[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


        SABOTAGE: THE TRUMP ADMINISTRATION'S ATTACK ON HEALTHCARE

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

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 23, 2019

                               __________

                           Serial No. 116-71
                           
                           
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                           


      Printed for the use of the Committee on Energy and Commerce

                   govinfo.gov/committee/house-energy
                        energycommerce.house.gov
                        
                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
43-607 PDF                  WASHINGTON : 2021                     
          
--------------------------------------------------------------------------------------                        
                        
                        
                    COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
BOBBY L. RUSH, Illinois              GREG WALDEN, Oregon
ANNA G. ESHOO, California              Ranking Member
ELIOT L. ENGEL, New York             FRED UPTON, Michigan
DIANA DeGETTE, Colorado              JOHN SHIMKUS, Illinois
MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California          CATHY McMORRIS RODGERS, Washington
KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland           PETE OLSON, Texas
JERRY McNERNEY, California           DAVID B. McKINLEY, West Virginia
PETER WELCH, Vermont                 ADAM KINZINGER, Illinois
BEN RAY LUJAN, New Mexico            H. MORGAN GRIFFITH, Virginia
PAUL TONKO, New York                 GUS M. BILIRAKIS, Florida
YVETTE D. CLARKE, New York, Vice     BILL JOHNSON, Ohio
    Chair                            BILLY LONG, Missouri
DAVID LOEBSACK, Iowa                 LARRY BUCSHON, Indiana
KURT SCHRADER, Oregon                BILL FLORES, Texas
JOSEPH P. KENNEDY III,               SUSAN W. BROOKS, Indiana
    Massachusetts                    MARKWAYNE MULLIN, Oklahoma
TONY CARDENAS, California            RICHARD HUDSON, North Carolina
RAUL RUIZ, California                TIM WALBERG, Michigan
SCOTT H. PETERS, California          EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             JEFF DUNCAN, South Carolina
MARC A. VEASEY, Texas                GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
A. DONALD McEACHIN, Virginia
LISA BLUNT ROCHESTER, Delaware
DARREN SOTO, Florida
TOM O'HALLERAN, Arizona
                                 ------                                

                           Professional Staff

                   JEFFREY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                MIKE BLOOMQUIST, Minority Staff Director
              Subcommittee on Oversight and Investigations

                        DIANA DeGETTE, Colorado
                                  Chair
JAN SCHAKOWSKY, Illinois             BRETT GUTHRIE, Kentucky
JOSEPH P. KENNEDY III,                 Ranking Member
    Massachusetts, Vice Chair        MICHAEL C. BURGESS, Texas
RAUL RUIZ, California                DAVID B. McKINLEY, West Virginia
ANN M. KUSTER, New Hampshire         H. MORGAN GRIFFITH, Virginia
KATHY CASTOR, Florida                SUSAN W. BROOKS, Indiana
JOHN P. SARBANES, Maryland           MARKWAYNE MULLIN, Oklahoma
PAUL TONKO, New York                 JEFF DUNCAN, South Carolina
YVETTE D. CLARKE, New York           GREG WALDEN, Oregon (ex officio)
SCOTT H. PETERS, California
FRANK PALLONE, Jr., New Jersey (ex 
    officio)
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Diana DeGette, a Representative in Congress from the State 
  of Colorado, opening statement.................................     2
    Prepared statement...........................................     3
Hon. Brett Guthrie, a Representative in Congress from the 
  Commonwealth of Kentucky, opening statement....................     4
    Prepared statement...........................................     6
Hon. Susan W. Brooks, a Representative in Congress from the State 
  of Indiana, prepared statement.................................     7
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     7
    Prepared statement...........................................     9
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................    10
    Prepared statement...........................................    12
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, prepared statement.............................    13

                                Witness

Seema Verma, Administrator, Centers for Medicare & Medicaid 
  Services, Department of Health and Human Services..............    14
    Prepared statement...........................................    17
    Answers to submitted questions \1\

                           Submitted Material

Article of October 22, 2019, ``The Health 202: Obamacare is 
  getting more affordable under the Trump administration,'' by 
  Paige Winfield Cunningham, Washington Post, submitted by Mr. 
  Burgess........................................................    88
Letter of July 1, 2019, from Senator Cindy Hyde-Smith to Alex 
  Azar, Secretary, Department of Health and Human Services, 
  submitted by Mr. Duncan........................................    94
Letter of March 27, 2019, from Ms. Blunt Rochester, et al., to 
  Alex Azar, Secretary, Department of Health and Human Services, 
  and Seema Verma, Administrator, Centers for Medicare and 
  Medicaid Services, submitted by Ms. Blunt Rochester............   107
Letter of May 16, 2019, from Ms. Blunt Rochester to Alex Azar, 
  Secretary, Department of Health and Human Services, and Seema 
  Verma, Administrator, Centers for Medicare and Medicaid 
  Services, submitted by Ms. Blunt Rochester.....................   111
Letter of June 17, 2019, from Seema Verma, Administrator, Centers 
  for Medicare and Medicaid Services, to Ms. Blunt Rochester, 
  submitted by Ms. Blunt Rochester...............................   113
Letter of September 3, 2019, from Mr. Rush, et al., to Alex Azar, 
  Secretary, Department of Health and Human Services, and Seema 
  Verma, Administrator, Centers for Medicare and Medicaid 
  Services, submitted by Mr. Rush................................   116
Letter of October 21, 2019, from Seema Verma, Administrator, 
  Centers for Medicare and Medicaid Services, to Mr. Rush, 
  submitted by Mr. Rush..........................................   120

----------

\1\ The information has been retained in committee files and also is 
available at https://docs.house.gov/meetings/IF/IF02/20191023/110123/
HHRG-116-IF02-Wstate-VermaS-20191023-SD002.pdf.

 
       SABOTAGE: THE TRUMP ADMINISTRATION'S ATTACK ON HEALTHCARE

                              ----------                              


                      WEDNESDAY, OCTOBER 23, 2019

                  House of Representatives,
      Subcommittee on Oversight and Investigations,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:02 a.m., in 
the John D. Dingell Room 2123, Rayburn House Office Building, 
Hon. Diana DeGette (chair of the subcommittee) presiding.
    Members present: Representatives DeGette, Schakowsky, 
Kennedy, Ruiz, Kuster, Castor, Tonko, Clarke, Pallone (ex 
officio), Guthrie (subcommittee ranking member), Burgess, 
McKinley, Griffith, Brooks, Duncan, and Walden (ex officio).
    Also present: Representatives Rush, Cardenas, Blunt 
Rochester, Rodgers, Bucshon, Carter, and Gianforte.
    Staff present: Kevin Barstow, Chief Oversight Counsel; 
Jesseca Boyer, Professional Staff Member; Jeffrey C. Carroll, 
Staff Director; Waverly Gordon, Deputy Chief Counsel; Tiffany 
Guarascio, Deputy Staff Director; Saha Khaterzai, Professional 
Staff Member; Chris Knauer, Oversight Staff Director; Kevin 
McAloon, Professional Staff Member; Meghan Mullon, Staff 
Assistant; Joe Orlando, Executive Assistant; Alivia Roberts, 
Press Assistant; Tim Robinson, Chief Counsel; Benjamin Tabor, 
Policy Analyst; Sydney Terry, Policy Coordinator; Rick Van 
Buren, Health Counsel; C. J. Young, Press Secretary; Nolan 
Ahern, Minority Professional Staff Member, Health; Jen Barblan, 
Minority Chief Counsel, Oversight and Investigations; Margaret 
Tucker Fogarty, Minority Legislative Clerk/Press Assistant; 
Caleb Graff, Minority Professional Staff Member, Health; 
Brittany Havens, Minority Professional Staff Member, Oversight 
and Investigations; Peter Kielty, Minority General Counsel; J. 
P. Paluskiewicz, Minority Chief Counsel, Health; and Natalie 
Sohn, Minority Counsel, Oversight and Investigations.
    Ms. DeGette. The Subcommittee on Oversight and 
Investigations hearing will now come to order. Today, the 
subcommittee is holding a hearing entitled ``Sabotage: The 
Trump Administration's Attack on Healthcare.'' The purpose of 
the hearing is to examine the efforts of the Centers for 
Medicare & Medicaid Services to ensure quality and affordable 
healthcare for all Americans. The Chair now recognizes herself 
for 5 minutes for an opening statement.

 OPENING STATEMENT OF HON. DIANA DeGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    It is no secret that the Trump administration has worked to 
sabotage healthcare in this country. On his very first day in 
office, President Trump issued an executive order directing all 
Federal agencies to dismantle the Affordable Care Act, ``to the 
maximum extent by law.'' And ever since then, the Trump 
administration has worked tirelessly to undermine the ACA and 
other critical health programs at every turn.
    In her role as the Administrator of the Centers for 
Medicare & Medicaid Services, Seema Verma has been behind many 
of this administration's efforts to undermine the Nation's 
healthcare. Despite her role in this effort, today is the first 
time Administrator Verma has appeared to testify in an 
oversight hearing in the House, and we have many questions 
regarding the administration's actions.
    Since the Affordable Care Act was signed into law, more 
than 20 million people gained affordable, high-quality 
healthcare coverage. But now, under President Trump and 
Administrator Verma, this administration is determined to take 
us in the wrong direction. Last year, we saw the number of 
uninsured people in this country increase for the first time 
since the ACA was passed. About 1.9 million more people were 
uninsured last year compared to the year before, including 
nearly half a million more children. Further, the Kaiser Family 
Foundation estimates that health insurance premiums are 16 
percent higher this year than they would have been if the Trump 
administration had not worked to undermine the ACA.
    We know the Trump administration has taken numerous steps 
to sabotage the ACA. They are chipping away at critical 
protections guaranteed by the law. They are allowing States to 
increase consumers' costs, reduce their coverage, and undermine 
protections for those with preexisting conditions. They are 
promoting junk insurance plans that do not provide essential 
health benefits and leave patients on the hook when they need 
coverage the most. They are making it more difficult and more 
expensive for individuals to find quality coverage on the 
health insurance marketplace, and, to top it all off, they are 
rooting for the ACA's collapse by declining to defend the law 
in the Texas v. United States lawsuit.
    We will likely hear today that Obamacare is the source of 
all our problems. But while the Nation's healthcare law may not 
be perfect, it is important to understand what would happen if 
the Trump administration succeeded in dismantling the ACA 
entirely. Twenty-one million people could lose their health 
insurance.
    Up to 133 million Americans with preexisting conditions 
could be denied coverage or charged higher premiums. Those 
lucky enough to keep their coverage if the ACA is dismantled 
could once again face lifetime caps on coverage and could lose 
coverage for things like prescription drugs and maternity care. 
Women could once again be charged more than men for their 
health coverage, and 60 million seniors and disabled Americans 
on Medicare will have to pay more for preventive care and 
prescription drugs.
    Yesterday, CMS announced that ACA premiums will drop by 
about 4 percent this year. That is good news. However, let's 
just think about how many more people would be covered now and 
how much lower premiums could be if not for the repeated acts 
of sabotage at the hands of this administration.
    The ACA is succeeding despite the Trump administration's 
efforts to tear it down. Time and time again, this 
administration's actions on healthcare have gone squarely 
against their duty to promote high-quality healthcare and the 
well-being of children and families in need. Under this 
administration, thousands of children and families have lost 
coverage of basic health services, and this administration's 
actions have disproportionately hurt those with disabilities, 
rural Americans, veterans, women, and young people of color.
    The Trump administration and Administrator Verma, in 
particular, have tried to make philosophical arguments for why 
they are doing these things, but the numbers just don't lie. At 
a time when we as a nation are facing a series of critical 
health challenges like the opioid epidemic and unacceptably 
high rates of maternal and infant mortality, it is 
unconscionable that this administration is working to reverse 
the progress that we have made.
    Today, the administration will have to answer for its 
unending sabotage of Americans' healthcare, and Administrator 
Verma will have to explain to the American public why she and 
this administration are actively trying to take their 
healthcare away.
    [The prepared statement of Ms. DeGette follows:]

                Prepared Statement of Hon. Diana DeGette

    It's no secret that the Trump administration has worked to 
sabotage healthcare in this country.
    On his very first day in office, President Trump issued an 
Executive Order directing all Federal agencies to dismantle the 
Affordable Care Act ``to the maximum extent by law.'' And ever 
since then, the Trump administration has worked tirelessly to 
undermine the ACA and other critical health programs at every 
turn.
    In her role as the Administrator of the Centers for 
Medicare & Medicaid Services, Seema Verma has been behind many 
of this administration's efforts to undermine the Nation's 
healthcare. Despite her starring role in this effort, today is 
the first time Administrator Verma has appeared to testify at 
an oversight hearing in the House, and she has many questions 
to answer regarding this administration's actions.
    Since the Affordable Care Act was signed into law, more 
than 20 million people gained affordable, high-quality 
healthcare coverage. But now, under President Trump and 
Administrator Verma, this administration is determined to take 
us back in the wrong direction.
    Last year, we saw the number of uninsured people in this 
country increase for the first time since the ACA was passed. 
About 1.9 million more people were uninsured last year compared 
to the year before--including nearly half a million more 
children. Further, the Kaiser Family Foundation estimates that 
health insurance premiums are 16 percent higher this year than 
they would have been if the Trump administration had not worked 
to undermine the ACA.
    We know the Trump administration has taken numerous actions 
to sabotage the ACA.
    They are chipping away at critical protections guaranteed 
by the law. They are allowing States to increase consumers' 
costs, reduce their coverage, and undermine protections for 
those with preexisting conditions.
    They are promoting junk insurance plans that do not provide 
essential health benefits and leave patients on the hook when 
they need coverage the most.
    They are making it more difficult and more expensive for 
individuals to find quality coverage on the health insurance 
marketplace.
    And to top it all off, they are rooting for the ACA's 
collapse by declining to defend the law in the Texas v. United 
States lawsuit.
    We will likely hear today that ``Obamacare'' is the source 
of all our problems.But while the Nation's healthcare law may 
not be perfect, it's important to understand what would happen 
if the Trump administration succeeds in dismantling it 
entirely:
     21 million people could lose their health 
insurance.
     Up to 133 million Americans with preexisting 
conditions could be denied coverage or charged higher premiums.
     Those lucky enough to keep their coverage if the 
ACA is dismantled could once again face lifetime caps on 
coverage, and could lose coverage for things like prescription 
drugs and maternity care.
     Women could once again be charged more than men 
for their health coverage.
     And 60 million seniors and disabled Americans on 
Medicare will have to pay more for preventive care and 
prescription drugs.
    Yesterday, CMS announced that ACA premiums will drop by 
about 4 percent next year. This is good news. However, just 
think about how many more people would be covered and how much 
lower premiums could be if not for the repeated acts of 
sabotage at the hands of this administration. The ACA is 
succeeding despite the Trump administration's efforts to tear 
it down.
    Time and time again, this administration's actions on 
healthcare have gone squarely against their duty to promote 
high-quality healthcare and the well-being of children and 
families in need.
    Under this administration, thousands of children and 
families have lost coverage of basic health services. And this 
administration's actions have disproportionately hurt those 
with disabilities, rural Americans, Veterans, women, and young 
people of color.
    The Trump administration, and Administrator Verma in 
particular, have tried to make philosophical arguments for why 
they are doing these things. But the numbers don't lie.
    At a time when we, as a nation, are facing a series of 
critical health challenges--such as the opioid epidemic and 
unacceptably high rates of maternal and infant mortality--it is 
unconscionable that this administration is working to reverse 
the progress we've made.
    Today, the Trump administration will have to answer for its 
unending sabotage of Americans' healthcare. And Administrator 
Verma will have to explain to the American people why she--and 
this administration--are actively trying to take their 
healthcare away.

    Ms. DeGette. And with that, the Chair will recognize the 
ranking member of the subcommittee, Mr. Guthrie, for 5 minutes 
for an opening statement.

 OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN 
           CONGRESS FROM THE COMMONWEALTH OF KENTUCKY

    Mr. Guthrie. Thank you, Chair DeGette, for holding this 
hearing with the Centers for Medicare & Medicaid Services 
today, and I would like to welcome Administrator Verma to her 
first appearance before the Energy and Commerce Committee.
    CMS oversees the two largest Federal healthcare programs, 
Medicare and Medicaid, as well as numerous other Federal 
programs. CMS programs will impact over 145 million Americans 
in fiscal year 2020, and a CMS budget of over 1 trillion 
represents more than 25 percent of the entire Federal budget. I 
share this information about CMS not only to emphasize the 
critical role that the agency plays in the Nation's healthcare 
system, but to illustrate how we cannot possibly cover all of 
CMS's work in a single hearing.
    And thank you, Administrator Verma, for your commitment to 
promoting competition and innovation for Americans' healthcare 
and for that work you have accomplished in your role thus far. 
Just yesterday, I was pleased to see CMS announce that premiums 
for mid-level Silver plans will decrease 4 percent for 2020, a 
far cry from the double-digit premium increases we have seen in 
past years.
    I have also heard from my constituents on how CMS's 
Patients over Paperwork initiative will help providers spend 
more time focusing on the quality of care provided to patients 
rather than the overly burdensome administrative tasks. I am 
also glad that CMS is strengthening the agency's oversight of 
nursing homes in recent months. Last Congress' subcommittee 
examined CMS's oversight of the quality and safety of care in 
nursing homes after numerous reports described instances of 
abuse and neglect in standard care occurring in nursing homes 
across the country.
    Another critical issue facing Americans that CMS has made a 
top priority is the opioid epidemic. This committee has long 
been at the forefront of the fight to combat the opioid crisis. 
Last Congress, our investigation and legislative work led to 
the SUPPORT for Patients and Communities Act, which was signed 
into law 1 year ago tomorrow. While there is much to be done 
both legislatively and through investigations, the SUPPORT Act 
included important provisions relating to CMS's role and 
responsibility in helping to address the opioid epidemic.
    Many of the initiatives I have just described share 
bipartisan support, which is why the title for this hearing, 
``Sabotage: The Trump Administration's Attack on Healthcare,'' 
is over the top. I don't think anyone can reasonably categorize 
CMS's effort to protect vulnerable populations in nursing homes 
and assist States in fighting the opioid epidemic as sabotage. 
Moreover, the Democrats are likely going to spend a lot of time 
today criticizing CMS's recent actions relating to Medicaid 
demonstration projects and Section 1332 State Innovation 
Waivers. I find it disingenuous, however, to lay CMS's 
commitment to strengthen its partnership with States and 
promote innovation as sabotage.
    I do, however, want to take some time to discuss areas 
where I hope CMS will take additional action in the future. We 
are at the beginning of flu season, and it will potentially be 
one of the worst flu seasons that we have experienced in recent 
years. This subcommittee held a hearing in 2018 examining HHS's 
efforts to respond to seasonal influenza, and while CMS was not 
a witness at the hearing, we did learn that FDA was working 
with CMS to use Medicare data to compare the effectiveness of 
different types of flu vaccines. I have some questions for CMS 
today about the status of this work, and I hope that we can 
hold another hearing on seasonal flu preparedness as soon as 
possible.
    I also have questions for CMS about the agency's efforts to 
improve the interoperability of healthcare records while also 
taking into consideration the sensitive nature of healthcare 
data. We appreciate the work CMS has done to implement the 21st 
Century Cures Act, but as I said in my letter to CMS with 
Congressman Schrader this summer, I am concerned that a recent 
proposed rule issued by CMS does not adequately protect 
consumers' sensitive healthcare data.
    Thank you again for being here today. I look forward to 
your testimony, and I would like to yield my time to the 
congresswoman from Indiana, Mrs. Brooks.
    [The prepared statement of Mr. Guthrie follows:]

                Prepared Statement of Hon. Brett Guthrie

    Thank you, Chair DeGette, for holding this hearing with the 
Centers for Medicare and Medicaid Services today. I would like 
to welcome Administrator Verma to her first appearance before 
the Energy and Commerce Committee.
    CMS oversees the two largest Federal healthcare programs, 
Medicare and Medicaid, as well as numerous other Federal 
programs. CMS programs will impact over 145 million Americans 
in Fiscal Year 2020, and CMS' budget of over $1 trillion 
represents more than 25 percent of the entire Federal budget.
    I share this information about CMS not only to emphasize 
the critical role that the agency plays in the Nation's 
healthcare system, but also to illustrate how we cannot 
possibly cover all of CMS' work in a single hearing.
    Thank you, Administrator Verma, for your commitment to 
promoting competition and innovation for Americans healthcare, 
and for the work that you have accomplished in your role thus 
far.
    Just yesterday, I was pleased to see CMS' announcement that 
premiums for mid-level ``silver'' plans will decrease 4 percent 
for 2020--a far cry from the double-digit premium increases 
we've seen in years past.
    I've also heard from my constituents on how CMS' Patients 
over Paperwork initiative will help providers spend more time 
focusing on the quality of care provided to patients rather 
than on overly burdensome administrative tasks.
    I am also glad that CMS is strengthening the agency's 
oversight of nursing homes in recent months. Last Congress, 
this subcommittee examined CMS' oversight of the quality and 
safety of care in nursing homes after numerous reports 
described instances of abuse, neglect, and substandard care 
occurring at nursing homes across the country.
    Another critical issue affecting Americans that CMS has 
made a top priority is the opioid epidemic. This committee has 
been at the forefront of the fight to combat the opioid crisis. 
Last Congress our investigative and legislative work led to the 
SUPPORT for Patients and Communities Act--which was signed into 
law one year ago tomorrow. While there is still much to be 
done, both legislatively and through investigations, the 
SUPPORT Act included important provisions relating to CMS' role 
and responsibility in helping to address the opioid epidemic.
    Many of the initiatives I just described share bipartisan 
support, which is why the title for this hearing, ``Sabotage: 
The Trump Administration's Attack on Healthcare,'' is so over 
the top. I don't think that anyone can reasonably categorize 
CMS' efforts to protect vulnerable populations in nursing homes 
and assist States in fighting the opioid epidemic as 
``sabotage.'' Moreover, the Democrats are likely going to spend 
a lot of time today criticizing CMS' recent actions relating to 
Medicaid demonstration projects and Section 1332 State 
Innovation Waivers. I find it disingenuous, however, to label 
CMS' commitment to strengthen its partnership with States and 
promote innovation as ``sabotage.''
    I do, however, want to take some time to discuss areas 
where I hope CMS will take additional action in the near 
future.
    We are at the beginning of a flu season that will 
potentially be one of the worst flu seasons that we have 
experienced in recent years. This subcommittee held a hearing 
in 2018 examining HHS' efforts to respond to the seasonal 
influenza, and while CMS was not a witness at the hearing, we 
did learn that FDA was working with CMS to use Medicare data to 
compare the effectiveness of different types of flu vaccines. I 
have some questions for CMS today about the status of this 
work, and I also hope that we can hold another hearing on 
seasonal flu preparedness as soon as possible.
    I also have questions for CMS about how the agency's 
efforts to improve the interoperability of healthcare records 
will also take into consideration the sensitive nature of 
healthcare data. We appreciate the work that CMS has done to 
implement the 21st Century Cures Act. But, as I said in my 
letter to CMS with Congressman Schrader this summer, I am 
concerned that a recent proposed rule issued by CMS does not 
adequately protect consumers' sensitive healthcare data.
    Thank you again for being here today, and I look forward to 
your testimony.

    Mrs. Brooks. Thank you, Ranking Member Guthrie. And 
welcome, Administrator Verma.
    Seema and her family are constituents of mine back home in 
Indiana, and we actually have been friends for a couple of 
decades. We worked together in Mayor Stephen Goldsmith's office 
where she was focused on health policy in the late '90s. That 
innovation was recognized also by former Indiana Governor Mitch 
Daniels, who asked Seema to work with him in ensuring that 
healthcare was working better for patients throughout Indiana.
    She is the architect of the Healthy Indiana Plan, which was 
Indiana's popular bipartisan--again, I repeat, it was a 
bipartisan Medicaid program. Healthy Indiana Plan requires 
individual responsibility through small member contributions 
utilizing what are called POWER Accounts that function like 
traditional HSAs, and the Healthy Indiana Plan incentivizes 
preventive care to drive down costs and keep patients 
healthier.
    We are very, very proud that Seema Verma stepped up at the 
invitation of the President to take the innovation and her 
incredible dedication to the health of Americans here in 
Washington, DC. We look forward to continuing working with you 
to continue to improve healthcare for all Americans.
    Thank you, I yield back.
    [The prepared statement of Mrs. Brooks follows:]

               Prepared Statement of Hon. Susan W. Brooks

    Thank you, Ranking Member Guthrie. Welcome Administrator 
Verma. Seema has been a dear friend throughout the years and is 
a constituent of mine. Seema and I served together in Mayor 
Goldsmith's office in Indianapolis in the late '90s.
    She was instrumental in our home State of Indiana in making 
healthcare work for patients. She is the architect of the 
Healthy Indiana Plan, Indiana's popular, bipartisan Medicaid 
program.
    HIP requires individual responsibility through small member 
contributions utilizing POWER accounts that function like a 
traditional HSA. And HIP incentivizes preventative care to 
drive costs down and keep patients healthier.
    We are proud to have a Hoosier working for the American 
people at CMS. We look forward to working with you to continue 
to improve healthcare for all Americans.
    Thank you and I yield back.

    Mr. Guthrie. Thank you. And I yield back.
    Ms. DeGette. The gentleman yields back. The Chair now 
recognizes the chairman of the full committee, Mr. Pallone, for 
5 minutes for purposes of an opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. I want to thank the chairwoman. Today's 
hearing continues this committee's ongoing work to bring 
oversight and accountability to the Trump administration's 
relentless attack on people's healthcare, whether it be attacks 
on the Affordable Care Act, Medicare, or Medicaid. Since day 
one, the Trump administration has engaged in a concerted effort 
to undermine, weaken, and outright eliminate health insurance 
coverage for tens of millions of Americans.
    I heard what my colleague Ranking Member Guthrie said, that 
I guess he doesn't think that this administration is sabotaging 
anything. But, you know, the problem I have here is, if someone 
is on the right ideologically and says, ``Look, the Government 
shouldn't be involved in healthcare, shouldn't get involved in 
health insurance, people are on their own,'' if you said that 
then I would say, ``OK, I understand. You know, you want to get 
rid of all the health insurance, you want to get rid of all 
this, this is not the Government's role.''
    But the problem is, I hear my colleagues on the other side, 
including the President, suggest otherwise. That they want to 
cover everyone. That they want to help people get health 
insurance. Well, I don't see that at all. I think, if you look 
at this practically and not ideologically, it is clear that 
fewer people have health insurance, that their essential 
benefits are being cut back, they are not being covered. So to 
suggest that somehow they are not responsible for that, I 
think, is not true. They are responsible. It is a concerted 
effort to cut back on people's health insurance, their 
benefits, what kind of coverage they have.
    And our witness today is the Administrator for the Centers 
for Medicare & Medicaid Services, CMS, Seema Verma, who is the 
administration's point person on these actions. I think she has 
a difficult record to defend. During her time as the 
Administrator, healthcare costs have gone up and health 
insurance coverage has gone down. And thanks to the 
administration's policies, the number of uninsured Americans 
increased by nearly 2 million people from 2017 to 2018, rising 
to 27.5 million uninsured.
     And between December 2017 and this June, more than 1 
million children lost health coverage through either Medicaid 
or the Children's Health Insurance Program, and these are, you 
know, bipartisan programs. Why is this administration making it 
more difficult for people to get coverage, and particularly 
kids?
    These are very disturbing trends, and unfortunately they 
could get even worse if CMS and the Trump administration are 
successful in pushing their harmful policies. The Trump 
administration is actively supporting a lawsuit that would 
overturn the Affordable Care Act. This would strip health 
insurance away from tens of millions of Americans and would 
allow insurance companies to once again discriminate against 
people with preexisting conditions.
    The administration has expanded junk insurance plans that 
are not required to cover essential health benefits like 
hospitalization, prescription drugs, and emergency care 
services. The Trump administration is also placing extremely 
burdensome, in some cases illegal, hurdles in front of Medicaid 
beneficiaries. These unnecessary roadblocks are certainly 
causing pain for low-income families, as more than 1 million 
children lost health insurance coverage through either Medicaid 
or CHIP between December '17 and June of this year.
    These disturbing numbers show that the Trump 
administration's policies to drive people off Medicaid, tie 
them up in red tape, or scare them into not even applying for 
insurance in the first place are working. And I am deeply 
concerned by the Trump administration's ongoing attempts to 
impose illegal work requirements waivers on Medicaid 
beneficiaries. These requirements are not only cruel and 
costly, but they are a clear violation of both Medicaid statute 
and longstanding congressional intent.
    And, fortunately, these illegal actions have been 
rightfully defeated in the courts, but the Trump administration 
refuses to give up. And the Trump administration is also not 
giving up in its ongoing attempts to sabotage the healthcare of 
millions of Americans through the ACA. In some instances, the 
proposals have been so extreme that even Administrator Verma 
has raised the red flag. In an internal memo dated August 2018, 
she wrote that several administration proposals at the time 
would, and I am quoting, ``cause coverage losses, further 
premium increases, and market disruption.'' And the memo 
concluded that 1.1 million Americans could lose their coverage.
    And I have repeatedly requested Ms. Verma provide the 
underlying analysis discussed in that memo. If the Trump 
administration is pursuing a policy that would have harmful 
impacts on millions of Americans, Congress and the American 
people have a right to know what exactly that analysis shows. 
To date, I have received a one-and-one-half-page response that 
answers none of my questions.
    So under Ms. Verma's leadership, CMS is following the rest 
of the Trump administration in stonewalling legitimate 
congressional oversight requests, and I am appalled by the 
flimsy, nonresponsive letters this committee has received back 
from CMS, many times well past the deadline. As I wrote in a 
letter to both Secretary Azar and Administrator Verma last 
week, obstruction of the committee's legitimate exercise of its 
oversight responsibilities is unacceptable and if continued may 
necessitate the use of additional measures, including 
compulsory process.
    So, Administrator, you cannot flout this committee's 
constitutional duty to conduct oversight. I appreciate you 
being here today. That certainly says a lot that you are here, 
and I don't want to take away from that. But the stonewalling 
of our oversight requests have to end.
    And with that, Madam Chair, I will yield back.
    [The prepared statement of Mr. Pallone follows:]

             Prepared Statement of Hon. Frank Pallone, Jr.

    Today's hearing continues this committee's ongoing work to 
bring oversight and accountability to the Trump 
administration's relentless attack on people's healthcare. 
Whether it be attacks on the Affordable Care Act, Medicare or 
Medicaid, since day one this administration has engaged in a 
concentrated effort to undermine, weaken, and outright 
eliminate health insurance coverage for tens of millions of 
Americans.
    Our witness today is the Administrator for the Centers for 
Medicare & Medicaid Services (CMS), Seema Verma, who is the 
administration's point person on these actions. She has a 
difficult record to defend: During her time as the 
Administrator, healthcare costs have gone up and health 
insurance coverage has gone down.
    Thanks to the administration's policies, the number of 
uninsured Americans increased by nearly 2 million people from 
2017 to 2018--rising to 27.5 million uninsured. And between 
December 2017 and this June, more than 1 million children lost 
healthcare coverage through either Medicaid or the Children's 
Health Insurance Program.
    These are disturbing trends, and, unfortunately, they could 
get even worse if CMS and this administration are successful in 
pushing their harmful policies.
    The Trump administration is actively supporting a lawsuit 
that would overturn the Affordable Care Act. This would strip 
health insurance away from tens of millions of Americans and 
would allow insurance companies to once again discriminate 
against people with preexisting conditions.
    The administration has expanded junk insurance plans that 
are NOT required to cover essential health benefits like 
hospitalization, prescription drugs and emergency care 
services.
    The administration is also placing extremely burdensome 
and, in some cases, illegal hurdles in front of Medicaid 
beneficiaries. These unnecessary roadblocks are certainly 
causing pain for low-income families--as more than 1 million 
children lost healthcare coverage through either Medicaid or 
the Children's Health Insurance Program between December 2017 
and June of this year.
    These disturbing numbers show that the Trump 
administration's policies to drive people off Medicaid, tie 
them up in red tape, or scare them into not even applying for 
insurance in the first place, are working.
    I am also deeply concerned by the Trump administration's 
ongoing attempts to impose illegal work requirements waivers on 
Medicaid beneficiaries. These requirements are not only cruel 
and costly, but they are a clear violation of both Medicaid 
statute and longstanding congressional intent. Fortunately, 
these illegal actions have been rightfully defeated in the 
courts, but the administration refuses to give up.
    The administration is also not giving up on its ongoing 
attempts to sabotage the healthcare of millions of Americans 
through the ACA. In some instances, the proposals have been so 
extreme that even Administrator Verma has raised the red flag. 
In an internal memo dated August 2018, Ms. Verma wrote that 
several administration proposals at the time would, ``cause 
coverage losses, further premium increases, and market 
disruption.'' The memo concluded that 1.1 million Americans 
could lose their coverage.
    I have repeatedly requested Ms. Verma provide the 
underlying analysis discussed in that memo. If the 
administration is pursuing a policy that will have harmful 
impacts on millions of Americans, Congress, and the American 
people, have a right to know what exactly that analysis shows. 
To date, I have received a one-and-one-half-page response that 
answers none of my questions.
    Under Ms. Verma's leadership, CMS is following the rest of 
the Trump administration in stonewalling legitimate 
Congressional oversight requests. I am appalled by the flimsy 
non-responsive letters this committee has received back from 
CMS, many times well past the deadline. As I wrote in a letter 
to both Secretary Azar and Administrator Verma last week, 
obstruction of the committee's legitimate exercise of its 
oversight responsibilities is unacceptable and, if continued, 
may necessitate the use of additional measures, including 
compulsory process.
    Administrator Verma, you cannot flout this committee's 
constitutional duty to conduct oversight. I appreciate you 
being here today, but the stonewalling of our oversight 
requests must end. With that, I yield back.

    Ms. DeGette. The Chair now recognizes the ranking member of 
the full committee, Mr. Walden, for 5 minutes for purposes of 
an opening statement.

  OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Mr. Walden. Well, good morning. Good morning, Madam Chair 
and Chairman of the full committee.
    Ms. Verma, thank you for being here. We really appreciate 
it, and we have enjoyed working with you over the years on many 
of these issues, and I am glad you are here.
    CMS, as we have talked about, is the largest administrator 
of health benefit programs in the United States. It is 
estimated in fiscal year 2020 over 145 million Americans will 
receive their benefits from programs administered by CMS. So 
you have got a big job, and we appreciate the work you are 
doing. That includes Medicare, Medicaid, and Children's Health 
Insurance Program, also known as CHIP.
    And under Republican leadership and with the support of 
this administration and, frankly, in opposition to votes on the 
floor by Democrats, we not only extended CHIP for 5 years and 
then 6 years, we did it for 10. We did it for 10 years, fully 
locked in, Children's Health Insurance, and a lot of Democrats, 
if not all, voted against this almost every step of the way, 
and especially on the House floor. And I don't want to get into 
this partisan back-and-forth, I hadn't planned to today, but it 
is just unfortunate because there are issues here that we need 
to focus on together.
    And I think about the meetings I have had with the 
President, with you and others. I have not seen a President who 
has leaned in more to get drug prices down. Now we may have 
agreements and disagreements to policy, but I wish you could 
have been here during our markup when nearly every Democrat was 
holding up posters of what President Trump had said about 
bringing down drug prices. And while we may have some 
disagreements about the policy, they were certainly the 
President's advocates last week when we were dealing with drug 
costs.
    In surprise medical billing, the chairman and I are working 
shoulder-to-shoulder with this administration, I believe, on a 
way to protect consumers from surprise medical billing. Because 
I tell you, what I run into out in my part of the world is 
people are so concerned about the high cost of healthcare and 
in the Affordable Care Act--and we have had our debates about 
what the best policies are there--it did not deliver as 
promised to bring down premiums 2,500 bucks. In fact, I can't 
find anybody in my district that has seen that level of 
reduction in their premiums.
    But what they have seen is an increase in deductibles and 
copays, and insurance by name is not insurance in function if 
the deductible and copays are so high you really can't afford 
to access the care. And so, there are issues there in terms of 
the Affordable Care Act and all, and there are things we, 
frankly, as Republicans supported that became part of the 
Affordable Care Act. Not the overall bill, but a lot of things 
contained in there, including protecting people with 
preexisting conditions, letting your kids stay on until they 
are 26, there is a whole host of things.
    And then we have done a lot of work together, and it was 
referenced earlier today about the SUPPORT Act. As chairman of 
the committee, I helped steer that through the legislative 
process here. We had an open session where Members of Congress 
could come and make their case. Tomorrow marks the 1-year 
anniversary. I just left a meeting, bipartisan, in the Senate 
with the First Lady and Secretary Azar. Well, we were 
celebrating what we accomplished together as a Congress, and 
almost unanimously as I recall, to address this horrible 
scourge of opioids.
    Now when it comes to first times, we are glad you are here, 
the first time for the committee. The other first time would be 
to have a hearing in this committee on Medicare for All. We 
were talking about, my colleagues were talking about how the 
Trump administration, their allegations, chipping away at ACA. 
I would argue that their presidential candidates are taking a 
chainsaw massacre approach to it, because they want to throw 
out the whole thing and go with a government-run system that 
wipes out Medicare and Medicaid, VA, all private health 
insurance, and they are having a fight over how to pay for it 
or whether to even talk about how to pay for it. And so, 
working Americans are going to lose their insurance under their 
plan, and I have asked for a hearing before this committee 
since the first of this Congress, and we have yet to have one 
on their Medicare for All proposal.
    So there is a lot of debate to be had here. There are also 
areas we should be working together on, and so we are glad you 
are here.
    [The prepared statement of Mr. Walden follows:]

                 Prepared Statement of Hon. Greg Walden

    Thank you. I'd like to welcome the witness for today's 
hearing--Seema Verma, Administrator of the Centers for Medicare 
and Medicaid Services (CMS). We are pleased that you are here 
today to discuss the operations of CMS.
    CMS is the largest administrator of health benefit programs 
in the United States. It is estimated that in Fiscal Year 2020, 
over 145 million Americans will receive benefits from programs 
administered by CMS--including Medicare, Medicaid, the 
Children's Health Insurance Program, also known as CHIP, and 
the Exchanges. CMS' budget request for Fiscal Year 2020 was 
nearly $1.7 trillion, and two of the programs administered by 
CMS--Medicare and Medicaid--are estimated to account for 86 
percent of all projected spending in 2020 for the U.S. 
Department of Health and Human Services (HHS).
    Given the breadth of programs administered by CMS, and that 
these programs represent a substantial financial obligation for 
the Federal Government and the States, it is important that 
this committee conduct oversight of the agency that administers 
those programs. Last Congress, under my leadership as chairman, 
we conducted oversight on a range of issues that fall under 
CMS' purview. It was this subcommittee that conducted the 
necessary oversight to help ensure that programs operate 
effectively, tax dollars are spent appropriately, and that 
Americans who benefit from these programs receive the quality 
of care that they deserve.
    Specifically, the committee conducted oversight over 
programs such as Medicaid, looking at data integrity and 
innovation, the 340B Drug Pricing Program, hospital accrediting 
organizations, and nursing homes, to name a few. The oversight 
of these programs consisted of letters, document requests, 
hearings, briefings, roundtables, meetings with stakeholders, 
and in some cases, reports with recommendations on ways to 
improve the administration and oversight of these programs.
    But oversight hasn't been our only focus. Last Congress, 
this committee worked tirelessly on legislation to improve some 
of the programs and services administered by CMS. For example, 
we led the effort to pass the Substance Use-disorder Prevention 
that Promotes Opioid Recovery and Treatment--or SUPPORT--for 
Patients and Communities Act.
    Everyone knows someone impacted by the opioid crisis. 
Everyone pictures a different face when they think of it. There 
are many people who come to mind for me from stories shared at 
roundtables I held across Oregon--like a mother I met earlier 
this month in La Pine who shared a poem about the son she had 
recently lost to an overdose. Whether it be parents, 
physicians, or law enforcement officials--everyone I've talked 
to has a story to tell, and everyone has urgency in their eyes 
to stop this epidemic.
    Tomorrow marks the 1-year anniversary of the SUPPORT Act 
becoming law, which is a point of pride for this committee and 
the administration. But we must also remain vigilant in our 
efforts to combat the opioid crisis and continue to help 
patients and communities move ``forward with support.''
    Among other things, the SUPPORT Act included provisions to 
strengthen law enforcement, public health, and healthcare 
financing and coverage, including under the Medicare and 
Medicaid programs. For example, under Section 1003, CMS, in 
consultation with another division within HHS, is conducting a 
54-month demonstration project to increase the treatment and 
capacity of Medicaid providers to deliver substance use 
disorder treatments and recovery services. CMS' first step to 
implement this section just occurred in June, when the agency 
announced a Notice of Funding Opportunity that provides State 
Medicaid agencies with information to apply for planning grants 
that will aid in the treatment and recovery of substance use 
disorders.
    In addition, the 21st Century Cures Act (Cures), signed 
into law in December 2016, made numerous changes to Medicare 
and Medicaid policies, including, but not limited to, 
provisions impacting infusion drug reimbursement, durable 
medical equipment policies, telehealth, hospital readmissions, 
long-term care hospitals, and reimbursement policies for 
hospital outpatient departments.
    It is critical that we continue to have a dialogue and 
conduct oversight of CMS to ensure that the implementation of 
the SUPPORT Act, Cures, and other legislation passed by this 
committee are implemented and administered as intended, and on 
schedule. It is also important to continue our work to ensure 
proper administration and oversight of other programs 
administered by CMS.
    I, again, welcome Administrator Verma and thank you for 
being here today. I look forward to listening to your 
testimony.

    Mr. Walden. I am going to yield now to the ranking member 
of the Health Subcommittee, Dr. Burgess.
    Mr. Burgess. I thank the gentleman for yielding. I would 
like to do something I don't normally do, which is quote from 
the Washington Post. In the Health 202 article yesterday by 
Paige Cunningham, it states, ``Obamacare premiums will become 
more affordable next year--despite the dire predictions by 
Democrats that the Trump administration would destroy the 
insurance marketplaces.'' She goes on to say, ``The 
improvements are striking, considering that Democrats have 
spent the last few years blasting the Trump administration for 
peeling away Obamacare regulations.''
    Quoting Alex Azar, ``President Trump, the President who was 
supposedly trying to sabotage the law, has been running it 
better than the guy who wrote it.'' Quoting President Trump 
himself, `` `Once we got rid of the individual mandate it made 
it better, but Obamacare doesn't work--but it works at least 
adequately now. And we had that choice to make. And politically 
it is probably not a good thing that I did, but it's the right 
thing to do for a lot of people,' he said in July.'' So I will 
just submit this entire article for the record. I ask unanimous 
consent to do so.
    Ms. DeGette. Without objection.
    [The information appears at the conclusion of the hearing]
    Mr. Burgess. And we will carry on. I yield back. Thank you.
    [The prepared statement of Mr. Burgess follows:]

             Prepared Statement of Hon. Michael C. Burgess

    Administrator Verma, thank you for being here today. I 
appreciate your willingness to engage with me and with the 
Energy and Commerce Committee over the course of your tenure at 
the Centers for Medicare and Medicaid Services.
    I especially want to thank you for your work on providing 
coverage of cardiac stenting in ambulatory surgical centers. I 
would also like to mention that the proposed Stark Law and 
Anti-Kickback Statute reforms as a step in the right direction 
for patients and physicians. You have been a great partner in 
shifting our payment system to reward value over volume, and I 
look forward to continuing to work together.

    Ms. DeGette. The gentleman yields back. The gentleman 
yields back. The Chair now asks unanimous consent that Members' 
written opening statements will be made part of the record. 
Without objection, they will be entered.
    I would now like to introduce our witness for today's 
hearing, Hon. Seema Verma, Administrator, Centers for Medicare 
& Medicaid Services, U.S. Department of Health and Human 
Services.
    Administrator Verma, thank you so much for coming today. 
You are aware, I know, that the committee is holding an 
investigative hearing, and when doing so we have the practice 
of taking testimony under oath. Do you have any objections to 
testifying under oath?
    Ms. Verma. I do not.
    Ms. DeGette. Let the record reflect the witness responded 
no. The Chair then advises you, under the rules of the House 
and the rules of the committee, you are entitled to be 
accompanied by counsel. Do you desire be accompanied by counsel 
today?
    Ms. Verma. I do not.
    Ms. DeGette. Let the record reflect the witness has 
responded no. If you would, then, please rise and raise your 
right hand so that you may be sworn in.
    [Witness sworn.]
    Ms. DeGette. You may be seated. Let the record reflect the 
witness responded affirmatively. And you are now under oath and 
subject to the penalties set forth in Title 18, Section 1001 of 
the U.S. Code.
    The Chair now recognizes the witness for a 5-minute summary 
of her written statement.
    In front of you is a microphone and a series of lights. The 
light turns yellow when you have a minute left, and it turns 
red to indicate your time has come to an end.
    You are now recognized.

STATEMENT OF SEEMA VERMA, ADMINISTRATOR, CENTERS FOR MEDICARE & 
   MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Ms. Verma. Thank you. Chair DeGette, Ranking Member 
Guthrie, and members of the subcommittee, thank you for the 
invitation to discuss efforts by the Centers for Medicare & 
Medicaid Services to transform and improve the United States 
healthcare system. When I came to CMS, our goal was to improve 
quality, lower costs, and improve the healthcare experience not 
only for the beneficiaries of our programs but for all 
Americans.
    In 2017, this administration inherited a chaotic and 
declining individual health insurance market. The relief 
promised by proponents of the Affordable Care Act never 
materialized. Quite the opposite. Premiums in States using the 
Federal exchange more than doubled from 2013 to 2017, the final 
year the previous administration oversaw the program. Issuers 
were fleeing the market, and we were scrambling to prevent bare 
counties.
    But after just over 2\1/2\ years as Administrator, I am 
happy to report that our market-based reforms have delivered 
lower premiums on the exchanges for the first time since the 
law started. Yesterday, we announced that for 2020 the average 
premium for a benchmark Silver plan will drop by 4 percent in 
States using the Federal exchange platform. This is on top of 
the decreases we saw last year.
    In some cases, the decline in premiums is substantially 
higher, with 6 States experiencing double-digit percentage 
decreases, including a 20 percent drop in Delaware, a 15 
percent drop in North Dakota, and a 14 percent drop in 
Oklahoma. On top of this, more issuers are entering the market, 
and the number of States with just a single monopoly issuer is 
declining. Only 2 States will have a single issuer in 2020, 
compared to 5 this year and 10 last year. This is success.
    Despite this progress, it was inevitable that Obamacare's 
affordability crisis would eventually increase the number of 
uninsured, and that is exactly what the latest census data 
show. The fact is, 85 percent of the 1.9 million newly 
uninsured in 2018 occurred among people with incomes higher 
than 300 percent of the Federal poverty level. These are people 
who do not qualify for large ACA subsidies and represent a new 
class of uninsured, those that can't afford Obamacare's 
premiums.
    Our work to lower premiums hasn't stopped with the 
exchanges. Under the President's leadership, we have 
strengthened Medicare, seeing similar success in Medicare 
Advantage and Part D. Medicare beneficiaries have more choices, 
with about 1,200 more Medicare Advantage plans available in 
2020 than in 2018. Average monthly premiums in Medicare 
Advantage are the lowest they have been in 13 years, and in 
Medicare Part D, the lowest they have been in 7 years.
    Across the board in Medicare and the exchanges, premiums 
are lower. All of our work at CMS focuses on making healthcare 
more affordable and accessible to the American people. We are 
using every lever and our large footprint to tackle 
longstanding issues and problems in the healthcare system. We 
are executing on our vision to transform care by putting 
patients first and focusing 16 strategic initiatives grounded 
in empowering patients, promoting competition, and unleashing 
innovation. CMS is committed to moving to a system of 
competition and value and giving patients the choice and 
control they want, the affordability they need, and the quality 
they deserve.
    While my written testimony provides more details, I will 
highlight a few of our efforts on these initiatives. We are 
empowering patients with the information they need to make 
decisions about their healthcare. We have efforts underway 
around price transparency, quality transparency, and ensuring 
that beneficiaries' medical records can travel with them while 
keeping the data private and secure.
    We're addressing issues that drive up healthcare costs, 
especially administrative costs. After becoming Administrator 
of CMS, one of my first actions was to launch the Patients over 
Paperwork initiative. Across our programs we have made 
commonsense changes to our regulations and guidance. Just last 
week, for example, we released a proposed rule to modernize and 
clarify the regulations that interpret the Stark Law. Our new 
policies will save providers an estimated 4.4 million hours a 
year previously spent on paperwork, with savings projected to 
be approximately $8 billion dollars over the next 10 years.
    We're also working to bring our programs into the 21st 
century. Last year, the administration launched the eMedicare 
and the MyHealthEData initiatives to modernize Medicare and 
meet the growing needs of a number of tech-savvy beneficiaries. 
This includes releasing two new cost calculator tools and the 
first redesign of Medicare Plan Finder in a decade. And as part 
of MyHealthEData, Blue Button 2.0 is already giving Medicare 
beneficiaries the ability to securely connect their claims data 
to apps and other tools developed by innovators.
    We have launched several historic efforts to improve 
quality and safety in nursing homes and across the healthcare 
system to improve rural health, to transform our program 
integrity efforts and to foster innovation throughout the 
American healthcare system, bringing new technology and 
breakthrough treatments to our beneficiaries. And we're also 
focused on transforming the Medicaid program around three 
pillars: flexibility, integrity, and accountability. Our goal 
is to restore the Federal-State partnership in Medicaid and 
allow States to resume their role as laboratories of 
innovation.
    We are approving groundbreaking waivers and doing it at a 
faster pace, and we are holding States accountable for results, 
including through our new Medicaid scorecard. At CMS, we are 
putting patients first----
    Ms. DeGette. The gentlelady's time has expired, if you can 
wrap up, please, Administrator.
    Ms. Verma. At CMS, we are putting patients first as we move 
forward with transforming the healthcare system and providing 
all Americans with an access to a variety of affordable 
coverage options.
    Ms. DeGette. Thank you.
    Ms. Verma. I greatly appreciate the opportunity today.
    [The prepared statement of Ms. Verma follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. DeGette. It is now time for Members to ask you 
questions, and I will recognize myself for 5 minutes.
    Administrator Verma, as I stated in my opening and as you 
mentioned in your statement, we saw the number of uninsured 
people in this country increase last year for the first time 
since the ACA was passed to about 1.9 million people, is that 
correct?
    Ms. Verma. That is correct.
    Ms. DeGette. And about half of those people were children, 
is that right?
    Ms. Verma. I don't think that number is correct, no.
    Ms. DeGette. OK. What is the correct number then?
    Ms. Verma. I think the number's around 400,000.
    Ms. DeGette. Four hundred thousand, thank you. Now, in the 
Texas v. United States case, that is the case that the 
administration has requested that the ACA be struck down, is 
that correct?
    Ms. Verma. That is correct.
    Ms. DeGette. And so, any day now the court will rule, and 
if the court rules the way the administration has asked, then 
the entire ACA will be invalidated, is that correct?
    Ms. Verma. That is correct.
    Ms. DeGette. OK. So now, if the ACA was invalidated, about 
21 million people would lose their health insurance, is that 
correct?
    Ms. Verma. I think what's clear----
    Ms. DeGette. Yes or no will work.
    Ms. Verma. No.
    Ms. DeGette. No, OK. How many people would lose their 
health insurance if the ACA was struck down, do you know?
    Ms. Verma. The President has made clear that we will have a 
plan in action to ensure that Americans have access.
    Ms. DeGette. OK. I am going to get to that in a minute. But 
if the ACA was struck down, isn't it true 12 million people 
would lose their insurance?
    Ms. Verma. The President has made clear----
    Ms. DeGette. No. Yes or no will work. Do you know how many 
people would lose their insurance?
    Ms. Verma. The President has made clear----
    Ms. DeGette. OK, you are not going to answer that. Now let 
me ask you this. Let me ask you this: If the ACA was struck 
down, then also the provision of the preexisting conditions 
would be struck down since it is part of the ACA, is that 
right?
    Ms. Verma. The President has made clear that we will do 
everything we can to ensure that Americans with preexisting 
conditions maintain the protection that they have today.
    Ms. DeGette. Well, let me just say then, since you are not 
answering my question: The ACA, if it was struck down, this is 
what would happen. Twenty-one million people who are insured 
under the ACA would lose their insurance. That includes 12 
million people on Medicaid and 9 million who have ACA 
protection. There are currently 133 million people with 
preexisting conditions who under the ACA get protections.
    Now there is about--I will ask you this. Maybe--I am sure 
you will give the same answer, but there are 2.3 million adult 
children under the age of 26 who because of the ACA are able to 
stay on their parents' insurance. Now, I will ask you this: If 
the ACA was struck down, would those 2.3 million adult children 
still have their insurance?
    Ms. Verma. The President has made clear----
    Ms. DeGette. OK.
    Ms. Verma [continuing]. That we will maintain what works, 
and we will try to address the problems that we're having with 
the ACA.
    Ms. DeGette. So did the administration file some kind of a 
motion in the Texas case to say that the preexisting conditions 
should be maintained? Yes or no will work.
    Ms. Verma. Individuals that have preexisting conditions 
today----
    Ms. DeGette. Yes.
    Ms. Verma [continuing]. That do not receive a subsidy, I 
would argue that they don't have the protections today. I mean 
if we give you an example of the 55----
    Ms. DeGette. So you don't think the ACA is protecting 
people with preexisting conditions?
    Ms. Verma. If you can't afford your health insurance, if 
you can't afford health insurance and you have a preexisting 
condition, then you don't have protections.
    Ms. DeGette. OK. What about the adult children? Did the 
Trump administration file a motion with the court to say they 
should still be able to stay on their parents' insurance until 
age 26? Yes or no.
    Ms. Verma. The President has made clear that we will have a 
plan in action to make sure that Americans have access to 
affordable coverage. We do not have that today. There are many 
Americans today, if they are not getting a subsidy, can't 
afford health insurance today.
    Ms. DeGette. I totally understand your position, 
Administrator Verma. You are not answering my questions 
because, frankly, if the ACA was struck down the preexisting, 
people with preexisting conditions, the adult children, all of 
those provisions of the ACA would be reversed. So you are 
telling me, Administrator, that the Trump administration has 
told people they will be protected. Can you produce for me 
right now the Trump administration's plan to protect the 
people? Can you produce that plan right now?
    Ms. Verma. So today, a 55-year-old couple making $60,000 a 
year----
    Ms. DeGette. No, no. That is not my question.
    Ms. Verma [continuing]. In Nebraska----
    Ms. DeGette. My question--excuse me. My question is, do you 
have a copy of the plan that will replace the ACA? Yes or no.
    Ms. Verma. I'm not going to get into any specifics of a 
plan, but the----
    Ms. DeGette. OK, you are not going to answer the questions. 
In that case, the Chair will yield back, and she will recognize 
the ranking member for 5 minutes.
    Mr. Guthrie. Thank you, Administrator. Do you want to 
finish your comments you were just making?
    Ms. Verma. Thank you. So a 55-year-old couple making 
$66,000 a year in Grand Island, Nebraska, could face an annual 
premium of over $31,000, and that's on top of a $12,000 
deductible. In that same situation in Colorado, that premium 
would be $32,800. In New Jersey, the premium would be almost 
$16,000. So we're talking about people having to spend a third 
to a half of their income on premiums, and that doesn't even 
include the deductibles.
    And so, if those individuals or that couple have a 
preexisting condition, they don't have any protections today.
    Mr. Guthrie. So I was going to talk about the lowering 
premiums, but you are lowering for minority very high premiums 
that increased since the ACA was passed. So the lower--but you 
have made efforts and put into place the lowering. What 
challenges remain to further lowering premiums?
    Ms. Verma. Well, I think one of the things that we need to 
do is focus on lowering the cost of care. There's been so much 
discussion about throwing more money, you know, at the problem, 
having more government control, but what we're focused on is 
lowering the cost of healthcare. Many of the initiatives that 
we have at CMS, whether it's around drug pricing, whether it's 
getting rid of administrative burdens that are getting in the 
way of doctors spending time with their patients and actually 
increasing costs, whether it's focusing on efficiencies in the 
system like interoperability and making sure that patients have 
access to their healthcare records, we are trying to focus on 
actions that are going to lower the cost of care for Americans. 
If we do that, more people will be able to afford healthcare.
    Mr. Guthrie. Thanks. And I want to switch a little bit. I 
have some Kentucky hospitals that have contacted me about the 
star rating system before, and their question is they 
understand the purpose, but it doesn't adequately, or--reflect 
the quality that they produce at their hospitals. So I know CMS 
decided to change the hospital star rating methodology, and so 
my question is that some stakeholders requested CMS remove or 
suspend star ratings from Hospital Compare website until the 
hospital star rating methodology is updated, but what does CMS 
plan to use the current methodology to update star ratings in 
early--can you, an estimate for the fix of this?
    Ms. Verma. Sure, and I appreciate the question. So, first 
of all, let's start with as we are focusing on lowering 
healthcare costs. We think that price transparency is very 
important, and along with price transparency quality 
transparency is important, and that's what the hospital star 
ratings are all about.
    I appreciate the comments and the concerns that hospitals 
have raised about their methodology, and we've made it clear 
that we want to work with them so we can make sure that 
Americans have access to quality information that's going to 
give them the best understanding of what type of hospital and 
what kind of issues that hospital may have, so we are dedicated 
to working with them. In the meantime, though, we want to be 
able to use what we have because we think it's important for 
patients to have that information.
    Mr. Guthrie. Thank you very much.
    Ms. Verma. But we will work with them.
    Mr. Guthrie. Thank you very much. And last week or the week 
before last, I think, last week we had a markup on a drug 
pricing bill here. And then the big concern that I have had, 
and one of the great things that has been bipartisan was the 
Cures Act, the things that we moved here. And being in DC, when 
I talk to people back home that things are working and things 
are moving forward, it is the blockbuster drugs that are coming 
out, the blockbuster procedures. In the bill that was--the CBO 
estimated that 10 to 15 remedies or cures would not come 
forward because of the impact of the bill.
    And there were a couple of Members on the other side, one 
that said 10 to 15 would be something to, you would just have 
to sacrifice for the fact of being able to negotiate lower drug 
prices. One said that, well, if we have these blockbuster 
cures, we can't afford them, then what good are they, so 
essentially they are not--the bill is better than those cures. 
And I just, my comment was, well, let's come up with the 
blockbuster cures and figure out how to pay for them and not 
lose them, because what if that one is Alzheimer's, diabetes, I 
mean all the things that are out there.
    So my question is I get to--is one of the ways is value-
based arrangements, and I know there are certain things such as 
Stark Law and other things that kind of get in the way of 
trying to do the value-based arrangements. Could you talk about 
value-based arrangements and pay, value-based arrangements for 
dealing with expensive cures?
    Ms. Verma. Sure. Well, I appreciate the question, and I 
think we are seeing the advent of new high-cost drugs. We've 
seen drugs priced at a half a million dollars, a million 
dollars, two million dollars. I mean, those are providing hope 
for so many patients because these new medications can actually 
cure diseases and can actually prevent some downstream costs 
for the healthcare system over the long term, so they can 
actually reduce costs.
    That being said, I don't think that our system is set up to 
handle this. In the Part B program, we pay the average sales 
price plus an add-on of right now it's about 4\1/2\ percent 
with a sequester. But it's an add-on payment, so if you think 
about paying an average sales price of a million to two million 
dollars, plus an add-on, I don't think the system can handle 
it. That being said, we do need to think about value-based.
    Ms. DeGette. The gentleman's time has expired. The chair 
now recognizes the gentlelady from Illinois, Ms. Schakowsky, 
for 5 minutes.
    Ms. Schakowsky. Thank you.
    Administrator Verma, your testimony before us, you said 
that ``the individual market was in a state of crisis because 
of the ACA.'' But in reality, it is you and the Trump 
administration who have done everything you can to sabotage the 
ACA and reverse the law's historic gains in health coverage. So 
let's go over some of the record of the past 3 years, your 
record.
    On his--and the President's. On his first day in office, 
the President signed an executive order directing Federal 
agencies to undermine the ACA ``to the maximum extent permitted 
by law.'' Days later, CMS pulled the funding for outreach and 
advertising for the final days of 2017 enrollment, an action 
estimated to have reduced enrollment by a half a million 
people.
    You cut the number of days people could sign up for 
coverage by half. You spent funds meant for promoting the 
enrollment on a public relations campaign to undermine the law. 
HHS changed its website, HealthCare.gov, making it more 
difficult for consumers to obtain appropriate health coverage. 
For 2018 open enrollment, you cut the outreach advertising 
budget by 90 percent, which resulted in as many as 1 million 
fewer people gaining access to coverage.
    You ordered the regional directors to stop participating in 
open enrollment events. In 18 cities, including my hometown of 
Chicago, you terminated contracts for in-person assistants who 
guide applicants through the ACA enrollment process and was 
designed to help them sign up for insurance, and those are now 
gone. You slashed funding for nonprofit navigator groups that 
help people shop for better coverage and you stopped making 
cost sharing reduction payments to insurers even though CBO 
warned that failure to make these payments would increase--that 
would increase premiums by 20 percent and add nearly $200 
billion to the national debt.
    And time and time again this administration, including you 
and President Trump himself, have used inflammatory rhetoric to 
spread falsehoods and misinformation about the ACA. And though 
you have slashed funding for ACA enrollment outreach, you have 
certainly pushed taxpayer funds elsewhere. According to a press 
report, you personally approved the awarding of millions of 
dollars of Federal contracts to Republican communications 
consultants who write your speeches, polish your brand, and 
travel with you across the country. This calls into question 
your stewardship of critical CMA resources that could be put to 
good use to give people coverage.
    Administrator Verma, it is simply your tenure that has 
focused on undermining the ACA. We received a report yesterday 
that premiums will go down by 4 percent in 2020, but imagine 
how much more money Americans could have saved if you were 
uplifting the ACA and helping them to get coverage. President 
Trump has said that his only plan is to ``let Obamacare fail.'' 
But you have gone further than that. You are actually 
sabotaging the law. You have led the effort, Administrator 
Verma. And, you know, you say--we have heard for 10 years now, 
well, actually since the passage of the ACA, that Republicans 
wanted to repeal and replace the law. Now you are telling us if 
there is a court decision very soon that overturns the 
Affordable Care Act, that you have a plan.
    Where is the plan? Do you have a plan that you can present 
to us or is this another pie-in-the-sky promise----
    Ms. DeGette. The gentlelady's time has expired.
    Ms. Schakowsky [continuing]. That we have heard for many 
years?
    Ms. DeGette. The Chair now recognizes the gentleman from 
Texas, Mr. Burgess, for 5 minutes.
    Mr. Burgess. I thank the Chair for the recognition. Just a 
point, here. For plan year 2017, navigators received $62.5 
million in grants and enrolled 81,000 individuals. There was a 
group of 17 navigators who enrolled less than 100 people, 
costing the taxpayers $5,000 per enrollee. Contrast: agents and 
brokers are able to enroll people at a much more cost-effective 
rate. We have had this discussion many times before in this 
committee.
    Ms. DeGette. Will the gentleman yield?
    Mr. Burgess. No, I will not. You know my time is limited. 
You have a quick gavel.
    So, let me just ask you this: Which is the more cost-
effective way of enrolling people? Is it navigators, or is it 
agents and brokers?
    Ms. Verma. I think the answer to that is agents and 
brokers. What we have found with the navigator program is that, 
when we looked at the numbers, we found that the navigator 
programs weren't meeting their goals. And that, in fact, 
despite the spending they were actually enrolling less than 1 
percent of all the enrollments. And when we did the math, 
sometimes we were spending $5,000, $7,000 per person for these 
navigator programs.
    And so, we felt like there was a better way. If we looked 
at the previous administration, they had doubled their 
advertising budgeT, and even after they doubled the advertising 
budget, enrollment went down, and so we sought for a more cost-
effective way. And all of our contracts at the agency are 
focused on promoting the work of the agency, and we focused on 
finding new and cost-effective ways of enrolling people, like 
digital ads, and those have been proven to be effective.
    Under our administration, premiums are lower. There are 
more choices. We have a 90 percent satisfaction rate at our 
call center for open enrollment, which has not happened before. 
It has only happened under our tenure. And because of the 
changes that we've made, because we've had a more efficient 
program, we're even actually able to use those savings to lower 
the user fees. We did that last year, and I hope to be able to 
do that again in the future.
    Mr. Burgess. That is an incredible figure about the call 
centers. And when the implementation of the Affordable Care Act 
came online in October of 2013, I did not take the special deal 
that Members of Congress afforded themselves. I went through 
HealthCare.gov, and that phone interaction took 4 months to 
actually accomplish, and it was one of the most miserable 
experiences I had ever been through in my life. So thank you 
for improving the customer experience at that end. A lot of 
times people don't care about the politics, they just need the 
deliverable, and it sounds like you are working hard on that.
    Thank you for your commitment to Mr. Guthrie on--we will be 
working on the next version of the Cures bill at some point 
over the coming months and, really, we do want to involve you 
and your office, members of the agency, in some of these 
fantastic gene therapies and self-therapies that are coming 
down the pike where a single shot may cure some significantly 
costly disease. And Mr. Guthrie is right. We have to have a way 
with value-based purchasing or amortizing that cost over a 
longer period of time, and certainly look forward to your help 
as the committee develops--no good to develop the cure if no 
one can afford to take it.
    Let me just ask you a question, if I could, on prior 
authorization. I get a lot of comments from my physician 
colleagues about prior auth. What are you doing to make the 
prior authorization, your Patients over Paperwork, how are you 
trying to reduce the burden of prior auth?
    Ms. Verma. Well, that is a issue that I hear a lot about 
from providers on the front line. We did a national listening 
tour, and I will say that was one of the number-one issues that 
physicians are complaining about, with good cause. As part of 
our Patients over Paperwork initiative, we've put out RFIs and 
we've heard from both sides on this.
    I can tell you right now that I have a group of individuals 
at the agency that's working on how we can figure out how to 
ensure that we have the appropriate protections in place for 
program integrity, because that's necessary. We want to make 
sure that evidence-based treatment is being provided to our 
beneficiaries, but at the same time the process can be 
burdensome.
    Mr. Burgess. Yes.
    Ms. Verma. And it can get in the way of providing good 
patient care. It can create delays in care. So we're working on 
it, and you can expect to see some action this year on that.
    Mr. Burgess. I appreciate that. Let me just try to get one 
additional question. We have had a lot of discussion in this 
subcommittee and Health Subcommittee both last Congress and 
this Congress on the issue surrounding maternal mortality. Had 
a very good hearing the other day with Dr. David Nelson, the 
residency director at Parkland Hospital, where I trained, in 
talking about his experiences at Parkland. Are there any tools 
that CMS does not currently have that would be helpful in 
addressing maternal mortality?
    Ms. Verma. Well, this is something that I started my career 
on, working on the area of maternal and child health, so it's a 
very important issue to me. We've had a conference on this 
issue. Some of the things that we're working on is streamlining 
eligibility, so as women are on Medicaid and then moving to the 
exchanges that we can make that process work better.
    Ms. DeGette. The gentleman's time has expired. The Chair 
now recognizes the chairman of the full committee, Mr. Pallone, 
for 5 minutes.
    Mr. Pallone. Thank you, Madam Chair. And I just want to 
pick up on the statement, you know, the questions you said 
about the administration's decision to ask the courts to strike 
down the ACA and the Republican lawsuit that is seeking to 
declare the entire ACA invalid. Obviously, if the district 
court ruling is upheld, Ms. Verma, you will be responsible for 
the largest coverage loss in U.S. history, or at least the 
President would be responsible for the largest coverage loss in 
U.S. history. Over 20 million Americans would lose their 
coverage, raising consumer costs and making lifesaving 
healthcare unaffordable for American families.
    Now, again, you know, as I said in my opening, if, you 
know, everybody on the right said, ``Oh, that is fine because 
we don't want the Federal Government to do anything about 
people's healthcare''--but that is not what I hear from Trump 
or my Republican colleagues. They say they want to provide 
health insurance even though they are sabotaging everything.
    So I wasn't here, but I want to know, does the President 
have a plan, and what is the plan? I mean, it sounds almost 
like there is some kind of secret plan that he doesn't want to 
reveal. Could you just tell us? What is the President's plan? 
Some information about his plan in the event that he is 
successful in this awful lawsuit, what is the plan?
    Ms. Verma. Well, I am not going to get into any specifics 
of the plan, but what I will say is that the President's 
healthcare agenda has been in action from day one. Our 
commitment to lower the cost of healthcare----
    Mr. Pallone. No, but I am not asking about that. You know, 
I disagree with you that he has had a plan so far other than to 
sabotage the ACA. But what I am asking is, if the court strikes 
down the ACA in this lawsuit, what happens then? What is he 
going to do next? What is his plan to deal with the reality 
that all these people wouldn't have health insurance?
    Ms. Verma. We have planned for a number of different 
scenarios, but we need to hear from the courts. The President 
has made his commitment clear that he wants to make sure that 
people with preexisting conditions have protections, that 
Americans have access----
    Mr. Pallone. Well, I know. But you are not giving me any 
details other than saying that he is going to give us 
something. So, look. I think that the administration----
    Ms. DeGette. Will the gentleman yield?
    Mr. Pallone. Sure.
    Ms. DeGette. In the court, the administration asked for the 
entire Affordable Care Act including----
    Mr. Pallone. Right.
    Ms. DeGette [continuing]. The preexisting conditions and 
the kids to 26 and the gender disparities and everything, they 
asked for the entire thing to be struck down.
    Mr. Pallone. Right, right.
    Ms. DeGette. They didn't ask for certain portions of the 
ACA to be retained.
    Mr. Pallone. But you see, this is my problem. And I want to 
move on to another topic, but my problem is, again, if the 
administration--if the President was honest and said, ``Look, I 
am just going to--I want to get rid of the ACA. I don't have 
anything else. I don't think people, you know, the Federal 
Government should be involved in healthcare, you are on your 
own,'' then I would say, ``OK, that is your ideology. I don't 
agree with it, but I understand that is where you are coming 
from.'' I just think it is so deceptive, though, to suggest 
that somehow we are going to cover everybody and we are going 
to do something better, but not give us anything. And you are 
not giving us anything.
    But let me go back to my other issue with, that I mentioned 
before about not being responsive. In June I sent you and 
Secretary Azar letters requesting--oh, I am going back to this 
memo.
    In April, you finalized a marketplace rule that changed the 
formula for ACA's subsidies despite your own objections to the 
policy, and I appreciate your objections. In fact, in an 
internal memorandum to Secretary Azar dated August 2018, you 
wrote that, I quote, ``I recommend not moving forward with this 
policy and that such a policy would cause coverage losses, 
further premium increases, and market disruption.'' And you 
cautioned that if the policies under consideration are adopted, 
and I quote, ``exchange enrollment would decline by 1.1 
million,'' and you wrote that these actions could result, I 
quote, ``potentially, in bare counties or States with no 
subsidized coverage available.''
    My question is, do you still believe that this policy would 
likely result in families losing coverage?
    Ms. Verma. I think there are several policies in that memo. 
I am comfortable with the final rule and where we came out, and 
I think that the evidence is clear that premiums are lower.
    Mr. Pallone. All right.
    Ms. Verma. We have more choices available on the exchanges, 
so the actions that we have taken have resulted in Americans 
having more choices about their healthcare----
    Mr. Pallone. Well.
    Ms. Verma [continuing]. And have lower premiums for the 
first time since the Affordable Care Act started.
    Mr. Pallone. All right, I understand that. That--in June I 
sent you and the Secretary letters requesting the underlying 
analysis that is discussed in the memo and the analysis of the 
impact of those policies conducted by CMS Office of the 
Actuary, and last week I sent you and Secretary Azar a followup 
letter reiterating my request. I requested a complete response 
to my letter by October 30th, but so far, as I have said, I 
have received a one-and-a-half-page response that answers none 
of my questions, not a single document. Your response has been 
unacceptable, and Congress and the American people have a right 
to know what exactly the analysis shows.
    So, again, would you commit to providing those documents to 
my letter by October 30th?
    Ms. Verma. CMS is a subagency. We are under HHS, and all of 
the documentation requests are handled by HHS, and so I would 
refer your question to the agency.
    Mr. Pallone. Well, I mean that is a really poor excuse.
    Ms. DeGette. The gentleman's time is expired.
    Mr. Pallone. Thank you.
    Ms. DeGette. The Chair now recognizes the gentleman from 
West Virginia, Mr. McKinley, for 5 minutes.
    Mr. McKinley. Thank you, Madam Chairman.
    Administrator, I think we virtually owe you an apology for 
the way you have been treated here. I have been--I go home 
every weekend, and I talk to the people. West Virginia, yes, is 
a red State. I was in Indiana the weekend before, a red State. 
But I was in Boston for a meeting up there, and I heard the 
same thing from people on the street, and we talked to the 
waitresses at how people--what is going on in Washington. And 
they talked about the tone, the accusatory language that is 
used, the lack of civility.
    And today I think it has hit a new point by this word 
``sabotage.'' Probably been, we are 42 times already today it 
has been used, like someone found it in a new dictionary that 
they want to use to try to stir up things. People are appalled 
by this, and they want us to work together, and to accuse you 
and this administration the way they have, I apologize for 
that.
    Ms. Verma. Thank you.
    Mr. McKinley. Now, let me ask you a couple questions, 
however, and that is in West Virginia and Appalachia we are 
disseminated with the opioid crisis, and we are trying to find 
ways of can there be something set up. So I am going to go away 
from what they want to--their sandbox they want to play in. I 
want to--what are ways that we can provide some additional 
funding or something for nonopioid rehabilitation treatment? 
Because we have got--there are incentives all for using 
opioids, but what about some of the other nonopioids?
    Could you come back with--when you all put together your 
rule, there is nothing in there about that, the nonopioid 
treatment, and I really hope that we can do that. Can we work 
together, Administrator, on that?
    Ms. Verma. Sure. CMS has worked with State Medicaid 
programs. We've actually approved 26 State Medicaid 1115 
demonstrations, which permit States to expand services for care 
for substance use disorder in institutions for mental disease 
and we have actually been working to implement all the sections 
of the SUPPORT Act that relate to CMS.
    In relation to your question, I will have our Office of 
Legislation reach out to you and your staff to work on that.
    Mr. McKinley. If you could, I would like to follow up with 
that. And the other is, and it began, again, I am not going to 
trash this administration and I am not going to trash the 
previous administration. We just have difference of opinions, 
but we can talk to each other. But what we asked under the 
Obama administration was, where did the--for the 
rehabilitation, for the Medicaid, Medicare, 28 days--where did 
that come up with? And no one has ever gotten back to us on 
that with--so, I am curious, to you, do you have an opinion? 
Is--and it is a trick question here, is 28 days enough for 
rehabilitation for someone deep in drugs?
    Ms. Verma. Well, I'd like to consult with our agency 
experts, and I'll have our department of legislation reach back 
out to you.
    Mr. McKinley. Wouldn't you be suspicious? Because we have 
had to deal with this pretty severely. We have 52 deaths per 
hundred thousand in West Virginia. We are leading the country 
on this. Every rehabilitation center I go to asks me that 
question: Where did the 28 days come up from? And I have asked 
that back under the previous administration, and I am asking it 
now under the--can we consider at least maybe a pilot project 
that maybe goes for 120 days or 180 days to find out?
    Because the impression I am getting under both 
administrations is that we are looking for quantity of people 
getting treatment, not quality, and if we put someone in a 
treatment facility for 120 days, I think the outcome is going 
to be far better than 28 days. So I really hope that you can 
get back to me on another time. Is that fair to say?
    Ms. Verma. That's fair to say, and we'll have our 
legislative folks reach out to you. But thank you for your 
question.
    Mr. McKinley. Thank you. And again, I apologize for the way 
you have been treated in this committee so far, OK. Thank you. 
I yield back my time.
    Ms. DeGette. The gentleman yields back. The Chair now 
recognizes the gentleman from Massachusetts, Mr. Kennedy, for 5 
minutes.
    Mr. Kennedy. Madam Administrator, thank you for being here. 
In Arkansas, more than 18,000 Medicaid recipients lost coverage 
after CMS approved a work requirement in that State, and in New 
Hampshire it was nearly 17,000. Both States, the evidence 
suggests that a large number of these people were either 
working or eligible for exemptions, but they lost coverage or 
would have lost coverage because of red tape.
    Now, you might try to tell us that those people found jobs 
and employer-sponsored coverage, but a recent study from the 
New England Journal of Medicine found that Arkansas' work 
requirement increased uninsured rates without increasing 
employment. Madam Administrator, are you aware of that study?
    Ms. Verma. So, first of all, community engagement----
    Mr. Kennedy. Ma'am, yes or no. Are you aware of the study? 
I have 5 minutes.
    Ms. Verma. I'm sorry. Can you repeat the question?
    Mr. Kennedy. Are you aware of the New England Journal of 
Medicine study that says that people lost healthcare because of 
work requirements in Arizona--or excuse me, in Arkansas?
    Ms. Verma. I'm aware of the article.
    Mr. Kennedy. OK. So in November of last year, MACPAC, a 
nonpartisan agency that makes recommendations on issues 
affecting Medicaid, said that low-level reporting in Arkansas 
was ``a strong warning that the current process may not be 
structured in a way that provides individuals with an 
opportunity to succeed with high stakes with beneficiaries who 
fail.'' And they called on you to pause disenrollments in order 
to make adjustments to the program.
    CMS did not pause disenrollments. Instead, you approved the 
work requirements in additional States. Why did you approve 
work requirements in additional States and not respond to the 
concerns of MACPAC?
    Ms. Verma. Community engagement requirements are about 
improving the lives of people in the Medicaid program----
    Mr. Kennedy. Ma'am, can you point to me to one study that 
says that a work requirement makes people healthier? One?
    Ms. Verma. So I have worked with the Medicaid program for 
over 20 years----
    Mr. Kennedy. Ma'am, one. I asked Secretary Azar this 
question, first question last year. I am certain you were 
prepped.
    Ms. Verma. There are many studies that talk about how 
employment has a positive impact on health outcomes. There are 
numerous studies.
    Mr. Kennedy. Ma'am, excuse me. No, excuse me. That is--once 
again, Secretary Azar, I asked this question to him 8 months 
ago. He gave the exact same answer. You guys run healthcare 
programs in this country. I am certain you understand the 
difference between correlation and causation. Healthier people 
might work. Work doesn't necessarily make people healthier. You 
are imposing policies on millions of people across this 
country. Can you show me one study that says that that is a 
good policy?
    Ms. Verma. I've spoken to many people on the Medicaid 
program----
    Mr. Kennedy. I will take that as a no.
    Ms. Verma [continuing]. Living in poverty and none of those 
individuals want to----
    Mr. Kennedy. Reclaiming my time, ma'am, so----
    Ms. Verma. [continuing]. Stay where they are. They want to 
find a pathway out of poverty.
    Mr. Kennedy. I am sure they do. So let's talk about Adrian 
McGonigal, who lost his Medicaid coverage in Arkansas because 
of the onerous work requirement that you approved. Without 
Medicaid, his medication was going to cost him $800, so he did 
what anyone would do, he left it at the pharmacy, did his best 
to ignore preventable pain and suffering. He failed, the 
illness caused him to miss a few days of work, and he got 
fired. Your work requirements caused him to lose a job and his 
healthcare.
    And again, do you consider that a success, yes or no?
    Ms. Verma. I think it's premature to draw conclusions about 
Arkansas. The program----
    Mr. Kennedy. Is it premature to draw the conclusion for Mr. 
McGonigal?
    Ms. Verma. The program was in effect for 10 months. What I 
will say about----
    Mr. Kennedy. Eighteen thousand people lost their 
healthcare. How many more people have to lose their healthcare 
before you can make a determination?
    Ms. Verma. Community engagement is about giving people a 
pathway out of poverty. People don't want to live in poverty.
    Mr. Kennedy. Show me the data that says that--no one wants 
to live in poverty. Show me the data that this actually lifts 
people out of poverty. One study. One.
    Ms. Verma. Again, there are studies that show that when 
we're looking at the social determinants of health and we look 
at----
    Mr. Kennedy. Ma'am.
    Ms. Verma [continuing]. Improving somebody's health 
status----
    Mr. Kennedy. You are not going to spin me----
    Ms. Verma [continuing]. Just giving them insurance----
    Mr. Kennedy. You are not going to spin me for the 5 
minutes.
    Ms. Verma [continuing]. Is not going to solve the problem.
    Mr. Kennedy. I'm going to reclaim my time, so----
    Ms. Verma. We need to address holistic issues.
    Mr. Kennedy. Ma'am, are you aware--you talked about the 
financial aspects of trying to deliver healthcare in a fiscally 
responsible manner. Are you aware of how much Kentucky is 
planning on spending to implement its work requirements?
    Ms. Verma. I have recused from the Kentucky matter.
    Mr. Kennedy. I will answer it for you. It is $190 million 
over 2 years. Do you know what per capita annual expenditure on 
CHIP in Kentucky is?
    Ms. Verma. So States are making investments----
    Mr. Kennedy. Two thousand dollars.
    Ms. Verma [continuing]. Trying to improve the lives----
    Mr. Kennedy. Two thousand dollars.
    Ms. Verma [continuing]. Of the people they serve, and those 
are one-time implementation costs.
    Mr. Kennedy. Ma'am.
    Ms. Verma. And that if----
    Mr. Kennedy. Reclaiming my time. Are you----
    Ms. Verma [continuing]. That are spread over the costs of 
the----
    Mr. Kennedy. A contract that----
    Ms. Verma [continuing]. That relate to the program.
    Mr. Kennedy. A contract that was made for your PR 
speechwriting and events services was referenced already 
earlier in this hearing. Are you aware that one of the line 
items was for a confidante of yours named Marcus Barlow, who is 
scheduled to receive $425,000 over the life of that contract, 1 
year?
    Ms. Verma. All of the contracts that we have at CMS are 
based on promoting the work of CMS.
    Mr. Kennedy. So----
    Ms. Verma. When we use contractors, we use them for two 
reasons. One reason would be when we require specialized 
expertise that we may not have in-house.
    Mr. Kennedy. Ma'am, specialized expertise to write 
speeches. Are you aware that for that same cost 2,000 kids 
could have--excuse me, 200 kids--in CHIP, eligible for CHIP in 
Kentucky, could have kept their healthcare?
    Ms. Verma. The contracts that we have----
    Mr. Kennedy. What is a better use of those healthcare 
dollars, of U.S. taxpayer dollars: to employ an additional 
communications person underneath CMS that already has dozens, 
if not hundreds, or 200 more kids that could get access to 
healthcare? What is a better stewardship of those taxpayer 
dollars?
    Ms. Verma. The use of our contracts are to promote the 
programs that we have in place. We use contractors----
    Mr. Kennedy. At the expense of those 200 kids?
    Ms. Verma. Those contracts are consistent with what 
previous administrations have done.
    Mr. Kennedy. At the expense of those 200 children.
    Ms. Verma. Those contracts that we have in place are 
consistent with how the agency has used resources in the past, 
and they're focused on promoting the work. One of the things 
that we want to do is make sure that people understand----
    Ms. DeGette. The gentleman's time has expired.
    Mr. Kennedy. That is a shame.
    Ms. DeGette. The Chair recognizes the gentleman from 
Virginia for 5 minutes.
    Mr. Griffith. Thank you very much.
    Did you wish to finish your answer?
    Ms. Verma. Yes. So what I was trying to say is that the 
contracts that we have in place are about promoting the work of 
the agency. One of the things that I wanted to do when we came 
to CMS is make sure that the American people understand the 
things that we're doing. We've had a historic number of 
initiatives, 16 initiatives, and it's important that the 
American people understand that. We did not have that expertise 
in-house at the time.
    And the other thing that we use contractors are for is when 
we have something that we cannot do in-house, so that's one 
reason, or we need some short-term help. My job at the agency 
is to set the vision and set the agenda, and it's up to other 
staff members to determine whether that work can be done in-
house or whether we need to hire contractors.
    Mr. Griffith. And in relationship to CHIP, wouldn't you 
agree that the Championing Healthy Kids Act was a major step 
forward?
    Ms. Verma. It absolutely was. I think it's very important 
that children have access to healthcare coverage, very 
important to their development.
    Mr. Griffith. And would you be surprised to learn that a 
number of members of this committee voted no, particularly 
those on the other side of the aisle?
    Ms. Verma. That would be very concerning.
    Mr. Griffith. I understand. Also, I find it interesting, 
just cleaning up some stuff here, that CBO estimates that 2.6 
million more people have employer-funded insurance today than 
before President Trump took office. Were you aware of that?
    Ms. Verma. Yes. I think that our agency's success and the 
success of the administration is clear. Premiums are lower not 
only in the exchanges but also in Medicare. There are more 
choices for people in Medicare and in the exchanges, more than 
what we had when we came into office.
    Mr. Griffith. Now, we have heard a lot today about 
sabotage, and my friend, the gentleman from West Virginia, Mr. 
McKinley, talked about the fact that sabotage has been used a 
lot. But I would have to say to my colleagues on the other side 
of the aisle that, when you write a bill such as Obamacare and 
you put in there 3,033 times the words ``the Secretary'' 
appears and 974 times the words ``the Secretary shall'' appear. 
And off the top of his head, Dr. Burgess indicated there were 
about 262 times that you, if you kept going out, you know, 
``shall determine,'' ``the Secretary shall determine'' appear, 
roughly, and we will have to double check that one, but that is 
off the top of his head.
    Wouldn't you think it would be unfair to say that the law 
had been sabotaged when the Congress--now, remember, that was a 
bill passed, Obamacare passed specifically and only by 
Democrats. No Republicans in the House voted for it. So, if it 
was sabotaged, it was sabotaged because they gave too much 
power to the administrative branch of government, and today 
they find themselves with an administrative branch of 
government that has a different philosophical outlook and, 
therefore, if it were in fact sabotaged, it was sabotaged at 
its initiation in the passage of that bill. Would you agree 
with me on that?
    Ms. Verma. I would agree and the results speaks for 
themselves. Premiums are lower. When I got into my role, 
premiums were going up, a hundred percent in some cases, some 
200 percent in some cases. This is for the first time that 
we've actually seen premiums go down. They went down last year. 
They're going down again. We've put out over 12 reinsurance 
waivers, and in some cases you've seen double-digit decreases, 
30 percent.
    So for all the work that we're doing, I don't know how we 
measure that, but to me that looks like success.
    Mr. Griffith. Yes, ma'am. And now, so let's get to 
something else I need to talk about. Earlier this year it came 
to my attention that CMS planned to include noninvasive 
ventilators in Medicare's competitive acquisition program for 
durable medical equipment. In June, Mr. Welch and I led a 
letter signed by 180 of our colleagues expressing concern about 
that decision.
    I support the goal of ensuring financial responsibility in 
healthcare, but I am not convinced that this method is 
appropriate in every situation. Until we know that access to a 
critical piece of medical equipment won't be compromised, I 
don't think we should be making monumental changes to the 
acquisition process. And I just got your letter--it arrived 
late yesterday afternoon--in response to that letter, where you 
said we are not going to do it on invasive.
    But here is the problem I have. I have a rural district, as 
does my friend Mr. Welch. And what happens is, is that if you 
go to this cost-only issue, in those rural areas you are going 
to make somebody drive 45 minutes, an hour. I remember talking 
to one of my suppliers about a case where the lady lived on top 
of one of the two highest peaks in Virginia, and he took her 
oxygen up there to her and made sure that she had what she 
needed for her ventilator supplies, noninvasive.
    She is not coming down the mountain, particularly not in 
the wintertime, to get what she needs if now the low-cost 
supplier is only located in the town. And if it becomes a point 
where they have to get to Bristol, you are talking about even 
more time. But just to get down the mountain to Marion, it is 
going to take a lot of time. So I would ask you all to really 
take a look at that because I am afraid that in the rural 
districts our folks are not going to get served. I yield back.
    Ms. DeGette. The gentleman's time has expired. The Chair 
now recognizes the gentleman from California, Mr. Ruiz, for 5 
minutes.
    Mr. Ruiz. Thank you. This administration has made clear 
from day one that they will not protect people with preexisting 
conditions or protect access to affordable healthcare for 
Americans. They continue to repeal the ACA first through 
legislation, and when that failed through the courts. And in 
lieu of complete repeal, they have done everything they can to 
chip away at the protections that it provides.
    Repealing the protections harms patients but helps 
insurance companies make greater profits. It gives them power 
to deny and delay care for people who really need it. And as a 
physician I took an oath to do no harm, and trying to take 
affordable coverage away from millions of Americans flies in 
the face of that oath. I practiced medicine before the passage 
of the Affordable Care Act, and I saw what that meant for 
patients.
    So let me tell you a little bit about what that was like. 
In fact, even when I was in medical school, during my medical 
school graduation at Harvard Medical School, my whole family--I 
have a big family, and they came from everywhere. And we were 
in my tiny little apartment and we were getting ready for my 
ceremony, and my little sister curls over in excruciating 
abdominal and flank pain, excruciating, shaking.
    And we were so very concerned, but she refused to go to the 
Emergency Department. It wasn't necessarily because she was 
going to miss my graduation, she didn't want to be a burden to 
us for that, but primarily she didn't have health insurance and 
she couldn't afford it and she was so afraid, so she just 
endured it. And that is what families do throughout our 
country, they endure this pain. Well, she was 22. Now, she 
could have been on her parents' health insurance.
    The second story is like a man 55 years old from Palm 
Springs with HIV positive status. Before the Affordable Care 
Act, infections after infections, life-threatening, very 
concerned he wasn't going to live past, you know, 58 or 
something. And now, because of the Medicaid expansion, he is 
happy. He is living well. He finally can get the care and the 
medications and everything that he can have, and he is living 
that life that he has always wanted to.
    It is like that young mother of two who came into my 
Emergency Department with the chief symptom of ``a lump in my 
breast.'' And I am thinking, a lump in your breast? Why are you 
coming during the holidays for a lump in your breast? She 
didn't have any primary care. She didn't have insurance. She 
knew it was growing, it was the size of a lemon. It was 
irregular in form, it was painless. Her sister forced her 
because they knew what they were afraid of. And, sure enough, 
it was most likely cancer. I was able to connect her with post-
Emergency Department care.
    But, because of the Affordable Care Act, that preventive 
mammogram is now covered, and that she couldn't afford it and 
now she potentially had cancer metastasized to her body. That 
is why we are angry. It is for those patients that we are 
standing up. It is for the American people who are today scared 
that we are going to go back to a time where they are going to 
be denied and delayed, that they are going to endure pain, that 
they are going to potentially lose their life and leave their 
children behind, that they are going to suffer infections, and 
that is why we are pressing you and this administrations for 
those questions.
    Because this administration is encouraging the Supreme 
Court to strike down the ACA in its entirety, all of it. There 
is no defense in court to protect people with preexisting 
condition. There is no defense in court for the young people to 
stay on their parents' health insurance. There is no defense of 
the Medicaid expansion. There is no defense of protections for 
preventive care that help my constituents, my patients, and my 
family.
    There is no defense for the American people in those 
protections for them. And to make matters worse, you have no 
plan. You can't produce a document. You can't give us a detail. 
You are skirting the issues, and all we are getting is only 
spin and talking points. The American people deserve better. I 
yield back my time.
    Ms. DeGette. The gentleman yields back. The Chair now 
recognizes the gentlelady from Indiana, Mrs. Brooks, for 5 
minutes.
    Mrs. Brooks. Thank you. And thank you, Administrator Verma, 
for being here today.
    Actually, the stories that you have heard from my 
colleagues, I assume that in your role for the last 3 years, 
you have mentioned that you have been having roundtable 
discussions. And that wasn't what I was originally going to ask 
you, and I do want to save a little time for what I want to 
talk about with you. But can you share very briefly, how you do 
stay connected with the patients and the people you are trying 
to serve?
    Ms. Verma. Well, I appreciate that. We've done a national 
listening tour, and we talk to people all over the Nation.
    Mrs. Brooks. People who--can you share who these people----
    Ms. Verma. People who are having trouble----
    Mrs. Brooks. Yes, the type of people you talk to?
    Ms. Verma [continuing]. Affording Obamacare. And so, in the 
examples that were used previously, I'm scared for those people 
too, because if they don't have a subsidy they often cannot 
afford health insurance under Obamacare. Obamacare structure is 
so expensive that the middle class can't afford health 
insurance, and that's why we're seeing increases in the number 
of uninsured, because premiums have gone up a hundred percent, 
200 percent.
    And while this administration has stabilized the market--
premiums are going down--they are still too expensive, and if 
you do not have a subsidy and if you have a preexisting 
condition, you do not have protections today. And that's why 
this administration is trying to advance efforts to try to make 
sure that every American has access to affordable coverage. 
That is not the case today.
     Mrs. Brooks. Thank you. I want to pivot and focus on, you 
talked about the role of technology and innovation in the 
healthcare system. Medical error is the third-leading cause of 
death in the United States, responsible for claiming over 
400,000 lives, and millions of dollars are wasted on 
duplicative and unnecessary tests and procedures. We know that 
patients want their up-to-date medical information at their 
fingertips.
    Congresswoman Clarke, a colleague of mine across the aisle, 
and I introduced the Mobile Health Record Act, and it directs 
CMS to do more to promote the use of secure medical records 
approved by CMS through the Blue Button 2.0 program. The 
proposed CMS Interoperability and Patient Access rule is to be 
published before the end of the year, requiring Medicare 
Advantage plans first and Medicaid plans next, to offer open 
APIs for their plan enrollees to access their medical data with 
their mobile application of choice.
    And you mentioned, more and more patients are tech-savvy 
and want this type of access, but I remain concerned about the 
lack of public promotion or awareness of the CMS Blue Button 
program and its Medicare-approved apps for the 60 million 
Medicare beneficiaries. And, in fact, a recent survey showed 
that only three out of a hundred Medicare Advantage members are 
even familiar that the Blue Button 2.0 program exists.
    Knowing how important this is, what more can be done to 
reach new enrollees? It is very complicated to get through your 
websites and process to find the Blue Button, and yet people 
want to have their medical records in their hands. So can you 
talk to us about what your plans are to improve access to our 
own medical records?
    Ms. Verma. I appreciate the question, and I agree with you 
that we can do more to make sure that people understand what's 
available. The issue of patient records--and if you'll indulge 
me for a second, I'll tell you a story, because I think it sort 
of sums up the issue of patient access.
    My family was traveling, they were headed home. I was 
headed back to DC when my husband had a cardiac event. He had a 
major seizure. My daughter called me and handed the phone to 
the paramedics, and they said, ``Ma'am, your husband's not 
breathing, and we need to understand his health history. Is 
there anything in his health history?''
    And at that moment----
    Mrs. Brooks. How long ago was this?
    Ms. Verma. This was about 2 years ago, in 2017. And so, at 
that time, you know, obviously I'm in a panic, but I did not 
have that information. My family didn't have that information, 
and my husband was in no condition to tell us about his health 
history. And I scrambled for about 2 hours in the time that it 
took me to get to my kids and get to my husband to try to find 
this information.
    In the end, the hospital had to do a number of tests 
because they couldn't figure out what was wrong. Luckily, he's 
OK and he survived something that maybe less than 1 percent of 
people survive, so he was very lucky. But when I left the 
hospital, I asked the staff there, can I have a copy of all the 
tests that you performed, so I had a complete medical record to 
give back to his doctors in Indiana, and unfortunately all they 
could give me was a CD-ROM.
    So after our Federal Government spent $36 billion on 
electronic health records, all I got was a CD-ROM, which really 
only had a record of one test, and so that really spoke to me 
of the issues. Patients need to have access to their complete 
medical records so that we can understand the issues that we 
face.
    Mrs. Brooks. Can I interrupt? Are you going to dedicate 
more people to this, and how are you going to fix this?
    Ms. Verma. This is one of our main priorities. We have 
several rules. One is about making sure insurers are providing 
claims data to patients. We are giving incentive payments to 
physicians to make sure that they're providing data to their 
patients. Hospitals are facing penalties.
    Ms. DeGette. The gentlelady's time has expired. The Chair 
now recognizes the gentlelady from New Hampshire, Ms. Kuster, 
for 5 minutes.
    Ms. Kuster. Thank you. And thank you, Ms. Verma, for being 
with us today.
    A quick yes-or-no question before we start. I understand, 
yesterday, Secretary Azar said that the reason he is not 
concerned about the court decision ending the ACA overnight is 
that he is relying upon an appeal to the Supreme Court. Is that 
your position? Is that why you don't have a plan to tell us 
today?
    Ms. Verma. We have planned for a number of different 
scenarios.
    Ms. Kuster. But are you expecting----
    Ms. Verma. I think what the Secretary is speaking to is 
that this is going to take some time for the courts to resolve, 
but we have planned for a variety of different scenarios.
    Ms. Kuster. Including an appeal to the Supreme Court?
    Ms. Verma. Correct.
    Ms. Kuster. So--because I am a little confused today by 
your testimony and particularly by the testimony of our 
colleagues. I have been in Congress for 7 years. I voted 55 
times not to repeal the Affordable Care Act because our 
colleagues were so persistent about week after week, month 
after month voting over and over again to repeal the Affordable 
Care Act in its entirety. And now this administration is in 
court asking to repeal the Affordable Care Act in its entirety. 
And yet, you sit here today singing the praises of the 
Affordable Care Act and how proud you are of your work to bring 
down the rates, but at the same time you are cutting access for 
400,000 children. That was your testimony this morning.
    So I just want to move to a particularly important part for 
my constituents, which is the issue of preexisting conditions. 
And you will recall that, before the Affordable Care Act, 
Americans could be denied their health insurance coverage if 
they had any kind of a preexisting condition. I think about it 
in my family. I will just start at the beginning of the 
alphabet: asthma, allergies, Alzheimer's, cancer, diabetes, the 
list goes on and on. And, in fact, over 50 percent of Americans 
have a deniable condition.
    In New Hampshire, that is 54 percent of our citizens have a 
deniable condition, and yet your administration, in fact your 
own actions with the short-term limited duration health plans--
by the way, a classic Washington, DC doublespeak, short-term 
limited duration health plans--have threatened families with 
preexisting conditions. And, in fact, you have encouraged 
States to promote junk plans through their waivers in order to 
circumvent essential health benefits and protections for 
preexisting conditions.
    I was very proud to lead bipartisan legislation. It passed 
the House, Protecting Americans with Preexisting Conditions, 
last May, and it will ensure that people with preexisting 
conditions are covered. But let me ask you, do you believe, Ms. 
Verma, that allowing individuals to once again be discriminated 
against or have their coverage declined due to preexisting 
conditions is moving America in the right direction for their 
healthcare? Just yes or no.
     Ms. Verma. None of the actions that we have taken do 
anything to undermine the protections for people with 
preexisting conditions.
    Ms. Kuster. Well, encouraging junk plans that do not cover 
Americans with preexisting--we heard the testimony right here. 
We had families right in front of us, and they had no idea. 
There was no requirement that they be warned of that, and 
instead of 3 months, these were a year and they could be re-
upped multiple times. So I think your testimony is not actually 
truthful to us today, and I regret that.
    According to a 2019 study by the Kaiser Family Foundation, 
half of Americans, as I mentioned, have a declinable condition. 
Did your agency conduct an analysis to evaluate the effects of 
the implementation of your guidance on these families and their 
access to affordable health insurance? Yes or no.
    Ms. Verma. I'm sorry. Which guidance are you referring to?
    Ms. Kuster. The guidance that you provided about the 
waivers and the junk health plans. Did you analyze the impact 
on American families that had preexisting conditions? Yes or 
no.
    Ms. Verma. So in the issue of the 1332 guidance that we put 
out for States, I can tell you that States have had an 
enormously difficult time----
    Ms. Kuster. Just a quick question.
    Ms. Verma [continuing]. Experiencing the double-digit 
rate----
    Ms. Kuster. Did you----
    Ms. Verma [continuing]. Increases. And we wanted to----
    Ms. Kuster [continuing]. Analyze what would happen to 
families with preexisting conditions? Yes or no.
    Ms. Verma. The way the guidelines work is, we give 
basically direction to States about how they can develop plans 
to make health insurance more----
    Ms. Kuster. I am asking if your office analyzed the impact 
of your guidance. Yes or no. This is not difficult.
    Ms. Verma. So we have to impact--we would have to review 
the proposals. And so for every proposal----
    Ms. Kuster. And can you provide that to this committee, 
your analysis?
    Ms. Verma. Every proposal that comes in under 1332 is 
analyzed around the four guardrails around comprehensive 
coverage.
    Ms. Kuster. And could you provide that analysis to this 
committee? My time is up. Yes or no.
    Ms. Verma. So every single proposal that comes in----
    Ms. Kuster. Yes or no, you'll provide that analysis to this 
committee?
    Ms. DeGette. The gentlelady's time has expired.
    Ms. Kuster. My time is up.
    Ms. DeGette. The Chair now recognizes the gentleman from 
South Carolina, Mr. Duncan, for 5 minutes.
    Mr. Duncan. Thank you, Madam Chairman.
    Administrator Verma, I will let you finish answering her 
question if you need to.
    Ms. Verma. Sure. So let me start with short-term limited 
duration plans. These are plans that have been available before 
Obamacare started and during Obamacare. They used to just be 
available for 3 months, and we extended the period of time. We 
also made sure and we strengthened these protections, which 
were not in place under the previous administration, to make 
sure that people understood what type of plan that they were 
buying and what the limitations were of these plans.
    But there are so many Americans today that cannot afford 
coverage under Obamacare when rates have gone up a hundred to 
200 percent, and I gave you some examples of a couple in 
Nebraska. They are 55 years old, and the premiums that they 
would have to pay are anywhere between a third to half of their 
income. Short-term limited duration plans provide a lifeline. 
They can provide coverage at rates that are perhaps 60 percent 
lower than what they could find under Obamacare, so it provides 
an alternative.
    There's many people that are in between jobs that cannot 
afford Obamacare, and this is an alternative. And our 
administration has done everything that we can to ensure that 
there are protections in place and that those plans clearly 
articulate the limitations of what they may or may not cover.
    Mr. Duncan. Yes. Thank you for that. I apologize for how 
some of my colleagues have treated you today.
    Let me say I appreciate the multiple conversations we have 
had regarding some of the nursing home issues occurring across 
the Southeast Region. We have touched on topics including 
inconsistencies and civil monetary penalties, citations given 
among the regions, and how facilities in Region 4 have been 
especially hit. We have also touched on the important need for 
specific guidance to be provided for abuse reporting rules.
    Another thing I would appreciate you looking further into 
is the red consumer alert icon that could be placed next to 
nursing homes that have been cited for incidents of abuse and 
the Nursing Home Compare website. I understand this initiative 
goes into effect today. However, I feel CMS needs to fully 
solve the CMP and abuse reporting issues, first, before we go 
negatively labeling facilities online. If facilities in the 
Southeast Region don't get relief soon, we are going to be in a 
tight spot.
    So can you and your staff please comment or at least commit 
to revisiting the issue of consumer alert icon being 
implemented?
    Ms. Verma. Well, we've put out a five-part strategy on 
strengthening oversight, enhancing enforcement, increasing 
transparency, improving quality, and putting patients over 
paperwork. One of the things that we've done is we have 
clarified immediate jeopardy guidelines. And I agree with you 
that there has been inconsistency in how CMS and State agencies 
have implemented the guidance, and so that's why we've created 
a new performance standard system so that we can monitor what's 
going on in the local level to ensure that we have consistency 
in how we are clarifying immediate jeopardy in cases of abuse 
and neglect.
    In terms of the icon, there's about maybe 5 percent of 
nursing homes that will be impacted by this, and it only alerts 
those in which we've had cases of abuse and neglect. And, you 
know, if there's other types of issues that have come up, 
they're sort of, I would say, not high-level areas of abuse and 
neglect, in those areas we only use the icon if they have been 
repeat offenders.
    So this isn't really going to impact very many nursing 
homes. There are many nursing homes that provide high-quality 
care, but there are some out there--and we think it's important 
to make sure that the American people have the information that 
they need to make the decisions that work best for them.
    Mr. Duncan. In the essence of time, we will move on. We 
will be watching some of the reforms and how they impact the 
nursing home facilities.
    I want to touch base on one other thing, and that is the 
exchange program integrity Section 1303 in the Affordable Care 
Act. We have asked--we talked yesterday about this. You say 
that the ruling finalization is supposed to be in HHS's hands 
now. Open enrollment period begins November 1st, and I think 
clarification on this is important. We sent a letter July 1, me 
and many, many of my colleagues signed this, asking for 
Secretary Azar to approve that.
    I want to submit that, if we can, to the record, Madam 
Chair. And also want to urge my colleagues, I am going to send 
another letter today, if you would like to sign on to that, on 
the 1303 urging fast implementation.
    Ms. DeGette. Without objection, the letter will be entered.
    [The information appears at the conclusion of the hearing.]
    Mr. Duncan. I would also like to add a letter from some of 
the care providers that have urged us to take action as well, 
for the record.
    Ms. DeGette. We will review that letter. I haven't seen 
that letter.
    Mr. Duncan. Thank you. It is important that this rule get 
finalized, and it was proposed November of 2018. That is almost 
a year later, and it still hasn't been. Can you speak to the 
work CMS has done to help finalize this rule and what the 
current status is? We know it is in Azar's hands, but if you 
would like to touch base on that in 10 seconds.
    Ms. Verma. We share your commitment to getting that rule 
finalized, and we'll be doing everything that we can to bring 
that to fruition.
    Mr. Duncan. OK. If any colleagues want to sign on to that 
letter to Secretary Azar today by close of business, you can 
contact my office. I yield back.
    Ms. DeGette. The Chair will admit the second letter that 
the gentleman referenced.
    [The information appears at the conclusion of the hearing.]
    Ms. DeGette. The Chair now recognizes the gentlelady from 
Florida, Ms. Castor, for 5 minutes.
    Ms. Castor. Thank you, Madam Chair. And thank you, 
Administrator Verma, for being here today.
    The Trump administration has made numerous policy changes 
that increase the costs on families across this country, 
increase health insurance premiums, and erode coverage for 
preexisting conditions, preexisting conditions like cancer and 
diabetes. We had all hoped that this fight was over, but we are 
going to continue to have to work to make sure that families 
who have preexisting conditions get their coverage.
    You stated earlier in your testimony that the Trump 
administration policies have stabilized costs. There is no 
evidence of that. A recent study by the Kaiser Family 
Foundation estimates that 2019 premiums are 16 percent higher 
than they otherwise would be due to the Trump administration's 
actions. And a report out of your own agency has established 
that the various sabotage policies of the Affordable Care Act 
has increased costs on families who are not eligible for tax 
credits.
    And one of the most egregious policies that has increased 
costs is the expansion of the junk health insurance plans, the 
short-term limited duration plans, because what has happened, 
after the Trump administration and the GOP failed to repeal the 
Affordable Care Act and dramatically cut health services under 
Medicaid, they turned to a very insidious plan to cut outreach 
and enrollment, weaken the health insurance pool by eliminating 
navigators, and then marketing, allowing these junk insurance 
plans to roll out, to the detriment of the families we 
represent.
    These junk insurance plans do not have to cover preexisting 
conditions. They don't have to cover hospital ER care or 
prescriptions drugs. They don't have to cover mental health 
services. And when Secretary Azar was here, Madam 
Administrator, we asked him, I asked him specifically, ``Are 
you aware that these plans can exclude coverage for preexisting 
conditions or decline to offer coverage to individuals with 
preexisting conditions, yes or no?'' And he responded, ``Yes, 
that's correct.''
    Do you disagree with him that these junk insurance plans 
don't have to cover preexisting conditions, or you agree with 
Secretary Azar?
    Ms. Verma. Short-term limited duration plans provide more 
flexibility. And under our administration, premiums----
    Ms. Castor. Well, by flexibility are you saying--you agree, 
then, they don't have to cover preexisting conditions. That 
is--see, this is very dangerous because we are about to enter 
into an open enrollment period, right, the open enrollment 
under the Affordable Care Act dates are--what date?
    Ms. Verma. They start November 1st.
    Ms. Castor. And run through?
    Ms. Verma. They go through December 15th.
    Ms. Castor. OK, so be careful, consumers, families across 
the country. If you go online and you type in ``I am looking, 
shopping for health insurance'' sometimes what will come up 
will be one of these junk insurance plans. The Federal Trade 
Commission has already had to act and shut down some of these 
fly-by-night health insurers, calling it a bait-and-switch 
scheme.
    So when you are shopping for your health insurance, be 
careful. A lot of these companies are going to market a plan 
that says, oh yes, we will cover you, we will cover your 
preexisting condition, and then they find it is not covered. In 
fact, the nonpartisan Congressional Budget Office confirmed in 
a report that short-term plans have large coverage gaps that 
expose consumers to catastrophic costs, especially for folks 
with preexisting conditions. For example, a woman who enrolled 
in a short-term plan and was then diagnosed with breast cancer 
could face between $41,000 and $111,000 in out-of-pocket costs. 
That is from the CBO and the American Cancer Society Action 
Network.
    Another one of the insidious sabotage efforts has been to 
our independent navigators across the country. And there is a 
lot of misinformation coming out that, oh, navigators aren't 
effective. Well, if you go to the Kaiser Family Foundation 
report and the Government Accountability Office report from the 
past few months, they said, wow, HHS is pedaling false 
information. These navigators are--brokers are fine, but 
navigators do not have allegiance to an insurance company, they 
have an allegiance to the consumer, often help them sort 
through all of their affordable options.
    So it is really unwise to eliminate navigators on one hand, 
market junk plans, cut outreach and enrollment--all of these 
things undermine a health insurance pool that helps keep costs 
down for families.
    Ms. DeGette. The gentlelady's time has expired.
    Ms. Castor. Thank you very much. I yield back my time.
    Ms. DeGette. The Chair now recognizes the ranking member of 
the full committee, Mr. Walden from Oregon, for 5 minutes.
    Mr. Walden. Good morning, Madam Chair. And, Ms. Verma, 
thank you again for being here. We appreciate your leadership 
at the agency and your sitting through these discussions.
    I want to talk about the navigators, because in the CMS 
report that I believe is from 2016, which is before the Trump 
administration, for plan year 2017, navigators received $62.5 
million in Federal grants, they enrolled 81,426 individuals, 
which, if I understand that right, equates to $767 per person 
is the math if you divide the total number enrolled versus the 
total amount spent. Now also, according to CMS from the Obama 
administration data, 17 navigators enrolled less than a hundred 
people each at an average cost of $5,000 per enrollee, and 78 
percent of the navigators failed to achieve their enrollment 
goals.
    So this is from the CMS information that is from 2016 for 
plan year 2017, and when did you become administrator?
    Ms. Verma. In March 2017.
    Mr. Walden. Yes. So in 2017, then, CMS announced that it 
would start awarding funding to navigators based on their 
ability to meet their enrollment goals. That sounds like pretty 
standard business practice.
    Ms. Verma. That's right. We have a duty to taxpayers to 
make sure that our programs are cost effective.
    Mr. Walden. And so, as a result, CMS reduced the funding 
for the program by 10 million for 39 organizations in 2018. 
Why? Why did you do that?
    Ms. Verma. We did that because the navigator program was 
not producing the types of results that we would expect to see. 
My goal is to make sure that consumers using HealthCare.gov or 
our call centers have a very smooth experience, and we felt 
like there were more different ways. When a program is new, it 
does require a lot of intensive investment in terms of outreach 
and enrollment.
    Mr. Walden. Sure.
    Ms. Verma. But looking at the Affordable Care Act, it had 
been in place, and we were looking, reviewing the types of 
investments that have been made. We had seen from the previous 
administration that they had actually doubled their advertising 
budget to a hundred million dollars, but actually enrollment 
went down, so we knew that those types of things weren't 
effective.
    And the same thing with the navigator program. When we did 
the math, it just didn't add up when you are spending $5,000 
per person. So what we tried to do is invest in more cost-
effective ways, digital ads, more of those types of things, and 
I think our results have been effective. We had a 90 percent 
customer satisfaction rate for people that used our call 
centers.
    We haven't seen the dire predictions in terms of enrollment 
going down. We've had minor fluctuations, which I think can be 
attributable to the Trump economy where things are move--are so 
good that people don't necessarily----
    Mr. Walden. Well, let me ask you that. And I am sorry to 
interrupt you, but on that very point, aren't--how many more 
people are now covered by private insurance as a result of the 
strong economy?
    Ms. Verma. Well, because of the strong economy, what we're 
seeing is that people aren't relying on public programs as 
much. We are seeing, however, some of the individuals, though, 
that aren't subsidized, that they're having trouble affording 
health insurance and that the increase in the number of 
uninsured is actually for people that are 300 and 400 percent 
of the poverty level.
    And so, what that shows us is that they can't afford health 
insurance premiums because of the way Obamacare is structured, 
and so people that are subsidized, we're seeing their 
enrollment go up, but it's the unsubsidized population where 
we're seeing problems. We've seen a 40 percent decrease.
    Mr. Walden. So this is kind of the middle class----
    Ms. Verma. That's right.
    Mr. Walden [continuing]. That is caught right there. Not 
getting a subsidy, can't afford the health insurance they are 
stuck with, and you are trying to give options and have States 
involved. My State has come to you and gotten relief from 
certain Federal requirements, right?
    Ms. Verma. That's correct. We've been doing reinsurance 
waivers, and I think the short-term limited duration plans and 
association plans, those are efforts of the administration to 
give people alternatives because we know the middle class 
cannot afford expensive Obamacare. So we're trying to provide 
more choices and let the American people decide what benefit 
plan is going to work best for them, not a one-size-fits-all 
government approach, which is expensive. We think Americans 
should make those decisions themselves.
    Mr. Walden. When we had a big debate on the floor on some 
healthcare issues, and a number of my friends on the other side 
of the aisle had amendments directing the navigators do a whole 
bunch of things--reach out to rural areas--and I raised the 
issue then, and I think we followed up with a letter to you 
recently. That told me the system is broken with the 
navigators, because they were having to have amendments 
directing the navigators to do all these different things. And 
so, is that system broken?
    Ms. Verma. Yes. And I also think that, you know, we look 
at--we do open enrollment for the Medicare program every year, 
and what we do there is we use a system of volunteers to help 
individuals.
    Mr. Walden. Are their navigators paid from, like, Medicare 
Part D or Medicare?
    Ms. Verma. No. We use a system----
    Mr. Walden. All right.
    Ms. Verma [continuing]. Something we called our SHIP 
volunteers, and they do an incredible job of helping seniors 
through the open enrollment process. So I think there's better 
ways and more cost-effective ways.
    Mr. Walden. Thank you. My time has expired. Thank you, 
Madam Chair.
    Ms. DeGette. Thank you so much. The Chair now recognizes 
the gentlelady from New York, Ms. Clarke, for 5 minutes.
    Ms. Clarke. I thank you, Madam Chair, and I thank our 
ranking member.
    Administrator Verma, Hubert Humphrey, he was the namesake 
of the building that you work in, said, ``The moral test of 
government is how the government treats those who are in the 
dawn of life, the children.'' This quote is even inscribed on 
the wall as you walk through the front door of HHS. On your 
watch, it is safe to say that this administration has failed 
that moral test.
    This administration inherited historically low uninsured 
rates among children, but thanks to this administration's 
sabotage and mismanagement of healthcare, those rates have gone 
up from 3.6 million uninsured in 2016 to 4.3 million uninsured 
children in 2018. You have said you want to preserve Medicaid 
for those who truly need it. Are low-income children among 
those who truly need Medicaid? This is a yes-or-no question.
    Ms. Verma. As a mom--I have two children--I think having 
health insurance for children is extremely important to their 
development.
    Ms. Clarke. Very well. So the New York Times has reported 
yesterday that, since 2017, more than a million children have 
lost coverage in Medicaid and CHIP. Further, the Census Bureau 
reported that on your watch the children's uninsured rate 
increased to 5.5 percent, largely because of the deadline in 
coverage under Medicaid and CHIP.
    Administrator Verma, do you agree with the findings of your 
administration's own Census Bureau? Yes or no.
    Ms. Verma. There's a couple of--there's two separate issues 
here.
    Ms. Clarke. Yes or no. Yes or no. Do you agree? Have you--
--
    Ms. Verma. It's not a yes-or-no question.
    Ms. Clarke. It is a yes-or-no question. Either you agree 
with what the Census has presented to you or you don't.
    Ms. Verma. I believe that the Census data is accurate.
    Ms. Clarke. Do you agree with it? Yes--it is accurate, so 
that is a yes. You have previously claimed that the children 
who lost Medicaid have transitioned into private coverage, but 
if that were true, we would see an increase in the enrollment 
in private coverage. However, your own Census Bureau says that 
that is not the case, that there has been no increase in the 
number of children covered under private insurance.
    Administrator Verma, can you explain why the rates of 
children enrolled in Medicaid CHIP are declining while private 
insurance coverage has remained flat?
    Ms. Verma. So, if we look at the number of uninsured 
children, which I'm deeply concerned about, the biggest drop is 
for families that are earning above 400 percent of the poverty 
level. And so what's happening is, under the Trump economy, the 
economy is the best that we've had in 50 years, unemployment is 
down.
    Ms. Clarke. I don't want to hear your talking points.
    Ms. Verma. There's less people living in poverty.
    Ms. Clarke. Reclaiming my time. The New York Times story 
talked about a little boy in Texas named Elijah whose family 
didn't know that he had been kicked off Medicaid until he was 
admitted to intensive care for a respiratory virus. Texas has 
the highest number of uninsured children in the country and 
conducts more frequent eligibility checks than any other State. 
Data shows that, of the 50,000 children in Texas kicked off 
Medicaid, more than half regained their coverage within 12 
months, which means these children were dropped erroneously.
    In Tennessee, tens of thousands of children lost coverage 
because of late or incomplete paperwork. Until recently, 
Tennessee used an application that could be up to 47 pages long 
that one Medicaid expert called ``daunting.''
    Administrator Verma, we all agree that the program 
integrity is a critical part of any Federal program, but would 
you agree that the program integrity requirement should not be 
weaponized to kick children off of Medicaid? That is a yes or 
no.
    Ms. Verma. I think it's important that children have 
coverage, first of all. In terms of program integrity, 
unfortunately, we're seeing that there are major problems in 
Medicaid eligibility. We're hearing cases all the time. I can 
tell you I saw data yesterday which is concerning.
    Ms. Clarke. I understand your concern. But you should be 
far more concerned about the decline or the increase in the 
numbers of children who are uninsured. You talked about being a 
parent and what you want for your children. What about low-
income children across this Nation? That is your 
responsibility. So you can say you want to preserve Medicaid 
for those who truly need it, but on your watch over a million 
children have lost Medicaid and CHIP coverage and the 
children's uninsured rate has reversed years of gains. The 
numbers don't lie and are clearly going in the wrong direction. 
You have failed the most vulnerable amongst us. You have failed 
the American people.
    With that, Madam Chair, I yield back.
    Ms. DeGette. The Chair now recognizes the gentleman from 
New York, Mr. Tonko, for 5 minutes.
    Mr. Tonko. Thank you, Madam Chair.
    Administrator Verma, CMS has promoted and expanded the 
availability of short-term limited duration insurance plans 
that are not required to comply with the comprehensive consumer 
protections of the Affordable Care Act. These junk plans 
undermine protections for people with preexisting conditions, 
increase costs, and leave American families with less financial 
protection and more exposure to fraud.
    Now I want to follow up on Representative Castor's 
questioning. Administrator Verma, isn't it true that these 
plans are allowed to exclude coverage for preexisting 
conditions?
    Ms. Verma. Short-term limited duration plans provide----
    Mr. Tonko. Yes or no. Yes or no.
    Ms. Verma [continuing]. An alternative. There's a----
    Mr. Tonko. Yes or----
    Ms. Verma. It depends on the plan.
    Mr. Tonko. Yes or no.
    Ms. Verma. It depends on the plan.
    Mr. Tonko. Isn't it true that these plans are allowed to 
exclude coverage, are allowed to exclude coverage? Yes or no.
    Ms. Verma. Short-term limited duration plans have more 
flexibilities than----
    Mr. Tonko. I am asking for a yes or no. I have 5 minutes, 
so I want to get----
    Ms. Verma. It depends on the plan. There are different 
types of short-term limited duration plans.
    Mr. Tonko. I am asking if these plans are allowed to 
exclude coverage. That is a yes-or-no question.
    Ms. Verma. Short-term limited duration plans have the 
flexibility around benefit design.
    Mr. Tonko. So it is a yes.
    Ms. Verma. But it depends on how that plan is structured.
    Mr. Tonko. But they are allowed to exclude coverage?
    Ms. Verma. Not all of the plans will do that. It depends on 
the plan.
    Mr. Tonko. Are they allowed to?
    Ms. Verma. And what we have done is to ensure----
    Mr. Tonko. You are not answering the question, ma'am.
    Ms. Verma [continuing]. That there are the appropriate 
protections in place for consumers so they understand the type 
of coverage they are buying.
    Mr. Tonko. Ma'am, I mean, you are eating up the clock. I am 
asking if they are allowed to exclude coverage for preexisting 
conditions.
    Ms. Verma. They have flexibility around benefit design.
    Mr. Tonko. So that is--I believe that is a yes answer. 
Administrator Verma, isn't it true also that people on these 
plans can be charged higher premiums without limit based on 
their health status, gender, age, and other factors? Yes or no.
    Ms. Verma. The CBO said that the short-term limited 
duration plans could be 60 percent lower than the Affordable 
Care Act plans.
    Mr. Tonko. Yes or no, can they be charged higher premiums 
without limit based on their health status, gender, age, and 
other factors?
    Ms. Verma. They have the flexibility. They do not have to 
comply----
    Mr. Tonko. They have the flexibility, so that is a yes.
    Ms. Verma [continuing]. With the Obamacare plans.
    Mr. Tonko. Thank----
    Ms. Verma. But that's why they're priced lower.
    Mr. Tonko. I don't want to use any more time.
    In addition to excluding coverage of preexisting 
conditions, charging people more based on their health status, 
I am concerned by the failure of these plans to cover basic 
healthcare services.
    Administrator Verma, isn't it true that junk plans can 
refuse to cover essential health benefits like hospitalization, 
maternity care, prescription drugs, mental healthcare, and 
preventive care? Yes or no.
    Ms. Verma. You know, I was talking to a family the other 
day that they lost----
    Mr. Tonko. Well, yes or no. It is OK that you had that----
    Ms. Verma [continuing]. Their health insurance. They lost 
their job.
    Mr. Tonko. Ma'am. Ma'am, yes or no. It is my time. Is it 
true that these can refuse, these plans can refuse to cover 
those essential benefits?
    Ms. Verma. There's a variety of different plans that are 
offered under short-term limited duration, and it depends on 
the plan.
    Mr. Tonko. You are not answering the question.
    Ms. Verma. It depends on the plan.
    Mr. Tonko. It depends on the plan, but can--again, the 
question is, can they refuse to cover essential health benefits 
like those I mentioned?
    Ms. Verma. They have flexibility on benefit design.
    Mr. Tonko. So that is a yes. They have flexibility. Even if 
some of these plans might cover some essential health benefits, 
I am concerned that what might happen should people get sick 
while they have a junk plan.
    Administrator Verma, isn't it true that these plans can 
impose lifetime and annual limits on coverage and are not 
subject to cost-sharing limits?
    Ms. Verma. If there were more affordable options available 
under Obamacare, people wouldn't have to make compromises. But 
unfortunately, premiums have gone up----
    Mr. Tonko. I don't want--don't filibuster on me.
    Ms. Verma [continuing]. So much that there's no 
alternative.
    Mr. Tonko. Please. Please. I am asking for a yes or no. 
Isn't it true that these plans can impose lifetime and annual 
limits on coverage?
    Ms. Verma. Yes, they can.
    Mr. Tonko. OK. Thank you for the yes. These plans seem to 
have very little utility if you need healthcare or don't want 
to be one sickness away from bankruptcy. That is exactly why 
the ACA was passed. It was to make sure that people had 
comprehensive coverage and were not one illness away from 
bankruptcy.
    So, Administrator Verma, I am curious. What are people with 
these junk plans supposed to do when they need vital healthcare 
services that are not covered by these junk plans?
    Ms. Verma. Well, what are they supposed to do when they 
have to spend half of their income on the Obamacare premiums 
and then another 10 to 12 thousand dollars on the high 
deductibles? They have no alternative. And what our 
administration is trying to do is to provide more choices where 
there aren't any. And so, when people are forced to pay half of 
their income or a third of their income on a premium plus a 
deductible, they can't afford health insurance, and short-term 
limited duration plans may give them a different option. It's 
better than having no insurance at all.
    And in absence of no solution by Congress to address----
    Mr. Tonko. I am going to reclaim my time.
    Ms. Verma [continuing]. Unaffordable premiums, there is at 
least something for people.
    Mr. Tonko. Well, I believe that the statistics with one in 
three people being able to afford something with the subsidies 
that we provide are an encouraging statistic. And with that I 
yield back.
    Ms. Verma. And many people don't get subsidies.
    Mr. Tonko. And I would just ask that you put children 
first. And with that, I yield back.
    Ms. DeGette. The gentleman's time has expired. The Chair 
now recognizes the gentlelady from Washington State, Mrs. 
McMorris Rodgers, for 5 minutes.
    Mrs. Rodgers. Thank you, Madam Chair. I would like to begin 
just by giving the Administrator a chance to answer anything 
that you didn't get to answer in the last questions since you 
were being cut off repeatedly.
    Ms. Verma. Thank you. I appreciate that. You know, first of 
all, Obamacare has become affordable--unaffordable for so many 
families, for the middle class, they can't afford the premiums, 
and if they're not getting a subsidy, they have no alternative. 
Short-term limited duration plans provide an alternative. I was 
just talking to a family where, you know, the husband lost his 
job. They have two kids in high school. And they couldn't 
afford--they couldn't afford premiums under Obamacare, and so 
they looked at a short-term limited duration plan. It met their 
coverage needs. They reviewed the benefits and felt like it was 
going to work for their family, and so they were able to buy 
this plan.
    You know, these plans can be 60 percent lower than what's 
on the exchanges, and so it gave them an alternative. You know, 
they may not need it for a long period of time, but it's 
important that we have alternatives. In absence of a solution, 
we're trying to do something for the American people, for the 
middle-class Americans that can't afford Obamacare.
    Mrs. Rodgers. I want to say thank you. I want to say thank 
you for your leadership. I want to say thank you for your 
commitment to making sure that we keep the promise, especially 
to those on Medicare, our seniors that are depending upon 
Medicare, for those on Medicaid, some of the most vulnerable in 
our country. I just want to say thanks for the work that you 
are doing.
    I also applaud you for the work you are doing to ensure 
that we continue to lead the world in innovation and thinking 
of how we ensure that we have a healthcare system that is going 
to provide access and quality at an affordable price for 
everyone. And I think the flexibility is so important. I think 
that offering a variety of plans is so important to meet an 
individual's or a family's need, particular needs. Certainly, 
Medicare and Medicaid are critical safety nets, and we must 
keep, fulfill the promise that we have made to those that are 
depending upon Medicare and Medicaid.
    I am committed also to making sure that those with 
preexisting conditions have the confidence and the certainty 
that they will always have quality, access to quality and 
affordable healthcare. I have a son with special needs with 
disabilities, and I remember during the debate on Obamacare 
that I was concerned about the impact that it was going to have 
on those with disabilities within Medicaid. According to the 
Kaiser Family Foundation, they have reported that more than 
450,000 individuals with developmental disabilities are on a 
waiting list today for Medicaid in this country--450,000 
individuals with disabilities.
    When I was, during the debate when I was--when I said I am 
concerned about people with disabilities being put on a waiting 
list for Medicaid, I was laughed at. Today in Washington State, 
15,000 individuals with disabilities are on a waiting list. 
This is Washington State that expanded Medicaid to the furthest 
degree possible. We have hundreds of thousands of people with 
disabilities that are waiting for care. I cochair the Rural 
Health Coalition. I have visited hospitals and healthcare 
facilities all throughout my district in Eastern Washington. It 
is heartbreaking when I hear from providers and hospitals that 
are having trouble keeping their doors open because of the low 
reimbursement rates and the high populations of Medicare and 
Medicaid.
    So Washington State is at the highest level, 130 percent of 
Federal poverty level are covered under Medicaid. The income 
threshold is even higher for children, at 210 percent of the 
Federal poverty level. We need to make sure that we are 
protecting current beneficiaries because they need to have that 
certainty.
    I wanted to ask you, could you just talk to me about CMS 
and what you are doing to track those that are on waiting lists 
and how do we ensure that the populations, some of the most 
vulnerable in our communities, are actually getting the care 
that we have promised to them?
    Ms. Verma. Well, I share your commitment to the vulnerable 
populations in the Medicaid program. Many of these individuals 
have no place to turn, and Medicare is a vital safety net that 
is so critical to improving their lives, the quality of care, 
and their day-to-day lives. One of the things that we're very 
concerned about is program integrity within the Medicaid 
program. We're seeing some alarming data that is showing that 
States aren't necessarily putting the right people on the 
program, and that we have some high cases and problematic 
eligibility systems that are putting people on the program that 
don't belong.
    And so, we'll be taking action to make sure that we can 
ensure that the people on the program actually belong on the 
program, because if we don't do that, we're failing taxpayers 
and people that deserve to be on the program.
    Ms. DeGette. The gentlelady's time has expired. The Chair 
now recognizes the gentlelady from Delaware, Ms. Blunt 
Rochester, for 5 minutes.
    Ms. Blunt Rochester. Thank you, Madam Chairwoman.
    And thank you, Administrator Verma, for joining us today. 
Today's hearing is critically important because CMS is tasked 
with overseeing the implementation of the Affordable Care Act, 
the landmark law that allowed thousands of Delawareans as well 
as millions of Americans to be protected and not be denied 
coverage based on a preexisting condition or removed from their 
parents' health plan at the age of 26, just to name a few. It 
is one of the significant reasons why I came to Congress, was 
to protect this because I know it gave hope to so many people, 
particularly people with preexisting conditions.
    And, unfortunately, Delaware's enrollment in the exchanges 
began dropping in 2016. And that is not a surprise when you 
factor in the administration's decisions to, number one, 
shorten significantly the enrollment period; number two, cut 
the navigator program by 84 percent, causing many people to be 
confused and not have the help and support that they needed to 
navigate, which--a sometimes incredibly difficult system for 
anybody, private sector or public sector; and three, cut 
outreach funds by a whopping 90 percent for a program that 
doesn't have the longevity of a Medicare or the name 
recognition. With less time to apply and fewer resources to do 
it, you can understand why people believe that these actions 
are deliberate attempts to unilaterally repeal the ACA.
    Administrator Verma, after cutting the Federal funding to 
facilitate enrollment in HealthCare.gov, you were quoted as 
saying, ``This decision reflects CMS's commitment to put 
Federal dollars for the federally facilitated exchanges to 
their most cost-effective use in order to better support 
consumers through the enrollment process.''
    I would like to focus on two parts of your statement. One, 
supporting consumers during the enrollment process and, 
secondly, the cost-effectiveness. According to a former senior 
advisor at CMS, Joshua Peck, who previously oversaw the ACA 
marketing program, the outreach and marketing programs that 
have been dramatically scaled back were working and they were 
cost effective.
    I have been informed that there is data on how Federal 
dollars should be effectively spent in order to reach Americans 
who need health insurance. Specifically, a July 2018 general 
Government Accountability Office report on HHS outreach and 
enrollment efforts in the individual marketplace cites an HHS 
study on the most effective forms of advertising for new and 
returning enrollees.
    In March, I along with 29 of my colleagues wrote from this 
committee, reached out to you to ask for this study because we 
wanted to really fully understand and get to the bottom of what 
ACA marketplace outreach strategies were actually working. 
After a follow-up, because I didn't receive a letter after that 
one, we wrote another letter. I received a letter back which, 
unfortunately, did not give us a direct answer, you know, and I 
would like to submit--I would ask unanimous consent to submit 
the three pieces of correspondence into the record.
    Ms. DeGette. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Ms. Blunt Rochester. Administrator Verma, my colleagues and 
I just wanted to understand how CMS can most effectively help 
our constituents enroll in ACA-compliant health coverage. And 
this one really is a yes-or-no question. Will you commit to 
releasing any and all documents, studies, relevant data created 
from 2014 onward related to marketing and outreach efforts for 
the Affordable Care Act so that we on the committee and 
particularly in our oversight role can have the information and 
understand that rationale? Yes or no.
    Ms. Verma. All document requests are handled by Health and 
Human Services, and so I would refer your request to the 
Department.
    Ms. Blunt Rochester. So the letter that we originally sent 
was actually sent to the Department. And it would be great to 
also have your commitment, I mean, I am assuming you had to 
have made the decision, so therefore you either had information 
or you didn't. You--I mean, you made the decision, so it would 
be really great to have that information so that we could make 
these decisions.
    Again, would you support the turning over of that 
information?
    Ms. Verma. All document requests are handled by the 
Department of Health and Human Services, and I would refer your 
request to them.
    Ms. Blunt Rochester. So I have 10 seconds left, and in my 
10 seconds I am going to just say, for many years I got to 
serve in public service just like you, deputy secretary of 
Health and Social Services, State personnel director. It is 
important that people have confidence and faith in these 
institutions, and the way we answer questions exhibits that 
confidence and faith.
    Just answer the questions. Just work with us, because we 
all want to see people have healthcare.
    Ms. DeGette. The gentlelady's time has expired.
    Ms. Verma. And if I have the time--I would be happy to 
answer your questions.
    Ms. DeGette. The Chair now recognizes the gentleman from 
Indiana, Mr. Bucshon, for 5 minutes.
    Mr. Bucshon. First of all, thank you, Administrator Verma, 
for being here today and thank you for the great work that you 
are doing at CMS, a difficult agency to lead, as I would 
imagine.
    First off, I want to thank you for your recent proposal to 
reform Stark Law. As a long-term advocate for reforming the 
Stark Law, I am pleased that CMS has proposed real reform to 
the law. The Stark Law is a dated regulatory structure designed 
for a fee-for-service payment model that has inhibited the 
value-based care and coordinated care arrangements that many 
physicians are eager to take advantage of in order to provide 
better and more efficient care for their patients. As we 
rapidly move to value-based care payment models, your proposal 
to modernize Stark Law will remove legal barriers that 
currently prevent physicians from entering into coordinated 
care and innovative payment models, which I believe can lead to 
better outcomes for patients and keep costs down.
    So I would like to bring up the DME fee-setting provisions 
of the proposed rule by CMS that was proposed in July, and 
there are some concerns, as you know, that the proposed rule 
will place authority in the hands of CMS staff to set Medicare 
rates for medical devices in ways that, number one, will expand 
disparities between private payor and Medicare reimbursement 
and, number two, inhibit the availability of innovative medical 
devices for Medicare beneficiaries.
    In particular, do you think that a developer of a 
breakthrough medical device with fairly robust sales in a non-
Medicare market could review the regulations and then calculate 
with reasonable certainty the fee that might be set by 
Medicare?
    Ms. Verma. You know, one of the things that we're trying to 
do around innovation is provide more transparency for 
innovations so people understand what they're going to face in 
terms of coverage decisions, coding decisions, and also 
reimbursements. So we have tried to--we've actually proposed 
some regulations that would give more flexibility so that we 
can look at the private market and bring in what they may 
expect to be reimbursed in the private market as part of our 
decisionmaking.
    Mr. Bucshon. Thank you. I very much appreciate that. And 
so, do you think that in this space that the Medicare fee will 
be roughly equivalent to the non-Medicare price?
    Ms. Verma. It depends on the particular product. Our goal 
with durable medical equipment is to make sure that our 
beneficiaries have access to the equipment that they need and 
make sure that we have a competitive environment.
    Mr. Bucshon. Thank you very much. So I appreciate your 
consideration on these issues as you work towards finalizing 
that rule.
    Another one is a little bit in the weeds but is important. 
It is the issue as it relates to Medicare beneficiaries who are 
on Coumadin therapy for atrial fibrillation and other medical 
problems that require anticoagulation--for example, a heart 
valve replacement. As you know, weekly blood tests are required 
to keep these patients in the safe treatment range.
    And the concern here is, is that this year's proposed 
physician payment rule includes a 20 percent reduction in INR, 
the International Normalized Ratio, which is a test of 
anticoagulation. That is being reduced for 20 percent and is 
being reduced for the third year in a row. And so, I would like 
to ask if we could hit the pause button and really reconsider 
that. Freezing the reimbursement paired with work over the next 
year to figure out what is a sustainable path forward will help 
ensure that these vulnerable Medicare beneficiaries can receive 
the care they need. So I hope that we can take a look at that 
and revisit that.
    And then, finally, I wanted to thank you for your letter 
that your office sent in response to the bipartisan letter that 
I sent on September 27th with 24 of my colleagues regarding the 
CY20 Physician Fee Schedule proposed rule. My colleagues and I 
have concerns with the agency's proposal not to apply a payment 
adjustment to the evaluation and management or E&M code 
component of global surgical codes even though the agency is 
proposing to update the E&M code values for standalone office 
visits. And as the agency works to finalize the rule, I 
appreciate your ongoing input and collaboration on that issue.
    I have 48 seconds left. Do you have anything else that you 
feel like you haven't been able to say during the hearing that 
you might want to tell the American people about your work?
    Ms. Verma. Well, I would appreciate the opportunity to be 
able to answer some of the questions that have been posed 
before, but we haven't had time. One of the things that I do 
want to talk about are the numbers on--the number of people on 
Medicaid and the declines there as well as what we're seeing on 
the uninsured. When we look at the Medicaid program, it is 
natural to see fluctuations in enrollment. As the economy does 
better, we can expect to see lower enrollment. We've seen that 
in the Clinton administration. There's an urban study report on 
this as well.
    And so, because we are in a booming Trump economy with the 
lower unemployment, less people on poverty, we are going to see 
that impact in the Medicaid program. That being said, our 
administration is committed to addressing children and making 
sure all kids have access to coverage.
    Mr. Bucshon. Thank you very much, and I will be submitting 
some other questions for the record. I yield back.
    Ms. DeGette. The Chair now recognizes the gentleman from 
California, Mr. Cardenas, for 5 minutes.
    Mr. Cardenas. Thank you very much, Madam Chairwoman. I 
appreciate this opportunity to have an open and public 
discussion about such an important program to millions and 
millions of Americans.
    One of the fundamental gains under the Affordable Care Act 
was the historic increase in coverage thanks to Medicaid 
expansion. Approximately 12 million people gained coverage for 
essential healthcare services thanks to this expansion, and it 
continues to be one of the most important payors for healthcare 
in this country. Studies have made clear that Medicaid 
expansion has greatly benefited Americans who gained coverage.
    Researchers from the Census Bureau, NIH, UCLA, and the 
University of Michigan recently found, and I quote, ``Medicaid 
expansions substantially reduced mortality rates among those 
who stood to benefit the most.'' They estimated that due to the 
States' Medicaid expansion in States that there were over 
19,000 fewer American deaths in the first 4 years alone. And 
the failure of other States to not expand Medicaid resulted in 
an estimated over 15,000 additional American deaths over the 
same period.
    Administrator Verma, are you aware of that particular 
research?
    Ms. Verma. I'm aware of it.
    Mr. Cardenas. OK, thank you. Other studies also show gains 
in access to quality and affordable care as well as positive 
health outcomes. And in the midst of the opioid crisis, 
Medicaid expansion has increased access to medication-assisted 
treatment for opioid addiction.
    My question to you, Administrator Verma, is, is it true 
that substance use disorder treatment is a top healthcare 
priority for HHS?
    Ms. Verma. I believe it is, yes.
    Mr. Cardenas. OK. That is good to hear. In fact, HHS has 
stated that its number-one strategy to combat the opioid crisis 
is ``access, better prevention, treatment, and recovery 
services.'' And as we know, Medicaid has been integral for 
increasing access to those services in expansion States. The 
American Medical Association has reported, and I quote, 
``Medicaid is on the front lines and often provides more 
comprehensive care for substance use disorders than the 
commercial insurance market does. There may be opportunities to 
extend Medicaid successes to commercial coverage. Expanding 
Medicaid would help even more patients.''
    So, Administrator Verma, do you agree with the AMA that 
Medicaid is critical for providing comprehensive care for 
substance disorder to Americans and that expanding Medicaid 
would help more American people who are suffering from 
addiction?
    Ms. Verma. Thank you. A couple things. One, on Medicaid 
programs, CMS has approved 26 State Medicaid 1115 
demonstrations to expand.
    Mr. Cardenas. How many States in the union?
    Ms. Verma. There's 50 States in the union, 26 States.
    Mr. Cardenas. OK, thank you. So just over half.
    Ms. Verma. But those are the ones that have applied, and if 
they've applied we've approved them. So we have tried to ensure 
that people with substance use disorder have a full array of 
options available to them and more places to receive treatment.
    Mr. Cardenas. So the States that have applied and are 
providing that service, are they doing better than the States 
that are not applying in this category?
    Ms. Verma. These waivers, we just started granting them 
probably late 2017, and so we're still evaluating those 
waivers.
    Mr. Cardenas. When do you anticipate having evaluations 
that you could report to Congress?
    Ms. Verma. We'll be happy to share any information that we 
can with you.
    Mr. Cardenas. About when? Is it 2019, 2020, 2030?
    Ms. Verma. You know, it depends on when it comes in. These 
are 5-year waivers.
    Mr. Cardenas. OK, 5-year.
    Ms. Verma. And so it would take us at least that, and it 
depends on when they started their waiver.
    Mr. Cardenas. OK. Thank you so much.
    As we know, the Trump administration is rooting for the 
ACA's demise by asking the court to strike down the entire law. 
But if that happens, Medicaid expansion would be reversed. 
Therefore, 12 million American people would lose coverage 
literally overnight.
    Administrator Verma, if the administration gets its way in 
the Texas v. United States lawsuit, what will happen to those 
12 million vulnerable people who suddenly find themselves 
without coverage?
    Ms. Verma. Well, we're rooting for all Americans to have 
coverage, and under the Affordable Care Act, the middle class 
can't afford Obamacare's coverage.
    Mr. Cardenas. I asked you specifically about that lawsuit 
and what would happen to those 12 million Americans.
    Ms. Verma. And we've been very clear, the President's been 
very clear he wants to make sure that people with preexisting 
conditions would have protections and we want to make sure that 
all Americans would have access to affordable coverage.
    Mr. Cardenas. OK, thank you. Reclaiming my time. That is 
not the answer to the question I specifically asked.
    I would like to state for the record that the Trump 
administration and Administrator Verma are paying lip service 
to caring about American people with these issues, but it is 
clear that not taking the steps to encourage the best thing a 
State can do to immediately improve the lives of millions of 
American residents of those States that it expands--that it 
should be expanding Medicaid.
    I am out of time, Madam Chair. I yield back.
    Ms. DeGette. The gentleman yields back. The Chair now 
recognizes the gentleman from Montana, Mr. Gianforte, for 5 
minutes.
    Mr. Gianforte. Thank you, Madam Chair. And thank you, 
Administrator Verma, for being here today to testify in front 
of our committee.
    Last year, Congress removed Medicare reimbursement 
restrictions in five areas, including telestroke services. Do 
you think telehealth would be useful and effective in other 
critical care scenarios, especially for rural hospitals like I 
have in my district that may not have specialists in these 
small communities?
    Ms. Verma. Absolutely. And I think that's one of the things 
that we're trying to focus on in the Medicare program and part 
of the reason why I have some concerns when you hear about 
proposals to put everybody into the Medicare program. 
Unfortunately, the Medicare program often is very slow to 
respond to new technology. That being said, our administration 
has focused on telehealth services. We've expanded the number 
of telehealth services that are available in rural communities 
and we've also provided remote communication technology to the 
entire program so our beneficiaries can easily access care.
    Mr. Gianforte. OK, I want to dig into this a little more. 
The Federal Government is among the most prolific users of 
telehealth and virtual care technologies, including the VA, 
DOD, IHS, NASA. Unfortunately, just one-quarter of 1 percent of 
Medicare fee-for-service beneficiaries used telehealth in 2016. 
Meanwhile, the Government has funds, grants, projects through 
HRSA, SAMHSA, FCC, and others. We know that some grants may be 
duplicative across HHS operating divisions, and it is often 
difficult for healthcare providers and patients to understand 
how they can better access telehealth services.
    With limited resources available for telehealth adoption, 
it is important that we spend all these funds wisely. Can you 
help us understand how these different entities across the 
Federal Government coordinate policy development, Federal 
funding opportunities, and best practices as it relates to 
telehealth?
    Ms. Verma. Sure. One of the things that we have going on at 
Health and Human Services is the Secretary has convened a Rural 
Health Committee. And so we have--he's bringing together all of 
the agencies under HHS to focus specifically on rural health, 
and as part of those discussions we're talking about how we can 
expand telehealth services to make sure not only people in 
rural communities but even urban communities can access those 
services.
    Mr. Gianforte. OK. And do you believe there is 
opportunities to exist to improve coordination and efficiencies 
further?
    Ms. Verma. Absolutely.
    Mr. Gianforte. OK. Are you aware of any national telehealth 
strategy and, if not, should one exist?
     Ms. Verma. I think there's been some focused effort on 
this in rural communities to make sure that--you know, a lot of 
the problem is, even if telehealth services are available, they 
may not have broadband access, and so the administration has 
focused on that as well. You know, telehealth is a great 
example of innovative technology that can really go a long way 
to improve access and to improve healthcare and outcomes, and 
so would love to continue to work with you on that issue.
    Mr. Gianforte. Well, it is a real area of attention for us 
given I represent the State of Montana. We have a lot of space 
and not many practitioners. We don't have specialists. 
Telehealth is one way to bring those to these rural communities 
so they can maintain the viability of our critical access 
hospitals and others. So I appreciate all that CMS has done to 
increase access to telehealth services.
    The Federal Government has a commitment to keep to our 
seniors and ensure they have access to high-quality, affordable 
healthcare. Congress should focus on leveraging both Federal 
funds and lessons learned so that those who need access most 
have it, particularly folks in rural areas. We should 
prioritize efforts to expand telehealth access and fully 
realize the potential it has to provide services to all our 
seniors with access to reliable, quality healthcare.
    I have a minute left. Is there anything else you would like 
to tell the American people that hasn't been addressed today?
    Ms. Verma. I would like to focus on some of our efforts 
around rural health because I think it's an important area. 
We've been concerned about the hundred hospitals that have 
closed, rural hospitals. We're also concerned that 40 percent 
of rural hospitals are operating at a negative margin. This is 
why we've taken action with the wage index to increase 
reimbursement to hospitals in rural areas, and we're also 
working on something, a new model for rural communities to 
basically think about how they can redesign their system.
    I think those decisions need to be made at the local level, 
can't be made in Washington, but it's an opportunity for them 
to rethink the structure and to move in more value-based care. 
So we're excited to continue our work and our commitment to 
rural communities across America.
    Mr. Gianforte. Again, I want to thank you for your work at 
CMS and thank you for being here today. And with that, I yield 
back.
    Ms. Verma. Thank you.
    Ms. DeGette. The gentleman yields back. The Chair now 
recognizes the gentleman from Illinois, Mr. Rush, for 5 
minutes.
    Mr. Rush. I want to thank you, Madam Chair. And welcome, 
Administrator Verma.
    Administrator Verma, last month I sent you a letter asking, 
to me, a very important question: Why are there so many 
dialysis centers in black neighborhoods? In the poor part of my 
district, it seems that there is a dialysis center on each and 
every corner. And I want to thank you for responding to my 
letter, and I am cautiously optimistic regarding CMS's 
aggressive goals to reduce the disproportionate rates of kidney 
disease in lower-income and minority communities.
    Madam Chair, I ask unanimous consent to offer my letter to 
CMS and to offer their response into the record.
    Ms. DeGette. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Rush. Administrator Verma, will you describe in detail 
how the goals you outline in your response to me will ensure 
minority communities in particular that they will have access 
to the care and education on treatment options that they may 
require if they are on dialysis?
    Ms. Verma. Well, thank you for your question. This is an 
important area. The President has actually put out an executive 
order around kidney disease, and the goal of that is 
multifaceted. First of all, we want to improve the quality of 
care. We want to make sure that people that are living with 
kidney disease have options about their care. The first thing 
that we want to do is make sure that the transplants, that the 
ability to have a transplant to cure their disease is 
available. And we know that there's a lot of regulations that 
get in the way of having more organs be available, and so the 
President has asked us to take action on that issue.
    The second thing we want to do is make sure that we're 
paying doctors for the quality and the outcomes that they 
achieve. And one of the things that we want to focus on is 
giving people living with kidney disease more options so that 
they don't necessarily have to go into a dialysis treatment 
center and they can have more home-based dialysis.
    Mr. Rush. Ms. Verma, I want to know about the dialysis 
centers and those patients who are on dialysis, not those 
patients who are looking for organ transplants. And that is 
really good, but please center your answers on the issue of the 
dialysis center epidemic in lower and minority communities 
throughout the Nation, certainly in my district.
    Ms. Verma. Well, I think that's what this executive order 
focuses on. We want to improve the quality of care. We want to 
make sure that people have options. That they're not forced to 
just go to a dialysis center, that they can even receive that 
care at home.
    Mr. Rush. So you don't have an answer to my question?
    Ms. Verma. Well, I think our executive order, writ large, 
focuses on it, on kidney care.
    Mr. Rush. Well, let me ask you another question then.
    I am concerned about hospitals closing in my district and 
in similarly situated districts across the Nation, all right. 
What do you have, any data on closures of hospitals in lower 
and minority income communities across the Nation?
    Ms. Verma. I'm sorry. The question is, you want to 
understand the impact on----
    Mr. Rush. I want to know, do you have any data on the 
number of hospitals that have been closed in my district and 
lower-income and minority districts across the Nation within 
the last 5 years?
    Ms. Verma. I don't have that data with me today, but I can 
commit to you that we can help your office and provide any data 
that we have available to your office.
    Mr. Rush. Do you know why there is an increase in the 
number of hospitals that are closing in lower and minority 
income communities?
    Ms. Verma. I have not studied that issue, but I'd be happy 
to work with my team and get you that information.
    Mr. Rush. Can you come up with any idea about how to 
prevent hospitals from closing in minority and low-income 
communities across the Nation if, in fact, the data reveals 
that we have such an epidemic?
    Ms. Verma. Well, we want to make sure that people all 
across the Nation have access. I think we've looked at the 
issue in rural areas----
    Mr. Rush. I yield back.
    Ms. Verma [continuing]. But happy to work with you on that.
    Ms. DeGette. The gentleman yields back. The Chair now 
recognizes Mr. Carter from Georgia for 5 minutes.
    Mr. Carter. Thank you very much, Madam Chair. And, 
Administrator Verma, thank you for being here. We appreciate it 
very much. Is there anything you need to respond to before I 
get--you are OK? OK.
    I want to thank you. I have been working with you now for 
close to 2\1/2\ years, and I appreciate your work. I think you 
understand what we are trying to do, and I think we are on 
board. I want to especially tell you how much I appreciate the 
proposed rule changes earlier this year concerning rebates with 
PBMs and especially with DIR fees. And whereas I know you have 
to temper your remarks, but I don't, I was devastated that they 
did not--that the administration blocked those rules and that 
we weren't able to get them through, and I hope that you will 
continue to work toward that.
    I, for one, believe that we need to do away with PBMs, and 
I certainly believe we need to do away with DIR fees. Both of 
them need to be eliminated. But one thing that I don't think 
needs to be eliminated is the 340B program. I do think it 
serves a useful purpose. However, I do think it needs to be 
updated, and I think that we need to tighten up that program. 
There are flaws in that program, and it can be better than what 
it is now if we simply make some changes to it.
    We did a study in the last Congress about the 340B program 
and made some recommendations, and one of the things that we 
cited was duplicate discounts. The discounts that are going to 
the recipient, the covered entity receives a rebate for the 
drug that is dispensed to the patient and the Medicaid agency, 
and it can be both the State Medicaid drug rebate plan or the 
Medicare managed care plan.
    And I just wanted to ask you, whereas I know HRSA has 
primary jurisdiction over the 340B program, CMS has 
jurisdiction over the Medicaid program. What are we doing about 
that? Can you help me?
    Ms. Verma. Sure. And I also do want to address the DIR 
fees. What I will say is we're very concerned about small 
pharmacies and we want to make sure that our policies ensure a 
competitive marketplace, and I can tell you that the agency 
continues to work on that issue. We're particularly concerned 
about some of the quality metrics that may be impossible for 
some of these pharmacies to comply, so we're going to continue 
to do what we can under the law.
    Mr. Carter. And, of course, as you well know we are trying 
to address it legislatively as well, and I want to thank my 
colleagues on the other side of the aisle for assisting in that 
as well.
    Ms. Verma. Thank you. And then, in regards to the 340B 
program, as you know that is the subject of litigation, so I 
won't get into that, but we are concerned about the double 
discounts. At the end of the day, some of the proposals that we 
made would result in our seniors paying less, and we're 
concerned about that. I also would add that the President's 
budget in terms of the 340B project or our proposal would say 
that if we made any changes to the 340B program that any 
savings could be directed back to the safety net institutions.
    And so, I would ask that you take a look at that because I 
think that would be helpful in reforming the program, ensuring 
that beneficiaries are paying less when they get their 
medications but also ensuring that we support safety net 
institutions.
    Mr. Carter. Absolutely. And I don't mean to be redundant, 
but again as I said earlier, I am not opposed to the program. 
It just needs--we need to upgrade the program, and we need to 
make it even better, and we can make it even better.
    OK, and then let's shift over to your oversight of hospital 
accrediting organizations because I know that is your 
responsibility as well. And it is my understanding that you 
have a new pilot program out there that is dealing with the 
``increase the agency's oversight of organizations involved in 
accrediting and inspecting most hospitals''?
    Ms. Verma. I think, one--we do have, we had an RFI out on 
this. One of the things that we've had some concerns about is 
that organizations that are reviewing safety and quality at 
hospitals--we put out an RFI because we've also heard some 
concerns that these organizations are also receiving consulting 
dollars from those same entities, so we're taking a look at 
that. We want to make sure that the American public can count 
on the accreditation and that they have the information that 
they need about the hospital at their fingertips.
    Mr. Carter. Obviously that is a conflict of interest, if 
they are doing the consulting and the accrediting. Is the pilot 
program in place, or you just have an RFI for it?
    Ms. Verma. We--so there's two different issues. One is 
around the accreditation issue and conflicts of interest. The 
other issue that we have in place is just looking at, we have a 
pilot program to do joint review so that we can have our 
oversight of the accrediting organizations and that we 
basically do the review of the hospitals at the same time so 
that we're not duplicating that. We're going to see how that 
goes.
    Mr. Carter. Great. And again, I want to thank you for all 
your work and especially for your work on the DIR fees, because 
as you say, particularly for small pharmacies, which we need in 
this country, this is devastating for them. So thank you, and I 
yield back.
    Ms. Verma. Thank you.
    Ms. DeGette. The gentleman yields back.
    I want to thank our witness for her participation in 
today's hearing, and I want to remind Members that, pursuant to 
committee rules, they have 10 business days to submit 
additional questions for the record to be answered by the 
witness who has appeared before the subcommittee.
    Administrator Verma, I would ask that you agree to respond 
promptly to any such questions should you receive them. And 
with that, the subcommittee is adjourned.
    Ms. Verma. Thank you.
    [Whereupon, at 12:31 p.m., the subcommittee was adjourned.]
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