meeting of the committee will please come to order in february president obama called upon the congress to enact legislation to reform america's health care system in april gov governor kathleen sebelius is sworn in as secretary of health and human services her department has the lead responsibility for improving the health of the american people last friday i join with   rangle and chairman miller and chairman emeritus dingell to propose a discussion draft on health reform this morning we have the honor of hearing secretary sebelius present the administration's view on the discussion draft based on her contributions today and on what we will hear and learn from the fifty stakeholders appearing before the health subcommittee this week and on the input from the members we will revise the discussion draft and introduce a bill for consideration by the three committees our legislation will reduce health care costs it will cover all americans it will improve the quality of care and it will be fully paid for the lead sponsor the lead author will be john dingell chairman emeritus of this committee who has faithfully carried on his father's legacy as an undisputed leader in the struggle for health reform i want to emphasize a few important points about the discussion draft first it is just that a draft for legislation for discussion for the legislation we are seeking input from the administration and others because we want to improve the draft before introducing legislation second the draft builds on what works in our you leave uniquely american system it builds on the employer based system for via the health coverage to workers and their dependents it relies on it improves medicare as the source of health coverage for the elderly and the disabled it builds upon medicaid to extend coverage to low income americans third the draft fixes what is broken it fixes the broken individual health insurance market by creating a new insurance exchange through which uninsured americans can enroll in their choice of health care plan those who cannot afford to purchase the coverage available in the exchange will receive assistance  public opinion using a public option will be available within the insurance exchange to give consumers an alternative to private health insurers for their health care coverage this public option will be self supporting will not receive ongoing subsidies from the federal government the public option will compete no one is obligated to sign up for the public option no provider is obligated to provide medical services under the private public option but the public option will provide competition so that we can make the market work and keep everybody this the draft contains provisions to reduce rural racial and ethnic disparities in disease incident and treatment the draft fixes the broken medicare physician payment system and prevents the irrational cuts that are scheduled under current law from going into effect the draft takes the steps necessary to fix the shortage of primary care practitioners and nurses and other providers and finally the draft ensures that people have a choice choice of doctors choice of benefits packages and choice among insurance plans this approach builds on what works and fixes what's broken and make sure that people have choices it's pragmatic and it will produce the results the nation's health care system so desperately needs lower costs broader coverage and brit better quality today we'll continue on a journey that began over one hundred years ago to provide health insurance for all americans some of our greatest presidents of the twentieth century teddy roosevelt franklin roosevelt and harry truman were advocates for health insurance for all americans president clinton fought hard for his administration's proposal those initiatives may have failed but the hope that inspired them was never defeated the time has finally come to redeem that hope and to deliver true health reform in my conversations with colleagues and constituents i'm getting the clear sense that there is now a willingness to tackle this issue and to resolve the problems and bring forward a much better health care system for all americans with president obama in the white house we now have the best opportunity ever to enact health reform i'm determined that we not let this opportunity slip from our grasp i look forward to this morning's testimony and continue with urgent pragmatism the senate health reform legislation to the president for his signature this year i want to recognize in opening statement the ranking  summits both in the large meetings and in the working group meetings and i said that the republicans in the house and republicans on this committee were very ready and very willing to work with the president with you  mr plone and other members of the majority to create a new health care system for america there's no member of congress on either side of the that supposed to improvements in reforms in our current health care system so we were ready to work you told me repeatedly that you were ready to work with myself in the republicans having said that actions speak louder than words well you know i have held several meetings personal meetings and we held one meeting with chairman pallone and ranking member deal of the subcommittee we agreed to work together the brown bag lunch that was supposed to occur because of that  was scheduled and rescheduled and finally last week we were supposed to head it had it last friday at noon we were called the afternoon before and said that that brown bag lunch on a bipartisan basis could not be scheduled because you were attending a press conference to unveil the democratic health care bill that's not bipartisanship that's not inclusiveness  sure sure made me feel like the  i guess or some people would do both but luckily you're not one and i'm not either but it is what it is that we now have a bill we've got the secretary of health and human services here to in support of your bill i haven't read her testimony but i bet it's going to be supportive but the good news is we're we're going to have a series of hearings and we will at some point in time go to mark up hope springs eternal on our side that some of our ideas may yet be included the bill in its current form i have not read all eight hundred fifty two pages of it i'm not go say about that but i've seen summaries and it's a massive government involvement in american health care is hugely expensive i've seen estimates as high as three trillion dollars over ten years i'm told that the word shall is mentioned over thirteen hundred times i'm told that there are thirty eight new mandates that there are dozens of new bureaucracies  listened to your opening statement mr chairman and heard you say that nobody has to take the government plan he doesn't want it that may well be true technically but if you put so many mandates  on private insurance that it becomes cost prohibitive and if you raise the medicaid eligibility to four hundred percent they're going to be millions of americans that lose or coverage because the private businesses that offer it can afford it and then they're going to be millions of americans who say why should i pay a monthly premium of x dollars when i can go on medicaid and pay little or nothing  short of it is that if your bill were to become law we wouldn't have much of a private health care system in america within ten to twenty years so put me down as undecided mr chairman we will work with you we have a number of amendments we have a republican alternative that's private sector based lets the individuals maintain their choice  do some of the things that you do in your bill we do have a permanent position reimbursement fixed we do have a a tax credit reimburse will tax credit for low income americans  but the big difference between the republican bill and the democratic proposal is that on the republican side we still believe in the marketplace we don't have all the mandate we don't force americans into a government plan that we think is not very good for america but that mr chairman i'll submit the rest of my statement for the record i look forward to these hearings thank you mr barton and i am sincere in saying i want to work with you and share a brown bag lunch thank you i want to and this bill is a draft i want to recognize mr dingell the chairman emeritus committee of a champion of health care reform and the man who will be the first name on the legislation that will produce health care reform mr dingell mr chairman first thank you for holding this important hearing and thank you for your mark of a leadership moving forward towards a resolution of the health care problems we have in this country i want you know that i'm grateful and proud and i'm particularly appreciative is a kind word you said about my dad and on behalf of my dad i want to thank you for your kind words and i thank you for your friendship i also want to do something of a personal character here that is to welcome secretary should be to the committee your father was a valuable member of this committee and sat in this room for a number of years and we is week marks the beginning of a truly historic process an opportunity to fulfill our moral and economic up again to provide quality affordable health care coverage for all americans the current system is not working but my dad started on this years ago it was a matter of humanitarian to turn americans were dying for want of health care and health care was not available to most americans today that still is true to one degree or another but it is now an economic necessity something which must be done to enable the united states to continue to compete in the world marketplace and our industries are being killed by the lack of this kind of support in a fiercely competitive world economy forty seven million americans are currently without health care and upwards of eighty six million will be without health care at some point during this year more and more americans are being forced to make decisions state never should be forced to make they pay their monthly health insurance premium if they can get a health insurance policy or do they pay the utility bills the mortgage or do they buy food for the family american business owners are facing a tough decision as to whether meat to meet monthly payroll or to pay health insurance contributions for their employees and if you look at your merit automobile it's got seven hundred fifty dollars worth of steel in it and sixteen hundred dollars worth of health care foreign competitors go to confront that problem the federal budget could no longer sustain our current health care spending if health care costs grow unabated the cost to the country will be more than twenty percent of its gross domestic product on health by twenty eighteen the discussion draft and i stress towards discussion draft where it could sugaring is  uniquely american solution to this crisis it's been a privilege for me to work with you mr chairman with chairman rangle and german miller on putting this graph together and i want to commend all of those including  committees who have worked so hard to bring about unprecedented coordination that went into producing this single discussion draft for the three committees of jurisdiction and i want to make things clear the discussion draft will not create a single payer system it will not raise should care it will not attempt to destroy the private market system or the system of employer sponsored health care many americans enjoy today and anybody who says otherwise simply hasn't read the bill or is not being truthful either with himself or anybody else that being said each of us in this room has her own vision of what ideal health care reform looks like what while the specifics may be different we all share some common goals first we must pass legislation that reduces the cost of health care for families businesses and government second we must pass legislation makes quality affordable health care available to all americans and we must pay for this legislation and we must pass the legislation now the choices we make over the coming months are going to be historically significant and they will rank with the passage of social security and medicare if we are courageous and comprehensive health care reform our product will meet the test of history and i would note well rank as i mentioned w medicare and with social security medicare was mentioned on the editorial page on sunday of the new york times is only short of the fly and its popularity if we are not courageous we will have failed this generation and generations to come and the country will suffer for it i am certain this year we will pass comprehensive health care reform that will build on the existing system keep intact that which is working in our system and give people the peace of mind that no matter what life changes they face they will always have access to health insurance their american people deserve nothing less thank you mr chairman thank you very much mr dingell i want now want to recognize mr deal mr plum as the chairman of the subcommittee gave his opening statement yesterday mr deal did not have that opportunity and i want by unanimous consent that all members have an opportunity to submit a written statement opening statement for the record mr deal for the last opening statement thank you mr chairman and thank you for holding this hearing a series of panels today and tomorrow to welcome all the witnesses who are joining us especially express my appreciation to welcome to dr todd williamson who is the president of the georgia medical association certainly as we consider this draft this week hearing from these witnesses is important mr chairman i think we've reached consensus that appropriate reforms are necessary but we differ with respect to the right methods of reform which will yield cost and higher quality savings and the decisions that should be left to doctors and patients and not federal bureaucrats as they make choices about health care for our people more government in my opinion is simply not the answer but the draft before us seems to think that that is the answer as far as the republican views are concerned we've seen thus far an attempt to approach health care reform in a bipartisan fashion has salted in what we consider to be a partisan proposal which of the it refuses to address the concerns of members on our side of the aisle last friday we received an eight hundred fifty two page reform draft that's nearly one legislative day before the committee began its hearings we are concerned about the costs congressional budget office has yet to weigh in on those cost early analysis by mr steeper into a who testified for health subcommittee yesterday scores the legislation at a whopping three and a half trillion dollars over the next decade we need to come up with real solutions to improve health care that american families can afford the promise of the  the leadership here on the hill has been that if you have you like what you have then you can keep it i believe that simply a play on words because if this draft does what i think it will do it will destroy that private health insurance market and will ultimately lead to what i consider a one size fits all government plan if we focus on reforming the health care delivery system with the benefit of the american people in mind then we should not focus our efforts on things that will destroy the private insurance market i believe we should be encouraging physicians to enter into the field of medicine as the demand for health care related services will continue to grow but with the proposal before us today which benchmarks public plan reimbursements to medicare that in itself continues to drive providers out of the system and i believe we will fall short of the objective that all of us share having a system that encourages doctors to enter it promotes physician patient driven decisions and allows everyone to gain access to health care coverage mr chairman we all agree that changes to our health care delivery system have the potential to yield sign savings and improvements in the efficiency of delivery of care but we must ensure that reforms that we put into place promote competition and transparency as we move forward i hope we will get that c b l score i think it's important to the deliberations that lie before us and mr chairman i want to reiterate again that those of us on our side of the aisle look forward to being able to work in a bipartisan fashion as we consider the potential for amendments that will obviously be suggested thanks again to our witness our secretary and thanks to all the witnesses who will make up the panels that will follow with that i yield back thank you very much mr deal was my pleasure to welcome kathleen sebelius to our committee for the first time as our nation's secretary of health and human services and it's highly appropriate that your first testimony is on the reforming of the nation's health care system that's the president's highest president's highest priority and is a subject of which secretary brings a unique breadth of experience most recently as a two term governor of kansas service for eight years as kansas state insurance commissioner exceptionally valuable experience as we proceed with an acting and implementing health care reform and before that eight years in the kansas house of representatives madam secretary i want to welcome you we look forward to working with you and to your testimony today your full prepared statement will be in the record and we'd like to recognize you to proceed as you see there's a there's a button on the base of the mike and be sure to pull it close enough to you on would be good thank you chairman dingell ranking member barton chairman palauan ranking member thank you for this opportunity to join you for a critical conversation about health reform in  america as the chairman emeritus is already recognized my father did serve on this committee and he was here when medicare was passed so i feel privileged to be part of this historic conversation and delighted to have the chance to work with you on this critical issue no question that your release of a draft discussion draft last week with your colleagues from education and labor and the ways and means committee represents an historic moment in this debate we not only appreciate the hard work you've already done but grateful for all the work you're about to do as we work together to at long last and act to reform h constitutes one of our most important domestic priorities and we know the cost of doing nothing is simply too high as the president has said unless we fix what's broken in our current system everyone's health care is in jeopardy reform is not a luxury it's a necessity today in america we have by far the most expensive health system in the world we spend fifty percent more per person than the average developed country spending more on health care than housing or food health insurance premiums have doubled since two thousand and the high cost of care is crippling businesses who are struggling to provide care to their employees and stay competitive in this global world small businesses and their workers the backbone of the american economy are clearly suffering as recently as sixteen years ago sixty one percent of small businesses offered health care to their employees today only thirty eight percent d last week i was in congress and colognes district with business owners in new jersey who met with me about the sacrifices they have to make in their companies in order to provide health benefits to their employees even then some of their employees can't afford the care they need we spend more on health care than any other nation but aren't any healthier only three developed countries in the world have higher only three developed countries have higher infant mortality rates our nation ranks twenty fourth in life expectancy among developed countries more than one third of our citizens are obese and we know that seventy five percent of our health costs are spent on chronic disease without reform these problems only get worse in two thousand and eight we spend an estimated two point four trillion dollars on health care if we do nothing by two thousand and eighteen we'll spend four point four trillion dollars today we spend about eighteen percent of our g d p on health costs doing nothing those costs reach thirty four percent of g d p by tw forty and seventy two americans will be uninsured seventy two million americans will be uninsured the c b l is recently estimated that by twenty twenty five twenty five percent of america's economic output will be tied up in the health system limiting all our other investments and priorities so there are many problems with our health system today but there's also a reason for optimism across this country there are lots of examples of hospitals and providers who are using new technology cutting costs and improving the quality of care two weeks ago i was in omaha nebraska at lakeside hospital and a legion health care system one of the nation's first fully digital hospitals and saw firsthand how health information technology can help doctors and patients health care providers like the kaiser system in california the mayo clinic guys in your inner mountain health care have lowered costs but more importantly have improved outcomes for their patients welcome to community health center providers from ohio tennessee and pennsylvania who helped outline how health information technologies help them save resources and provide better care our challenge is how to take the best practices and spread them across the entire country i have every confidence we can meet this challenge and achieve our goals of reducing costs for families businesses and government protecting people's choices of doctors hospitals and health plans and at long last assuring affordable quality health care for all americans and we can do it without adding to the deficit now the president is open to good ideas about how we finance he reform but we're not open to deficit spending health reform will be paid for and it will be deficit neutral over ten years the president has already introduced his proposals that provide about nine hundred fifty billion dollars over the next decade to finance health reform many of the resources come from wringing waste out of the current system and aggressively prosecuting fraud and abuse we're currently paying for strategies which don't work or overpaying for medicines and equipment it's time to make a better use of these dollars we know that reform can reduce costs for families businesses and government protect people's choice and assure fordable health care as we move forward will be guided by simple principles protect what works about health care and fix what's broken we've reviewed the key features of the tri committee draft proposal mr chairman you and your house colleagues and it's clear that you and your committee have embraced these principles by creating a health exchange that will ensure numerous private insurance plan options along with a public insurance option the plan promotes choice and competition by lowering health costs and providing premium crap that's the plan make health care affordable for all americans by investing in prevention and wellness initiatives that help to prevent disease and illness and allow americans to live longer healthier lives and with meaningful delivery system reforms your policies offer lower cost higher quality health care under the plan you proposed americans will no longer have to worry about being denied care because of a preexisting condition they'll have easier access to tools that can help them prevent disease and stay healthy investments in primary care and under served areas will improve all americans access to care and the medicaid reforms proposed in this bill have taken important steps to improve the critical safety program making it an income based program and proving reimbursement for primary care this discussion draft represents an historic step forward and while we're still examining all the details i agree with the president who said this proposal represents a major step toward our goal of fixing what's broken about health care we're building on what works so mr chairman i'm eager to work with this committee and your colleagues in the house and colleagues across the aisle in the senate to deliver the reform we so desperately need and i appreciate the opportunity  this discussion and look forward to your question thank you very much secretary sebelius for your testimony i want to start off the questions period myself this issue of campaign  the health care reform was part of the campaign that president obama waged in order to be elected president and if there's any issue for which he has a clear mandate it's to work on this very issue and he has  made this his number one domestic priority and i want to underscore and questioning you some of the aspects of what he hopes to accomplish and what he wants us to do in this effort  based on the president's approach to our draft is just a draft that's out a pretty comprehensive approach to reform it addresses prevention and wellness health care workforce quality of care broad based shared responsibility the in dealing with the cost of coverage through insurance reforms a new exchange for people to go to get their insurance  believes strongly that we can fix the economy without fixing health care and so a comprehensive approach to a reform of this is what is required and i think is what this legislation addresses in many of its components there's no question that you can do just one thing at a time in order to have the system work for all americans and fundamentally lower costs there's no question that we can't continue on the cost curve that we're on right now it is unsustainable and will not serve anyone well those who have health insurance now are a month or two years away from the being able to afford the coverage they have those who don't have coverage can access some of the best technology and the best medical care in the world so we need a comprehensive approach and we need to essentially shift the system toward wellness and prevention and away from the sickness system that we have and so i think the elements that you have put forward in the discussion draft do just that  undertaking this kind of comprehensive reform is pretty complicated and it's going to recall require an enormous amount of effort from members of congress some of whom will say well maybe we should delay where we should go slow or maybe we should do it next year or the year after what's the administration's view of the timetable for for action and the need for action and i think the president feels strongly that there is enormous urgency about this issue which has directly to do with our economic well being as a nation and our competitiveness in a global society that our workers are less competitive with their colleagues across the world because of the increasing cost of health care borne by individual business owners small business owners the engine of our economy in states across this country the fastest growing segment of our economy are often less competitive to have high quality workers talented workers because they seek to have health care provided along with their wages and too many small employers can any longer do that  our focus on prevention and wellness needs to be dramatically increased so we not only have a healthier society and lower costs but have a society where our children are not facing the prospect which currently american children face where we're seeing the first generation who may live shorter lives and their pair based on the rise and so we have some challenges mr chairman that cause us to an active legislation this year to urge action of both the house and the senate on this important issue it is difficult it is complicated if it were easy as the president likes to say it probably would have been done a long time ago but let me ask you one one last question is my time is almost out we have businesses too much we have government that's paying too much we have small businesses that can't afford it all for their employees and of course if you're without insurance you have to go pay for your health care bill it's impossible to let people go out without the needed services do you think we need a shared responsibility every sector individuals collectively we're all better off as a society i don't think there's any question that if you build on the current system which is absolutely what the president wants to do and what the discussion draft proposes then there is a shared responsibility  over ninety nine percent of large employers provide health care coverage a lot of small employers already do but we have situations where some americans opt in and some opt out of the insurance market we need more personal responsibility certainly in the life choices we make which can help lower health costs we need parents to get involved and inform we need more preventive care so there's certainly a sense of where we are in this together this is a fundamental issue it's probably the most thank you mr chairman thank you madam secretary for being here you said in your opening statement that there would be no deficit financing as a result of this health care reform package if it became law is that literally true chairman i was quoting the president the president has said consistently that he will not sign a bill unless it's paid for so we do see one of those stablish on the record right off the bat but it will be no increase in the deficit as a result of a comprehensive health care package if it does become law that's just i mean plain language that's what the president has stated is one of his top priorities it will be paid for with ok let me walk through just one part of your program creates a new category of coverage under medicaid  one hundred thirty three percent of poverty which will be hundred percent paid for by the federal government no state match for childless adults between the ages of nineteen and sixty four this one provision if i understand it correctly could add as many as twenty million americans to the medicaid program i don't know what the cost number is for coverage per person under medicare so i just picked in effect if my numbers are wrong correct me but i said six thousand dollars a year for insurance that may be too high but if you cover twenty million people that's six thousand dollars per year that's one hundred twenty billion dollars right there per year how do you pay for that some of your papers because in the bill to be determined later sixty billion dollars in savings from the current medicare and medicaid program in addition he has proposed a revenue enhancers of about that over a ten year period yes or and i think you figure is per year hundred twenty billion per year well i would start with the premise that first of all i don't know the numbers accurately and i assume that your twenty million is within the money within the revenues we had yes ma'am now again my numbers may not be the number but they are definitely in the ballpark if i give the president the benefit of the doubt that there are out there six hundred billion dollars over ten years and savings sixty billion a year this one expansion in medicare is still sixty you're short you're the secretary of health and human services i assume you have had some interaction with chairman waxman chairman rangle chairman miller in providing this draft bill you have to have some idea of how you're going to pay for it and again i'm giving you the benefit express it says sixty billion a year i stipulate for purposes of this hearing save sixty but i think you and you need to put sixty more billion in savings or in tax increases on the table while mr barr if you had to do in your governor that's true and this is a discussion draft what i can assure you is at the end of the day the bill that passes will be paid for we will work closely with the chairman here in the house and the senators on the other side to come up with strategies to do just that which should we tell him up front we don't have a score yet for this bill nor a score for the various proposals that are in this bill but at least right that you've got to put on the table where you're going to get the money i'm not a box of chocolates you don't know what you're going to get you just pull it out oh there's sixty billion whatever well  chairman my time has expired but i think we've established a basic point i mean it's a good thing if you're going to have no deficit financing i commend the president for that but it's a bad thing if you don't shoot straight with the american people where you're going to get the money and nobody says that we're going to be able to save money to pay for these huge expansion totally by savings pay for these huge expansions i just pointed out one part of the bill and already we're at least answer now madam secretary there's been quite a dispute a discussion about the inclusion of a public health insurance option in the reform legislation does president obama support the inclusion of is that correct that's correct premiums and co pays under that part of the proposal will cover the claim not i'm sorry i didn't i said premiums and co payments under the public option will cover the cost that's my understanding the public option must adhere to the same rules and regulations as all other plans that's correct that the public option will be administered by a separate agency from the one that runs the exchange that's the way the draft is right the public option will offer the same minimum benefit design as all other plans in the exchange yes a level playing field individuals and families will permit will be is i think what the public option within the marketplace within the new health exchange does is to use market principles competition and choice to lower costs and provide consumers a choice of plans so i think that the public option absent a public option in many areas in the country two thirds of my state for instance in states around this country there would be only one choice which is not terribly effective in terms of holding costs down and certainly does not provide consumer choice of a side by side plan which is why states and state employee plans create public option standing side by side with private why many states have done that in the children's insurance program side by side options to give choice and provide some competition former governor former and you're able to speak to this question of state insurance regulatory are not able to regulate except as regard chairman madam secretary our esteemed chairman made a comment back during the markup of the american recovery and reinvestment act which said i think it is highly unlikely that you're going to find millionaires who would like to go on medicaid one of the concerns that this bill arises in the minds of many of us is whether or not we are treating low income citizens as second class citizens by automatically and rolling them in medicaid so my question would be they asked why do you believe that a family making twenty nine thousand dollars a year is not as able to make choices as a family making thirty thousand dollars a year and why would it be better to simply automatically enroll them with no choice in medicaid as opposed to giving them a subsidy to allow them to go into the private insurance market well congressman some of those families a limited number are in jobs right now where they have employer provided coverage and they certainly would not shift that coverage but a large number particularly of not families but single adults who are at the one hundred percent or below the poverty line who are making often a very small amount of money have no coverage at all the uninsured and find themselves not in an ownership good past city so the i think the committees look at expanding medicaid to one hundred percent one hundred thirty three percent i'm sorry also follows the experience of many states that have already done that and found that the most effective strategy to expand coverage it is a larger market and it often provides a benefit package that is cost effective and frankly is often far less expensive than the private options that exist which is why states to have expanded coverage of joe's and the medicaid route instead of the private insurance route as i understand the draft it would propose that everyone under the age of sixty five who is under the hundred thirty three percent of the federal poverty level would be enrolled in medicaid can you give us first of all the how many people do you think that that encompasses and how many of those people currently have private health insurance sir i don't want to cite numbers that the top of my head and i i can easily return to you with those numbers i apologize i know that there are a fairly significant number of the so called childless adults not parents typically because a number of states again have taken steps for  parents whose children are eligible for the chip program to actually provide expanded family coverage because they found that a very effective strategy when enrolling children but i think we're talking primarily about childless adults often below that i think they make less than sixty six hundred dollars a year if you're at one hundred thirty three percent of poverty and that i can i can get back to you with those specific numbers i would you would you i appreciate that nice the young woman who was an intern here on the capitol got dizzy and fell down her head and she was attended to by a number of members and staff for medical people doctors and merchants see assistance at the capitol so hopefully she will be fine god willing and will be no consequences as a result of it but i did want to make that comment and as we get any further reports all inform everybody of the situation we are distressed about this incident but with good medical care and the resilience of youth even the president's health care bill will not scare her from recovery maybe the hope of it will spur her on mr deal you are in the middle of your questions and i want to recognize you for two two minutes thank you mr chairman madam secretary page seventy three of the bill it provides for the automatic enrollment of individuals into the medicaid program i want to just ask you if the citizenship and identity verification requirements that are in the current law will still appertaining into the automatic enrollment process is and will you assure us that individuals who are illegally in our country or otherwise eligible for taxpayer supported medicaid will not be enrolled under this provision of this bill while you serve as our secretary mr deal i can assure you that states now because of the serious federal rules requiring  verification of identity have those systems in place and really you have to think develop systems to verify identity not only of existing clientele but of and roll and rolling clientele and that would certainly be in place as we showed it would not be your intention or something that you would not allow to happen that the automatic enrollment process would not overlook or secretary for being with us today i wanted to take my time just to ask about medicare and medicaid i think there's a certain amount of confusion because obviously in this discussion draft and the president has stressed that we can save money that would be used to pay for this plan through savings in medicare and medicaid but at the tamed at the same time the major enhancements and improvements in both programs that are in the in the discussion draft and i did a certain amount of confusion about that overall i think that if you use a combination of the medicare and  medicaid savings and the benefit enhanced ment's overall there's a market improvement in both medicare and medicaid but i want to issue questions about that and other words the draft proposes to begin filling in the donut hole in the medicare prescription drug benefit to eliminate core sharing on preventive services to expand the eligibility and accessibility of medicare as subsidies for low income enrollees had taken it as a whole how do you view the combination these medicare savings proposals and the benefit enhanced cements as an improvement in the medicare program congressman i think that there's no question right now there are areas where we are spending money that don't result in higher quality care or better results for patients i think what this discussion draft puts forward is a way as you suggested to enhance the current program to put dollars into areas where we think there will be much better results for patients hospital readmissions is it is a category that's targeted for some focused attention one of every five patients leaving the hospital is readmitted within a series of weeks that's not good for the patient and it certainly costs a lot of money to the system so coordinating post  release care actually providing incentives for follow up care is a significant improvement that will not only lower costs for readmissions but actually provide a lot better care for the patients and those i think are the kinds of examples that discussion draft incorporates better quality in the long run following what we know are best practices that are in some parts of the system but not appearing throughout the system and frankly not continuing to overpay for services that have no shown benefit or results did you want to talk about the filling the donut hole in this context as i know that's very much on the minds of the seniors and we do propose to do that  in this discussion dress well i think that's a huge step forward as you saw the chairman of a r p recently endorsed the strategy that is appearing in both the house and the senate to fill the donut hole it's a huge issue i can tell you as a as an insurance commissioner we used to face the situation with citizens who had no idea really hadn't counted on the fact that their benefits would suddenly cease and their premiums would continue on they hadn't saved appropriately for it and often they were the i mean the first people they had the donut hole where the folks who had the highest cost of prescription drugs and it was a not only huge shock but something that forced a lot of people to stop buying their medications to stop following the doctor's prescriptions and up in the hospital again without the cared to keep them well so this is a huge issue for seniors across this country who have benefited greatly from lower cost drugs but when they hit when they hit the barrier are really and worship than they were in the beginning because they're still paying premiums and they have no help but about medicaid i mean there is a major expansion here in terms of increased reimbursement rates covering people in many states that that might be you know that are below the hundred percent of the one hundred thirty three percent with federal dollars would you want to comment on that because i just want to stress how even though we're making we're having savings for medicare medicaid we're really improving the program significantly well there's again a  lot of the conversation with providers at least in my home state was not really focused on medicare which is often a very popular program but on medicaid which often under reimburses doctors and particularly primary care and family providers so and hands reimbursement for primary care i think is a huge step forward and frankly having a situation where if you are an adult or a family below one hundred thirty three percent of poverty wherever you go you would have the same benefits if you move across the state line if you need to travel with your family elsewhere you would have similar benefits the kind of portability that currently is not available to a lot of people because their benefits changed time so that is a significant step forward and mr paul on why you're disabled childless adults who are in medicaid is really a three thousand dollars a person average cost not six thousand dollars just thank you very much thank you mr pillow i want to now recognize mr mr whistled but i do want announce to members there is a pending on the house floor a republican motion to adjourn we're going to continue the hearing so those who want to respond to that vote should do so and then come back but we will proceed mr chairman thank you very much and madam secretary please that you're with us here today you know the question about the prescription drug benefit reminds me that of course before we passed the prescription drug benefit most citizens on medicare did not receive that benefit and so they were paying for those medicines and now we're trying to fill the donut hole so they don't have to pay for that either so as politicians you know we like to expand coverage and give coverage and make it it sounds like that we don't want anyone to pay for anything and yet i know your father was involved with medicare according to your testimony and i was looking at it's some of the debate about medicare when it was adopted in one thousand nine hundred sixty five and they're making some of the same arguments that you were making really in your testimony in one nine hundred sixty five they projected that by nine hundred ninety the cost of medicare would be nine billion dollars as it turned out it was almost two hundred billion dollars and so we all like to and we know that our health care needs to be  reformed and then when you talk about it being paid for somebody budget neutral and then when they talk about well we're going to we're going to get a lot of money out of increasing efficiency bringing waste out of the current system and being more aggressive to stop fraud you know it is so nebulous and you're a very practical person you've had experience as a governor do you honestly think that we can reform this system and actually save money and yet provide better quality health care congressman i i do and i do so not based on some hypothetical situation but based on visiting health systems throughout this country in the middle of the country and the coasts that do just that to have higher quality outcomes time in and time out for their patients who have used technology and  provider protocol provided to make sure that the results are better each and every time and a lower cost i've seen it in systems around the country and i'm absolutely confident that we can do it  throughout the united states but i'm glad you are confident that you know i really am skeptical about hope you're right but when we talk about being a budget neutral budget neutral that's good for the government of course the taxpayers pay for the government then this bill has a pay or play mandate on employers requiring them to provide a minimum benefit as a stablished by the health benefits advisory council of eight percent of wages paid so there's a mandate there for small business people to pay eight percent of wages to provide a benefit defined by a commission that's established in this bill so for the these small businesspeople that they have if someone has a wages they're paying five hundred thousand dollars a year that's going to cost them forty thousand dollars how are you concerned  ability of small businesses to be able to continue to be competitive and provide jobs for the employees and pay this is well absolutely i'm i'm concerned about the competitive this of  owners and i think health care costs are one of the areas that is huge challenge for every small business owner i talk to they can't get great employees without offering health benefits their prized out of the market so several things in this bill first of all the discussion draft makes it clear that there will be a specific small business exemption from the payer that it's my understanding that the committees are still working on the language that will occur in the masses you know i know that there's an exemption but there are going to be some people that will be hit by this and the and that's ok the creation now in the marketplace i would suggest actually gives them a cost they don't have now pulling hard to risk giving a four and let me ask just one other question yes my time's about to expire and one of the criticisms we always hear about one payer single payer system and universal health coverage other countries is that it rationalizes health care and in america our most expensive part of health care deals with the end of life care that's a big percentage of the way we spend money and i'm not saying there's anything wrong with rationalizing health care but to really get big savings do you think that we should be rationalizing health care in the us many countries do because that's the way they control their costs i mean do you think that we should be doing that absolutely not and i think that again the the creation of a health exchange marketplace is not a single payer system and i think you'll hear today from some proponents who will strongly suggest that we should be looking at a single payer system but that is not what the president does not what the chairman of put forward they put forward a plan that builds on the current system rationing care frankly is something that happens each and every day under our current system and is often done by private insurers to get between a doctor and their patient and decide which practices can be met which procedures can be paid for what secretary i introduced legislation with then congressman rahm emanuel and congressman chris smith from new jersey called the independent at home act and the bill created a medicare pilot project focused on improving the coordination of care and reducing costs for the most vulnerable medicare beneficiaries those with multiple severe chronic conditions such as all timers a l s parkinson's and other complex debilitating diseases who also need help two or more activities of daily living such as dressing feeding etc has reported that five percent of medicare beneficiaries account for forty three per cent over all medicare spending and c m s has noted that approximately twenty percent of medicare beneficiaries five or more chronic conditions account for sixty six percent program spending could you talk a little bit about how we can focus on those medicare beneficiaries with multiple chronic diseases and how perhaps a program like that focusing on home and better coordination can help to reduce the cost well we have not only the demonstration that you are responsible for but i think a number of project underway looking at coordinating care particularly for the vulnerable high cost individuals and certainly having an opportunity to do that in a home base instead of a hospital based services kno e better for the patient but may provide enhanced cost savings so we are eager to work with you mr markey to continue to figure out better ways to not only coordinate care for individuals who suffer from various chronic diseases and have ongoing underlying conditions but also to make it a more patient centered system which would lead us to more home care delivery so in terms of home based programs for the beneficiary population do you see a shifting in that direction to make sure that you know that we try to reduce cost by trying to stabilize these people at home while you know there is a lot of effort underway and a lot of it has been at the state basis and i'm hoping that with health reform we can have a real collaborative partnership on rebalancing care not only trying to prevent hospitalizations before they occur and provide care at home but also the nursing home a number of the patients that you're describing often end up in a nursing home setting because they don't have access to the wrap around services that they need so we would like to enhance that sort of home base care the care that really allows people to not only be more independent but also at a lower cost than in a hospital or a nursing home our bill also would enable teams of primary care doctors  p s pharmacists and other care providers to form an organization to contract with h h s to provide services to these chronically ill beneficiaries in their homes as part of a three year  demonstrations the organizations would be required to achieve savings of at least five percent compared to what these beneficiaries would cost if they were served by these coordinated care organizations  if they don't they must repay medicare if they achieve more than five percent they can keep eighty percent of the savings with twenty percent of the savings returned to medicare do you do you think that makes any sense to cost savings sharing that as a system that we could construct in the country i certainly support the notion of beginning to pay for outcomes and not for contact too much of the medicare system is driven right now by the number of times a provider such as a patient not necessarily what happens at the end of the day the system you which not only would provide for a coordinated strategy which is really what we need to occur throughout the country but also save money it makes sense to provide those incentives to providers thank you for your service thank you for being here thank you mr markey ms christiansen thank you mr chairman and i guess there is some benefit i guess at least in this instance to being a delegate and then having to go to vote welcome madam secretary good to see you last week we had some very good conversations on health disparities but i know that at least in reading your testimony because i was that about both in the senate and here there was very little if any reference made to this very important issue that by itself results in close the hundred thousand people who are preventable deaths every year so i hope that you will work to ensure that your entire department is very sensitive to this critical issue and that the office of minority health and in particular the office of the senate national center for minority and health disparity research will be elevated to and in to do that's very critical to achieving the goals of eliminating health disparities the bill  required directs that a national prevention and wellness strategy initiative be in place and you'll be responsible for identifying the key health and health care disparities could you discuss briefly how you plan to fulfill this requirement and ensure that all areas of concern be identified and how will the agency for health care quality and research be involved since they have been doing national disparate health well as i shared with you congresswoman last week we are i am as a new secretary concerned that we make sure we do a lot more than publish the yearly  reports have alarming statistics about health disparities and frankly they are not getting any better the gap is in fact widening health reform is a piece of the problem i don't think there's any question having access for everyone to  higher quality preventable care health home is a step in the right direction but i i had a recent very productive meeting with stakeholders representing a lot of the groups who are often under served and assure them that we not only wanted a one time meeting but i want an ongoing strategy i've met with our team at our center for research and quality about how it is that we are going to actually begin to close this gap because just providing reform and continuing that gap doesn't work so we are aggressively taking on not only the what has been already reported as effective strategies but want the new team to be particularly focused on on the issue of great concern to you and to me i have another great concern that really relates to territories than your testimony  is that reform is not a luxury it's in the sense of the and i definitely agree with that that and because it's a necessity i think that certain issues like equitable coverage for all americans should not really be held hostage the costs and we discussed that a lot of the hearing yesterday that said i'm interested in hearing your thoughts about the treatment of the u s territories in the current draft we've been working for years to remove the medicaid cap the bill while it does provide additional funding to the territories does not move us in that direction at all and we're not eligible for subsidies so to me it makes it far less possible for men and women american citizens  legal residents living in the territories to the benefits that this bill will provide for the rest of americans so i'd like their thoughts on that well congressman i would like to provide an opportunity for you to  have that discussion with with me and our staff and i really would like to work with you as this process this is a work in progress and it is a discussion draft and i i would just like to work with you to see how we can help enhance the the areas that you've identified as problematic thank you thank you chairman thank you very much a secretary just i note that you earlier said with the donut hole that the benefits of the payment continues but of course you understand that for a small amount of time to get above a certain amount and then almost a hundred percent of their benefits are paid for i think you understand that so it's not proper to say that their benefits stopped because their benefits of a staffer a substantial period of time depending on how fast you bought yeah yeah but anyway  i have two questions madam secretary the president has indicated that if you he said quote if you like your health care plan you'll be able to keep your health care plan period no one will take it away take away take it away from you no matter what i have here the lewin group has done a study it's a bipartisan study which found that one hundred twenty million people nearly sixty seven percent of non medicare americans would lose their current coverage and be forced into a government run insurance if a government plan was included do you have any evidence that if a government plan is offered that one hundred twenty people will be able to keep their current insurance well congressman it's my understanding that that l has been updated and or at least disputed by a number of people that those numbers were significantly higher than folks so your answer is that you dispute the lewin plan i do ok next question is then i have here a study by the network i'll see june twenty fourth two thousand and nine their study said that the bill we're discussing today would cost of this down to three point five trillion dollars do you dispute that fact sir i'm i'm waiting to see what the c b s score says i don't i don't know the figures that you've just quoted i don't know the group of you have you seen this no i have not ok all right now the president indicated that if any bill arrives from congress that is not controlling costs that's a bill he can't support so the first question is you don't agree with this report you don't know about it they say is going to cost three point five trillion dollars where if it's not three point five or three point two let's say two point eight where you going to get the money to pay for this bill again congressman i think that once the bill is scored and once the proposals are put forward i'm eager to work with the committees in the house and the committees in the senate to identify the cost savings the president has proposed about a billion dollars worth of revenue enhancements and cost savings that he feels are appropriate to spend on them with their how their ideas that are being proposed by members of the senate and members of the really don't have any idea where you're going to get the money to pay for it do you have any evidence that shows if the government spends three and a half trillion dollars that will save money let's not take the three they have let's just ask you where if we spend all this money we're going to save i think i think you start from the premise that we can't afford what we're doing so not doing anything is not an option to really and plus a year is being spent and americans are less healthy than they were years ago so we have to change what currently is happening and i think there's every evidence that the combination of health technology driving quality and actually beginning to pay for prevention and wellness  promoting primary care instead of disease care is a huge cost saver over time it is effective to have americans in a healthier conditions it's good for our businesses it's good for our work well  money all the things you suggested both sides would agree on what the question is how do we do that how to reform the system so that there's universal access universal affordability but the same time we don't have a government mr stearns mister thank you very much mr chairman madam secretary one area that i've been working extensively with chairman waxman and also senator rockefeller and white house on is legislation that would strengthen the federal health care quality infrastructure in order to identify and track key health indicators as well as to develop and implement new science across the states what this bill does that we introduced would establish national priorities for health care quality and specifies that pediatric health care quality is one of the first and a lot of this legislation has now been incorporated in the discussion draft that we're talking about today but the draft bill also contains a provision that requires the directory director of the agency for health care research and quality to work with you as secretary to develop quality measures for the delivery of health care services in the united states and i think this is an important requirement but i'm worried about the implications for pediatric health care quality measures because even though that the discussion draft requires the measures to be designed to assess the delivery of health care services to individuals regardless of age the section is funded with medicare dollars and so under the previous h s determined that medicare dollars could not be used for pediatric measures i'm wondering if you can comment on this and what plans the administration has to address pediatric health care quality and what  the view of the agency's going to be well congresswoman i think that we are convinced that medicare can be a leader in improving quality of care for all americans and certainly the development of quality standards i think is is appropriately done under that umbrella but all americans definitely children and that is a huge priority of the country's moving forward so there will be a coordinated effort to make sure that the pediatric standards are very much developed in terms of quality outcomes and do you think that can be done with the medicare dollars or is that is that something we're going to have to explore as we move forward to to the final legislation in the discussions with our current leadership team at c m s they are confident that we could fulfill the  mandate that's in the bill right now to develop standards including pediatric ok cuz there's i'm i know you recognize the medical establishment record and of course our icon who was here marian wright edelman yesterday children are not just many adults so we've got to develop separate standards that's right i wonder if you can talk for a minute about the administration's view on the title seven how health work for dollars that are included in the discussion draft well i think as you look toward the future of a reformed health system workforce issues are hugely important and i think th step was taken a significant step in the stimulus act beginning to fund the pipeline of critical health care workers doctors mental health providers nurse practitioners additional nursing staff and this discussion draft i think takes that to the next chapter which recognizes not only a shift in incentives for doctors to focus on primary care but also has  enhanced workforce capacity again with a whole series of initiatives that would provide for more health care for watters and more parts of the country thank you one last question one of the provisions i was really pleased to have included in the discussion draft was the idea of auto enroll meant at birth for children whose parents don't have insurance plans to put those babies in and then twelve months continuous eligibility for children i'm wondering if you can comment on the administration's position on that kind of auto enrollment well i think it's been shown that the enrollment efforts vary from state to state often and  some still require a face to face visit others have various complicated forms so what's been proven as best practices i think is an easier presumptive enrollment when kids show up at the hospital certainly auto enroll men at the time of birth would facilitate including children in the system and make sure they get a healthy start on life so i think that's a that's a big step forward thank you thank you very much mr chairman  three hundred forty billion dollars is my recollection i made what are some other ideas that have been discussed that's the revenue enhancer that the president has proposed that's three hundred forty billion what  that's the revenue enhancers that the president has discussed he's also proposed over six hundred sixty billion dollars worth of saving so worried about just under a trillion dollars ok and we're still looking for another two trillion sir i don't know i have never had anybody discuss a three trillion dollar bill so i'm i'm not really prepared to talk about a three trillion dollar bill i don't think there's a score on this bill and they go into the itemized deduction can you talk about that just a little bit further who who would have that impact it would impact basically the the wealthiest americans who currently are paying a different level of tax rate on their optimize deduction and it's my understanding that it's over two hundred thousand dollars the last time i saw the proposal but that could have changed at two hundred thousand paying what happened but then what happened to the president's promis assurance the american people that he would not increase taxes on anyone making below two hundred fifty thousand aren't you going to set to fifty otherwise he breaks his promise the american people or he's pushed for this proposal and eager for congress to talk about it he thinks this is a way to raise ok avenue for the it's ok for him to promise one thing the american people into another just like what george bush did i won't crease taxes and he did it anyway so that's what that's what your boss is proposing did you say to remind your boss wait a minute i'm i'm your cabinet secretary i'm responsible for this you realize you're about to break your promise to the american people if you do this i did not say that to the president what did you say to the president what did you advise the president i told him i was eager to help him pass health reform and i was eager to help fulfill his commitment that it would be paid for within the period of time that the bill proposes over a decade i think that's a fair promise to the american people that it won't increase the deficit and i'm eager to we're going to use or to help medicaid plans medicaid when you were governor and commissioner medicaid states get a grade with regard to the administration of medicaid by the states what was your grade when you were the commissioner and governor with regard  raydon plan pardon i don't grade ing me i don't know what you're talking about but i mean i guess the people of kansas thought i got a pretty good grade because i got reelected as insurance commissioner and as governor well you got a d maybe you thought that was good and that was acceptable i only concern that if you think that a d is good mix acceptable in your glib about it here today know i'm not going to the the question i have here is if we're going to say under there are states that we're going to the federal government will pick up an additional cost on medicaid how are we sending a signal under the states that if the federal government is going to pick up additional costs that they don't have to be as concerned and cost conscious so i worry about that well i would say that the bulk of the medicaid beneficiaries will still have a very significant state share and i don't know any governor in the country who is not concerned about the cost of medicaid one of the things that does concern me though is with regard to doctors you say that everyone will will be guaranteed their choice of their doctor yet when we're going to have shifting that in fact will occur and that in fact recognize so an individual who likes going to their doctor now with their plan may not be their doctor may say i'm not going to participate in the government option then they lose their choice of doctor would that be correct under this plan so are uses the public option but again only if that individual chooses the public option then they lose their choice of doctor well that doctor individuals or doctors would not be mandated to be and the program that's correct and that's true private insurance as well that's true so much time has expired ms cups welcome madam secretary and thank you very much for being here today and for your testimony to one make one brief comment about a population about a group of people being discussed earlier and the conversation those who will be covered the childless adults who would be covered under medicaid in this legislation with the cost amount you're being asked about it is not as though these  are folks that were not paying for already and the kind of health care they receive currently which is most often way expensive and inappropriate for their health needs no prevention and so forth i think that needs to be part of the discussion but my question to you have to do with the part of the country you come from kansas as well as my part of my district which is rural america and some of the barriers to care there but first i want to take advantage of your expertise as insurance commissioner for a state and have you share with us briefly about some of the types of reforms that are needed to improve our current insurance market some of the common abuses that you have seen  how you believe this bill will address and that will be actually be a big cost saving this well well thank you congresswoman i think there's no question particularly in the individual market but also often in the small business market there are constantly cherry picking activities by private insurers which do one of two things and often both simultaneously cost can be dramatically increased year after year driving people out of the marketplace but also in the individual marketplace the preexisting condition barriers often either make insurance impossible to obtain or totally on affordable to obtain so it is a huge barrier to americans accessing quality health care and other provisions specifically in this legislation that you believe will address this absolutely not only the the kind of you have a couple of provisions of loss ratio provision which would allow a different oversight to medical loss ratios helping to eliminate some of the overhead costs there is a provision that would exclude insurers any longer from denying people coverage based on preexisting condition and there is a much more community rated aspect to the health exchange which would again limit the kind of spikes in costs that small business owners often see driving them out of the marketplace thank you now to my part of my district i represent a county in think california san luis obispo which in which one company well point has more way more than fifty percent of the market it's the only private insurer and the county also has a shortage of primary physicians because of  locality or reimbursement issue that's far different from what the cost of living in the in the area really is the the health but this county also doesn't quite qualify i for a health professional shortage area so there's these traps that that many of the folks feel like they're existing and could you talk about your experience maybe that similar but also how this legislation could improve the choice of health plans for consumers in a county such as the one i've described and how also we need it we really need to be able to attract new physicians to certain areas like the one i mentioned and many others in rural america as well as some under served areas in in metropolitan areas as  well there's no question i think that the public option in the marketplace achieves very goals that you just described where consumers would have choice and there also be cost competition  to principles i think that the administration very much believes in in terms of the workforce issue again the initial investment in the stimulus act began the pathway to enhancing workforce particularly in under served areas with the doubling of the commission corps but i think this bill takes an even bigger step forward recognizing that loan repayment as an effective strategy at tracks people to under served areas i would say the implementation of health i t will be a significant and hands factor for providers who often don't want to be isolated but with health i t can be in frequent consultation with specialists and with colleagues in various parts of the country in various parts of the state so they are not in isolated practices so there are a number of features that are not only in this discussion draft but in the bills that you've before the senate i believe the statement was made the said if confirmed i will not only be a need or partner to work with congress but that i understand bipartisanship is at a a reasonable facsimile of the of the testimony that  yes or now i know that the senate health committee the ranking member has sent a letter june sixteenth in a follow up to a request submitted june tints sent by the ranking member of the senate health committee where they note that despite providing technical assistance to the majority regarding the affordable health choices act that same courtesy had not been available at available to the minority of the committee when my understanding that our staff and nancy and of parle who is the white house head of the health reform office have been in the house and in the senate on a daily basis providing information and expertise modeling a whole variety of situations i'm not sure specifically what was requested that has not been provided but i know that they have been available accessible and very present day in and day out was chairman consent to make the senate letter part of the record and then just a follow up for our committee here on the house side will that same technical x peace be made available to the minority in the house sir as much as we can provide background information and assistance we stand ready to do that well and we stand ready to access that libya let me ask you a question in your prepared testimony this morning there's a discussion about the president has introduced proposals that will provide nearly nine hundred fifty billion dollars over ten years to finance reform that's following the statement the president open to good ideas how we finance would not add to the deficit now in a world in which ninety six percent of people have health coverage am i correct in presuming that the money that is afforded for just for porsche chair hospitals and other payment limits that that those funds will no longer be necessary for our safety net hospitals and is that where where a portion of this nine hundred fifty billion dollars is coming from there is a proposal in the as part of the package that at least a reduction in the dish payments be anticipated as health reform is fully implemented i don't think anybody anticipated a world in which there would be no  additional help and assistance to those hospitals that are providing the bulk of care to people who are uninsured but hopefully uninsured will go down there are additional i think features about that  cultural competency a range of additional services that have to be provided and just point out of my home state of texas a significant number of the uninsured are in the country without benefit of a social security number to until we resolve that issue the need for safety net hospitals is going to continue because i suspect that there will be some people who are left out of the ninety six percent who actually have health coverage now and i was glad to hear you reemphasize this morning that the resident  wanted to protect what works what works and fix what's broken i'm glad you went to omaha i went to omaha earlier this year in fact allegiant came here last year and did a did an event with us they are one of the forward looking institutions of this country and there are many others but testimony at this committee yesterday really without the ability to have the health savings account on the health reimbursement account to be able to provide the correct incentives for their to to access the preventive care that we all want people to feel is important without those tools it would be very very difficult for them to operate the kind of the kind of facility that they have today i'm sorry without the health saving without health savings accounts and the money made available through health reimbursement accounts and i guess what i'm getting at is could we get this morning a definitive answer from my read of this bill was before us it appears that health  not going to count as qualified coverage is that correct from your reading of the bill sir i can't i will go back and make absolutely sure i don't i know that there is no intent to eliminate health savings accounts how they are actually defined i need to recheck but health savings accounts would still be available to americans as they are today i'm not certain if that's correct under the language of the bill and i think i would president could do a good service by instructing us to to help people avoid a penalty for not having credible coverage or qualified coverage if they choose to get their insurance through a health savings account and again don't want to dispute with you on that but i'll be happy to yield i wanted to clarify that i do believe that health savings accounts are not adversely affected in the draft bill that would be a ways tax issue but i don't think that's the intention mr we'll get a clarification because you raised important question just briefly reclaiming my time if you look at the rate of increase of all of the different products out there option p p o medicare medicaid all increase at a rate of seven and a half percent a year we heard testimony from the chief medical officer at a legion yesterday that their rate of increase was about five percent a year so it seems to me that if we want to figure out what works we would look at those types of programs give people an incentive to select healthy behaviors make it important to them and i think we will find that people by and large will do the right thing is that your everyone mr burgess thank you very much other members are waiting in the secretary's going to leave  thank you mr chairman and welcome madam secretary we're so happy to see you here thank you i was pleased to see the components of legislation that i authored the public health workforce investment act were incorporated into the draft bill before us today the creation of a public health with fourscore as a major step forward and will revolutionary revolutionize health public health forever it's also as you know a necessary step because we're staring a public health crisis directly in the face in order to satisfy our future public health needs will need to train three times as many public health workers as we are today otherwise your rates of obesity diabetes and other chronic diseases will likely rise and we need to reinvest in this crucial part of our public our infrastructure so that we can take community base actions to event long term public health crisis you are head of what i figure is the largest public health agency in the world you probably know as well as anyone that public health with force is rapidly aging by two thousand and twelve how half of the public health reports in some states will be ready to retire in my opinion our public health system did a good job of managing the recent h one n one flu outbreak but this incident has showed us how critical it is to not let our public health workforce to chair it any further and i'm pleased that the my piece of it was incorporated into the draft bill man secretary i want my colleagues to understand how critical the public health with force is will you please outline for the benefit of this committee how your job is dependent on having a robust public health workforce backing you up well congressman first of all thank you for your leadership in this area and your long standing expertise and insistence that the public health infrastructure has to be part of this dialogue and discussion and i think you appropriately identify the the recent situation still with us with the h one n one virus and the anticipation that we will need additional activity points to the need for a robust infrastructure and as you correctly point out in many parts of the country it's not robust enough now and we're facing a looming retirement of lots of individuals so having not only the pipeline the commission corps doubled there are efforts to and hands again through the recovery act the community health center aspect of the public health backbone in this country and i think that's an important step forward no question that we need not only further attention to workforce issues but also further attention to quality standards in public health agencies throughout the country a i can assure you that our new leadership of dr tom frieden at the centers for disease control is a huge believer that the public health infrastructure needs to be enhanced and needs to be improved and needs to be focused on and he is coming to this job as a new c d c leader with that agenda at the forefront of his priorities and it's one that i share well why are we facing such a crisis in public health workforce today i know part of it is that we need more graduates from public health programs but i think the other part of it is that we may not have the right incentives for the graduates we do have to enter public service well i think i think the whole incentive system in health care is one that is on the table for review as we look at the reform agenda how we not only attract more students to medicine in the first place but how we attract more of those students to the appropriate shortages what do you think that the scholarship and repayment provisions in the draft bill will help in stand by the health graduates to the public workforce i don't think there's any question that those strategies have been proven to be enormously effective students unfortunately today are emerging with thank you the gentleman from georgia mr gingrey secretary thank you for being with us this morning i ask a little bit earlier about your grade as governor i would say that your grade so far this morning has been pretty good so hopefully you won't mind a couple  percent of g d p numbers are indeed staggering and i share your concerns however i have another concern and need to be reassured that you share that the medicare trustees report that the sector private sector health insurance companies and ways in which they should be reported since his inauguration president obama has spoken for entitlement reform certainly president bush did the same so given that forty five percent of all americans get the health care from a government program and the fact that your department oversees a large program with insurance a quality health care for our seniors is available today in the future should entitle reform be an integral part of this legislation yes or i think it definitely should and that's why i am confident that not only a number of the proposals to enhance quality for seniors are important and we've talked a bit about closing the donut hole which is a huge issue but also the savings that are proposed by the president will enhance the lifetime of the medicare program that you've just cited and also lower premiums the premium rights for the seniors who are paying them so it has a win win win situation and helps to pay for a longer life frankly of the program that's is so limited i would have to tell you that i think that's nibbling around the edges when you the latest medicare trustee report says it back twenty eighty three we'll have thirty seven point eight trillion dollars worth of unfunded liability on the medicare program since two thousand the year two thousand private health insurance premiums have almost doubled growing three times doubled since two thousand one hundred eleven percent that's how much medicare part b premiums have gone up since two thousand so i would suggest to you that the parity between medicare part b premium increases and insurance premium private insurance premium increases suggest health care costs are rampant and they're integrated so it's not just private but it's public as well so we need both private insurance reform and medicare reform simply turn the system over the government i think will not that reform will guarantee choice of doctors and health plans no american should be forced to give up the doctor they trust or the plan by law if you like your current health care you can keep it take it from your testimony that you mean all americans will be able to keep their health plan that you why including the eleven million seniors who get their medicare from medicare advantage well sir i certainly hope so  the proposal to stop overpaying for medicare advantage is one that is included in the president's cost savings after years of examination there are no enhance benefits and they're being paid about fourteen percent higher rate than other programs as you know the the center for medicaid for medicare services has proposed that there be fewer plans year because of the proliferation of plans and the fact that consumers often didn't choose them we got a bunch of plans that have fewer than one hundred people choosing them and that is not a very cost effective way to run a system so there will be a about but given the rural nature of my district and ohio generally and given the special challenges that those in rural america face when accessing health care  and the barriers that we've got and given that one of those challenges happens to be attracting and retaining sufficient workforce specifically primary care  doctors specialists some adolescent specialists in particular what in your assessment does the president's initiatives and what does this bill do with respect to attracting and retaining quality workforce in rural areas where that's historically been a problem well congressman i share your concerns about rural access certainly it's something i worked on as  governor of a state like kansas where two thirds of our population is in very rural areas i think there's no question that the incentives  for enhanced workforce is a step in the right direction i think the telemedicine which is on the horizon and certainly important component of health i t is a huge step forward a lot of providers in kansas and i'm sure ohio  are concerned about their isolation and want to make sure they they're able to access colleagues and access consultation and i think the steps that are included in this legislation that pay  have a couple more minutes and i want to just make a comment as a follow up you mentioned telemedicine and i guess i want to take this opportunity to explain to you as a member of the ministration how just how important is to access broadband and high speed internet in those areas that can benefit from telemedicine that bridging the digital divide is so very important in so many areas including accessing quality healthcare one other area i wanted to bring up has to do with some of the geographic disparities pertaining to chronic disease and coming from appalachian one of the things we see for example is a higher rate than average or normal in  diabetes incidence how do we make wellness and prevention programs address these specific regional disparities when it comes to chronic diseases like diabetes well there is a new grant we just made available which actually focuses specifically on areas with the highest rates of diabetes and chronic disease in terms of providing incentives and providing additional resources to not only coordinate care but do much more effective monitoring of conditions i think that there's no question that preventive care at a much earlier stage helps but also what helps to prevent hospitalizations amputations a variety of things is to make sure that those suffering from diabetes a ctually are staying on a proper regime and that monitoring is is what the grandest designed to do i think we were trying to follow some best practices which have proven to be very effective and my guess is that your area is likely to be julie rising high on the list of an area that's likely to be one of the i think there are one hundred thirty three communities that will have additional resources to focus just on this effort thank you madam secretary now you're back my time thank you mr weld thank you mr chairman madam secretary thanks for being here today and the work that you're doing i have some questions i like many of my colleagues i'm just starting to look through the discussion draft that's out and i know that you've undoubtedly played a role and working with some members of the committee on this so if if you can help me with some of these things is it true that under the bill an employer could be subject to eight percent tax even if they offer a worker an employer sponsored health care policy  yes i think that is accurate that there are some ways if it is and determined to be credible coverage that you could have the pay or play provision and i think it's all if i'm reading it correctly is it also true that if the employee decided to go with the through their own plan the employer could still end up having to pay that if they went through the exchange i guess it is tell me how that process works if they do i am not familiar with that specific provision i'd be glad to get back if you want to give me the questions i will immediately respond i'm just not well my understanding is that the employer could offer an employee employer sponsored health coverage than the worker could turn it down and enroll in the exchange plan the employer would still be liable for the tax even though providing employer sponsored care could have been cheaper is what i understand so if you could take a look at that  this and is it true that in order for an employer to avoid paying the eight percent tax the employer has to offer a plan that the new commissioner deems to be a qualified health benefit plan that is correct and can an employer require an employer to accept the employer provided health care coverage can you require an employer to accept it i don't know again how the provisions are drafted i'm not aware of any mandatory  private insurance market how you mandate that anyone except a plan but i haven't read the ok of the bill sorry do you know if state if these provisions are states and federal government considered employees under this dra be the person to comment what's in it but i mean if you want to continue but i well yeah we are in my time and i'm going to give you some extra time but i just want you to understand that we didn't ask her here to comment on the provisions of the draft per se  thought earlier she was indicated support of the draft that the administration supports this draft of the concepts in this draft is that not true that we support the principle that prompted the draft i'm sorry i am not the draft came out on friday and i i didn't write the draft and i'm not intimately familiar but i'd be happy to answer questions if you if you have ok for me i'd be i mean i don't want to stop you but i'd lay me my time if i could so you haven't you haven't read this draft either th i have read it i can't i don't have it memorized yet so i know i appreciate that i so you're ahead of me i haven't read it fully but i also know the way this committee has been operated of late it moves rather rapidly so i doubt we'll have a chance to ask you these questions before suddenly have to vote on this so it is that's why i'm i don't mean to be disrespectful i know that others in the committee of ask you a pretty specific set of yes or no question and i get i'm just trying to be honest with you if i down on the answer i'd be happy to get it for you i just well let me let me go to another point then and that was a comment you made about medicare part d and this i don't think is necessarily in the draft do you know what the medicare part b premium was in two thousand i wouldn't and i'm not going to play a gotcha game here it was about forty five dollars fifty since in two thousand and eight it was ninety six dollars and forty cents medicare part d for two thousand and nine was twenty nine dollars which was thirty percent lower than the original projected when we passed medicare part d and in two thousand and three i understand you issued a report yesterday showing that employer sponsored premiums for health care doubled between i think it's two thousand two thousand and eight for health insurance medicare part b premiums have more than doubled one hundred ten percent increase in the same time span i think what a lot of people are asking me about when i was home in rufus in arlington and fossil and out in my district they're saying medicare is going broke by twenty seventeen and we're going to just expand and add all these people into a government run system and we can't get access to providers now when the government runs a system which is you know is a big issue in rural areas gain access to a doctor here in medicare they're saying how does this new government run plan going to hold down costs and how is it going to expand our we're going to pay for this is the underlying issue here and the estimates they're just saying you know you talked about health insurance could cost us our health every four trillion dollars or something this plan alone i think some estimates are that so people at home are really struggling with with the dollar amounts  the life expectancy of the medicare trust fund an important feature and lower overall costs in the part b premium for the beneficiaries who are currently paying as you say a higher cost i am a believer that medicare has to get at the front of the lower cost higher quality care for the beneficiaries of the system and that we can be not only innovative but help to drive the best practices which exist now in various parts of the country to scale so that's really one of the intents of the new program moving forward by i appreciate that and i'll close with this that i spent five years on a small community hospital board and  seem like medicare gave us the most headaches not the least reimbursement but second the least reimbursement and there was enormous cost shift going on when the federal government was involved and now you've got this access issue trying to get physicians that will even take medicare patients and so i don't want to see is create a government run system that mirrors one that isn't sustainable right now and so i and you know as well as i do some of the goofy rules in medicare that seniors to the hospital to get you know an injection when they should be able to get it at home telemedicine is a great thing but if you're a provider and you're on the other end of the telemedicine you don't get reimbursed for that consultation under medicare so there's a disincentive to doctors to protest there are some things irrespective this debate we could do to really improve medicare i think mr chen thanks for your generosity and i would like my life now let me just remind members we mentioned this earlier but i want you to know that the secretary has to leave the twelve now course we're going to have written questions for many members including those have already spoken and those who have not to follow up and she'll get back to us  chairman yes could we ask the secretary if she could have those answers back by july the sixth i think that would give a week normally we we submit the questions within ten days so that would be trying to think figure this out here if you all agree to get sent to the questions within ten days then i think she has to have at least july sixth kind of early isn't it miss mr chairman has a form suggestion to this maybe with the remaining time those of us who do have specific questions if we can just address our question to her and then not get a response that gets a response oh well this is what i'm going to do i did she has about ten minutes left or five minutes left i have mr angle is next and then i have you the gentleman from tennessee i think that's all we're going to be able to do i'm not going to put a timetable on when you get back to us with a written response as i may have and i don't want to run out of time i can be on that list too for questions let me explain again anyone can submit written to your next thank you thank you very much mr chairman madam secretary first of all welcome her dropping statement and i was delighted when president obama selected you and i i think you are doing and will continue to do a great job so welcome i want to call two things to your attention which is to health priorities of mine firstly i was pleased to see that my legislation the early treatment for h i v act which i introduced w speaker pelosi was included in the house try health reform draft we call the bill and ethan up in conjunction with the house's proposal to cover all lower income people under the medicaid program to up to one hundred thirty three percent of the federal poverty level is a significant step towards reducing the number of uninsured people with hiv in our country as you know if this bill addresses a cruel irony in the current medicaid system under current medicaid rules people must become disabled by aids before they can receive access to medicaid provide and this is care that could have prevented them from becoming so on the first place in other words medicaid won't help you unless you have full blown aids and as you know if someone tests positive to hiv could be a number of years before they have full blown aids so it makes much more sense to help those people once they test positive to try to stave off the full blown aids and it's an irony that you president said that he supports it when he was i'm a senate he co sponsored the bill and i just want to ask you if i can continue count on the administration to continue to support eva and will you work with the states to take up this option if it's included in the final reform package yes thank you that's the answer i was looking for and secondly the second priority is home infusion and we know that some delivery system changes need to be part of our health reform package and this legislation the second piece addresses and an anomaly in the medicare program that forces patients into hospitals and nursing homes to receive a multi week infusion therapy when the same care could be delivered safely and the patients home where the patient prefers to be with outstanding results a lower cost and virtually no risk of health care or acquired infections so i believe that it makes no sense that medicare pays for all costs associated with infusion therapy when it is provided in far more costly hospital and nursing home settings but will not pay for the cost of home infusion for decades private health insurance has covered home infusion therapy it's used extensively by medicare advantage plans medicaid programs cover it but medicare fee for service stands alone in the failure to cover the services quitman supplies needed for home fusion therapy so my bill which is the medicare home infusion therapy coverage act i've introduced with ninety two members of congress i have introduced it with my republican colleague tim murphy and twenty members of the energy and commerce committee our sponsors so i'm going to ask you the same question can i have your commitment that your staff will work with me and chairman waxman staff i meaningful legislation to close the medicare home infusion benefit gap we will certainly look forward to working with you and seeing what can be done about this area and i thank you and i'm turning back my time minutes seventeen seconds i want to duly noted mr chairman to give someone else is duly noted the gentleman from blackburn thank you so much mr chairman madam secretary thank you very much for taking your time to be here i understand you have to go to the white house for a taping and i would hope that you know with the attorney general but i am sorry that i was misinformed but i i would certainly hope that you will be able to return and answer the questions that those on the committee have about the health care  plan could you give us a commitment to answer these before the mark let me i'm not going to take away from your time and give you extra minute or so i know that members are interested in getting timely responses but we're not we don't have the opportunity at this point to say that the secretary's going to come back so what i'm going to ask is that members submit their questions as quickly as possible and i would ask jerry to respond to those questions will you when you know i want to get through point of order yes the secretary is here to speak yes on the single most important piece of legislation most far reaching piece of legislation in my fifteen years the united states congress  there are at least four members here at least four maybe five or more who have not had an opportunity to question her and would like to be able to do so we fully understand her schedule she has important things to do that perfectly all right but i think it would be reasonable for this committee given the scope of the legislation that is moving to ask the secretary to come back some time before this bill moves through what i'm saying to you and i will repeat is the following the secretary is here to give the administration's response to that discussion draft i am not asking her to commit at this time to come back because first of all i don't know her schedule and i don't know whether that's possible going to have to ask the secretary to leave because she has to leave so i'll go back to ms blackburn was start the clock again it's the gentlewoman's time and thank you mr chairman and madam secretary i hope that we will be resolve this  know when when my constituents talk to me about this issue they are fearful of what may be included in this plan and coming from tennessee and you having been a governor i think you can understand that and when they hear remarks about it being deficit neutral are yes deficit neutral not increasing the debt you've made statement that it would be paid for you've talked about reducing the item deductions my constituents are very very concerned about how this would be paid for the other members of this committee have constituents who are equally concerned about this of course our concern in tennessee finds its nexus in the problems that existed with didn't hear i know governors have many times gone to school on what happened with to in care and use that as an example of what they did not want to like to have a response from you you can submit it to me in writing you can begin the response here because i do have a question on what you would see as the lessons learned and what you would not want to do that was from the tin tin care template what were the lessons that you aren't looking to do you realize that you can't provide gold plated all health care for free for everybody do you realize that a public option which is government run government finance does not work in competition with a private option that is one question i have to present to you the second one is medicare advantage and i know you have a heart for dealing with health care for seniors and i appreciate that my constituents i have fifty six thousand seniors in tennessee that are on medicare advantage they very much want to keep those options and i would like to hear from you what you envision a medicare advantage program looking like what the obama plan goes into place how you see that being being delivered what you think the options are going to be it is of concern that those options are going to be restricted and again when individuals when members of this committee sit here when we hear from our constituents the panic into a system this was a part of their retirement security a part of their savings if you will because it was money that the government took first right of refusal on their paycheck took that money out and now be a one size fits all program and this causes tremendous concern from them so your responses to what medicare advantage would look like would be appreciated by congress  i'd be happy to answer both of those questions i can't do it now in person as you said earlier you wanted to address the question respond and i will do that promptly thank you i appreciate that and at this time i will  bill states that there is an amount that is going to be appropriated to the secretary for the purposes of starting up the government plan and that number is quote to be supplied in the text of the bill do you have any idea how much it will cost you to start up this government run plan  you mentioned the president's repeated promise that the health reform bill will be deficit neutral are there any other deal breakers for the administration does the legislation have to include a government plan does it have to include an individual mandate have to include an employer mandate and increase taxes on families making under two hundred fifty thousand per year for example i think that the symbols are that the plan needs to lower costs for everyone needs to improve quality of care needs to provide coverage for all americans and around those principles that he and be paid for within the period of time those are the fundamental principles that he is articulated and he has you know during the course of the discussion had various proposals on some of those areas  i need to mention that i misspoke earlier to the congressman the proposal that he had for the itemized deduction return is for families making to fifty or more two hundred fifty thousand dollars or more  i was corrected and i happy to provide that additional information so the gentlemens time is or the gentlewoman's time i should say has expired now again i'm just going to repeat i know you have to leave and members will get back to as quickly as possible with written questions and we would ask madam secretary that you try to respond the quickly as possible very quickly and thank you so much really for being here today we appreciate your time thank you now let me explain we are going to adjourn the full committee and then the subcommittee reconvenes the health subcommittee reka means reconvene at one o'clock and we have three panels hearing on a draft yes we have heard the secretary say that she did not participate in that draft preparation nor has she apparently as she said had the opportunity to read it which is one of the limitations that we all labor on in this time i would simply urge you to urge our fool chairman the full committee that it would be almost mandated i think that she returned to answer questions when we move to a legislative proposal we're talking about a draft but here when it moves to a legislative proposal that we be allowed the opportunity to answer me to ask and to have answered questions  you made the statement that she was speaking on behalf of the obama administration as it relates to the draft i know that she has done so in general terms but i think there are some specifics that we would should have the opportunity to ask specifics about urge you to urge our chairman to ask her to return to this committee i think it is due diligence for all of us to have the opportunity to explore these questions in person with her well let me just say i can't make that commitment mr deal and for various reasons i think part of it is the fact that we you know we have a draft and obviously they're going to be changes to that based on your input the input from both sides of the aisle and we really esther here today to comment on you know what the administration thought about the draft there never you know that the bill is never going to be exactly what the president wants or or doesn't want but i just can't make that commitment so i appreciate your asking but i can point  subcommittee hearing at one there are there are twelve republicans who have not even had a chance to speak or and and ask her questions members were told that she was going to leave it twelve o'clock we understand that we're simply asking that she come back on have made  motion i think what we'll do at this time we had a vote and it was defeated to adjourn so at this time we're just going to recess we so that's the full committee that's in recess