iraq and i have to go to several meetings or that score at about three fifteen so i apologize for having to leave early i understand you all have to be out here also by four o'clock so to try to accommodate that and to speed up the process i'm going to forgo any opening statement and simply a welcome you and ask you to proceed with just one caveat i've asked every subcommittee when they begin their hearing process this year to do one thing to first begin by asking the question what is this country going to look like in ten years what's it going to look like in terms of population in terms demographic changes with that population what what kind of demands do we expect to be placed on our education system our health care system our transportation system our physical infrastructure and and the like because i think we have a tendency to talk about these programs is over a bunch of accountants and c p a s types when in fact lower supposed to be is facilitators trying to see to it that we're prepared for what this country is going to be or what we want to be ten years from now so and i would hope that one of the things that we want is that ten years from now every american is going to be covered by health insurance if we can put aside the theology and get to the practicalities reasonable people ought to be able to pull that off so having said that let me go to mr a lot refly for an opening statement and then would be happy if you could summarize your statement in five to ten minutes or so so we can begin the question thank the chairman i'll be i'll be very brief also i welcome the secretary thank him for his service to to the country in this very challenging job i heard mr robey say at the beginning of this process that the reason that he is has decided to chair the subcommittee is because he's going to stay around here until he gets this health your thing right so  suspect we'll have an interesting hearing but i look forward to your to your thoughts we have some specific questions that we'll ask during the hearing process  very large budget and it is complex it has taken hundreds of people the better part of the year to assemble it consequently a person in my situation starts that process i give them guidance and i think in terms of rather than try to give you a bird's eye view of the entire budget which will spend time doing over the next couple of hours on specifics i think i'd rather you wouldn't know mind just talk about some of the guidance i gave those who prepared the budget i think that would be helpful to you first of all i'd like to talk with you about the guidance that i got obviously the president needed to give me a sense of guidance and he set priorities and he has he's indicated he wants to be a budget that reduces the deficit over the course of the next several years to a balanced budget by two thousand and twelve and so consequently he's given us that is that instruction with that in mind i gave my budget prepares and team a set of principles i told them first of all just because we're reducing the deficit doesn't mean that we don't have some new needs that we need to meet and and  if you're going to be adding things to this budget i'd like to make certain you're adding in the areas of high demand high efficiency programs i gave them examples headstart and indian healthcare s chip for example i want to make certain that we're preserving the integrity of programs that i believe are highly efficient high the high demand area secondly there are a couple of things that the president's made clear he wants to accomplish during his service and i want to fill most one of those community health centers and you'll see in this budget driving the commitment on community health centers also pandemics and hiv aids things we commit commitments we've made as a country third there are some new pressing problems i'm quite concerned about drug safety  efficacy and you'll see that there are new initiatives in this budget despite the fact that it's intended to reduce the budget there there are new initiatives in that area and there are some things that i feel deeply about that will turn up here that have not been funded in years past help information technology for example as it is an example fraud and abuse in medicare and medicaid areas that i've emphasized and also a desire i have to retool the emergency  management role at h h has which is considerable then we turn to the saving aspect of the deficit reduction and i gave them a series of six principles that i wanted them to follow in terms of where they would apply  reductions than the first as i said if you find things that are one time funds that don't have to be repeated let's let's make that part of our reduction effort and you'll see that i mean if your if you like to c s budget for example you'll see that there were some one time funds there that i didn't repeat and consequently you'll see their budgets gone down a little bit it's because of the one time funds i told them second of all i want to i want to given the fact that we're going to be reducing deficits i  want to use the funds we have available to for direct services i recognize that it takes both infrastructure and services but if we if we've got the choice and having to do one or the other i want to default to services we're providing services to people not just building infrastructure third i want to look for grant activities that have been completed an example of this is if you look at the national cancer institute you'll see that the budget is slightly less than it was but what you don't see is that we're adding a lot of new competitive grants and consequently we'll have more new grants than we did new years past but it's because we've chosen to eliminate non competing grants that weren't producing what we thought was  a proper outcome i also asked them to look for to eliminate programs whose purposes are being addressed by a number of different parts of this department this is a big department and it's not unusual for me to discover that people have undertaken the same project in more than one operating division and when i find that i've asked them to consolidate or to eliminate them one example of that is the indian the urban indian health clinics  are funding a lot of community health clinics in the same town and i asked the question why are we having duplicate activities here couldn't we even though they're in different operating divisions combine those efforts and so you'll see that as an example i asked  look for underperforming programs where there was an analysis that said this is an underperforming program where there was no analysis that could demonstrate that we were making progress and then lastly there are some things that i have been trying to get reduce for some time that have been passed budgets that i've continued to put particular in the area of medicare i suspect we'll have a chance to talk about durable medical equipment and so forth so mr chairman the reality is this is a deficit reduction budget and it's my guess is we'll spend a fair amount of our time with members of the committee asking me why did you choose this priority as opposed to that priority and i have no illusions about the fact that there will be members of the committee who will disagree with some of the priorities i selected and this is my chance to tell you why i did it although my best to own up to our decisions and then obviously the legislative branch will have their turn at being able to make those hard decisions  like to do is to forgo my questioning until the members who are here at the start of the hearing have had a chance to question mr a lot of things chairman were just talking about the weather at the beginning of the hearing and one of the things that we worry about in new york is cold weather and and the like he bill is always an issue this budget proposal slate's any thousand percent reduction from zero seven and the president's budget request my state would would go from two hundred fifty one million dollars which i think it's the largest recipient state to two about two hundred  twenty three million dollars that is going to work real hardship on people and while we did start out with a relatively mild winter it's not anymore and looks like it's going to stick around for a while so why an eighteen percent reduction in like he it's it's pretty severe you probably recall that in the previous year we accelerated a billion dollars out of this budget to meet a need that was there last year and so we concluded that because we had accelerated money in this budget that we would let that carry forward we would mention that there's about one point four billion dollars that have not been drawn down by the states and carry over yes that has not yet been drawn by the by the states and we're very anxious to this tends to be a balance that in the account and in past years when we  have tried to maintain a reasoned balance and then if we get to the point where we can see that more is necessary we've it's been a very serviceable relationship between the administration and the congress and we've been cooperative in being able to make certain that we fill that account which we need to take care of the need we will but we felt like because we'd exterminated that that was a reasonable thing to do that is somewhat reassuring but just to be clear this one point one billion this is these are on obligated these are they have yet to spend one for the states have have these are amounts that i believe have been honored ok they have been allocated but not drawn in other words the bills are out there but they just haven't been paid is that correct or not in other words these are these are funds that will be required to pay prior we have made out like yours is there to a large the fund as you know one is the allocations and the other is the funds we use to disperse in cases of emergency and we have made allocations to states and they have not had needs that they have drawn it well we will watch that  and it's it's good to know that there is seemingly somewhat of a cushion there and and we'll work with that with you and the other members of congress if it becomes evident that those funds need to go into the accounts we're prepared to act in the ways to get them there we just felt that the balance of we're currently sufficient the the issue of health information technology is really gaining momentum around the country  issue a lot of industries have the last twenty years attaining attained tremendous productivity increases as a result of information technology but while there's a lot of interest in the health care industry it's just not keeping a pace with the other breakthroughs in the other productivity increases in other industries if you think that's a fair statement can you can you give us your thoughts i know why we haven't garnered those sorts of  productivity and technological increases or breakthroughs in healthcare i would offer two things if time permits three thoughts the first has been lack of standards people have been interested by systems but in the words of a young practitioner i met at stanford who was just going off to practice he said mr secretary i believe we need a system i want to buy a system but you need tell me which one because i can only afford to do this one time we now have a system of certification toward interoperability that i could say to him by a system that's c c h i t certified and you're on your way but so lack of standards and lack of the second has been lack of adoption much of the standards issue as a result it is not entirely resolved but the pathway to resolve it is in place and we now have of a rigorous process to develop the standards and we have a certification process in place so that existing systems can begin to migrate towards create sort of an open architecture that everybody can that we've clearly identified and or do that existing systems need to move toward and then we've begun to build critical mass by saying for example if you're going to do business with the federal substantial progress here but it's going to take a few years while existing systems can come into full interoperability and i guess the third point i would make is that there is a dilemma that those who have to buy the systems are not always the ones who bear the early benefit and the macro economics of the system are having to change they are changing and we're well on our way to solving this problem but we're not there yet quickly what do you anticipate was once that's widespread what sort of benefits to the to the certainly to the consumer but also to the payers so it's number on a number of different organizations who have made estimates they range generally from fifteen percent to thirty efficiency that can be developed once we have a system i would just add that i think the lack of electronic medical records has created a situation where we really don't have a health care system what we have is a health care sector and we have to thank you very much chairman and a welcome secretary a pleasure to see you again let me ask a question if i can several but question on child care i think we all agree that  the issue is is really at the top of the list for working families in this country today in my own state we just released a report by a group called connecticut voices for children which really has standing not only in connecticut but nation nationwide and what they found is that more than sixty percent of children under six have all available parents in the workforce everyone is working which means that in order for parents to be able to work to have that sense of comfort that their children are in a good place not being warehoused but to have the opportunity for intellectual pursuits as well that they need to depend on that childcare in order for them to be able to hold on to their jobs also in connecticut for connecticut families with two children childcare costs simply makeups the single largest part of the basic needs family budget thirty percent of gross income of a family with children is spent on childcare and you've got families today that are working longer hours making less so the issue is the quality child care now the administration has frozen child care funding now for the sixth year in a row your own budget figures show that three hundred thousand children stand to lose child care assistance by two thousand and ten in addition to the hundred fifty thousand who have already lost assistance since two thousand so four hundred fifty thousand children over a period of ten years my question is how can you justify this what are we doing in terms of child care why are we moving backward instead of forward on this incredibly important issue for families we know about middle class families we know about the squeeze we know that there everybody is in the workforce why are we not there them in this in this effort and what is it going to take for the administration to be able to help parents have that access to quality care and affordable care how do we make this a bigger priority with this administration that's been first let me be with you on the importance of having available child care we have recently reauthorized temporary assistance for needy families which requires in this case  that parents who are receiving that kind of assistance are also working it's unrealistic for us to recognize to expect that parents will be out of the home helping to meet the family's needs and not have some way of caring for the children as you know we partner with the states on this and we watch very carefully the number of those who are in need of care i'm not familiar to be more familiar with the statistics you cite the ones that i am familiar with tell me that we've seen a steady reduction in the number of of families who are drawing assistance under ten f and the available funds per family have been substantially increasing as a result of the denominator going down but i'd be interested to see the facts that you're you're citing i'll be happy to share them with you and specifically about connecticut will get you a copy of the connecticut voices for children report and what's happening there i can't imagine this is not happening in other places you know the the chairman when he started before the hearings got underway talked about trying to place what we do on this committee in the context of the changing economics the changing demographics this is an area where as i said you've got sixty percent of the availability of parents in that workforce these are folks not dogging it they are working hard and they can't make it and they cannot do this without without childcare assistance i don't know if my time is up a move to early childhood education and head  and i appreciate all the work you do to advance public health and your concern for the health of the nation as you know i practiced medicine before i was elected in one of the things i've always been interested in is defensive medicine because i practiced it on a daily basis and i crudely estimated at an added expense of somewhere between two hundred and two thousand dollars a day and most doctors readily admit to this privately we had a very interesting hearing that the chairman convened right before the break and we had a bunch of health experts in front of the committee and i brought the subject up and as you know medicare is under tremendous strain all of us are constantly getting letters and phone calls from providers that reimbursement shrinking and shrinking in the unfunded liability of medicare over the next thirty years dwarf social security we've had a lot of effort on the part of the president to educate the public on the social security challenge but as i understand it the medicare unfunded liability is an order of magnitude larger anyway this panel we had previously there was a very nice study done by dr mcclellan i think he previously worked for you when he was at stanford which clearly measured this as a phenomenon and a huge multi billion dollar cost to the medicare program and i was curious if you were aware of that if you have looked at this because i believe we as a  congress need to start taking action in the years ahead to try to address the un funded liability of medicare and one of things that i think can help is to try to come up with some sort of solution for the liability problem because not because of the premiums that doctors pay that it's really not the issue in my opinion it's really the huge cost of defensive medicine were you aware of the study because it actually measured the impact of defensive medicine in the tens of billions of dollars annually on medicare i think it was one of the best studies ever done that actually looked at this issue i'm aware of a number of studies that have reached essential of the same  reaches his father's age it will be eight percent of the entire economy in one program if he reaches my age which i expect he will will be fourteen percent i mean it's that's unsustainable  and it's a problem we have to deal with and defensive medicine is part of it i will tell you that the budget we proposed i introduced it earlier as a deficit reduction budget but it's also beginning to at least deal with some of the one way we can begin to slow or reduce the rate of growth just barely lowers the line a little bit and it has the effect of allowing it to be sustainable for at least four more years these are hard choices and things that we need to do will also mention that in the area of tort reform we clearly believe that i'll be part of the solution not just for medicare but for the medical system in general and lastly i would make they're not going to be well that's a very important point and i just said in that study they looked at that issue and what they were doing is looking at the california reforms when they went into place and they looked at quality and cost and they showed that quality did not deteriorating costs went down i don't have a lot of time left it's always a great challenge whenever you're in front of the committee to to settle on just a few issues and if i could just touch on one other issue that i know you and i have discussed last year senator lieberman put some language in our bill that i help support over here asking for a committee to look at the  mercury issue in terms of the quality of the studies that were done at the c d c and the report that the committee received back this panel was convened they issued their report was basically that the v s p the vaccine safety data could not be used to measure this and this was a criticism that i had been leveling for some time that all the studies that have looked at this issue are really bad studies and i don't think we have resolved this issue satisfactorily from a scientific perspective but the real question one of the get at is this this congress is looking at f d a reform and and the focus is on safety and i don't know if you're aware and particular i don't know if the panel is we're aware that for vaccines are pre marketing studies are much less rigorous than for pharmaceuticals are post marketing research is much less rigorous than for pharmaceuticals and most pharmaceutical products are voluntary where is that scenes where mandating and now we've given you billions to develop this new avian flu vaccine i believe we need to address this issue and we need a better vaccine safety protocol in order to maintain public confidence in our vaccine program jaime we had the same problem with this before red but yeah and it's in the i'm physician so one of the things that you're working on in the emergency preparedness i was looking at the numbers and that is pretty good but yet there's a cut to local preparedness by seventeen percent and we back home see that is it is a key role that the national government should be helping in coordinating to out of the administration about how we address the labor shortage of nurses in particular and then one other one other piece of the this puzzle in preparedness is when i  visit my hospitals in minnesota for decontamination areas ramsey county hospital which is the emergency response for the capital city of st paul our firefighters get to stand outside of the first responders and twenty below weather and get hosed down and so that i want to illustrate why i think cutting this local emergency preparedness to local funding case of an attack or something in  side change and i notice that you said purchased a number of respirators and that on hand could you tell me how many how many people and for how long if someone was on those respirators what kind of impact we really have for public preparedness thank you chair let me just briefly comment on all three with respect to local preparedness there is little question and no and no doubt that local preparedness particularly in the area of pandemic and percent you're referencing having a hard time reconciling that with my knowledge of the budget it may be that you're talking about the block grants to states we concluded a couple of things one is that  we are funding that area in many different parts of the budget and that particular one may be down but i think if you look overall you'll see that we continue to support local preparedness in a robust way because we believe it's so important i would like also to comment on the work force issue i mentioned but i think before you came that this is a budget reduction and i budget and i've had rather ok thank you  this is an area of what we've chosen to focus on the providing of services not just the infrastructure and of also on workforce issues focused on looking where there are specific needs as opposed to general populations what we what i what i noted was that in many cases we were finding nurses training in other kinds of areas where there where there wasn't as much deficiency or the where there was a deficiency and we weren't doing a good enough job in funding the areas where there were deficiencies for example i found in some of the programs that we were having a very low percentage actually going into nursing or into providing care in the areas where we needed it the most so we've we have focused and then lastly with respect to your question on respirators we are much better prepared in this country for kinetic local event than a pandemic event if we had a bioterrorism event or a nuclear event where we would need respirators we would be able to bring them from stockpiles all over the country if we were to have an event that was taking place everywhere at the same time the national supply of respirators would not be adequate and for that reason i've been saying to local and state governments look we need to vide you with as much money as we have the capacity but the state and local governments and their public health entities also need to be thinking about this any any any community that fails to prepare on the basis that the federal government in this kind of a circumstance will come in and rescue you at the last minute  sadly disappointed because we simply don't have that capacity not because of lack of wallet or will but it's just because you can't get to every community in the country at the same time frankly no state can get every community in the in their state it's a matter of local communities making this a priority many cases people have not made local help a priority they've assumed that the state would fund it with the national government would fund it and that it was their primary responsibility public health and emergency preparedness is fundamentally a local responsibility and state governments add to that and the national government adds to that but we have to be all three and we're doing quite a bit i think if you look at the over the last five years you'd see is close to eight billion dollars we've put in to pump that capacity then we'll have a lot of questions in writing let me ask you just a couple of quick things you mention that the growth in medicare is unsustainable as well as some of the other programs and yet i look at the budget that's being proposed and it concerns me that we we seem to just kind of put band aids on problems and never really look at the overall program see how effectively they're working or not working or as an example in some of the things that are being proposed in here congress one except they've been proposed in the past it won't be they haven't except in the past it won't be accepted now reducing the provider payments save sixty save thirty nine point five four billion over five years congress is going to do that every year that that happens we get our constituents coming to us saying you know we're already being played below cost and can't afford to do that now the doc fix a five percent reduction in two matter same thing with wheelchair payments i suspect you're going to see all the people who provide wheelchairs coming out of woodwork so much much of the proposals that that are in here saving thirty five million over one year two hundred ten million over five years by requiring states to provide states where providers use handwritten prescriptions to use tamper resistant pads save two hundred ten billion dollars over five years some of the numbers i think are speculative at very best and consequently when we see a growth rate in a program like this no one seems to step back and say is this program working and how what would the ideal the program be if we didn't have want to start with so what would we do to create the  ideal program out there and there are the changes we're making it working us more closer toward that ideal program or further away from it so i have some concerns with the overall budget that is that is being proposed here and the band aid the fixes that we continue to put on this program without really getting down and you know the people that i think steps to siri to make the medicare system work in the future your point is a good one to five point six percent each of the and i've gone through each one i've gone through medicare and said if we were to slow that growth rate a little how would we do it and you mention the reimbursement that we chose to fund it at point six five less than one percent less than what med pac recommended why did i do that two reasons one is that i'm working very hard to find a way to slow the growth rate because that's not sustainable and i had to come up with a rationale for the rationale i said med pac also says that there's a one point three percent increase in productivity we should be able to expect is it reasonable for us to ask that half of that goes to reduce the growth rate half of the ghost of the physicians were not cutting reimbursement rates that were just slowing the growth of it if you take every one of these and add them up and they're all difficult things that somebody will be against it reduces the growth rate from point six five point five five point six and i said six i met six point five to five point six so well let me ask the program termination programs that we concluded because they were less efficient programs were things that we thought would be looked at to of we have chosen to propose that they not continue are they are they program terminations because of the ineffectiveness of the program or because of the budget  chose to terminate programs we thought were less effective or because they were duplicative the same time we propose a new latin american initiative that you mentioned in your in your testimony that we're going to expand offering  presence in latin america indicated to you that i thought there were some new pressing needs and that's one i think if you understood if i had the time for me i'd be happy to do it after understand why i think i think that's a priority a million and a half dollars i think you might find  compelling as i do when it is a program start date got a program start date i know you started in zero eight if it's appropriated or zero seven actually we're in the midst of trying to organize it now there will be more said about it in the near future where do you plan on getting the physicians and there is no health component to this i suspect that where you're getting we're going to get to physicians and dentist to do that and many cases they would come from n g o s that are already going down there in some cases there are already existing south america you see the evidence of cuban physicians who are in that region i answering services they are reaching out and touching the hearts and minds of people there and having and these are not always just physicians they are political organizers and there is a real mission for medical diplomacy and we want to do our part of the tribute to the not just to help the people that are in that area but we'd also like them to understand how  in this aspect that you're that you're looking at so i appreciate it we will have substantial other written questions that that will ha areas we have a concern about the center of excellence the health career opportunities program one thing that happened is that generally in the past march she would name the grantee so that they receive the money in august now you're saying that we're not going do that march they have to wait till august all these these groups that will be successful in getting the grants how are they supposed to know and how it is supposed to be able to preplan so that they can take care of their clients in the programs between march august can you look at that me sir change enough so that those who will be successful will be able to bridge and be able to work their butts so they can funded can you explain to me why the such a drastic cut in these areas i'm not familiar with the details of that sound like legitimate reasonable questions and i think probably the best way data we can work with you on that perhaps you could reconsider that decision on the area of a cuppa titus be asian american are very very specifically hit by the disease  i'd like to know whether h h s has taken those recognition incorporated them or not if so would we be notified and if not i'd like to know why they were not incorporated  that's going to affect my area to about forty thousand dollars and that's serious hit i'm sure that's probably hitting also open chicago los angeles and other urban areas and i have a series of know what sleep disorders affect greater number of populations and we like to work with you c d c s national sleep awareness roundtable to be a little more aggressive in our  let me simply get my my questions in at this point first of all as you know the mount sinai school of medicine and its partner institutions released in interesting study an alarming study which indicated serious long term health problems associated with the workers who worked on the scene after nine eleven  is estimated that the long term medical costs associated with those melodies might be as much as two hundred fifty million and the mayor has issued a study which is considerably higher in terms of its estimate of cost  the president has acknowledged a federal obligation to provide screening examinations of medical care to those personnel and has provided twenty five million in his budget my question with that kind of a screening and and treatment and well will the administration be willing to provide additional funding down the line to fully sustain the world trade center medical monitoring and closely the availability of funds to make certain that people are being screened and that they're being treated and we currently have a task force working right now to assess the need and i'm to receive a report likely around the end of march and the president put twenty five million dollars as a placeholder in his budget once we have the report back and we're able to respond to that report and it would be our intent to work with congress to assure that we're able to meet that commitment well i hope that we recognize that that's going to be a long term commitment and we need for some participation by the federal government i have a series of questions which i would like you to respond to for the record but let me let me spell them out now because i'm going to be asking every subcommittee test the same questions a report last year by congressman waxman staff indicated that the amount of departments spending on outside contracts grew from four billion in two thousand and their early eight billion dollars in two thousand five more than ninety three percent increase i would like to know if you have the later figures for the two thousand and six years of would like to know what the explanation is for such a rapid growth in reliance on outside contractors which agencies within h h s account to the biggest share of the increase how much has the department relied on contracts that were not fully and openly competed how much has that reliance changed since the year two thousand could you provide a listing of such contracts for both two thousand and five and six on many contract employees now i work in space with regular civil service employees of the department how has that number changed over the past seven years could you provide the committee with a listing of how many contracts and civil service employees now work in each major location that being more than two hundred fifty employees that are maintained by the department many of the grants that the department makes are given out on the basis of formulas that are written in the law other such as our own grants and then i h are handed out on the basis of a highly competitive outside peer review process i would like to know what portion of your grants department wide are made neither on the basis of the legal formula or on the basis of outside peer review panels could you also provide a listing of such grants and an explanation as to how the department decides who the grantee should be  and then lastly given the fact that the office of personnel management last we are last month posted some of the results of their federal human capital survey for two thousand and six listing that the top ten agencies in terms of employee satisfaction i note that your agency did not rank in the top ten new the did many others what i'd like to know what your view is as to why h h s did not have a stronger  showing this is a seventy three question multiple choice survey i'd like to have you provide the committee with the complete results for the department with respect to each question on on the survey and i do as i say i don't expect you to respond but i would like you to respond to just one last comment i note in the new york times this morning in your discussion with the governors yesterday were out of an allotment we just discontinued in rolling people until we had real i hope that that isn't going to be the attitude of the administration and the congress i would not want to see a new version of no room in the end and let me simply say that as far as i'm concerned the supplemental that we report out will contain at least seven hundred fifty million also participate in in state programs there are too many adults in this country who have serious health problems who wind up with no health insurance and i think we have to recognize that poor children are are incredibly damaged if their parents can't get decent health care just as they're incredibly damaged if they can mr chairman we share the widely held aspiration that every american have access to a basic insurance policy and price and we believe that the children's health insurance plan has been extraordinarily important tool we support its reauthorization we support the solving of the short term problem that wisconsin a number of other states have that would be resolved by the seven hundred forty five million you you a will explain the circumstance that you reference as you know this children's health insurance plan was the product of a created an allotment for every state the allotment had to be and needs to be managed in thirty six states they were able to one way or another to assure that they they were managing the available funds and some states they chose not to enroll enough people to be bumping up against that an allotment in the state that i governed we aggressively went out to enroll children and and did so but it would be wrong  for people to overspend their budget and so we chose to manage the enrollment we didn't have anybody kicked off we just made certain that we had and we and we added thousands and thousands of children are proud of it and  as as other states are as well in the future we need to make certain that the formula is right so that we don't have states as i believe probably the case in some situations they didn't get big enough allotments and hence they are having a difficult problem managing it  my point is that when states are provided with allotments they need to manage it just like i expect those who are in the federal departments to manage the funds they wouldn't want to appear in front of a committee if i had dramatically overspent my budget in a particular area and you expect me when you appropriate money for me to manage it as a manager and that's our that's our responsibility well it seems to me when we have a huge percentage of children still still not being covered by this program that the ultimate management failure would be if we don't reach every single one of those kids we believe that it's in all of our interest to have every person in america children and adults alike having access to an affordable basic policy and i look forward to working with the committee to find tools to make certain that we can accomplish that and states and the mississippi was the most rural till i guess maine now it's more rural but i've spent all of that time trying to help rural health care stay alive i guess i'd be interested in what your perception of the health rural health care in america is you come from a rural state governed a state where there were areas so rural you had to order a hair cut out of a catalog let alone getting health care and i know how hard it is to deliver health care services of a quality nature in parts of rural america we have had to and and my state as well as i suspect in yours use tools such as telemedicine and  extend it we've worked hard to make certain community health centers were available and many liberal communities throughout this country communities have developed the community health centers for that purpose i acknowledge and recognize that some community hospitals and small areas drug and sometimes a community just can't sustain a hospital and they have to partner with other communities to do it there are many programs in the federal government as well as in state governments to try to supplement that as you're aware in the medicare modernization act twenty five billion dollars was allocated for the purpose of being able to increase the federal assistance in that area  and perhaps that would give you a place to start well i was very much a part of that and it didn't come easy believe me that's it was a fight but that's the first initiative i've seen in washington to help the rule that really helped rule and i guess i'd hoped maybe and i know you don't control the budget budget office but i'd hope with a rural governor i wouldn't be fighting real cuts every year whether it's flexibility grants or outreach grants or clinic medical malpractise money i mean that these are small amounts of money and let me tell you where i think your department long before you got there is very foolish when you don't treat people in a small rural area near their home you ship them to urban suburban markets where you pay more and i'm a businessman first i was a retailer and so when you ship people to distances away from their home you  life and you know people hundred miles from home or fifty miles from home and then the system pays a whole lot more and i'll tell me that makes sense to displace families people not being able to work when their mothers in the hospital or children or whatever and you travel distances you know in my view as a business man you could save money by keeping rural health care healthier and actually growing the amount of care you get there not i'm not talking about high end stuff in every little town but whenever you don't have basic health care die they don't get their health care soon enough you pay a lot more because they get sicker and i have a realistic i i can give you you know data on that but there has never been an issue out of your agency long prior to you that i've ever seen that dealt with the health of rural health care and i don't know how we got to the point the medicare changes were didn't make a sequel it just brought it up to we wouldn't die quite so quick and if the state level there's no regulations in my state medicaid pays rural much less than urban suburban and you can have a huge amount of medicaid at a hospital you'll get anything extra for it in a suburban urban hosp where you get a lot more money we allow that to go  mean i guess the whole picture of why has your agency never had an initiative to help with the health of rural health care because it would save you money keeping people healthy and not having because when they go to the big hospital you lowey thank you secretary leavitt and i will submit many questions for the record because there are so many areas of which i'd like to get on which i'd like to get more information but i want to focus on a couple areas that wall ready mentioned because i feel there's so critical first of all following up on this mccollum's question before it's hard for me to believe that the administration believes that the state and hospitals are adequately prepared for bioterrorism and you said that there is another source of money for states in the absence of adequate funding for bioterrorism grants i've been looking at the emergency preparedness program because it's so very important to new york and i look forward to your response on that and in light of the vulnerability of states and localities to respond to potential acts of terrorism shouldn't rethink cutting these programs and i also would like to know from you when you are responding to us on this issue does h h s incorporate factors such as population density threat of a biological terror attack or regional vulnerabilities when it distribute these funds so i have a real problem with your response to congresswoman mcmullen and i do look forward to the details of your response secondly i appreciate  congressman chairman old be bringing up the issue of the nine eleven worker health needs it it's been now a year since the naming of the nine eleven health czar and we haven't seen a plan from s so we're looking forward to that it's estimated that the annual cost as chaman o b said could be as high as three hundred ninety three million dollars and none of the funds provided thus far by the federal government have been able to be used to treat residents schoolchildren area workers and others in the area nine eleven so following up by like to know why or if the twenty five million could be used to treat these individuals i'd like to know when the department is planning to release the plan and i'd be interested in your response what you think is sufficient and what do you think the health program should provide nationwide and the third question again which you don't have to on to today i'd be interested in your comments regarding surge capacity for the  under your guidelines quote all hospitals are required to have a certain amount of surge capacity and the lack of surge capacity is one of the greatest vulnerability as we face in the ever in the event god's a bit of a p emic i'd like to know which h h s agency is in charge of assuring that states and localities create the medical surge capacity for treating people who become ill during a pandemic is the department providing specific guidance and performance measures with respect to creating surge capacity and has the department estimated the cost of creating a minimum level of surge capacity i'll leave these  written response and perhaps i could just add to that i remember secretary comm secretary thompson giving us a view with this extraordinary headquarters with t v s all over the place and god forbid there was an outbreak he would know exactly in which hospital they have search capacity so maybe you can let us know what you doing with that how many millions of that was that price and any time i speak to a local hospital they say w i don't need they don't even know we're talking about so perhaps you can respond to us in writing is this a facility being kept up to date can you really estimate what's going on in every state in every hospital i'd love to have a further discussion with you about that thank sector as i've indicated ms lloyd i have to leave for that other meeting let me just ask with respect to the questions on contracting  know i just suggested last week that every time i'm going to pick on the chairman i would rather pick on the archie the cockroach rather than the chairman because you dig yourself a deeper hole by me and in the minority in the last on the committee nice to see you again once again it's a pleasure to welcome you i guess to to congress and we served in the same executive branch together mizzling walker was lieutenant governor when i was and  we had some pretty good years and my question and it relates back to what the chairman was suggesting i wasn't here of course nor were you during one nine hundred ninety seven when we first put in s chip but if i remember correctly because i was in the executive branch of the montana level the whole purpose was child health insurance coverage and i heard the chairman talk about adult coverage under health insurance and i don't deny the fact that we need health insurance for all americans it's extremely important but if i remember correctly the point was children's health insurance my question of you is the administration taking a position on the states  i believe there are fourteen that have expanded their coverage because we the congress gave them enough flexibility to create the program for themselves has the ministration taken a position on the expansion of the s chip program within those fourteen states if if if if fourteen right number to expect to include adults and how do we gain control and should we not go back to the original intent and if the question is there's not enough funding or the func formula is incorrect or  reduction act prohibited any further expansion of s chip with single adults or with childless adults scuse me there are however states that have  expanded prior to that time their s chip rolls with adults in fact there are three states that have more adults than they have children we proposed to in the to refocus s chip on its original mission which was low income children we think it does exceptional job and needs to be reauthorized but we ought to focus on low income children we believe that those adults who are currently served by as chip should continue we don't want to have people lose their health insurance however we do believe that adults should be  matched at the normal medicare medicaid rate as opposed to getting an enhanced match purpose of the enhanced match was to help states attract going to top you lay she was children since that time that as chip was put into place we've also seen another change that is under the deficit reduction act it made possible for adults to be covered under under medicaid and then have children join them at the higher match so that families could be together we believe that that adequate tools exist to accomplish that task we do believe that we need to pursue the objective of every american having access to an affordable basic policy and that we should be focusing not just on children but on adults and the president has made some important proposals about how that could be done and we look forward to working with congress to both reauthorize s chip in the long term solve the problems that it currently exist in the short term and our secretary there but i'm concerned that your f y o eight budget request for community health centers has no significant new funding above the level that we've been concluded for this year and this is true despite the fact that included in this request is the president's high poverty counties initiative to put a health center in every poor county that doesn't have one los angeles county has more than one point five million residents and some two point eight million of those have no health insurance so obviously we have at least one how fenner in the county but there remains a critical need to expand the health cent infrastructure in los angeles county to reach that two point eight million uninsured with that in mind what is the rationale for designating a county as the most appropriate geographic bound boundary for these new funds as opposed to communities which could better address the unmet healthcare needs of large high poverty urban areas i spent about an hour and a half today with governor schwarzenegger and his key policy health policy staff talking about their ambitious plans to provide insurance to every citizen of california a resident of california we actually talked specifically about los angeles county and some of the challenges in to and providing health care in that area frankly i'm not able to give you a response i don't know the answer as to why counties were selected as th geographic unit of measure that happened before i was secretary i will however make a point that the president made a commitment that we would see twelve hundred new community health centers around the country then added the idea of making certain we were focusing a good share of them in the most impoverished areas this budget will complete that commitment it's been a commitment that they the president made and we have a each budget had adequate funds to make incremental progress and i think it's something the president's quite proud of so you're saying even though you're not haven't included additional funding for this expansion you still expect that you're going to be able to meet that goal and that counties like los angeles will be able to expand or you know i think that's what you're referencing is a comparison between the joint resolution and in our oath seven  budget we had adequate funds to add new community health centers i am not able to reconcile all of these different versions of the budget but i can tell you that we made a commitment for twelve hundred we have new funds in the seven budget m changed as you know designation of new county health centers is currently based on a number of criteria including the proportion of migrants homeless and public housing units in the community and another concern i have is that the president's budget proposes waiving the statutorily we call quired proportionality where these populations why is this necessary and what will you do to ensure that this new expansion is implemented in such a way that the nation's poorest communities are targeted without regard to aid you get a graphic boundary such as a county again it will be important for me to reconcile why that was selected i can't  was published last march by her son the office of public health science and the office of minority health that summarizes the evaluations of pipeline development programs that are designed to increase diversity in the health profession and these evaluations are overwhelmingly positive about the effectiveness of these programs in increasing the number of minorities entering the health professions which we've had expert testimony that has said that this is critical to to meeting the healthcare needs in this country especially given the changing demographics for that reason i i  was surprised and fail to understand that the administration's lack of support for the centers of excellence and the health careers opportunity programs for example we know that the hispanic population is the fastest growing in this country yet the budget proposal for fiscal year two thousand and eight completely wipes out all hispanic serving centers of excellence and only leaves four h ca programs functioning when there were testimony that you were zeroing out urban indian health and in that you said the reason you were see were in and out was because this population was served by a community health centers i'm not sure what the situation is in other areas but in the city of albuquerque and i think you probably have a significant urban indian population in the state that you came from there about ten thousand native americans living in albuquerque  a while back they had a hospital and in the end health service ospital and then and it provided very good service that's now been downgraded to a clinic and now under your budget is being closed with this explanation that they're going to be served by community health centers but the fact is that that what's happened is that these health centers have gone back to the reservation and  many many miles away from where the people that need the health care are so if a if a if a if a pueblo or a tribe is one hundred thousand two hundred three hundred if you're navajo for example and you're in albuquerque you'd to get to the navajo indian health clinic would be quite a ways so i don't i don't quite understand the the explanation here in terms of how we're achieving our objectives by closing something that's serving a population in an urban area and telling people to go and it's it's kind of the river is it related to what mr peterson said earlier can you give me and like me a little bit why that's a wise choice we're making there we're looking for constantly for areas where one part of h h s may be duplicating an effort with another and i will say that we increasing the budget of the indian health service budget that i've already confessed to you as a budget designed to reduce the deficit which would indicate i think clearly we have a high opinion and a strong belief in the mission of the indian health service however in being able to use the dollars we have available for that purpose just hasn't made sense to me that we should be with dollars from one part of h h s developing a community health center that we'd like to be a first rate facility and then with the dollars from another part of h h s be developing a clinic that would do essentially the same thing in the same community if we had one we could make it better serve everyone in a more robust way and it was clearly designed to be an act of efficiency to create a single better clinic than having t left less ideal clinics but the i think the real problem is that with those kinds of numbers with the urban indian numbers if they actually went back to the clinics if they were able to make it and get the transportation all that that the clinics at this point couldn't handle that capacity i you know i hope that maybe you're moving in the direction of putting those kinds of resources in there although i'm not sure i necessarily see it in this this budget shifting a little bit on the to the prevention front and i want to applaud you for your inclusion in the budget of a youth health promotion initiative and i think that's great but at the same time you zero out to preventive health and health services block grant for this is for the second time i believe you flats on the c d c s division of nutrition and physical activity you basically flat fund the chronic disease and health promotion portion of the budget and you decrease funding for steps to a healthier usa the overall c d c budget request is lower than what what was provided in the c r prevention and promotion are the areas that will help slow some of the entitlement spending it will help slow the exploding medical costs and yet almost across the board prevention and promotion are either decreased or flat funded  could you point to me where in this budget you've made a real commitment to prevention in light of all these cuts we've mentioned except for this one small program i mean where where you really  push to move us in the direction of prevention to bring down those entitlement costs and save dollars the most significant part is beginning to create quality measures that every patient has access to an independent assessment of the quality of care that they're getting electronic health records all of that is about creating quality majors and quality and quality of care there's no question the fact that and until we focus on prevention robustly as we do treatment we won't stem the cost and the programs you've mentioned are worthy programs but the bigger picture is turning the way we actually deliver clinical care  couple of those programs we deemed not to be effective a couple we found had run the course of their original appropriation some are new there's no question about the point being right that prevention is a critical part but it starts with quality treatment our you said that you were meeting with governor schwarzenegger and you mentioned that trying to provide health insurance for every citizen and you quickly changed that to every resident i assume you did that consciously his proposal  goal everything else i guess the question i ask is what is the government's responsibility to make sure that every individual has health insurance and one of the other aspects of that is that i don't think that we're ever to control health care costs until we make people become health care consumers again insurance has done many great things people have better access to health care now have better health care than they've ever had before better dental care better everything than they've ever had before because of insurance the downside of that is it's taken much of the sponsibility becoming health care consumer away from the individual and intel we get them involved in making health care decisions again so they become a health care shop or we're never going to i think we do see health of the cost of health care i always use the example in my dental office when i practiced dentistry what was the incentive for someone that had insurance that was in insurance was paying eighty percent of the cost of a procedure find out why i charge less than the guy down the street or be charged less than i did there wasn't any incentive it was very minimal for the individual at some point in time we have to get them involved could you explain to me the president's new proposal on health insurance that he talked about in the state of the union address and will that bring more market incentives back into  shopping for health care insurance and hopefully reducing the cost you ask about what is the role of the government and what is the role of the individual let me do my best to respond to state what i believe and what i know the president believes first that is that every american needs to have access to basic insurance policy at an affordable price we're a compassionate country if a person is elderly or if they are poor or if they're  disabled or child meaning protection the government needs to provide health care to them and do the best and pay for most of it everyone else has a responsibility to do everything they can before they turn to the government for help but the government and i believe specifically the state governments have a responsibility to organize the marketplace in their state to assure that they have the capacity to get a basic health insurance policy and those who can't afford it then we have it is i think our nation's desire that we help those who can't afford even a basic policy to get one and it's in all of our interests because to have everyone in an organized system of care is important for prevention if we don't have people getting care when they need it and just going to merge and see rooms it's more expensive now with respect to the bigger question which is how are we going to get consumers involved let me say intel they have information about the cost of their care in a way that they can understand and compare until they have the ability to have independent assessments of the quality of their care they can't make a judgment based on value of the federal government has made a very clear statement on this point if you there are four cornerstones  believe must be in place for a system to provide that information the first is electronic medical records we've talked about that the second is quality of care that can be standard measures of quality people can compare quality and lastly having the ability to compare the cost now we've made clear that if you're going to business from the future you know in the future with the federal government you'll need to provide that information our time is up i'd love to tell you more about it  someone asked me about it i'll break into song over it congressman peters and i were just talking i would like to sit there with some time and talk about rural health care and some of these other initiatives that you're but you've got underway and i do i say i appreciate the job you're doing at the are above a two hundred percent of the poverty line so that in fact this is there was a rationale for dealing with for with with children and with regard to let me just lay of twenty five billion and then new money four point eight billion and then there are four there's four billion dollars that is currently unutilized from previous allotment a but that doesn't start until that will not be available immediately last year as chip covered four point four million children according to your budget estimates how many children do you estimate s chip will cover every year assuming your budget proposals are implemented and how many children would be eligible for the program in these years i would have to respond in writing to those can tell you how we chose that number if you're interested in that well what i want to do is if you can deal with that because i want to my other several other my colleagues here and i know you have a deadline of four o'clock so i want to not because you can address that question as well as answer these and then is it true that there will be a decline in the number of children covered in s chip if the president's budget goes into effect is not true it is not true then what we will need to do is to get back to you with the with the data in the information if you can lay that out as to how that is the case given all the statistics that are out there now including what the governors have been talking about in the last several days where they are going to they are they are talking about the children who will not be covered by the president's budget so if you if you can square that for us and heard you in your commentary talk about maintaining the integrity of the head start program which gives me some pause is to when i take a look at the budget where there is a proposal to cut head start funding by a hundred million dollars budget and reduces services to over thirty thousand additional children if we are not investing in this program with its history a proven success what early childhood initiative is worthy of our investment for the future i'm sure we continue to invest a lot of money in the head start and deficit reduction budget as i characterized very early i wanted the budget for a start to be protected from from the serious reduction and we believe that the budget we presented will allow them to continue to operate serve the children as they do we we are things that we believe could be done that make it more efficient and for example we think the closer coordination with state efforts for example could provide for elimination of a lot of duplication i think we just have a different vantage points of view points of as to whether we had started not eligible children now are not part of head start we're going to remove an additional thirty thousand children it doesn't seem to get us to the goal of making sure that every child is ready to learn and in going to school i think one has to in  even in a deficit budget take a look at where our priorities lie and the deficit is not in this particular agency but it's as as a overall federal budget and where  dollars are being spent where our dollars are being wasted and where our priorities are being just shortchanged more than retells care and s chip whether ridges early childhood education chairman for yelling i first of all want to compliment you on what you're doing with community health centers they have really released my experience with them has been very positive it provides a family doctor for poor people and it keeps and the doctors tell me this hospital administrators lightens up the load in their emergency rooms so they can truly develop or deal with emergencies madam chairman i'd like to submit several questions for the record  conflicts all day today and so i couldn't be here but just one mr secretary i know that you emphasize management in the department to get results and i wish you that elaborate on the initiatives you've taken to eliminate waste fraud and abuse we always talk about it but what have you done in this effort perhaps like you illustrate our efforts with one very serious need that represented in this budget not long ago group of durable medical equipment distributors i say distributors in a very loose word be away because there were no real businesses here it was office building there may have been eighty different businesses in this building and i'd say sixty of them were durable medical equipment dealers they knock on the door and they'd be locked despite the fact that they  indicated that it was in the middle of their business hours and when you would find people there they would be people who couldn't speak english it was just very evident that you looking at the  area that i'd like to highlight in this budget because it's a desperate need we have to have more resources for enforcement how much time do i have two minutes what dates can you provide on the development of the cell based technology for for vaccines we have engaged in a number of different contracts with pharmaceutical companies who are working jointly with different number of different technologies we've invested well over a billion dollars i'm happy to report that we are making substantial progress in the development of the cell based vaccine we're also making saying substantial technology enhanced since in the area of a  the i notice need ministration propose a significant reduction in the children's graduate medical education program and the evidence of this children we graduate medical education is an important part of medical the way we finance medical training that particular recommendation was based on the fact that we believe that  it is already contemplated in the rates that we're paying particularly in managed care situation just going to mr honda you would be next but our colleague mr ryan has not yet had a first round so it's it would be alright with you i would move to mr ryan so he could get his question man i'm sure i'd be happy to yield to my friend if if we have time to do that now we have i get it and i got that look get your question in but thank you has to leave it for and i apologize for being late i was this specifically he wanted me to remind you of a question here regarding an issue and this is why i could use a minute but i want to just ask it to you here why have you we have an issue with title ten that we're trying to deal with and the deficit reduction act from last year there was an issue where health care providers non profits outpatient family clinics after and that's it you'll back mr peterson thank you mr secretary a man issue is that has always bothered me from my time at stake government with the medicaid program and i want to say this in no way am i oppose the medicaid program or i oppose of the services we provided but i want to tell you what bothered me then and i be interested in your perspective now when i was a state senator in charge of health care for ten years i never had data from our partner will pick welfare on the medicaid program that allowed us policymakers to even make suggestions of what we cover or we don't cover because we did not know what we were paying for we only knew broad categories and i find that unacceptable in today of computers today that we don't know what we're paying for now i don't know whether that's changed or not i was at a conference just about eleven years ago as i was running for congress in chicago strictly on medicaid and i asked at that conference if anybody what states knew what they were paying for i really had good data and they thought it was one state i think it may have been arizona but i'm not sure now that was getting there but most states did not have good records of what they were actually paying for  i'm told that policymakers in pennsylvania they don't have any better data than i had when i was there chairing the committee trying to deal with fair medicaid payments and because if you pay for everything you can't pay enough to but you should prioritize what you pay for because you know it runs from fifty four percent federal payment to seventy eight percent i think an average of fifty seven percent that we pay for but there are fifty or more state programs do we have better data today of what we're paying for do we really know what we're an important point you've made is that people think about medicaid as one program medicaid is fifty separate program that's correct same name that have one thing in common that's the federal government's a partner the federal systems are primarily systems that reconcile our relationship with state but they do not include a lot of patient records they don't include a lot of detailed information about what we're buying that is a function of the state  i will tell you that there are some states that have better information systems than others but as a taken in total in my judgment this is an area that needs a lot of great systems in state medicaid programs aren't what they need to be well we know with your standard systems in medicare that fraud is still rampant there's always a clever that's true  much and we all know we've all seen it well if you have a system that's not accountable you're going have a lot more of it than you would and i guess the other point i want to make is that in our system we don't require an equal payment because of urban clout urban hospitals and urban providers have always done better than merle that's about cloud it's not about some law we design it's just about clout where where there have been additional medicaid payments to urban hospitals and urban centers who have a certain amount of f a have twenty or twenty five percent of medicaid they get a lot of money but a rural hospital can have that same amount of medicaid payment or part portion of their payments for many and then get anything if the state doesn't i when i was there we for a while we had some rural help but when i left it left it soon went away because it was nobody there to push but it seems to me shouldn't be some fairness in the system should should rural people be on the short end all the time when it comes to help you know the first the first point you made is extraordinarily important as that is the availability of systems so that you can begin to make management decisions on the basis of something other than regional influence that's right and and of just i just wanna make one thing please coming ok i mean it seems to me i'd like to work with you in your department if we need to make medicaid payments accountable somehow you know with fifty states you ha great ability to major who who effectively uses those dollars and why we've never used the fifty states and you know i said that to julia gerberding from c d c i said why don't you rate the states and how they implement the health data you give out and what they do for you she said that would be dangerous but but would it be very helpful because the governor wouldn't want to be last the one want to be below the fifty percent tile that chairman kent sent us both out of the room we don't quit talking but i will say that we've got to get the incentives right yes a lot of love to work with about thirty three million ok you have contracted services to i guess which totals about five hundred seventy million for contract for services not available to  centers a really critical and they do provide very specific services to those populations in urban centers i don't know if you've ever visited one i have and seen how particular and how specific their services are which require which would require specific services by the clinics that you say they should go to i think it's a bad decision and i don't think that it's going to really enhance the kind of relationship and legal kinds of beneficiaries will cost my county hospital over thirty five million dollars i'm just wondering how the department justifies this administrative proposal on our public hospitals nationwide under so much fiscal strain  regulations aimed at one thing medicaid is a partnership between the states and the federal government and when it comes to a partnership both partners have to be putting up real money and the states have created him from having been a governor but the states have very innovative lee found ways to circulate money in a way that they're using federal money to essentially pay federal match so we're matching ourselves and these regulations and i'm happy to go into more detail with you but these regulations are aimed at making certain that our partners the supervisors i know how some of the thing works and i understand what you're saying but i'm not sure that that's in charge of the case just to be with you in just regular thank you madam chairman one other question mr secretary and that is that you request a hundred million for health information technology and i know this is been a high pressure how this progressing in developing a well for lack of a better term smart character or something that we would all have our health information on a card so that of wherever you were in the world they could plug it in know what your allergies were what your medications and so are you making progress on that our vision is for three to five years from now for every doctor every pharmacy every laboratory every hospital to be electronically connected i'm happy to report to you that we are making substantial progress in the first step of that which is to have standards so that systems can talk to each other once the systems can talk to each other we can begin to see that vision flourish we can see those systems within hospitals now a within small groups of physicians but they've got to be able to connect with each other and that's the thing we're working on i believe it is we now have over sixty vendors of electronic medical records that are seeking and have received the first step of certification so they have standards that will allow that interoperability we're making very significant progress now we have a lot to work a lot of work to do but when you and i first started talking have interesting news in that respect the veterans administration is a very fine system they call vista suppressive everything's electronic in the military and the defense department they have a system they have that does a similar thing once we started developing the standards they both concluded they needed to upgrade their systems and they have now concluded that they will upgrade them together so that the defense depart one could talk to the veterans administration they'll be using the same standards that  that the cleveland clinic will ultimately be working toward in the week and kaiser permanente and interment health care and small doctors offices all over the country the fact that those two systems are now adopting the same standards is a major step  i have but two very quick comments to press my question one is last week i met with about fifteen to twenty of my clinics and they're very very anxious about the president's high priority counties initiative so with regard to the question  asked previously if i could have some kind of response within the next two weeks i'd very much appreciate that would it be or would you be willing to express your specific question so that we're responding to the right thing and maybe we could we could area of prevention the response was that that prevention starts with treatment and perhaps maybe that's where the problem i'm a lie that the the premise may be wrong the way the administration the president is looking at that and i would respectfully suggest that perhaps that you turn it around and that the the goal is that prevention makes treatment unnecessary and if that were to be the focus and the goal perhaps some of the cost savings that were highlighted by congressman udall could in fact become a reality that perhaps is an art the way i express that so let me take another run at it one of the big worries we all have is childhood obesity for example we are now spending in the federal government about six hundred million dollars on obesity prevention some of it's in animated cartoon characters from that movie to tell that story we've engaged in a public service campaign that i'm told by the ad council will generate more than three hundred million dollars in advertising qualify three or four very central messages that they're going to start using those messages to with their marketing budgets to drive home prevention on obesity so if i left the impression that we don't see does orders and genetic diseases in newborns and children was established to provide advice and recommendations concerning the grants and projects authorized under the heritable disorders program and also the development of policies and priorities for newborn and child screening counseling and health care services for heritable disorders the advisory committee recently sent you a letter recommending that you facilitate the adoption of the american college  medical genetics screening panel for twenty one conditions by every state newborn screening program when will your office be responding to this letter and when will you act on the recommendations for federal we were just a couple of minutes over your four o'clock deadline i'm sure people will be submitting as i will be submitting for the record i hope we have an opportunity to come to talk about the issue of the g a o report on food safety but i will  it well but we have to find out what we're going to do about it that's the question thank you very much the hearing