the repeal of Medicaid expansion funding?

        Answer. We are committed to supporting Community Health Centers,
    providing increased access to care for patients across the Nation.

        Question. Please provide an economic impact, including lost jobs
    and diminished economic impact, that will occur as a result of ACA
    repeal and the repeal of Medicaid expansion funding?

        Answer. To my knowledge, repeal of the ACA is projected to have a
    positive impact on the labor market and the economy.

        Question. If the ACA is repealed, list the specific steps you will
    take to further promote the importance of seeking preventative care
    rather policies which encourage patients to wait until they have to go
    to the emergency room?

        Answer. Our goal is to ensure that all Americans have access to
    affordable coverage that best meets the needs of them and their
    families so that they can receive preventative care from the doctor of
    their choice in a primary care setting.

        Question. Do you commit to maintaining current funding levels for
    Community Health Centers, not only in the Department's annual budget
    submission to Congress, but in ongoing operations that will be
    financially damaged by the repeal of the Affordable Care Act?

        Answer. I support Community Health Centers, however, funding levels
    are determined by Congress. If confirmed, I will uphold the law as
    passed by Congress and signed by the President.
                      interstate sale of health insurance
        Question. One of the policies that you and President Trump often
    refer to in your talks about an ACA ``replace'' plan is to allow
    insurance to be sold across State lines. As you must be aware, the ACA
    already allows for this, and several States--including your home State
    of Georgia--have passed State laws to allow for it too.

        In the 5 years since Georgia started allowing out-of-state
    insurance to be sold, how many insurance companies have started selling
    out-of-state plans?

        How has allowing out-of-state plans impacted consumer choice in
    available health insurance plans, what has been the impact on insurance
    costs, and what has been the impact on access to care in Georgia?

        How many States have indicated they want to form a compact to allow
    out-of-state plans, under the current law?

        How would this lack of interest on the part of States and insurance
    companies change under the plan you've previously proposed (e.g., title
    III of H.R. 3200, the Empowering Patients Act)?

        As a former physician who had to negotiate with insurance companies
    to be in their networks, wouldn't you prefer to work with an insurance
    company that knew you and your patients, or would you prefer one from
    across the country that knows nothing about you, your practice, or your
    patient population?

        Answer. It's no surprise that an overwhelming majority (85%) of
    Americans support the ability to purchase insurance across State lines.
    More important than insurance companies' views about more competition
    or State regulators' views about greater regulatory competition is the
    fact that American families are desperate for more affordable health-
    care choices. It's our job to make certain that every American has
    access to the highest quality care and coverage that is possible.
    Opening up more health options for American families by allowing them
    to purchase a plan from another State will do just that.
    Understandably, insurance companies and States have been reluctant to
    take bold action to sell products across State lines with the heavy
    burden of Obamacare already on the books. Removing Obamacare's
    insurance mandates and regulations combined with the ability to reach
    more customers will ultimately reward American families with more
    choices at lower costs.

        Question. One of the consistent arguments you've made against the
    ACA is that it was a Federal takeover of health care and that oversight
    of the health industry is better left to States.

        If you do in fact believe that, how does undermining States and
    their insurance commissioners by imposing interstate sale of health
    insurance follow that same logic?

        Answer. If confirmed, I look forward to working with States to
    increase access to affordable coverage.
                      recusal from ama-related activities
        Question. The American Medical Association's (AMAs) House of
    Delegates is, to quote their website, the ``principal policy-making
    body of the AMA.'' You've been a Delegate for more than a decade and
    have presumably been involved in the development of the organization's
    policies relating to key issues before both Congress and HHS during
    that time. You've stated that if confirmed you intend to recuse
    yourself from any issues the AMA has worked on for 1 year.

        How did you determine that a year is a sufficient period of time
    for your recusal from all AMA-related activity?

        Answer. This matter has already been addressed with the OGE and
    designated agency ethics official, and I will abide by the obligations
    agreed to in my publicly available ethics agreement.

        Question. Does the clock on this year start on the day you assume
    the role of Secretary or do you currently consider that year to have
    already started?

        Answer. The terms of my publicly available ethics agreement, which
    I entered into in consultation with the Office of Government Ethics and
    my designated agency ethics official, make clear that the 1-year
    recusal window begins on the day of the confirmation.

        Question. If the Department's General Counsel, Office of Inspector
    General or any other authority within the HHS determines that a year
    recusal is insufficient to properly distance yourself from your
    previous work with the AMA, will you commit to extending the recusal
    period for the remainder of your tenure as Secretary?

        Answer. I will abide by the obligations agreed to in my publicly
    available ethics agreement, which I entered into in consultation with
    the OGE and my designated agency ethics official.

        Question. A quick search on the AMA's website shows that the
    organization has formally commented on issues as varied as Medicare
    Advantage, the physician fee schedule, FDA oversight of laboratory
    developed tests, Medicaid and CHIP, CMS quality measures, Medicare
    prescription drug benefits, electronic health record meaningful use
    requirements, guidelines for opioid prescribing, and the comprehensive
    joint replacement model you've spoken out against so frequently.
    Obviously the group representing doctors has myriad interests in the
    workings of virtually every agency and office within HHS.

        Please provide me with documentation outlining exactly how you will
    recuse yourself from all AMA-related activities, which includes
    specific details on the HHS policies this recusal impacts. Further,
    please provide a list of all personnel within the Department that will
    be designated to act on your behalf for all the listed polices for
    which you will be recused.

        Answer. This matter has already been addressed with the OGE and
    designated agency ethics official, and I will abide by the obligations
    agreed to in his publicly available ethics agreement.

        I have not yet been confirmed or hired any personnel to assist
    efforts in the Department of Health and Human Services.

        Question. As a member of the AMA's House of Delegates for more than
    a decade, it's safe to presume that you are familiar with, and
    supportive of, their policies. One of these policies states that the
    ``AMA recognizes that uncontrolled ownership and use of firearms,
    especially handguns, is a serious threat to the public's health''
    because they are the leading cause of premature death in the country.

        Do you agree that guns are a top cause of intentional and
    unintentional death, as the AMA states?

        As a member of the AMA's House of Delegates, at any point did you
    fight against the AMA taking a stance declaring guns to be a public
    health issue?

        Do you oppose government prohibitions on studying how gun violence
    affects the public health? If confirmed, will you commit to not
    imposing government prohibitions on any agency, department or office
    from conducting gun-related health research to improve public health?

        Answer. Violence is a challenge in our society that deserves
    greater attention. All Americans want our communities to be safe places
    to live, learn, work and play. To my best recollection, I have not
    taken an individual stance on this matter. To the question of how best
    to prevent the tragic loss of innocent lives, I believe we must take a
    hard look at the underlying issues contributing to these tragic events,
    including too often unmet mental health needs among our citizens. A
    proper diagnosis and treatment as part of patient-focused care are
    critical to ensuring we are identifying indicators of violent behavior
    that may contribute to tragic events.
                     evidence-based home visiting programs
        Question. I have been a strong supporter of the Maternal, Infant,
    and Early Childhood Visitation program (MIECHV), which has always
    enjoyed bi-partisan support. MIECHV was enacted as part of the
    Affordable Care Act to help States build capacity to provide in-home
    visits to at-risk mothers and families with the stated goals of
    improving maternal and child health, preventing child abuse and
    neglect, encouraging positive parenting, and promoting child
    development and school readiness.

        The Medicare Access and CHIP Reauthorization Act (MACRA), passed in
    2015, reauthorized the program for 2 years. This reauthorization
    maintains current funding, which unfortunately is only enough resources
    to provide services to only 3 percent of the eligible population who
    are currently receiving MIECHV services. This points to a missed
    opportunity to improve the life course development of children born
    into low-income households, while also reducing preventable government
    spending in the short and long term.

        Do you commit to supporting continuation of funding for the MIECHV
    program in the Department's annual budget submission? Do you recognize
    the value of the MIECHV program and its evidence-based design by
    proposing increases in funding to capture more than just 3 percent of
    those children and families who could greatly benefit through the
    program's services?

        Answer. I share your goal of increasing access to affordable,
    quality health coverage for rural America. While I cannot comment
    specifically on legislation that would reauthorize MIECHV, I look
    forward to working with you on examining this program's funding and
    working on ways to improve rural and child health using evidence-based
    approaches.
                              diversity in hiring
        Question. The Affordable Care Act expanded health-care coverage to
    millions of Americans who were previously uninsured. Because of the
    greater demands on the health-care industry, the ACA has also become an
    engine for job growth in the health related fields. This is especially
    true for women and people of color.

        For example, women represent 75% of the health-care workforce.
    Nearly half of workers in the long-term/residential and home health-
    care services are people of color. The future of our American workforce
    in the health industry promises increasing diversity. Between 2003-2004
    and 2013-2014 the number of doctoral degrees conferred in health
    profession fields increased by 61 percent (from 41,900 to 67,400
    degrees).\14\ In 2013-2014, one-third of those doctoral degrees were
    awarded to people of color.\15\ The importance of a diverse workforce
    in the health industry has been well-documented in scientific
    literature. One of the more significant outcomes of a diverse workforce
    is greater access to and quality patient care.\16\ Diversity in the
    workforce also increases career opportunities for people of color.
    ---------------------------------------------------------------------------
        \14\ https://nces.ed.gov/programs/coe/indicator_svc.asp.
        \15\ https://nces.ed.gov/programs/digest/d15/tables/
    dt15_324.25.asp.
        \16\ Mitchel, D.A. and Lassiter M.A. (2006) Addressing health care
    disparities and increasing workforce diversity: The next step for the
    dental, medical, and public health professions, American Journal of
    Public Health, 96 (12), pp. 2093-2097.

        Given the fact that the current administration intends on gutting
    the Affordable Care Act, which, along with leaving millions of
    Americans uninsured, will also leave thousands of women and minorities
    ---------------------------------------------------------------------------
    without an opportunity to build a career in their field of study:

        Will you commit to minimizing the impact of leaving thousands of
    incoming women and minority health-care professionals without a career
    path to look forward to?

        Answer. Workforce issues are a major challenge in health care. We
    should work together to expand career options and paths for all health-
    care professionals.

        Question. The Department of Health and Human Services is among the
    most diverse agencies to work for within the government, except when it
    comes to its Hispanic labor force. In FY 2015, Hispanics comprised
    3.08% of HHS's workforce compared to 9.96% of the National Civilian
    Labor Force.\17\
    ---------------------------------------------------------------------------
        \17\ https://www.hhs.gov/sites/default/files/asa/ohr/spd/di/
    newsletter/dinewsletterfallwinter
    15.pdf.

        What concrete steps does the Department of Health and Human
    Services plan to take to increase diversity and inclusion in its
    ---------------------------------------------------------------------------
    agency, especially at its Senior and Executive levels?

        Answer. If confirmed, I would be pleased to work with you to
    identify steps that could be taken to ensure the Department is drawing
    upon the widest and most diverse pool of applicants possible in the
    hopes of it resulting in an even more diverse workforce.
                          diversity in health outcomes
        Question. Eliminating health-care disparities among Americans from
    minority racial and ethnic backgrounds has long been a bipartisan
    issue. In 1985 under President Reagan, then Secretary of Health a Human
    Services Margaret Heckler commissioned a report on Black and Minority
    Health where she noted that there was a ``continuing disparity in the
    burden of death and illness experienced by [. . .] minority Americans
    as compared with our Nation's population as a whole.'' The report, as
    she envisioned, should have marked ``the beginning of the end of the
    health disparity that has, for so long, cast a shadow on the otherwise
    splendid American track record of ever improving health.'' \18\
    ---------------------------------------------------------------------------
        \18\ https://minorityhealth.hhs.gov/assets/pdf/checked/1/
    ANDERSON.pdf.

        Unfortunately that shadow is still cast over our country. There is
    a significant body of literature that indicates that disadvantaged
    populations, such as racial and ethnic minorities, still face systemic
    barriers to achieving ideal health. For example, African Americans are
    50% more likely to die from heart disease or stroke; Asian/Pacific
    Islanders are 60% more likely to have acute Hepatitis B, which causes
    liver disease; and African-American, Native Hawaiian/Other Pacific
    Islander, and Hispanic adults all have rates of HIV infection diagnosis
    that range from three to nine times the rate of non-Hispanic Whites.
    \19\ To that end, the Affordable Care Act established Offices of
    Minority Health within six agencies, thus expanding the work begun by
    President Reagan 30 years ago. The purpose of creating these offices
    was to have greater interagency coordination when it comes to
    eliminating minority health disparities.
    ---------------------------------------------------------------------------
        \19\ https://minorityhealth.hhs.gov/assets/pdf/
    FINAL_HHS_Action_Plan_Progress_Report_11_2
    _2015.pdf.

        To the extent that this administration has taken and will continue
    to take concrete steps to repeal the ACA, which created the Offices of
    Minority Health within the Agency for Healthcare Research and Quality
    (AHRQ), the Centers for Disease Control and Prevention (CDC), the Food
    and Drug Administration (FDA), the Health Resources and Services
    Administration (HRSA), the Centers for Medicare and Medicaid Services
    (CMS), and the Substance Abuse and Mental Health Services
    ---------------------------------------------------------------------------
    Administration (SAMHSA):

        Will you commit to prioritizing the elimination of minority health
    disparities in America a priority? Please provide specifics of how you
    plan to make this a priority.

        Answer. Health outcome disparities are a challenge and prioritizing
    work in this area is important. Using the proper metrics may provide
    important insight into new solutions.

                                     ______

         Question Submitted by Hon. Rob Portman and Hon. Sherrod Brown
        Question. HHS, through CMS, has a long tradition of supporting
    nursing education. Our State of Ohio is home to 12 facilities that
    receive Medicare pass-through funding for nursing education. Over the
    past few years, CMS support for nursing education funding has been
    under threat due to accreditation changes. We have authored a bill, the
    MEND Act that would ensure CMS support of nursing education through
    pass-through funding continues and that we can continue educating high
    quality nurses.

        If you are confirmed, will you commit to work with us in Congress
    to provide technical assistance and ensure that the MEND Act is quickly
    implemented if passed?

        Answer. I look forward to working with you on this issue and
    sharing both feedback and assistance regarding the important policy and
    technical issues in nursing education funding, an issue related to and
    similar to the challenges with physician shortages but broader in
    geographic scope and impact. If the law is implemented, and if
    confirmed, I will ensure it is implemented on the timeline Congress
    imposes.

                                     ______

      Question Submitted by Hon. Rob Portman and Hon. Robert P. Casey, Jr.
        Question. Section 154 of MIPPA 2008 specifically excludes from the
    Medicare DME competitive bidding program (CBP) CRT power wheelchairs,
    as well as the accessories that consumers use with those wheelchairs.
    Consistent with the law, Congress did not include those CRT items in
    Rounds 1 or Rounds 2 of the DME bidding program and has repeatedly
    expressed to CMS that it was not the intent of the law to apply bid
    rates to accessories used with CRT wheelchairs. Unfortunately, CMS has
    interpreted MIPPA contrary to congressional intent and in December 2014
    CMS posted on-line a ``Frequently Asked Questions'' (FAQ) document
    stating that starting in January 2016 CMS intended to use bid pricing
    information obtained from the CBP for standard wheelchair accessories
    to reduce the payment amounts for CRT wheelchair accessories.

        At the end of 2015, Congress included in the Patient Access and
    Medicare Protection Act (PAMPA) a 12-month delay (through December 31,
    2016) of CMS's planned application of CBP prices based on standard
    accessories to CRT accessories that share the same HCPCS code. In
    December 2016, as part of the 21st Century Cures Act, Congress included
    an additional 6-month delay that will expire on June 30, 2017.

        Based on your support for this non-application of CBP prices to CRT
    accessories as a member of Congress, if confirmed as Secretary of HHS,
    can you commit to work with Congress to correct this CMS policy and
    adhere to the intent of Congress in MIPPA?

        Answer. As a member of Congress, I have been engaged in
    understanding and improving the competitive bidding program. If
    confirmed, I will continue this work but with the different role of
    carrying out the law for the benefit of the American people. If
    confirmed, I fully expect to work with Congress on this issue and many
    others that arise when Congress's intent encounters the details of
    implementation. I also hope to bring to that role, if confirmed, the
    informative and valuable perspective of serving as a member of Congress
    writing and voting on these laws.

                                     ______

                 Questions Submitted by Hon. Benjamin L. Cardin
                    cmmi and health care delivery innovation
        Question. What are your views of State demonstrations, State
    innovation, and Centers for Medicare and Medicaid Innovation (CMMI)
    authority?

        Answer. I believe these authorities can be important ways to ensure
    there is flexibility in CMS programs and activities for the individual
    and varying needs of States.
                                  drug prices
        Question. Last year the country was shocked by a series of price-
    hikes on older, off-patent drugs by manufacturers who had played no
    part in the research and development that produced them. The Senate
    debated numerous solutions last Congress to prevent price gouging
    behavior, and many put the ball squarely in HHS's court.

        What is your view on HHS's role in preventing price-gouging, and if
    confirmed, how do you propose to use the Office of Secretary to ensure
    Americans have access to affordable prescription drugs?

        Answer. The issue of drug pricing and drug costs is one of great
    concern to all Americans. You have my commitment to work with you and
    others to make certain that Americans have access to the medications
    that they need. If confirmed, I look forward to focusing on how we can
    make health care more affordable, including prescription drugs. I share
    your concern regarding the importance of individuals and families being
    able to afford the prescription drugs they need.
                           emergency health services
        Question. The Balanced Budget Act of 1997 requires Medicaid managed
    care organizations (MCOs), and others, to cover emergency services
    without prior authorization and established a Federal ``prudent
    layperson standard.'' This standard defines an ``emergency medical
    condition'' as one that manifests itself by acute symptoms of
    sufficient severity (including severe pain) such that a prudent
    layperson, who possess an average knowledge of health and medicine
    could reasonably expect the absence of immediate medical attention to
    result in placing the health of the individual in serious jeopardy,
    serious bodily functions, or serious dysfunction of any bodily organ or
    part.

        Do you support this Federal policy?

        Answer. I appreciate the aim of this Federal policy is to ensure a
    minimum level of emergency room coverage for Medicaid managed care
    organizations. Every State has different demographic, budgetary, and
    policy concerns that shape their approach to Medicaid and potential
    Medicaid managed care coverage requirements. While I believe that in
    the long run a one-size-fits-all approach is not workable for a country
    as diverse as the United States, my hope is to make sure that Medicaid
    beneficiaries need not rely on the emergency room to reliably access
    care because they have a doctor they trust in their community and a
    strong relationship and reliable access to that doctor.

        Question. Will you ensure the Centers for Medicare and Medicaid
    Services continues to enforce the prudent layperson standard for all
    Medicaid MCOs?

        Answer. If confirmed as Secretary, I will faithfully implement laws
    written by Congress and the regulations issued by the Department. This
    includes enforcement action as appropriate. As a doctor who has
    actually treated thousands of Medicaid patients, I do care deeply about
    the Medicaid program and the access of Medicaid patients to actual
    care, not just a card they can carry with them.
                                federal workers
        Question. Do you believe that the Office of the Actuary's actuarial
    and economic projections should be based on ``best professional
    estimates'' and remain as free as possible from political
    considerations? Why or why not?

        Answer. In getting advice from any professional it is important
    that advice be objective and consistent with relevant professional
    standards. Just as I would expect that from any doctor I visit I would
    expect the same from an actuary.
                         global health security agenda
        Question. What are your views on President Obama's Global Health
    Security Agenda?

        Answer. In an interconnected world, no nation is safe from the
    risks posed by infectious diseases. I agree that the international
    community must continue to work together towards the common goal of a
    world safe from infectious diseases. I also agree that the
    international community must build-up our capacities in order to
    achieve this goal. If confirmed I will meet with the Office of Global
    Affairs and CDC to review the progress we have made on this agenda.

        Question. For decades the U.S. Government has been a leader in
    strengthening health systems around the world to prevent, detect, and
    minimize the impact of emerging infectious diseases. The United States
    is one of over 50 countries that have committed to the Global Health
    Security Agenda, which aims to help countries improve their capacity to
    prevent, detect, and respond to infectious disease outbreaks.

        As Secretary, how would you support and enhance global efforts to
    detect, prevent, and respond to diseases internationally to prevent
    them from becoming a threat to the United States?

        How will you ensure that we effectively address emerging crises and
    maintain our leadership role in global health?

        Answer. No global effort to detect, prevent, and respond to
    diseases internationally can be successful without an active and
    engaged United States. Rapid response in fighting infectious diseases
    is essential. Oftentimes, we can ensure these diseases do not spread to
    our shores if we do what we can to stop them spreading abroad. Few
    responsibilities are more important than keeping the public safe from
    potential public health pandemics and if confirmed I will make this a
    top priority.

        Question. America's approach to global health has been extremely
    successful, including the effort to move toward ending the epidemics of
    AIDS, tuberculosis and malaria. The hallmark of America's work against
    the three diseases has been to support results-oriented, accountable
    and transparent programming through the Global Fund and bilateral
    programs including PEPFAR, PMI and the USAID tuberculosis program. The
    Global Fund and our bilateral programs closely coordinate their work
    and depend on each other to implement comprehensive programming.

        As Secretary, will you be committed to continuing America's
    leadership against AIDS, TB and malaria through Global Fund
    investments?

        Answer. United States leadership has been crucial in fighting AIDS,
    TB and malaria. Should I be confirmed, I fully expect these efforts to
    continue as we build upon and learn from our past and current
    initiatives. HHS and CDC are critical to fighting a range of global
    health security threats from Ebola and Zika to polio and HIV/AIDS. Yet,
    as was made clear during the Ebola epidemic, severe shortages of health
    workers greatly hamper efforts for infectious disease prevention,
    detection and response.

        Question. HHS and CDC are critical to fighting a range of global
    health security threats from Ebola and Zika to polio and HIV/AIDS. Yet,
    as was made clear during the Ebola epidemic, severe shortages of health
    workers greatly hamper efforts for infectious disease prevention,
    detection and response.

        In your view, what is the role of the Department of Health and
    Human Services in growing and developing a better-trained health
    workforce worldwide?

        Answer. If confirmed as HHS Secretary, I look forward to working
    with the health secretaries of other nations in helping the world
    community train an international health workforce capable of tackling
    the myriad public health challenges of the 21st century.
                        graduate medical education (gme)
        Question. The current Medicare GME system is not producing enough
    doctors who will practice in rural America. Data show less than 5% of
    all graduates practice in rural areas. When Congress set limits on the
    number of Medicare funded GME slots (BBA 1997) there was clear intent
    in both the statute and the report language to treat rural training
    differently and provide special consideration to meet the needs of
    underserved rural areas. Unfortunately, the technicalities of the
    statute, and the regulations deriving from it, have not succeeded in
    achieving this intent.

        What will you do as Secretary of HHS, specifically, to support
    changes to Medicare GME to increase the production of physicians
    practicing in rural areas?

        Answer. I have always been a strong supporter of efforts to support
    medical education. Congress has used the Medicare program from its
    inception to invest in future generations of doctors. Regardless of
    what we do in Washington, health care should always be about that one
    to one relationship of a patient to a doctor. That relationship of
    course requires a doctor. And so I am hopeful we can continue to find
    ways to remove disincentives to the practice of medicine and its
    rewards as well as support the profession in other ways. This issue is
    all the more important in the case of a rural area, where there is
    already an ongoing physician shortage and difficulty in recruiting
    talent and capital for medical infrastructure. If confirmed as
    Secretary, I would look for opportunities to address these situations
    through GME but also through programs administered by the Health
    Resources Services Administration and by taking a closer look at
    telemedicine.
                                    medicare
        Question. Your ACA replacement proposal, the Empowering Patient's
    First Act, eliminates benefit expansions for beneficiaries such as free
    preventive benefits (blood pressure screenings, colorectal screenings
    and immunizations) and closing the Part D donut hole which helped with
    out-of-pocket prescription drug costs.

        If confirmed as HHS Secretary, how will you prevent any care
    reductions for or our-of-pocket health-care cost increases to Medicare
    beneficiaries?

        Answer. In considering Medicare, it is important to appreciate that
    the bipartisan Medicare Trustees have told everyone that Medicare, in
    less than 10 years, is going to be out of the kind of resources that
    will allow us as a society to keep the promise to beneficiaries of the
    Medicare program. My goal, if confirmed, is to work with Congress to
    make certain that we save and strengthen Medicare. It is irresponsible
    for us to do anything else. If I am confirmed, my role will be one of
    carrying out the laws Congress passes and as to that I would convey to
    the Medicare population that we look forward to assisting them in
    getting the care they need.
                            mental health workforce
        Question. Mental health professions face chronic workforce
    shortages, and the future for many of these professions remain grim.
    For example, a recent survey from the American Association of Medical
    Colleges found that almost 60% of psychiatrists are aged 55 or older,
    making psychiatry the fourth oldest medical specialty in terms of
    practitioner age.

        Along with the overall shortage, the distribution of mental health
    practitioners heavily favors key urban and suburban areas of the
    country over rural regions. The 21st Century Cures Act requires the
    Substance Abuse and Mental Health Services Administration to develop a
    strategic plan every 4 years to identify strategies to improve the
    recruitment, training, and retention of a mental health and substance
    use disorder workforce.

        While this provision and similar provisions are steps in the right
    direction, the numbers clearly suggest that growing a robust workforce
    to meet the mental health and substance use needs of nearly 70 million
    Americans will be of paramount importance in the coming years. Please
    describe in detail how you, if confirmed, will support the growth of
    the next generation of mental health practitioners.

        What strategies will you use to encourage medical students and
    others to pursue careers in these fields?

        Answer. It is important that we as a nation make sure that every
    single individual has access to the kind of mental health and substance
    abuse care that they need. If I am confirmed, I look forward to working
    closely with you and the other members of Congress to faithfully
    execute the 21st Century Cures Act, which aims to ensure that the
    mental health profession is adequately staffed for current and the
    future generations.
                                minority health
        Question. In Maryland, the ethnic minorities make up roughly 41% of
    the State's population. This is important because the health outcomes
    of minority populations are significantly lower and morbidity rates are
    higher than that of majority populations. Your Department, HHS,
    recognized this when it produced with what is commonly called the
    Heckler Report back in the 1980s, under President Ronald Reagan,
    looking at what are now commonly called ``health disparities'' and the
    need for more health professionals coming from minority and
    underrepresented backgrounds.

        Racial and ethnic communities suffer disproportionate higher rates
    of illnesses, disabilities and preventable deaths. In fact, according
    to Johns Hopkins and University of Maryland researchers, racial health
    disparities cost the United States $229 billion between 2003 and 2006.

        The Affordable Care Act is allowing communities coverage and access
    to much needed care, treatment, and prevention services from diabetes,
    to cancer, to asthma, and more. Specifically, how do you plan to
    further the elimination of racial and ethnic health disparities?

        Answer. I am committed to ensuring that minorities in this country
    have access to the highest quality care. To address these challenges,
    we need to examine what is happening on the ground in these
    communities. From there, we can establish better metrics and better
    accountability, and I look forward to working with you on this when I
    am confirmed.
                      national institutes of health (nih)
        Question. Young scientists in the United States are finding it more
    difficult--and more time-consuming--to secure stable funding to launch
    their research careers, which stifles America's competitiveness. More
    and more talented young people are dropping out of the scientific
    workforce or choose not to enter in the first place.

        What do you plan to do to ensure barriers facing young scientists
    are addressed and can we count on your leadership to implement the
    recommendations that come out of the National Academies report?

        Answer. If confirmed, I will look at flexibilities given to us
    through the 21st Century Cures Act and the focus on ``young emerging
    scientists'' to better recruit and retain top talent in order to help
    us achieve our mission of promoting innovation in order to benefit
    patients and their families across the country.

        Question. What do you see as the future roadmap for NIH over the
    next four years?

        Answer. If confirmed, I will work with NIH leadership to map out a
    forward-
    leaning NIH agenda. As I mentioned in my testimony, NIH is a true
    treasure for our country. With the increased resources provided in the
    Cures Act and the President's commitment to innovation and patient-
    centric health care, great opportunities lie ahead for the NIH.
                                pediatric dental
        Question. According to the CDC, tooth decay (cavities) is one of
    the most common chronic conditions of childhood in the United States
    and if left untreated, tooth decay can cause pain and infections that
    may lead to delays in important cognitive skills, such as eating,
    speaking, playing, and learning.

        How will you plan to ensure that children will continue to have
    access to early prevention services for oral health?

        Answer. If confirmed as Secretary, I would hope to work with you to
    revisit the current CMS' ``Oral Health Strategy'' for children (https:/
    /www.medicaid.gov/medicaid/quality-of-care/downloads/cms-oral-health-
    strategy.pdf). I would also aim to provide States with flexibility in
    their Medicaid programs to provide both coverage and access to these
    services. Lastly, there may be opportunities to encourage innovation in
    both the coverage and payment for these services as well as the actual
    technology and even the relevant public health education strategies.
                       social services block grant (ssbg)
        Question. This important program funds a variety of social services
    programs, from child protection to elder abuse to Meals on Wheels. I
    see every day in Maryland how this grant program helps our neediest and
    most vulnerable citizens. You proposed eliminating this $1.7 billion a
    year program as the chairman of the House Budget Committee.

        What was your rationale for trying to eliminate this program, and
    what would you put in its place?

        Answer. During my time in Congress, I have been acutely aware of
    the need to eliminate duplicative programs and strengthen those
    programs that work. As a 2011 GAO report pointed out, SSBG is a program
    of fragmentation, overlap, and duplication. SSBG essentially offers no-
    strings attached approach and a blank check to States. However, as SSBG
    continues to be a program authorized by Congress, I will do all I can
    to effectively administer this law should I be so honored as to be
    confirmed as HHS Secretary.
                            substance use disorders
        Question. The United States currently faces a growing epidemic in
    the form of prescription drug misuse, abuse, addiction and overdose.
    The numbers are disquieting. One person dies every 19 minutes from a
    drug overdose, now the leading cause of death among those ages 25-44,
    according to Johns Hopkins experts.

        In Maryland in 2015, fatal overdoses in the State were up 21
    percent from the year before, and nearly twice the number in 2010.
    There is an urgent need for evidence-informed solutions ready for rapid
    implementation.

        How will HHS balance the twin-priorities of preventing new cases of
    opioid addiction and expanding access to effective addiction treatment
    while safely meeting the needs of patients experiencing pain?

        Answer. The opioid epidemic is real. This epidemic is a rampant
    crisis that is harming families and communities across the Nation. I
    firmly believe it is vital that those suffering from substance abuse
    have continued access to addiction treatment. If confirmed, I am
    committed to working closely with you and the other members of Congress
    to ensure that the Substance Abuse and Mental Health Services
    Administration (SAMHSA) fulfills its duty of treating those who are in
    addiction recovery, and prioritizes prevention efforts to keep
    America's families and communities healthy.

        Question. Last month, the Centers for Medicare and Medicaid
    Services (CMS) granted Maryland a Medicaid section 1115 waiver to
    implement initiatives to address substance use disorders throughout the
    State. This is great news for my home State and a first step to
    addressing opioid abuse and heroin use. Now, Medicaid enrollees will
    have access to residential treatment for substance use disorders,
    putting them on the road to recovery.

        If confirmed as HHS, will you commit to ensuring States' ability to
    use Medicaid section 1115 models to provide life-saving care, including
    addiction treatment and recovery services covered by Medicaid, to
    Americans in need?

        Answer. If I am confirmed, I will work with CMS and SAMHSA to help
    low-
    income adults with mental health and substance use disorders. With
    respect to Medicaid specifically, every State has different
    demographic, budgetary, and policy concerns that shape their approach
    to Medicaid. That is one of the reasons I devoted so much time to
    working with States to help them to identify creative solutions, and
    why I believe a one-size-fits-all approach is not workable for a
    country as diverse as the United States. Waivers are an important tool
    for States to innovate within the Medicaid program. If confirmed, I
    would work with CMS to ensure that it evaluates waivers like Maryland's
    on their merits, taking into account the desirability of States
    charting their own course, and ensure that they are compliant with the
    law.
                 temporary assistance for needy families (tanf)
        Question. I am concerned that, while the TANF caseload had declined
    by over 60 percent over the last 2 decades, the number of children in
    poverty and deep poverty (meaning income below half the poverty line)
    has increased.

        What steps would you take to reverse this trend?

        Answer. If confirmed as HHS Secretary, I am going to do all I can
    to effectively and efficiently administer the laws passed by Congress
    to address and alleviate the very real problem of children living in
    varying levels of poverty.

        Question. Do you agree that TANF is not succeeding as a program
    even if caseloads are declining while the number of persons in poverty
    and deep poverty are increasing?

        Answer. Respectfully, I must disagree with this assessment of
    TANF's success. Since passage of TANF, we have seen employment rates of
    single mothers increase, lower poverty rates among female-headed
    households with children and African-American households, a reduction
    in child poverty overall, and a sharp decline in the number of families
    receiving cash assistance.
                                  therapy caps
        Question. As you know, the therapy cap exceptions process expires
    in less than a year--on December 31, 2017. We have all heard from
    constituents whose therapy needs exceeded the cap and their conditions
    have deteriorated, necessitating more expensive medical intervention.

        As Secretary of HHS, how will you support the repeal of these
    arbitrary and discriminatory limits and maintain access to
    rehabilitation therapy that Medicare beneficiaries clearly need?

        Answer. If confirmed as Secretary, I will look into this issue and
    seek to understand the competing objectives and issues motivating the
    current CMS policy. Part of the frustration with the current health-
    care system is rules like this that do not make sense to many people.
    However, that is not surprising when one considers that Medicare Parts
    A, B, C, and D have each developed in silos and that even payment for
    particular types of services sometimes reflect silos within the silos.
    It may be that other approaches to therapy provide greater quality care
    at reduced cost with more respect for the individual needs of each
    patient in consultation with their doctor. If confirmed as Secretary, I
    would hope to break down these silos and encourage approaches based on
    a broader perspective.

        Question. Given the problems associated with monitoring the therapy
    cap, are the Centers for Medicare and Medicaid capable of achieving a
    timely uniform and defensible streamlined, responsive, and transparent
    process for manual medical review of Medicare records by Medicare
    administrative contractors?

        Answer. Any time there is manual review of anything in an
    organization with the scale of Medicare, there is a recipe for
    something to go wrong. If confirmed as Secretary, I would be pleased to
    work with you to confirm whether the staffing and other resources
    needed would be up to the challenge you describe.

                                     ______

                    Questions Submitted by Hon. Dean Heller
                               medicaid expansion
        Question. Do I have your commitment to working with Congress, and
    members of this committee, to protect access to care for all patients
    in Nevada, particularly the over 600,000 Nevadans currently covered
    under Medicaid?

        Answer. I am committed to ensuring that Medicaid is available for
    eligible beneficiaries, and working with States to ensure they are able
    to make the most use of available resources to serve their citizens, if
    confirmed as Secretary of Health and Human Services. Each State has
    different needs, and I believe CMS needs to work with States to ensure
    that, consistent with those needs, the Medicaid and CHIP programs
    provide the best possible coverage to their residents.

        Question. Under your leadership, how will the U.S. Department of
    Health and Human Services work with States likes Nevada, who expanded
    Medicaid, to ensure that they are successful in protecting access to
    health care, particularly the 200,000 newly eligible Nevadans, as we
    transition out of Obamacare?

        Answer. I look forward to faithfully executing whatever law that
    Congress passes and the President signs, if I am confirmed. I will
    promise you this: Regardless of the final legislative outcome, I would
    work as HHS Secretary to ensure that the Medicaid program is well
    administered, effective, and available for eligible beneficiaries and
    that the States/Governors are given the flexibility to pursue
    innovative approaches that fits the needs of their States.
                                doctor shortage
        Question. Nevada is 47th in the Nation for doctor-to-patient ratio.
    What can Congress and HHS do to attract more health-care providers to
    practice medicine in rural and underserved areas in States like Nevada
    that are facing a significant doctor shortage?

        Answer. If confirmed, I would work closely with the Center for
    Medicare within CMS to see that critical access hospitals are able to
    serve rural populations well. I would also work with the HRSA (Health
    Resources and Services Administration) Administrator to consider how
    CMS and HRSA can best cooperate with regards to community health
    centers and other issues. I would also consider how we can allow for
    reimbursement of telehealth in general and to further help address
    provider shortages.

        Question. Do you believe that tele-medicine would be helpful for
    predominantly rural States like Nevada expand access to care for
    patients in underserved areas?

        Answer. Telemedicine is an exciting innovation that will allow for
    individuals to access resources that are otherwise not available. In
    the State of Georgia, we have a program that is a spoke and wheel
    program. There is a neurologist who works with a network of clinics and
    hospitals around the State. If somebody comes in with symptoms of a
    stroke, that neurologist is able to see the patient in real time and
    determine if they are having a stroke, whether they can be treated in
    the community or ought to be transferred. Innovations like this have
    been particularly helpful for rural areas.
                              financial disclosure
        Question. To the best of your knowledge, as a member of the House
    of Representatives, did you fully comply with the Stop Trading on
    Congressional Knowledge Act (STOCK Act, Pub. L. 112-105) and the Office
    of Government Ethics (OGE) to publicly disclose your personal financial
    transactions?

        Answer. To the best of my knowledge, I have met all compliance
    obligations for the disclosure of personal financial transactions by
    members of the House of Representatives.

        Question. If confirmed, do you commit to fully complying with the
    law that would require you to sell stock in companies regulated by HHS?

        Answer. If confirmed, I commit to fully comply with all applicable
    ethics and conflict of interest obligations required by law, including
    the divestment of all applicable securities identified for sale in my
    publicly disclosed ethics agreement with the Office of Government
    Ethics (``OGE'').
                            nevada state legislature
        Question. Please see the attached questions from the Nevada State
    Legislature. I respectfully ask that you respond to these important
    issues in the State, and cc Governor Sandoval.

        Answer. I look forward to writing to you and the Governor regarding
    these important issues. I expect my response will include the
    following.

        Q. What steps do you plan to take to ensure that the more than
    88,000 Nevadans who have purchased health insurance through the Silver
    State Health Exchange continue to have the ability to purchase health
    insurance with adequate coverage in a transparent marketplace?

        A. I think the conversation and focus in these topics has been the
    question of coverage rather than true access for too long. By that I
    mean that Americans might have an insurance card and yet not be able to
    afford care or it might not be available to them for other reasons. And
    so when we talk about coverage we ought to make clear what we really
    mean and want to have happen. In any case, the President has made clear
    his hope and plan for a replacement to Obamacare. The goal is to make
    certain that every single American has access to the coverage they want
    for themselves.

        Q. What steps do you plan to take to ensure that the more than
    77,000 Nevadans who are eligible for Federal tax credits under the
    Affordable Care Act to help purchase private insurance will continue to
    have access to affordable health insurance options with adequate
    coverage?

        A. I think the conversation and focus in these topics has been the
    question of coverage rather than true access for too long. By that I
    mean that Americans might have an insurance card and yet not be able to
    afford care or it might not be available to them for other reasons. And
    so when we talk about coverage we ought to make clear what we really
    mean and want to have happen. In any case, the President has made clear
    his hope and plan for a replacement to Obamacare. The goal is to make
    certain that every single American has access to the coverage they want
    for themselves.

        Q. What steps do you plan to take to ensure that the 217,000
    Nevadans who are receiving health care under the Medicaid expansion
    remain covered?

        A. Regardless of the final legislative outcome, I would work as HHS
    Secretary to ensure that the Medicaid program is well administered,
    effective, and available for eligible beneficiaries and that the
    States/Governors are given the flexibility to pursue innovative
    approaches that fits the needs of their States.

        Q. The Affordable Care Act guarantees coverage vital to
    preventative services for women, including cancer screenings and birth
    control. What steps do you plan to take to ensure that the Affordable
    Care Act's coverage guarantees remain intact for women's health?

        A. My hope is to move in a direction where insurers can offer
    products people want and give them the coverage they want. Getting to
    that kind of system requires changes that will inevitably involve
    working with Congress and considering the tradeoffs of various
    proposals to achieve our shared objective of the best and highest
    quality care being available to Americans. And note that I refer to
    care because ultimately, having maternity or other coverage is not
    meaningful if one cannot access the care they need or the quality of
    care leaves them worse off. So we must work towards both coverage and
    care.

        Q. The Affordable Care Act guarantees that Nevadans with pre-
    existing conditions will not be denied health care and ends lifetime
    minimums on coverage. It also allows younger people, many of whom are
    saddled with college debt and cannot afford insurance, to stay on their
    parents' insurance until they are 26. What steps do you plan to take to
    preserve those coverage guarantees?

        A. Nobody ought to lose insurance because they get a bad diagnosis.
    As to coverage until age 26, the insurance industry has applied that
    across the board. In any case, if confirmed as HHS Secretary, my role
    would be to implement the replacement passed by Congress and signed by
    President Trump. Regardless of my own ideas, it is Congress that will
    ultimately decide what a replacement bill will look like, and my job
    would be to faithfully execute the law as passed by Congress.

                                     ______

                 Questions Submitted by Hon. Michael F. Bennet
        Question. The Medicare Advantage program has been used to provide
    quality, affordable health care to about 18 million seniors and
    individuals with disabilities. Many of these seniors indicate that they
    are satisfied with their choice of Medicare Advantage program. In fact,
    36% of Coloradans are in Medicare Advantage plans.

        In your role as Secretary of HHS, how do you plan to support
    Medicare Advantage plans? What other steps do you plan to take to
    ensure that seniors have access to coordinated care plans?

        Answer. Medicare Advantage provides an important option for
    Medicare beneficiaries to access coordinated care and greater benefits.
    If confirmed as Secretary, I would seek to ensure Medicare Advantage
    remains a stable option for beneficiaries and that Medicare Advantage
    plans are afforded the flexibility to design plans that beneficiaries
    want and give them the coverage they want.

        Question. According to the Medicare Boards of Trustees, the
    Affordable Care Act (ACA) has extended the solvency of the Medicare
    hospital insurance trust fund by 11 years in total. The Committee for a
    Responsible Federal Budget estimates that a full repeal of the ACA
    would push up the insolvency date to 2021 and more than triple the
    program's 10-year deficit.

        How would you structure an ACA replacement bill that does not
    reduce the solvency of the Medicare Hospital Insurance Trust Fund?

        Answer. Neither President Trump nor I are wedded to a particular
    plan to the exclusion of all others. We are looking forward to giving
    the American people what they've been longing for, for 7 long years:
    real health-care reform. But they have never wanted Obamacare: It has
    raised premiums and deductibles, narrowed doctor networks, reduced
    choices of plans, limited Americans' liberty, and undermined the doctor
    patient relationship. A replacement need not affect the Medicare trust
    fund if the provisions related to Medicare are ones that are carefully
    considered.

        Question. Do you plan to advise the administration to advocate for
    premium support as a means of extending the Medicare trust fund?

        Answer. One of my goals in discussing these matters is to lower the
    temperature regarding what we are talking about. These issues have
    real-life impact for folks in their lives and so, if confirmed, I would
    advise the administration that we convey to the Medicare population
    that they do not have reason to be concerned and that we look to
    assisting them in getting the care they need and the caregivers that
    they need too.

        Question. Colorado has 2.3 million people living with a pre-
    existing condition that rely on the protections of the ACA to receive
    coverage.

        How would your plan keep coverage for pre-existing conditions and
    control costs while dissolving other parts of the ACA such as the
    individual mandate, the exchanges, and Medicaid expansion?

        Answer. Our goal is to ensure every single American has access to
    the coverage they want for themselves and ensures the individuals who
    lost coverage under the Affordable Care Act get or maintain coverage.
    If we preserve the patient-doctor relationship and put the patient at
    the center, then we will see quality go up and costs go down. In any
    case, I look forward to faithfully executing whatever law that Congress
    passes and the President signs, if I am confirmed.

        Question. I have heard from rural hospitals in Colorado that may
    lose significant funding if the ACA is repealed. The Medicaid Expansion
    provided some financial stability to hospitals that were on the brink
    of closure before the bill was passed. In fact, hospitals in Colorado
    saw a 30% drop in uncompensated care.

        What metrics would you use to ensure that an ACA replacement does
    not hurt rural or critical access hospitals?

        Answer. Our goal is to ensure every single American has access to
    the coverage they want for themselves and ensures the individuals who
    lost coverage under the Affordable Care Act get or maintain coverage.
    This of course includes individuals who access care at rural or
    critical access hospitals. And so the best metric in the end is one
    that measures the extent of access to actual care, not just coverage
    and the quality of that care as determined by patients working
    individually with their doctors.

        Question. You have included health savings accounts in previous
    proposals to replace the ACA. As you know, health savings accounts are
    essentially a way for people to save their own money that they can then
    spend on health care. They are not a substitute for quality coverage
    and are paired with a high deductible, making it difficult to obtain
    health care.

        How can a middle-class family making $60,000 a year successfully
    use a health savings account if they live paycheck to paycheck and
    can't afford to set aside thousands of dollars to pay for their health-
    care bills?

        Answer. Our goal is to ensure every single American has access to
    affordable coverage they want for themselves and their families. Health
    savings accounts are powerful tools that can be used to help lower
    costs and empower individuals, providing greater flexibility to spend
    health-care dollars as they see fit.

        Question. The ACA took steps to enhance price transparency of
    health-care services by requiring health plans to be more explicit
    about what they cover. A knee replacement in the United States could
    cost $11,000 in one area of the country and nearly $70,000 in another
    area. Consumers are still largely unaware of what they will be billed
    after a certain test or procedure.

        What steps do you plan to take as HHS Secretary to improve price
    transparency for consumers?

        Answer. If confirmed as HHS Secretary, I would work to improve
    price transparency to foster and facilitate patient choice. In so
    doing, I would be focused on actual costs and not costs billed to
    insurance companies or from a master price list no one uses. At the end
    of the day though, until patients rather than government are making the
    purchasing decisions, the price transparency information we might aim
    to provide is of limited utility because it does not reflect the
    patients' collective choice and willingness to pay but the
    government's.

        Question. I worked with Senator Portman to introduce the Medicare
    PLUS Act which would set up a pilot program to help the top 15% of the
    highest-cost Medicare beneficiaries by coordinating their health care
    needs. As you may know, 15% of Medicare beneficiaries have six or more
    chronic conditions and account for 50% of total Medicare spending.

        What steps will you take as HHS Secretary to pilot this program and
    ensure that these patients get the coordinated care they need?

        Answer. If confirmed as Secretary, I would explore what voluntary
    options we can make available to the Medicare beneficiaries with the
    greatest needs and their physicians. I think many will appreciate the
    opportunity to work with a care manager and possibly others who will
    spend the time and effort needed to help the patient make different
    choices to manage their own care. I would seek to work with you on your
    proposal to explore how it and others like it can be a path to
    empowering those who are subjected to the most uncoordinated and
    challenging aspects of our health-care system.

        Question. Congress and the last administration have made it a
    priority to pursue delivery system reforms that improve quality and
    lower costs. The Advancing Care for Exceptional (ACE) Kids Act, on
    which I worked with Senator Grassley, aims to coordinate care for
    vulnerable children with complex medical conditions.

        What steps will you take as HHS Secretary to promote increased
    emphasis on reforms that target the needs of children with complex
    medical conditions?

        Answer. If confirmed as Secretary, I would look across the
    Department to identify all the ways in which HHS aims to help these
    children in need. And I would hope to encourage our use of existing
    authorities and funding to better align resources to meet this
    challenge. I would also work with members of Congress on their ideas on
    this important topic.

        Question. Over 500,000 children in Colorado are enrolled in
    Medicaid. Nationally, the program covers over 30 million kids.

        If Medicaid is transformed from an entitlement program to a block
    grant, can you guarantee that those children will maintain coverage?
    What metrics will you use to ensure that those children are covered and
    have access to the same services that they do today?

        Answer. It is important that every child has access to high-quality
    health coverage, and Medicaid plays an important role in accomplishing
    this objective. If confirmed as Secretary, my goal would be to ensure
    that no child in Colorado or anywhere else is left behind.

        Question. The Children's Health Insurance Program (CHIP) currently
    covers 60,000 children in Colorado, increasing access to routine check-
    ups, prescriptions, and emergency services for vulnerable kids.
    Extension of the program needs to occur early this year in order for
    States to plan and have budget certainty.

        What is your position on CHIP? What reforms would you recommend as
    HHS Secretary before supporting extending the program?

        Answer. It is important that every child has access to high-quality
    health coverage, and CHIP plays an important role in accomplishing this
    objective. CHIP plays a major role in this, but there is also a need
    for coordinated family coverage in the private market and employer
    plans, and giving States the needed flexibility.

        Question. The National Health Service Corps Loan Repayment Program
    has been vital in supporting primary care providers who then practice
    in Health Professional Shortage Areas (HPSAs). The ACA expanded this
    program and it has added necessary primary care providers in Colorado.

        If confirmed as HHS Secretary, will you recommend that Congress
    support this program to increase the number of primary care providers
    in rural and underserved areas?

        Answer. As a physician, I understand the value and importance of
    the National Health Service Corps (NHSC) and the NHSC Repayment
    Program. I have included loan forgiveness for primary care providers in
    past legislative proposals, and I look forward to working with Congress
    on this issue when I am confirmed.

        Question. The Pharmacy and Medically Underserved Areas Enhancement
    Act recognizes pharmacists as health-care providers in underserved
    areas in order to expand access to care. In areas with a shortage of
    primary care providers, pharmacists may play a key role in helping
    patients manage their diseases to avoid Emergency Department visits and
    hospitalizations. These services are especially important for patients
    with multiple chronic conditions who may be taking several medications
    at a time. As HHS Secretary, would you support this approach as a way
    to increase care in rural and underserved areas?

        Answer. We ought to step back and say, ``What are we doing wrong?''
    as one out of every eight physicians no longer sees Medicare patients.
    Therefore, if confirmed as Secretary, I would be open to all options to
    address the impact of the ongoing physician shortage in rural areas.
    Paying pharmacists in underserved areas to engage in certain medical
    services could work well in those States where pharmacists have such
    licensure and a setting appropriate to the services, where primary care
    doctors continue to be involved in care, and where there is a patient
    and consumer demand for such services.

                                     ______

                   Questions Submitted by Hon. Sherrod Brown
                               medicaid expansion
        Question. During your testimony in front of the Senate HELP
    Committee last week, you told Senator Murkowski that Medicaid is an
    absolutely imperative program. You also said, in a response to one of
    Senator Young's question, that Medicaid is a program where ``the States
    know best how to care for their Medicaid population.''

        I agree that every State's role in the Medicaid program is
    significant, which is why I want to protect State flexibility when it
    comes to this program. Thirty-one States--including my home State of
    Ohio--have made the decision to expand Medicaid coverage under the
    Affordable Care Act (ACA).

        Ohio's Governor John Kasich, in a letter to Senator Hatch just last
    week, wrote ``we strongly recommend that States be granted the
    flexibility to retain the adult Medicaid coverage expansion and Federal
    matching percentage.''

        Governor Kasich's letter also said that those States that have
    opted to expand Medicaid are experiencing significant positive results.
    In Ohio, high-cost ER utilization has gone down, health status has
    improved, and most enrollees have found it easier to keep or find work.
    Further, thanks to ACA's Medicaid expansion, Ohio was able to extend
    coverage to 700,000 previously uninsured Ohioans.

        Do you support the flexibility provided to States under the ACA to
    expand Medicaid?

        Answer. State flexibility is an important component in making
    Medicaid more workable for patients. Every State has different
    demographic, budgetary, and policy concerns that shape their approach
    to Medicaid and Medicaid expansion. That is one of the reasons I
    devoted so much time to working to help identify creative solutions,
    and why I believe a one-size-fits-all approach is not workable for a
    country as diverse as the United States.

        Question. As a cabinet-level advisor to the President, how will you
    advise the President on any bill that would limit a State's flexibility
    to expand Medicaid--like Ohio did--as provided for under the ACA?

        Answer. I look forward to faithfully executing whatever law that
    Congress passes and the President signs, if I am confirmed.
    Furthermore, I am committed to ensure that the Medicaid program is well
    administered, effective, and available for eligible beneficiaries and
    that the States/Governors are given the flexibility to pursue
    innovative approaches that fit the needs of their States.

        Question. As part of the Medicaid program in Ohio, Governor Kasich
    has led efforts to engage providers, payers, community organizations,
    and employers and encourage them to work with the Medicaid population
    and provide a ladder out of poverty. As a result, more than 70% of the
    expansion population in Ohio reports that, since getting covered, it
    has been easier for them to keep or find a job.

        One program in particular, CareSource's Life Services pilot program
    provides supports and mentoring to help individuals achieve physical
    and behavioral health and economic stability. The CareSource Life
    Services program could serve as a national model for lifting
    individuals out of poverty.

        As Secretary of Health and Human Services, how will you work to
    support and expand funding for programs like Life Services?

        Answer. I understand that some enrollees in CareSource's Medicaid
    managed care product have access to a program called Life Services
    which provides services and supports to help the enrollees obtain and
    keep jobs. Although I understand this Life Services program is a
    benefit of the managed care plan and not part of an Ohio Medicaid 1115
    waiver demonstration, I would be interested to explore with you and
    others how such programs might be integrated or associated with a
    Medicaid waiver. This kind of development shows why waivers are an
    important tool for States to innovate within the Medicaid program, as
    they have for many years prior to the ACA becoming law.
                       medicare negotiations/drug prices
        Question. Last week when you testified in front of the HELP
    Committee, you were also asked how we should address the high cost of
    prescription drugs.

        You avoided answering questions from many of my colleagues by
    saying that, as Secretary of HHS, your job will be to ``administer''
    programs and not ``legislate.''

        President Trump supports the elimination of the noninterference
    clause in Medicare Part D. He would like to have the Centers for
    Medicare and Medicaid Services (CMS) negotiate directly with drug
    manufacturers to get the best deals on prescription drugs for our
    Nation's seniors.

        If Congress passes legislation supported by the President that
    gives the Secretary of HHS the authority to negotiate and this
    legislation is signed into law--would you use this administrative
    authority to negotiate better prices on behalf of the more than 40
    million Part D beneficiaries?

        What are your ideas on effective ways to reduce out-of-pocket
    prescription drug costs for Medicare beneficiaries?

        Answer. We all share concern when prescription drug prices are too
    high for anyone to access the drugs they need. This especially concerns
    me as a doctor. If confirmed, I look forward to using tools Congress
    provides to lower health-care costs. In addition, we need to continue
    to build on the gains towards affordability allowed by the Generic Drug
    User Fee Act and find additional ways to facilitate more efficient
    generic entry. This starts with making sure that we are giving generic
    sponsors clear guidance so that they can prepare approvable
    applications on the first try. If I'm confirmed, I'm committed to
    working with the FDA (and Congress, if appropriate) to find additional
    efficiencies and administrative steps that can help facilitate
    appropriate generic entry.
                           fair pay/home-care workers
        Question. The majority of the home-care workforce--or those
    individuals who provide services to older Americans and individuals
    with disabilities who receive home- and community-based services
    through Medicaid--is made up of female workers.

        This workforce is primarily paid through Medicaid and, on average,
    States pay these workers an average of just $13,000 a year. This means
    that those women caring for the disabled and elderly are often forced
    to rely on Medicaid themselves.

        In order to provide the highest level of quality care to our most
    vulnerable Americans--the elderly and those with disabilities--do you
    agree that those home-care workers providing this care full time should
    be paid more than $13,000 a year by their State Medicaid program--
    ``yes'' or ``no''?

        Answer. I agree it is important to provide those who care for our
    most vulnerable total compensation that reflects the important work
    they do. In many cases, this compensation may include more than wages
    and could, depending, e.g., on housing prices, be significantly more
    than the number given.

        Question. Past leadership at CMS committed in writing to exploring
    Federal actions under its current authority that could work with States
    to strengthen and support home-care workers. In a meeting with Finance
    Committee Staff last week, you expressed an interest in building off of
    the work of the prior administration.

        Will you commit to continuing this work to ensure fair pay and
    advancement opportunities for the home-care workforce. Describe how you
    would go about achieving this goal.

        Answer. If confirmed, I would be pleased to work with you to
    explore such options. One potential issue is to ensure that such
    workers are not somehow considered State employees and therefore
    subject to unique requirements and diversions from income that relate
    to that labor workforce. Another longer term situation is to empower
    patients, as the ultimate recipient of these services to make choices
    regarding providers of these services that leads to a competitive
    market for higher performing workers who satisfy customers.
                            infant mortality/tobacco
        Question. Ohio has one of the highest infant mortality rates in the
    country. In 2015, our State ranked 42nd in the Nation for infant
    mortality, and even worse for African American babies.

        We don't know exactly why Ohio does so poorly when it comes to
    infant mortality, but one thing that we do know is that health
    complications caused by preterm births are the leading causes of infant
    mortality. We also know that a major factor in premature births is
    tobacco use, and Ohio's smoking rate among pregnant women is nearly
    twice the national rate.

        In addition to providing coverage to an additional 20 million
    Americans, the Affordable Care Act also strengthened Medicaid coverage
    of services that help tobacco users to quit. Local groups have taken
    advantage of these provisions in their fight against infant mortality.

        Medicaid covers nearly 50 percent of births in this country. Do you
    support the current requirement that State Medicaid programs provide
    pregnant women with effective tobacco cessation services without cost
    sharing?

        Answer. The science is pretty clear that tobacco use during
    pregnancy is risky for both moms and babies. States should have maximum
    flexibility to prioritize critical health risks such as smoking during
    pregnancy. When it comes to Medicaid requirements, I hope to return a
    lot of control to States, and if confirmed, I will be reviewing such
    requirements and their efforts in order to develop policy
    recommendations for reform.

        Question. How will you work with Congress to maintain this
    requirement so that all pregnant women--regardless of their income--has
    access to tobacco cessation services?

        Answer. The science is pretty clear that tobacco use during
    pregnancy is risky for both moms and babies. Availability of cessation
    programs is important. I look forward to faithfully executing whatever
    law that Congress passes and the President signs, if I am confirmed.
    Regardless, I commit to work as HHS Secretary to ensure that the
    Medicaid program is well administered, effective, and available for
    eligible beneficiaries and that the States/Governors are given the
    flexibility to pursue innovative approaches that fits the needs of
    their States.
                                infant mortality
        Question. As I mentioned in the hearing and in my question above,
    the infant mortality rate among African American infants in the State
    of Ohio is among the worst in the United States. The overall rate of
    infant mortality in Ohio is 42nd in the Nation. I have introduced
    legislation to improve prevention efforts nationwide by improving
    Federal reporting of infant and childhood deaths, putting the power in
    the hands of the Secretary of HHS to generate the metrics by which
    these incidences are reported.

        As Secretary of HHS, how would you work to ensure adequate funding
    for the issue of infant mortality, and which metrics and protocols
    would you use to improve reporting of infant mortality cases across the
    country?

        Answer. Infant mortality is a serious concern for our Nation. While
    many of the underlying factors that contribute to infant mortality are
    poorly understood, we know that certain health behaviors, including
    alcohol consumption and tobacco use during pregnancy, have contributed
    to higher rates of infant mortality in the United States. Access to
    prenatal care is also vitally important.

        If confirmed as Secretary of HHS, I would work to examine the range
    of HHS programs, including research to prevent infant mortality,
    programs to prevent child abuse and neglect, efforts to increase access
    to health services for low-income pregnant women and infants, childhood
    vaccination initiatives, home visitation programs, and other
    initiatives across the Department to ensure these resources are used
    more effectively to address this issue and, if necessary, seek
    additional funds.

        Regarding metrics used to report infant mortality, I agree that
    measurement is extremely important as we tackle this problem. I intend
    to work with the Congress and within the Department to bring more
    consistency and accuracy to how we measure infant mortality.
                          medicare part d/dir payments
        Question. As you know, community pharmacies serve on the front
    lines as health-care providers and play an integral role as part of the
    Medicare Part D benefit. In recent years, however, pharmacies have
    faced increasing uncertainty in their ability to serve Medicare
    beneficiaries due to the increasing use of post-claim adjudication
    price concessions and fees imposed by pharmacy benefit managers, called
    Direct and Indirect Remuneration (DIR) fees.

        CMS has recognized issues with how DIR fees are reported by part D
    plan sponsors, how these fees impact pharmacy business, and the
    resulting challenges they create for Part D beneficiaries. To respond
    to these issues, CMS proposed guidance (Proposed Guidance on Direct and
    Indirect Remuneration and Pharmacy Price Concessions) to standardize
    the timing of how these fees are reported on September 29, 2014. This
    proposed guidance would help pharmacists better serve Part D
    beneficiaries by providing greater clarity about their reimbursement
    when medications are dispensed and would benefit beneficiaries in that
    they would be able to make more accurate comparisons in plan
    selections.

        Will you commit to supporting the finalization of such guidance?
    Are there other things you would do to ensure pharmacies have the
    information they need--in real time--to best serve their beneficiaries?
    If so, what are they?

        Answer. If confirmed, I will look forward to working with you to
    consider how to resolve this pending guidance issue. Incidentally, I
    understand that on January 19, 2017, CMS released a fact sheet with
    information about recent trends in drug costs and Direct and Indirect
    Remuneration (DIR) under Medicare Part D.
                                     epsdt
        Question. Identifying and treating conditions early in life--during
    childhood--before they become expensive long-term liabilities, is not
    only the right thing to do, but also cost effective. In 1967, Congress
    added a guaranteed benefit for children in the Medicaid program called
    Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
    benefit.

        To this day, EPSDT continues to guarantee that children in the
    Medicaid program are appropriately screened and given the necessary
    treatments they need to thrive. If Medicaid were turned into a block
    grant--and existing Federal standards were cut back--EPSDT would be at
    serious risk, and child health would be put in jeopardy.

        Are you committed to maintaining EPSDT as a guaranteed benefit for
    children in the Medicaid program?

        Answer. Children are, and will continue to be, a high-priority
    population within the Medicaid program. States are well-positioned to
    determine the most appropriate ways to ensure access to the highest
    quality care for children, which includes diagnosis and screening
    procedures and the illnesses and conditions they uncover.

        Question. What are the most important metrics in evaluating the
    success of the EPSDT program?

        Answer. From a clinical perspective, successful diagnosis and
    screening procedures are determined by how well they identify illnesses
    and conditions. Successful treatment of those illnesses and conditions
    is best evaluated by the extent to which the patient's care goals are
    achieved.

        Question. If confirmed, how will you use your authority to make
    sure EPSDT remains an effective program in ensuring children's health
    through Medicaid?

        Answer. I look forward to working with States interested to advance
    initiatives designed to improve the quality of care provided to all
    Medicaid members, especially children.

        Question. Through the creation of the EPSDT benefit, Medicaid
    solidified dental services as a necessary component of coverage for
    low-income children and adolescents. Similarly, Congress recognized the
    need to include dental coverage as a requirement in the second
    iteration of the Children's Health Insurance Program (CHIP). The ACA
    then built on these two programs, and now pediatric dental coverage and
    preventive oral health services are included in many private insurance
    packages. Despite these advances, tooth decay remains the most common
    chronic condition among children.

        How would you ensure that any major health reform efforts
    appropriately prioritize children's oral health, both in terms of
    benefits and affordability?

        Answer. If confirmed as Secretary, I would hope to work with you to
    revisit the current CMS's ``Oral Health Strategy'' for children
    (https://www.medicaid.gov/medicaid/quality-of-care/downloads/cms-oral-
    health-strategy.pdf). I would also aim to provide States with
    flexibility in their Medicaid programs to provide both coverage and
    access to these services. Lastly, there may be opportunities to
    encourage innovation in both the coverage and payment for these
    services as well as the actual technology and even the relevant public
    health education strategies.
                            medicaid payment parity
        Question. On average, Medicaid pays providers about 70 percent of
    what a Medicare provider receives for the same service. The only
    difference is the age of the patient being served. There are 45 million
    children enrolled in Medicaid and as you noted in your hearing, and
    inappropriately low Medicaid payments impede the ability of providers
    to accept more patients--both pediatric and adult--covered through this
    program.

        Along with Senator Murray, I have worked to introduce the Ensuring
    Access to Primary Care for Women and Children Act in past Congresses,
    legislation that would solidify parity between Medicare and Medicaid
    reimbursements for primary care.

        In today's hearing, you mentioned that only one in three providers
    accepts Medicaid patients. You cannot deny that lower Medicaid
    reimbursements is a contributing factor to this issue.

        This is a platform in which the HHS Secretary can take a stance and
    move legislation forward. Do you believe that a child's care should be
    valued at only 70 percent of that of an adult?

        Answer. A child's care should not be valued at only 70 percent of
    that of an adult. The current Medicaid payment system is an inelegant
    combination of base rates set by States, supplemental payments to
    providers, and other Federal and State funding sources for care to the
    Medicaid or uninsured populations.

        Question. If confirmed, how will you work to improve access to care
    under Medicaid by adequately and equitably reimbursing physicians that
    treat Medicaid patients?

        Answer. I agree that adequate Medicaid reimbursement is essential
    to ensuring care for some of our most vulnerable citizens, and I look
    forward to working with Congress to accomplish this important
    objective.
                                      lead
        Question. Dr. Price, do you believe that there is no safe level of
    lead in children's blood?

        Answer. Science should guide our conclusions in this area. If
    confirmed, I look forward to working with you to ensure safe
    environments for America's children.

        Question. The CDC very recently lowered its reference level for
    public health intervention for elevated childhood blood lead levels
    from 5 to 3.5 micrograms per deciliter.

        Lead is a neurotoxin, and exposure to it can have devastating
    lifelong consequences for children. Ohio is one of 29 States receiving
    funding from CDC for a State-wide lead poisoning prevention program. In
    2014, almost 6,000 children under age six in Ohio, or 3.85% of those
    tested, had elevated blood lead levels.

        If confirmed, will you keep the CDC's lowered lead reference level?

        Answer. If confirmed, I pledge to work with our public health
    specialists at CDC and throughout the Department to learn more about
    the impact of lead poisoning and communicate the dangers to families
    and communities.

        Question. At the end of 2016, CMS committed to developing and
    improving a targeted blood lead screening policy to ensure more
    children eligible for EPSDT benefits are tested. Can you commit to
    continuing this work and improving coordination across Federal agencies
    to enhance our lead screening and treatment policies and achieve better
    outcomes?

        Answer. If confirmed, I commit work to improve coordination across
    Federal agencies to enhance our lead screening and treatment policies
    to achieve better outcomes.

        Question. What additional actions would you have HHS take to reduce
    the number of American children with elevated blood lead levels?

        Answer. If confirmed, I pledge to work with our public health
    specialists at CDC and throughout the Department to learn more about
    the impact of lead poisoning and communicate the dangers to families
    and communities in order to reduce the number of American children with
    elevated blood lead levels.
                 temporary assistance for needy families (tanf)
        Question. As part of welfare reform, Congress restructured the
    Temporary Assistance for Needy Families--or TANF--program as a fixed
    block grant. Evidence shows that one effect of turning TANF into a
    block grant program has been that States are spending less and less on
    TANF programs and instead using these Federal dollars to support gaps
    in State budgets. This change has resulted in more Ohioans who struggle
    to support their families with earnings below the poverty level.

        What does that say about other proposals to block grant programs
    like Medicaid? Do you think that the block grant approach should be a
    model for other safety net programs?

        Answer. While this would ultimately be a matter for Congress to
    decide, I have long supported States finding their own solutions in
    addressing unique or complex situations in their States.

        Question. In November 2015, the State of Ohio asked HHS for a TANF
    waiver that would have (1) removed the distinction between ``core'' and
    ``non-core'' hours, (2) increased the vocational education training
    limit from 12 to 36 months, (3) increased the job search and job
    readiness time limit from 6 to 12 weeks and removed the 4 consecutive
    week time limit, and (4) removed the 16 hour monthly cap on good cause
    hours credited towards work participation (while maintaining the 80
    hour annual cap). HHS never acted on this request.

        Given that this application has the support of Governor Kasich, if
    confirmed as HHS Secretary, would you grant this waiver to the State of
    Ohio?

        Answer. In 2012, GAO responded to a congressional inquiry about an
    ACF Information Memorandum inviting States to apply for waivers to the
    TANF work requirement. GAO concluded that the Information Memorandum
    was a rule that must be submitted to Congress and the Comptroller
    General before taking effect. If confirmed as HHS Secretary, I will
    enquire about the status of this matter and the waiver request from the
    State of Ohio, and provide a response if one has not previously been
    sent.
                     medicare observation status/3-day rule
        Question. Instead of privatizing Medicare or raising the
    eligibility age, we should be discussing ways to make Medicare stronger
    for our Nation's seniors. One way to strengthen the program--which you
    brought up in today's hearing--is to enable beneficiaries better access
    to skilled nursing facilities after hospitals stays by revisiting the 3
    day rule.

        In order for Medicare Part A to cover skilled nursing facility
    care, a beneficiary must be admitted to a hospital for 3 days under
    inpatient status. I have heard from too many Ohioans whose skilled
    nursing facility care was not fully covered by Medicare because their
    hospital stays were classified as ``observation'' rather than
    inpatient.

        My Improving Access to Medicare Coverage Act, which I plan to
    reintroduce this Congress, which would enable time beneficiaries spend
    in the hospital under observation to count toward the 3-day requirement
    for Medicare coverage.

        If confirmed, will you work to administratively correct this
    billing technicality that adversely impacts Medicare beneficiaries? If
    you are unable to do so administratively, will you work with me to pass
    this legislation to correct the deficiency in current law?

        Answer. If confirmed, I will be pleased to work with you to further
    consider the necessity of the 3 day rule and its pros and cons. I will
    endeavor to work with CMS to identify what more can be done with regard
    to the observation status issue as well. And if the best path forward
    involves legislation, I would be pleased to work with you on that as
    well.
                                  biosimilars
        Question. Last year, a number of my colleagues and I sent a letter
    to then President-elect Trump, encouraging him to work with us on
    reducing prescription drug prices for all Americans. Specifically, we
    highlighted the need to promote innovation and foster competition in
    drug development.

        I have introduced legislation in the past that would help achieve
    this by shortening the patent exclusivity period for expensive, brand-
    name biologic drugs and allow biosimilars to enter the market sooner.
    Biosimilars, which are equivalent in safety and efficacy to their
    reference biologics, have the capacity to reduce prescription drug
    costs, yet physicians must be willing to prescribe them and patients
    need the information necessary for them to be confident in taking them.

        As a physician, do you believe physicians and patients understand
    what biosimilars are and how they work? Do you believe the patients and
    physicians see biosimilars as a safe, effective, and less-costly
    alternative to biologics?

        What do you believe to be the FDA's role in educating patients,
    providers, and other stakeholders about biosimilars? How will you, as
    Secretary of HHS, support and encourage the robust uptake of
    biosimilars in the United States?

        Answer. As a doctor, I appreciate your concern that health-care
    providers and patients be informed when making health-care decisions.
    It is important that the FDA provide clear and timely guidance as it
    carries out its responsibilities with respect to biosimilars. I
    understand that this is particularly important given that the number of
    biosimilars available to consumers is expected to increase and the
    potential that these products have to increase consumers' health-care
    options.
                                  cost-sharing
        Question. More than 25 years ago, Congress implemented protections
    to ensure that Medicare beneficiaries are treated and billed fairly by
    their providers in response to growing concerns that patients charged
    more than the standard 20% Part B coinsurance were opting out of
    critical care due to high out-of-pocket costs. However, while you were
    in Congress, you backed legislation that would have weakened these
    protections, allowing Medicare providers to enter into private
    contracts with seniors and people with disabilities to determine cost
    sharing amounts.

        Do you maintain your position that these patient protections should
    be undone and will you continue to advocate for permitting doctors who
    serve seniors to charge them more than 20% over what Medicare pays,
    your concern being that those limits compromise access to care for
    seniors?

        Answer. If there are any program changes in this area, they should
    be voluntary for both patient and physician.

        Question. Do you believe that Medicare doctors should be allowed to
    charge patients whatever they choose?

        Answer. If there are any program changes in this area, they should
    be voluntary for both patient and physician.

        Question. What would you say to fixed-income seniors who receive
    unexpected additional costs simply so that physicians can be paid more
    than the agreed-upon insurance coverage limit? Is this not putting
    patients above profits?

        Answer. Our goal is to ensure all Medicare recipients are able to
    obtain the highest quality health care. If there are any program
    changes in this area, they should be voluntary for both patient and
    physician.
               state health insurance assistance programs (ships)
        Question. The State Health Insurance Assistance Programs (SHIPS)
    are the only source of one-on-one Medicare counseling for seniors and
    people with disabilities. In 2015, over 7 million people with Medicare
    received help from SHIPs, including 375,000 Ohioans using the Nation's
    best-ranked SHIP program in the country. Since 1992, counseling
    services have been provided via telephone, one-on-one in-person
    sessions, interactive presentation events, health fairs, exhibits, and
    enrollment events. Individualized assistance provided by SHIPs almost
    tripled over the past 10 years.

        This modest program is operated in every State and U.S. territory,
    and has been significantly under-funded for years despite the growing
    demand for services by our Nation's seniors and individuals with
    disabilities.

        Will you pledge to support increased funding for SHIPs as the
    country's Medicare-eligible population continues to grow in the
    President's proposed budgets?

        Answer. If confirmed, I will fairly consider the needs and work of
    the SHIPs in light of a growing Medicare population, as well as
    consider other ways to support them to make them even more efficient.
    SHIPs and others like them play an important role in making sure
    patients are actual health-care consumers. This is a virtuous cycle
    because it facilitates putting the patient at the center of both health
    care and health-care coverage decision-making.
                                  drug pricing
        Question. In December, President Trump told Time magazine, ``I'm
    going to bring down drug prices. I don't like what has happened with
    drug prices.''

        Do you agree with President Trump? If confirmed as Secretary of
    HHS, will you work to bring down drug prices?

        Answer. Yes. We all share concern when prescription drug prices are
    too high for anyone to access the drugs they need. This especially
    concerns me as a doctor. If confirmed, I will ensure that CMS looks for
    ways to ensure that it uses the authorities and tools it has at its
    disposal to ensure drug prices in the Medicare program, in both part B
    and part D, are manageable for beneficiaries.

        Question. Given the significant burden prescription price tags have
    on individuals and taxpayers, what do you see as the best market-based
    solution to combat prescription drug price gouging?

        Answer. In addition, we need to continue to build on the gains
    towards affordability allowed by the Generic Drug User Fee Act and find
    additional ways to facilitate more efficient generic entry. This starts
    with making sure that we are giving generic sponsors clear guidance so
    that they can prepare approvable applications on the first try. If I'm
    confirmed, I'm committed to working with the FDA (and Congress, if
    appropriate) to find additional efficiencies and administrative steps
    that can help facilitate appropriate generic entry.

        Question. Do you believe that Americans deserve more information
    about when and how prescription drug prices rise so that they can make
    the most informed decisions for their families?

        Answer. Yes. I support empowering patients by putting more
    information in their hands so they can make health care consumer
    choices that make sense for them and their families.
                         office of refugee resettlement
        Question. The Secretary of HHS responsible for overseeing the
    Office of Refugee Resettlement at HHS. This office is in charge of
    providing for the basic needs of refugees when they first arrive in the
    United States, including victims of human trafficking, torture
    survivors, individuals who are granted asylum, and those who are
    resettled here after helping our troops abroad because it is no longer
    safe for them in their home country.

        If confirmed, what will you do to ensure these necessary services
    are provided despite a significant lack of funding for this program?
    What are your plans for this office?

        Answer. The law is clear when it comes to administering services
    for refugees, survivors of torture, and other populations who receive
    assistance through ORR. If I am confirmed, I will work to effectively
    and efficiently administer this Office.

        Question. Will you advocate for additional resources for this
    office, given the current refugee crisis across the globe?

        Answer. Should circumstances on the ground change, and current
    resources are found to be insufficient, I will inform Congress and work
    with them on finding solutions.

        Question. How will you work with our partners around the globe to
    ensure a safe and smooth transition for refugees coming into the United
    States?

        Answer. Should I be confirmed, it would be my expectation to work
    with the U.S. Department of State, as well as our partners around the
    globe, to ensure a safe and smooth transition for refugees coming into
    the United States.
               center for medicare and medicaid innovation (cmmi)
        Question. You've stated that you support innovation and see
    potential in CMMI. Would you support continued testing through CMMI in
    its current form?

        Answer. CMMI is a program providing significant opportunity for
    testing new models for health-care financing and delivery. I defer to
    the Congress regarding the funding of the Innovation Center and any ACA
    repeal and replacement legislation. If confirmed, as HHS Secretary--and
    if the Innovation Center remains funded--I will ask CMS to pursue
    models that will lower health-care costs and improve quality for
    Medicare and Medicaid beneficiaries.
                     accountable care organizations (acos)
        Question. Many hospitals, physicians, nursing facilities, and
    others have invested significant resources to participate in ACOs and
    bundled payment systems. Ohio is home to some of the largest ACOs, by
    membership, in the Nation.

        How would you respond to the concerns of ACO administrators and
    providers that there may be delays or disruptions in their innovative
    models due to a repeal of the ACA?

        Answer. If confirmed, I am committed to working with all providing
    health care to incentivize innovative models for care financing and
    delivery.

        Question. Do you support the continued implementation of the
    current voluntary models--ACOs and bundled payment models?

        Answer. In general, yes. I look forward to reviewing all models, if
    confirmed. As a physician, I appreciate the goal behind the creation of
    the ACO model: better patient care. As a legislator, I would agree
    their successes have been modest to date, and there are some challenges
    they face as well. ACOs are a tool in the toolbox to help ensure high
    quality, low cost health care for beneficiaries. They are not a silver
    bullet to all of our country's delivery system challenges. If
    confirmed, I plan to work with the CMS Administrator to ensure that we
    learn from ACOs' successes and challenges to date as we chart the path
    forward.

        For certain populations, bundled payments make a lot of sense. And
    they can often lead to both better health outcomes and reduced costs.
    But it is important we not get fixated on one of those two outcomes.
    That is, I support making certain that we deliver care in a cost-
    effective manner but we absolutely must not do things that harm the
    quality of care being provided to patients.

        What we ought to do is allow for all sorts of innovation. Not just
    in this area. There are things that haven't been thought up yet that
    would actually improve health-care delivery in our country and we ought
    to be incentivizing that kind of innovation. And in finding our way to
    those innovations, we ought to remember we are not talking about
    science experiments in a lab or a computer simulation, but about
    experiments involving real patients' lives.
                              pama implementation
        Question. In 2014, Congress passed the Protecting Access to
    Medicare Act (PAMA), which included a provision to change the way labs
    are reimbursed under the Medicare program by moving away from the
    Clinical Laboratory Fee Schedule (CLFS) and toward a more market-based
    payment methodology.

        We are concerned that CMS's regulations implementing this
    provision, finalized in June 2016, contain a reporting deadline that is
    difficult for the laboratory community to meet. In addition, many of
    our community-based and regional laboratory constituents serving the
    Medicare program have expressed significant concerns over requirements
    from the regulation that make reporting accurate data a concern, and
    requirements from the regulation that result in the exclusion of market
    data from the hospital outreach laboratory community. Lastly, we have
    concerns over CMS's definition of an ``applicable lab'' in the final
    regulation. We believe the current definition would result in very few
    labs having to report their data.

        The Office of the Inspector General has also raised each of these
    issues--the timeline, accuracy, exclusion of hospital labs, and lack of
    required reporting--as potential flaws in the regulation in their
    September 2016 report, which addressed PAMA implementation. In fact,
    the OIG reported that only 5% of labs will be required to report payer
    data, excluding 95% of the market and thereby potentially skewing the
    market rates.

        In order to fulfill the goals of PAMA, it is critical that the
    market data collected and assessed by CMS represents the entire
    laboratory market, consistent with the statute, to ensure both
    equitable and successful implementation of the law. Understanding that
    this regulation is on a short time-line, given that CMS is set to
    finalize a new fee schedule in 2017 for implementation in 2018, what
    would you do to address the concerns listed above and ensure the new
    market-based payment methodology and payment processes for clinical
    laboratory tests are not unduly burdensome on community-based labs or
    potentially detrimental to patient access?

        Answer. I appreciate your concerns regarding the implementation of
    PAMA. Certainly, we should strive for accuracy in this market data
    collection process. I look forward to following up with CMS staff and
    agree that community-based labs should not be unduly burdened and thus
    limiting patient access.

        Question. Will you commit to revisiting the definition of
    ``applicable lab'' to ensure equitable and successful implementation of
    the law, accurately reflecting the entire market?

        Answer. As you know, section 216(a) of the Protecting Access to
    Medicare Act of 2014 (PAMA) added section 1834A to the Social Security
    Act (the Act), which requires revisions to the payment methodology for
    clinical diagnostic laboratory tests paid under Medicare, including
    reporting requirements for laboratories.

        CMS finalized a low expenditure threshold to reduce the reporting
    burden on small laboratories. Under the final rule, CMS will generally
    exclude a laboratory from being an applicable laboratory, and thus from
    having its private payor data reported, if it is paid less than $12,500
    under the CLFS during a data collection period. CMS expects that 95
    percent of physician office laboratories and 55 percent of independent
    laboratories will not be required to report. Additionally, I understand
    CMS-imposed reporting requirements at the TIN level will be less
    administratively burdensome for the laboratory industry as compared to
    requiring data to be reported at the NPI level.
                     medicaid and family planning services
        Question. Two-thirds of births from unintended pregnancies in the
    United States are paid for by Medicaid or the Children's Health
    Insurance Program (CHIP). In 2010, these unintended pregnancies cost a
    total of $21 billion dollars, including $824 million in Ohio.

        We know that publicly funded family planning allows families to
    prevent unwanted pregnancies, and it is estimated that investing in
    family planning services would have saved public funding of unintended
    pregnancies by a total of $15 billion, including $607 million for Ohio.
    That's striking--almost 75 percent of the money that would otherwise be
    spent could be saved through more robust, fully funded family planning
    programs.

        Do you acknowledge the effectiveness of investing in contraception
    and the need to continue the Medicaid State option to expand family
    planning services?

        Answer. If confirmed, I would work as HHS Secretary to ensure that
    the Medicaid program is well administered, effective, and available for
    eligible beneficiaries and that the States/Governors are given the
    flexibility to pursue approaches that fit the needs of their States.
    That being said, I would be hesitant to develop policy on the basis of
    financial cost of life.

        Question. How will ensure that family planning services, included
    access to preferred contraception methods, will remain available to all
    women, as you committed to do in today's hearing?

        Answer. Women should have the health care that they need and want.
    The system we ought to have in place is one that equips women and men
    to obtain the health care that they need at an affordable price. As we
    work towards a replacement for the ACA, I expect this will be one of
    the topics of discussion.
                                federal research
        Question. As chairman of the House Budget Committee, you stated in
    your FY17 Budget Resolution that ``the Federal Government has a role to
    play in supporting breakthrough research.'' As a medical doctor, you
    must understand the importance not only of funding research to find
    better cures for your patients, but also of funding the training of the
    next generation of doctors and researchers.

        If confirmed, how do you pledge to protect and advocate for the
    government's critical Federal research initiatives?

        Answer. As a physician, I am keenly aware of the progress that has
    been made and still to be made through important research initiatives
    that are fully or partially funded by the Federal Government.
    Implementing the recently passed 21st Century Cures Act will be a
    priority in coming months and years, including leveraging the
    significantly increased funding for the NIH. NIH plays a leading role
    in so many public-private initiatives, and if confirmed, I look forward
    to working with leaders at the NIH to advance their important mission
    and our administration's efforts to promote innovation on behalf of the
    American people.
                           syringe exchange programs
        Question. Like many communities in Ohio, your district in Georgia
    has been hit by a significant increase, a 4,000 percent increase, in
    opioid-related deaths in the last 5 years. Simultaneously, we are also
    seeing an increase in hepatitis C infections and HIV infections among
    those who inject opioids and share syringes. One of the clearest
    examples of this connection is the HIV outbreak in Scott County,
    Indiana, the home State of Vice President Pence. In response to this
    crisis, then-Governor Pence declared a public health emergency and
    changed Indiana's policy to allow State dollars to support Syringe
    Exchange Programs or SEPs.

        The Centers for Disease Control and Prevention (CDC), Institute of
    Medicine, and many other scientific bodies have stated unequivocally
    that SEPs are highly effective in stopping the spread of HIV/AIDS and
    Hepatitis C. Cleveland has one of the longest standing SEPs, and as a
    result has seen a decrease in the rate of new HIV infections as a
    result of intravenous drug use. In response to progress like this,
    Congress partially lifted the restrictions related to the use of
    Federal funds for SEPs in 2015. In fact, I note that your wife, who
    serves in the Georgia House of Representatives, has also worked to
    expand access to needle exchange programs.

        In the past, you have voted against funding for needle exchange
    programs. Has your position changed?

        Answer. As I mentioned in the hearing, I recognize that the opioid
    epidemic is real and that substance abuse disorders are plaguing many
    Americans. It is important that we as a nation make sure that every
    single individual has access to the kind of mental health and substance
    abuse care that they need. I have a broad and open mind and welcome
    proposals to our Nation's mental health and substance-abuse related
    crises, particularly those solutions that are evidence-based. If I am
    privileged to serve as the HHS Secretary, I will follow the policies
    adopted by the Congress and signed into law by the President.

        Question. Do you support continued availability of Federal funds
    for SEPs, based on local public health department determination of
    need? Why did you oppose it in the past?

        Answer. The opioid epidemic is real and substance abuse disorders
    are a serious concern for communities across the country. It is
    important that we as a nation make sure that every single individual
    has access to the kind of mental health and substance abuse care that
    they need. I recognize that we may not always agree on the solutions,
    but we have a duty to those who are suffering to work together to find
    the best answers to these severe problems. I welcome proposals to our
    Nation's mental health and substance-abuse related crises, especially
    those that are well supported by evidence. Funding decisions ultimately
    rest with the Congress, which holds the power over the purse. If I am
    privileged to serve as the HHS Secretary, I will follow the policies
    adopted by the Congress and signed into law by the President.

        Question. If confirmed as Secretary of HHS, how will you work with
    States to ensure they have the resources and support necessary to
    continue and open new SEPs?

        Answer. It is important that we as a nation make sure that every
    single individual has access to the kind of mental health and substance
    abuse care that they need. All levels of government need to engage and
    collaborate to identify effective solutions to these problems.
                             antibiotic resistance
        Question. The emergence of this superbug is extremely serious and
    illustrates both how quickly infectious pathogens can spread across the
    world and the need for international cooperation in detecting newly
    emerging health threats.

        Do you agree that a dedicated effort to improving surveillance,
    data collection and research efforts is needed to prevent such rapid
    spread and evolution of antibiotic resistant bacteria?

        Will you advise President Trump to continue President Obama's
    National Strategy for Combating Antibiotic-Resistant Bacteria (CARB
    initiative)?

        How will you ensure that the threat of antimicrobial resistance
    remains a high priority for HHS and its affiliates the National
    Institutes of Health (NIH), Food and Drug Administration (FDA), and
    CDC? In your opinion, how should the United States work with other
    nations to combat these threats?

        Answer. I share your concern regarding the need to take seriously
    the public health threat posed by antibiotic resistance. I appreciate
    the important role HHS can play in combatting this public health
    threat, from identifying resistance and educating the American people
    about it, to helping to advance innovative, new therapies to treat
    emerging infections. If confirmed, I look forward to continuing to work
    in this area as part of HHS' public health mission.
                               powdered caffeine
        Question. In 2014, Logan Stiner--who was a senior at Keystone High
    School in LaGrange, OH--died just 3 days before his high school
    graduation from ingesting too much powdered caffeine. For the last
    several years, I have worked with Logan's family to raise awareness
    about the dangers of powdered caffeine and encourage the FDA to take
    meaningful action to limit access to powdered caffeine.

        Right now, children and teenagers can buy this potentially deadly
    chemical in bulk from domestic and international retailers by simply
    going online and clicking a button--without their parents even knowing
    about it. Further, companies are trying to find creative new ways to
    reach consumers and to dodge States like Ohio that have already passed
    laws cracking down on this dangerous substance.

        The FDA advises consumers against using powdered caffeine and has
    called upon manufacturers to more accurately label these products. But
    these actions by the FDA do not go far enough. As Secretary of HHS,
    which has jurisdiction over FDA, how will you ensure that the
    Department's affiliates, particularly the FDA, are effectively
    educating and protecting consumers about the products available to
    them?

        Answer. FDA plays a valuable role in providing the American public
    with timely information about FDA regulated products. I appreciate the
    importance of FDA informing individuals and families about whether or
    how to use these products. If confirmed, I will ensure that FDA is
    fulfilling its statutory responsibilities consistent with its public
    health mission.
                    medicare advantage star ratings program
        Question. As you know, CMS uses a star rating system to display the
    quality of Medicare Advantage plans. High performing plans receive
    quality bonus payments. CMS also has an audit and appeals process by
    which to periodically evaluate plans on specific measurements.

        Over the past several years, there have been several circumstances
    we are aware of where plans are penalized in their star-ratings based
    on deficiencies found in an audit. We have heard from a plan based in
    our home State of Ohio that was penalized by the interaction between
    the audit and appeals policies and the star-ratings program.

        If you are confirmed, can you commit to taking a deeper look at the
    interaction of these two policies and the potentially negative effect
    on plans, on beneficiaries, and on innovative care delivery?

        Answer. Yes. If confirmed, I would be pleased to work with your
    office and CMS to ensure that the Medicare Advantage stars system
    reflects quality and the Medicare Advantage sanctions system reflects
    program audit performance, as well as explore whether and how these
    policies can be made to work in concert rather than against each other.
                                cancer moonshot
        Question. During last year's State of the Union address, President
    Obama announced the Cancer Moonshot initiative, an ambitious project
    aimed at improving cancer prevention, diagnosis, and treatment at twice
    the rate of current progress of clinical cancer research. The 21st
    Century Cures Act re-committed to this critical initiative through the
    inclusion of funding for the next 5 years of the program.

        Academic and clinical centers in Ohio are playing important roles
    in the execution of this initiative, through partnerships like that
    that exists between The Ohio State University's Comprehensive Cancer
    Center and Columbus's Richard J. Solove Research Institute with Tampa's
    Moffitt Cancer Center to form the ORIEN partnership. This initiative is
    particularly focused on inclusion and retention of minorities in
    cancer-specific clinical trials, an important diversity metric to
    improve clinical care for all Americans.

        As Secretary of HHS, how will you work to facilitate collaborations
    between researchers and clinicians to improve cancer care under the
    goals outlined by the Cancer Moonshot?

        Answer. If confirmed, we will make treating and helping to cure
    cancer a priority and there likely will be overlap with the Cancer
    Moonshot goals. Implementing the recently passed 21st Century Cures Act
    will be a priority in coming months and the administration will
    accelerate efforts to promote innovation in many areas--including the
    prevention, diagnosis and treatment of cancer.
                                  tuberculosis
        Question. Globally, tuberculosis is now killing more people than
    HIV/AIDS, with a death toll of nearly 5,000 per day. In 2015, the
    United States experienced the first national increase in TB cases since
    1992, with 9,557 total cases. And in 2013, CDC identified drug
    resistant TB as a serious public health threat.

        CDC provides critically important support to local health
    departments to address the TB epidemic, and it supports crucial TB
    research. CDC also provides crucial support to the global fight against
    drug resistant TB.

        Despite these sobering statistics and impressive work done by the
    CDC, funding for CDC's domestic TB program has remained stagnant since
    FY 2005 at $135 million. As a result, the CDC has stated that are our
    national response to TB ``has stalled.''

        If confirmed, will you implement the U.S. National Action Plan for
    Combating Multi-Drug Resistant Tuberculosis, and will you support
    increased Federal funding for the U.S. response to this deadly,
    airborne infectious disease?

        Better TB drugs and diagnostics are being developed, thanks to U.S.
    ingenuity, and these new tools can help us stop this epidemic. What
    will you do, if confirmed as Secretary of HHS, to advance these drugs
    and diagnostics and provide support to the communities working to
    develop new treatments?

        Answer. As a physician, I recognize and share your concern
    regarding the public health threat posed by tuberculosis, particularly
    drug resistant tuberculosis. If confirmed, I look forward to working
    with CDC officials in their efforts to combat the spread of
    tuberculosis.
                 low-income heating assistance program (liheap)
        Question. As you may know, the LIHEAP program plays a key role in
    helping low-income families stay warm in the winter and avoid dangerous
    heat in the summer. It is a program that is critical to nearly 450,000
    households in Ohio that otherwise would be forced to choose between
    keeping warm or going hungry.

        If confirmed, will you commit to maintaining the program as
    currently structured?

        Answer. If I am confirmed, I will implement the program dutifully
    in as effective and efficient manner as possible.

        Question. Nationwide, nearly 7 million of our Nation's poorest and
    most vulnerable households rely on the program. Will you commit to
    maintaining and possibly even supporting an increase in the program's
    annual appropriation?

        Answer. If I am confirmed, I will implement the program dutifully
    in as effective and efficient manner as possible. Should circumstances
    on the ground change, and current resources are found to be
    insufficient, I will inform Congress and work with them on finding
    solutions.
                                nuclear medicine
        Question. Diagnostic nuclear medicine procedures help millions of
    Medicare beneficiaries detect life altering illnesses, such as heart
    disease and cancer, each year. The quick turnaround on nuclear testing,
    when used appropriately, helps improve the quality and efficiency of
    care by helping to reduce inappropriate or unnecessary procedures.
    Despite these positives, CMS continues to treat the diagnostic
    radiopharmaceutical drugs used in nuclear medicine procedures as
    supplies--not drugs--and, as a result, they are not appropriately
    reimbursed under this system.

        Physician and industry groups have been working for years to try to
    address this issue. If confirmed, will you work with stakeholders to
    develop superior payment models to these drugs and nuclear medicine
    procedures are appropriately reimbursed?

        Answer. I share your concerns and look forward to working with you,
    if confirmed.
                                  therapy caps
        Question. As you know, the therapy cap exceptions process expires
    in less than a year--on December 31, 2017. We have all heard from
    constituents whose therapy needs exceeded the cap and their conditions
    have deteriorated, necessitating more expensive medical intervention.

        As Secretary of HHS, how will you support the repeal of these
    arbitrary and discriminatory limits and maintain access to
    rehabilitation therapy that Medicare beneficiaries clearly need?

        Answer. Rehabilitative therapy is a vital component of recovery for
    many patients. Arbitrary limits on its use are not a wise decision for
    patient-centered care. If confirmed as Secretary, I will look into this
    issue and seek to understand the competing objectives and issues
    motivating the current CMS policy. Part of the frustration with the
    current health care system is rules like this that do not make sense to
    many people. However, that is not surprising when one considers that
    Medicare Parts A, B, C, and D have each developed in silos and that
    even payment for particular types of services sometimes reflect silos
    within the silos. It may be that other approaches to therapy provide
    greater quality care at reduced cost with more respect for the
    individual needs of each patient in consultation with their doctor. If
    confirmed as Secretary, I would hope to break down these silos and
    encourage approaches based on a broader perspective.

        Question. Given the problems associated with monitoring the therapy
    cap, is CMS capable of achieving a timely uniform and defensible
    streamlined, responsive, and transparent process for manual medical
    review of Medicare records by Medicare administrative contractors?

        Answer. We will strive to do so. Any time there is manual review of
    anything in an organization with the scale of Medicare, it is a recipe
    for something to go wrong. If confirmed as Secretary, I would be
    pleased to work with you to confirm whether the staffing and other
    resources needed would be up to the challenge you describe.
                              addiction treatment
        Question. If confirmed as Secretary of HHS, how will you prioritize
    the prevention, treatment, and recovery from mental and substance use
    disorders in States like Ohio?

        As our country continues to explore potential reforms to our health
    care delivery systems, what will you do to prioritize access to
    behavioral health services?

        Answer. Mental and substance abuse disorders continue to be a
    serious challenge felt in communities across the Nation. I firmly
    believe, that it is absolutely vital that substance abuse disorders and
    other mental health problems are treated. If confirmed, I will work
    closely with you and the other members of Congress to ensure that the
    Substance Abuse and Mental Health Services Administration fulfills its
    duty of treating those who are in addiction recovery while working to
    prevent people from becoming addicted in the first instance.
                                  pharmacists
        Question. The Pharmacy and Medically Underserved Areas Enhancement
    Act recognizes pharmacists as healt-care providers in underserved areas
    in order to expand access to care. In areas with a shortage of primary
    care providers, pharmacists may play a key role in helping patients
    manage their diseases to avoid Emergency Department visits and
    hospitalizations. These services are especially important for patients
    with multiple chronic conditions who may be taking several medications
    at a time.

        If confirmed as HHS Secretary, would you support this approach as a
    way to increase care in rural and underserved areas?

        Answer. We ought to step back and say, ``What are we doing wrong?''
    as one out of every eight physicians no longer sees Medicare patients.
    Therefore, if confirmed as Secretary, I would be open to all options to
    address the impact of the ongoing physician shortage in rural areas.
    Paying pharmacists in underserved areas to engage in certain medical
    services could work well in those States where pharmacists have such
    licensure and a setting appropriate to the services, where primary care
    doctors continue to be involved in care, and where there is a patient
    and consumer demand for such services.

                                     ______

                Questions Submitted by Hon. Robert P. Casey, Jr.
                               medicaid and chip
        Question. You have proposed eliminating the Patient Protection and
    Affordable Care Act, an action that would end the expansion of Medicaid
    to millions of people and would result in an addition $1.1 trillion
    being cut from State budgets. This action would throw millions of
    people into the realm of the uninsured, including hundreds of thousands
    with disabilities. They would no longer have access to such services
    and treatments as behavior health care, mental health treatment, and
    preventative services. The services provided by Medicaid expansion have
    greatly improved the quality of life for millions of citizens,
    particularly those with disabilities.

        Do you propose those individuals return to being uninsured? Do you
    propose that their health care, including mental health treatments, be
    discontinued? Does your plan mean you support returning hundreds of
    thousands of people with disabilities into the category of the
    uninsured?

        Answer. Our goal is to ensure access to affordable, quality health
    care for all citizens.

        Question. If your plan is implemented, many people who will lose
    Medicaid coverage will be people with disabilities who depend on
    Medicaid for services that are unavailable through private insurance;
    services such as personal care services, respite care, or intensive
    mental health services. These health, personal care, and preventative
    services allow individuals to live in the neighborhoods of their
    choice, be independent, work, and participate in their communities.
    Many of these people, capable, able people, will be forced into
    institutions if they lose access to these crucial services. They will
    lose their independence and we will pay more tax dollars for their
    care.

        How is this a good outcome for these people and for America?

        Answer. Changes to the ACA should not be done in isolation. Our
    goal is to ensure access to affordable, quality healthcare for all
    citizens. This, of course, includes people with disabilities who depend
    on Medicaid. I note that community integration, beneficiary autonomy in
    decision making, and person-centered planning are central tenets
    articulated in CMS' approach to Home and Community Based Services and
    the HCBS Settings Rule with a compliance date in March 2019, and I
    support each of those principles. It is also important to note that
    many residential, disability-
    specific settings have long provided a safe and integrated community
    alternative to institutional placement for individuals with
    disabilities, and appropriate weight should be given to the preferences
    of families and individuals with disabilities because they are in the
    best position to decide what type of setting best meets their
    individualized needs and circumstances.

        Question. Federal flexibility in Medicaid has allowed Pennsylvania
    to take extra steps to ensure that children with extensive health care
    needs have access to Medicaid, in what's referred to as Family of One
    program. This program, in addition to the Medicaid expansion for
    parents, has improved the economic security of families in
    Pennsylvania. The State's budget relies on the Federal share in order
    to support these Medicaid programs. However, the budget you authored in
    the House last year would have cut Medicaid funding by $1 trillion
    dollars, about one-third over a 10-year period.

        Given that half of Medicaid enrollees in this country are children,
    how will you ensure that children and families aren't harmed by cuts in
    Medicaid funding through block grants?

        Answer. Changes to the ACA should not be done in isolation. Our
    goal is to ensure access to affordable, quality health care for all
    citizens.

        Question. As a physician you know that Medicaid covers a broad
    range of services to address the diverse needs of the populations it
    serves. In addition to covering the services required by Federal
    Medicaid law, many States elect to cover optional services such as
    prescription drugs, physical therapy, eyeglasses, and dental care.
    Coverage for Medicaid expansion adults contains the ACA's ten
    ``essential health benefits,'' which include preventive services and
    expanded mental health and substance use treatment services. Medicaid
    provides comprehensive benefits for children, known as ``EPSDT,'' that
    are considered a model of developmental pediatric coverage. EPSDT is
    especially important for children with disabilities because private
    insurance, which is designed for a generally healthy population, is
    often inadequate to their needs.

        Unlike commercial health insurance and Medicare, Medicaid also
    covers long-term care, including both nursing home care and many home
    and community-based long-term services and supports. More than half of
    all Medicaid spending for long-term care is now for services provided
    in the home or community that enable seniors and people with
    disabilities to live independently rather than in institutions. Given
    that both EPSDT for kids and long term services and supports are not
    generally covered in commercial health plans, I fail to see how people
    will not be worse off if the structure or financing of the Medicaid
    program is restructured in the ways that you and other administration
    officials have suggested.

        Can you guarantee that under a block grant, per capita cap and/or
    an HSA structure that all of these vital services will be covered for
    the millions of Americans who count on them?

        Answer. My work in the Congress has been to improve Medicaid and
    provide additional flexibility. If I have the privilege of being
    confirmed as Secretary I would look forward to the opportunity to work
    with States and Congress using the tools and authorities given by
    Congress in legislation to ensure the highest number of people get
    access to the highest quality care.

        Question. Forty percent of Pennsylvanian children rely on Medicaid
    and CHIP, which serves our State's most vulnerable children: children
    living in or near poverty; infants, toddlers and preschoolers during
    key developmental years; children with special health-care needs; and
    children who have been place in foster care due to neglect or abuse.
    Medicaid's comprehensive, pediatrician-recommended services under
    EPSDT--Early and Periodic Screening, Diagnostic and Treatment
    services--are critical for their health and to ensure that they hit key
    development milestones. In recent years, there is clear evidence of the
    long-term return on investments in Medicaid. Children enrolled in
    Medicaid are healthier as adults and more likely to graduate from high
    school, attend college, resulting in greater economic success.

        Do you support the EPSDT benefit package for children which ensures
    that America's most vulnerable children receive the services they need
    to thrive? Are you willing to protect these benefits by not allowing
    States to waive this important benefit?

        Answer. Every State has different demographic, budgetary, and
    policy concerns that shape their approach to Medicaid and Medicaid
    expansion. That is one of the reasons I devoted so much time to working
    with States to help them to identify creative solutions, and why I
    believe a one-size-fits-all approach is not workable for a country as
    diverse as the United States. If I am confirmed, I will work with CMS
    as they take a look at waivers that are pending and appropriate for my
    input and will have to make a decision at that point.

        Question. Your 2016 budget proposal would have block granted
    Medicaid and would have eliminated many critical patient protections.
    With our current Medicaid structure, children have a right to the full
    array of services they need, from critical health screenings for cancer
    treatment to services for children with autism or mental health needs.
    For many children, this coverage can be the difference between life and
    death. Medicaid as currently structured also enables children with
    disabilities to live up to their potential, be successful in school,
    and have the opportunities to be full citizens.

        Do you support the continuation of Medicaid's requirement to cover
    a comprehensive array of services for children through the Early
    Periodic Screening Diagnosis and Treatment (EPSDT) program? Will you
    commit to ensuring that HHS will actively enforce the requirement to
    provide screenings, diagnosis, and treatment for children with
    disabilities or with potential disabilities?

        Answer. Our goal is to ensure every single American has access to
    the coverage they want for themselves or their children and dependents.
    I think the conversation and focus in these topics has been the
    question of coverage rather than true access for too long. By that I
    mean that Americans might have an insurance card and yet not be able to
    afford care or it might not be available to them for other reasons.

        Question. Many people with disabilities want to work and can do so
    with the services only available through Medicaid, to help them work.
    These services include supported employment for people with mental
    health disabilities or personal care attendants for those with
    intellectual or physical disabilities. Without these services, many
    people with disabilities will be unable to work.

        How will you ensure that a person with a disability, mental health,
    intellectual, physical, sensory, or any other type of disability as
    defined by the Americans with Disabilities Act, has access to the
    services currently available through Medicaid?

        Answer. I look forward to faithfully executing whatever law that
    Congress passes and the President signs, if I am confirmed. I commit to
    work as HHS Secretary to ensure that the Medicaid program is well
    administered, effective, and available for eligible beneficiaries and
    that the States/Governors are given the flexibility to pursue
    innovative approaches that fit the needs of their States.

        Question. As economies evolve, professions change and while new
    types of jobs emerge, certain types of jobs are reduced or eliminated
    and workers must make transitions. This happens to people across the
    workforce, but it happens almost twice as often to workers with
    disabilities.

        Do you support taking away people's Medicaid coverage because they
    lose their jobs? How will you ensure that people with disabilities who
    become unemployed are able to retain Medicaid benefits?

        Answer. Medicaid is a vital safety-net program, and it is our goal
    to strengthen it. If confirmed, I look forward to faithfully executing
    laws to strengthen the Medicaid program that Congress passes and the
    President signs.

        Question. In 1999, in the Olmstead decision, the U.S. Supreme Court
    agreed that individuals with significant disabilities have the right,
    under the Americans with Disabilities Act, to access services in the
    community rather than only in an institutional setting. Since the
    Olmstead decision, the U.S. Department of Health and Human Services has
    employed its authority over Medicaid waivers to encourage States to
    expand home and community-based services and to shift away from
    overreliance on institutional care.

        Will you continue this longstanding Federal policy? If no, why not?
    If yes, what steps will you take?

        Answer. I support encouraging the use of home and community-based
    services if the services are appropriate, the individual does not
    oppose the treatment, and the services can be reasonably accommodated.

        Question. Since the Olmstead decision, Congress has authorized
    several programs to incentivize States to meet their obligations under
    the Olmstead decision by increasing Federal dollars for providing
    community-based services. These programs include the Money Follows the
    Person program, the State Balancing Incentive Program, the Community
    First Choice State Plan option, and the Home and Community Based
    Services option. These programs are implemented and managed through the
    Department of Health and Human Services.

        Is it your view these programs should continue? Why or why not?

        Answer. I support ensuring that individuals are able to receive
    services in community-based settings.

        Question. You are a vocal proponent of passing Federal laws to
    change Medicaid from a program that includes an open-ended Federal
    financial commitment to fixed block-grant payments to the States.

        Would this change end the Federal oversight and incentive programs
    that have helped State systems transform into systems that allow
    individuals with significant disabilities to live in the community? How
    would you ensure that any changes in Medicaid would not move people
    with disabilities back into nursing homes and other institutional
    settings that are linked to significantly poorer quality of life,
    physical and mental health outcomes, and longevity?

        Answer. We are committed to supporting high-quality health care for
    all Americans, including individuals with disabilities. If confirmed, I
    look forward to working with you to achieve these goals.

        Question. In 2011, the Department of Health and Human Services
    promulgated a rule to ensure that Medicaid funds designated for
    services in home and community-based settings were not used to fund
    services in segregated, institutional settings. For example, the second
    floor of a building used to provide inpatient hospital care could not
    be considered a community-based setting. That rule has been championed
    by the disability community as critical to afford people with
    disabilities the chance to live independent and fulfilling lives in
    their own homes and communities.

        Do you support the continuation of this rule? Do you commit to
    ensure that HHS assertively enforces it?

        Answer. Community integration, beneficiary autonomy in decision
    making, and person-centered planning are central tenets articulated in
    the Home and Community Based Services (HCBS) Settings rule you refer
    to, and I support each of those principles. It is also important to
    note that many residential, disability-specific settings have long
    provided a safe and integrated community alternative to institutional
    placement for individuals with disabilities, and appropriate weight
    should be given to the preferences of families and individuals with
    disabilities because they are in the best position to decide what type
    of setting best meets their individualized needs and circumstances.
    States must come into compliance with the final rule by March 17, 2019,
    and I plan to work with States during this transition period to ensure
    continuity of services for Medicaid participants and minimize any
    disruptions to them and the service systems they currently rely on.

        Question. With an additional 16 million people gaining access to
    Medicaid since its expansion and a total of 75 million people covered
    by the program, Medicaid continues to be a critical, State-based health
    care program. In order to provide effective, high-quality care, States
    need dedicated funding for the full Medicare-eligible population as
    well as sufficient Federal funding that reflects actual State costs and
    increases in health-care costs.

        As Secretary of HHS will you ensure that State-funding for health
    care is adequate and reflects the actual costs of caring for each
    State's Medicaid population?

        Answer. States are not just regulatory partners in the Medicaid
    program but also co-funders. As we look to provide them with more
    flexibility but also continue to provide Federal funds, I agree it is
    important States meet their funding commitments and the Federal
    Government oversee and check that is the case.

        Question. Medicaid provides care to some of the Nation's most
    vulnerable and complex populations. In order for States to continue to
    provide high-quality and effective care, adequate and sustainable
    funding is required.

        As Secretary of HHS, will you work to prevent disruption and ensure
    adequate and sustainable funding for Medicaid?

        Answer. If confirmed, as Secretary I will work to prevent
    disruption and ensure adequate and sustainable funding for Medicaid. In
    fact, it is just this goal that is at the root of many improvements I
    have offered in my career.

        Question. During the hearing in the Finance Committee, you gave
    your commitment that you would ``absolutely'' support an extension of
    the Children's Health Insurance program, and even expressed support for
    a longer extension of the program, beyond the typical 5-year
    authorization. Yet Gene Sperling wrote in the New York Times on
    Christmas Day that--``Mr. Price's own proposal, which he presented as
    the chairman of the House Budget Committee, would cut Medicaid by about
    $1 trillion over the next decade. This is on top of the reduction that
    would result from the repeal of the Affordable Care Act, which both Mr.
    Trump and Republican leaders have championed. Together, full repeal and
    block granting would cut Medicaid and the Children's Health Insurance
    Program funding by about $2.1 trillion over the next 10 years--a 40
    percent cut.''

        Do you deny that you have advocated for these changes to Medicaid
    and CHIP? You also said during the hearing that there were elements of
    the budget that you did not support. Which parts do you not support?

        Answer. In the past, as a member of Congress, I have advocated
    policies that would strengthen our health-care programs so that they
    remain solvent for the sake of future generations.

        Question. During the hearing, you claimed we were looking at CHIP
    and Medicaid in a silo, instead of looking at the entire range of what
    the policy will be with respect to health insurance programs. We do not
    have anything to compare CHIP and Medicaid to, because this
    administration cannot provide a clear plan that is a viable alternative
    to the Affordable Care Act, the CHIP program and Medicaid.

        What will those policies be, and how will they provide better
    options for the children and individuals with disabilities who rely on
    CHIP and Medicaid?

        Answer. If confirmed, I look forward to working with you to ensure
    there are better options available.

        Question. In your answer to Senator Alexander's question at the
    HELP Committee hearing, you stated, ``folks at the State level know
    their populations better than we (in Washington) ever could know
    them.'' The bipartisan, consensus-driven National Association of
    Medicaid Directors advocated for continuing the State Innovation Model
    (SIM) out of the Center for Medicare and Medicaid Innovation. The SIM
    has fueled 35 States (led by both Democrats and Republicans) to improve
    their local health-care systems.

        Given your desire to move decisions and innovation to the local
    level, as HHS secretary would you continue to support CMMI's State-
    level initiatives?
    http://medicaiddirectors.org/wp-content/uploads/2016/12/Key-
    Considerations-in-Affordable-Care-Act-Repeal-and-Replace-
    Initiatives.pdf

        Answer. CMMI is a program providing significant opportunity for
    testing new models for health-care financing and delivery.

        Question. In reference to your reply to Senator Alexander, 16
    States who have expanded Medicaid have Republican leadership. As of
    January 19th, at least 5 Republican governors have publicly advocated
    to retain the Federal-State Medicaid expansion partnership.

        Given that several local leaders--including Republicans--favor
    retaining this program, what is your plan as HHS secretary to honor the
    wishes of State leadership, preserve this program, and avoid adverse
    consequences to States?
    http://www.politico.com/story/2017/01/gop-governors-republicans-
    obamacare-233576

        Answer. If confirmed, I look forward to working with Congress and
    Governors to ensure access to affordable, quality health care for all
    citizens.

        Question. In the past, you have stated support of expanding State
    waiver authority for the Medicaid program. Do you support efforts to
    evaluate the impact of these waivers in terms of access to care,
    quality of care, and costs of care?

        Answer. It is my strong belief that we need to look at all possible
    outcomes of policy changes.

        Question. In 2015, your budget proposal would have repealed the
    Affordable Care Act, reduced Medicaid spending, and cut the
    Supplemental Nutrition Assistance Program--all told, up to $519 billion
    in cuts to needy families--yet your proposal would have increased
    defense spending higher than the administration requested, gathering
    criticism from other Republicans.

        Are you only concerned with increased Federal spending when it
    benefits families and children?

        Answer. In my time in Congress, I have been concerned with
    increased Federal spending at all levels.

        Question. In your conversation with Senator Warren and Senator
    Kaine during your appearance at the HELP committee, you cited access to
    care as your critique for the Medicaid program. You stated that
    Medicaid recipients have access to insurance, but they do not have
    access to the care they need. Yet the Government Accountability Office
    has stated that ``Medicaid enrollees report access to care that is
    generally comparable to that of privately insured individuals and
    better than that of uninsured individuals.'' The report does cite more
    challenges with accessing specialty and dental care.

        Do you agree with the GAO's assessment? If so, what strategies
    would you suggest to increase access to specialty and dental care for
    Medicaid recipients? If you don't agree with the GAO's assessment,
    please outline your plan to increase access to Medicaid-eligible
    Americans.

        Answer. As a doctor who has actually treated thousands of Medicaid
    patients, I do care deeply about the Medicaid program and the access of
    Medicaid patients to actual care, not just a card they can carry with
    them. I know from personal experience the difficulties Medicaid
    patients face, and I receive letters about it all the time. My plan is
    to work with States to ensure they have the flexibility to make high
    quality care truly available.

        Question. It is true that Medicaid faces challenges, including low
    payment rates and barriers to interstate care which limit access and
    must be improved. Greater consistency of national data could
    significantly improve Medicaid's ability to serve children and other
    beneficiaries and drive quality improvement. Access to certain
    services, such as pediatric mental health services is a pressing
    concern.

        What would you do as Secretary to drive improved outcomes in child
    health across States?

        Answer. Ensuring children have access to the health care they need
    is undoubtedly a top priority. If confirmed, I look forward to working
    with you to increase access to affordable health plans for families and
    children as well as taking the necessary steps to strengthen American
    families.

        Question. A major focus of Congress and the administration has been
    on pursuing delivery system reforms that improve quality and reduce
    costs. The Federal Government over time has focused more on the needs
    of children in these reforms, but Medicaid for children still lags
    behind Medicare in supporting improvements in care.

        What steps will you take to promote increased emphasis on reforms
    targeting the unique needs of children?

        Answer. Our goal is to make certain that every single American has
    access to the coverage they want for themselves and their children; and
    we must ensure that the individuals and children who lost coverage
    under the Affordable Care Act are able to access quality health care.
    If confirmed, I look forward to working with you on this effort.

        Question. To ensure kids continue to receive the critical care they
    need under Medicaid, any potential restructuring needs to consider
    children's unique health care needs and the impact of limiting our
    investments into their future and the Nation's as a whole. Any reforms
    must ensure children's funding is stable, clearly defined, protects
    current services, and begins to remediate shortages in critical areas,
    such as mental and behavioral health services.

        How will you ensure that Medicaid continues to deliver essential
    services tailored to the unique needs of children?

        Answer. If confirmed, I look forward to working with you to
    prioritize a nation of healthy children through increased access to
    affordable health plans for families and children, as well as taking
    the necessary steps to strengthen American families.
                                    medicare
        Question. Do you support converting Medicare's successful
    Independence at Home (IAH) demonstration into a nationwide program? Do
    you support the inclusion of licensed mental health professionals on
    the primary teams for home-based team care?

        Answer. If confirmed, I look forward to working with you on this
    issue. As a general matter, I believe we ought to allow for all sorts
    of innovation. Not just in this area. There are things that haven't
    been thought up yet that would actually improve health-care delivery in
    our country and we ought to be incentivizing that kind of innovation.
    And in finding our way to those innovations, it is important to
    remember many of these experiments involve real patients' lives.

        Question. The Medicare program requires that to receive telehealth
    services, a patient must be in a rural area and at an eligible
    originating site that currently does not include the patient's home. Do
    you support making a rural Medicare beneficiary's home as an eligible
    originating site for the use of telehealth services?

        Answer. This is certainly something that we will take under
    consideration. Telehealth holds great promise, particularly for rural
    areas experiencing physician shortages and for patients with limited
    mobility. At the same time, allowing a beneficiary's home to qualify as
    an eligible originating site could create significant Program Integrity
    challenges. If confirmed, I will certainly direct CMS to take another
    look at this issue to ensure we are doing everything we can to maximize
    beneficiary access to care with appropriate safeguards against fraud.

        Question. Do you support the continuation of the new Merit-based
    Incentive Payment System as presented in the final rule on the Medicare
    Access and CHIP Reauthorization Act (MACRA)?

        Answer. The recent CMS MACRA final rule approached the first year
    of the Quality Payment Program as a transition year, and took steps to
    address physician concerns regarding the burdens associated with
    program participation. I think significant challenges remain with
    respect to provider burden, and, if confirmed, I plan to direct the CMS
    Administrator to ensure that the program is structured to achieve its
    quality and budgetary goals, while ensuring that patients and the
    providers who care for them are at the center of our reform efforts.

        Question. In both the Medicare and Medicaid programs, we are
    witnessing increased participation in managed care plans. Yet in 1995,
    you objected to managed care as ``the antithesis of our society,''
    citing that managed care threatens the doctor-patient relationship.

        As HHS Secretary, what plans do you have to monitor the quality and
    effectiveness of Managed Care plans offered in Medicare (through
    Medicare Advantage) and Medicaid programs?

        Answer. If confirmed, I will not pick winners and losers among
    different plans or methods of health-care delivery. It is my intention
    to fairly and accurately monitor the quality and effectiveness of our
    entire care system, including managed care Medicare and Medicaid plans.
    The facts on the ground will determine our plan ahead.

        Question. In September 2011, DHHS released a new policy that
    implements the recommendations of the Memorandum on Hospital
    Visitation. The rules updated the Conditions of Participation (CoPs).
    The policy states that hospitals receiving Medicare or Medicaid
    payments should allow patients to designate visitors, regardless of
    sexual orientation, gender identity, or any other non-clinical factor.
    The HHS policy has enhanced hospital visitation rights of same-sex
    couples.

        Assuming no legislative changes are made, as HHS Secretary, will
    you continue to support and enforce these existing rules?

        Answer. It is essential that health-care services be available to
    all people with the highest level of quality, affordability, and
    respect for their human dignity. As a physician, I believe that
    patients should be at the center of health care. This policy allows
    patients to designate their visitors, regardless of their identity, and
    I believe patients should have that authority.

        Question. In 2012, the Center for Medicare and Medicaid Innovation
    under Provision 5590 of the ACA funded the Medicare Graduate Nurse
    Education Demonstration project to address the primary care provider
    shortage, including the Hospital of the University of Pennsylvania. In
    Philadelphia alone, the project has produced 703 advanced practice
    nurses, the majority of whom have assumed primary care roles, a 78%
    increase since before the project launched.

        As HHS Secretary, do you plan to continue to support novel
    reimbursement models to address the Nation's shortage of primary care
    providers? Would you consider expanding the successful Graduate Nurse
    Education demonstration project to other sites?

        Answer. I remain committed to ensuring that every American receives
    access to the care that he or she needs. Funding decisions, however,
    ultimately rest with the Congress, which holds the power over the
    purse. If I am privileged to serve as the Secretary of Health and Human
    Services, I will implement the policies agreed upon by the Congress and
    signed into law by the President.

        Question. There is universal agreement on the need to improve
    patient care and reduce costs. One way to do so is for the Federal
    Government to continue to promote the growth of health information
    technology and electronic health records. One success in this space
    over the past several years has been the development and growth of the
    Direct Exchange network, which has allowed for millions of health care
    record exchanges over the past several years.

        Will you as HHS Secretary continue to support the expansion of
    Health IT and the use of networks such as Direct Exchange working with
    HHS-ONC to encourage and ensure the safe and interoperable exchange of
    medical records?

        Answer. Electronic information sharing, as supported by
    interoperable health information technology (IT) systems, impacts
    overall care and the patient experience. Patients and providers often
    rely on the fast exchange of relevant, trustworthy information across
    health IT systems. Methods to improve flexibility and patient
    engagement, and clear the way for increased health IT interoperability
    should be examined as we work to improve health-care delivery. I look
    forward to continued discussions with you regarding various means to
    improve the current health IT infrastructure.
                         foster care and child welfare
        Question. You have hardly any record on child welfare issues. The
    largest Federal investment in child welfare is made through title IV-E
    of the Social Security Act, which reimburses States for activities
    associated with foster care, and it is managed by the Department of
    Health and Human Services. While foster care is a critical, often life-
    saving intervention, we should be moving toward a system that not only
    supports children who can no longer remain safely with their families,
    but one that also helps stabilize struggling families so that they can
    keep their children when it is possible to do so safely. This focus on
    prevention is not only often in the best interest of children, but also
    in the best interest of State budgets, and States that have started
    shifting to a prevention-focused model have seen lower downstream costs
    associated with foster care, homelessness, health care and criminal
    justice. This is an especially critical issue right now, at a time when
    we are seeing foster care caseloads increasing as a result of the
    opioid epidemic.

        Do you agree that we must make investments in services aimed at
    helping vulnerable families?

        Answer. Yes. The family is the foundation of society. It is
    critical that we build and sustain strong families by providing
    assistance when necessary for those struggling with addiction and
    mental health issues so that we prevent child neglect and violence
    against children.

        Question. The Department of Health and Human Services is the lead
    Federal agency responsible for addressing child abuse and neglect,
    including prevention, foster care, reunification, and adoption when
    children cannot return home. As was discussed during your hearing, the
    new administration is proposing to block grant Medicaid, which is the
    primary source of services to help families involved in the child
    welfare system. This system is experiencing additional strain as a
    result of the opioid epidemic, which has shattered many families across
    the Nation.

        Have you considered the potential implications of block-granting
    Medicaid for families in the child welfare system?

        Answer. I look forward to working with the Congress to ensure that
    all children have access to the coverage, regardless of family
    situation or personal circumstance.

        Question. Will you commit that, if confirmed as Secretary of Health
    and Human Services, you will take action to guarantee parents coverage
    of and access to mental health and substance use disorder services, to
    prevent child abuse and neglect and help reunify families?

        Answer. Substance abuse disorder is a problem and the opioid
    epidemic is real. As I mentioned in the hearing, this is a rampant
    crisis that is harming families and communities across the Nation. This
    harm includes the potential for abuse and neglect that you mention. I
    also said, and I firmly believe, that it is vital that substance abuse
    disorder and other mental health problems are treated. If confirmed I
    will work closely with you and other members of Congress to ensure that
    the Substance Abuse and Mental Health Services Administration (SAMHSA)
    fulfills its duty of leading public health efforts to advance
    behavioral health and reduce the impact of substance abuse and mental
    illness on America's communities.

        Question. According to the Substance Abuse and Mental Health
    Administration, there are 21.6 million people that have a substance use
    disorder, with just 9.3 percent receiving treatment. According to
    research by Richard G. Frank, the Department of Health Care Policy at
    Harvard Medical School, and Sherry Glied, Dean of the Wagner School of
    Public Service at NYU, repeal of the Affordable Care Act will take $5.5
    billion from the treatment of low-income individuals with mental and
    substance use disorders--11 times the funding that Congress just
    provided through the 21st Century Cures Act.

        Do you think such a reduction in both mental health and substance
    use treatment funds through a repeal will have an impact on the child
    welfare system and foster care numbers?

        Answer. Changes to the ACA should not be done in isolation. I
    remain committed to ensuring that every American receives access to the
    mental health and substance abuse care that he or she needs. If I am
    privileged to serve as the Secretary of Health and Human Services, I
    will implement the policies agreed upon by the Congress and signed into
    law by the President.

        Question. The Affordable Care Act included a provision to allow
    children aging out of foster care to continue their health coverage
    through Medicaid up to age 26. Block-granting or capping Medicaid would
    essentially end this guarantee.

        Do you believe we should end this right to health coverage for
    former foster youth?

        Answer. This would be a part of the new legislation that Congress
    will be voting on, so that decision is in Congress's hands. If
    confirmed, I will work to ensure that HHS appropriately implements the
    statutes within its purview.

        Question. Currently, when families adopt children with special
    needs from foster care, those children are guaranteed Medicaid coverage
    through the age of 18. This is an important support for these children
    and their adoptive families.

        If confirmed as Secretary of Health and Human Services, what
    assurances can you give to these children and their adoptive parents
    that their health-care needs will continue to be met?

        Answer. The life and health of children with special needs is of
    great importance to me, as it has been when I practiced medicine and
    while I have been in Congress. I offer every assurance to children and
    their adoptive parents that I will do all I can, if confirmed as HHS
    Secretary, to ensure their needs continue to be met to the best of the
    Department's ability.
           ethics of providing health care to people on public plans
        Question. You have been a member of a fringe physician group, the
    American Association of Physicians and Surgeons (AAPS), which espouses
    a number of very dangerous ideas, including perpetuating debunked myths
    about vaccines and claiming that it is ``immoral'' for doctors to
    provide care to people who rely on publicly funded health plans such as
    Medicare, Medicaid, and CHIP.

        Were you aware of these positions published by AAPS before joining
    the organization, and do you support those positions?

        Answer. My initial membership in AAPS was based on their successful
    opposition to destructive health policy changes promoted in the early
    1990s.
                              the opioid epidemic
        Question. According to the recent Facing Addiction: Surgeon
    General's Report on Alcohol, Drug, and Health, ``Substance misuse and
    substance use disorders are estimated to cost society $442 billion each
    year in health-care costs, lost productivity, and criminal justice
    costs.'' The National Survey on Drug Use and Health (NSDUH) reported in
    2015 that 21.5 million people in the United States, over 8 percent of
    the population, had a substance use disorder. The Center for Disease
    Control and Prevention reported over 52,000 drug overdose deaths in
    2015. Of the millions of people struggling with a substance use
    disorder, only about 10 percent receive substance use disorder
    treatment in a given year.

        If confirmed as Secretary of Health and Human Services, what
    actions will you take to address the needs of Americans struggling with
    substance use disorders, especially those who are seeking treatment?

        Answer. Substance abuse disorder is a problem and the opioid
    epidemic is real. As I mentioned in the hearing, this is a rampant
    crisis that is harming families and communities across the Nation. This
    harm includes the potential for abuse and neglect that you mention. I
    also said, and I firmly believe, that it is absolutely vital that
    substance abuse disorder and other mental health problems are treated.
    If confirmed, I will work closely with you and other members of
    Congress to ensure that the Substance Abuse and Mental Health Services
    Administration (SAMHSA) fulfills its duty of leading public health
    efforts to advance behavioral health and reduce the impact of substance
    abuse and mental illness on America's communities treating those who
    are in addiction recovery while working to prevent people from becoming
    addicted in the first instance, and explore other means available to
    HHS to assist those struggling with substance use disorders obtain
    treatment and to prevent addiction.

        Question. If confirmed as Secretary of Health and Human Services,
    will you commit to supporting, and as a Cabinet member advising the
    President to support, continued funding for opioid crisis grants, as
    administered by SAMHSA?

        Answer. I remain committed to ensuring that every American receives
    access to the mental health and substance abuse care that he or she
    needs. Funding decisions, however, ultimately rest with the Congress,
    which holds the power over the purse. If I am privileged to serve as
    the Secretary of Health and Human Services, I will implement the
    policies agreed upon by the Congress and signed into law by the
    President.

        Question. If confirmed as Secretary of Health and Human Services,
    will you commit to supporting, and as a Cabinet member advising the
    President to support, funding for the Substance Abuse Prevention and
    Treatment Block grant to preserve the critical safety net for Americans
    who require substance abuse treatment but who are uninsured?

        Answer. Access to mental health and substance abuse care is
    absolutely vital. If I am privileged to serve as the Secretary of
    Health and Human Services, I will implement the policies agreed upon by
    the Congress which holds the power of the purse, and signed into law by
    the President.

        Question. If confirmed as Secretary of Health and Human Services,
    would you commit to supporting, and as a Cabinet member advising the
    President to support, funding requests for the National Institute of
    Mental Health and the National Institute on Drug Abuse to develop
    better treatments for substance use disorders?

        Answer. I remain committed to ensuring that all Americans maintain
    access to the mental health and substance abuse disorder treatments;
    however, funding decisions ultimately rest with the Congress, which
    holds the power over the purse. If I am privileged to serve as the HHS
    Secretary, I will implement the policies adopted by the Congress and
    signed into law by the President.

        Question. Integrated primary care and mental health care is one
    promising strategy to improving outcomes for Americans with substance
    use disorders. If confirmed as Secretary of Health and Human Services,
    will you support demonstration programs--which as Secretary you would
    have the ability to direct--to integrate primary and behavioral health
    care, through the Center for Medicare and Medicaid Innovation?

        Answer. CMMI is a program providing significant opportunity for
    testing new models for health-care financing and delivery. If
    confirmed, as HHS Secretary, I plan to work closely with CMS to ensure
    that CMMI--after appropriate consultation with Congress, the States,
    health-care stakeholders, and Innovation Center staff--tests innovative
    models that reduce costs and improve quality for Medicare and Medicaid
    beneficiaries.

        Question. A key challenge to effectively addressing the opioid
    epidemic in the United States is a shortage of qualified providers. The
    Affordable Care Act included a provision to establish a National
    Healthcare Workforce Commission, yet this Commission has never met.

        If confirmed as Secretary of Health and Human Services, would you
    commit to supporting, and as a Cabinet member advising the President to
    support, a congressional appropriation to convene this commission so we
    can understand the root cause of mental health provider shortages and
    develop evidence-based strategies to address them?

        Answer. As I mentioned in the hearing, it is important that we as a
    nation make sure that every single individual has access to the kind of
    mental health and substance abuse care that they need. I look forward
    to working closely with you and the other members of Congress to ensure
    that the mental health profession is adequately, if not robustly,
    staffed for this and the future generations.
                                    coverage
        Question. On January 7, 2009, you penned a commentary in the Wall
    Street Journal that advocated for ``access to coverage for all
    Americans and coverage that is truly owned by patients.'' Yet under the
    policy proposals you have authored, according to the Congressional
    Budget Office, ``the number of people who are uninsured would increase
    by 18 million in the first new plan year.'' After repeal of Medicaid
    expansion and exchanges, 32 million Americans would be uninsured by
    2026.

        How do you reconcile your position in 2009 with the analysis by the
    CBO in 2017?

        Answer. I disagree with the conclusion drawn by CBO. If there are
    any changes to Medicaid, they should not be done in isolation.

        Question. You introduced the Medical Freedom Act of 2015, which
    would repeal the requirement that insurers offer dependent coverage
    until the age of 26. HHS estimates this provision has affected 2.3
    million young adults.

        If confirmed, what is your plan to protect the health and well-
    being of young adults under the age of 26?

        Answer. This would be a matter for Congress to determine through
    legislation. If confirmed, I will work to ensure that HHS appropriately
    implements the statutes within its purview.
                                    children
        Question. Oftentimes, changes in the larger health-care landscape
    take place, for example in the Medicare program, without a full
    examination of how these changes could potentially impact children,
    even inadvertently.

        As you look at health-care changes at the national level as
    Secretary, how will you ensure that children's unique health-care needs
    are taken into account?

        Answer. I look forward to working with Congress to ensure that
    children will not be inadvertently impacted by potential changes to the
    health-care system.
                                     liheap
        Question. The Low-Income Home Energy Assistance Program (LIHEAP)
    provides short-term aid to vulnerable populations for heating or
    cooling assistance, crisis assistance or weatherization assistance.
    Without this support, many low-income participants would quickly fall
    behind on their bills and face shut-off of essential energy services.
    The program effectively utilizes a partnership between the Federal
    Government, State government and the private sector.

        LIHEAP protects the most vulnerable in our society. According to
    the Campaign for Home Energy Assistance, in Pennsylvania in 2014, 35%
    of households receiving LIHEAP were elderly, 30% were disabled, and 18%
    had children under 5. You were a member of the Task Force on Poverty,
    Opportunity, and Upward Mobility that drafted the ``A Better Way'' plan
    that proposed to combine LIHEAP with 10 other social program grants to
    create a large block grant to States. Should such a plan come to pass,
    it would eliminate a dedicated fund for utility crisis assistance. In
    addition, your recent budget took across the board cuts from safety net
    programs and highlighted LIHEAP as one of several ``duplicative anti-
    poverty programs.'' While the Department of Energy also oversees an
    energy program (the Weatherization Assistance program), this program
    provides grants to States to improve the weatherization and energy
    efficiency of low-income homes. Thus, serving a different, though just
    as important, service from LIHEAP.

        Can you explain why you think LIHEAP is a duplicative anti-poverty
    program and which other programs in particular you think are providing
    the same services?

        Answer. One of the main goals of the ``A Better Way'' plan was to
    match poverty-fighting programs with the needs of those on Federal Aid
    more effectively so that it is easier for them to get back on their
    feet. Using block grants, rather than dedicated grants, gives States
    and communities more freedom to use the funds where they are most
    necessary.

        Question. According to the National Energy Assistance Directors
    Association, States have been forced to reduce the number of households
    served by LIHEAP from 8 million to the current level of 6.7 million due
    to Federal cuts to the program. This equates to 1.3 million eligible
    households nationwide that did not receive assistance.

        LIHEAP is a critical safety net program to support the elderly and
    families as the country recovers from the economic recession. Families
    should not have to choose between heating their homes and putting food
    on the table. You have previously voted in the House of Representatives
    against increasing funding for LIHEAP.

        Do you support increasing funding for LIHEAP? If not, why do you
    not support it?

        Answer. If confirmed, I will administer LIHEAP as effectively and
    efficiently as possible. If once in office, and should circumstances on
    the ground change and current resources are found to be insufficient, I
    will inform Congress and work with them on finding solutions.

        Question. Will you support maintaining the funding at the current
    level of $3.3 billion in the President's final recommendations for FY
    2017 and proposed FY 2018 budget?

        Answer. If confirmed, I will administer LIHEAP at the levels passed
    by Congress.
                                   tax issues
        Question. Do you think the President should disclose how much he
    stands to benefit from the repeal of the net investment income tax
    prior to signing the repeal of the Affordable Care Act into law?

        Answer. This is a matter for the President.

        Question. With respect to subsidizing the cost of health care,
    please explain why an annually disbursed refundable tax credit is
    superior to a monthly insurance premium support credit.

        Answer. There are many health-care scholars who have promoted the
    superiority of a credit versus a subsidy, as it may provide greater
    flexibility and options for patients.

                                     ______

                  Questions Submitted by Hon. Debbie Stabenow
                              continuous coverage
        Question. Last week we held a forum and asked folks from around the
    county to share their stories and help inform the debate around repeal
    of the ACA. One of the women on the panel, Holly Jensen, was a small
    business owner insured with a plan she selected on the marketplace.
    Holly was living with undiagnosed depression, anxiety, and obsessive
    compulsive disorder that was getting worse by the day. It got to the
    point that she withdrew from her community, her work, and was really
    struggling. She was unable--understandably--to make her monthly premium
    payments. Luckily, because of Medicaid expansion, she was able to get
    the treatment she needed a few months later and is doing well today.
    Her small business is back up and running. However, she did not
    maintain coverage continuously, as your plan and many others require.

        If the continuous coverage requirement were in place, Holly would
    re-enter the health insurance market and could be labeled with a pre-
    existing mental health condition, correct? How do you believe this
    problem is best addressed?

        Answer. I believe it is important that we as a nation make sure
    that every American has access to the kind of mental health care and
    health coverage that best meets their need. Additionally, it is
    imperative that all Americans have access to affordable coverage and
    that no one is priced out of the market due to a bad diagnosis. This is
    a matter for the legislative branch, however, and if confirmed, I will
    work to ensure that HHS (appropriately) implements the statutes within
    its purview.
                               maternity coverage
        Question. As I mentioned today, prior to the ACA, the vast majority
    of plans on the individual market did not offer maternity coverage. You
    said today that women would likely opt not to purchase one of those
    plans if they were pregnant or planning to be. However, over the course
    of a health plan year, couples and families make many decisions about
    their health-care future, sometimes including whether or not to have a
    child.

        Given this fact, do you believe that all health plans should be
    required to cover maternity and newborn care?

        Answer. My hope is to move in a direction where insurers can offer
    products people want and give them the coverage they want. That, of
    course, can and would in many cases include maternity and newborn care.
    Getting to that kind of system requires changes that will inevitably
    involve working with Congress and considering the tradeoffs of various
    proposals to achieve our shared objective of the best and highest
    quality care being available to Americans. And note that I refer to
    care because ultimately, having maternity or other coverage is not
    meaningful if one cannot access the care they need or the quality of
    care leaves them worse off. So we must work towards both coverage and
    care.

                                     ______

                   Questions Submitted by Hon. Maria Cantwell
                                 long-term care
        Question. Do you share my view that patients should be able to age
    in their homes and communities instead of in nursing homes and other
    institutional/inpatient settings, so long as the patient chooses this
    option and it is clinically appropriate?

        Answer. Our health-care system should be able to accommodate the
    choices of patients, in consultation with their physicians, regarding
    the ideal setting for their care.

        Question. Do you agree with me that home- and community-based care
    is, in general, far less costly and more convenient for patients
    compared to institutional care in nursing homes?

        Answer. Home- and community-based care is often less costly and
    more convenient as compared to institutional care in nursing homes. Our
    goal ought to be the right care in the right setting and the best care
    possible for Medicaid patients and all Americans. Too many Medicaid
    beneficiaries lack access to care.

        Question. Do you support incentives for States to transition or
    ``rebalance'' their Medicaid long-term care population from nursing
    homes to home- and community-based care?

        Answer. If confirmed, I will work to provide States the flexibility
    to pursue innovative approaches that fit the unique needs of their
    citizens.

        Question. Are you aware that, under the Affordable Care Act's
    Balancing Incentive Program (section 10202), the State of Georgia was
    approved for $57 million to transition Medicaid beneficiaries from
    institutional long term services and supports (LTSS) settings to home-
    and community-based settings (HCBS), and, as a result of that
    investment, Georgia has been able to shift more than 10 percent of its
    long-term care costs from high-cost nursing homes to low-cost home and
    community care, according to reports submitted to CMS and Georgia's
    program application?

        Answer. Each State has different needs, and I believe CMS needs to
    work with States to ensure that, consistent with those needs, the
    Medicaid program provides the best possible coverage to their
    residents. It is not surprising that providing States with flexibility
    to tailor their Medicaid program leads to good results in general.

        Question. Do you support the Balancing Incentives Program in the
    Affordable Care Act?

        Answer. I am committed to ensuring that Medicaid is available for
    eligible beneficiaries, and working with CMS to make sure that States
    are able to make the most use of available resources to serve their
    citizens with the highest quality care, if I am confirmed.

        Question. If you do support this program, or if you at least agree
    with its intent and goals, will you commit to working with me and my
    staff to expand Federal incentives for States to ``rebalance''?

        Answer. Yes, I will look forward to working with you and your staff
    to explore proposals you have in mind and otherwise consider how best
    to provide States with flexibility to provide the highest-quality care
    for Medicaid beneficiaries.

        Question. Do you believe that, if executed well, ``rebalancing''
    programs such as Balancing Incentives can improve the care experience
    for patients and reduce State Medicaid costs?

        Answer. The experience of our system is that while many different
    States may face the same problem, the approach that is most likely to
    succeed may depend on the particular State and other details specific
    to the circumstances.
                              basic health program
        Question. The Basic Health Program (section 1331 of the Affordable
    Care Act) is a State option that is providing health insurance and
    access to care to more than 750,000 working low-income individuals in
    New York and Minnesota. States that have taken advantage of this
    voluntary program are seeing lower costs for beneficiaries, higher
    enrollment, and net State budget savings, compared to not implementing
    the program. Through the Basic Health Program, States are price-makers,
    not price-takers.

        Do you support the Basic Health Program as a way to empower States
    to negotiate a better deal on health insurance for their citizens?

        Answer. I support the efforts of States to innovate and find
    solutions for their citizens with respect to health care, in the area
    of insurance and otherwise.

        Question. Will your Department and CMS commit to funding and
    administering the Basic Health Program as required under current
    Federal law?

        Answer. If confirmed as Secretary of HHS, my role will be to
    administer the laws of the land as they originate from the Congress,
    including those relating to the Basic Health Program.

        Question. If Congress repeals the Affordable Care Act, will you
    commit to ``not pulling the rug out'' from the 750,000 low-income
    individuals who are benefitting from the Basic Health Program?

        Answer. In working through the current situation and options for
    the future, I am committed to working towards solutions that provide
    meaningful access to care, not just insurance but actual care, for all,
    including--of course--these individuals.

        Question. In other words, will you use your administrative
    discretion as HHS secretary to not rescind funding for State Basic
    Health Programs, unless a rescission of that funding is explicitly
    required by a change to the statute?

        Answer. If confirmed, I will follow the directions of Congress as
    contained in appropriations and other law regarding funding for health-
    care programs.
                             delivery system reform
        Question. Washington State and the Pacific Northwest have led the
    way in pioneering nationally recognized innovations in the delivery of
    health care--whether it is the Qliance Direct Primary Care medical home
    model, Group Health Cooperative's highly popular integrated coverage
    and care model, the Everett Clinic's price transparency initiatives,
    Boeing's Accountable Care Organizations, or dozens of others. Despite
    their innovations, health-care providers in my State are paid nearly
    $2,000 less (per Medicare enrollee, per year) than the national
    average, based on CMS spending data compiled by the Kaiser Family
    Foundation. I would argue that, due to our current volume-based system,
    my constituents are paid less specifically because they are efficient
    and because they do a good job of keeping patients healthy.

        Should the Federal Government reward such high-value health care
    providers, as long as we clearly define and agree upon metrics for what
    constitutes ``high-value'' care?

        Answer. I look forward to faithfully executing the laws Congress
    passes pertaining to health-care provider reimbursement.

        Question. Does the current fee-for-service system encourage
    unnecessary health-care spending? If so, can you please explain
    specifically how this system encourages unnecessary health-care
    spending, including in which specialties of medicine?

        Answer. The current system encourages unnecessary spending since
    too many of the decisions providers and patients make are determined by
    a distant Federal bureaucracy and not based on the value of care that
    is provided to patients by their health-care providers. If confirmed, I
    look forward to executing laws that reduce unnecessary health-care
    spending.

        Question. As a physician, do you share my view that clinicians
    should focus more on keeping their patients healthy and less on
    paperwork?

        Answer. Clinicians should focus more on keeping their patients
    healthy and less on paperwork. Unfortunately, it does not seem that is
    the current trend.

        Question. As a physician, do you share my view that the current
    fee-for-service system requires significant paperwork, including
    substantial time spent on coding and billing for each individual
    procedure or service rendered?

        Answer. Clinicians should focus more on keeping their patients
    healthy and less on paperwork. Unfortunately, it does not seem that is
    the current trend.

        Question. You voted for the bipartisan Medicare Access and CHIP
    Reauthorization Act (MACRA) when it was considered on the House floor.
    Will you commit to working with Washington State health-care providers
    to help them succeed in Medicare's new Quality Payment Program, as
    outlined in regulations by CMS, including Advanced Alternative Payment
    Models?

        Answer. If confirmed, I commit to work closely with the CMS
    Administrator to make sure we implement MACRA in a way that is easy to
    understand, minimizes burden, and is fair to all affected providers.

        Question. Will you commit to fund and administer Medicare's
    Accountable Care Organizations, including the Medicare Shared Savings
    Program under section 3022 of the Affordable Care Act, and will you
    commit to helping health-care providers participate in these models,
    should they choose to do so? Will you commit to not taking any
    administrative action that would make it more difficult for Medicare
    beneficiaries or health-care providers to participate in this voluntary
    program?

        Answer. As a doctor, I appreciate the goal behind the creation of
    the ACO model: better patient care. As a legislator, I would agree
    their successes have been modest to date, and there are some challenges
    they face as well. ACOs are a tool in the toolbox to help ensure high
    quality, low cost health care for beneficiaries. They are not a silver
    bullet to all of our country's delivery system challenges. If
    confirmed, I plan to work with the CMS Administrator to ensure that we
    learn from ACOs' successes and challenges to date as we chart the path
    forward.

        Question. Will you commit to fully fund approved grants under the
    Center for Medicare and Medicaid Innovation (CMMI), and will you
    continue to fund and administer future payment initiatives under CMMI,
    consistent with the legislative intent of Congress in the Affordable
    Care Act?

        Answer. If confirmed, I will work to ensure that HHS
    (appropriately) implements the statutes within its purview.

        Question. Do you share my view that, given Congress's significant
    ongoing investment in the delivery of health-care services, the Federal
    Government should fund research into health-care quality? Will you
    commit to not taking administrative actions that would weaken the work
    of the Agency for Healthcare Research and Quality (AHRQ) within HHS?

        Answer. I appreciate your concerns about health-care quality. I
    also appreciate the fact that health-care research may address patient
    safety, care management and methods to broaden access to health-care
    services, among other issues. Health-care studies also help to inform
    the discussion on ways to improve the quality of care and reduce costs.
    As you know, Congress will ultimately make the decision on whether to
    fund the Agency for Healthcare Research and Quality (AHRQ).
    Nonetheless, if confirmed, I look forward to working with you to more
    carefully examine AHRQ and determine how it may best drive positive
    patient-centered solutions in healthcare. And if confirmed, I will work
    to ensure that HHS (appropriately) implements the statutes within its
    purview.
                            health care legislation
        Question. I have authored bipartisan legislation (S. 2259 in the
    114th Congress) to make it easier for rural health-care providers to
    participate in the Medicare Shared Savings Program by allowing CMS to
    adopt a broader beneficiary assignment method than is provided under
    current law. Will you commit to providing me and my office responsive
    and accurate technical assistance on this legislation?

        Answer. I look forward to working with you on this issue and
    sharing both feedback and assistance regarding the important policy
    issues in beneficiary assignment for the Medicare Shared Savings
    Program.

        Question. I have authored bipartisan legislation (S. 2373 in the
    114th Congress) to require Medicare to cover an essential preventive
    product, compression therapy items, for beneficiaries who experience
    swelling from lymphedema. Will you commit to providing me and my office
    responsive and accurate technical assistance on this legislation?

        Answer. As you know, CMS has a detailed process for making
    determinations regarding whether items and services are reasonable and
    necessary, if they can be considered eligible for Medicare coverage
    given other restrictions and prohibitions. From time to time, Congress
    sees it fit to make its own determination regarding specific items or
    services. If confirmed, I would be pleased to work with your team to
    provide information on the Medicare coverage process and potentially
    relevant considerations.

        Question. I have cosponsored bipartisan legislation (S. 3129) to
    preserve patient access to outpatient therapeutic services in Critical
    Access Hospitals and other rural hospitals. Similar legislation has
    been signed into law the last 3 years. Will you commit to working with
    me, my staff, and bill sponsors and cosponsors, on this issue?

        Answer. If confirmed, I look forward to working with you and others
    in the Congress to see that critical access hospitals are best enabled
    to serve rural populations well.

        Question. Will you commit to providing me and my office responsive
    and accurate technical assistance on any future legislation I author or
    on which I seek assistance?

        Answer. Federal agencies play a significant role in the legislative
    process, often including providing technical assistance. Such technical
    assistance can involve situations where the agency provides feedback
    but clarifies that the assistance does not reflect the views or
    policies of the agency or administration. If confirmed, I will endeavor
    to work with you in this way as appropriate to ensure proposed
    legislation is consonant with the existing statutory and regulatory
    scheme.
                washington state's section 1115 medicaid waiver
        Question. On January 9, 2017, CMS approved Washington State's
    proposed Medicaid waiver (``Medicaid Transformation Project, No. 11-W-
    00304/0'') under section 1115(a) of the Social Security Act. In
    securing agreement on this waiver, Washington State health officials
    and CMS spent countless hours over more than a year in good-faith
    negotiations. This approved waiver will help Washington State pursue a
    smarter and more innovative Medicaid program that reflects changes in
    health-care delivery, technology, and the preferences of patients.

        Will you commit to honor this approved waiver and not take any
    administrative action to rescind, weaken, or de-fund its components?

        Answer. It would be inappropriate at this point to comment on any
    specific waivers under consideration at CMS, but, if confirmed, I would
    work with the CMS Administrator to ensure that CMS uses its waiver
    authority to provide much needed flexibility to States to innovate
    within the Medicaid program.
                           graduate medical education
        Question. The vast majority of Washington State counties are Health
    Professional Shortage Areas (HPSA's) according to HHS's HRSA. Do you
    agree with an established body of research illustrating that there are
    physician shortages in the United States, especially in primary care
    specialties and in rural communities?

        Answer. Access to care is a critical issue in many parts of the
    country, particularly for primary care in rural areas. The underlying
    physician shortage is sometimes worsened by government policies. If
    confirmed, I look forward to the opportunity to address these physician
    shortages, particularly as they relate to the Medicare and Medicaid
    programs.

        Question. Do you agree with previous congressional intent that the
    Federal Government, through Medicare and other programs, has a strong
    role to play in graduate medical education (GME) policy and funding?

        Answer. I have always been a strong supporter of efforts to support
    medical education. Congress has used the Medicare program from its
    inception to invest in future generations of doctors. Regardless of
    what we do in Washington, health care should always be about that one
    to one relationship of a patient to a doctor. That relationship of
    course requires a doctor. And so I am hopeful we can continue to find
    ways to remove disincentives to the practice of medicine and its
    rewards as well as support the profession in other ways.

        Question. Was your own surgery residency funded by Medicare?

        Answer. Both my wife and I were residents at Emory University. I
    completed my residency in 1984. The Medicare program has paid for some
    portion of GME at participating hospitals since its inception in 1965.

                                     ______

                   Questions Submitted by Hon. Mark R. Warner
                              affordable care act
        Question. In December 2016, the Congressional Budget Office issued
    a report noting that it would define as insurance coverage only ``a
    comprehensive major medical policy that, at a minimum, covers high-cost
    medical events and various services, including those provided by
    physicians and hospitals.'' The ACA established a set of services,
    known as Essential Health Benefits, that all insurance policies must
    include to make sure patients have appropriate health coverage.

        What would you advise the President define as ``coverage'' under a
    Republican ACA replacement plan?

        In a repeal-and-replace scenario, will coverage obtained by
    individuals provide adequate financial protections against high medical
    costs?

        Will you advocate for insurance policies under the Republican
    replacement plan that provide meaningful coverage so that insurers
    could not once again: (1) charge higher premiums to women, people with
    pre-existing conditions, or others for reasons such as their profession
    or the industry in which they work; (2) drop or severely limit benefits
    such as maternity care and prescription drugs, which insurers must
    currently cover as ``essential health benefits;'' (3) reinstate annual
    and lifetime limits on coverage; or (4) charge deductibles, co-payments
    and co-insurance without limits?

        Will you commit to safeguarding the consumer protections that the
    Affordable Care Act put in place?

        Answer. This is a work in progress. If confirmed, I would
    appreciate your thoughts on how best to address these matters. It is
    important that any system have safeguards so that no one loses access
    to care due to a bad diagnosis. Additionally, credible coverage is
    important. Patients should be provided an array of options so they may
    select the one best for themselves and their family; and consumer
    protections are integral to any patient-centered system.
                                  drug prices
        Question. The rise in prescription drug costs is squeezing American
    families as well as Federal spending. We need to address this now. In
    your testimony to the HELP Committee last week, you agreed that we need
    to work in ``a bipartisan way (to address the) root causes of drug
    prices, (and) to make sure that drug pricing is reasonable.'' But you
    refused to commit to specific policies. President Trump has said that
    we should allow Medicare to leverage its power as a payer, and
    negotiate drug prices with pharmaceutical companies.

        Do you agree with President Trump that Medicare should negotiate
    drug prices?

        Answer. The issue of drug pricing and drug costs is one of great
    concern to all Americans. You have my commitment to work with you and
    others to make certain that Americans have access to the medications
    that they need. If confirmed, I look forward to focusing on how we can
    make health care more affordable, including prescription drugs. I share
    your concern regarding the importance of individuals and families being
    able to afford the prescription drugs they need.
                              drug price and value
        Question. While we are moving towards paying for value in many
    areas of healthcare, in the drug space we have largely lagged behind.
    In the past year, we have seen some insurers and drug manufacturers
    pilot value-based arrangements that hold the manufacturer accountable
    for how their product performs in the real world on an agreed upon set
    of metrics. In 2015, I led a letter with my colleagues, Senator Kaine,
    Senator Nelson, Senator Shaheen, and Senator Heitkamp, to the Centers
    for Medicare and Medicaid asking them to examine the potential of using
    value-based arrangements in Medicare and other public programs.

        Will you commit to working with me to identify potential regulatory
    policy barriers that should be reviewed in order to continue to move
    towards reimbursement for value rather than volume in the drug space?

        Answer. If confirmed, I look forward to working with you and others
    to ensure that we are moving toward a health-care system defined by
    high-quality, patient-focused care. I appreciate how reimbursement--and
    other regulatory policies impact physician behavior. If confirmed, I
    will ensure that HHS is a good steward of taxpayer dollars, with the
    goal of delivering the highest-quality care through its health-care
    programs, including the Medicare program serving our Nation's seniors.
                              gabriella miller/nih
        Question. Gabriella Miller, a 10-year old girl from Leesburg, VA
    who suffered from pediatric brain cancer, became an extremely
    impressive activist on behalf of childhood cancer awareness before her
    untimely death. Her work led to the passage of the Gabriella Miller
    Kids First Act, and NIH has been moving forward to implement this law
    and expand pediatric research.

        Will you prioritize pediatric cancer research and implement the
    Gabriella Miller Kids First Research Act?

        Answer. I am always inspired by the courage cancer patients bring
    to their fight against this devastating disease. This is particularly
    true when the patients are some of the youngest amongst us. It
    underscores why we must cure cancer. The NIH plays a pivotal role in
    supporting cutting-edge biomedical research across our country,
    including key efforts related to pediatric research, and I recognize
    that we must make progress on this front for the adults and children
    fighting cancer. If confirmed, I look forward to continuing HHS's
    important work to advance cancer research and bring forward innovative
    treatments as part of our shared goal of defeating cancer.
                        cybersecurity/internet of things
        Question. The declining cost of digital storage and Internet
    connectivity have made it possible to connect an unimaginable range of
    products and services to the Internet, with medical devices at the
    forefront of this trend. However, in many cases, manufacturers have
    brought insecure devices to market, with few incentives to design the
    products with security in mind, or to provide ongoing support to
    address vulnerabilities. For example, we have seen cases where an
    implantable device lacked meaningful authentication methods, leaving it
    susceptible to unauthorized or malicious commands sent remotely.

        The FDA has taken important steps to addressing cybersecurity in
    the ``Internet of things.'' This includes promulgating post-market
    guidance, working closely with cybersecurity researchers, and engaging
    manufacturers to promote development of more secure devices. Will you
    commit to continue and build on these efforts?

        Answer. The safety of American citizens will always be a top
    priority of the HHS and ensuring the security of medical devices
    against the threat of hacking is critical to that end. If I am
    confirmed, the FDA will continue and improve upon its efforts to
    strengthen cybersecurity within the medical device industry as well as
    other related industries.
                            ban on cdc gun research
        Question. Since 2013, Americans have died from incidents involving
    firearms and automobiles at almost identical rates. Over the last two
    decades, the Federal Government has spent $240 million a year on motor
    vehicle safety research, and motor vehicle deaths plummeted nearly 25
    percent from 2004 to 2013 thanks to data supporting new policies. CDC
    has done virtually no research into gun-related injuries and deaths
    after an appropriations rider was added that prohibits the CDC from
    ``participating in advocacy or promotion of gun control.'' Roughly
    100,000 Americans injured or killed each year by guns, including over
    2,000 in 2016 from accidental shootings alone. The original author of
    the appropriations rider, Representative Jay Dickey (R-AR), has
    declared he regrets it and would like to see the CDC able to research
    violence and injury related to firearms. To make smart policy, it's
    necessary to have accurate information and data.

        If confirmed, would you direct CDC staff to interpret the
    appropriations rider in a reasonable way, so that CDC could in fact
    conduct unbiased research on the relation of firearms to public health?

        Answer. The CDC performs an important role in helping to understand
    and communicate public-health issues. If confirmed, I will work to
    faithfully ensure that the Department and its operating divisions
    fulfill their statutory responsibilities.
                                rural hospitals
        Question. Rural hospitals, serve older, sometimes more economically
    disadvantaged populations challenged by less access to primary, dental,
    and mental health care than their urban counterparts. Rural hospital
    leaders from across Virginia continue to share with me their concerns
    with efforts to repeal the Affordable Care Act. The ACA lowered the
    percentage of uninsured by 8 percentage points in rural counties,
    decreasing bad debt for providers in these areas, and providing them
    with some financial breathing room. Yet despite this progress, the
    Virginia Hospital Association estimates that 43% of rural hospitals in
    Virginia operate at a financial loss.

        Should there be supports included in an ACA replacement proposal to
    ensure these safety net providers can afford to keep their doors open
    to serve these vulnerable patients?

        Answer. Our goal is to ensure access to affordable, quality health
    care for all citizens. This of course includes individuals who access
    care at rural or critical access hospitals. And so the best metric in
    the end is one that measures the extent of access to actual care, not
    just coverage, and the quality of that care as determined by patients
    working individually with their doctors. I look forward to working on
    this important issue with you, if confirmed.

        Question. Last week, CBO reported that in the first year after a
    repeal of the ACA marketplace subsidies would take effect, about half
    of the Nation's population would live in an area that would have no
    insurer participating in the individual market, increasing to three-
    quarters of the population by 2026. You have emphasized ``access'' to
    coverage but the report suggests repeal in its effects will eliminate
    choice, competition, and access in rural communities, reversing much of
    the progress we've made to reduce the number of the uninsured, as well
    as reducing uncompensated care.

        What advice would you give President Trump on addressing the bad
    debt issues these rural hospitals would face post-repeal?

        Answer. Changes to the ACA should not be done in isolation. Our
    goal is to ensure access to affordable, quality health care for all
    citizens.
                                 home infusion
        Question. While I supported the 21st Century Cures Act when it
    passed in December, I remain concerned about a provision which caused
    the misalignment of effective dates of two important policies. The act
    included a provision Senator Isakson and I fought hard to include that
    would pay for services associated with allowing Part B to reimburse for
    Medicare patients to receive infusion drugs at their home starting in
    January 2021. However, a provision which was used to help pay for such
    payment, a cut to the reimbursement rates for Part B Durable Medical
    Equipment (DME) home infusion drugs, had an effective date of January
    2017. This leaves a 4-year gap where home infusion services will not be
    adequately reimbursed. While I work with my colleagues in Congress to
    fix this issue, I hope that the Centers for Medicare and Medicaid
    Services (CMS) will make every effort to ensure Medicare beneficiaries
    continue to have access to these lifesaving medications.

        Can you commit to report back on actions CMS and HHS can take to
    protect beneficiaries from losing access to life-saving care?

        Answer. Yes. I look forward to working with you to find approaches
    to this issue that ensure access to the highest quality care.
                                   telehealth
        Question. I've worked with bipartisan members of the Finance
    Committee to expand the use of telehealth, especially in Medicare, and
    I was glad that at your hearing last week you called telehealth an
    ``exciting innovation for rural and underserved areas.''

        As Secretary, will your Department work with my staff and others to
    find ways to fully leverage HHS's existing authority to lower barriers
    for telehealth and remote patient monitoring in Medicare?

        Answer. I share your interest in promoting telehealth. Telehealth
    can provide innovative means of making health care more flexible and
    patient-centric. Innovation within the telehealth space could help to
    expand access within rural and underserved areas. If confirmed, I look
    forward to continued discussions on telehealth, including on the best
    means to offer patients increased access, greater control and more
    choices that fit their medical needs.

                                     ______

        Submitted by Hon. Debbie Stabenow, a U.S. Senator From Michigan

                    DPCC FORUM ON HEALTH AND HUMAN SERVICES
                               NOMINEE TOM PRICE

    _______________________________________________________________________

                           THURSDAY, JANUARY 19, 2017

                  OPENING STATEMENT OF HON. DEBBIE STABENOW,
                          A U.S. SENATOR FROM MICHIGAN

        Senator Stabenow. Well, good afternoon. We so appreciate all of you
    being with us, and I want to thank all of my colleagues for being here
    and for their hard work.

        Senator Murray will be joining us; she has been involved in helping
    to create the success of today, as well as Senator Warren. Senator
    Kaine of course is here, and Senator Hassan. It's very important for us
    to have an opportunity to hear from all of you as we are reviewing and
    making decisions on who will head the Health and Human Services
    Department for our country.

        And Senator Murray has joined us; welcome. Let me just start by
    saying that on all of these issues this is not personal to any nominee,
    this is about differences, fundamental differences, and ideas and
    policies and what helps people, what hurts people. I mean these are
    very important debates, and your voice, your opinions are very
    important to all of us.

        So you're here at a critical time, and we know that just last week
    Republicans in both the House and the Senate pulled the first thread
    that will unravel potentially the entire health-care system, voting to
    adopt a budget resolution that would allow for repeal of the Affordable
    Care Act, and we don't know what comes after that. If this happens,
    according to the Congressional Budget Office, 32 million people,
    including many of you on this panel today, would lose health insurance
    coverage and individual market premiums would double in the next 10
    years, according to the budget office.

        Unfortunately, the damage would not end there. Another 52 million
    adults, including 1.7 million in my own home State of Michigan, could
    become uninsured due to pre-existing conditions. Forty-eight million
    people could lose mental health parity protections, which makes sure
    that diseases are treated above the neck, as well as below the neck. We
    could be sent back to a time when being a woman was a pre-existing
    condition, when insurance companies would cut you off when you hit an
    annual or lifetime limit on coverage, even if you needed more care.

        One hundred and five million Americans no longer face bankruptcy
    when they get sick because those caps have been eliminated, and that is
    a good thing. The Medicare trust fund has been extended by 11 years,
    preserving future benefits, and 11 million seniors have saved an
    average of $2,000 because what has been called the ``donut hole,'' this
    gap in coverage, has been phased out; it's now closed so there is
    continuous coverage.

        I could go on with the numbers, but the most important thing is not
    the numbers. The most important thing is how all of this effects your
    families, our families, our children, our parents, our grandparents.

        If confirmed by the Senate, the Secretary has tremendous power. His
    or her decisions in office will affect all of us. His or her voice will
    strongly influence the President's decision to promote, sign, or veto
    legislation.

        We have heard mixed messages. Our President-elect campaigned on not
    cutting Medicare or Medicaid. Just over the weekend he said we would
    have insurance for everyone. We would certainly welcome the opportunity
    to see that plan, we do welcome it. But at the same time, just this
    fall, Congressman Price said he expects Medicare to be overhauled
    ``within the first 6 to 8 months'' of President Trump's administration.
    He also believes, ``the age of eligibility needs to be increased,'' and
    that, ``the better solution is premium support,'' which is another word
    for vouchers.

        When it comes to covering pre-existing conditions, he has indicated
    that he thought that was, ``a terrible idea.'' So this is important,
    this is about ideas and policies and values and perspectives, and we
    are very grateful that all of you are here.

        We had asked the Chairmen of the two committees responsible for the
    nomination if we could in fact have a panel of all of you, of others,
    to share voices at the formal confirmation hearing. That was rejected,
    and so we're doing a public forum to give you an opportunity to share
    your thoughts.

        So thank you again, and before introducing our panelists, our
    terrific ranking member from the Health, Education, Labor, and Pensions
    Committee, Senator Murray, is here, if you would like to say a few
    words.

                    OPENING STATEMENT OF HON. PATTY MURRAY,
                         A U.S. SENATOR FROM WASHINGTON

        Senator Murray. Well, I won't talk long because I really do want to
    hear from all of you, it's so important, and I want to thank Senator
    Warren and Senator Stabenow for putting this together, because, as all
    of you know, we did have a hearing yesterday.

        I was disappointed we couldn't ask more questions of the nominee
    himself. We were only given one round. There is a lot to be concerned
    about.

        Congressman Price has a long record of making decisions I would not
    make, taking away affordable health care, going after people who depend
    on Medicaid. He is a politician who has worked hard to undermine
    reproductive rights, seniors who rely on Medicare--the list goes on--
    and this is a cabinet secretary who will oversee the lives of literally
    every family in this country.

        So we have a responsibility to hear from those families in this
    country and the impact this department will have on them. So I really
    appreciate your doing this, and I look forward to all of your
    testimony.

        And I just want to give a shout out to our Democrats, both here and
    on my committee, who really did an excellent job, both with this
    hearing and the DeVos hearing, in really, in the very limited amount of
    time we had, showing some of their record.

        So, thank you all very much for being here.

        Senator Stabenow. Thank you so much. Senator Warren, who has played
    such an integral role as we have been bringing forth public voices on
    the nominees, is here. Thank you.

        Senator Warren?

                  OPENING STATEMENT OF HON. ELIZABETH WARREN,
                       A U.S. SENATOR FROM MASSACHUSETTS

        Senator Warren. So, thank you very much, Senator Stabenow, for your
    leadership in pulling this together so we get to have these people's
    hearings, and I also want to say ``thank you'' to Senator Murray. She
    really is our leader, and the one who is keeping us in this fight on
    the nominees, and the fight to protect what it is that we stand for
    here.

        And I welcome our newest member, Senator Hassan, who is also on the
    committee, and Senator Kaine. So we have a bunch of people who are in
    there fighting.

        You know, President-elect Trump has spent the past few weeks
    filling his cabinet and putting together his team for how he wants to
    run his administration. The decisions that he makes will have
    tremendous consequences on the lives of everyone in this country, and
    when it comes to the Secretary for the Department of Health and Human
    Services, President Trump's choice will have an enormous effect on the
    lives of everyone in this room and everyone in this country.

        They will help determine whether millions of Americans continue to
    have access to medical care, whether contraception or cancer screenings
    or flu shots must be covered by your health insurance, whether Medicare
    and Medicaid are protected for the 100 million Americans that rely on
    this program. In short, the hiring decisions that President-elect Trump
    is making tell us about the values of the incoming Trump
    Administration.

        Now, unlike many of President-elect Trump's nominees, who have
    little or no experience as they take over their various departments,
    Congressman Price has a lot of experience in health-care policy, and
    that is why we are so worried. His record makes clear that he has some
    very radical, scary ideas about how to change health care in America.
    Congressman Price once described the ACA's ban on discriminating
    against individuals with pre-existing conditions as ``a terrible
    idea.'' He has voted 10 times to defund Planned Parenthood, which
    provides lifesaving cancer screenings and treatment for sexually
    transmitted diseases to millions of people a year. He has proposed
    privatizing Medicare and increasing the eligibility age for coverage,
    and he has championed massive cuts to the Medicaid program that will
    leave millions of people either uninsured or with fewer benefits.

        Twenty-four Senators, led by Senator Casey of Pennsylvania, sent
    letters to Senator Hatch and Senator Alexander, asking them to include
    witnesses in Congressman Price's nomination hearings, witnesses who
    could talk about what the impact of his radical policy proposals would
    be on the lives of real people.

        Now, I am sorry that the Republicans refused to hear your voices,
    but I am deeply grateful that you came here today to make sure that
    your voices are heard anyway. I am grateful to my colleagues who are
    doing everything they can to amplify your voices, and to make sure that
    as the United States Senate considers its sacred obligation on advice
    and consent of the nominees in front of us, that we remember, most of
    all, that we are here to serve you. So thank you for being here.

        Senator Stabenow. Thank you so much.

        We have been joined by Senator Hirono from Hawaii, and with the
    indulgence of the rest of our distinguished Senators who are here, I
    think I'll move to hearing from our guests and then move to questions,
    if that is all right with everyone.

        So let me first take home State advantage here, our prerogative, by
    introducing Anne Serafin from Ferndale, Michigan. She lives with
    Multiple Sclerosis and is covered by Medicare.

        Anne and her husband also supported Anne's mom for the last decade,
    and after years of financial stress were able to get her mom into a
    nursing home, with the cost of her care covered by Medicaid, and we
    greatly appreciate hearing your story.

        We'll introduce everyone and then we will come back to you. And I
    am going to turn now to Senator Warren for our next guest.

        Senator Warren. That's right. I have the privilege of introducing
    Kanisha Hans, who is here today with us to talk about the impact of the
    Affordable Care Act on her personally.

        I just want to add that Kanisha discovered her passion for advocacy
    by volunteering in political campaigns, good for you, candidates for
    local office.

        Today Kanisha lives in Boston, and she works in a Cambridge tech
    start-up. She graduated from Boston University in 2015 with a B.A. in
    Political Science and a minor in Public Health.

        She is taking off time from work to be here today, and we are very
    grateful that she is willing to share her story, which underlines the
    critical protections that the Affordable Care Act gives us for women's
    health care.

        So thank you very much for joining us today, Kanisha.

        Senator Stabenow. Kanisha, welcome.

        Now we have also been joined by Senator Blumenthal from
    Connecticut; welcome.

        Alyce Ornella from Harpswell, Maine. So you've come a little bit,
    how is the snow up there right now? Much colder; okay.

        Alyce and her husband were self-employed when they were able to get
    health insurance coverage through the ACA exchange. Alyce's plan
    provided free pre-natal care, including prenatal tests while she was
    pregnant with her son, Sam. When Sam was unexpectedly born with serious
    birth defects, her plan covered all of his intensive care and surgery
    costs, and Sam now receives care through Medicaid, which has covered
    every test and exam that he has needed, and we wish him well, we hope
    where is Sam?

        Oh, well we want to see Sam.

        Okay, is that who I met earlier, with the terrific sweater on?

        Okay, we need to have him come back.

        So welcome, we're so glad to have him, and close to home, riding
    the Metro in I think today to avoid all the traffic, Diane Fleming.
    Diane is 75 years old, lives in Washington, DC, went on Medicare at age
    65, 5 years ago was diagnosed with thyroid cancer. Medicaid has covered
    the bills from the four surgeries, radioactive iodine treatment, CT
    scans, sonograms, MRIs, and needle biopsies she has needed to treat her
    cancer.

        We are very grateful to have you here to hear from your story and
    have you elaborate as well.

        And I know that Senator Brown is hoping to join us. I know I just
    left him a while ago in the Finance Committee.

        So, Holly, he wanted to introduce you, but I know he is going to
    join us if he can. Holly is from Cleveland, Ohio. Self-employed as a
    non-profit consultant in Cleveland, runs her own LLC., was able to
    access mental and behavioral health services through Medicaid, and has
    been able to go on--I'll let you tell your story about what you have
    been able to actually receive in terms of help as a result of that, but
    we are so pleased you are here as well.

        And Senator Bob Casey from Pennsylvania has just joined us. So I am
    going to ask Anne if you could share your story. We ask everyone to
    take no more than 5 minutes to start so that we can have an opportunity
    to ask questions as well, but, Anne, thanks so much for you and your
    husband being here.

             STATEMENT OF ANNE SERAFIN, PANELIST FROM FERNDALE, MI

        Ms. Serafin. Good afternoon. My name is Anne Serafin. I live in
    Ferndale, Michigan, and I am 66 years old. I just want to say, I'm
    reading this statement, so it may not convey the real passion I feel
    about this issue. But please know how important this is to me.

        I've had personal experience with Medicare since I was 40 years
    old, when I was diagnosed with multiple sclerosis.

        As you may know, MS is a neurological condition, which varies in
    severity and it's very unpredictable. My particular version resulted in
    functional quadriplegia. As a result, I am unable to walk, but I can
    stand up with personal assistance and a grab bar. I can use my right
    arm, in a limited fashion, but have no use of my left arm. Fortunately
    my vision, speech and cognitive abilities have been spared.

        At the time I was diagnosed, I was a marketing professor at
    University of Detroit-Mercy. The University placed me on disability,
    and a year later my application for Social Security disability benefits
    and Medicare was approved. Thanks to strong union support, the
    University picked up my secondary health insurance until I turned 65.

        Within a few years, new MS medications started coming onto the
    market, and my neurologist and I chose Copaxone. The price started out
    at about $8,000 a year, but is now $84,000 a year. After ten years, it
    became apparent that Copaxone was not working, so I tried several other
    medications, including Acthar Gel.

        In the '70s, this cost $50 a month, but when the drug company
    realized it could benefit many people with MS, it shot up to $30,000 a
    month. Because it was off label, my insurance would not cover it. The
    National Organization for Rare Diseases helped for two months, but I
    could not afford to continue after that.

        I am currently on Gilenya, with a co-pay of $38 per month. Without
    Medicare or secondary insurance, this one drug would cost about $75,000
    a year, which is nearly our total household income including our Social
    Security benefits. I have a handout that can show you if you'd like to
    see it about how prices have shot up for all MS medications.

        Disability is costly even beyond medications. Making our home
    accessible, purchasing an accessible vehicle, the scooter I drive, and
    hiring personal assistance; it gets expensive. This is why my 68-year
    old husband continues to work part time as a self-employed writer,
    while also serving as my primary caregiver. His monthly insurance costs
    were $900 before he turned 65.

        We rejoiced when he was able to get Medicare and have that number
    come down to $200 for supplemental insurance. Without Medicare, I would
    have had to decide: do I eat, or do I get my meds? Without Medicare, I
    would have to pay an astronomical cost for private insurance, if I can
    get coverage at all.

        While I was dealing with my own health issues, my aging parents
    needed increasing care and support. My father was a U.S. Army veteran
    who served as a paratrooper in World War II. He helped liberate
    Normandy with his D-Day combat jump. He was also an independent artist
    and relied on Medicare and the VA hospital for his health care. Even
    though my dad worked until his death at age 91, my husband and I needed
    to financially support my parents to keep them in their home. This is
    what they wanted, to age with dignity. We're Greek, and Greeks take
    care of their own.

        I also have experience with Medicaid, which my mother relied on for
    the last 3 years of her life. My husband and I took care of her
    financially before she passed away at 98 this past October. Until my
    dad passed, my mother had Medicare with supplemental insurance. But my
    parents had no savings and no assets--we had bought them a condo and
    took over the mortgage payments. When my mother's dementia worsened to
    the point that she needed full-time care, we had to place her in a
    nursing home. I could not care for her complex needs; I needed help for
    my own care.

        Even a bare-bones nursing home would've been too much for us at
    $6,000 a month. She received $1,190 a month in Social Security and
    widow's VA pension benefits. It was only because of Medicaid that she
    was able to get the help that she needed at the end of her life.
    Without Medicare and Medicaid, things would have been very different
    for my family. I don't know how I could have cared for my mother on top
    of managing my own care. My family would have lost our home and all our
    savings trying to keep up with the bills.

        So many families are squeezed like ours, having to afford care for
    their aging parents and their own care or childcare at the same time.
    But with support, we don't have to suffer just being alive.

        I can't cook for myself, I can't get myself out of bed, but I can
    still contribute. Because of these public programs, I can be productive
    and be involved in things that are important to me. This includes being
    here with you in Washington, talking with legislators, and volunteering
    as an advocate with Michigan United, Caring Across Generations, and the
    MS Society. All because of the support I get from Medicare.

        If these programs are cut, people will face more catastrophes than
    ever before. People are panicking. If these services are cut, it will
    have a huge, huge, huge impact on the lives of many people. Congress
    needs to know that. Thank you for listening.

        Senator Stabenow. Thank you so much, Anne. We really appreciate it.
    Kanisha Hans, welcome again.

              STATEMENT OF KANISHA HANS, PANELIST FROM BOSTON, MA

        Ms. Hans. Hi my name is Kanisha Hans, and I am from Boston,
    Massachusetts. I am 23 years old and an Indian immigrant, and a recent
    college graduate. Thank you to Senator Warren and all the Senators here
    who have invited me today to share my story about how important the
    affordable care act and access to reproductive health-care providers
    like Planned Parenthood cannot be repealed without devastating impacts
    on the health and well-being of millions of people.

        Like the vast majority of American women, I rely on birth control.
    And like millions of young people I rely on my parent's insurance plan
    for my health-care coverage. Both have allowed me to pursue a college
    education and ultimately secure and maintain employment. When I was 15
    years old I needed a birth control prescription for debilitating
    periods I was having that caused me to pass out during class. Being
    from a reserved Indian family I didn't feel comfortable discussing my
    situation at home. So I told a friend whose mother brought me to
    Planned Parenthood. My doctor at Planned Parenthood prescribed me birth
    control and helped me to afford it. This was one of the first times I
    felt like someone was listening to me about my own health-care needs.
    Remembering the caring and non-judgmental services provided to me, I
    saw Planned Parenthood again when I needed to change birth control
    methods due to other health concerns.

        Unfortunately my insurance failed to cover the high cost of the
    specific type of birth control that I needed. Forcing me to use a
    prescription that didn't suit me and even exacerbated my symptoms.
    Luckily, I was eventually able rely again on a doctor I trusted at my
    local planned parenthood to manage my condition. There they were able
    to cover the cost of my long acting reversible contraceptives at a cost
    that I could afford. This was before the Women's Preventative Benefits
    in the ACA and I was charged $100 instead of $1,000. This was critical
    for me because I would have been unable to afford the method that was
    best for my health while I was also pursuing an undergraduate degree
    and balancing other living expenses like tuition and rent.

        Unfortunately, I know many women and many students who were priced
    out of this privative care. But today thanks to the Affordable Care Act
    these same barriers no longer exist like they once did for me.

        Six years ago the passage of health-care reform was a historic step
    for women of all ages. Thanks to the Affordable Care Act, I've joined
    the 55 million women nationwide who benefit from no co-pay for birth
    control and expanded insurance coverage. What's more important is that
    women like me are able to afford the right of birth control for our
    bodies or conditions with no out of pocket cost and in consultation
    with our doctors.

        Beyond just birth control I now join millions of young people
    getting access to needed health-care coverage as a result of being able
    to stay my parents insurance until age 26 and I am not forced to pay
    more because I am a women or because I have a preexisting condition. I
    am grateful to have a job and while I am not financially dependent on
    my parents I am able to stay on their health care. So by staying on my
    parents plan I am both able to stay healthy and pay my student loans on
    my own every month. Hopefully someday I will also be able to pursue a
    graduate degree and pay that off as well.

        This winter I was able to go back to Planned Parenthood to get a
    new IUD. After the results of the election I became fearful that I
    wouldn't be able to afford this care anymore. Tom Price has a history
    of working to reduce access to care and leading the Federal health care
    agency. I am concerned he is out of touch of the health-care needs of
    patients like myself. To be clear without Planned Parenthood and the
    Affordable Care Act I would not have been able to afford the birth
    control I needed to manage my condition. If Congressman Tom Price is
    successful in rolling back the ACA I will be forced to pay for care I
    need, charged more because I am a women and could even lose my health
    insurance all together. He isn't looking out for me and he isn't
    looking out for women, men, or young people. And he isn't looking out
    for the well-being of Planned Parenthood patients. He cannot be trusted
    with my health or the health of this country. Thank you.

        Senator Stabenow. Thank you very much. We have been joined by
    Senator Jeff Merkley from Oregon. Welcome, and, Alyce, I believe Sam
    has entered the room. Yes, welcome, Sam. Sam has the coolest sweater
    on, you have to see Elmo. Hi, Sam. He is living proof of the importance
    of affordable access and health care.

        Senator Kaine. He can have my seat if I can have the sweater.

        Senator Stabenow. Yes, just not for a while. Yes, welcome.

            STATEMENT OF ALYCE ORNELLA, PANELIST FROM HARPSWELL, ME

        Ms. Ornella. Yes, thank you. I hear myself echoing. Three years ago
    my husband and I were expecting our first child. At the time we were
    self-employed as small business owners and we couldn't afford the high
    cost of health insurance. This was before the ACA. When the Affordable
    Care Act was passed we found an affordable plan on the market place.
    Suddenly all of my prenatal care was covered, my pregnancy was
    completely normal and uneventful. Just as everyone hopes the plan we
    signed up for through the marketplace covered advance testing for
    genetic conditions and all my results came back clear. But then the
    unexpected happen as tends to happen. No one wants to face the
    devastation of their baby being born with life threatening medical
    problems but that is exactly what happened to us.

        Our son Sam was born with multiple congenital birth defects, none
    of which could be detected before he was born. He was rushed by
    ambulance teams to the Maine Medical center in Portland. When he was
    just 2 days old the pediatric surgeons performed surgery there to save
    his life. The medical bills in his first month alone toped $100,000.
    Within his 2 years of life Sam has been seen by nearly a dozen
    specialist and has gone through 20 tests and procedures to ensure that
    his health remains stable.

        Later in his infancy Sam was approved for SSI benefits which meant
    he also became covered by Medicaid--the transition to that coverage was
    seamless I only needed to make sure his pediatrician put in an
    authorization for his medication and specialist. He was able to
    continue seeing the same specialist that he'd seen since birth and his
    Medicaid coverage has fully provided for every test and exam he's
    needed. Knowing that Sam can receive all the care his doctor's want for
    him has greatly lessened anxiety we've felt regarding his multiple
    conditions. His access to testing has enabled us to confirm positive
    side changes in his conditions which has allowed him to go off certain
    medications sooner than expected.

        Sam is now a thriving happy 2 year old who seems like any kid his
    age. I've been able to return to work part time since he is doing so
    well. Sam's health will still require a team of pediatric specialists
    to ensure care for him throughout his childhood.

        The protections the Affordable Care Act has provided ensure that we
    have been able to get him the tests, medicine, therapies, doctor visits
    that he needs to stay healthy. The Affordable Care Act ensures that he
    can never be denied coverage. And that our family is not charged
    exuberant premiums fees and high deductibles because of his medical
    needs and means he will never face lifetime limits in coverage for the
    conditions he has had since he was born. The Affordable Care Act has
    been critical to how well he is doing today.

        Due in part to our fears regarding the ACA repeal my husband and I
    have given up self-employment so that we can attain more security
    regarding health-care coverage in the future. My husband has recently
    accepted a job that will take him away from home more than we are used
    to but comes with a solid employment based health-care coverage for our
    family. This is our priority now that the new administration and Senate
    Republicans have made the ACA repeal their first goal. However I cannot
    rest assured that Sam's long-term future will be as secure if we lose
    the provisions for no denial pre-existing conditions. I fear the return
    of yearly or lifetime limits on coverage. And high risk pools. What if
    my husband loses his job? What will health-care access look like for
    Sam 5 or 10 years from now? What will be available to him when he is an
    adult looking for coverage as a person who was born with multiple
    medical conditions and has a complex medical history? No one should
    face financial ruin because they need medical help and no one should be
    forced to go without the medical care they need.

        It would be irresponsible to our representatives in Washington to
    pull the rug out from under millions of people around the country who
    have health care because of the Affordable Care Act. I know how it
    would affect my son's life if that were to happen and it would be
    devastating for him and our family.

        Senator STABENOW. Thank you so much for sharing your testimony and
    for sharing Sam. It is a blessing to see him acting so well, like a
    normal 2-year-old. Oh, before I forget, welcome, Senator Sheldon
    Whitehouse, joining us from the Great State of Rhode Island. So, Diane,
    welcome.

            STATEMENT OF DIANE FLEMING, PANELIST FROM WASHINGTON, DC

        Ms. Fleming. Good afternoon, everyone. It is such a pleasure, and
    thank you for allowing us to be here. My name is Diane Fleming. I am a
    75-year-old young adult. I live in Anacostia neighborhood which is ward
    eight, 10 minutes from the Capital here. I am a retired member of the
    International Association of Machinists. And I am here today on behalf
    of the alliance for retired Americans. I am pleased to be surrounded by
    others who are fighting to protect our hard earned Medicare benefits. I
    worked for United Airlines for 35 years as a reservation and ticket
    agent. But when the airline went bankrupt I lost most of my pension. So
    you know that is a little less money. Luckily, my job provided me with
    health care coverage until I was 65 and went on Medicare.

        Five years ago I was diagnosed with thyroid cancer. Since then I
    have had four surgeries, radioactive iodine treatment twice, the cancer
    has recurred and I will need to have surgery again. After being
    diagnosed with the thyroid cancer I've had CT scans, sonograms, MRIs to
    detect the target areas, little biopsies, and most of these procedures
    are very expensive. We are talking $1,000 to $3,000, to $3,000 for one
    thing. I have also had to have blood work regularly to check the
    levels. And I don't know how I would have been able to afford all of
    these treatments and test done without Medicare to cover the bills.

        In addition to the cancer, I suffer from glaucoma, which is
    hereditary through my family, and I need daily drops.

        Medicare has help to make sure I receive treatment every 4 months
    to check the eye pressure. While others have private Medicare advantage
    plans. I chose the traditional Medicare. It has made my cancer a lot
    more bearable, enabling me to focus on getting better rather than going
    bankrupt. I know I speak for millions when I say no cuts to Medicare
    and no privatization. With premium support of vouchers a person with my
    pre-existing condition, with my age, I probably wouldn't be able to get
    insured, and if I could it would be very costly. So I need the
    guaranteed coverage that Medicare offers. Not a coupon or voucher.
    Those things don't work anyway that I could not afford. Millions of
    older Americans are able to enjoy their retirement without astronomical
    medical expenses because of Medicare.

        In the age of small or nonexistent pensions, minimal retirement
    savings, and skyrocketing prescriptions, Medicare is literally a
    lifesaver. My sister just had to go on a medication, and a 28-day
    supply is $30,000. So without Medicare she would not be able to do
    this. I retired at age 62, but I was lucky that United did provide
    health coverage and I was able to continue with that until I turned 65.
    So most Americans don't have that. We must make sure that Donald Trump
    keeps the promise not to cut Medicare so medical expenses don't
    bankrupt millions of seniors and their families.

        Since November the President-elect and Republican support on
    Capitol Hill have taken steps towards dismantling and cutting our
    earned Medicare benefits. President-elect Trump has named house budget
    committee chairman Tom Price of Georgia to be the Secretary of U.S.
    Health and Human Services. Representative Price has spent years trying
    to privatize and cut Medicare in the past. I wonder what he is cutting
    out of his area. Representative Price has promised to cut and change
    Medicare into a voucher program. As Secretary, Price will have
    significant control over Medicare including RD plan and policies
    affecting the price of prescription drugs. His views are out of touch
    and he is just not a very sensitive person. We Americans have paid for
    decades and we continue to pay. Money comes out of my monthly Social
    Security checks to cover Medicare.

        So Representative Price and the President-elect will be working
    closely together with House Speaker Paul Ryan. He has tried to do this
    over and over again. If Speaker Ryan's plans were to become law,
    seniors would become deeply hurt. We simply cannot afford to wait until
    we are 67 to go on Medicare and the privatization that the speaker
    calls for. The members of the Alliance will fight Donald Trump, and
    thank all of you all, fighting Paul Ryan and Price every step of the
    way. We need to guarantee the benefits that Medicare offers, not coupon
    care that leaves seniors like me hanging out to dry. Thank you very
    much.

        Senator Stabenow. Thank you very much. We are pleased to be joined
    by Senator Baldwin; welcome. And we are so pleased now to hear from
    Holly Jensen. Welcome again.

             STATEMENT OF HOLLY JENSEN, PANELIST FROM CLEVELAND, OH

        Ms. Jensen. Thank you so much and good afternoon. I am Holly
    Jensen, and I am 32 and from Cleveland, and I am honored to tell you
    how the ACA and Medicare saved my life. I own a small business that
    helps nonprofits with communications and fundraising. I am a really
    hard worker and I love what I do. Most of my business comes from
    referrals from causes I support and I am proud to say that I am good at
    my work. This is my first business card, I still am proud of it and am
    excited by it. Part of the gig economy comes with the risk. If I don't
    produce I don't get paid. I don't get paid sick days. I don't get paid
    vacation days. So when the Affordable Care Act passed, it was huge
    relief.

        I had never had my own insurance before. I had been living before
    undiagnosed with anxiety, depression, and OCD. It began to severely
    impact my life. Tasks that normally took an hour began to take all day
    and things began to feel insurmountable. I remember one project I was
    excited about working with the Compassionate Communications Center for
    Ohio and was going to go down from Cleveland to Columbus to meet with
    the board to discuss their Middle East peace activism. As I was
    preparing my disorder was beginning to spiral out of control and pretty
    much fell apart. I had to cancel this trip that I was really looking
    forward to at the last minute. This is one example of the way my
    untreated disorders were effecting my life. It was horrible and really
    embarrassing. My increasing inability to function dealt not only a blow
    to my bank account but also my livelihood and self-respect. I withdrew
    from my community and the arts world, which often involved organizing
    small business owners such as myself. My once active life became small
    and empty. I felt like I was slipping out of society.

        However, the most painful act of being untreated was seeing my
    relationship with my loved ones crumble. Including my mom who is my
    best friend in the world. She just turned 65 in August. I hope she
    doesn't mind me saying that. Sorry, mom. She is going through the
    process of Medicare and is having tests that she has never had before.
    So my mother lives three blocks from me, and my brother lives one block
    from me. And at this point weeks would go by without me as much as
    answering a text message from them. So it was getting scary. And about
    a year ago I hit rock bottom. I couldn't keep up with my premiums or
    any bill. And it was winter in Cleveland and I don't have a car, so I
    slug through the snow and sleet to the free medical clinic in
    Cleveland. At this point I didn't have anywhere else to turn. Asking
    for help took a really long time and was incredibly humbling. When I
    got there my mind was so rattled that I didn't even know how to begin
    filling out the paperwork. A women there walked me through it, helped
    me through it, and treated me with respect and efficiently helped me
    re-figure out my life. Ta-da; this is my ticket, my golden ticket.

        On that day, I felt like a person who deserved to care. And even
    before the process of receiving treatment started, that glimmer of hope
    meant so much. It meant I wasn't a disposable person. And it took so
    long to ask for help, if I would've been turned away, I really might
    have lost hope entirely. And if they'd said I needed regular employment
    to access Medicaid, I definitely would've continued going in a downward
    spiral. Requiring employment for Medicaid would've been like telling me
    you'll throw me a life preserver after I stop drowning.

        My psychiatric care has given me the foundation on which to rebuild
    my life. I take medications, such as this, and I have weekly counseling
    therapy sessions that help me heal and grow. I also do an enormous
    amount of work on my own to make sure that I keep up my progress. This
    care not only saved my life, it gave me back my life. Thanks to
    Medicaid, I'm becoming the professional I want to be again. But more
    important, I'm becoming the person I want to be.

        I have faith in growing my business, not just struggling to keep it
    alive. I'm back, actually working with [the] compassionate
    Communications Center of Ohio, doing psych redesign and branding, and I
    really love working with all of my clients. And once again, organizing
    and participating in arts events in my community and I'm volunteering
    at my local recovery clubhouse, applying my communication and
    development skills to help them to continue to support the community.
    I'm reconnecting with my friends and loved ones. Perhaps most
    important, [I'm] restoring my relationship with my mom. It feels good
    to pay my bills, but it feels even better to be part of something.

        Mental and behavioral health is no joke. Without Medicaid, I know I
    would have eventually depended on emergency care, taxpayer funded
    rehab, and the legal system. I would've cost taxpayers much more than
    the expense of my basic care now. My goal is to continue healing,
    regain my earning potential, get my private health coverage, and
    happily support Medicare and Medicaid in my tax dollars. Despite my
    relatively high tax rate for self-employed people, I would be proud to
    support these life-saving and tax dollar saving programs. And I know
    I'm not alone. We cannot afford to discard and destroy the ACA and
    Medicaid for millions of people like me who would be turned away. For
    me, that would've meant discarding me exactly when I needed support the
    most. Thank you for allowing me to share my story.

        Senator Stabenow. Well, thank you so much. Hi, we've been joined by
    my friend and colleague, the great Senator of Michigan, Gary Peters.
    You have the full Michigan delegation here, Anne. You have all of us
    here with you. So, let me begin. We want to give all of our colleagues
    the chance to ask a question.

        I have to say that listening to all of you, whether it's talking
    about maternity care, I remember the fights in the Finance Committee
    when colleagues did not believe that that should not be in the central
    service and it makes me smile to hear you talk about maternity care and
    to see Sam and to have each of you talk about things that so many of us
    fought so hard for. But, I do want to particularly, Holly, thank you
    for being here, as the author of the mental health parity provisions in
    the ACA because of my own family's situation. I want to thank you for
    your courage, because we have done less research over our country's
    history on the organ called the brain, we're finally doing that. But,
    whether it's a chemical imbalance in the brain, like my dad had, and
    was finally diagnosed as bipolar. And once that happened and he got the
    mediation he needed, he went on to live a very effective life. So, I
    saw what it was like when he didn't and when he did. And, a tremendous
    difference. So, I have always felt that, and I know my colleagues have,
    that whether its diabetes and you're checking your sugar, or whether
    it's a chemical imbalance in your brain, we want to have the same view
    in terms of access to care. And not have a stigma, depending on which
    part of our body the disease is in. So, I just want to thank you for
    your courage and for speaking out for millions of people; one out of
    five people in our country are struggling with a disease that involves
    behavior health. And so, thank you very much for doing that.

        Anne, I wanted to ask you a question, actually a couple of
    questions. You were talking about your prescription drug costs. When we
    look at these numbers, unbelievable, $50/month to $30,000/month or
    $8,000/year, was it, to $84,000/year. I mean, these are astronomical
    increases, and there's a whole range of things, dealing with cost of
    medicine that we need to tackle still in this country for sure. But, I
    wonder if you might speak about where you would be right now without
    Medicare, speak a little bit more about that. So, costs, what that
    would mean to you. And if we saw Medicare turn into some kind of a
    voucher, no matter what we call it, being in support of a voucher,
    where it wasn't guaranteed coverage and guaranteed prescription drug
    coverage, how would that work for you?

        Ms. Serafin. Well, first of all, without Medicare, I would have to
    get insurance and because of my preexisting condition, I would not be
    able to get insurance. Second, without Medicare, I think my husband and
    I would've ended up on Medicaid because we would've been bankrupt. I
    mean, we have a small nest egg, which we have, as I've shared before,
    used a substantial portion of to help out my parents. That would've
    been gone. The costs are just prohibitive; we couldn't have done that.
    $6,000, $8,000, $84,000/month and actually, the MS----

        Senator Stabenow. A month? So, it's $84,000/month?

        Ms. Serafin. No, sorry; that was a year.

        Senator Stabenow. Oh, a year, okay. Either way it's a lot of money.
    More than most people make a year.

        Ms. Serafin. It's a lot of money, but the Acthar Gel is $30,000/
    month.

        Senator Stabenow. All right, thank you. We have many colleagues I
    want to make sure have a chance to ask questions. So, thank you, for
    now and, Senator Warren.

        Senator Warren. Thank you, and thank you all again for being here.
    You know, yesterday at the hearing for Congressman Price to be
    Secretary of HHS, I asked him about the cuts that he has proposed to
    Medicare and Medicaid. You know, he's already proposed $449 billion in
    cuts to Medicare and over $1 trillion in cuts to the Medicaid program.
    And so I asked him if he would commit to follow through on Donald
    Trump's promise, ``I won't cut Medicare or Medicaid.'' And, there was a
    lot of dancing back and forth, but the bottom line is, no, he would not
    commit, which I'm suppose should not have been a surprise. But what I
    just want to do, as briefly as I can, is to just focus in, just a
    little bit, down the line and put a face to that. What it means to put
    those kind of cuts into the system. So, if I can, let me start with you
    Ms. Fleming. You used to work at United Airlines, as I understand. How
    many years did you pay into the Medicare system?

        Ms. Fleming. [Mic did not pick up.]

        Senator Warren. And how long have you worked there?

        Ms. Fleming. Thirty-nine years.

        Senator Warren. Thirty-nine years that you paid into the Medicare
    system. So, when Congressman Price proposes cutting $449 billion out of
    the Medicare system, I just want to ask, that's going to put more out-
    of-pocket costs on you. Does that sound fair to you?

        Ms. Fleming. [Mic did not pick up.]

        Senator Warren. Nice question. Where else is it we so much need to
    spend $449 billion that you can spend more out of pocket so that money
    can go somewhere else--like tax cuts for rich people. Ms. Jensen, can I
    ask you--just because I want to be clear about this. One of the things
    that Medicaid does is make sure you get access to mental health
    services. If you lose that access, what happens to your life?

        Ms. Jensen. Um, that would entirely change my life. I wouldn't be
    able to afford the services I need. My medications alone right now run
    about as much as my rent. And I know that weekly counseling or therapy
    sessions would really be out of reach. It would threaten not only the
    growth of my business but the existence of my business. Basically no
    Medicaid, no business. That would kind of be the end of one of my
    dreams. And, untreated disorders--my untreated disorder, I know I would
    retreat from society. I would retreat from my loved ones. I would not
    be a productive citizen. I would probably get in trouble and cost the
    taxpayers some money. Mental and behavioral health is no joke. There
    are fatal consequences, and it's a matter of life and death for a lot
    of people--including me.

        Senator Warren. Thank you. Thank you. And Ms. Serafin--I know that
    you have dealt with both systems, both Medicare and Medicaid. For just
    1 minute, I'd like to focus on the Medicaid part of that. Your mother,
    after your father passed, your mother declined, needed full time care.
    And she was supported by Medicaid during that period of time. She was
    able to be in a facility that could take care of her. If Medicaid
    hadn't been available to you--if there had been a trillion dollar cut
    to Medicaid, what would have happened to you and your husband?

        Ms. Serafin. Well, physically I could not take care of anyone else,
    I can hardly take care of myself. So, we would have had to hire someone
    or we would have had to move because our home was not accommodating for
    another person with a disability. Second, the care my mother received
    in the nursing home was so personally gratifying; I could sleep at
    night. My mother was a really strong woman, she could have been a CEO.
    She was born in the wrong era. But as a daughter, as mothers and
    daughters often do, we didn't always see eye to eye on everything. And
    people in the nursing home loved her--they loved her feisty manner,
    they loved the things that she would say. And I would think, ``Oh god,
    I would never say that.'' But they thought she was wonderful.

        Senator Warren. My mother was like that too.

        Ms. Serafin. I could sleep at night. I could feel good because I so
    cannot do things as it is for myself, and there were loving people who
    would go to her and say, ``I love you, Anita,'' and it just made my
    heart feel that wonderful feeling.

        Senator Warren. That's the face of Medicaid. And one more on
    Medicaid. And that is Sam. Right, Ms. Ornella?

        Ms. Ornella. Yes.

        Senator Warren. Sam is the happy face of Medicaid. If there's $1
    trillion in cuts to Medicaid, and Sam is not able to get help through
    Medicaid, what happens to Sam?

        Ms. Ornella. We barely qualified for Medicaid as it was, so if
    there are any cuts to it, we would have been in that group of people
    who I believe wouldn't have qualified on the financial basis. Medicaid
    has provided him to be able to go to his kidney doctors and to keep his
    status check on his kidneys, which is what we think his long-term
    issues are going to be. Medicaid has been there to cover tests for
    swallowing, for swallowing functions, for all the different parts of
    his body that are affected by his disorder. So, my fear is that if we
    do get employer based coverage, anything can happen in life--what if my
    husband lost his job and then we didn't qualify for Sam to get Medicaid
    anymore? How would we deal with that double whammy of losing employer
    coverage and then not qualifying for Medicaid for a medically complex
    child?

        Senator Warren. Thank you. I'm very grateful to all four of you for
    putting a face on what Medicare and Medicaid mean. I suggested
    yesterday to Congressman Price that if he is confirmed to be the head
    of HHS, that he cut out the statement of Donald Trump, ``I will not cut
    Medicare or Medicaid,'' and tape it above his desk and look at it every
    single day--because you are what that's all about. You are the reason
    we must not cut Medicare and Medicaid. Thank you, thank you for being
    here.

        Senator Stabenow. Thank you so much, that is so true. Senator
    Kaine?

        Senator Kaine. Well thank you, Senator Stabenow, and to my
    colleagues for doing this. Thank you for sharing your stories, these
    are very important.

        Kanisha mentioned the words, ``kind of afraid of what might
    happen,'' and I just kind of jotted that down. There's about 66 million
    Americans who are really disappointed about what happened in November,
    but there's a subset of people who are really personally very, very
    afraid. And I think the job of us, the job of those of us who are
    disappointed is to have the backs of those who are afraid.

        People are afraid because they might lose their healthcare. People
    are afraid because they're worried about rollback of marriage equality.
    People are afraid because they're worried that they might be deported.
    People are afraid for a lot of reasons. And it gives me a lot of
    motivation to try to have the backs of folks who have legitimate
    concerns and fears. And coming and sharing your stories is important.

        Congressman Price poses particular challenges to us because you can
    kind of look in vain in his record to see support for virtually
    anything that's a part of the health-care coverage safety net. He wants
    to turn Medicaid into a block grant program and is against ESGIA, voted
    repeatedly against it, called it ``socialized medicine.'' Most programs
    cover more than 800,000 Virginians.

        He wants to repeal the Affordable Care Act. That's a program that
    helps millions of Virginians, if you add up all pieces of it together.
    He wants to change Medicare into a premium support program that would
    raise costs, by CBO estimate, of 1.3 million Virginian seniors. And he
    wants to defund Planned Parenthood which is the primary health care
    provider of choice for tens of thousands of Virginians. If you look at
    everything that's in the coverage space, that's in the access space, he
    is opposed to it. And so that's what makes him so problematic as a next
    HHS Secretary.

        On my webpage I put up a little thing, kaine.senate.gov/ACAStory,
    and a week ago I asked Virginians to share stories much like you shared
    today. We have more than a thousand submissions of stories just like
    yours.

        I'm going to ask one question based on a theme that's emerging from
    the stories that I have not been paying much attention to but both
    Alyce and Holly, you mentioned it in your testimony. The ACA makes it
    easier to be self-employed and start your own business compared to what
    we had before. And if we can get over the rush to repeal that's
    injecting so much uncertainty into this question of, ``will we be able
    to count on this or should we go back and work with an employer
    provided plan?''

        The ACA has turned into this motivator for entrepreneurial spirit
    and start-up businesses and innovators. Exactly the kind of thing we
    want to do, so, separate and apart from all the health care benefits,
    which are fantastic--that's reason enough to fight for them--the ACA
    has also given people who have a dream to start their own business, to
    start their own nonprofit the ability to do it, and have health
    insurance if they do it.

        It's interesting, Senator Stabenow, the number of stories I've
    gotten on my website of people who have come up to me and mention this
    aspect of the Affordable Care Act, even though sometimes that's not the
    story they're telling me. Something about their child who has a special
    need, but they're telling me they're able to have health insurance as
    an entrepreneur, as a small business owner, as a startup or nonprofit
    because of the ACA.

        So I'm seeing this really positive economic effect and I imagine
    that again, that was in Alyce and Holly's stories. It might not have
    been the main theme of the story, but it was an element in both your
    stories. And I think that's something we have to fight to protect. I'd
    be interested in hearing your thoughts.

        Ms. Ornella. I'll just give an example. Before the ACA was passed,
    my husband and I, who were both self-employed, went without insurance,
    because in Maine the quote for what was available to us, and we were
    two adults under the age of 35, was $1,200 a month. And that was a huge
    part of our income. We've not ever been people who have made a lot of
    money so we went without insurance. And then when we were able to sign
    on to the ACA plan we paid $200 a month.

        So, for that reason, we were able to continue our small business
    activities for longer than we would have otherwise and we supported
    ourselves for a number of years that way. Obviously priorities change
    when you have a child and if you have a child that has complex medical
    needs you start to assess whether or not you can--especially when
    there's talk of repealing the ACA and protections for people with
    preexisting conditions you start to rush into thinking, ``I need to
    work for someone else now.''

        Senator Kaine. But if we stabilize this and get over this rushed,
    this foolish rush to repeal----

        Ms. Ornella. Yes.

        Senator Kaine. We have something that we think we need in place for
    people like you, the chance again to say, ``Hey I want to be my own
    boss and start my own business.''

        Ms. Ornella. Oh yes, absolutely.

        Ms. Jensen. I've actually never had health insurance from my
    employer. I went without it for a long time until the ACA and
    eventually Medicaid. It is absolutely essential to my business. My
    well-being is the cornerstone of it. It's more important than my credit
    line, it's more important than tax rates. Nothing gets done when I'm
    unwell. And we can't claim to support small businesses if we don't
    support small business owners. Yes, my business would probably not
    exist without Medicaid at this point to be honest. And in the larger
    picture, I worry about how that will dampen America's innovation and
    entrepreneurship. If it becomes an unbearable risk to start your own
    business, guess what? We're losing a lot of small business owners in
    America.

        Senator Kaine. Thank you. I appreciate it.

        Senator Stabenow. Thank you so much. And, Senator Kaine, I have
    heard the same thing from so many people who have been able to go into
    small business and their life's dream because they've been freed from
    that chain of having to be somewhere with insurance from their
    employer. So thank you so much for that. I know Senator Merkley has to
    leave at 1 and, to just briefly say something, we will let you jump in
    here to do that. I am going to step away to ask a question at the
    Finance Committee of Mr. Mnuchin--we're beginning a second round--and I
    will stop back, so we're doing our version of Beam Me Up, Scotty, as
    we're running back and forth between everything--but, Senator Merkley?

        Senator Merkley. Inaudible 1:12:33-1:13:13. I think it's vetted in
    the issue of Medicare, Medicaid, and ACA. We have a health-care system
    that's just, when you need care, when you have that disease, that
    accident, you know you can access it, and then you pay more and you get
    the care that you need. So I just wanted to share that comment.
    [Inaudible comment] . . . have questions for Sue. Thank you for sharing
    your testimony. We need a health-care system. It gives peace of mind to
    Americans, not distress of whether you'll be able to get care, not go
    bankrupt, and that's what we're fighting for. Thank you.

        Senator Hassan. Well, thank you. I want to thank Senator Stabenow
    more--you really were the driving force in organizing this. I also just
    really want to thank all five of you for being able to be here to tell
    us your experiences, because change occurs when people are willing to
    stand up, especially in a democracy, and not only talk about ideas, but
    talk about real life experiences so that policy makers understand what
    the impact of their ideas and philosophies are and really can be
    informed as we work to make sure that things work for the American
    people. I am struck by the themes that your combined testimony have
    raised for today's panel, and I hope for everybody who's watching and
    listening cause I think we really see and heard from you a wide range
    of experiences that really talks about the individual peace of mind,
    the physical health, and the economic health that comes with
    accessible, affordable, high quality health care. I want to touch on a
    particular subset of what I've heard, just because I think given
    Congressman Price's, nominee Price's, record is important. But before I
    do that, a special shout out, Alyce, to you, we have something in
    common having had kids with special needs and it has its challenges but
    it has its good rewards too, so, thank you for what you're doing to
    raise Sam.

        Ms. Ornella. Thank you.

        Senator Hassan. You're Welcome. And, Kanisha, I wanted to talk to
    you a little bit more about your experience. First of all, given
    Congressmen Price's record of repeatedly voting to defund Planned
    Parenthood, you talked about how important Planned Parenthood had been
    to your care at critical times in your life. Can you just tell us a
    little bit more about what your experience as a patient at Planned
    Parenthood was like and how it impacted your ability to do what you
    wanted to do with your life?

        Ms. Hans. Sure. So, when I went to Planned Parenthood when I was in
    high school; it's because I had no other place to go. And now I go to
    Planned Parenthood by choice because I trust them with my health care.
    I've mentioned before I had a medical condition that went undiagnosed
    for a while. I'd gone to several different doctors before, and Planned
    Parenthood was the first one to diagnose me with my condition and was
    able to treat me. And thanks to title X funding, I was able to afford
    my care, and that's why I keep returning to Planned Parenthood, because
    I trust them.

        Senator Hassan. I take it would also concern you to know that Dr.
    Price voted as a Congressmen against a District of Columbia law that
    would prohibit employers from discriminating against employees with the
    decisions they make about their reproductive health and birth control.
    Is that something you're aware of and does it concern you?

        Ms. Hans. Yes it does concern me. I'm 23 years old and I am
    employed so I am worried about getting kicked off my parent's
    insurance, and if I do go on my employer's insurance, it's not my
    boss's business about my health care and it is something that is very
    concerning, and having grown up most of my adult life with the Obama
    administration, I never imagined I would have to worry about this. And
    it's kind of really throwing me for a loop.

        Senator Hassan. Right; well, thank you. I too am going to have to
    leave; this is what happens. Senator Kaine, you can sit right here.

        Senator Kaine. I do have other questions, but I wasn't planning on
    sharing. I may have to go too. I'll keep it rolling.

        Senator Hassan. What I hope you all know, again, is how grateful we
    are to you for telling your stories. Each and every one of you has been
    willing to talk about something that used to be very hard to talk
    about, and particularly Holly, as I just ended my term as Governor of
    New Hampshire, and I'm dealing with an opioid crisis, as many States
    are. We also know that behavioral health challenges and substance use
    disorder sometimes co-occur, and so the importance of people with
    behavioral health challenges and/or substance misuse speaking up for
    themselves, the same way it's important for women who need access to
    strong and good reproductive health care speaking up for themselves,
    for people with disabilities, or parents for people with disabilities,
    the willingness to speak up about the need to be included is just
    critical, and in a democracy, where every single one of us counts, you
    guys have done us all proud today reminding us of that, so thank you so
    much, and let's keep at it because this rush to repeal is so misguided,
    and with regard to Congressman Price's nomination, I hope very much, at
    the very least, that he will understand and reflect on your testimony
    should he become confirmed. Thank you.

        Senator Hirono. Senator Kaine, you have one question to ask?

        Senator Kaine. I do, I do, thank you, Senator Hirono. I'm so glad
    that we got into the reproductive health issue. This week, there was an
    amazing announcement, and it didn't get enough attention and that's the
    unwanted pregnancy rate in the United States, it's at its lowest ever
    since history has been able to record that rate. What a great thing.
    The Affordable Care Act and the fact that Planned Parenthood has not
    been defunded is one of the reasons--two of the reasons why unwanted
    pregnancy rates has come down. This is not really a question, it's an
    editorial comment. I am stunned at the number of individuals who take
    policy positions that would suggest they're very much against unwanted
    pregnancies who want to repeal the Affordable Care Act. I'm stunned at
    institutions that have taken an anti-ACA position who are institutions
    that would suggest production of the unwanted pregnancy rate. I can't
    imagine anybody in society who would look at the reduction of unwanted
    pregnancy and say that's a bad thing. I think virtually everybody in
    society, regardless of politics, political party or political at all,
    regardless of region, regardless of race, regardless of anything, would
    look at reductions in unwanted pregnancy and say ``that's a good
    thing.'' And yet some of the people who are the most claiming to be
    forward are the ones trying to undo the very health-care safety that
    has been able to bring down the rates of unwanted pregnancy. If they
    are successful in that, the unwanted pregnancy rates will go back up.
    That's one of the many things I have a hard time figuring out. And I
    will turn it back to my colleague, Senator.

        Senator Hirono. Thank you now that everybody has left, not you
    folks, but Mahalo for being here, and you know that we were joined by
    so many of our Senate colleagues today to hear your stories, and I know
    you understand that we are in the midst of confirmation hearings for
    many of President-elect Trump's nominees, and so I know you understand
    why people are going in and out.

        We have a nominee for HHS Secretary who wants to privatize
    Medicare, who wants to dismantle Medicaid, who wants to defund Planned
    Parenthood, and you have come in today to tell us your own experiences
    and stories about how these programs have literally saved your
    families, saved you and allowed you to go forward and thrive. So, I
    will join my colleagues in fighting tooth and nail against the
    voucherizing of Medicare and the privatizing of these kinds of programs
    that really are the lifelines for millions of people in our community.

        I think that finally, with the potential demise or repeal of the
    Affordable Care Act and voucherizing of Medicare and the huge cuts to
    Medicaid, the defunding of Planned Parenthood, it is finally, I think,
    sinking into our country what these kinds of actions would mean to
    them.

        I was a member of the United States House of Representatives when
    we were working on the Affordable Care Act, and I remember, sadly, how
    many people on Medicare, including people from the state of Hawaii who
    were on Medicare, who came to me and called me and said, ``Don't touch
    Medicare but don't pass the Affordable Care Act.'' These seniors are
    going to find out that with the repeal of the Affordable Care Act, they
    will end up paying more for drugs because the Affordable Care Act was
    the prescription drug donut hole. They will not be able to access the
    kind of preventative care that allows them to age in place and maintain
    their lives with the repeal of the Affordable Care Act.

        This is sad, that so many people who came forward to say that we
    shouldn't pass the ACA will be among the millions who will be hurt with
    the repeal of the ACA. So, we have a President-elect who recently said
    that ``my health-care plan will cover everyone.'' Did you . . . he said
    that. There will be health care for everyone. How do you all think that
    is supposed to happen? How is that supposed to be implemented with
    Secretary Price at the helm? Anybody? It's more than just a rhetorical
    question.

        I would like you all to say that on the record what you all think
    will happen to President-elect Trumps pledge that his health care plan
    will cover everyone.

        Ms. Jensen. It does not seem logical to me if he is making that
    statement and he is nominating or choosing someone who, in what touches
    me personally, says he does not believe that preexisting condition
    should be considered as an accommodation or a protection, and I'm
    thinking of my own child who was born that way. He didn't acquire them
    through any of his own choices in life, or anything that he did.
    There's millions of children and individuals who are in way worse
    position than Sam is. So how does that add up if you say you want to
    have coverage for everyone but then the person you pick to be in charge
    is already excluding individuals before their record is of exclusion. I
    don't understand how that makes sense.

        Senator Hirono. Thank you. With the other people who have come
    forward, would you like your comments to this question to be on the
    record?

        Ms. Fleming. Yes, I'd like to comment. Obviously, the President-
    elect has not really looked at Representative Price's record in voting
    the things that he has voted against, so I think that hopefully, he
    will take a look at his record in what he has done in the past and give
    him some new ideas that this is not good in what you're planning to do.

        Senator Hirono. Ms. Serafin?

        Ms. Serafin. I think that if he is chosen, he will decimate
    Medicare and Medicaid as we know it. I believe that his stance will be
    ``you can go out and figure out how to take care of yourselves on your
    own. We'll give you the costs, we'll give you the money for whatever
    else we need the money for.'' It will be chaos, I believe it will be
    complete chaos.

        Ms. Hans. Yes, I would like to go in everyone else's comments in
    that I don't think the President-elect has really done his homework in
    who he's been nominating and that's been made very clear by Tom Price's
    record. And it doesn't seem like Tom Price doesn't really care about
    the health of the citizens of the United States. And therefore, it
    makes no sense that he should be at the helm of HHS. His record has
    consistently shown that he doesn't care about people who rely on these
    health programs the most.

        Senator Hirono. Ms. Jensen, would you like to add to this?

        Ms. Jensen. Yes, I would. Thank you for the opportunity. I very
    much agree, it's like Trump hasn't met Price. For instance, one of the
    ideas thrown around about employment requirements for Medicaid seem
    counter intuitive for me. I feel like it's the law makers' job to
    represent the caring majority, not the minority of the wealthy, and I
    feel like we're going in that direction. Yes, and I don't know how
    we're supposed to reconcile these two entirely exclusive plans that we
    have on the table. Yes, I believe that lawmakers need to work to
    protect the vulnerable, nurture small business, and save the taxpayers
    money.

        Senator Hirono. Thank you. Senator Blumenthal, we can proceed to
    you with your question.

        Senator Blumenthal. Thank you Senator. Thank you all of you for
    being here today. Your stories, as Senator Warren said, have really
    given us a face and a voice to this somewhat abstract issue to many
    Americans. People take their health for granted until they don't have
    it and then it becomes the most important thing in the world as each of
    you know from your personal experience. All of us know it because we've
    all had bad health, it's not like wealth gives you immunity, but it
    enables you to do a lot of preventive care, and that's what I want to
    focus on is the prevention. Cause just as we ignore the economic impact
    of small businesses as Holly has said so well, we also ignore the
    increased cost of health care if preventive steps aren't taken. At a
    very early age, Sam's age, to forestall diabetes and obesity and
    smoking and even opioid prevention because preventing addiction is so
    much more cost effective than treating it later. You mentioned, Anne,
    that the cost of your medicine is $75,000 a year; do I have that right?

        Ms. Serafin. It would be, for the one drug I talked about, it would
    be $84,000 a year. As it is now, the Gilenya I'm on is $6,000 a month,
    so that is $72,000 a year.

        Senator Blumenthal. So, you can see just the cost of that one
    medication and your medical cost may not be preventable in the same way
    but we can really save a lot of money through prevention and we can
    bring down the cost of medication. One area that I think perhaps in
    this conversation that has not been emphasized is the effects and the
    goals of the Affordable Care Act in restraining and diminishing the
    growing cost of health care. That was one of the objectives, not just
    create more demand for it and put more money into the health-care
    system, but also try to make it more efficient and effective. So I
    don't know whether any of you any have observations on that aspect of
    it, I would welcome.

        Ms. Hans. Yes, I think that a lot of people have kind of lost sight
    that that was the goal of the ACA: when more people have coverage, it
    actually drags cost down. When people don't have coverage, they keep
    putting off care. I know--I personally had to put off care because I
    couldn't access it, and when you keep delaying care, it's more costly
    in the end. And in the end, the taxpayers are still paying for it,
    they're just paying a lot more.

        Ms. Fleming. My view is that preventive care is necessary. This is
    a good thing, we're becoming a healthier society with this, and if you
    eliminate some of the preventive care, the early exams that you can
    have, which we cannot do before, because of the cost, you can really
    target if there is an issue, you can target right away and take care of
    it which in the long run will cost us a lot less than someone that has
    to have really severe care, so the preventive part of it is from early
    childhood all the way up, to us older folks. Thank you.

        Ms. Ornella. I'll just quickly add with Sam's conditions, he
    requires regular monitoring to ensure that no further problems arise or
    if they do, they are caught in a timely manner. So I don't know if we
    want to consider that, I guess we'd consider it because by doing
    monitoring, which can range from minor tests that cost a few hundred
    dollars to tests that cost a few thousand dollars, it's heading off any
    problems be exacerbated but, you know, especially with a young child
    that cannot really communicate what's going on in their body, so being
    able to access that kind of care is important to maintaining a stable
    health condition.

        Ms. Serafin. I just want to add that the disease modifying drugs
    that are there for multiple sclerosis are there to retard any
    advancement. So even though they are costly, hopefully they're actually
    lessening your chances of developing a more severe disease and more
    costly problems.

        Ms. Jensen. And I'd like to add specifically for mental health and
    behavioral health, preventative care in that world is kind of a new
    frontier. I definitely had that attitude of ``I can handle this. I can
    do this. I can dig my way out of this.'' I didn't want to ask for help.
    Maybe that's a very American thing: ``I can do it myself.'' And that is
    what the preventative care is coming up against a lot of times. And I
    would say that education about mental health and behavioral health, the
    idea that was raised before that mental health and behavioral health
    are part of health care. So education about that could be very
    effective. And also reducing the stigma, even by covering these things
    we do a little bit to reduce the stigma. You're saying, you're a person
    worth care. You're not disposable, you're not discardable. And also
    reducing the stigma about asking for help which I hope I can do in a
    tiny way today.

        Senator Blumenthal. Just so you know Holly, for, I think it's more
    than 8 years, there's been a law on the books that requires, it's
    called, parity. In other words insurance companies are required to
    cover mental health care in the same way that they cover physical
    healthcare. That's a matter of Federal statute but there was a delay in
    adopting regulations to implement the statute. That delay occurred
    under both the Bush and Obama administrations and I was involved in
    helping to advocate that law. We did it in Connecticut which is my
    State, and then that law became a model for the Federal statute but
    only recently has it been implemented and even now it's not fully
    enforced. So my colleague Chris Murphy and I, we're both from
    Connecticut, we've both advocated that there be enforcement of that
    statute in part to deal with the stigma that you mentioned which is
    still a major obstacle.

        Ms. Jensen. You can't ask for help if you don't think there's
    anyone out there to help you.

        Senator Blumenthal. Well said. Thank you all.

        Senator Hirono. Thank you, Senator Blumenthal. I'm going to ask
    Senator Casey to wrap up, but before I do that I want to thank all of
    you once again. You represent millions and millions of affected people
    in our country and I think our voices, and I say ``our'' because you
    know we are with you, need to be heard. As we say in Hawaii, ``Mahalo
    nui loa.'' And thank you, Ms. Jensen, for pointing out the importance
    of mental health services because, as Senator Blumenthal has pointed
    out and many of us know, there has been a lack of parity as to the
    treatment and the access to care for the mental health side which can
    be just as debilitating if not more so than physical injuries, so,
    Senator Casey, thank you very much. Mahalo.

        Senator Casey. Senator Hirono, thank you very much, and Senator
    Blumenthal and all those who are here. I'm the last one; because I am,
    I won't ask questions. I just wanted to make a comment about your
    testimony, maybe a comment about the process, and give you the last
    word if you so choose. We've been here a while.

        One thing I want to say at the outset is, both Alyce and Diane, I'm
    using your first names even though we don't know each other, I don't
    know who to commend more on multitasking with Sam, but that's a pretty
    good tag team. I don't know if you practiced that this morning but it
    sure looked seamless. But we're grateful for your testimony.

        I want you to know something and I say this in a very serious way,
    not just as a way to say thanks for making the trip here. We live in a
    society where on an hourly basis it seems, the lives of movie stars or
    athletes or even politicians or wealthy people, depending on what
    category someone's in, their lives are always chronicled, always on the
    news, always a subject of interest and debate and coverage so to speak.
    Every once and awhile the lives of real people are put up with the same
    degree of prominence but frankly not enough. And in this debate, right
    now it's more than just a debate, it's a fight.

        Chapter 1 is stopping the repeal of the Affordable Care Act, and
    that's a fight we're in right now. Chapter 2, in my judgment, would be
    if they're successful in Chapter 1, fighting like hell to make sure
    whatever they replace it with, and no one's been able to find it--we
    might want to hire a private investigator to find it in the replacement
    bill, but it doesn't seem to have surfaced yet; I'm hoping it does--but
    to fight like hell to make sure that whatever is in the replacement
    bill is substantial enough to meet all of your needs and the needs of
    lots of other people.

        But your stories are not stories that are customarily on display in
    Washington; yours are the stories of people that have lived quietly
    triumphant lives. You've had to triumph over things that I've never had
    to worry about and a lot of people in this building have not had to
    worry about. Not everyone, but a lot of us haven't had those same
    worries. So in your own way, in a very quiet way, you've been
    triumphant in a way most of us haven't been able to appreciate. And
    that story that you told is both inspirational but also instructive and
    even instrumental. And I say that because the process. If you take your
    stories out of the debate, years ago when we were trying to pass the
    ACA and I was here and played a role in that, but even more so now if
    you took your stories out of this debate to stop repeal and to make
    sure we get the right result down the road, we lose.

        Because if it's just a bunch of Senators rattling off numbers--and
    they're great numbers to talk about: 20 million people insured and all
    of that. We've got to keep using numbers; they're important. But what
    is indispensable in winning this battle is how often we tell your
    story, how often we excerpt from it in a floor speech, and how often we
    use a 20-second sound bite in an interview or back home or on the road
    or in debates in committee. All of those stories are going to be
    indispensable to that.

        So this isn't just a nice thing to do today. You're contributing to
    the effort to win the battle. Your stories are persuasive, numbers once
    and awhile can help you persuade, your stories are persuasive. So it's
    up to us to make sure that we keep telling your stories, and stories
    like yours all across the country. So you're playing a big role in this
    debate and in so many ways that's doing something for your country.

        You've come here to talk about your life which isn't easy to do.
    And politicians like me, we talk a lot and we talk about issues but
    rarely we don't talk about our own personal lives. That is much more
    difficult than what we do every day. To tell a story, to admit that
    things weren't going well in your life or that the struggles you had or
    that the suffering you or your family endured. That's not easy to do
    for anyone and we appreciate you doing that.

        So that effort, that sacrifice, that commitment to going beyond
    yourself is very, very meaningful to the debate. So I hope you
    understand that and that you don't ever get dispirited in this fight
    because we need you very much in this fight and you've already been
    willing to sign up and not only put your hand up but walk towards the
    goal that we're trying to achieve.

        Holly, one of the best lines today is yours: ``It feels good to pay
    my bills, but more so to be part of something.'' And not just the kind
    of care that saved your life but gave your life back. So the measure of
    our success will be how often we can put your stories on the record in
    the interview. So I just want you to know how much we appreciate you.
    Secondly in the process, today I'm going back and forth between the
    hearing from the Finance Committee--we have Mr. Mnuchin for Treasury
    Secretary. That's what we're doing today, we're asking him a lot of
    questions about tough topics like mortgage foreclosures and things like
    that. But we're going to finish that hearing today; obviously it'll go
    for a while more, and we'll vote on that nomination.

        But we're kind of in the middle of the Representative Price
    nomination. I'm on both committees that he testified in front of, but
    only the Finance Committee will be where the vote is. So he'll appear
    there in front of our committee where we're doing Treasury today, and
    that's where the vote will be. And because of your testimony today,
    you've given me more, I won't use the word ammunition, but you've given
    more information for us to be able to present in questions or comments
    in that hearing on Representative Price.

        And obviously we can't just do a good job in these hearings, we
    have to do a lot more on the road back in our States. So that's the
    process and we're going to continue to fight very hard to give meaning
    and value and really to validate what you've told us today.

        This is critically important, that we preserve all these
    protections. And absent any other comments, we can wrap up, but I just
    want to give you the last word. You traveled and took time to be here,
    so if anyone wants to make any final comments, and then we'll gavel out
    with the gavel. We actually have a gavel; I'll do that.

        Ms. Serafin. Thank you for this opportunity. It has helped me
    personally to be able to share this story and feel like I'm part of
    what's going on and it's helped me to live with the next 4 years.

        Senator Casey. Ann, thank you very much. We're grateful. Anybody
    else?

        Ms. Fleming. I just want to thank everyone. It's good to put faces
    to it all with you all as well and I think one of the things that's
    missing is the eye to eye contact that you're, you know, going to
    implement something but you can't look me straight in the face or
    straight in the eye and tell me what you're going to take away and not
    give me anything else. This is good to be able to, the empathy that you
    have and that you have all presented in front of us today, which I
    don't see that happening in the next round of people. There's no
    compassion--where is it? It's missing. So thank you all.

        Senator Casey. We'll do a better job on our end. If we're in the
    middle of a debate, figuratively speaking and sometimes literally, we
    say, ``Well, I know you don't like what I said, but answer Diane's
    question. How can you help her? How can you make sure she doesn't have
    a circumstance that's unimaginable and will have the help that she
    needs?''

        Ms. Fleming. I wanted to say, I live right across the bridge, so
    any time, just give me a call.

        Senator Casey. You're close.

        Ms. Fleming. I'll come in.

        Senator Casey. Thanks. Anybody else?

        Ms. Hans. Yes, I would like to echo Diane's comments. It was really
    great meeting everyone. After everyone's questions and comments, I feel
    hopeful, and I haven't since November.

        Senator Casey. Good; thank you. Well, absent any other comments, I
    get to--this is really amazing that I get to hit this gavel. I just
    want to make it official. We are adjourned.

                                     ______

    Anna Isis-Brown

    Caring Across Generations activist
    Los Angeles, CA
    January 2017
    Attn: Members of Congress and fellow Americans

    Every member of my immediate family has benefitted from the Affordable
    Care Act (ACA). I am a 30-year-old newly-wed. I applied for individual
    health insurance in 2010, before the ACA went into effect. At the time,
    I was working full-time at a university bookstore, but the job did not
    offer me health insurance. I was denied coverage due to my pre-existing
    conditions--which included various allergies, minor dermatologic issues
    (eczema, acne), and depression. I went without an Epipen (a lifesaving
    emergency medication for my most severe food allergies) and stopped
    taking my antidepressant medication for the 2 years that followed
    because I didn't have health insurance. I have health insurance through
    my employer now, but it is very important to me to know that if I ever
    lost my employer-sponsored health insurance in the future, the ACA
    would protect me from being excluded from the individual insurance
    market again.

    Last year, at age 60, my father was diagnosed with two types of skin
    cancer. He lost his job about 2 years before the diagnosis. After he
    lost his job, he paid for COBRA for a while, but its high cost became
    completely unaffordable for him. He didn't seek treatment for the
    suspicious-looking patches of skin on his face, ears, and back because
    he was frankly afraid to find out what they were and how much they
    would cost to treat. He eventually applied for insurance through the
    Arizona state exchange, on the assumption that it would be cheaper to
    pay for the plans available on the exchange than it would be to keep
    paying for COBRA. When he finally applied to the exchange, he learned
    that, due to his income and Arizona's Medicaid expansion, he was
    actually eligible to get coverage for free. With his new coverage, he
    finally got a diagnosis and treatment. His doctor told him that without
    treatment, his face could have been disfigured by the basal cell
    carcinoma, and if the patches of squamous cell carcinoma had just
    spread unchecked, they could've become much more serious. My dad is
    still with us today because his cancer was caught and treated early
    enough.

    My sister is 27 years old and has a mental health condition. She works
    full-time as the General Manager of a movie theater that is part of a
    small local chain. Until December 2016, her job did not offer health
    insurance. They just began offering her a plan last month, and she is
    now on it. For about the past 2 years, she purchased her health
    insurance through the California state exchange. The ACA allowed her to
    have coverage she could afford, and get treatment for her mental health
    conditions, when her company didn't offer any coverage.

    My husband also works full-time as the Operations Manager for a small
    company in the film industry here in Los Angeles. He is the company's
    only full-time employee. The company does not offer health insurance.
    Until we got married in August 2016, he purchased his health insurance
    through the California state exchange. For about a year, when his
    income was lower, he got a small subsidy to help pay for the insurance.
    The ACA is the only option for many working people whose jobs simply do
    not offer insurance.

    The ACA has made a difference in each of our lives, and for that, I am
    very grateful. I have such a sense of security knowing that, whatever
    happens in my career path in the future, I will always be able to get
    the Epi-pens that have saved my life once already. I am grateful for my
    time with my father, knowing that he was able to access the care he
    needed to treat his cancer before it got too advanced, and that he will
    be able to treat it again if it ever returns. And I felt enormous peace
    of mind that my sister and husband have been able to get the coverage
    they needed when they couldn't obtain it through their employers. In a
    time when many people need more help, it is not right to be offering
    less and to get rid of the only affordable option that many have. The
    ACA has been a lifeline for my family, as I'm sure it is for so many
    others.

                                     ______

    Carol Gloor

    Savanna, IL

    In 2015, after several years of chronic pain, MRI's, and cortisone
    injections, I was finally told I needed to have my left hip replaced. I
    have always been an active person and the gradual loss of the ability
    to walk long distances was devastating to me. Thanks to Medicare, I had
    my hip replaced over a year ago. The hospital bill alone was over
    $50,000, not counting the cost of the physical and occupational therapy
    which followed. Medicare paid for most of it, my supplemental insurance
    paid for some, and I paid the balance. I am one of the lucky ones in
    that I have supplemental insurance and some liquid assets, but without
    Medicare I could never have afforded the operation. Being well and my
    quality of life would have come at the cost of my savings and my
    assets. I am sure there are many others in the same situation looking
    for assistance. Instead, some people want to take that away from the
    people who need it most. I am hiking again and volunteering in many
    ways to make my community and my state a better place. Thank you,
    Medicare.

                                     ______

    Kim Thomas

    Raleigh, NC

    My name is Kim Thomas. I'm a home care worker from Raleigh, NC. I
    became a home care provider after caring for my terminally-ill mother.
    As a home care worker, I assist with activities of daily living--such
    as toileting, bathing, mobility, meal preparation, and medication
    reminders--that make it possible for seniors and people with
    disabilities to live at home with dignity and independence. I have a
    true passion for caregiving. I became a Certified Nursing Assistant. I
    obtained my LPN, with special certifications and training in
    Alzheimer's/Dementia care, Diabetes care, all stages of cancer,
    Parkinson's, end-of-life care, wound, and respiratory care. I have a
    genuine love for seniors and the elderly--that's why I work as hard as
    I do.

    And I work hard. I work about 100 hours a week or more. I work 16-hour
    shifts Monday through Saturday and three 14-hour night shifts each
    week. I don't receive paid time off, holidays, vacation, sick time,
    health insurance, or retirement benefits. And still, my wages are so
    low, $8 or $9 per hour, that I struggle to get by.

    Though my job is all about taking care of people, I found it hard to
    take care of myself before the Affordable Care Act. I have diabetes and
    had a hard time finding coverage because of this pre-existing
    condition.

    I used to go to the Emergency Room and pay $100 a visit for diabetes
    medication. But I wasn't getting the care I needed to stay healthy and
    work hard for my family. I determined to find insurance coverage.

    After weeks of research and rejections, I was able to get a ``high
    risk'' plan for $479 per month with huge deductibles.

    Not long after that, I got really sick. I was vomiting and had diarrhea
    for more than 24 hours. I clearly needed to go to the hospital. But I
    was scared of using my insurance plan--scared they would take it away
    from me. I finally crawled across the floor to call 911.

    Doctors at the hospital determined my gallbladder had erupted and I
    needed surgery. But I kept telling the hospital staff that I couldn't
    stay there because I couldn't afford it. And when I called in to work,
    they asked me if I was ``really sick'' and suggested I get a second
    opinion.

    I was in the hospital for 5 days. I came home to a $3,000 hospital bill
    and a note from my insurance company that my premium was being raised
    to more than $800 per month. I had to let my life insurance plan go,
    because I couldn't afford both. I sometimes missed car insurance
    payments--and I need my car to get to work. When the Affordable Care
    Act went into effect, I decided to visit HealthCare.gov and see if I
    could do better than $800 per month. I visited the website, then spoke
    with an agent who told me they could have me insured starting January 1
    for $73.28 per month. Now, I get my diabetes medication at the pharmacy
    for $4, instead of haphazard $100 ER visits.

    Without the Affordable Care Act, I wouldn't be able to manage my
    diabetes and be as healthy as I am. If it goes away, I am scared of the
    impact it will have on my life, including my ability to work and
    support my family. When every dime goes to medication or insurance
    premiums, you can't afford your other bills.

    I can't believe someone would want to take this healthcare away from
    the American people. As a home care worker, it's not just me who
    depends on Obamacare and other programs such as Medicaid, it's my
    consumers, too, who receive Medicaid coverage. Medicaid is largest
    provider of long term care coverage in the country and more
    specifically home and community based care. Many of my consumers would
    be unable to remain in their homes or get the life-saving care they
    need if it were not for Medicaid. In fact, one of my consumers had a
    massive stroke and lost his ability to speak. Without Medicaid
    coverage, he would be unable to afford his medications--putting him at
    risk for another stroke.

    If I lose my health coverage, if I'm no longer covered because of a
    pre-existing condition, if I have to go back to paying $800 per month
    for health insurance, it will cause chaos in my life. If the Medicaid
    program is cut and if I no longer have a job or my hours are reduced
    and my consumers don't have access to the care they need, it will not
    only cause chaos in my life, but chaos in their lives as well.

    The Affordable Care Act and Medicaid have changed my life and the life
    of my consumers for the better. It has made me healthier and able to
    work hard to support my family. Please don't take that away.

                                     ______

    Michael Lostutter

    Bloomington, Indiana 47401
    January 6, 2017

    My wife Mary and I are both age 64, we have been married 43 years. We
    grew-up in rural Indiana. We had one child, a daughter who passed away
    in 2010. She was a traumatic brain injury survivor due to an auto
    accident in 1996. We were her caregivers for 14 years as she was
    permanently disabled due to her injuries, confined to a wheelchair.

    Mary and I both worked longer than we were married, her mostly part-
    time at various jobs, myself from several full time positions finally
    retiring as the administrator of a multi-employer pension plan.

    Prior to our daughter's demise, we had no plans to retire early or
    otherwise as we had our daughter's economic future as our primary
    consideration. After her unexpected death, our world changed as did our
    expectations for the future. We decided to retire early.

    Working full time provided Mary and I with group health insurance
    however, at retirement the employer sponsored group plan was no longer
    available. COBRA coverage also was not available due to the size of the
    employment group.

    The Affordable Care Act (ACA) with it requirement to insure without
    regards to preexisting conditions allowed us to secure affordable
    coverage at age 62. We have maintained coverage through 2016, as I have
    now become eligible for Medicare and Mary likewise will be eligible in
    February.

    The ACA has allowed us to enjoy our early retirement. It also, has
    allowed deserving younger folks the opportunity to replace us in the
    workforce improving their lives as well.

                                     ______

    Mikki Chalker

    Binghamton, NY

    Most people do not realize what a godsend the ACA has been for people
    with disabilities. Until the ACA, many people with disabilities were
    doomed to poverty. Private insurance was unaffordable, or simply
    unavailable. My daughter suffered a traumatic brain injury at birth,
    leading to severe spastic cerebral palsy, a lifelong condition which
    will require lifelong care. Until the ACA, private insurance simply
    would not cover her. People like my child, who need insurance to be
    able to live, were doomed to stay under the limits of poverty for life
    in order to qualify for Medicaid and Social Security. Removing the pre-
    existing conditions barrier allows my 13 year old daughter, and others
    like her, to have insurance and yet still become tax-paying citizens
    with full independent lives.

    Also, Medicaid and the waiver services it provides have allowed
    millions of people to live and thrive in the comfort and dignity of
    their own homes. Medicaid waiver services have allowed my daughter to
    receive nursing care at home which makes a difference in how often she
    is hospitalized. It also means that we can have the equipment to give
    her the care she needs at home--wheelchairs, lifting equipment, suction
    machines, mobility aids, and bathing aids. My daughter needs almost 100
    percent assistance with daily living activities. Having insurance to
    provide these means she lives at home, not in an institution. With me
    providing that care at home with help from a nurse means she is
    hospitalized less, improving not just her health and daily life, but
    also saving untold thousands in hospital care and additional medical
    costs. Most importantly, it allows her to be a 13-year-old girl, with
    hopes and dreams and ambitions, not just a patient, not just a body in
    a nursing home or institution. I can't imagine going back to life with
    less access to these services. Not only does my daughter deserve
    better, she deserves more.

    These are not small things in our lives. I am grateful for the work of
    Caring Across Generations that allows me to share how critical the ACA
    has been for my life and my daughter's life.

                                     ______

    Mina R. Schultz

    Fairmont, WV

    When I was 25, I was finishing my graduate program at the University of
    Missouri and preparing to enter the Peace Corps. I had student
    insurance, but it would end upon graduation, and I would have about 9
    months without coverage before my Peace Corps service began. I didn't
    give it much thought; I was young, healthy, didn't go to the doctor
    much. My parents foresaw the gap in coverage and told me about a new
    law that would allow me to stay on their coverage until I turned 26. I
    said, sure, sign me up. Didn't really matter to me, but why not? So I
    joined their plan.

    The pain started in April 2011, about a month before graduation. I
    wrapped my knee, iced it, and took a break from running for a while so
    it would heal. After graduation I was planning on taking a temporary
    job in rural Montana, to pay the bills until my Peace Corps service
    started. I was still having pain, and not wanting to end up in the
    middle of nowhere Montana with a torn ligament, I scheduled an MRI. I
    will never forget the MRI techs telling me, ``You'll be glad you came
    in.'' I was sure I had torn something. I was on my parents' insurance
    at the time.

    I will never forget the phone call, when the doctor said, ``Ms.
    Schultz, it appears you have a tumor.''

    The tumor was osteosarcoma, an aggressive bone cancer usually found in
    children and adolescents. I endured 5 surgeries, including a total knee
    replacement, and 9 rounds of chemotherapy (each involving 3 doses of
    chemo, so 27 doses all together) over the course of a year. Most of my
    treatment was inpatient, though I also received at-home physical
    therapy and IV services. Just one of my post-chemo injections cost
    thousands of dollars. Because I had taken that insurance, most of my
    treatment was covered, and my parents avoided bankruptcy. I would not
    have qualified for charity care. I don't know how we would have
    afforded my lifesaving treatment had I chosen to forego coverage
    because I was 25 and thought I was healthy. I think about it every day.

    Now I am an enrollment assister in rural north-central West Virginia. I
    help my community members navigate the Health Insurance Marketplace,
    expanded Medicaid, and the ACA in general, because I believe everyone
    has the right to the access and care that I received when I was sick.
    No one should have to experience what I did, but especially no one
    should go bankrupt because they want to survive an illness. I try to
    explain this to people on a daily basis, that it is a responsibility to
    get coverage to protect yourself from the exploding cost of health care
    in our country, because you truly never know when something
    catastrophic might happen. I carry coverage so that I can cover my own
    costs and remain a contributing member of society. While I am coming up
    on 5 years cancer free, I have secondary conditions as a result of
    treatment, and take medications to manage my health. Because of my
    previous diagnosis and resulting side effects, I would be considered
    uninsurable without the ACA requirement to cover those of us with pre-
    existing conditions.

    I am a contracted worker. I purchase my own insurance through the
    Marketplace exchange and receive a subsidy to help me afford this
    coverage. Because of the threat to the law, I am having to look for a
    new job, one that will offer me benefits so that I can't be denied
    coverage, and hopefully one that won't cap my benefits. I love my
    current job, but I won't be able to afford high risk pool coverage
    should the ACA be repealed and replaced. I take pride in being able to
    cover my own expenses, and I fear that I will have to rely on my
    community to care for me if I no longer have the ACA to protect me. I'm
    just trying to do my best, but I feel like my congressmen and women are
    trying to take away my autonomy by taking my care. I thought government
    was supposed to protect its people. Please protect me by keeping the
    ACA in place, so I can continue to have access to the care I need to
    maintain my health and contribute to my community.

                                     ______

    Risa Morimoto

    Caring Across Activist
    New York, NY
    January 2017
    Attn: Members of Congress and fellow Americans

    Without Medicare, Medicaid, and the Affordable Care Act, health care
    would be much more difficult for my family. Like many others, my family
    is pressed between providing care for our parents and for ourselves
    too. These programs are what make it possible for all of us to access
    the different kinds of care that we all need.

    My mother had just turned 65 when she had a stroke in 2001. She was
    covered by Medicare and spent 3 months receiving care in the hospital.
    Ten years later, she was diagnosed with Parkinson's disease and needed
    24/7 care. She refused to go into a nursing home and insisted that she
    be cared for in her own home.

    Until her stroke, my mother was a hardworking small business owner--she
    opened up the first Japanese restaurant in Long Island. When she got
    sick, we had to sell her business, the thing she had worked so hard on
    for most of her life, and that was difficult for all of us. That left
    her with her house, but she didn't have many assets beyond that. We are
    Japanese, and taking care of our parents is a very big deal in Japanese
    culture. My brother and sister and I did our best. At the time, we
    weren't aware that my mother was eligible for Medicaid, and we could
    not afford to pay out of pocket for in-home help. Even with taking
    turns, after 10 years, my siblings and I were both completely burned
    out from our own full-time work and full-time caregiving. It really
    started to tear our family apart, both financially and emotionally.

    Now she is covered by Medicaid, and we've been able to hire aides
    through the community-based Medicaid program. My mother is eligible to
    receive 106 hours of in-home care per week, but Mom is very particular
    about who spends time in her home with her. We were able to hire
    Japanese caregivers, which helped us transcend some of these cultural
    and language barriers and made her feel much more comfortable. Living
    with the effects of a stroke and Parkinson's for 16 years shows what a
    strong person my mother really is, and my siblings and I are happy we
    get to support her. It's not easy--she cannot really do anything
    without assistance, but she knows she wants to be in her home where she
    is most comfortable and everything is familiar. Community Medicaid is
    what keeps her safe and comfortable at home, keeps her out of a nursing
    home, and we know it saves the state money.

    My brother moved into my parents' home, and my sister lives next door.
    I make the trip out to Long Island every weekend from my home in New
    York City to help out. Even with the three of us sharing the
    responsibility of caring for her, we could not do it if it weren't for
    the caregivers who come to her home to take care of her. This is what
    allows my brother and sister and I to continue our full time jobs and
    maintain our own lives as well as pitch in to help with Mom. Without
    these aides, she would lose everything and I have no idea where she
    would live.

    My husband and myself are small business owners, and insurance has
    never been easy or inexpensive for us without the benefit of receiving
    coverage through an employer. So when the Affordable Care Act was
    announced, we thought this would finally be something where we'd have a
    real option for substantial health care. Before the ACA, we had health
    insurance through Freelancers Union. I was always trying to cobble
    something together for both of us, or thinking we'd have to just rely
    on a catastrophic plan. Last year was stressful and frustrating--mid-
    year our insurance company cut my doctor and hospital out of the
    network. One example is that my husband and I needed to get physicals
    and blood work in September so I had to find a new doctor who turned
    out to be one of the worst doctors we had ever been to. The doctor's
    office mistakenly sent our bloodwork to the wrong lab (even though we
    explicitly told them they had to go to Quest Lab to which they answered
    they knew).

    Even though they said they would fix the error, they didn't. Their
    mistake cost us $500. I don't know why our doctor and hospital dropped
    our insurance coverage mid-year, and while I understand that there have
    been some problems since the ACA rolled out, I don't believe the answer
    is throwing it all out. The solution is to improve it and make it
    stronger. Getting more people covered through the ACA will help
    stabilize it. Having coverage that we can afford through the ACA is a
    huge relief. I have a close family friend who for many years could not
    afford insurance. When he finally had to drop his coverage, he was
    diagnosed with leukemia shortly afterwards. He lost his house, his
    business--everything. I get such peace of mind knowing that my coverage
    provides preventative care, and knowing that if some unexpected
    emergency arises, we will be covered and we will be okay.

    My family has been able to afford the care we need because of Medicare,
    Medicaid, and the Affordable Care Act, and I think we as a country can
    do even better to make sure that everyone is able to get the care they
    need. Cuts and defunding these programs would make things much more
    difficult for many Americans--and no one says that it should be easy,
    or that the government should do it all, but where we can make things
    better, why wouldn't we? I am proud of these programs that help people
    get the help they need.

    I am happy to be an advocate for better care with Caring Across
    Generations as part of the Caring Majority, and to be able to tell my
    family's story. Supporting these programs is bigger than politics--it
    is about people's lives. This is a moment when we need to take steps
    forwards, not backwards. I hope Congress does what the majority
    actually wants--it's their job.

                                     ______

    Rita Morris

    Birmingham, Alabama

    I am Rita Morris of Birmingham, AL and proud daughter of Mrs. Katie. I
    thank you in advance for your valuable time in allowing me to share my
    personal experience as a family member and consumer of nursing home
    care with Medicaid. At some point in our lives we will be a caregiver
    or in need of a caregiver. I ask of you today to consider your family
    as I share a glimpse of ours. I ask that you recognize your partnership
    with us. As Mother's caregiver of 14 years, an only child, wife, cancer
    survivor and mother, my hope was for quality of life, quality of care
    and peace of mind for all of us. Nursing home care directly affects our
    loved ones as well as our families. My mother became a widow at the age
    of 45; I was 16. Out of necessity I quickly learned about our family
    finance needs and importance of health care. Years later as a
    Registered Nurse, I was well aware that health care is driven by
    federal and state regulations. When my Mother was diagnosed with
    vascular dementia, her life and our family's life changed. At that
    time, I was a stay at home mom with a child in kindergarten. Our
    journey started at that time. We had many partners in caring for Mother
    along the way--the Grace of God, family, friends, faith, Medicaid,
    Medicare, Social Security, and many wonderful health care providers--
    but our journey would have been completely different if not for
    Medicaid.

    As Mother's dementia advanced, her physical, mental and spiritual needs
    increased. She was able to live in her home for 2 years with
    assistance, in our home for 1 year with sitters, for 4 years in
    specialty assisted living, and for 7 years in a nursing home. After 4
    years in assisted living, the dementia had progressed and she required
    pureed food and more care. When this occurred, we were no longer
    eligible for assisted living. The next transition was to the nursing
    facility. I researched the regulations (OBRA) for nursing homes and
    Medicaid before we moved in. We were prepared. The rules and
    regulations of Medicaid, Medicare, and Social Security are clear in
    purpose and process. They served our family as intended and were
    greatly needed.

    In 2007 we were told that Mother could possibly live 6 months in the
    nursing home. We recognize and respect that the decisions for our
    federal funded health insurance programs are in the hands of our
    legislative partners. Medicaid was the most life-enriching benefit that
    Mother received at her most vulnerable time. She moved into the nursing
    facility in August of 2007. Her financial assets were depleted, her
    dementia had advanced, and she required care around the clock. Dementia
    symptoms were not limited to the hours of 8 am to 5 pm; they were
    around the clock for 24 hours. I completed the Medicaid application
    with the online form and directions. I submitted the form personally to
    our local office and received a follow-up call 3 weeks later. She moved
    into the nursing home in August 2007 and was approved by Medicaid
    retroactively in October 2007.

    As a cancer survivor, my biggest fear was that I would no longer be
    there to care for her. I often asked myself: Who would care for her in
    my absence? My hope was to be able to care for her as she did for me,
    my father, and my family: simply with love. Her focus was always on us;
    she did not focus on finances, insurance or direct care. Medicaid
    provided Mother with the 24 hour a day care that she needed, the
    necessities that she required, and a state surveyor to monitor the care
    and assure that the facility was in compliance with the regulations. As
    an only child, I had peace of mind knowing that in the event of my
    absence, her care would be paid for and she would get the care she
    needed, with protection and oversight.

    As a result of the necessities and protections Medicaid provides, my
    Mother lived an additional 7 years with respect, dignity, and quality
    of care and quality of life. Her wishes were simple. She used to say,
    ``I don't want to be the one someone would see and say `that poor
    thing' '' and ``I don't want to be a burden on you.'' She was never in
    a situation of being neither ``that poor thing'' nor a burden. In those
    7 years she was admitted to the hospital only one time for a fractured
    hip. She had no skin breakdown, limited contractures, and was treated
    in her own bed for pneumonia and urinary tract infections over the
    years. She was provided care by loving caregivers, and she was loved by
    many. The staff of the two sister facilities that she called home
    became our extended family.

    I was able to be a partner, assist in her care, be an involved mother
    in after school activities, help my son with his homework, and serve as
    room mom at his school. I was able to be present in our home as wife
    and mother in our family commitments. Our one income family was able to
    provide for our immediate needs and to save for our son's college
    needs. This was not always easy, but it was our new ``normal'' and we
    did the best we could. The stress of caregiving is tremendous. It takes
    a village to raise our children and it takes a village to care for our
    vulnerable loved ones of all ages and needs in all settings. The
    nursing home setting had a profound impact on our family. Long-term
    care is the most precious, personal and spiritual time for transitions
    in roles and in preparation for the final transition to Glory.

    I would like to take a moment to share with you a glimpse of what our
    lives could have been without our Medicaid partner. In 2007 the
    potential of living 6 months could have been a reality. We would have
    had two options if we had to leave the assisted living without
    Medicaid. One would have been to care for Mother in our home, a home
    with a then 13 year old still needing to be driven to school and
    activities, increased homework, wife to prepare meals and provide 24
    hour care during a time that Mother was still walking and wandering.
    The focus was caring for Mother and family. When Mother was in our
    home, she found it to be stressful living with us before she chose to
    move to the assisted living. She wanted to be with friends her own age
    in her own ``home.'' In our home, she had the constant reminder of her
    losses and her dependence on us. We required sitters in my absence
    along with medical equipment. If we continued to care for Mother in our
    home, she may not have received the highest quality of care that she
    deserved and she may never have achieved a high quality of life.

    Our second option without Medicaid would have been to pay privately for
    the nursing care that she needed 24 hours a day. As an estimate in
    2007, the private rate for the nursing home was $5,000 per month or
    $60,000 a year. Over a period of 7 years the total would have been a
    minimum of $420,000. Our family would have required loans to meet those
    needs. We were and still are a one income family. We would have done
    everything needed to care for Mother. However, as parents to our only
    child, we also had to anticipate his college needs. This would have
    been an overwhelming situation and limited at best.

    These are two very different options both affecting our family and most
    importantly the quality of care and the quality of life that Mother
    would have experienced. There would have been no peace of mind for any
    of us with either of these two options. In closing I would like to
    express my thanks to you and to ask for your continued support of
    Medicaid as an essential way to meet our medical needs and financial
    support not only for our loved ones, but for families as well. As the
    generation before us, we have contributed to our Social Security and
    have anticipated having Medicare and Medicaid in place as our needs
    arise. It has been a privilege and an honor to walk with Mother as her
    partner on this journey. Mother's last transition occurred on September
    1, 2014 when she was called home to Glory. As my husband and I walked
    with Mother out the front door in the early hours we left with no
    regrets. It was well with my soul. I hope that our experience with
    Medicaid can relay the profound impact that the decisions made with a
    vote can have on the lives of those you serve. The photo of my hand
    with Mother's reflects my commitment of love and care and her fragile
    dependence and trust.

    With our Medicaid partner, Mother was afforded quality of care and
    quality of life while I was afforded the peace of mind to continue to
    serve in my proudest role, Daughter.

    Sincerely,
    Rita Morris
    Daughter of Mrs. Katie

                                     ______

    Susan Flashman

    Mt. Rainier, MD

    My name is Susan C. Flashman, and I have been on Social Security since
    I became disabled following brain surgery in 2011. And 2 years later I
    was eligible for Medicare coverage. My husband, Richard A. Bissell, has
    been on Medicare for 12 years.

    We are both retired and live on a fixed income made up of Social
    Security and our retirement pensions from our years of Union employment
    with the International Brotherhood of Electrical Workers. We pay
    monthly for our Medicare coverage, as well as our supplemental
    insurance offered through our UNION.

    Because we have Medicare coverage, we have been able to repair injured
    and worn parts of our bodies through surgery. The repairs have helped
    us to maintain an active life with minimal pain. Following my brain
    surgery, and as soon as I was well enough, I could have a breast biopsy
    performed to make certain that a mass seen during my annual mammogram
    was not the start of cancer.

    This peace of mind following brain surgery was priceless. Since then,
    Medicare has helped to pay for the repair of my left wrist, and my
    broken toe. Both important to keep me living a full and independent
    life. In this same manner, my husband had surgery to repair a torn
    rotator cuff in his shoulder. Without such surgery, the pain would have
    incapacitated him.

    The importance of Medicare to us is that we can stay healthy enough to
    continue to contribute to our community in voluntary activities, as
    well as maintain an independent life in our own home. In doing so, we
    do not burden our families, or the long-term care system.

    If we were unable to have Medicare help maintain our health through
    regular doctor's visits and medical tests, we might become less healthy
    more quickly as we age. The enormous cost of health care for those who
    are no longer able to earn additional funds is critical.

    If Medicare were to become part of the insurance business, I am afraid
    that I and every subscriber would have to hire a lawyer to be certain
    that these companies fulfilled their legal obligations of coverage. I
    have personally encountered this type of dilemma following my brain
    surgery. In order to receive the benefits I deserved from a
    catastrophic medical insurance plan, I had to rely on legal counsel.
    What is even worse than having to fight for what is due, is to have to
    fight when you are least able. The insurance industry counts on this to
    help reach their profit margin.

    While we were working, we contributed to Social Security and Medicare
    and now the Congress thinks privatizing care for seniors should be
    profitable. Hogwash!

    It is time to expand Social Security--so that everyone in this country
    has the basics they need to live a decent life, not just those lucky
    enough to have inherited wealth.

    Sincerely Submitted by Susan C. Flashman on January 16, 2016.

                                     ______

    Lezrette Hutchinson

    Bronx, NY

    My name is Lezrette Hutchinson. I live in the Bronx, NY, and I am 60
    years old and a mother of three. Thank you for convening a public forum
    to give voice to American families who would be harmed by proposals
    that would make people with Medicare and Medicaid pay more for their
    care. Please accept this letter as formal comment for the forum record.

    In 1999, after years of working at New York's Board of Education, I was
    diagnosed with sarcoidosis. Sarcoidosis is an inflammatory disease that
    affects my lungs, which makes me depend on oxygen. With little
    information about the disease, I became extremely ill.

    Two years later, I became homeless for a time after a fire burned down
    my home. The side effects of the disease and my medications made me
    depressed. This was because I didn't know where to go for proper
    treatment, and I was prescribed the incorrect medications. I was unable
    to go to work nor to take meaningful part in my children's lives as
    they grew into adulthood.

    My health turned around once I found a sarcoidosis clinic at Mount
    Sinai Hospital, which accepts both my Original Medicare and fee-for-
    service Medicaid coverage. After receiving the care I desperately
    needed, I was able to become an activist and participate in a support
    group for those with sarcoidosis. Later, I joined the board of my
    medical center to implement changes that my fellow advocates and I knew
    would improve patients' quality of life. I also attended a recreational
    support group called the 50s-plus Program, and then joined the
    Workgroup for People with Medicare and Medicaid, part of the Duals
    Coalition of New York's Medicare Rights Center.

    If I didn't have my original Medicare, I would need to find a plan that
    would cover me best, knowing that I have a serious, rare disease. I
    would need to make sure I found a way to continue to receive the care I
    need with the right doctors who can service my chronic disease. This
    would be a challenge for me since not many doctors specialize in my
    illness, and if I couldn't continue to see them my illness would take a
    turn for the worse.

    With my current income, by the time I pay my rent and bills, I do not
    have much left. If my Medicare costs increased that would be a big
    financial hardship for me. Thanks to my Medicare and Medicaid, I am
    provided with affordable, vital services that enhance my life. I would
    love to continue to get the quality of care that I am getting now. Yes,
    I am ill but I don't want that to stand in my way. I recently found out
    I am going to be a grandmother and I want to take part in my
    grandchild's life and make up for the years I was unable to be in my
    own children's lives due to my illness.

                                     ______

    Theresa Maguire

    Queens, NY

    My name is Theresa Maguire. I live in Queens, NY, and I am a mother of
    two and recently became a grandmother. Thank you for convening a public
    forum to give voice to American families who would be harmed by
    proposals to repeal the Affordable Care Act (ACA) and undo the Medicare
    and Medicaid guarantee. Please accept this letter as formal comment for
    the forum record.

    On December 28, 2010, I received a fully favorable (100% disabled)
    decision in connection with my Social Security Disability Insurance
    Benefits application. At 57 years old, I had been a grammar school
    teacher consecutively for the previous 26 years. I am disabled from
    Chronic Interstitial Cystitis (IC) with Hunner's Lesions. I also have
    Pelvic Floor Dysfunction, Pudendal Nerve Involvement, hypertension,
    tachycardia, IBS, and anxiety.

    Since 2010, I have been treated by Dr. Robert Moldwin for my IC
    condition and its related issues. Dr. Moldwin is one of the leading
    specialists in the United States for IC and is the author of ``The
    Interstitial Cystitis Survival Guide.'' He has played a primary and
    pivotal role in my treatment. I first saw Dr. Moldwin in May of 2010
    and I continue to visit his practice generally on a weekly/bi-weekly
    basis.

    In June of 2010, Dr. Moldwin ordered me to begin bladder installations.
    Each installation lasts approximately 1 hour and consists of 15 steps.
    I must undergo these treatments on a semi-weekly, and often weekly,
    basis. On several occasions, the installations will puncture one of my
    Hunner's lesions which causes five or more hours of steady bleeding.
    During this time, I am forced to stay in or near a bathroom and drink
    copious amounts of water. With time, the bleeding subsides. In addition
    to the installation procedures, I receive ``internal nerve block
    injections'' into the walls of my pelvis. I also endure ``internal
    physical therapy.'' This is to assist with the pain associated with my
    conditions.

    All efforts at relieving my pain thus far have been only temporary in
    nature. After suffering from the pain and devastating change of
    lifestyle brought about by my condition, I began to see a mental health
    specialist in October of 2010, and my treatment with her has been
    ongoing since. My pain is moderate to severe, and occurs on a daily
    basis. This is exacerbated by my particularly small bladder which
    causes further pain. This also causes my frequency of urination to
    increase along with the increased pain.

    I wake up multiple times a night. I live with fatigue, loss of sleep,
    and bladder spasms, among other symptoms. My experience of pain or
    other symptoms is severe enough to interfere with attention and
    concentration on a frequent basis, and I am incapable of even a low
    stress job. I can only sit continuously for 20 minutes, stand for 20
    minutes, and total sit, stand, or walk less than 2 hours in an 8-hour
    period.

    My condition dictates bathroom visits that can be 20 times in a 24-hour
    period. Urinating is a burning painful experience for me a majority of
    the time. I suffer the inability to sit at times due to the
    excruciating pain of my condition. I have a prescription from my
    neurologist that allows me to be in a kneeling position in the car when
    I cannot transfer to a sitting position due to temporary paralysis of
    my pelvic floor. All together, I need 10 prescription medications, 5 to
    regularly manage my conditions and an additional 5 for bladder
    installations.

    I had to wait 2 years to receive Medicare. For those 2 years, I needed
    to pay COBRA premium payments. The burden of my illness exacerbated and
    strained my ability to meet even the simplest daily tasks. Furthermore,
    the emotional and psychological strain and stress of medical insurance
    payments and medical co-payments while waiting for Medicare was enough
    to push me over the edge. Since I was a teenager, I worked diligently
    as a tax-paying citizen and continued to do so my entire adult life.
    Here I was at 57 years old sinking with a monetary situation that added
    to my already debilitated medical condition. If I were to get sick now,
    I would have the ability to shop for other, potentially less expensive,
    insurance options than that COBRA coverage through New York State's
    health exchange--thanks to the Affordable Care Act (ACA).

    Since I began receiving Medicare, I have been privileged with being
    treated by the same doctors as prior to my Medicare coverage, and I
    have been comfortably reassured with my present Medicare coverage that
    I can continue to receive the cutting edge treatments available to me.
    I pay $104 per month for Medicare (which is deducted from my Social
    Security Disability Benefit), and I do not have any other medical
    insurance coverage. I cannot take on the burden of paying for
    additional coverage. I receive a Social Security Benefit of $1,550 per
    month, and I receive a disability insurance check for $775 per month.
    My out-of-pocket co-pays for 2016 were slightly more than $3,215 in
    addition to my Medicare premiums.

    I hope my story conveys the fragile, debilitating situation one is put
    in when one can no longer function as a productive member of society
    and can therefore no longer earn a living. Medicare needs to remain
    with its benefits, at the very least, intact. I cannot endure the
    thought of elected officials dictating changes in Medicare that
    determine not only my quality of life, but my life itself. I deserve to
    have a fighting chance, and I need my Medicare benefits to remain
    stable to be granted that fighting chance. With your help, your
    actions, your foresight, and your good consciences, you can save lives.
    I hope all members of Congress will step up to the challenge and battle
    for what is a human right--the right to decent medical benefits for the
    disabled.

                                     ______

                     Prepared Statement of Hon. Ron Wyden,
                           a U.S. Senator From Oregon
        The American public heard a lot of promises about health care from
    the new administration. No cuts to Medicare or Medicaid. Nobody hurt by
    ACA repeal. ``Insurance for everybody . . . much less expensive and
    much better.'' Congressman Price's own record undercuts those promises,
    and this morning I'll get to those issues.

        But first I'm going to start with questions about ethics and
    undisclosed assets. Congressman Price owns stock in an Australian
    biomedical firm called Innate Immunotherapeutics. His first stock
    purchase came in 2015 after consulting Representative Chris Collins,
    the company's top shareholder and a member of its board. In 2016,
    Congressman Price was invited to participate in a special stock sale
    called a private placement. The company offered the private placement
    to raise funds for testing on an experimental treatment it intends to
    put up for FDA approval. Through this private placement, Congressman
    Price increased his stake in the company more than 500 percent. He has
    said that he was unaware he paid a price below market value.

        That claim doesn't pass the smell test. Company filings with the
    Australia Stock Exchange clearly state that this specific private
    placement would be made at below-market prices. The Treasury Department
    handbook on private placements says they are ``. . . offered only to
    sophisticated investors in a nonpublic manner.'' Congressman Price also
    said last week that he directed this stock purchase himself, departing
    from what he said was his typical practice.

        Then there's the issue of what was omitted from the Congressman's
    notarized disclosures. Congressman Price's stake in Inna te is more
    than five times larger than the figure he reported to ethics officials
    when he became a nominee. He disclosed owning less than $50,000 of
    Innate stock. At the time the disclosure was filed, by my calculation,
    his shares had a value of more than $250,000. Today his stake is valued
    at more than half a million dollars. Based on the math, it appears that
    the private placement was excluded entirely from the Congressman's
    financial disclosure. This company's fortunes could be affected
    directly by legislation and treaties that come before Congress.

        It also appears Congressman Price failed to consult the House
    Ethics Committee following trades of several health care stocks, as
    they were directly related to two bills he introduced and promoted.
    Even if some of those trades were not made at his direction, he would
    have been aware of them as soon as he filed his Periodic Transaction
    Reports with the House of Representatives.

        Set aside the legal questions. It's hard to see how this can be
    anything but a conflict of interest and an abuse of his position.

        Finally, one of the most important questions on the Finance
    Committee's biographical questionnaire is whether nominees have been
    investigated for ethics violations. Congressman Price has been the
    subject of two investigations stemming from fundraising practices. This
    too was not disclosed.

        I believe this committee needs to look into these matters more
    thoroughly before moving ahead with this nomination.

        Let's turn now to policy, starting with the Affordable Care Act and
    the scheme known as ``repeal and run.'' The secret Republican
    replacement plan is still hidden away, but already the administration
    is charging forward with a broad executive order endangering people's
    health care. As the Budget chairman, Congressman Price is the architect
    of repeal and run.

        If his repeal bill became law, 18 million Americans would lose
    their health-care plans in less than 2 years. In one decade you'd go
    from 26 million people without insurance to 59 million. Repeal and run
    would raise premiums 50 percent in less than 2 years. Costs would
    continue to skyrocket from there. The market for individuals to buy
    health insurance would collapse. No-cost contraceptive coverage for
    millions of women--gone. By defunding Planned Parenthood, nearly
    400,000 women would lose access to care almost immediately. Hundreds of
    thousands more would lose their choice to see the doctors they trust.

        The Price plan takes America back to the dark days when health care
    worked only for the healthy and the wealthy.

        Congressman Price's other proposals don't offer much hope that the
    damage will be undone. By the Trump rubric of ``insurance for
    everybody,'' ``great health care . . . much less expensive and much
    better,'' the Congressman's plans get a failing grade.

        In another bill, the Empowering Patients First Act, the Congressman
    Price brought back discrimination against people with pre-existing
    conditions such as pregnancy or heart disease. It gave insurers the
    power to deny care and raise costs on people with pre-existing
    conditions if they didn't maintain coverage. In effect, the bill said
    insurance companies could take patients' money and skip out on paying
    for the care they actually need.

        His bill also gave insurers the green light to reinstate lifetime
    limits on coverage and charge women higher rates just because they're
    women. It gutted the tax benefits that help working people afford high-
    quality health-care plans. It slashed the minimum standards that
    protect patients by defining exactly what health plans have to cover.
    All this from a proposal called the Empowering Patients First Act. It'd
    be a stretch to find a bill with a more ironic title, considering how
    much power it handed to giant insurance companies.

        If there's a theme developing, it's that the Congressman's
    proposals push new costs onto patients. The massive cuts to Medicare
    proposed in Congressman Price's budget are another prime example. In my
    view, the Congress has a duty to uphold the promise of Medicare--the
    promise of guaranteed benefits.

        Congressman Price advocated privatizing Medicare and cutting it by
    nearly half a trillion dollars. After his nomination, he said he wants
    to voucherize Medicare within the first 6 to 8 months of the
    administration.

        He also supports ``balance billing.'' That means seniors could be
    forced to cover extra charges above what Medicare pays for the services
    they receive in the doctor's office. So in this case, it's extra costs
    pushed onto elderly people who live on fixed incomes.

        Congressman Price has also called for block granting and capping
    Medicaid, a plan that would shred the safety net for millions of
    America's most vulnerable patients.

        Medicaid insures 74 million people. More people rely on Medicaid to
    help pay for nursing home care and home-based care than any other
    program. The program pays for nearly half of all births and covers
    millions of children. It's a critical source of mental health care and
    substance use treatment, which is vital at a time when communities
    nationwide are battling the opioid epidemic. But Congressman Price's
    most recent block grant proposal cut Medicaid by a trillion dollars.

        Setting that huge cut aside, there's also a concerning pattern to
    the way some lawmakers look at programs that have undergone this kind
    of transformation. At first it's a block grant, a few years later it's
    declared a slush fund, and then it gets slashed to the bone.

        Unfortunately, that pattern has also defined Congressman Price's
    approach to other areas that would be within his jurisdiction as
    Secretary. His budget called for trillions of dollars in cuts to
    programs that support millions of vulnerable people--everything from
    job training to housing assistance to child nutrition. He also voted no
    on the reauthorization of the Violence Against Women Act when it sailed
    through the House on a bipartisan basis.

        As I wrap up, I want to return to health care. The Congressman and
    many others say patients should be at the center of care, and nobody
    would dispute that idea. When I look at Congressman Price's proposals,
    I don't see the patient at the center of health care. I see money and
    special interests at the center of health care.

        His plans would tell vulnerable Americans that their health care
    will go only as far as their bank accounts will take them. The well-to-
    do might be able to afford Congressman Price's proposals and the costs
    they push onto patients, but millions of working Americans cannot.

        Congressman, I thank you for joining the committee today and I
    appreciate your willingness to serve. I look forward to your testimony.

                                     ______

                    MEMORANDUM FOR FINANCE COMMITTEE MEMBERS

    From: Senate Finance Committee Staff
    Date: January 23, 2017
    RE: Nomination of Dr. Thomas E. Price
    _______________________________________________________________________

        This memo describes the Senate Finance Committee staff review of
    the 2013, 2014, and 2015 tax returns, and other documentation of Dr.
    Thomas E. Price in connection with his nomination to be the Secretary
    of the Department of Health and Human Services (HHS).

    Background

        Finance Committee staff conducted a review of Dr. Price's Senate
    Finance Committee (Committee) Questionnaire, tax returns for 2013,
    2014, and 2015, and financial disclosure statements. As part of this
    review, a due diligence meeting was held with the nominee and his legal
    representation on January 16, 2017. His accountant participated via
    telephone. In addition to the due diligence meeting, staff submitted
    multiple rounds of written questions to the nominee.

        At the conclusion of this process, three issues have been
    identified that have been deemed appropriate to bring to the attention
    of committee members.

    Senate Finance Committee Questionnaire--Ethics Investigation and Late
    Property Tax Payments Omitted

        All nominees referred to the committee are required to submit the
    Senate Finance Committee Statement of Information Requested of Nominee
    (``Questionnaire'').

        Part D. Legal and Other Matters, Question 1, asks nominees: ``Have
    you ever been the subject of a complaint or been investigated,
    disciplined, or otherwise cited for a breach of ethics for
    unprofessional conduct before any court, administrative agency,
    professional association, disciplinary committee, or other professional
    group?''

        In his response, submitted December 21, 2017, Dr. Price responded,
    ``No.'' However, in 2010, the Office of Congressional Ethics (OCE), an
    independent office of the House of Representatives, conducted an
    investigation into Dr. Price's 2009 fundraising activities. OCE voted
    4-0-1 to refer the case to the House Ethics Committee, which, after
    conducting a second investigation, ultimately found no wrongdoing in
    2011.

        In written questions submitted to Dr. Price on January 6, 2017,
    committee staff requested an explanation for the omission of the ethics
    investigation. Dr. Price stated it was an inadvertent omission and that
    the majority of activities investigated related to his authorized
    campaign committee, rather than him personally. The information
    pertaining to this investigation has been and continues to be available
    on the web page of the House Ethics Committee.

        Part F. Financial Data, Question 10, asks nominees: ``Have you paid
    all Federal, State, local, and other taxes when due for each of the
    past 10 years?'' Dr. Price responded, ``Yes.'' However, upon examining
    Washington, DC and Nashville, Tennessee real estate tax records,
    Committee staff determined late tax payments had been made in relation
    to rental properties owned by Dr. Price, totaling $1,583.45 for late
    payments made over the past 7 years.

        In written questions submitted to Dr. Price on January 6, 2017,
    Committee staff requested an explanation for the omission of the late
    tax payments. Dr. Price stated that, regarding the DC property, he
    believed that ``late fees and penalties derived from not receiving
    timely property tax notices.'' Regarding the Tennessee property, the
    nominee noted that ``notices regarding property taxes for this rental
    property . . . were either not being received or being wrongly mailed
    to the tenant at the property and not reaching the nominee and his
    spouse.''

    Depreciation of Land Value and Miscellaneous Employment Deductions

        Committee staff received 2013, 2014, and 2015 tax returns from Dr.
    Price on December 21, 2016. In addition to the written questions
    submitted on December 28, 2016 and January 6, 2017, Committee staff
    spoke with Dr. Price's accountant on January 9, 2017. Following the due
    diligence meeting with Dr. Price, Committee staff then submitted an
    additional round of written questions to the nominee on January 16,
    2017.

    Improper Inclusion of Land Value in Depreciation Calculations

        Taxpayers who own rental property are generally allowed to deduct
    depreciation expenses associated with the wear and tear of those
    buildings. Taxpayers are not, however, allowed to include the value of
    land in the depreciable amount.

        Dr. Price owns rental condominiums in Washington, DC and Nashville,
    Tennessee, and claimed depreciation expenses associated with those
    properties for years 2013, 2014, and 2015. It appears these values
    included depreciation for the value of the land. According to property
    tax records, the land value of Washington, DC condominium was listed as
    $95,640, and the land value of his Nashville condominium was listed as
    $30,000.

        Under current tax rules,\1\ these values are not allowable for
    depreciation expenses. Committee staff asked for clarification on this
    issue in the due diligence meeting with Dr. Price and sent written
    follow-up questions on January 16, 2017.
    ---------------------------------------------------------------------------
        \1\ Treasury Reg. Sec. 1.167(a)-5, T.C. Memo. 1982-51, Meier v.
    Commissioner.

        In his response to the committee, received on January 23, 2017, Dr.
    Price's accountant stated he had taken the position that the land had a
    fair market value of zero. However, given the lack of another valuation
    besides the property tax assessments, Dr. Price has committed to
    address the discrepancy by filing a Form 3115 to adjust the
    depreciation and account for the improper deductions on his 2016 tax
    ---------------------------------------------------------------------------
    returns, though adjustments may be spread out over 4 years.

    Absence of Documentation of Employment Deductions

        In 2013, 2014, and 2015, Dr. Price claimed miscellaneous employment
    deductions, totaling $19,034. Dr. Price, and his wife, also a medical
    doctor, both list their occupations as ``PHYSICIAN'' on the second page
    of their Form 1040s. Neither Dr. Price nor his wife actively works as a
    physician, though Dr. Price has noted he has maintained his medical
    license. Committee staff requested substantiation and further
    explanation of the deductions in written questions submitted December
    28, 2016.

        Committee staff spoke with Dr. Price's accountant on this matter on
    January 9, 2017, and again during the due diligence meeting on January
    16, 2017. In those discussions, Dr. Price's accountant noted that Dr.
    Price and his wife, Elizabeth, would compile a variety of expenses,
    including vehicle expenses, and discuss with the accountant what
    portion of those expenses would be appropriate to deduct as employment
    expenses, frequently settling on an amount equal to roughly 60 percent.
    Though the Prices no longer actively work as physicians, their
    accountant believed that the deductions were appropriate, and were
    reflective of expenses incurred by Mrs. Price. After the January 16,
    2017, due diligence meeting, staff suggested that in the absence of
    full documentation of the deductions, that the returns be amended.

        In a response, received January 23, 2017, Dr. Price's accountant
    noted that proper documentation could not be located. Dr. Price's 2013,
    2014, and 2015 tax returns will be amended to remove the $19,034 of
    deductions. Since Dr. Price was subject to the Alternative Minimum Tax
    (AMT) in each of those years, the changes will not result in any change
    to tax liability.

    Asset Values

        In separate financial disclosure filings to the House of
    Representatives, to the committee, and to the public through the Office
    of Government Ethics (OGE) Form 278, the nominee reported ownership of
    stock in an Australian pharmaceutical company--Innate
    Immunotherapeutics Ltd. The nominee purchased these shares in two
    tranches: one in 2015 valued at $10,000 at the time of purchase, but
    was valued at between $15,000 and $50,000 on December 20, 2016, the
    date of filing. A second tranche was purchased in August 2016 of
    400,613 shares, through a private placement offering, and was listed on
    the committee questionnaire as being valued between $50,000 to
    $100,000, which was based upon the purchase price. An analysis done by
    multiplying the number of shares by the market price on December 20,
    2016 demonstrates a value higher than that reported by the nominee. The
    nominee noted that the amounts reported to the committee were a good
    faith valuation. The nominee agreed to recalculate the value of the
    shares based on the market value at the time the committee
    Questionnaire was completed. The revised value of the second tranche
    was between $100,000 and $250,000 when filed.

        The nominee and committee staff also agreed that the tranche of
    shares acquired in August 2016 was not accounted for on the OGE Form
    278, and the nominee told staff that income attributable to his holding
    in the company reported on OGE Form 278 was incorrect. The nominee
    noted that it is unclear how information related to his holding in this
    stock was misstated on the published form. The nominee agreed to
    contact OGE to correct the form.

                                     ______

              Senate Finance Committee--Bipartisan Vetting Process

                                January 24, 2017

    The Finance Committee has a long, bipartisan tradition of engaging in a
    very thorough process for vetting nominees. It has served the committee
    well and it has served the country well.

    It has several steps. First, we review the paperwork, consisting of the
    committee questionnaire, financial disclosure (OGE Form 278), ethics
    agreement, ethics letters, and 3 years of tax returns. Frequently,
    there have to be several rounds of written, follow-up questions before
    the paperwork is satisfactorily reviewed.

    Next, we have three staff meetings; one to complete the due diligence
    review (financial), one to discuss policy with the chairman and ranking
    member's staff, and one with the staff of committee members. Only after
    all of these steps have been completed do we notice a hearing, seven
    days prior to the hearing's date.

    The two nominations that we are considering so far each raise issues
    that have taken some time to review. In the case of Mr. Mnuchin, he has
    very complicated financial affairs, with partnerships embedded within
    other partnerships. It took some time just to get a good understanding
    of his financial affairs. In the case of Dr. Price, it has been
    difficult to value his stake in an Australian drug company. In fact,
    Dr. Price revised his committee questionnaire just yesterday, January
    23, 2017, to correct inaccurate information about the ownership of this
    stock.

    Below is an overview of the dates of meetings, materials received,
    rounds of questions asked, and responses received between committee
    staff and the nominees through the bipartisan vetting process.

                                     ______

    Mr. Steven T. Mnuchin
    Materials Submitted
          December 16: Tax Returns
          December 19: Questionnaire; Interim OGE Form 278
          January 10: Revised Questionnaire; OGE Ethics Materials; OGE
    Form 278
          January 15: 2nd Revised Questionnaire
    Meetings
          January 13: 1st due diligence (financial)
          January 17: 2nd due diligence (policy)
          January 17: 3rd due diligence (Committee Member staff)
    Rounds of Questions
          December 23: Initial Tax Compliance
              Responses received: December 30, January 4,
    January 6
          January 4: Follow-up Tax Questions and due diligence matters
              Responses received: January 6, January 9, January
    13
          January 10: Follow-up Tax Questions and due diligence matters
              Responses received: January 12, January 18
          January 13: Tax and Non-tax follow-up questions, following 1st
    due diligence meeting
              Responses received: January 18

    The Honorable Thomas E. Price
    Materials Submitted
          December 21: Questionnaire; Tax Returns
          January 11: OGE Ethics Materials; OGE Form 278
          January 23: Revised Questionnaire
    Meetings
          January 16: 1st due diligence (financial)
          January 17: 2nd due diligence (policy)
          January 17: 3rd due diligence (Committee Member staff)
    Rounds of Questions
          December 28: Initial Tax Compliance
              Responses received: January 4
          January 6: Due diligence matters
              Responses received: January 12
          January 10: Additional Tax Compliance
              Responses received: January 12
          January 16: Tax follow-up questions, following 1st due diligence
    meeting
              Responses received: January 23
          January 17: Non-tax follow-up questions, following 1st due
    diligence meeting
              Responses received: January 22

                                     ______

                     The Washington Post, January 23, 2017

           HHS Nominee's Mix of Investments, Donations, Legislation
                            Keeps Raising Questions
                      By Kimberly Kindy and Amy Goldstein
    Representative Tom Price, the Georgia Republican nominated by President
    Trump to lead the Department of Health and Human Services, is under
    increasing scrutiny for a trifecta of financial, campaign and
    legislative activities that some longtime ethics lawyers describe as
    ``extremely rare'' and revealing ``an extraordinary lack of good
    judgment.''

    In recent years, Price has repeatedly traded stock in dozens of health-
    related companies while pushing bills that could have benefited many of
    them. At the same time, he has been uncommonly reliant on campaign
    contributions from the health-care industry, accepting more than
    $700,000 from physicians, hospitals, drug companies and insurers during
    his 2016 run for a seventh congressional term, according to the Center
    for Responsive Politics.

    ``I haven't seen anything like this before, and I've been practicing
    and teaching about securities law for 30 years,'' said Richard W.
    Painter, who was chief White House ethics lawyer for President George
    W. Bush from 2005 to 2007.

    Given that Price has some influence legislatively over the health-care
    sector, his volume of trades in related companies is unusual, according
    to a former chief counsel to the House and Senate ethics committees. In
    the past few years, more lawmakers have moved away from investing in
    individual stocks, opting instead for mutual funds, Treasury bills or
    municipal bonds as investments.

    ``They are allowed to do this type of trading, but I would advise
    against it,'' said Rob Walker, who served in the bipartisan counsel
    positions from 1999 to 2008. ``The level of scrutiny he is facing goes
    along with the territory of making these kinds of investments.''

    Price's investments and donations coincide with a pattern, dating back
    to his years as a state senator, of strenuously promoting legislation
    that advances the interests of the medical profession. An orthopedic
    surgeon for 20 years before he entered politics and still an active
    member of the American Medical Association, he has sought as both a
    Georgia legislator and congressman to make it more difficult for
    patients to win medical malpractice lawsuits and to limit certain
    damage awards in such cases.

    ``Whether it be liability or any policy issues about how health care is
    delivered, how it is paid for, how it is accessed, it is doctors all
    day every day,'' said longtime critic Mark Taylor, a Democratic
    lieutenant governor in Georgia during most of Price's tenure in the
    state Senate and first years on Capitol Hill.

    And while Price speaks often of pursuing a patient-centered health-care
    system, he rails against what he calls an excessive federal role in
    health care, voting at one point against an expansion of the Children's
    Health Insurance Program. ``The desire of those on the left to
    gradually move every American to Washington-controlled bureaucratic
    health care is so strong they will stop at nothing,'' he said before
    casting that vote in 2007.

    In Congress, he has been one of the most ardent opponents of the
    Affordable Care Act, sponsoring the only bill to repeal the sprawling
    health-care law that passed Congress. Then-President Barack Obama
    vetoed it early last year.

    Price's investment and legislative records are central themes that
    Democrats plan to pursue in his confirmation hearing Tuesday before the
    Senate Finance Committee. During a ``courtesy'' hearing last week
    before a different Senate panel, he faced sometimes-heated
    interrogation by Democrats over the timing of stock purchases and the
    extent of his involvement in them.

    The nominee has said he would divest financial interests in any
    companies that could pose a conflict of interest for him as HHS
    secretary. But some lawmakers, as well as the advocacy group Public
    Citizen, are calling for an investigation by the Office of
    congressional Ethics. They also have filed complaints against Price
    with the Securities and Exchange Commission.

    A congressional probe would cease if he were to become HHS secretary.
    An SEC investigation would continue.

    An HHS spokesman reiterated Monday that Price had no knowledge of any
    trades in his financial portfolio, with the exception of those in one
    company. The spokesman declined to provide the name of Price's broker
    or to share a copy of his written agreement with the investment firm.
    Price's legislative office did not respond to repeated requests for
    comment over several days.

    If confirmed, the 62-year-old congressman, who chairs the House Budget
    Committee, would run one of the biggest federal agencies and its $1.1
    trillion budget. Supporters suggest a doctor best understands what the
    nation's health-care system needs, with Senator Orrin G. Hatch (R-Utah)
    describing Price as ``very upfront and very straightforward, very
    honest, and somebody who really understands the health-care system of
    this country.''

    Price has largely defended his investment activities by saying his
    broker made nearly all of the stock purchases without his knowledge.
    Brokers cannot make securities trades for clients without their
    expressed permission in writing, and Senators Patty Murray (D-WA) and
    Ron Wyden (D-OR) sent a letter Friday asking Price for such proof.
    Aides in their offices said Monday that he has not responded.

    And regardless, said Painter, now a law professor at the University of
    Minnesota, ``It's a pretty weak defense since he could have gone online
    at any time and seen the trades that were being made on his behalf.''

    Representative Louise M. Slaughter (D-NY), the co-author of the 2012
    Stop Trading on Congressional Knowledge (STOCK) Act, shares that
    sentiment. The law passed after media reports on the close ties between
    lawmakers' stock portfolios and legislative actions. It requires that
    trades be publicly reported within 45 days instead of annually--the
    sole reason Price's stock activity last year has come to light in the
    midst of his confirmation.

    ``The weakest link here is this notion that some broker bought all
    these things without his knowledge,'' Slaughter said.

    A spokesman for the Trump transition countered on his behalf last week,
    although Phil Blando addressed only the issue of campaign fundraising.
    ``Any effort to connect campaign contributions to Dr. Price's policy
    positions is an increasingly stale and desperate Democratic talking
    point,'' he said.

    Of particular concern to Slaughter and her Democratic colleagues is
    Price's largest stock buy last year--between $50,000 and $100,000--in
    an Australian biomedical firm, Innate Immunotherapeutics. Price
    acknowledged last week that this purchase, and several smaller ones
    made in the company in 2015, occurred without a broker's aid. He told
    members of the Senate Health, Education, Labor and Pensions Committee
    that he learned of the company from Representative Chris Collins (R-
    NY), who serves on Innate's board, and then did his own research on it
    and the multiple sclerosis drug it was developing.

    The 2016 investment was done through what's known as a ``private
    placement offering'' made by a company to a select group of potential
    investors. Price contended that he received no insider information
    ahead of time.

    Price's denial didn't satisfy Murray, who also pressed him on the
    timing of the trades. They coincided with final negotiations on the
    sweeping 21st Century Cures bill, aimed in part at helping to
    accelerate clinical trials and approval of drugs like Innate's.

    Simon Wilkinson, Innate's chief executive, told The Washington Post
    that about 640 investors purchased stock through the special offer. The
    company did not directly approach Price, he said.

    According to David Blake, an Australian securities analyst, the shares
    the lawmaker purchased in the special offering are now worth between
    $337,500 and $675,000--a 575 percent increase.

    Another trade in the spotlight involves Zimmer Biomet, a major
    manufacturer of orthopedic and dental implant devices.

    CNN was the first to report financial disclosure records showing that
    Price bought between $1,001 and $15,000 worth of Zimmer Biomet shares
    last March. A week later, he introduced legislation to delay a new
    payment model that industry analysts said could have serious financial
    implications for the company.

    The HHS regulation carried ``tremendous risk and complexity for
    patients and health-care providers,'' Price said when he introduced his
    bill. ``Rushing its implementation would be unreasonable and
    potentially detrimental to patients and their quality of care.''

    Federal Election Commission records show Price received $2,000 in
    campaign donations from the company's political action committee in
    November 2015 and June 2016.

    In a statement, Zimmer Biomet spokeswoman Monica Kendrick said it ``did
    not support'' Price's legislation and was unaware of his investment in
    the company. She said the company had long backed efforts such as the
    payment model Price sought to block.

    Price also purchased stock in three pharmaceutical companies in the
    months leading up to his introduction last June of a bill that would
    have provided the businesses with massive tax breaks for their
    manufacturing and production activities in Puerto Rico, records show.
    Amgen, Eli Lilly and Bristol-Myers Squibb gave a combined $20,000 to
    his 2016 reelection campaign, according to filings with the Federal
    Election Commission.

    The bill ultimately did not pass the House. Blando stressed last week
    that Price had ``no say or input into these trades'' and that to
    insinuate a connection ``is insulting.''

    Overall, Price is far more reliant on donations from health
    professionals than other lawmakers in comparable positions in the
    House. Since he was first elected to Congress in 2004 from an affluent,
    conservative district in northern Atlanta, they have given more than
    $3.5 million in campaign contributions, more than any other donor
    sector, according to data from the Center for Responsive Politics.

    In contrast, the previous chairman of the House Budget Committee,
    Speaker Paul D. Ryan (R-WI), has received $1.3 million in contributions
    from health professionals since 1998.

    While Price resembles many House Republicans in his zeal for
    dismantling the ACA, his focus on medical malpractice lawsuits is
    distinctive.

    Starting in 2009, he has four times introduced the Empowering Patients
    First Act, with the most recent three bills seeking to repeal the ACA.
    All would have weakened patients' hand in medical malpractice cases by
    setting $250,000 caps on noneconomic damages, creating clinical
    guidelines to protect doctors from liability or both. And he sponsored
    two separate bills aimed at creating such guidelines for use in
    malpractice lawsuits.

    None got out of House committees.

    Julie Tate, Alice Crites, and Matea Gold contributed to this report.

                                     ______

                                 Communications

                                  ----------

             American Association of Hip and Knee Surgeons (AAHKS)

           OFFICE: 847-698-1200  FAX: 847-698-0704  WEB: aahks.org

           9400 W. Higgins Road, Suite 230  Rosemont, IL 60018-4976

    The Honorable Orrin Hatch           The Honorable Ron Wyden
    Chairman                            Ranking Member
    U.S. Senate                         U.S. Senate
    Committee on Finance                Committee on Finance
    219 Dirksen Senate Office Building  219 Dirksen Senate Office Building
    Washington, DC 20510                Washington, DC 20510

    Dear Chairman Hatch and Ranking Member Wyden:

    The American Association of Hip and Knee Surgeons (AAHKS) strongly
    supports the nomination of Congressman Tom Price, MD as Secretary of
    the United States Department of Health and Human Services (HHS). AAHKS
    is the foremost national specialty organization of 2,900 physicians
    with expertise in total joint arthroplasty procedures. The mission of
    AAHKS is to advance hip and knee patient care through education and
    advocacy, and we look forward to working with federal officials to
    improve our health care system.

    Prior to entering public service, Congressman Tom Price practiced
    medicine as an orthopaedic surgeon. He spent nearly two decades in
    private practice caring for patients and their families. Dr. Price's
    experience as a physician gives him a critically important perspective
    on the real-world impact of health policy including the importance of
    access, coverage, the doctor-patient relationship, clinical decision
    making and challenges of navigating a complex health care environment.
    Most importantly, we have confidence that as a physician, he will seek
    to put patients first in his role as HHS Secretary.

    Dr. Price was also an educator. He was an assistant professor at Emory
    University School of Medicine and Medical Director of the Orthopedic
    Clinic at Grady Memorial Hospital, a public hospital serving the
    greater Atlanta area. His contributions to the education of resident
    physicians under his tutelage are a testament to his commitment to
    secure a healthy future for all Americans.

    AAHKS respectfully urges the Senate to confirm Dr. Price's appointment
    as Secretary of HHS.

    Sincerely,

    William A. Jiranek, M.D.            Michael J. Zarski, J.D.
    President                           Executive Director

                                     ______

           Association of Web-Based Health Insurance Brokers (AWHIB)

    Introduction

    The Association of Web-Based Health Insurance Brokers (AWHIB)
    appreciates the opportunity to provide comments on the nomination of
    The Honorable Thomas Price to be Secretary of the Department of Health
    and Human Services. AWHIB is a trade association of web-broker entities
    (WBEs) that have signed agreements with the Centers for Medicare and
    Medicaid Services (CMS) and are currently leveraging the Federally
    Facilitated Marketplace's (FFM) direct enrollment application
    programming interfaces (APIs). Our members include brokerage firms that
    sell health insurance online directly to consumers, private health
    insurance exchanges, and technology companies that support individual
    agents and brokers. AWHIB seeks to collaborate with consumers, issuers,
    regulators, lawmakers, and other industry groups to continually develop
    technologies and enrollment strategies that provide Americans with the
    greatest access to health insurance products and services.

    AWHIB members have played a significant role in enrolling consumers in
    individual market health insurance policies. During the plan year 2016
    annual open enrollment period, AWHIB members alone facilitated nearly 1
    million initial enrollments and active reenrollments, or over 12% of
    initial enrollments and active re-enrollments by consumers in the
    Federally-facilitated Marketplace states and states using the Federal
    platform. This amount is in addition to the hundreds of thousands of
    off-exchange individual market enrollments facilitated by AWHIB member
    companies. Our web broker technology is used by tens of thousands of
    independent health insurance agents nationwide, and AWHIB member
    companies have partnerships with the world's largest health insurance
    brokers, tax preparation firms, and health insurance technology firms,
    including Jackson Hewitt; Tax Act; Mercer; Buck (Xerox); Lockton;
    Bankrate; NFP; SummaCare Inc.; HealthSpan Inc.; HealthSpan Integrated
    Care Inc.; H&R Block; Walgreens; Working America; CUNA Mutual Group;
    Benaissance; Direct Health; and Assurex Global.

    AWHIB offers its support for Congressman Price to be the next Secretary
    of HHS based upon his significant experience in the House of
    Representatives, including his role as Chairman of the House Budget
    Committee during the 114th Congress, as well as 20 years as a
    practicing orthopaedic surgeon. If confirmed by the Senate, AWHIB looks
    forward to working with Secretary Price to improve the health of all
    Americans.

    Principles for Stabilization and Reform of the Individual Health
    Insurance Market

    The nation's individual health insurance market is at a critical
    juncture as it enters its fourth year following the full implementation
    of the Affordable Care Act. AWHIB recognizes that the Administration,
    along with many members of Congress, intend to take steps to modify
    and/or replace many of the elements implemented under the Affordable
    Care Act, including potentially the health insurance Exchanges. As key
    players in assisting consumers make an informed choice of insurance
    products, AWHIB's members want to offer their perspectives and
    recommendations regarding the individual health insurance market for
    consideration by an incoming Secretary of HHS.

    To promote the availability of coverage, AWHIB recommends that an
    incoming Secretary consider the following six key tenets to help guide
    changes to the individual health insurance market:

          Expand Consumer Choice of Enrollment Venue--Provide consumers
    with choices on how to enroll in health insurance and support multiple
    channels for enrollment, including private sector channels. Private
    health insurance exchanges and WBEs have enrolled consumers in health
    insurance products prior to the ACA, and as part of the ACA both on and
    off the exchanges. They also have extensive third party partnerships
    with retailers, tax preparation firms, unions, employers and other
    organizations that could be leveraged to reach consumers ``where they
    are.'' Despite this experience, private sector enrollment channels have
    been highly underutilized by the Exchanges to date.

          Provide for Versatile Eligibility Determination Regardless of
    Enrollment Channel--Whether the ACA Exchanges continue or are replaced,
    Federal and state governments should provide simple and versatile
    approaches to render eligibility determinations, such as a standalone
    eligibility service (SES), that can interact with a variety of
    enrollment channels. This would enable health insurance enrollment
    efforts to leverage a variety of private and public sector based
    enrollment channels.

          Promote Innovation--One of the core strengths of private health
    insurance exchanges and WBEs is their ability to use technology
    innovations to meet the needs of their consumers. While AWHIB
    recognizes the need for robust consumer protections, WBEs and private
    exchanges also need flexibility to take full advantage of innovation.
    To achieve this balance, Federal and state governments should focus on
    defining the overall policy aims, while permitting flexibility for
    innovation within defined policy guardrails.

          Strengthen Support for Continuous Coverage--Improve the health
    of the insurance risk pool by implementing enrollment policies
    emphasizing continuous coverage. This includes improving the
    administration of special enrollment periods and making changes to the
    annual open enrollment process. If the individual mandate is removed,
    AWHIB supports guaranteed renewability and other incentives to further
    continuous coverage.

          Use Refundable Advanceable Tax Credits to Further Insurance
    Accessibility--Base tax incentives for health coverage on refundable
    advanceable tax credits rather than tax deductions. Refundable
    advanceable tax credits are versatile and can be used by consumers to
    lower the cost of monthly health insurance premiums, making health
    insurance accessible to more consumers than tax deductions and non-
    refundable credits.

          Improve the Overall Health of the Insurance Market--Implement
    policies that would support a more healthy insurance market that is
    sustainable for health insurance carriers and affordable for consumers.
    Congress and HHS should consider implementing risk mitigation
    strategies such as a revised reinsurance program or national high-risk
    pool, as well as allowing for greater availability and incentives for
    health savings accounts.

    Near-Term Changes to Strengthen the Current Exchange Market

    Based upon the above principles, AWHJB recommends the following near-
    term actions should the ACA Exchanges remain in place for the near term
    or an indefinite period of time:

          Implement Enhanced Direct Enrollment for the FFM for PY 2018--
    Federally-
    facilitated Exchanges and state Exchanges that use the Federal
    enrollment platform permit WBEs to enroll consumers into Exchange
    coverage using a so-called ``direct enrollment process.'' However, the
    current process is not consumer friendly and requires the consumer to
    be redirected to HealthCare.gov before being redirected back to the WBE
    website to select a plan. This experience is jarring and confusing to
    the consumer, rendering it nearly non-functional.

           HHS has proposed to replace the current direct enrollment
    process with an enhanced direct enrollment process, which would permit
    the consumer to complete the Exchange application and select a plan on
    the WBE platform, however, has not firmly committed to a timeframe for
    fulfilling those original intentions. AWHIB strongly recommends that
    HHS implement enhanced direct enrollment for PY 2018, as this would
    permit WBEs to significantly increase the number of consumers that
    could enroll in coverage through the Exchanges. Furthermore, this could
    also be used to support eligibility determination for refundable
    advanceable tax credits under future replacement plans.

          Strengthen Special Enrollment Periods--To improve the health
    insurance risk pools, HHS should require full verification of
    eligibility for special enrollment periods. In addition, Congress and
    HHS should shorten the 3-month grace period for non-payment of premiums
    by consumers receiving advance premium tax credits, and prevent such
    consumers from taking advantage of enrollment rules to drop and
    reenroll in coverage. These changes would help to stabilize the
    individual market, providing greater predictability for carriers and
    reducing the potential for adverse selection.

    Long-Term Changes if the Role of Public Exchanges Is Altered
                        Significantly

    If the public exchanges' role in facilitating consumer shopping is
    significantly altered or replaced, consumers will still need tools to
    help them understand, compare, select and enroll in available health
    insurance products. WBEs and private exchanges are well positioned to
    fill this void as a private sector alternative to the public exchanges,
    as they already provide consumers with online shopping platforms
    designed to help consumers understand, compare and select available
    health insurance products. Furthermore, they have extensive experience,
    having served as an additional channel for consumers to shop for and
    enroll in public exchange coverage (specifically with respect to
    Federally-facilitated Exchange), and as a shopping and enrollment
    portal for off-exchange health insurance products.

    AWHIB recommends the following changes to promote broad access in a
    reformed market:

          Promote Consumer Choice in Enrollment Venue--AWHIB recommends
    that consumers be able to shop for and enroll in health insurance
    coverage in any online portal that meets Federal or state requirements,
    including a public exchange, WBE/private exchange or carrier portal.
    This will provide consumers with greater choice according to which type
    of portal best suits their needs, as each type of portal may provide
    value to different types of consumers.

          Implement Refundable Advanceable Tax Credits--As noted above,
    AWHIB recommends that tax incentives in a reformed marketplace be
    structured as refundable advanceable tax credits, as this will enable
    consumers to use their tax credits to lower the cost of health
    insurance premiums. Refundable advanceable tax credits help make health
    insurance more accessible for consumers than tax deductions.

          Seamlessly Verify Tax Credit Eligibility--If tax credits are
    refundable and advanceable, consumers need to know whether they are
    eligible for the tax credit when shopping for a health plan. To support
    broad access to insurance, HHS should provide WBEs, private exchanges
    and carriers with access to a standalone eligibility service (SES).
    With SES, a WBE, private exchange or carrier would be able to submit
    tax credit application data to the Federal government (IRS or HHS on
    behalf of IRS), and then receive an official Federal eligibility
    determination--all through back-end web-services. As a result, the
    consumer could obtain a tax credit eligibility determination as part of
    the WBE, private exchange or carrier's consumer shopping and enrollment
    experience, making it easier for consumers to access health insurance
    coverage.

          Transact Enrollment Directly With Carrier--Permit WBEs and
    private exchanges to enroll consumers directly with the health
    insurance carrier, unless otherwise specified by a state. ACA
    enrollments are currently processed through the Exchange, even if plan
    selection takes place on a WBE/private exchange or carrier shopping
    platform. A more efficient and seamless process would allow for WBEs,
    private exchanges and carriers to enroll consumers directly with the
    carrier, with the carrier transmitting enrollment information with HHS
    for purposes of tax credit administration once the consumer has
    effectuated enrollment with the carrier.

          Maintain Guaranteed Renewability; Implement Incentives for
    Continuous Coverage--Should the individual mandate be eliminated,
    maintain guaranteed reewability provisions in order to encourage
    consumers to maintain coverage and avoid enrolling in coverage only
    when needed. Also implement clear disincentives for incurring gaps in
    coverage, including late enrollment fees or waiting periods for
    consumers who do not maintain continuous coverage and otherwise qualify
    for a special enrollment period. Such measures would help to mitigate
    adverse selection and support risk pool health in place of an
    individual mandate.

          Improve the Overall Health of the Insurance Market--Consider
    changes to improve the overall health of the insurance market,
    including risk mitigation strategies such as revised reinsurance, risk
    adjustment, risk corridor, and/or national high-risk pool programs.
    Also consider options to promote a broader range of health insurance
    products, including the expanded availability of health savings
    accounts.

    Conclusion

    The individual health insurance market is at a critical moment--one
    that will require strong leadership from HHS. AWHIB believes that
    short-term action is needed to help bring greater stability to the
    market and offers specific recommendations if broader reforms are
    undertaken. AWHIB looks forward to working with Congressman Price to
    improve the health of all Americans if confirmed by the Senate as the
    next Secretary of HHS.

                                     ______

                   Letter Submitted by Steven P. Brasch, M.D.

    January 26, 2017

    Senate Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Dear Senators:

    I hereby file my OPPOSITION to the confirmation of Representative Tom
    Price for Secretary of Health and Human Services.

    Because of many of Dr. Price's views on matters of public health, the
    ACA, medical and social services to the poor, underserviced, gay, and
    disenfranchised citizens of America, I believe he is poorly qualified
    to serve as our next Secretary of HHS.

    Please contact me if you have any questions.

                                     ______

                   Letter Submitted by Lesli Choat, MT (ASCP)
                                                       January 24, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    I would like to express my opposition to the Nomination of Tom Price
    for HHS Secretary.

    My health care career has spanned 32 years and I continue to function
    as STD Counseling and Testing Coordinator in an STD program. I was
    working in health care before HIV and hepatitis C (HCV) were
    identified. I am a scientist who has seen the great strides the United
    States and the world have made to test and treat for HIV, HCV and other
    infectious diseases. I saw so many die in the beginning of the AIDS
    epidemic and I am proud to see so many live healthy lives with the
    advances we have made in HIV care. I serve on my local HIV planning
    group to advance HIV prevention and care in my community. I support
    Planned Parenthood and the services they provide to so many that have
    no other access to health care. I see HCV as a looming public health
    threat that must be addressed. My voice should be heard as a citizen
    who works every day on the front lines of American Public Health!

    I oppose Representative Tom Price as HHS Secretary. I do not feel Tom
    Price has the expertise or background knowledge to run such a vital
    department overseeing so many branches of American health care.
    Representative Price has spent the last 8 years undermining efforts
    aimed at providing health care and social services to communities both
    living with, and vulnerable to, HIV/AIDS and other health conditions.
    These actions include voting to repeal the Affordable Care Act (ACA)
    multiple times, pushing for the privatization Medicare, supporting to
    defund Planned Parenthood, pledging cuts to social service and safety
    net programs--all while demonstrating a hostile voting record on
    lesbian, gay, bisexual, transgender and queer (LGBTQ) issues.
    Throughout the recent hearing before the Senate Committee on Health,
    Education, Labor and Pensions (HELP), Price made several indications to
    continue a trend to dismantling existing systems, without details of a
    replacement that sustains access to health care and social services.

    At a time when we are at the forefront of new and exciting science to
    deliver better antiretroviral therapies for HIV, breakthroughs in cures
    for HIV, and pathways for making TB treatments shorter and more
    tolerable, the nomination of Tom Price threatens to impede the progress
    of both scientific research and its implementation. Upon confirmation,
    I feel Tom Price will, as promised, oversee the dismantling and
    overhaul of health care systems that are responsible for delivering
    many of these medical advances to people in the United States,
    particularly those communities impacted by health, social, and economic
    disparities as well as stigma.

    HHS is not just the department that oversees our health care system,
    but also governs our public health, research, and regulatory agencies,
    such as the Centers for Disease Control and Prevention (CDC), National
    Institutes of Health (NIH), and the Food and Drug Administration (FDA).
    The recent revelation of ethics violations and refusal to clearly
    answer questions on these issues during the Senate HELP hearing clouds
    my trust in Price to ensure the sanctity and impartiality of these
    agencies. Trust in HHS leadership is needed in prioritizing pressing
    public health challenges and countering emerging threats such as Zika,
    Ebola, drug-resistant TB and antimicrobial resistance through robust
    R&D, proactive epidemiology, pharmacovigilance, and accelerated
    research and response.

    Price's worrisome background as a member of the American Academy of
    Physicians and Surgeons--an organization that promotes and endorses the
    theory that HIV does not cause AIDS, despite a substantial evidence
    base to the contrary--puts into question his capabilities to end an
    epidemic. Health conditions like HIV thrive on stigma. Price has only
    perpetuated stigma and marginalized vulnerable communities by voting
    against bills that afford protections to the LGBTQ community. With
    attention needed for other neglected populations, such as prisoners
    impacted by HIV and HCV, it becomes less likely under a Price-led HHS
    that key populations will be able to access needed health care and
    treatment.

    With Price's support of the repeal of ACA and efforts to defund
    Medicaid, the hopes and vision of providing health care that include
    ending the HIV epidemic and curbing HCV transmission among the poorest
    and most vulnerable Americans will vanish.

    Sincerely,

    Lesli Choat

                                     ______

                 Letter Submitted by Richard and Jill Claybour

                                January 25, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Honorable Chairman and Members of the Committee:

    We are private citizens writing to beg that you oppose confirmation of
    Tom Price as the new Secretary of Health and Human Services.

    His history of support for views with little or no foundation in
    science, his apparent willingness to leave needy sick citizens without
    health care and a reasonable transition to a supposed ``much better''
    program are in themselves sufficient reasons in our eyes to disqualify
    him. We are shocked, however, at the continued revelations of his
    conflicts of interest and believe that in no way should these matters
    be swept under the rug. At a time when Americans have sent a clear
    signal of their distrust in Washington, we look to you to make sure
    that our leaders are setting an example of probity and conformance to
    the highest ethical standards.

    Thank you for your consideration.

                Sincerely,

                Richard and Jill Claybour

                                     ______

                      Letter Submitted by Robert K. Darrow

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    January 27, 2017

    Senators:

    I am writing to you as a 32-year survivor, thriving and living with
    AIDS, and in opposition to President Trump's nomination, Tom Price, for
    Secretary of HHS. Tom Price's questionable fitness to head a multi-
    agency cabinet-level department charged with the health of U.S.
    residents can simply be ascertained from his own record as a
    Congressional representative to parts of Atlanta's northern suburbs--a
    district and metro area with extremely high rates of HIV and a
    flourishing opioid epidemic. Despite the abundance of epidemiological
    data illustrating the impact of the HIV epidemic in his own district
    and in the southeastern United States, Representative Price has spent
    the last 8 years undermining efforts aimed at providing health care and
    social services to communities both living with, and vulnerable to, HIV
    and other health conditions. These actions include voting to repeal the
    Affordable Care Act (ACA) multiple times, pushing for the privatization
    of Medicare, threatening to cap and block-grant Medicaid, supporting to
    defund Planned Parenthood, pledging cuts to social service and safety
    net programs--all while demonstrating a hostile voting record on
    lesbian, gay, bisexual, transgender and queer (LGBTQ) issues.
    Throughout the recent hearing before the Senate Committee on Health,
    Education, Labor and Pensions (HELP), Price made several indications to
    continue a trend to dismantling existing systems, without details of a
    replacement that sustains access to health care and social services.

    At a time when we are at the forefront of new science to deliver better
    antiretroviral therapies for HIV, breakthroughs in cures for HCV, and
    pathways for making TB treatments shorter and more tolerable, the
    nomination of Tom Price threatens to impede the progress of both
    research and implementation. Upon confirmation, Tom Price will, as
    promised, oversee the dismantling and overhaul of health care systems
    that are responsible for delivering many of these medical advances to
    people in the United States, particularly those communities impacted by
    health, social and economic disparities as well as stigma.

    Before the ACA, hundreds of people every year were waitlisted for the
    AIDS Drug Assistance Program (ADAP). People living with HIV (PLHIV)
    would need an AIDS diagnosis to be eligible for Medicaid. Pre-existing
    conditions would also disqualify many PLHIV from gaining insurance.
    While the ACA is not perfect, thousands of PLHIV have been transitioned
    onto insurance through marketplaces and have become eligible for
    Medicaid benefits. This has provided many with access to comprehensive
    health care for the first time, with profound effects on public health
    and prevention outcomes. Much of the success we're seeing in increasing
    viral suppression rates and reducing the number of diagnoses annually
    will be put in jeopardy if the ACA is repealed without replacement.
    Without replacement and stewardship by the incoming Secretary of Health
    and Human Services, access to treatment, prevention and other services
    will remain out of reach for many of these communities.

    HHS is not just the department that oversees our health care system,
    but also governs our public health, research, and regulatory agencies,
    such as the Centers for Disease Control and Prevention (CDC), Indian
    Health Services (IHS), National Institutes of Health (NIH), and the
    Food and Drug Administration (FDA). The recent revelation of ethics
    violations and refusal to clearly answer questions on these issues
    during the Senate HELP hearing clouds any trust in Price to ensure the
    sanctity and impartiality of these agencies. Trust in HHS leadership is
    needed in prioritizing pressing public health challenges, ensuring drug
    and device safety, and countering emerging threats such as Zika, Ebola,
    drug-resistant TB, and antimicrobial resistance through robust R&D,
    proactive epidemiology, pharmacovigilance, and accelerated research and
    response.

    Price's worrisome background as a member of the American Academy of
    Physicians and Surgeons--an organization that promotes and endorses the
    theory that HIV does not cause AIDS, despite a substantial evidence
    base to the contrary--puts into question his capabilities to end an
    epidemic. Health conditions like HIV thrive on stigma. Yet, Price has
    only perpetuated stigma and marginalized vulnerable communities by
    voting against bills that afford protections to the LGBTQ community.
    With attention needed for other neglected populations, such as
    prisoners impacted by HIV and HCV, it becomes less likely under a
    Price-led HHS that key populations will be able to access health care
    and treatment.

    Now more than ever, ending the epidemics of HIV, TB, and HCV requires a
    combination of bipartisan federal and state leadership, evidence-based
    policies, and adequate resources in proper alignment to deliver the
    promise of biomedical and public health advances. Efforts to lower drug
    prices for HIV and HCV while sustaining U.S. leadership in R&D for TB
    and other neglected diseases remain inevitable challenges to the
    successor of HHS and the Trump administration. Tom Price, however,
    remains a concerning and unqualified candidate to lead HHS given a
    track record that only marginalizes communities, raises questions on
    his ethics and integrity to run an expansive $1 trillion department,
    and putting forth policy proposals that seek to fast-track the loss of
    lifesaving health care for 18 million Americans. Ending the epidemics
    remains impossible by destroying access to health care and treatment.
    With Price's support of the repeal of ACA and efforts to defund
    Medicaid, the hopes and vision of providing health care--including
    ending the HIV epidemic, curbing HCV transmission, eliminating TB--
    among the poorest, sickest, most disenfranchised, most vulnerable
    Americans will vanish.

    Respectfully,

    Robert K. Darrow, executive director emeritus
    The Philadelphia Center--Shreveport

                                     ______

                   Letter Submitted by Angela Wilson Gyetvan

    January 19, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Dear Committee Members:

    I am writing in regards to the Full Committee Hearing for the
    Nomination of Tom Price to serve as Secretary of Health, held January
    18, 2017.

    I object to Mr. Price's nomination on the following grounds:

        (1)  Potential ethics violations: There is evidence that Mr. Price
    invested in at least one health-care company, then introduced
    legislation favorable to the company after he made the investment. At
    the very least, this is a violation of House ethics rules. At the most,
    it is insider trading--and must be investigated before any
    confirmation.

        (2)  Conflicts of interest: Price holds positions in multiple
    healthcare companies, and must divest or put those holdings into a
    blind trust prior to any confirmation. He also has ties to the tobacco
    industry--smoking is the leading cause of preventable death!--and has
    consistently voted against tobacco regulation as a result.

        (3)  Non-support for social safety net and general lack of
    compassion: Price supports the roll-back of Medicare and Medicaid, the
    repeal of the Affordable Care Act, and blocked the expansion of the
    Children's Affordable Health program. He even voted to block medical
    treatment if a Medicare co-pay is not available: a position that is
    directly opposed to the Hippocratic Oath he took when he became a
    doctor.

        (4)  Track record on women's and LGBTQ rights: Price supports
    overturning Roe v. Wade and has voted against legislation that prevents
    discrimination based on sexual orientation.

    The Health Secretary needs to be a representative for all of us. Mr.
    Price is not that person.

    Thank you.

    Angela Wilson Gyetvan

                                     ______

                             Human Rights Campaign

                           1640 Rhode Island Ave., NW

                              Washington, DC 20036

                                 P 202-628-4160

                                 F 202-423-2861

                              http://www.hrc.org/

                        Written Statement of David Stacy

                          Government Affairs Director

    I submit this testimony on behalf of the Human Rights Campaign's 2
    million members and supporters. As the nation's largest organization
    advocating for the civil rights of lesbian, gay, bisexual, transgender,
    and queer (LGBTQ) people, I raise severe concerns regarding the ability
    of Representative Tom Price to serve and represent the health and well-
    being of all Americans as Secretary of the Department of Health and
    Human Services (HHS). Representative Price has developed a lengthy
    public record attacking LGBTQ people and every hard-fought victory that
    we have achieved as a community in recent years. He has used his
    position as a Congressman elected to represent Georgia voters as a
    national platform to deny federal rights--including protection from
    violence--for LGBTQ people nationwide.

    Representative Price has consistently voted against critical pieces of
    legislation that would protect LGBTQ people including the Employment
    Nondiscrimination Act (ENDA), the Matthew Shepard and James Byrd, Jr.
    Hate Crimes Prevention Act, and the 2013 reauthorization of the
    Violence Against Women Act (VAWA). Beyond these votes, Representative
    Price has publicly spoken against equality, regularly partnering with
    groups known for promoting anti-LGBTQ views--using the privilege of his
    position to spread intolerance and misinformation. He has even argued
    that legislation like ENDA, designed to protect vulnerable workers and
    promote equal opportunity, would have ``remarkably negative''
    consequences and should be evaluated for the medical and health-care
    costs of ``promoting a homosexual lifestyle.'' I must clarify that the
    real impact of nondiscrimination provisions on health and well-being of
    LGBTQ people are remarkably positive, to use Representative Price's
    descriptor.

    We know that systemic discrimination in employment, housing, health
    care, and education increases the risk of poverty and compounds the
    health disparities already facing our community. Fear of discrimination
    deters many LGBTQ people from seeking necessary and important
    preventative health care, and when they do enter care, studies indicate
    that the respect that LGBTQ people receive is not consistent with the
    respect that all patients deserve. Recent studies have shown that
    transgender people are particularly at risk for discrimination--
    especially in the health-care setting. One third of transgender people
    seeking care reported experiencing discrimination, harassment, assault,
    or even denial of care simply because of their gender identity. One in
    four transgender people avoided care altogether fearing discrimination.
    Nondiscrimination provisions provide individuals and families with the
    security they need to lead full and productive lives. They also
    increase access to insurance coverage and reduce incidents of arbitrary
    denial of care based on bias.

    It is critical that healthcare facilities treat every patient with
    respect, recognize patients' gender identity, and provide equal access
    to gender appropriate facilities while providing treatments. This basic
    standard of care is embraced by major medical establishments and
    organizations including the American Academy of Pediatrics and the
    American Counseling Association. These groups have made it clear that
    this access is not just an issue of civil rights, but also public
    health. However, Representative Price has directly attacked transgender
    people's rights to access appropriate facilities calling this most
    basic right ``absurd.'' This dismissal of basic rights and welfare is
    deeply disturbing.

    Since joining Congress, Representative Price has failed to adequately
    represent the nearly 10,000 LGBTQ Georgians living in his district. He
    has consistently refused to recognize them as deserving constituents
    and has failed to represent even their most basic needs to Washington.
    Representative Price's repeated choice to place his personal anti-LGBTQ
    ideology ahead of this significant portion of his own Congressional
    district calls into question his ability and true willingness to serve
    all Americans as Secretary of HHS. This role demands a public servant
    dedicated to improving health-care coverage and outcomes for all
    people, not a culture warrior with an outdated and dangerous agenda.

    We are also concerned by Representative Price's longstanding opposition
    to the Affordable Care Act (ACA). The ACA is a critical tool to combat
    the stark disparities facing our community by expanding access to
    coverage and ensuring that everyone--regardless of who they are or who
    they love--has access to the care they need. The federal government has
    published regulations implementing the nondiscrimination provision of
    the ACA to explicitly protect individuals on the basis of gender
    identity or sex stereotyping. These protections are critical for some
    of the most vulnerable members of our community. This rule also makes
    clear to providers that transgender patients must be treated consistent
    with their gender identity, including with respect to facilities and
    patient rooms. The regulation also prohibits the categorical exclusions
    in insurance coverage that have plagued the transgender community for
    so long and have put basic transition related care out of the reach of
    so many.

    Because of the ACA, many LGBTQ people have access to comprehensive
    health-care coverage for the first time. This security and assurance of
    quality care without discrimination can be life changing.
    Representative Price's clear commitment to dismantling the ACA and his
    hostility towards nondiscrimination provisions generally could
    seriously undermine the health-care outcomes for our community for
    years to come.

    Finally, as Secretary of HHS, Representative Price will be charged with
    leading one of the world's largest medical and health research
    organizations--overseeing the Centers for Disease Control and
    Prevention as well as the National Institutes for Health. He will also
    lead administrations and sub-agencies like the Substance Abuse and
    Mental Health Services Administration (SAMSHA) that has published
    cutting edge research impacting the LGBTQ community including a report
    addressing the well-established medical harms of so-called ``conversion
    therapy.'' However, Representative Price has done little throughout his
    career as a Congressman or as a physician to prove his commitment--or
    even belief--in evidence based science.

    Representative Price is a longstanding member of the Association of
    American Physicians and Surgeons, a fringe organization that publicly
    questions well-established public health concepts including childhood
    vaccination and the safety or abortion. Perhaps most troubling for our
    community is the organization's suggestion that HIV does not in fact
    lead to AIDS. Although Representative Price has stated that he does not
    personally hold this view regarding HIV/AIDS, his continued association
    with an organization that is so clearly anti-science is deeply
    disturbing. As Secretary of HHS Representative Price will be called on
    to be a research visionary, committed to science and to pursing answers
    to the nation's most complex health questions with dedicated
    compassion. Absolutely nothing in Representative Price's record shows
    that he is up to this job.

                                     ______

                                   LeadingAge

                           2519 Connecticut Ave., NW

                           Washington, DC 20008-1520

                                 P 202-783-2242

                                 F 202-783-2255

                             http://leadingage.org/

    January 24, 2017

    Dear Senator:

    LeadingAge is a nonprofit aging services association. Our 6,000+
    members and partners include nonprofit organizations representing the
    entire field of aging services, 39 state partners, hundreds of
    businesses, consumer groups, foundations, and research partners. Among
    our members, we count more than 2,000 nonprofit nursing homes, either
    as free-standing nursing homes, or as a component of a multi-level
    community. According to GAO, nonprofit nursing homes tend to have
    higher staffing ratios and are more likely to be higher quality as
    rated by the CMS 5-star system.

    CMS recently issued a final rule implementing new requirements for
    participation for nursing homes in the Medicare and Medicaid programs.
    This 105-page rule adds new requirements, mandates previously voluntary
    provisions such as corporate compliance programs, and revises
    requirements currently in effect.

    As you consider the nominations of Representative Tom Price for
    Secretary of HHS and Seema Verma for Administrator of CMS, we urge you
    to address the following concerns.

    LeadingAge strongly supports high quality for nursing homes and
    transparent standards. Our community based, nonprofit providers are a
    vital element of the post-acute and long-term care continuum, and are
    often recognized as exemplars of person-centered care and quality. We
    support many aspects of these new regulations, including the focus on
    person-centered care. In fact, prior to the enforcement date of the new
    regulations, our members were actively engaged in the process of
    integrating the components of Compliance and Ethics, and Quality
    Assurance Process Improvement (QAPT) into their day-to-day operations.

    However, we are gravely concerned about the broad scope of these new
    regulations (stated by CMS to be the most significant changes to
    nursing home regulation since 1991), as well as the incredibly short
    time frame by which providers must comply. We submitted extensive
    comments to CMS during the regulatory comment period on the content of
    the regulations including a particular concern about having sufficient
    time to implement. We are also participating as stakeholders in the
    various meetings and calls conducted by CMS. To date, the agency has
    not been responsive.

    Specifically, we have particular concerns about the following aspects:

        (1)  Workforce: Many sections of the regulations require new
    staffing or changes to the training and competencies of existing staff.
    Some of these went in to effect November 28, 2016 less than 2 months
    after the final rules were published. Providers were expected to comply
    immediately with the requirements, but given little guidance as to
    these competencies. This left insufficient time for providers to
    develop the necessary skills training and assessments to comply with
    the new requirements. And lastly, many rural communities have a
    workforce shortage and simply do not have sufficient numbers of workers
    to employ to meet these regulations.

        (2)  Delayed Guidance: CMS normally develops written guidance
    explaining the regulations, provides definitions and instructions for
    implementation, and identifies resources for training. However, it has
    failed to do so for many of the new policies and procedures that went
    into effect in November, or for the new systems that must be in place
    later this year.

        (3)  Guidance Going Beyond Regulatory Language: Where draft
    guidance has been shared with stakeholder groups, there is considerable
    concern that this guidance goes well beyond the scope of the actual
    regulations and thus creates a whole new set of compliance requirements
    for enforcement that are not defined in regulation. Guidance that
    exceeds the regulations but is enforced like regulations should not be
    enforceable.

        (4)  Timing: As stated above, the extremely short time frames
    required for compliance create impossible burdens for many providers,
    particularly for those smaller and rural providers. The risk is
    therefore that many of these vital community-based homes will close,
    rather than face severe enforcement penalties. When these homes close,
    the negative impact on the community is widespread: Vulnerable
    residents often are displaced and providers--who are often the primary
    employer in that community--lose their jobs.

    Implementation of broad regulations that impose unrealistic time
    frames, fail to recognize the negative impact in a challenging
    workforce environment, and for which guidance and resources have not
    yet been thoroughly considered or shared with the very providers who
    will be expected to comply, can only set up providers for failure. This
    will negatively impact patients and communities for years to come.

    We ask for a thoughtful evaluation of these new regulations and a
    realistic time frame by which providers are able to comply.

    Thank you for your consideration.

    Sincerely,

    Katie Smith Sloan
    President and CEO
    LeadingAge

                                     ______

                       Letter Submitted by Debbie Murzyn

    January 24, 2017

    Dear Senate Finance Committee:

    I oppose the nomination of Tom Price for the Secretary of Health and
    Human Services. I request that you oppose President Trump's pick and
    challenge his nomination. Tom Price's questionable fitness to head a
    multi-agency cabinet-level department charged with the health of U.S.
    residents can simply be ascertained from his own record as a
    Congressional representative to parts of Atlanta's northern suburbs--a
    district and metro area with extremely high rates of HIV and a
    flourishing opioid epidemic. Despite the abundance of epidemiological
    data illustrating the impact of the HIV epidemic in his own district
    and in the Southeastern United States, Representative Price has spent
    the last 8 years undermining efforts aimed at providing health care and
    social services to communities both living with, and vulnerable to, HIV
    and other health conditions. These actions include voting to repeal the
    Affordable Care Act (ACA) multiple times, pushing for the privatization
    Medicare, threatening to cap and block-grant Medicaid, supporting to
    defund Planned Parenthood, pledging cuts to social service and safety
    net programs--all while demonstrating a hostile voting record on
    lesbian, gay, bisexual, transgender, and queer (LGBTQ) issues.
    Throughout the recent hearing before the Senate Committee on Health,
    Education, Labor and Pensions (HELP), Price made several indications to
    continue a trend to dismantling existing systems, without details of a
    replacement that sustains access to health care and social services.

    At a time when we are at the forefront of new science to deliver better
    antiretroviral therapies for HIV, breakthroughs in cures for HCV, and
    pathways for making TB treatments shorter and more tolerable, the
    nomination of Tom Price threatens to impede the progress of both
    research and implementation. Upon confirmation, Tom Price will, as
    promised, oversee the dismantling and overhaul of health care systems
    that are responsible for delivering many of these medical advances to
    people in the United States, particularly those communities impacted by
    health, social and economic disparities as well as stigma.

    Before the ACA, hundreds of people every year were waitlisted for the
    AIDS Drug Assistance Program (ADAP). People living with HIV (PLHIV)
    would need an AIDS diagnosis to be eligible for Medicaid. Pre-existing
    conditions would also disqualify many PLHIV from gaining insurance.
    While the ACA is not perfect, thousands of PLHIV have been transitioned
    onto insurance through marketplaces and have become eligible for
    Medicaid benefits. This has provided many with access to comprehensive
    health care for the first time, with profound effects on public health
    and prevention outcomes. Much of the success we're seeing in increasing
    viral suppression rates and reducing the number of diagnoses annually
    will be put in jeopardy if the ACA is repealed without replacement.
    Without replacement and stewardship by the incoming Secretary of Health
    and Human Services, access to treatment, prevention and other services
    will remain out of reach for many of these communities.

    HHS is not just the department that oversees our health care system,
    but also governs our public health, research, and regulatory agencies,
    such as the Centers for Disease Control and Prevention (CDC), Indian
    Health Services (IHS), National Institutes of Health (NIH), and the
    Food and Drug Administration (FDA). The recent revelation of ethics
    violations and refusal to clearly answer questions on these issues
    during the Senate HELP hearing clouds any trust in Price to ensure the
    sanctity and impartiality of these agencies. Trust in HHS leadership is
    needed in prioritizing pressing public health challenges, ensuring drug
    and device safety, and countering emerging threats such as Zika, Ebola,
    drug-resistant TB, and antimicrobial resistance through robust R&D,
    proactive epidemiology, pharmacovigilance, and accelerated research and
    response.

    Price's worrisome background as a member of the American Academy of
    Physicians and Surgeons--an organization that promotes and endorses the
    theory that HIV does not cause AIDS, despite a substantial evidence
    base to the contrary--puts into question his capabilities to end an
    epidemic. Health conditions like HIV thrive on stigma. Yet Price has
    only perpetuated stigma and marginalized vulnerable communities by
    voting against bills that afford protections to the LGBTQ community.
    With attention needed for other neglected populations, such as
    prisoners impacted by HIV and HCV, it becomes less likely under a Price
    led HHS that key populations will be able to access health care and
    treatment.

    Now more than ever, ending the epidemics of HIV, TB, and HCV requires a
    combination of bipartisan federal and state leadership, evidence-based
    policies, and adequate resources in proper alignment to deliver the
    promise of biomedical and public health advances. Efforts to lower drug
    prices for HIV and HCV while sustaining U.S. leadership in R&D for TB
    and other neglected diseases remain inevitable challenges to the
    successor of HHS and the Trump administration. Tom Price, however,
    remains a concerning and unqualified candidate to lead HHS given a
    track record that only marginalizes communities, raises questions on
    his ethics and integrity to run an expansive $1 trillion department,
    and putting forth policy proposals that seek to fast-track the loss of
    lifesaving health care for 18 million Americans. Ending the epidemics
    remains impossible by destroying access to health care and treatment.
    With Price's support of the repeal of ACA and efforts to defund
    Medicaid, the hopes and vision of providing health care--including
    ending the HIV epidemic, curbing HCV transmission, eliminating TB--
    among the poorest, sickest, most disenfranchised, most vulnerable
    Americans will vanish.

    Thank you for your time.

    Debbie Murzyn

                                     ______

                   National Center for Lesbian Rights (NCLR)

                          1100 H Street, NW, Suite 540

                              Washington, DC 20005

    January 25, 2017

    4The Honorable Orrin Hatch          The Honorable Ron Wyden
    Chairman                            Ranking Member
    U.S. Senate                         U.S. Senate
    Committee on Finance                Committee on Finance
    104 Hart Senate Office Building     221 Dirksen Senate Office Building
    Washington, DC 20510                Washington, DC 20510

    The Honorable Lamar Alexander       The Honorable Patty Murray
    Chairman                            Ranking Member
    U.S. Senate                         U.S. Senate
    Committee on Health, Education,
    Labor, and Pensions                 Committee on Health, Education,
                                        Labor, and Pensions
    455 Dirksen Senate Office Building  154 Russell Senate Office Building
    Washington, DC 20510                Washington, DC 20510

    Dear Chairman Hatch, Ranking Member Wyden, Chairman Alexander, and
    Ranking Member Murray:

    The National Center for Lesbian Rights (NCLR) writes to oppose the
    nomination of Representative Tom Price as Secretary of Health and Human
    Services (HHS). We have grave concerns that Representative Price will
    not work toward HHS's goal of enhancing and protecting the health and
    well-being of all people.

    It is imperative that the person chosen to lead the Department of
    Health and Human Services demonstrate a commitment to health-care
    access and science-based public health and health-care policy. This
    important federal official must also be free from discriminatory or
    hostile attitudes toward minority and vulnerable groups, and administer
    our critical health-care programs free from ideological bias.
    Representative Price's record as a legislator casts serious doubt on
    his ability to perform this role.

    Representative Price's Opposition to LGBT Equality

    Representative Price has espoused negative views of LGBT people, who
    have only in recent years begun to achieve critical protections for our
    health and relationships. In 2013, on a conference call, Representative
    Price was asked if Congress should be required to consider the ``fiscal
    impact'' of legislation involving LGBT people because of the supposed
    health and economic costs of LGBT people's so-called ``lifestyles.'' He
    stated that was ``absolutely right,'' and that ``the consequences of
    activity that has been seen as outside the norm are real.'' \1\
    Representative Price is also a member of the Association of American
    Physicians and Surgeons, which supports conversion therapy and calls
    transgender identity a pathology.
    ---------------------------------------------------------------------------
        \1\ http://www.rightwingwatch.org/post/rep-tom-price-fears-
    negative-health-and-economic-impacts-of-gay-rights-bills/.

    In May of 2016, the Departments of Justice and Education issued
    guidance to schools on title IX clarifying that the law protects
    transgender students and requires that they be treated consistent with
    their gender identity in schools. Representative Price responded with a
    Facebook post that the guidance was ``absurd.'' \2\ Such an attitude
    calls into question his ability to enforce essential health care
    nondiscrimination protections. In a 2015 national survey,\3\ 3% of
    transgender people who had gone to a doctor or a hospital had been
    turned away because of who they are. In that same survey, 23% of
    transgender people nationally said they had avoided getting care when
    they were sick or injured because they were afraid of that kind of
    discrimination. Section 1557 of the Affordable Care Act (ACA) prohibits
    discrimination in health-care programs or activities on the basis of
    race, color, national origin, sex, age, or disability. This is the
    first time that federal law has broadly prohibited sex discrimination
    in health care. Health insurers, hospitals, clinics, and any other
    entities that receive federal funds are covered by this law. Prior to
    section 1557, there were no broad federal protections against sex
    discrimination in health care or health insurance. The regulations
    implementing this important provision that were issued last year state
    that prohibited sex discrimination includes discrimination based on
    gender identity and sexual orientation. These critical protections
    would not exist if the ACA had not been enacted or were repealed, as
    Representative Price has repeatedly voted to do. Representative Price's
    plan to replace the ACA, the Empowering Patients First Act, did not
    include a similar prohibition on discrimination in health care programs
    on the basis of sex.
    ---------------------------------------------------------------------------
        \2\ https://www.facebook.com/reptomprice/posts/10154118633590421.
        \3\ http://www.transequality.org/sites/default/files/docs/USTS-
    Full-Report-FINAL.PDF.

    Representative Price has also co-sponsored the ``First Amendment
    Defense Act,'' considered by many to be the most sweeping anti-LGBT
    bill in Congress as it would establish sweeping new religious
    accommodations that would seriously harm legal rights and protections
    for millions of Americans and permit unprecedented types of
    discrimination against LGBT individuals, same-sex couples, and others.
    Its aim is to enable a wide range of ``persons''--defined in the bill
    to include government employees, recipients of government grants and
    contracts, and even for-profit businesses--to violate constitutional or
    statutory law so long as the violation is based on a sincerely held
    ---------------------------------------------------------------------------
    religious belief about marriage or sexual relationships.

    In 2007, Representative Price offered an amendment to Federal Housing
    Finance Reform Act that required all adults in a household to present
    specific forms of identification before they could receive assistance
    through affordable housing grants.\4\ Such a law presents a significant
    barrier to homeless persons because they often lack these types of
    identification.\5\ Given that homelessness has become a critical issue
    for those in the LGBT community,\6\ we cannot support a nominee who
    actively works to build barriers to safe shelter for those in need.
    ---------------------------------------------------------------------------
        \4\ https://www.congress.gov/crec/2007/05/22/CREC-2007-05-22-pt1-
    PgH5560.pdf.
        \5\ https://www.nlchp.org/documents/ID_Barriers.
        \6\ http://williamsinstitute.law.ucla.edu/wp-content/uploads/Durso-
    Gates-LGBT-Homeless-Youth-Survey-July-2012.pdf.

    We are further concerned by Representative Price's record of opposing
    the repeal of Don't Ask, Don't Tell,\7\ legislation that would ban
    employment discrimination on the basis of sexual orientation, and LGBT
    hate crimes protections, as well as his continued opposition to the
    Supreme Court's recognition that the Constitution requires equal
    protection of LGBT people, including with respect to marriage.\8\
    ---------------------------------------------------------------------------
        \7\ https://www.congress.gov/crec/2010/12/15/CREC-2010-12-15.pdf.
        \8\ https://tomprice.house.gov/press-release/price-responds-scotus-
    marriage-ruling.

    Representative Price's Opposition to Reproductive Health Care

    Representative Price's consistent opposition to reproductive health
    care for women also raises serious concerns. Despite access to birth
    control being widely recognized as one of the most important public
    health achievements of the 20th century, resulting in improved health
    and safety for millions of women, Representative Price has consistently
    opposed the publicly funded family planning network, the title X
    program, the contraception benefit under the Affordable Care Act, and
    the Medicaid program's family planning freedom-of-choice provision,
    while seeking to bar Planned Parenthood from receiving critical federal
    funding even for health care services entirely unrelated to abortion
    and despite the dependence of millions of low-income women on those
    services.

    Representative Price has co-sponsored legislation that would define
    life at conception, which would outlaw abortion entirely, along with
    several of the most effective and widely used forms of birth control,
    and prohibit in vitro fertilization. Representative Price also
    sponsored legislation in Georgia that would require health-care
    providers to give medically inaccurate information to patients seeking
    abortion.

    Ideological opposition to contraception and abortion, and the use of
    misinformation to reduce access to these essential reproductive health-
    care services, renders Representative Price unfit to hold the position
    as the head of our nation's public health care infrastructure.

    Representative Price's Opposition to Protecting Access to Healthcare

    As a member of Congress, Representative Price has proposed a
    ``replacement'' for the ACA that would strip coverage from millions of
    Americans, including LGBT people and their families. Under
    Representative Price's plan, LGBT people would lose not only
    nondiscrimination protections (described above) but also health-care
    coverage they can only afford because of the law.

    Representative Price's alternative legislation would allow insurers to
    dramatically raise premiums for some people with pre-existing medical
    conditions, including HIV/AIDS, which would have a dramatic impact on
    gay and bisexual men. His plan would also fully repeal the Medicaid
    expansion, a provision of the ACA that extended Medicaid coverage to
    people making less than approximately $16,000 per year. Because of
    employment discrimination that pushes many LGBT people into
    unemployment or low-wage jobs that do not offer health insurance, LGBT
    people are disproportionately likely to need alternatives such as
    Medicaid. Representative Price's ACA alternative would also decimate
    federal funding for HIV/AIDS treatment.

    For the foregoing reasons, we oppose the nomination of Representative
    Tom Price to lead the Department of Health and Human Services.

    Sincerely,
    National Center for Lesbian Rights

                                     ______

                      Letter Submitted by Marilyn D. Quinn
                                                       January 24, 2017

    Re: The potential appointment of Tom Price to be Secretary of HHS

    Dear Committee Members,

    As a citizen and a woman who will soon be 70, I want to tell you what I
    think about the nomination of Congressman Tom Price for Secretary of
    HHS and some of the health-care issues that are important to me, my
    family, my friends, and to all Americans. I was able to watch some of
    his hearing, and I have read some of his statements concerning health
    care and health insurance.

    (1) Obamacare:

    My 36-year-old working daughter was finally able to get health
    insurance due to Obamacare. As a resident of New York State, she was
    also able to pick her coverage from a state-endorsed exchange. I tried
    to help her get insurance before Obamacare, I called health insurers
    who would have charged twice the amount she finally paid for a policy
    after passage of the ACA. She also has a pre-existing condition
    (asthma), and her employer does not offer health insurance.

    We are afraid of a future without the ACA. I believe that the ACA was
    damaged by two actions during its enactment: (1) the removal of the
    coverage mandate and (2) the removal of the ``public option.'' These
    would have created a bigger pool of insured and would have provided
    insurance for those who are too poor to pay the coverage fees. These
    two provisions were killed by the Republicans (and a few misguided
    Democrats under pressure from people with the wrong information).

    I say, ``Fix it.'' Don t kill it.

    This country would be spending less on health care if it considered it
    to be a right for all American citizens, as it is in many other
    nations. I believe that single-payer Medicare for all would create the
    kind of broad pool necessary to keep costs down for patients and
    providers alike, as it does in most other developed countries. Imagine
    how much less time and money it would take for the government and the
    nation's medical offices to administer the policies. Imagine how much
    less it would cost if everyone had access to affordable preventive
    care. I keep hearing that the potential problem with ``single payer''
    is the ensuing difficulty for many doctors and hospitals to make more
    money off their patients. (Why not reward those who successfully
    improve their patients' lives or fill the needs of the under-served and
    those who are unlucky enough to live in impoverished urban deserts?)

    I believe firmly also that many of the people I know who would love to
    change jobs, or love to move to another state for work or study, or
    want to start their own business, perhaps by working from home as
    entrepreneurs, would also benefit by having a policy that is affordable
    and portable. My best friend started a business in Europe where health
    care was available for everyone, regardless of employment, place of
    domicile, and income.

    Too much time, stress, and money go into the intricacies, changes, and
    details regarding insurance, which consume and direct the courses of
    our lives. This is a waste for all citizens and ultimately for our
    government.

    It is advantageous for citizens to learn the truth about all of this.
    People should know that if they help pay for the health care of
    everyone else, not just themselves, both the country and themselves
    will benefit.

    (2) Access to affordable contraception and legal abortion:

    I need only point out how these benefits to women have saved many lives
    and improved the health of women and their families. Pregnancy and
    childbirth wreak many changes on a woman's body, some of them deadly.
    Illegal abortion, of course, is dangerous. The protection of the right
    to a safe abortion should not be weakened by those who follow religious
    dogmas or unscientific views of pregnancy and the medical procedures
    used in modern America. I know women who suffered great indignities in
    the 1960s (e.g., transport in the trunk of a car) and dangers (e.g.,
    inserting sharp objects into the vagina or ingesting poison) before the
    passing of Roe v. Wade. Women will always be willing to do these things
    in order to control their destinies.

    For many years, I have been protecting access to clinics and doctors
    who bravely give women the service they need to reduce their family's
    size, or to complete a college education, or to take a job that would
    be impossible without affordable quality childcare. This country was
    founded on freedom of and from religion. We need to respect that right,
    which formed the basis of our country's beginnings. Someone's religious
    beliefs should not be used to deny another woman even minimal access to
    these basic needs. The lives of individual women and of their family
    members should be respected no matter how much their religious belief
    differs with regard to definitions of life, personhood, female versus
    male, sexual preferences and activities, and health conditions. There
    is no 100% effective form of birth control, but many of them work well
    enough to permit modern women sexual fulfillment, wider career choice,
    and a healthier body for starting a family when she is ready and
    willing.

    One other aspect of reproductive choice should be included in the work
    of the HHS. The United States must cooperate with organizations and
    help other nations in need of assistance to provide contraception,
    childcare, health care, and safe abortion access. When women have these
    benefits, they become more economically productive, better mothers, and
    better able to counter the actions of autocratic or theocratic
    governments. The world's environment would also benefit from the
    amelioration of the effects of overpopulation, the resulting pollution,
    and increasing warfare over necessities for life.

    Thank you for listening. I was one of those many, many individuals,
    along with my husband and daughter, who marched in Washington on
    January 21st. If I must, I will return, and I will march, write, and
    put my money toward keeping women's healthcare and reproductive choices
    free from misinformed or misogynistic people in power. I will speak out
    against anyone who tries to take away any person's right to affordable
    health care and reproductive choice.

    Sincerely,

    Marilyn D. Quinn

                                     ______

                      Letter Submitted by Stacey Ravanesi

    To: Senate Finance Committee

    Date: January 24, 2017

    I am in deeply concerned about the nomination of Representative Tom
    Price (R-GA) for Secretary of Health and Human Services (HHS). As a
    matter of fact I am intensely opposed to his nomination. I strongly
    request the Senate Finance Committee to challenge his nomination to
    helm an agency that plays an exceedingly important and complex role in
    ending the certain epidemics in the United States and around the world.
    Individuals impacted by HIV, tuberculosis (TB), hepatitis C (HCV), and
    other infections; their families and their communities could face
    serious and often deadly consequences if someone with Representative
    Price's agenda leads this vital multi-agency cabinet-level department.

    Representative Price's questionable suitability to head HHS and be
    ultimately responsible for policies that directly affect the health of
    U.S. residents can simply be ascertained from his own record as a
    congressional representative to parts of Atlanta's northern suburbs--a
    district and metro area with extremely high rates of HIV and a
    flourishing opioid epidemic. Despite the abundance of epidemiological
    data illustrating the impact of the HIV epidemic in his own district
    and in the Southeastern United States, Representative Price has spent
    the last 8 years undermining efforts aimed at providing health care and
    social services to communities both living with, and vulnerable to, HIV
    and other health conditions. These actions include voting to repeal the
    Affordable Care Act (ACA) multiple times, pushing for the privatization
    of Medicare, threatening to cap and block-grant Medicaid, supporting to
    defund Planned Parenthood, pledging cuts to social service and safety
    net programs--all while demonstrating a hostile voting record on
    lesbian, gay, bisexual, transgender, and queer (LGBTQ) issues.
    Throughout the recent hearing before the Senate Committee on Health,
    Education, Labor, and Pensions (HELP), Price made several indications
    to continue a trend to dismantling existing systems, without details of
    a replacement that sustains access to health care and social services.

    At a time when we are at the forefront of new science to deliver better
    antiretroviral therapies for HIV, breakthroughs in cures for HCV, and
    pathways for making TB treatments shorter and more tolerable, the
    nomination of Representative Price threatens to impede the progress of
    both research and implementation. Upon confirmation, Representative
    Price will, as promised, oversee the dismantling and overhaul of
    health-care systems that are responsible for delivering many of these
    medical advances to people in the United States, particularly those
    communities impacted by health, social, and economic disparities.

    HHS is not just the department that oversees our health-care system,
    but also governs our public health, research, and regulatory agencies,
    such as the Centers for Disease Control and Prevention (CDC), Indian
    Health Services (IHS), National Institutes of Health (NIH), and the
    Food and Drug Administration (FDA). The recent revelation of ethics
    violations and refusal to clearly answer questions on these issues
    during the Senate HELP hearing clouds any trust in Representative Price
    to ensure the sanctity and neutrality of these agencies. Trust in HHS
    leadership is needed in prioritizing pressing public health challenges,
    ensuring drug and device safety, and countering emerging threats such
    as Zika, Ebola, drug-resistant TB, and Gonorrhea, infant mortality
    increases from infections such as congenital Syphilis, and
    antimicrobial resistance through robust R&D, proactive epidemiology,
    pharmacovigilance, and accelerated research and response.

    Representative Price's worrisome background as a member of the American
    Academy of Physicians and Surgeons--an organization that promotes and
    endorses the theory that HIV does not cause AIDS, despite a substantial
    evidence base to the contrary--puts into question his capabilities to
    end an epidemic. Health conditions like HIV thrive on stigma. Yet Price
    has only perpetuated stigma and marginalized vulnerable communities by
    voting against bills that afford protections to the LGBTQ community.
    With attention needed for other neglected populations, such as
    prisoners impacted by HIV, HCV, and TB; it becomes less likely under a
    Price-led HHS that key populations will be able to access health care
    and treatment.

    Now more than ever, ending public health epidemics requires a
    combination of bipartisan federal and state leadership, evidence-based
    policies, and adequate resources in proper alignment to deliver the
    promise of biomedical and public health advances. Efforts to lower drug
    prices while sustaining U.S. leadership remain inevitable challenges to
    the successor of HHS and the Trump administration. Representative
    Price, however, remains a concerning and unqualified candidate to lead
    HHS given a track record that only marginalizes communities, raises
    questions on his ethics and integrity to run an expansive $1 trillion
    department, and putting forth policy proposals that seek to fast-track
    the loss of lifesaving health care for 18 million Americans. Ending the
    epidemics remains impossible by destroying access to health care and
    treatment. With Representative Price's support of the repeal of ACA and
    efforts to defund Medicaid, the hopes and vision of providing health
    care among the poorest, sickest, most disenfranchised, most vulnerable
    Americans will vanish.

    The practice of slashing proven best public health practices from the
    most helpless Americans is shameful and morally horrendous, while also
    stigmatizing populations that have been historically marginalized
    throughout American history. Therefore, I am begging please do NOT
    confirm Representative Price for Secretary of HHS.

    Thank you.

    Stacey Ravanesi

                                     ______

                  Letter Submitted by Indu Subaiya, M.D., MBA

                                CEO, Health 2.0

                               350 Townsend Ave.

                            San Francisco, CA 94107

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    January 30, 2017

    Honorable members of the Senate Finance Committee:

    My name is Indu Subaiya, M.D., MBA, and I am Co-Chairman and CEO of
    Health 2.0, the largest health care innovation conference and network
    in the world. I submit this letter to oppose Tom Price's nomination for
    Secretary of Health and Human Services.

    We know that the ACA reduces barriers to health care for millions of
    Americans, but what many don't know is that it also fuels a vibrant
    segment of the private sector, the health technology innovation
    economy.

    In a decade of working alongside thousands of health-care innovators
    globally, and in chapters in over 40 U.S. cities from Nashville to
    Boston, Dallas to Chicago, we have never seen our health-care system
    adapt so beautifully to reward private enterprise while saving lives
    and taking care of our most vulnerable without the heavy hand of
    government.

    Dr. Price appears to be a well-intentioned, educated man, but he has
    been out of both the practice of medicine and a transforming health-
    care industry for too long to lead us in this dynamic market.
    Appointing him to architect a replacement plan for the ACA would be
    like hiring a dinosaur to build a space station.

    What health care needs today is a pragmatic voice who can put pedal to
    metal on the progress that's begun, who can work on reforming the ACA
    dispassionately with business leaders, entrepreneurs and patients
    represented in equal proportions, and who understands the health care
    innovation economy.

    But Dr. Price is far too polarizing in his politics to be taken
    seriously by the diverse and moderate mainstream on both sides of the
    aisle. Those of us fixing health care on the ground have blasted silos,
    left partisanship at the door and figured out how to advance a common
    interest. Ask Republican Governor Charlie Baker, Republican former Head
    of the ONC, Dr. David Brailer, Chelsea Clinton of the Clinton
    Foundation, Mark Bertolini, CEO of Aetna, Bernard Tyson, CEO of Kaiser
    all of whom we've warmly welcomed on stage at Health 2.0 not just as
    speakers but as partners in the work of transforming health care.

    Dr. Price on the other hand has never reached out to our community, and
    he's had a decade to do so. Instead he has represented the Association
    of American Physicians and Surgeons, seen as a fringe group promoting
    self-interest, technophobia, and a ``doctor knows best'' philosophy.
    That era in medicine is over. The era of shared decision-making, data
    transparency, evidence-based medicine and providers as partners in care
    and innovation is here. Our era needs a Secretary of HHS who will
    command the respect of the brightest lights in the health care
    innovation economy and Dr. Price is just not that person.

    What do I mean by the innovation economy in health care? I am not
    referring to the old generation of electronic medical record companies
    (EMR) that indirectly received incentives under the HITECH act. I'm
    referring to the more than 4,000 new companies and many more thousand
    jobs that were created in response to the ACA's imperative to make
    health care more accountable for its outcomes. These companies have
    applied the best of American business and technological ingenuity to
    support doctors in their workflow and decision-making, to promote
    collaboration among caregivers, to avoid redundancy in testing, to
    improve patient safety and to allow patients to take more
    responsibility for their health and care.

    As a sector, they've raised over $19.8 billion in venture capital since
    2011 because investors could bet on the momentum of a system aligning
    around the best interests of patients for the first time in history.
    What happens when you leave the doctor's office or hospital has always
    mattered to individuals and families; but now it made business sense.

    All this capital isn't just lining the pockets of Silicon Valley
    startups. Economic development corporations in New York City,
    Massachusetts, Detroit, and Louisiana are making long-term, strategic
    investments in the health technology innovation economy to attract
    innovative companies to set up shop in their cities to provide badly
    needed solutions and to be powerful engines of job growth.

    That's great you say. We'll keep this thriving and virtuous economy
    alive, we're just going to get rid of the individual mandate, some
    nasty corporate penalties and poorly run exchanges that limit choice
    and raise premiums for patients and we'll handle pre-existing
    conditions with hiving off those patients into separate pools. But
    that's a fool's errand.

    It was precisely because the ACA widened the tent of coverage that new
    private sector markets were created. It was precisely because of
    exchanges that Americans woke up to the fact that you need to take
    responsibility for your health and spend your pre-deductible dollars
    wisely, and private sector businesses rose to the occasion to build
    tools to educate consumers on managing health-care expenses and
    decision-making.

    Overstretched health systems also see innovative technology as a way to
    do more for patients with less overhead, to reach people in rural areas
    and at home cheaply and effectively, to refer repeat visitors to the ER
    to a lower cost option in the community. Hospitals like Massachusetts
    General in Boston, Cedars Sinai in Los Angeles, Dell Medical Center in
    Texas, UPMC in Philadelphia and New York Presbyterian in New York City
    all have either started their own or participated in health technology
    innovation programs to test new models of care delivery in partnership
    with the entrepreneurial community in health care.

    It was the ACA's imperative to take care of a wider and more diverse
    population that created demand for new products to address the social
    determinants of health that are killing our small towns: caregiving
    burden, mental health, substance abuse, food insecurity, health
    literacy, social support for the elderly and so much more. These social
    ills normally depend on inefficient government programs. But thanks to
    the ACA, for the first time entrepreneurs have paying customers for
    solutions to these issues. Customers like public health departments,
    community clinics and hospitals. At the national conference we run on
    health innovation, the session on ``Community Health'' normally draws a
    handful of do-gooders. This past year you couldn't get in the room if
    you tried; it was packed with entrepreneurs. The ACA had created a
    market for doing well by doing good.

    The train of progress toward a healthier America and a more efficient
    health-care system has left the station. If confirmed, Dr. Price would
    waste time trying to run after it only to get run over by it. We have
    better Republican candidates to choose from who have worked shoulder to
    shoulder with patients and innovators, who've been part of the
    transformation of American health care on the ground, not in DC and not
    in the ivory tower.

    Don't appoint him because you are comfortable with him as a congressman
    and a doctor. Neither role prepares him for this job. Don't appoint him
    because the AMA endorsed him. The AMA is a friend to the innovation
    community but it speaks for a minority of physicians. You have already
    heard from thousands of doctors who aren't involved in politics who
    oppose this nomination. Take your time and don't rush this vote. Let's
    fix what's broken together without taking a wrecking ball to progress.
    On behalf of those of us with real experience making positive change in
    the trenches of health care, I ask you to vote ``no'' on Tom Price.

    Thank you for your consideration.

    Sincerely,

    Indu Subaiya, M.D. MBA
    CEO, Health 2.0

                                     ______

                          Treatment Action Group (TAG)

                            90 Broad St., Suite 2503

                               New York, NY 10004

                               Tel 1-212-253-7922

                               Fax 1-212-253-7923

                      http://www.treatmentactiongroup.org/

    January 24, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Dear esteemed members of the Senate Finance Committee:

    Treatment Action Group (TAG) submits this statement for the record in
    strong opposition to the nomination of Representative Tom Price (R-GA)
    for Secretary of Health and Human Services (HHS). We urge critical
    community action and implore the Senate Finance Committee to challenge
    his nomination to helm an agency that plays an exceedingly important
    and complex role in ending the HIV, tuberculosis (TB) and hepatitis C
    (HCV) epidemics in the United States and ultimately around the world.

    TAG is an independent, science-based research and policy think-tank
    fighting for better treatment, vaccine and a cure for HIV/AIDS, TB, and
    HCV. We work closely and interface extensively with U.S. health care,
    research, and regulatory institutions to support expanded access to
    health care, centralize community engagement and ethically accelerate
    vital research.

    Tom Price's questionable fitness to head a multi-agency cabinet-level
    department charged with the health of U.S. residents can simply be
    ascertained from his own record as a Congressional representative to
    parts of Atlanta's northern suburbs--a district and metro area with
    extremely high rates of HIV and a flourishing opioid epidemic. Despite
    the abundance of epidemiological data illustrating the impact of the
    HIV epidemic in his own district and in the Southeastern United States,
    Representative Price has spent the last 8 years undermining efforts
    aimed at providing health care and social services to communities both
    living with, and vulnerable to, HIV and other health conditions. These
    actions include voting to repeal the Affordable Care Act (ACA) multiple
    times, pushing for the privatization of Medicare, threatening to cap
    and block-grant Medicaid, supporting to defund Planned Parenthood,
    pledging cuts to social service and safety net programs--all while
    demonstrating a hostile voting record on lesbian, gay, bisexual,
    transgender, and queer (LGBTQ) issues. Throughout the recent hearing
    before the Senate Committee on Health, Education, Labor and Pensions
    (HELP), Representative Price made several indications to continue a
    trend to dismantling existing systems, without details of a replacement
    that sustains access to health care and social services.

    At a time when we are at the forefront of new science to deliver better
    antiretroviral therapies for HIV, breakthroughs in cures for HCV, and
    pathways for making TB treatments shorter and more tolerable, the
    nomination of Representative Tom Price threatens to impede the progress
    of both research and implementation. Upon confirmation, Representative
    Price will, as promised, oversee the dismantling and overhaul of
    health-care systems that are responsible for delivering many of these
    medical advances to people in the United States, particularly those
    communities impacted by health, social, and economic disparities as
    well as stigma.

    Before the ACA, hundreds of people every year were waitlisted for the
    AIDS Drug Assistance Program (ADAP). People living with HIV (PLHIV)
    would need an AIDS diagnosis to be eligible for Medicaid. Pre-existing
    conditions would also disqualify many PLHIV from gaining insurance.
    While the ACA is not perfect, thousands of PLHIV have been transitioned
    onto insurance through marketplaces and have become eligible for
    Medicaid benefits. This has provided many with access to comprehensive
    health care for the first time, with profound effects on public health
    and prevention outcomes. Much of the success we're seeing in increasing
    viral suppression rates and reducing the number of diagnoses annually
    will be put in jeopardy if the ACA is repealed without replacement.
    Without replacement and stewardship by the incoming Secretary of Health
    and Human Services, access to treatment, prevention and other services
    will remain out of reach for many of these communities.

    HHS is not just the department that oversees our health-care system,
    but also governs our public health, research, and regulatory agencies,
    such as the Centers for Disease Control and Prevention (CDC), Indian
    Health Services (IHS), National Institutes of Health (NIH), and the
    Food and Drug Administration (FDA). The recent revelation of ethics
    violations and refusal to clearly answer questions on these issues
    during the Senate HELP hearing clouds any trust in Representative Price
    to ensure the sanctity and impartiality of these agencies. Trust in HHS
    leadership is needed in prioritizing pressing public health challenges,
    ensuring drug and device safety, and countering emerging threats such
    as Zika, Ebola, drug-resistant TB, and antimicrobial resistance through
    robust R&D, proactive epidemiology, pharmacovigilance, and accelerated
    research and response.

    Representative Price's worrisome background as a member of the American
    Academy of Physicians and Surgeons--an organization that promotes and
    endorses the theory that HIV does not cause AIDS, despite a substantial
    evidence base to the contrary--puts into question his capabilities to
    end an epidemic. Health conditions like HIV thrive on stigma. Yet
    Representative Price has only perpetuated stigma and marginalized
    vulnerable communities by voting against bills that afford protections
    to the LGBTQ community. With attention needed for other neglected
    populations, such as prisoners impacted by HIV and HCV, it becomes less
    likely under a Price-led HHS that key populations will be able to
    access health care and treatment.

    Now more than ever, ending the epidemics of HIV, TB, and HCV requires a
    combination of bipartisan federal and state leadership, evidence-based
    policies, and adequate resources in proper alignment to deliver the
    promise of biomedical and public health advances. Efforts to lower drug
    prices for HIV and HCV while sustaining U.S. leadership in R&D for TB
    and other neglected diseases remain inevitable challenges to the
    successor of HHS and the Trump administration. Representative Tom
    Price, however, remains a concerning and unqualified candidate to lead
    HHS given a track record that only marginalizes communities, raises
    questions on his ethics and integrity to run an expansive $1 trillion
    department, and putting forth policy proposals that seek to fast-track
    the loss of lifesaving health care for 18 million Americans. Ending the
    epidemics remains impossible by destroying access to health care and
    treatment. With Representative Price's support of the repeal of ACA and
    efforts to defund Medicaid, the hopes and vision of providing health
    care--including ending the HIV epidemic, curbing HCV transmission,
    eliminating TB--among the poorest, sickest, most disenfranchised, most
    vulnerable Americans will vanish.

    In summary, we urge the Senate Committee on Finance to challenge the
    nomination of Representative Tom Price as he is unqualified and unfit
    to lead HHS in a critical juncture to end the HIV/AIDS, TB, and HCV
    epidemics. Should you have any questions or concerns in regards to our
    statement of opposition to the nomination of Representative Tom Price
    for HHS Secretary, please contact TAG policy staff Kenyon Farrow at
    (202) 236-3274 or via email at kenyon.farrow@treatmentactiongroup.org,
    and Suraj Madoori at (917) 530-5996 and
    suraj.madoori@treatmentactiongroup.org.

    Thank you.

    Mark Harrington
    Executive Director
    Treatment Action Group

                                     ______
                     Letter Submitted by Elizabeth Vallance
                                                       January 25, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    To the committee members:

    I write in strong protest of the nomination of Tom Price to head the
    Department of Health and Human Services.

    Nothing in Representative Price's record suggests that he is fit to
    hold this position. Nothing in his record suggests an understanding of
    the public health issues faced by people of limited incomes, by the
    elderly, by people with AIDS or addiction problems, by people in
    minority communities including the LGBTQ community. He has repeatedly
    fought efforts to provide women's health through Planned Parenthood,
    has fought to cut desperately needed social services and safety-net
    programs which are effective and solvent, including (they work, though
    he disdains them) the Affordable Care Act, Medicare, and Medicaid.

    My mother was a proud nurse practitioner in a public clinic in
    Appalachian Pennsylvania for many years before she died (of cancer--we
    need that cancer research!) in 1997, and her stories of the many women
    (anonymous of course)--young women, poor women, women without health
    plans, women who were alone and frightened by symptoms they couldn't
    understand, many with their male partners, women new to the area who
    had no other resources--were extremely moving tales of gratitude for
    the compassionate care they received. It was clear to her, and it is
    clear to me, that providing professional health care was critical to
    the health of these women and the well-being of their families, their
    children, and the community. Surely all existing programs can be
    improved upon, and I would welcome genuine improvements--in
    accessibility and efficiency--in any of them. But Representative Price
    has offered no solutions, only his intentions to reduce important
    national programs without a clue as to what might replace them. The
    women my mother treated in those years before the Affordable Care Act
    were fortunate to have that clinic, but that was not typical and her
    clinic couldn't reach everyone.

    Donald Trump seems bent on destroying much of what we as a nation have
    so painstakingly created over the past decades, programs that might
    begin to bring this country a bit higher in the lists of international
    rates of healthiness and longevity. The Programs under HHS are the most
    crucial to this slow progress we have made. HHS needs a leader who
    understands, respects, and wants to improve on them, not someone whose
    only interest in the job seems to be to wreck the department and its
    critical programs.

    There are thousands of FAR better candidates out there, responsible
    health-care and health-policy professionals whose commitment to the
    health and well-being of our citizens is clear. Reject this terrible
    choice and let's find someone more qualified than Tom Price to head the
    programs that the health and well-being of so many millions of
    Americans depends on.

    Thank you for your consideration,

    Elizabeth Vallance,
    Citizen and voter.

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