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99–443 PDF 2016

EXAMINING THE POLICIES AND 

PRIORITIES OF THE 

U.S. DEPARTMENT OF HEALTH 

AND HUMAN SERVICES 

HEARING 

BEFORE THE

COMMITTEE ON EDUCATION 

AND THE WORKFORCE 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

HEARING HELD IN WASHINGTON, DC, MARCH 15, 2016 

Serial No. 114–41 

Printed for the use of the Committee on Education and the Workforce 

( 

Available via the World Wide Web: www.gpo.gov/fdsys/browse/ 

committee.action?chamber=house&committee=education 

or 

Committee address: http://edworkforce.house.gov 

CEWDOCROOM with DISTILLER

(II) 

COMMITTEE ON EDUCATION AND THE WORKFORCE 

JOHN KLINE, Minnesota, Chairman 

Joe Wilson, South Carolina 

Virginia Foxx, North Carolina 

Duncan Hunter, California 

David P. Roe, Tennessee 

Glenn Thompson, Pennsylvania 

Tim Walberg, Michigan 

Matt Salmon, Arizona 

Brett Guthrie, Kentucky 

Todd Rokita, Indiana 

Lou Barletta, Pennsylvania 

Joseph J. Heck, Nevada 

Luke Messer, Indiana 

Bradley Byrne, Alabama 

David Brat, Virginia 

Buddy Carter, Georgia 

Michael D. Bishop, Michigan 

Glenn Grothman, Wisconsin 

Steve Russell, Oklahoma 

Carlos Curbelo, Florida 

Elise Stefanik, New York 

Rick Allen, Georgia 

Robert C. ‘‘Bobby’’ Scott, Virginia 

Ranking Member 

Rube ́n Hinojosa, Texas 

Susan A. Davis, California 

Rau ́l M. Grijalva, Arizona 

Joe Courtney, Connecticut 

Marcia L. Fudge, Ohio 

Jared Polis, Colorado 

Gregorio Kilili Camacho Sablan, 

Northern Mariana Islands 

Frederica S. Wilson, Florida 

Suzanne Bonamici, Oregon 

Mark Pocan, Wisconsin 

Mark Takano, California 

Hakeem S. Jeffries, New York 

Katherine M. Clark, Massachusetts 

Alma S. Adams, North Carolina 

Mark DeSaulnier, California 

Juliane Sullivan, Staff Director 

Denise Forte, Minority Staff Director 

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(III) 

C O N T E N T S 

Page 

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

Statement of Members: 

Kline, Hon. John, Chairman, Committee on Education and the Workforce 1 

Prepared statement of ............................................................................... 3 

Scott, Hon. Robert C. ‘‘Bobby’’, Ranking Member, Committee on Education and the Workforce ............................................................................. 4 

Prepared statement of ............................................................................... 7 

Statement of Witnesses: 

Burwell, Hon. Sylvia Mathews, Secretary, U.S. Department of Health 

and Human Services, Washington, DC ....................................................... 9 

Prepared statement of ............................................................................... 12 

Additional Submissions: 

Byrne, Hon. Bradley, a Representative in Congress from the state of 

Alabama: 

Slides .......................................................................................................... 37 

Carter, Hon. Buddy, a Representative in Congress from the state of 

Georgia: 

Letter dated March 22, 2016, from Secretary Burwell .......................... 65 

Chairman Kline: 

Prepared statement of the U.S. Chamber of Commerce ........................ 67 

Pocan, Hon. Mark, a Representative in Congress from the state of Wisconsin: 

Letter from Brent Nathan Brown ............................................................ 72 

Questions submitted for the record by: 

Allen, Hon. Rick, a Representative in Congress from the state of 

Georgia ................................................................................................... 83 

Bishop, Hon. Michael D., a Representative in Congress from the 

state of Michigan ................................................................................... 82 

Mr Byrne .................................................................................................... 81 

Mr. Carter .................................................................................................. 82 

Clark, Hon. Katherine M., a Representative in Congress from the 

state of Massachusetts .......................................................................... 86 

Foxx, Hon. Virginia, a Representative in Congress from the state 

of North Carolina ................................................................................... 77 

Fudge, Hon. Marcia L., a Representative in Congress from the state 

of Ohio .................................................................................................... 84 

Heck, Hon. Joseph J., a Representative in Congress from the state 

of Nevada ................................................................................................ 79 

Chairman Kline ......................................................................................... 76 

Messer, Hon. Luke, a Representative in Congress from the state 

of Indiana ............................................................................................... 81 

Polis, Hon. Jared, a Representative in Congress from the state of 

Colorado .................................................................................................. 85 

Roe, Hon. David P., a Representative in Congress from the state 

of Tennessee ........................................................................................... 78 

Mr. Scott .................................................................................................... 83 

Walberg, Hon. Tim, a Representative in Congress from the state 

of Michigan ............................................................................................. 78 

Wilson, Hon. Frederica S., a Representative in Congress from the 

state of Florida ....................................................................................... 85 

Secretary Burwell’s responses to questions submitted for the record .......... 88 

CEWDOCROOM with DISTILLER

CEWDOCROOM with DISTILLER

(1) 

EXAMINING THE POLICIES AND PRIORITIES 

OF THE U.S. DEPARTMENT OF HEALTH 

AND HUMAN SERVICES 

Tuesday, March 15, 2016 

U.S. House of Representatives 

Committee on Education and the Workforce 

Washington, D.C. 

The Committee met, pursuant to call, at 10:00 a.m., in room 

2176 Rayburn House Office Building. Hon. John Kline [chairman 

of the committee] presiding. 

Present: Representatives Kline, Foxx, Roe, Thompson, Salmon, 

Rokita, Barletta, Messer, Byrne, Carter, Bishop, Russell, Curbelo, 

Stefanik, Allen, Scott, Hinojosa, Davis, Courtney, Fudge, Polis, 

Sablan, Wilson, Bonamici, Pocan, Takano, Jeffries, Clark, Adams, 

and DeSaulnier. 

Staff Present: Andrew Banducci, Workforce Policy Counsel; 

Janelle Belland, Coalitions and Members Services Coordinator; 

Kathlyn Ehl, Professional Staff Member; Ed Gilroy, Director of 

Workforce Policy; Callie Harman, Legislative Assistant; Christie 

Herman, Professional Staff Member; Tyler Hernandez, Press Secretary; Amy Raaf Jones, Director of Education and Human Resources Policy; Nancy Locke, Chief Clerk; Michelle Neblett, Professional Staff Member; Brian Newell, Communications Director; 

Krisann Pearce, General Counsel; Alexandra Pena, Staff Assistant; 

Lauren Reddington, Deputy Press Secretary; Alissa Strawcutter, 

Deputy Clerk; Juliane Sullivan, Staff Director; Leslie Tatum, Professional Staff Member; Olivia Voslow, Staff Assistant; Tylease Alli, 

Minority Clerk/Intern and Fellow Coordinator; Pierce Blue, Minority Labor Detailee; Jacque Chevalier, Minority Senior Education 

Policy Advisor; Denise Forte, Minority Staff Director; Christine 

Godinez, Minority Staff Assistant; Carolyn Hughes, Minority Senior Labor Policy Advisor; Eunice Ikene, Minority Labor Policy Associate; Brian Kennedy, Minority General Counsel; Richard Miller, 

Minority Senior Labor Policy Advisor; Alexander Payne, Minority 

Education Policy Advisor; Veronique Pluviose, Minority Civil 

Rights Counsel; and Marni von Wilpert, Minority Labor Detailee. 

Chairman KLINE. A quorum being present, the Committee on 

Education and the Workforce will come to order. Good morning, everyone, and welcome, Secretary Burwell. We appreciate you joining 

us to discuss the policies and priorities of the Department of 

Health and Human Services. 

CEWDOCROOM with DISTILLER

2 

From welfare and health care to early childhood development 

and support services for older Americans, the policies your department oversees affect the lives of millions of Americans. 

Conversations like this one are vitally important as we work to 

ensure that the Department is acting in the best interest of the 

taxpayers and those in need. 

As we examine what programs and policies are working and 

which ones are in need of improvement, I hope there are a number 

of areas where we can find common ground. 

Of course, there are also areas where we will ultimately agree to 

disagree, and perhaps the most prominent example is the President’s health care law. As has been the case for nearly six years, 

this flawed law continues to hurt working families, students, and 

small businesses. It is still depressing hours and wages for low-income workers, still making it harder for individuals to receive the 

care they need, and still driving up health care costs. 

One Emory University professor recently wrote that his family’s 

health insurance premium is now their biggest expense, even 

greater than their mortgage. Before the health care law went into 

effect, this man was able to cover his entire family of four for less 

than $13,000. Now, the cost of insuring just him and his wife is 

nearly $28,000. Twice the cost to cover half as many people. In 

fact, paying more for less is becoming a hallmark of the health care 

law. 

Over the years, Republicans have put forward a number of 

health care reform ideas, ones that would expand access to affordable care and lead to a more patient-centered health care system. 

We will continue to do so, because we firmly believe the President’s 

health care law is fatally flawed and unsustainable, and more importantly, because we believe the American people deserve better. 

Again, I suspect we will have to agree to disagree, but as I mentioned, there are areas where I am hopeful we can find common 

ground. 

Head Start, for example, currently supports nearly 1 million children at a cost of more than $9 billion annually. It is an important 

program for many low-income families. However, concerns persist 

that it is not providing children with long-term results. 

We both agree, I am sure, changes need to be made, but so far 

we have different ideas of what reform should look like. The Department is in the process of fundamentally transforming Head 

Start through regulations that will have serious consequences for 

the vulnerable families this important program serves. 

We, on the other hand, have outlined a number of key principles 

that we believe will strengthen the program based on feedback we 

collected from parents and providers. 

I look forward to discussing where we might be able to find middle ground and work together so that these children can have the 

solid foundation they need to succeed in school and in life. 

I am also hopeful that we can work together to ensure changes 

to the Preschool Development Grants program are implemented as 

Congress intended. The Every Student Succeeds Act reformed the 

program to help States streamline and strengthen early learning 

efforts. 

CEWDOCROOM with DISTILLER

3 

To accomplish this goal, Congress moved the program from the 

Department of Education to HHS, which already oversees the bulk 

of early learning programs. As you take on this responsibility, 

Madam Secretary, please know we intend to stay engaged with the 

Department to ensure a successful transition. 

Finally, the Department is also responsible for helping States to 

prevent and respond to child abuse and neglect, specifically those 

outlined in the Child Abuse Prevention and Treatment Act or 

CAPTA. As I am sure you are aware, this law provides States with 

resources to improve their child protective service systems, if they 

make a number of assurances concerning their child welfare policies. 

It has come to our attention that some States are making these 

assurances without putting the necessary policies in place. Yet, not 

a single State is being denied Federal funds. 

A Reuters’ investigation recently revealed the shocking and deadly consequences of this neglect and cast serious doubts as to whether basic requirements of the law are being met and enforced. 

In light of this tragic report, we wrote to you to better understand the Department’s process in reviewing and approving State 

plans under CAPTA, and I would like to continue that discussion 

here today. 

It is clear that the current system is failing some of our country’s 

most vulnerable children and families, and something has to 

change. 

As you can see, we have quite a bit to cover today. These and 

other issues are vitally important to the men and women we serve, 

and we have a responsibility to ensure that we are serving those 

individuals in the best way possible. 

With that, I will now recognize the ranking member, Mr. Scott, 

for his opening remarks. 

[The information follows:] 

Prepared Statement of Hon. John Kline, Chairman, 

Committee on Education and the Workforce 

From welfare and health care to early childhood development and support services 

for older Americans, the policies the Department of Health and Human Services 

oversees affect the lives of millions of Americans. Conversations like this one are 

vitally important as we work to ensure the department is acting in the best interests of taxpayers and those in need. As we examine what programs and policies are 

working, and which ones are in need of improvement, I hope there are a number 

of areas where we can find common ground. 

Of course, there are also areas where we will ultimately agree to disagree, and 

perhaps the most prominent example is the president’s health care law. As has been 

the case for nearly six years, this flawed law continues to hurt working families, 

students, and small businesses. It’s still depressing hours and wages for low-income 

workers, still making it harder for individuals to receive the care they need, and 

still driving up health care costs. 

One Emory University professor recently wrote that his family’s health-insurance 

premium is now their biggest expense – even greater than their mortgage. Before 

the health care law went into effect, this man was able to cover his entire family 

of four for less than $13,000. Now, the cost of insuring just him and his wife is nearly $28,000. That’s right – twice the cost to cover half as many people. In fact, paying 

more for less is becoming a hallmark of the health care law. 

Over the years, Republicans have put forward a number of health care reform 

ideas, ones that would expand access to affordable care and lead to a more patientcentered health care system. We will continue to do so, because we firmly believe 

the president’s health care law is fatally flawed and unsustainable, and more importantly, because we believe the American people deserve better. 

CEWDOCROOM with DISTILLER

4 

Again, I suspect we will have to agree to disagree, but as I mentioned, there are 

areas where I am hopeful we can find common ground. 

Head Start, for example, currently supports nearly one million children at a cost 

of more than $9 billion annually. It’s an important program for many low-income 

families. However, concerns persist that it’s not providing children with long-term 

results. 

We both agree changes need to be made, but so far, we have different ideas on 

what reform should look like. The department is in the process of fundamentally 

transforming Head Start through regulations that will have serious consequences 

for the vulnerable families this important program serves. We, on the other hand, 

have outlined a number of key principles that we believe will strengthen the program based on feedback we collected from parents and providers. I look forward to 

discussing where we might be able to find middle ground and work together so that 

these children can have the solid foundation they need to succeed in school and in 

life. 

I’m also hopeful that we can work together to ensure changes to the Preschool 

Development Grants Program are implemented as Congress intended. The Every 

Student Succeeds Act reformed the program to help states streamline and strengthen early learning efforts. To accomplish this goal, Congress moved the program from 

the Department of Education to HHS, which already oversees the bulk of early 

learning programs. As you take on this responsibility, Secretary Burwell, please 

know we intend to stay engaged with the department to ensure a successful transition. 

Finally, the department is also responsible for helping states to prevent and respond to child abuse and neglect, specifically those outlined in the Child Abuse Prevention and Treatment Act or CAPTA. As I’m sure you’re aware, this law provides 

states with resources to improve their child protective services systems – if they 

make a number of assurances concerning their child welfare policies. It’s come to 

our attention that some states are making these assurances without putting the 

necessary policies in place. Yet, not a single state is being denied federal funds. 

A Reuters’ investigation recently revealed the shocking and deadly consequences 

of this neglect and cast serious doubts as to whether basic requirements of the law 

are being met and enforced. In light of this tragic report, we wrote to you to better 

understand the department’s process in reviewing and approving state plans under 

CAPTA, and I’d like to continue that discussion today. It’s clear that the current 

system is failing some of our country’s most vulnerable children and families, and 

something has to change. 

As you can see, we have quite a bit to cover today. These and other issues are 

vitally important to the men and women we serve, and we have a responsibility to 

ensure they are serving those individuals in the best way possible. 

Mr. SCOTT. Thank you, Chairman Kline, and welcome, Secretary 

BURWELL. Thank you for being with us. We look forward to your 

testimony. 

Today, we will hear about the President’s Fiscal Year 2017 

Health and Human Services’ budget proposal and the Department’s 

policy priorities. Once again, I commend the Secretary for her work 

to ensure that the budget reflects the priorities of this committee, 

protecting access to health care for all Americans, giving all children the chance to succeed, and making sure that we meet the 

needs of families and children affected by public health threats 

when they occur. 

In many areas, I believe we have made great progress on these 

priorities. In the not so distant past, many families were left without affordable health care options and many more could not have 

access to basic consumer protections in their insurance. 

Double digit increases in prices were routine every year. Women 

routinely charged more for insurance than men. If you lost you lost 

your job and wanted to start a new business and you had a preexisting condition, you were essentially out of luck. If you were a 

senior and fell into the Part D doughnut hole, you did not get any 

CEWDOCROOM with DISTILLER

5 

help, and when we consider the Affordable Care Act, thousands of 

people every day were losing their insurance. 

Passage of the Affordable Care Act has given millions of Americans access to health care coverage, many for the first time in their 

lives. The ACA has helped slow the growth in health care costs, it 

is closing the doughnut hole for seniors, and has encouraged and 

improved access to mental health services and preventive care. Instead of thousands losing their insurance, millions more have 

gained insurance. 

So, I thank Secretary Burwell for her efforts and her Department’s hard work in implementing the Affordable Care Act. I recognize the challenge your department faces in implementing this law 

with limited resources and unlimited attacks. 

Despite these challenges, the ACA has expanded coverage to millions and given millions more robust consumer protections in their 

health coverage. The ACA has provided a historic foundation for 

which we are going to accomplish our ultimate goal, making sure 

that all Americans have the opportunity to succeed. 

I do not believe that we have reached the finish line yet, but I 

look forward to working with the Department and my congressional colleagues to make meaningful improvements as we 

strengthen the law. 

I also pleased that the President’s budget has placed a priority 

on giving all children a chance to succeed by ensuring robust funding to increase both access to and quality of early learning and 

child care programs. We must invest in high quality early learning 

programs because all children deserve to enter kindergarten with 

the building blocks to success. 

Decades of research have shown that properly nurturing children 

in the first five years of life is essential to supporting enhanced 

brain development, cognitive functioning, and emotional and physical health. 

All too often, low-income working families lack access to high 

quality affordable child care in their early childhood education, and 

these children tend to fall behind. Beyond the achievement gap, 

children that do not participate in high quality early learning programs are more likely to have weaker educational outcomes, lower 

earnings, increased involvement in the criminal justice system, and 

affordable high quality child care is, therefore, not just critical for 

children, it is also critical for working parents. 

Child care is a two generation program. Parents of young children need child care to work and go to school, and lack of stable 

child care is associated with job interruptions and job loss for working parents. Child care ought to be a national priority for America’s 

children and working families. 

Just two programs survived the bulk of the Federal role in early 

education, the Head Start program and the Child Care and Development Block Grant. Unfortunately, because of limited Federal 

funding, too few children have appropriate access. This unmet need 

continues to grow. Only four of 10 eligible children have access to 

a Head Start program, and fewer than one out of six eligible children receive Federal child care assistance. 

We have decades of evidence that investing in programs like 

Head Start and the Child Care and Development Block Grant 

CEWDOCROOM with DISTILLER

6 

works. This is the time to invest in these programs and ensure that 

we are giving all children the chance to succeed. 

I also want to commend the Secretary and her department for 

their efforts in response to some of the most troubling health crises 

of our time, the Ebola outbreak, Zika and opioid crisis. The Department has been in the forefront of responding and keeping Americans safe and healthy, particularly when you talk about budgeting, 

some do not always see the value of investing in prevention or 

readiness activities so that we are equipped to deal with a public 

health crisis. 

Like many Federal programs, in fact, like health care insurance 

itself, you often do not miss it until it is gone. It is important now 

more than ever that we invest in our Nation’s current and future 

health and well-being. The President’s proposal does this with the 

Cancer Moonshot and other long-term investments. 

Lastly, I would like to thank the Department and the Secretary 

for their efforts to respond to the catastrophic situation in Flint, 

Michigan. The research is clear on the impact of exposure to lead 

on young children, the adverse effects of lead exposure range from 

decreased academic attainment to increased needs for special education, and a higher likelihood of behavioral challenges. These impacts can result in a significant decline in earnings, loss of tax revenue, additional burdens to the criminal justice system, and increased stress on our hospital systems. 

The opportunity for a strong start to a successful life will be 

stunted for Flint’s children if they are not given the necessary resources, including early intervention and access to high quality 

early learning programs, such as Head Start, to help them overcome the lifelong effects of exposure to lead. 

We need to come up with the money to make that possible, and 

make no mistake, we should not expect to fix this crisis easy or on 

the cheap. In fact, it will cost approximately $1.2 billion to provide 

long-term comprehensive services to all Flint children exposed to 

lead just in the areas that cover programs under this committee’s 

jurisdiction. 

Furthermore, it is imperative that this committee and the Department continue to examine how Federal programs can be responsive and ensure that every Flint youth is receiving the necessary services to mitigate the effects of lead exposure. 

The Department’s response so far has been commendable. Additional funding for health centers in Flint, Medicaid expansion to 

provide vital health coverage and important health screenings, $3.6 

million onetime emergency funding to help Head Start grantees expand early childhood education, health care and nutritional services. 

These are examples of targeted Federal solutions, but this committee and this Congress has to do more. The impact of lead exposure on young children is long-lasting, and a response must have 

a long-term approach. 

We must use all of the tools available to us, starting with prenatal care and screenings of pregnant moms, early literacy resources, early interventions to identify special education needs, 

Title I and Title II funding from the Elementary and Secondary 

CEWDOCROOM with DISTILLER

7 

Education Act, after school programs, at-risk youth prevention programs, even investments in college access efforts. 

I know with all the Department’s leadership, we can continue to 

respond to this crisis, and I am hopeful that together we can put 

forward real solutions and help mitigate the damage from the 

water crisis in Flint, and make sure young children there get back 

on track to a prosperous fulfilling life. 

So, thank you, Mr. Chairman, and thank you, Secretary Burwell. 

I look forward to your testimony. 

[The information follows:] 

Prepared Statement of Hon. Robert C. ‘‘Bobby’’ Scott, Ranking Member, 

Committee on Education and the Workforce 

Thank you Chairman Kline, and welcome Secretary Burwell. Thank you, Secretary, for being with us and I look forward to your testimony. 

Today, we will hear about the President’s Fiscal Year 2017 Health and Human 

Services Budget proposal and the Department’s policy priorities. Once again, I commend the Secretary for her work to ensure that the budget reflects the priorities 

of this Committee – protecting access to healthcare for all Americans, giving all children a chance to succeed, and making sure that we meet the needs of families and 

children affected by public health threats when they occur. 

In many areas, I believe we have made great progress in these priorities. In the 

not so distant past, too many families were left without affordable health care options and many more did not have access to basic consumer protections in their insurance. Women were routinely charged more for insurance than men. If you lost 

your job or wanted to start a new business and you had a preexisting condition, you 

were out of luck. If you were a senior and fell into the Part D donut hole, you didn’t 

get any help. 

The passage of the Affordable Care Act has given millions of Americans access 

to health coverage, many for the first time in their lives. The ACA has helped slow 

the growth in health care costs, is closing the donut hole for seniors, and has encouraged and improved access to mental health services and preventive care. 

I thank Secretary Burwell for her efforts and her Department’s hard work implementing the Affordable Care Act. As I’ve said before, I recognize the challenge your 

Department faces in implementing this law with limited resources and unlimited attacks. Despite these challenges, the ACA has 

expanded health coverage to millions and given millions more robust consumer 

protections in their health coverage. The ACA has provided a historic foundation on 

which we can work to accomplish our ultimate goal – making sure all Americans 

have the opportunity to succeed. I do not believe that we have yet reached the finish 

line and I look forward to working with the Department and my Congressional colleagues to make meaningful improvements to strengthen the law. 

I was also pleased that the President’s budget request placed priority on giving 

all children a chance to succeed by ensuring robust funding to increase both access 

to and the quality of early learning and child care programs. We must invest in 

high-quality early learning programs because all children deserve to enter kindergarten with the building blocks to success. 

Decades of research has shown that properly nurturing children in the first five 

years of life is instrumental to supporting enhanced brain development, cognitive 

functioning, and emotional and physical health. But all too often, low-income working families lack access to high-quality, affordable child care 

and early childhood education, and these children tend to fall behind. Beyond the 

achievement gap, children who don’t participate in high-quality early education programs are more likely to have weaker educational outcomes, lower earnings, and increased involvement in the criminal justice system. Affordable, high-quality child 

care is not just critical for children, it is also critical for working parents. Child care 

is a two-generation program. Parents of young children need child care to work or 

go to school. And a lack of stable child care is associated with job interruptions and 

job loss for working parents. Child care ought to be a national priority for America’s 

children and working families. 

Just two programs provide for the bulk of the federal role in early education: the 

Head Start Program and the Child Care and Development Block Grant. Unfortunately, because of limited federal funding, too few young children have access. This 

unmet need continues to grow – only 4 out of 10 eligible children have access to 

Head Start, and fewer than 1 out of 6 federally-eligible children receive federal child 

CEWDOCROOM with DISTILLER

8 

care assistance. We have decades of evidence that investing in programs like Head 

Start and the Child Care and 

Development Block Grant works. It is time to invest in these programs and ensure that we are giving ALL children the chance to succeed. 

I want also to commend Secretary Burwell and her Department on their efforts 

to respond to some of the most troubling health crises of our time. From the Ebola 

outbreak to Zika to the opioid crisis, the Department of Health and Human Services 

has been at the forefront of responding and keeping Americans safe and healthy. 

Particularly when you talk about budgeting, some do not always see the value of 

investing in prevention or readiness activities so that we are equipped to deal with 

a public health crisis. But like many federal programs and in fact like health care 

insurance itself, you often don’t miss it until it’s gone. So it’s important, now more 

than ever, that we invest in our nation’s current and future health and well-being. 

The President’s budget proposal does this with the ‘‘Cancer Moonshot’’ and other 

long-term investments. 

Lastly, I sincerely thank the Department’s for their efforts to respond to the 

catastrophic situation in Flint. The research is clear on the impact of exposure 

to lead on young children. The adverse effects of lead exposure range from decreased academic attainment to increased need for special education and a higher 

likelihood of behavioral challenges. These impacts can result in a significant decline 

in earnings, loss of tax revenues, additional burdens to the criminal justice system, 

and increased stress on our hospital systems. 

The opportunity for a strong start to a successful life will be stunted for Flint’s 

children if they are not given the necessary resources, including early-intervention 

and access to high-quality early learning programs, such as Head Start, to help 

them overcome the life-long effects of exposure to lead. 

We need to come up with the money to make that possible. Make no mistake – 

we should not expect the fix to this crisis to be easy or cheap. In fact, it will cost 

approximately $1.2 billion to provide long-term, comprehensive services to all Flint 

children exposed to lead. And that cost only covers the programs that fall under this 

Committee’s jurisdiction. Furthermore, it is a moral imperative for this Committee 

and the Department to continue to examine 

how federal programs can be responsive and ensure every Flint youth is receiving 

the necessary services to mitigate the effects of lead exposure. 

The Department’s response has been commendable – additional funding for health 

centers in Flint, Medicaid expansion that will provide vital health coverage and important health screenings, and $3.6 million in one-time emergency funding to help 

Head Start grantees expand early childhood education, health, and nutrition services. These are examples of targeted federal solutions. But this Committee and this 

Congress should do more. 

The impact of lead exposure on young children is long lasting and our response 

must have a long-term approach. We must use all the tools available to us, starting 

with pre-natal care and screenings for pregnant moms, early literacy resources, 

early interventions to identify special education needs, Title I and II funding from 

ESEA, after-school programs, at-risk youth prevention programs, even investments 

in college access efforts. I know that with the Department’s leadership, we can continue to respond to this crisis. I am hopeful that, together, we can put forward real 

solutions to help mitigate the 

damage from the water crisis in Flint and make sure the young children there 

get back on track to a prosperous, fulfilling life. 

Thank you and Secretary Burwell, I look forward to hearing from you today. 

Chairman KLINE. I thank the gentleman. Pursuant to Committee 

Rule 7(c), all members will be permitted to submit written statements to be included in the permanent hearing record. Without objection, the hearing record will remain open for 14 days to allow 

such statements and other extraneous material referenced during 

the hearing to be submitted for the official hearing record. 

It is now my pleasure to introduce our distinguished witness, 

welcome back to our new environs here. The Honorable Sylvia Mathews Burwell serves as Secretary of the U.S. Department of Health 

and Human Services. Prior to joining HHS, she served as director 

of the Office of Management and Budget under President Obama 

and in a whole bunch of other positions in the Clinton AdministraCEWDOCROOM with DISTILLER

9 

tion. This will be the Secretary’s second appearance before the 

Committee during her tenure at HHS. 

Secretary Burwell, I will now ask you to please stand and raise 

your right hand. 

[Witness sworn.] 

Chairman KLINE. Let the record reflect she answered in the affirmative. Before I recognize you to provide your testimony, let me 

remind you of our lighting system. It is pretty straightforward. It 

is a green, yellow, red system. The lights are right in front of you. 

As in the past, I have no intention of ever dropping a gavel while 

you are speaking, but I would ask that you try not to go on too long 

so that members have a chance to engage in the discussion. 

Members will each have five minutes to ask questions, and as my 

colleagues know, I am not quite as reluctant to drop the gavel if 

they are exceeding the five minutes, and, I would ask my colleagues, please do not talk for 4.5 minutes and then ask a question 

that will take her five minutes to respond to. 

We do not have time for that today, because I would advise all 

of you that the Secretary has a hard stop time at noon. We are 

going to try to give everybody the five minutes, but we may have 

to curtail that time if we start running short. So, I would appreciate your cooperation. 

Madam Secretary, you are recognized. 

TESTIMONY OF THE HONORABLE SYLVIA MATHEWS 

BURWELL, SECRETARY, U.S. DEPARTMENT OF HEALTH AND 

HUMAN SERVICES, WASHINGTON, D.C. 

Secretary BURWELL. Chairman Kline, Ranking Member Scott, 

and members of the Committee, thank you for the opportunity to 

discuss the President’s budget for the Department of Health and 

Human Services today. 

As many of you know, I believe all of us share common interests 

and that we can find common ground. In recent legislative sessions, 

this committee took important steps to strengthen our workforce 

and open the doors to new early learning opportunities. Thank you 

for your leadership in passing the Workforce Innovation and Opportunity Act and the Child Care and Development Block Grant Act of 

2014. We look forward to working with you on both of these in the 

year ahead. 

The budget before you today is the final budget for this administration and my final budget as Secretary. It makes critical investments to protect the health and well-being of the American people. 

It helps ensure that we can do our job to keep people safe and 

healthy, accelerates our progress in scientific research and medical 

innovation, expands and strengthens our health care system, and 

helps us continue to be responsible stewards of the taxpayers’ dollars. 

For HHS, the budget proposal is $82.8 billion in discretionary 

budget authority. Our request recognizes the constraints in our 

budget environment and includes targeted reforms to Medicare, 

Medicaid, and other programs. Over the next 10 years, these reforms to Medicare would result in net savings of $419 billion. 

Let me start with an issue we have been working on here at 

home and abroad, and as we work aggressively to combat the 

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spread of Zika. The administration is requesting $1.9 billion in 

emergency funding, including $1.5 billion for the Department of 

Health and Human Services. We appreciate Congress’ consideration of this important request. This funding will help us implement the essential strategies to prevent, detect, and respond to this 

virus, with a focus on reducing the risks to pregnant woman. 

I know the rise of opioid misuse, abuse, and overdose has affected many of your constituents. Every day in America, 78 people 

die of opioid related deaths, and that is why this budget proposes 

significant funding, over $1 billion, to combat the opioid epidemic. 

Research shows that early learning programs, as the Chairman 

mentioned, can set a course for a child’s success throughout their 

life. That is why over the course of this administration, together 

with congressional support, we have more than doubled access to 

early Head Start services for infants and toddlers. Our budget proposes a total of $9.6 billion to the Head Start program and an investment in child care services that would allow us 

to serve over 2.6 million children. Beyond this budget, for the children in Flint, Michigan, we have already announced $3.6 million, 

as Mr. Scott mentioned, in one-time emergency for Head Start 

money. 

With these funds, they can expand early childhood education, behavioral health services, and other vital nutrition services. Today, 

too many of our Nation’s children and adults with diagnosable 

mental health disorders do not receive the treatment they need. So, 

this budget proposes $780 million in new mandatory and discretionary resources over the next two years to close that gap. 

While we invest in the safety and health of Americans today, we 

must also relentlessly push forward on the frontiers of science and 

medicine. This budget invests in the Vice President’s cancer initiative. Today, we are entering a new era in medical science. With 

proposed increases of $107 million for the precision medicine initiative and $45 million for the administration’s BRAIN initiative; we 

can continue this progress. 

In order for Americans to benefit from our recent breakthroughs 

in medical science, we need to ensure that all Americans have access to quality affordable health care. The Affordable Care Act has 

helped us make historic progress. Today, more than 90 percent of 

Americans have health coverage—the first time in our Nation’s history that has been true. 

The budget seeks to build on that progress by improving the 

quality of care that patients receive and spending dollars more 

wisely. It proposes investments to improve the access to care for 

underserved groups across the United States, including many in 

rural communities, with $5.1 billion in health center funding and 

nearly $14 billion over the next decade for our Nation’s health care 

workforce. 

By advancing and improving the way we pay doctors, coordinate 

care, and use health data and information, we build a better, 

smarter system. 

Finally, I want to thank the employees of HHS. In the past year, 

they fought Ebola in West Africa, helped millions gain health coverage, and have done the quiet day-to-day work that makes our 

Nation healthier and stronger. I am honored to be a part of the 

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team, and as members of this committee know, I am personally 

committed to working closely with you and your staff to find common ground to deliver for the American people. 

Thank you. 

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Chairman KLINE. Thank you, Madam Secretary. That is close to 

a record, seven seconds over five minutes. Well done. Thank you 

very much. 

I mentioned in my opening remarks that we are concerned about 

the recent Reuters’ investigation into abuse and neglect of children 

born in families battling drug addiction, and there was a law, 

CAPTA, that falls under your department’s jurisdiction. 

We sent a letter to you asking for information. The Department 

responded, and we thank you for that, but clearly, we still have a 

problem out there, it seems to me. 

Congress has taken steps to streamline the application process, 

but the application still goes through the Children’s Bureau at 

HHS, where they review States’ applications and sign off that it is 

adequate before Federal funds are dispersed. 

So, I know you looked at this. Do you feel like that within the 

law, the Department is doing everything it can to ensure that 

States are upholding the law, or is there more that should or could 

be done? 

Secretary BURWELL. So, when these issues were raised, some of 

the issues raised in the Reuters’ articles, we have gone and followed up on the examples that were raised, and right now, the 

State of South Carolina is being put on a performance improvement plan. So, specific actions are being taken where we have 

found there is wrongdoing. That is in terms of when things are 

brought to our attention. 

As part of this process of review, we also put in place a different 

process to review what the States are saying. When they say they 

have a plan, in this next year’s round, we will be asking for more 

details of those plans, so we can understand that the States actually have something that is a workable plan. So, we have taken 

steps in terms of where we understand there is something wrong 

and trying to get in front of it by making sure that we do a different process with regard to review of the plan. 

The other thing I would just say is it will be an important part 

of the Administration for Children and Families as we review their 

budget. 

Chairman KLINE. Okay. That is a change to the practice— 

Secretary BURWELL. It is a change. 

Chairman KLINE. We will be watching with interest. It does 

seem to us there needed to be a way for the Department to be able 

to confirm that the States are doing what they are supposed to be 

doing, without waiting for somebody to come and complain. 

Secretary BURWELL. Which is why we have taken that step to do 

it in a more proactive fashion with the proposal, so we will look forward to the Committee’s support for the Administration for Children and Families as a part of the budget process that we are able 

to enforce and do, I think, what the Committee rightfully is raising. 

Chairman KLINE. Thank you. We just passed and the President 

signed into law the Every Student Succeeds Act. It took six, seven, 

eight, or 12 years or something to get to it and through it, but it 

is done, and it is the law. Under the Act, as I mentioned in my 

opening remarks, the Act now authorizes a preexisting program 

known as the ‘‘Preschool Development Grants Program.’’ 

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Your department now has the lead under the law, with respect 

to funding authority and responsibilities. As I mentioned, it seemed 

to us that was clear because you already have billions of dollars in 

preschool funding through $9 billion in Head Start alone. 

We believe that Congress specifically limited Federal interference 

in State early childhood systems to maximize State and local control over the improvement or development of the early childhood 

systems. 

So, given the language of the law and what I think are clear protections in the law, what are you doing, where are you in the process in effecting that transition from the appropriated but not authorized program that was in Education and is now authorized and 

will be appropriated, I am sure, program that is in your jurisdiction? 

Secretary BURWELL. So, the transition by statute will occur in 

2017, not in this fiscal year. Right now, we are working with our 

colleagues at the Department of Education to actually formulize 

the relationship between us. We are going to do an MOU, a Memorandum of Understanding, to formalize the way we incorporate the 

best practices from Education and their input, as we integrate this 

program into the continuum. 

I think you know at the Department, we have home visiting. We 

have early childhood. We have early Head Start. We have this program. We will integrate across that continuum, having the Department of Education be a contributor, and we decided to formalize 

the relationship. 

Chairman KLINE. I am very pleased to hear that. It is because 

you are involved in all of those programs and you have that continuum that made sense to many of us to put this program there 

so it can be managed altogether. 

I am going to try to set the example for my colleagues and yield 

back the balance of my time. Pay attention, please, all. Mr. Scott, 

you are recognized. 

Mr. SCOTT. Nice try. Thank you. Madam Secretary, much has 

been made about the increasing cost of health care. Can you tell 

us briefly how the increases in health care costs now compare to 

what they were before the Affordable Care Act? 

Secretary BURWELL. So, we have some of the lowest levels of 

Medicare growth on record that we have had since the passage of 

the ACA and the implementation. So, that has been a very important part. We have seen four of the five lowest years of growth in 

Medicare spending, and that is important for the taxpayer and for 

the Federal budget. 

With regard to employer-based care, and that is the care that the 

vast majority of Americans have in this country, last year, the increase in employer-based care was around 4.2 percent in terms of 

the premiums. When we look at the period from 2000 to 2010, that 

number was 7.6. So, what we see is a decrease in the premium 

growth costs for those in the employer system. 

With regard to the marketplace itself and the individual market, 

last year in the marketplace, the premium increases averaged in 

about the 7 percent range, and what we know is before the Affordable Care Act, in the individual market, premium increases were 

regularly in the double digit space. 

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So, whether one is looking at employer-based care, Medicare, 

which I know we are all concerned about from a taxpayer perspective, or looking at the marketplace itself, what you see is slowing 

in the growth of health care costs. It brings us to slowing but still 

increasing, and that is why I believe we need to spend a lot of time 

on delivery system reform and reforming the way we provide quality care at more affordable prices. I hope we will be able to talk 

about that some today. 

Mr. SCOTT. How much more do people with preexisting conditions have to pay? 

Secretary BURWELL. With regard to the preexisting, and I think 

this gets to the quality portion of what I was just talking about, 

in the system today, and I think everyone in this room knows 

someone who has had cancer or has asthma or some other condition, for all of those individuals, they no longer need to worry that 

they will either be cut off from their care or not be able to access 

the care. 

I have had the opportunity to travel around the country and 

meet those people who previously did not have that opportunity. 

Making sure that those with preexisting conditions can no longer 

be discriminated against is a very important part of the progress 

on quality of care that we have seen. 

Mr. SCOTT. Do the people with preexisting conditions have to pay 

any extra? 

Secretary BURWELL. No. They are neither kept out nor do they 

pay extra in terms of what they would pay in their premiums. 

Mr. SCOTT. Can you say briefly how the failure to expand Medicaid in some States affects those who have insurance? 

Secretary BURWELL. With regard to how that impacts those who 

have insurance, it comes in the form of uncompensated costs. So, 

the work that we have done—we have seen about a $7.8 billion reduction in uncompensated costs since the passage of the implementation of the Affordable Care Act. The vast majority of those benefits are going to the States that have expanded Medicaid. What 

that means is that reduction in uncompensated care gets translated through the system, and it gets translated through the system to individuals and to hospitals and communities. 

We know that now in terms of rural hospital closures, which are 

something many are concerned about, we see more of those rural 

hospital closures in States that have not expanded. This is because 

of the uncompensated care issue. It flows to individuals. It flows to 

communities, and it flows to hospitals. 

Mr. SCOTT. Thank you. Disasters can happen anywhere. If a disaster were to happen in one of our districts, we could look at how 

you respond to Flint, Michigan to see how you would respond in 

our areas. Can you say what you are doing in Flint, Michigan for 

that disaster, particularly in Head Start? 

Secretary BURWELL. So, the President asked that the Department of Health and Human Services lead the Federal response, 

which we are doing. So, we are coordinating the response of FEMA 

delivering water, SBA making sure that loans can get through, 

HUD helping housing get different pipes into public housing, and 

then the work we are doing. 

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You mentioned our Medicaid expansion, as well as our Head 

Start work. The Head Start work, we have done a $3.6 million addition to expand both coverage and services, and that is because a 

lot of what you do to mitigate lead has to do with education and 

nutrition. 

Our colleagues at USDA are working very closely with us as well 

on the nutrition component, and put in place an ability for mothers 

to use WIC money to do formula that was not water based, because 

obviously that was a problem for those children focused on 0 to 6. 

Mr. SCOTT. Does the Zika request include research? 

Secretary BURWELL. Yes, it does, and I hope we will have more 

time to discuss Zika. I just got the report today, and for U.S. citizens, there were over 450 million cases, and I hope we will have 

an opportunity to discuss that more. 

Chairman KLINE. The gentleman’s time has expired. Dr. Roe? 

Mr. ROE. Thank you, Mr. Chairman. Thank you, Madam Secretary, for your pushing the rule for the end of life counseling. That 

is a huge thing. I have heard a lot of positives about that. I want 

to thank you for that. 

Just a couple of quick questions. 

Stop-loss insurance regulation, as you know, in the private sector, a majority of those plans are basically self-insured plans, like 

we had in the City of Johnson City when I was the mayor. We used 

stop-loss insurance to protect our losses if they went above what 

we calculated they might be. 

Would you commit to the Committee not to regulate stop-loss insurance as health insurance because it is clearly not, in the future 

as Secretary of HHS? 

Secretary BURWELL. I want to understand exactly what the regulations and laws are, I apologize, this is one I am not familiar with, 

I want to look into it, and we will get back to you in terms of how 

we think about that issue. 

Mr. ROE. Okay. Thank you. Just for the record, our increase in 

the marketplace in Tennessee was over 30 percent this year. 

A couple of things on Meaningful Use and electronic health 

records. As you know, physicians are struggling to meet the Meaningful Use and full disclosure. The primary care group I was in had 

over 100 physicians, and we have met—1 of the 12 percent in the 

country—they have met that, and about 40 percent of hospitals in 

Stage 2. 

Why would you go to the penalty phase of Stage 3 this year, 

which I think you are going to do, when 80 plus percent have not 

met Stage 2 yet? So, you know that the doctors, providers, hospitals, and physicians are going to be cut; why not just put it on 

pause for a year until they can get the systems to help? They are 

trying. They are out there trying to do this day and night, so why 

not do that? Why not pause for a year? 

Secretary BURWELL. I think what we have tried to do is hear the 

concerns that have been expressed, and I think you know in the 

rulemaking that we recently put out, we were working to also include the legislation you all recently gave us on MACRA, and 

transferring to that system that we have been given legislatively 

to work through. 

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So, working to make sure that we can get to the place where we 

are listening to providers— 

Mr. ROE. That is what I am hearing out in the real world, that 

you are not listening. That is a concern because they are going to 

get the penalty phase this year. So, I appreciate you are working 

on that, but what I think I am hearing out there in the real world 

is we are trying the best we can to comply with these things, but 

there are so many things with electronic health records and so 

forth, and I say this jokingly, but an electronic health record, I 

think, made me a congressman not a doctor any more. 

A couple of other things I want to go through very quickly, and 

I wrote you a letter about the breast cancer screening guidelines. 

I appreciate you putting that on hold for two years. One of my 

partners in practice, if he had followed the guidelines, one doctor 

in one practice, 24 patients would have fallen through the cracks 

and not been picked up early: 24 breast cancers, one doctor. 

The other I want to mention is the PSA screening. The United 

States Preventive Task Force Services, which had no urologists and 

no oncologists, made a recommendation that absolutely should not 

be done, and you, as the Secretary, are going to penalize the primary care doctor if they order a PSA regardless of the patient’s 

family history, regardless of their race, and regardless of their 

symptoms, essentially. 

So, I want to know—last night, I got a call from someone who 

had a PSA of two, a 59-year-old man, got up to go to the bathroom 

one time at night, went to his doctor. His primary doctor had ordered one previously, ordered another one, ignoring these guidelines, it was three. He said we better check it again in 90 days. It 

was five point something then. Sent to an urologist. This man has 

prostate cancer at 59. He would have been missed by these guidelines and might have died. 

I think these guidelines are going to cost people their lives. I 

think we need to seriously step back and take a look at them, at 

least let the science get worked out before you penalize a primary 

care doctor for ordering a PSA, a test that is not perfect, but it is 

an adjunct to clinical history and other things. I would strongly encourage you to do that. 

This was last night. I do not know how you would answer that 

patient’s family when that patient would very likely have died had 

they followed these guidelines. 

Another issue I want to just bring up briefly: affordability of 

health insurance. I am in a billion dollar health care system at 

home where I practiced, 60 percent of the uncollectible debt in that 

hospital are people with insurance. To make these plans affordable, 

we have increased the out-of-the-pockets and co-pays so high, that 

people cannot pay those, just average, normal people, rural America, where I live. 

The last comment, we mentioned this last year. In rural America, where I live, what is killing our hospitals in Medicare is the 

Medicare Wage Index, which is very unfair to rural areas. We get 

0.74 cents to what another place might get $1.50. I would like to 

hear from you on that. I want to work with you on that. 

With that, Mr. Chairman, I yield back. 

Chairman KLINE. I thank the gentleman. Mr. Hinojosa? 

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Mr. HINOJOSA. Thank you, Chairman Kline and Ranking Member Scott. I support President Obama’s Fiscal Year 2017 budget for 

the Department of Health and Human Services because the administration’s priorities for HHS support the well-being of all Americans, and are closely aligned with the needs of my congressional 

district. 

Madam Secretary, it is a pleasure to have you testify before this 

committee, and I want to ask the chairman as a member of this 

committee for unanimous consent that the three pages of my opening remarks be included in today’s report. 

Chairman KLINE. Without objection. I am sorry. I am blaming it 

all on the ranking member here. 

Mr. HINOJOSA. Thank you, Mr. Chairman. Madam Secretary, as 

you know, the State of Texas did not expand Medicaid, and that 

has hurt us a great deal. I am pleased to hear of your efforts to 

incentivize these vital programs. In your view, why is it important 

for States to expand Medicaid? 

Secretary BURWELL. So, the Medicaid expansion issue, I think, 

has two different elements to it. It has the element of the individual, and it is about providing financial and health security for 

the individual. 

In the State of Texas, over 40 percent of those who would be eligible are working folks, so for many working people, making sure 

they can have both that financial and health security is a very important thing to their individual well-being. 

Separately, there is the issue of what it means economically to 

hospitals and to the States. We know that in the State of Kentucky, what we have seen in terms of an analysis by Deloitte as 

well as the University of Louisville, that until 2021, 40,000 new 

jobs would be created in Kentucky, and $30 billion would flow into 

the State of Kentucky. 

So, it is an economic issue in a broader sense, but it is also about 

the individuals and how their lives can be changed, and certainly 

as you reflect, we have a budget proposal to try and keep encouraging States to come in. 

Mr. HINOJOSA. Thank you. Parental engagement and involvement has been one of the most critical if not the most critical part 

of a Head Start program over the last 50 years. This holistic approach ensures that children are ready for school. How does this 

proposed rule for Head Start strengthen parental involvement? 

Secretary BURWELL. So, Head Start, and I think you know I am 

a Head Start kid, it has been a successful program for many years, 

and certainly not just my professional opinion but my personal 

opinion, but the issue of the intergenerational part of this, and Mr. 

Scott referenced it in his opening testimony, is an essential part, 

and it is essential both to get the full benefit of the program, and 

as we work forward, that is some of the changes in the proposed 

rule. 

It is everything from making it easier—in the current rule that 

is there, one-third of some of the requirements are cut out, in trying to get to simplification, to make things easier for parents and 

easier for providers, so they can engage and participate. 

As a parent of a 6 and 8 year old, I am very clear about the engagement and what it means in terms of children’s well-being, and 

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also having quality places for your children to be in terms of your 

ability to focus on your work. 

So, it is about— 

Mr. HINOJOSA. Thank you for that clarification. Thank you, 

Madam Secretary. Helping children and young people who qualify 

for help through DACA, Deferred Action for Childhood Arrivals, is 

very important to my region because I have such a large number 

of students, K–12, who qualify. 

How do the priorities in your proposal help them? 

Secretary BURWELL. With regard to the DACA issues, I am 

afraid I will most likely need to defer to my colleagues at Justice 

and DHS, who are much more engaged in those issues. 

With regard to the programs that are available, I think you know 

that the health centers throughout the Department are an important part of health care for people who do not have coverage or coverage access any other way. 

Mr. HINOJOSA. Thank you. Madam Secretary, the ACA has been 

instrumental in increasing access to health care for residents in my 

district and across the Nation. What can communities such as mine 

do to increase participation in ACA’s health insurance marketplace? What are some of the best practices that you can share? 

Secretary BURWELL. So, open enrollment, I would just remind everyone, November 1 through the end of January next year, and 

preparing for that open enrollment is a very important thing because it is about the communities’ engagement. 

Having visited communities all over the country, what I see are 

stakeholder groups and groups that have come together. The hospitals, the insurers, all kinds of local community groups come together and make sure that the information is there, and that people have a place to go. 

I have visited in the State of Texas. There is some great United 

Way 2-1-1, you just dial 2-1-1 and you are able to get that kind of 

access. 

Mr. HINOJOSA. Madam Secretary, in my district, the uninsured 

was 40 percent before ACA. Today, it is only 18 percent. So, we 

have made great progress. Thank you. 

Secretary BURWELL. Thank you. 

Chairman KLINE. The gentleman’s time has expired. Mr. Byrne? 

Mr. BYRNE. Thank you. Madam Secretary, I want to talk to you 

about the transitional reinsurance program and some current concerns that I and others have about the legality of the way these 

funds have been used. 

We are going to put on the screen the actual text of the law, that 

you see there now. I also have here the same legal memorandum 

that my colleague, Chairman Pitts, showed you two weeks ago 

when you testified before the Energy and Commerce Committee. 

The nonpartisan Congressional Research Service, which put out 

this memo, analyzed this issue and stated, and I am going to quote 

them, ‘‘Insofar as CMS’ interpretation allows the entire contribution of an issue in any given year to be used only for reinsurance 

payments such that no part of it is allocated for the U.S. Treasury 

contribution, and that would appear to be a conflict with a plain 

reading of Section 1341(b)4,’’ that is the language up there. 

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‘‘Because the statute unambiguously states that each issuer’s 

contribution contain an amount that reflects its proportionate 

share of the U.S. Treasury contribution, and that these amounts 

should be deposited in the General Fund of the U.S. Treasury, a 

contrary agency interpretation would not be entitled to deference 

under the Chevron decision.’’ 

We have that second piece of language up there now. So, you 

have had two weeks since Chairman Pitts brought this to your attention. You had the legal memorandum. I assume you have had 

a chance to go over this with your staff and your counsel. 

[Additional submission by Mr. Byrne follows:] 

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You would agree that you did not put $5 billion in the Treasury 

that you were required to. My question now is do you know not 

agree that you violated the law in not putting the $5 billion with 

Treasury? 

Secretary BURWELL. We believe that our reading of the law is accurate and correct. As we put out— 

Mr. BYRNE. Can you give me some authorization for that? 

Secretary BURWELL. Yes. What we did was we actually put out 

our reading of the law in a Notice of Proposed Rulemaking for public comment. We put out our logic. We put out our reasoning to the 

public to review our proposal, not in an interim final rule, but in 

a Notice of Proposed Rulemaking, so we could have comments. 

A wide range of groups commented on our rule, as is regular 

practice. No one raised any concerns— 

Mr. BYRNE. Madam Secretary, let me take my time back on that. 

Whether they commented or not, the law is plain on its face. It 

does not matter what you think or somebody outside of your department thinks if the law is plain, you do not get to interpret it 

any other way, and the nonpartisan Congressional Research Service says you directly contradicted the law in the way you actually 

carried it out. 

So, are you saying now that because you put it out in comment 

that you get to interpret it any way you want to, despite the plain 

wording of the statute? 

Secretary BURWELL. What I am suggesting is that we believe our 

reading is accurate. The public had an opportunity to point out if 

they thought it was inaccurate. That was not done. We believe that 

our reading of the law is accurate. 

Mr. BYRNE. Well, Madam Secretary, let me just say this, the 

nonpartisan Congressional Research Service directly contradicts 

you. They say you read it completely wrong and that you clearly 

violated the law. 

Now, there is a lot of concern in America right now about the 

anger among the electorate. I just came through a primary a few 

weeks ago. The electorate is angry. They are angry because people 

in positions of responsibility like you violate the law. You violated 

the law. The nonpartisan Congressional Research Service has said 

you violated the law. 

Here we are today with some excuse that you put it out for comment. The fact that you put it out for comment does not relieve you 

of the responsibility to enforce the law as it is plainly written. It 

is plainly written. There is no wriggle room around this. 

The fact that you have had two weeks to look at this and you 

cannot offer me any legal authority for what you did tells me that 

you just decided or your staff decided we are not going to put the 

$5 billion in the Treasury as we are required to do by law. 

I can tell you my constituents and the people across the United 

States of America are sick and tired of that. So, if you want to provide to this committee at a later date whatever your legal staff 

wants to provide as whatever legal basis for their interpretation, 

that is fine, but telling me you put it out for notice and comment 

does not answer the question as to how you get around the clear 

requirements of this law, and it is not just my interpretation that 

CEWDOCROOM with DISTILLER

39 

I am going on here, I am going on the interpretation of the nonpartisan Congressional Research Service. 

I appreciate you telling us what you have told us here today, but 

it is not an answer. I hope you and your legal staff after this is 

over will put something together and send it back to us. I yield 

back. 

Secretary BURWELL. Congressman, I would like to reflect that 

what I said was we have put out our legal argument. I understand 

and respect there is a disagreement in the interpretation of the 

law. 

What I was saying is we have articulated why we believe our 

reading of the law is correct, not only have we articulated that 

through communication, we did it in a very public way. We believe 

our reading of the law is correct, and I would also reflect that with 

regard to this, and this particular issue, there have been 71 IG and 

GAO investigations in terms of the question that you are raising. 

We are working hard to implement the law. There are thirty 

open, there have been over 100 examinations. With regard to what 

I am hopeful for is that we can get to the place where we can have 

the conversations about how to control costs and improve quality 

in this country in our health care system. That is what we are 

working to do. 

Chairman KLINE. Madam Secretary, the gentleman’s time really 

has expired. We will not get to any of that if we do not try to stay 

within the five minutes. Mrs. Davis? 

Mrs. DAVIS. Thank you, Mr. Chairman, and good to have you 

with us, Madam Secretary. I wanted to really go to one of the areas 

where as you said we are trying to create a smarter system. 

In that regard, I think there has been some early success of the 

diabetes prevention program. We have seen evidence that really is 

common sense, I think, that if you speak to the need for providing 

better nutrition, exercise training, that you are going to see a reduce on the onset of diabetes. We have seen that particularly in 

seniors. 

I just wanted to mention that there is bipartisan legislation to 

expand the diabetes prevention program to Medicare. There have 

been numerous pilots to demonstrate that really can have a demonstrable effect on saving lives, as well as cutting costs. 

I am hoping that you can take a look at that as well, how can 

we work to expand that. I would love to see all my colleagues come 

together on that legislation, but there may be some other tools that 

we have as well. I hope you will take a look at that. 

I want to shift quickly to early childhood, because that is an area 

that you are going to be working heavily in as we go forward, and 

certainly reflected in the legislation, the transition is in 2017. 

I know that within that legislation, there is a call to expand the 

length of the school day among other requirements. I am wondering what you are doing, what the staff is looking at now, how 

are we going to move forward with that while at the same time 

being certain we are keeping the quality the same or at least better, maintaining quality, and certainly finding ways that we hit the 

bar of lengthening but we are not losing some of the other ingredients that make up such a successful program. 

CEWDOCROOM with DISTILLER

40 

Secretary BURWELL. So, as part of our Head Start rulemaking 

right now, it is an open rulemaking, so with regard to what the 

conclusion will be, it is not something I can comment on. At this 

point in time, we are reviewing a number of comments in different 

places. 

It does get, I think, to a little bit of the chairman’s comment at 

the beginning, about making sure we are continuing to make 

strides, so that the benefits of these programs are known for the 

children in the short-term as well as the long-term, in terms of that 

third grade level and some of the research that we have seen. 

One of the suggestions out of that research that had some questions was the question of lengthening of time, that time there 

makes a difference to the child’s ability to gain and retain what 

they need in order to build the building blocks, especially at that 

critical point in the third grade where we really need them reading 

in a way that it will take off, because then they are using the reading for learning when they get to the third grade. 

So, the time issue is related to the quality issue that the Chairman had raised earlier. 

Mrs. DAVIS. I appreciate that. I know that what we do not want 

to see is enrollment have to drop as a result of that. That is a big 

concern. 

The other one is regarding homeless children. In San Diego, we 

certainly have a number of children who come in and out of the 

school year. As you are working on the rulemaking, how can we 

provide for spaces for children who may be in and out of the program and be sure we guarantee they have a spot when in fact they 

are present and they need to be part of that program? 

Secretary BURWELL. I think it has two elements to it, as we continue to think about the issue of making sure there is flexibility for 

those children, but also working deeply on the issue of homelessness as well, so that you are addressing the problem for those that 

are, but taking on that issue. 

At the beginning of this year, I became the chair of the United 

States Government’s Interagency Council on Homelessness, and because of the work that we actually share, this committee and the 

Department, we will be focusing on youth homelessness as one of 

the main priorities. 

We will continue the work on veterans’ homelessness because 

great progress has been made, but we want to take that next step. 

So, working on flexibility within the programs but also trying to 

get to the root of the issue, we will engage in. 

Mrs. DAVIS. Yes, thank you so much. I know in terms of stability 

of young children’s lives, it is key they are in a program and they 

can count on that when their families are moving and not stable. 

That is so important to them. 

Very quickly, just on one other issue. In the Administration for 

Children and Families, the plan is to provide about $9.5 million in 

demonstration grants to help prevent youth sex trafficking. I am 

wondering if you could just speak briefly to how you expect different States to utilize these funds. 

Secretary BURWELL. You know, I think this is a place where different States are going to use different tools based on their problems and their approach to those problems. This is also a place 

CEWDOCROOM with DISTILLER

41 

where our regional offices are engaging directly with the communities. 

Mrs. DAVIS. Thank you. 

Chairman KLINE. The gentlelady’s time has expired. Mr. 

Curbelo? 

Mr. CURBELO. Thank you, Mr. Chairman. Madam Secretary, 

more than 4,000 foreign children and adolescents have resettled in 

Miami, Dade County, in Fiscal Year 2015, and 937 more in the 

first quarter of Fiscal Year 2016. Foreign born students add an average of $2,720 in extraordinary costs to local school districts, 

above and beyond the per pupil State reimbursements. 

The numbers of refugees, especially Cuban refugees, has increased substantially in our community. The estimated number 

was over 4,000 last year and is expected to be on a similar pace 

in the current year. However, this could be an understated number 

because many parents are immigrating without their children, and 

their children join them later once they have adjusted their status. 

This presents a problem because the later arriving children of 

refugee parents do not count under refugee data, but they still represent major costs to local communities. 

Since school districts are barred from inquiring into immigration 

status, is there a proxy measure for school-wide services that can 

be used to determine the actual impact of the significant influx on 

affected school districts? 

Secretary BURWELL. You know, I apologize, but I am going to 

need to defer to my colleague at the Department of Education with 

regard to how those measures would be done in schools. I apologize. 

Our role, I think you know, is with the parents as they come in 

terms of the Office of Refugee Resettlement. So, I apologize, but we 

can get that to my colleague. 

Mr. CURBELO. Okay. Let me ask you, what is HHS doing, if anything, to address the recent increase in foreign born students that 

are challenging communities like ours? How can we help school districts like Miami, Dade County, serve these students? 

Secretary BURWELL. You know, with regard to our role, I think 

one of the things that we can do is make sure that those transitions of the individuals—the Office of Refugee Resettlement, which 

is a part of HHS—the thing that I think we can do is make those 

resettlements as successful as possible. 

Part of that success, I think, is making sure they become employed members of communities. At that point, our contribution 

can be making sure they are engaged, employed, and contributing 

members of the community in terms of employment and taxes, so 

that then is a part of the regular system. 

With regard to other issues, again, I will defer to my colleague 

at Education. 

Mr. CURBELO. So, let me ask you also, because this is a critical 

issue for our community, and as you know in the past, we have 

seen over 50,000 or close to 50,000 Cubans resettle in the United 

States, and the Miami, Dade County School District and Monroe 

County Schools, for that matter, obviously carry a heavy burden. 

CEWDOCROOM with DISTILLER

42 

Do you know if funding from the Cuban Haitians Social Services 

Set-Aside—can school districts draw from those funds to mitigate 

some of the impacts on these school districts? 

Secretary BURWELL. I am not familiar that they can, but why do 

we not go back and check, and I am happy to get back to you on 

that issue. 

Mr. CURBELO. Well, this is just a critical issue for our community, Madam Secretary. I hope to work with you and with your department to find ways, to find more support for Miami, Dade County. This is another case where a local community faces the results 

or the consequences of what I believe is a flawed Federal immigration policy, a flawed Federal refugee policy in this case, and I think 

it is incumbent on the Federal Government to help communities 

like ours solve these problems because it is unfair for all of these 

costs, for all of the burden, to fall on local school districts and on 

local municipalities. 

Thank you, Mr. Chairman. I yield back. 

Chairman KLINE. I thank the gentleman. Mr. Courtney? 

Mr. COURTNEY. Thank you, Mr. Chairman, and thank you, 

Madam Secretary, for your outstanding service. Your portfolio is 

about as complex and broad as any in government, and I think you 

are doing an outstanding job. Thank you. 

Secretary BURWELL. Thank you. 

Mr. COURTNEY. In your testimony on page 11 you talked about 

the heroin and opioid component in the President’s budget, $1.1 billion. Again, it is allocated to help law enforcement, treatment, prevention, and education, which is what I am hearing back home in 

my district, 28,000 people lost their lives to accidental overdoses, 

as you pointed out, in 2014. 

That is a 14 percent increase from the year before. The 2015 

numbers are not going to be any better, and I know that because 

in Connecticut we saw a 20 percent increase since 2015 numbers 

by the Office of the Medical Examiner just a few weeks ago. 

Director Botticelli was up in Eastern Connecticut talking to folks 

who are on the front lines on this, and you know, what is striking 

is police and law enforcement are totally engaged in doing their 

job, but they are the first to say you cannot arrest your way out 

of this problem. 

Emergency room providers who are saving lives with Narcan are 

frustrated because there is not enough detox beds and treatment 

beds, so there is a revolving door for a lot of these folks who are 

addicted and have no place to go after they have been revived. 

The medical provider community is ready, I think, to talk about 

reforming the prescription overprescribing of pain killers. 

What I think is of concern is that again, you just released new 

funding to HRSA, to community health centers, which is much appreciated, but there is no request for emergency funding this year. 

When you look at Zika and you look at OCO, what Mr. Kline and 

I are going to be voting on, billions in emergency funding for our 

overseas military operations on the Armed Services Committee, but 

when you look at a problem where we are losing 28,000 people a 

year—Senator Shaheen and myself have a bill to sort of move that 

push to get resources into this year, which is so obviously needed. 

CEWDOCROOM with DISTILLER

43 

I just wondered if you could just sort of talk about your perspective on that, you know, the administration’s willingness to work 

with us, who really want to get folks who are on standby ready to 

help with a solution. 

Secretary BURWELL. So, the issue of the treatment and treatment 

opportunities, that is the biggest part of the money, the $1 billion 

that we have asked for. It is about treatment. 

I think all of you know in your communities as you visit, behavioral health is something that was paid for at the community level, 

and so it has never been built up, and now we have a very acute 

problem with people dying but as your law enforcement reflect, 

every law enforcement I talk to, they tell you I am not a social 

worker or a health worker, so that is why it is so critically important that we get funds to move, because those funds move to the 

States and the communities— 

Mr. COURTNEY. Right. 

Secretary BURWELL. To get that treatment. The other parts are 

very important, but without the treatment, we now have a bolus 

of people who are addicted, sadly. I wish that was not the case. We 

need to prevent any more, but we have to take care of that which 

we have. 

Right now, Narcan or preventing an overdose death is not the 

only solution. If people are in medication assisted treatment, we 

can make progress. That is why we are pushing hard. We appreciate your leadership and others in terms of trying to make sure 

we get that funding for the treatment. Funding will also go to other 

issues, as to Naloxone, getting access to people, because not all— 

I am sure you hear this in your communities—not everybody in 

terms of first responders have access. 

We also have work at FDA. They have approved a nasal approach which will be easier for others to use that do not have to 

be a trained first responder to do that. 

So, we will work across, but the money for treatment, which I 

think is what you are focused on right now, is an essential part of 

getting to another place in this crisis. 

Mr. COURTNEY. So, again, the Senate sort of went partway there 

last week in terms of the Comprehensive Addiction Recovery Act, 

but again, it is authorizing legislation without resources, and as 

Congressman Kildee used to say, ‘‘An unfunded authorization is 

kind of like a get well card to somebody who is sick, it does not 

really fix the problem.’’ 

Again, that is where I think the HRSA funding that was put out 

last week is getting to the house on fire that is happening out 

there, but again, the budget priorities are totally on target, as you 

said, but the question right now is on timing, because this issue is 

accelerating and intensifying. 

I hope all of us are going to work together because it affects 

every district, rural, suburban, urban. It is hitting veterans again 

because of Service connected injuries. This should be an easy one 

for us to work together on. 

Secretary BURWELL. Yes. The fire alarm, this is a seven alarm 

fire and we sent one department. We need seven or eight others to 

get to the real issues and the problem. 

Mr. COURTNEY. Thank you. I yield back. 

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Chairman KLINE. The gentleman yields back, without mentioning basketball. Ms. Stefanik? 

Ms. STEFANIK. Thank you, Mr. Chairman. First, I want to echo 

my friend and colleague, Mr. Courtney’s, statements that the heroin and opioid epidemic is an issue that I have been focused on in 

my district, and I look forward to working with you on that issue. 

Thank you, Madam Secretary, for being here today. Shifting 

gears, I think we can all agree here that we need to make sure that 

our seniors receive the best care possible, and in order to do that, 

we must accept there are differing needs across this country. 

The Older Americans Act is an important law that helps seniors 

remain in their homes and out of expensive institutional care. As 

you know, what may work for seniors receiving meals or care in 

urban areas is likely to be inadequate to the unique challenges facing rural areas such as the district I represent in New York’s 

North country, where we have one of the highest concentrations of 

seniors in New York State. 

One of the hallmarks of the Older Americans Act is the State and 

local control provided through the structure of the aging network. 

This is a great example of legislation that understands one-sizefits-all does not always work. 

Can you speak to how this structure is important to meeting the 

needs of this Nation’s elderly and what we will do to continue the 

successful model? 

Secretary BURWELL. Yes, and thank you for your leadership in 

terms of the reauthorization, we think it is important to continue. 

I think what you are reflecting is we need to make sure we maintain the flexibility for States because it is in very wide variance in 

terms of what it means to serve that community and serve that 

community well. 

So, we want to continue. We think the reauthorization does not 

need major changes, but some small changes that can help us with 

making sure we are using the best data and evidence that we have, 

which is based on some of our learnings that different things are 

working in different places, and keep that flexibility in place. 

I think you know in this budget that is before us, even without 

the reauthorization, we have some funding increases in particularized areas, and whether that is protecting against elder abuse and 

how that is done in rural areas versus urban areas, protecting in 

that space as well as some of the food programs that you mentioned, but we want to work across the spectrum of needs and work 

with those communities on what their priorities are. 

Ms. STEFANIK. Great. Thank you for that, and I yield back. 

Chairman KLINE. The gentlelady yields back. Mr. Polis? 

Mr. POLIS. Thank you, Mr. Chairman. I want to thank the Secretary for joining the committee today, and I want to thank her 

and the administration for putting forward a budget that reduces 

our deficit, makes important investments in health and education 

that our country needs. 

I applaud the work of the Department of Health and Human 

Services for working to implement the Affordable Care Act. I congratulate on the especially successful 2016 third quarter enrollment period and 4.9 million new customers in the Federal Exchange. 

CEWDOCROOM with DISTILLER

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Madam Secretary, you have seen firsthand, of course, the positive effects of the Affordable Care Act. I know in my home State 

of Colorado, 16.5 percent of people lacked health care insurance before the Affordable Care Act, and last year, the number fell to 6.7 

percent, a historic low. 

I am concerned, however, about how the geographic rating areas 

for each State can skew the cost of health care. My constituents in 

Grand County, for example, face among the very highest premium 

increases in the country. Their premiums went up at least 25 percent this year. They pay, by the way, nearly twice as much as other 

Coloradoans for insurance. 

How is the Department helping States to guarantee that families 

and individuals who live in rural mountain communities are able 

to access high quality care at a reasonable cost the way the Affordable Care Act intended? 

Secretary BURWELL. So, one of the things that is important in 

both the employer-based market as well as the individual market 

is the fact that the Affordable Care Act actually put out-of-pocket 

caps in terms of what people will spend, and that is another important benefit getting to quality and affordability that we have not 

touched on, and I think that is important. 

With regard to the other issues in terms of the Affordable Care 

Act and the steps it is taking to work on places where I think it 

is fair to say that in our country there are pockets, such as that 

you have described, and in some cases, States, such as the State 

of Alaska, where a market is not working in terms of creating the 

amount of competition either in providers or insurance companies 

to put downward pressure on price. 

I think a part of that is why some of the changes that came in 

the Affordable Care Act that help us with delivery system reform 

and some of the work we are doing in the innovation centers to create models that people can use to have that downward pressure. 

So, there are two parts to it. It is focusing on specific markets 

themselves where the problems exist, but then overall, as a Nation, 

figuring out the steps we need to take to put that downward pressure, and our Accountable Care Organizations, we have already 

seen hundreds of millions of dollars of savings, and while the statutory level that you all gave us is very high to meet success before 

one can replicate, we have met that, and are now in a phase two 

of that. 

So, it is about regional and retail strategy, and then a strategy 

across the Nation. 

Mr. POLIS. Are there are some States that have rolled out single 

geographic rating areas for their entire State? 

Secretary BURWELL. I will have to go and check. I think—I will 

check. 

Mr. POLIS. Thank you. 

Secretary BURWELL. I do not want to give you an incorrect answer, so we will come back on that. 

Mr. POLIS. Sure. To transition to Head Start, of course, I am a 

firm believer in the benefits of Head Start for kids and communities, and in my district and my State, we also have many high 

quality charter schools that serve at risk kids. Public charter 

schools have the autonomy to offer a unique curriculum, many stuCEWDOCROOM with DISTILLER

46 

dents and parents take advantage of that. In Denver Public 

Schools, about a quarter of the kids attend public charter schools. 

You know Head Start grants are given to non-profits, community 

centers, sometimes traditional public schools, but to my knowledge, 

no charter school has received Head Start grants and few have applied. 

Can you talk about what your agency is doing to clarify guidance 

and do outreach so that high quality charter schools know they are 

eligible for Head Start grants and understand how to meet the 

Head Start requirements so they can offer those services for families? 

Secretary BURWELL. Out of our conversation last year, this is 

something that we have followed up on, and are issuing hopefully 

clearer guidance. I think we believe it is possible and people can 

do it, but clearly, I think as you reflect, people do not understand 

that charters can do it, so we are issuing guidance to make that 

clearer, and then we will work to implement that so people can 

know what process they need to do to do it, because we think it 

is quite possible and people can do it. 

Mr. POLIS. Thank you. I also wanted to briefly address 

transgender health. I have worked closely with my colleagues in 

the Equality Caucus, Representative Takano, Representative 

Pocan, also on this committee. 

HHS proposed a rule to implement the non-discrimination provisions of the Affordable Care Act that would prohibit discrimination 

on the basis of gender identity. When can we expect a final rule, 

and are there improvements to the proposed form to the final rule, 

which is so important to the LGBT community? 

Secretary BURWELL. Because it is an open rulemaking process, 

we will not be able to talk about the specifics of the final rule, but 

a rule that is very important. I think you probably know that 1557 

we were implementing before, but it had been five years. 

Mr. POLIS. You will have time to complete that rule, correct? 

Secretary BURWELL. Yes. 

Mr. POLIS. Okay. Thank you. I will have some other questions for 

the record, and I will yield back. 

Chairman KLINE. The gentleman yields back. I need to advise 

my colleagues that we are going to restrict the time now to four 

minutes and hope we do not have to go to three minutes. The math 

shows we have too many people and not enough time. 

Mr. Russell, you are recognized for four minutes. 

Mr. RUSSELL. Thank you, Mr. Chairman, and thank you, Madam 

Secretary, for being here today. 

As a returning combat veteran, I had some firsthand experience 

with prescription pain killers. In my case, Percocet, but, while it 

did reduce the pain, it left me with a clouded mind. I became concerned about that. I did not like not having my faculties, so I quit 

taking them. 

However, pain management, and not just among our veterans, 

has resulted in perhaps a lot of what is categorized as suicides, it 

might have been accidental death. On a broader scale nationally, 

at least 18 States now have more deaths due to prescription opioids 

than car fatalities. 

Secretary BURWELL. Correct. 

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Mr. RUSSELL. The fatality rates have increased five-fold since 

1990. Accidental overdoses are up 360 percent since 1999. In 2004, 

prescription and other over-the-counter drugs were responsible for 

more years of lost potential life than all accidents from falls, firearms, drownings, fires, and non-medication poisonings combined. 

Opioid pain killer prescriptions have increased 800 percent from 

1997 to 2006, and the data for the next decade will probably exceed 

even further. 

America now has had an increase in these, but I cannot imagine 

they have had an 800 percent increase in pain. Instead, America 

now has seen a health science environment that allowed law makers to pass these laws in the first place, and I think America has 

been sold faulty health science and a bill of goods. So, my question to you, Madam Secretary, in the $1.1 billion 

spending program to provide treatment to those exposed and suffering this abuse, we have been exposed to prescription heroin nationwide, what actions will you be taking to curtail the science that 

suggested these laws be passed in the first place? 

Secretary BURWELL. The research on pain and pain treatment, I 

think, is an important part of the solution. I think when we look 

at the steps that we need to take to push back on many of the statistics you articulated, number one, we need to change prescribing 

practices, because that is how many folks are getting the prescription, and then that is sometimes a transfer to heroin itself. I think 

you were referring to both. We need to work on the medication assisted treatment, and we need to get access to Naloxone. 

With regard to the research issues, at NIH, there are two parts 

to this, and one part is making sure that we are researching pain 

issues as well as the treatment of pain, and this is a space where 

I actually work with my colleague at the Department of VA, because they have much of the research and are doing some of the 

advances. As you articulated, it is a pool of people, sadly, who have 

these issues in terms of pain. 

So, we are working on it there. We are working on it at NIH, and 

with regard to FDA, what we are trying to do is speed along the 

process for those that can find drugs that are not opioid based in 

terms of pain, as well as those that are tamper-resistant. Those are 

some of the changes we most recently made at FDA. 

Mr. RUSSELL. I would hope rather than chase more money after 

bad practices that we would take these things off the market. I 

think we existed for a long time as a country, we fought world 

wars, we did a lot of other things. America has not had an 800 percent increase in pain. 

I would hope that you would devote more effort towards the 

faulty science that has allowed these laws to pass. We are creating 

an epidemic that we are not likely to recover from. I do appreciate 

your efforts thus far. Thank you. Mr. Chairman, I yield back. 

Chairman KLINE. The gentleman yields back. Mr. Sablan? 

Mr. SABLAN. Thank you very much, Mr. Chairman. Madam Secretary, you mentioned this would be your last budget hearing. I 

think you should be proud. There are so many things in the proposal that would serve Americans greatly. 

I am the only member here who is not representing a State. I 

am going to limit my conversation to one issue. The President proCEWDOCROOM with DISTILLER

48 

posed in his fiscal 2017 budget that the National Medicaid program 

be available to the 4 million Americans who live in the insular 

areas, including my constituents, in the Northern Mariana Islands, 

and thank you, this is a very welcomed proposal. 

The people of the Mariana Islands are not as well off as the rest of Americans. Our median household income is about $20,000, and 

the national median income is $50,000. Because we have so many 

who are poor, we have many who qualify for Medicaid, 15,036 of 

our total population of 53,000 receive medical care through the 

Medicaid program. 

As you know, Medicaid in the Mariana Islands and the other insular areas is not the same as Medicaid elsewhere. There is a cap 

on the amount of Federal Medicaid money that goes to our islands, 

only about $5 million per year to the Marianas. 

The local cost-share of Medicaid is not computed on overall income as it is with the rest of America. So our Commonwealth, our 

local government has to pay 45 percent of the cost more like one 

of the richer US states would pay. We are not rich, however. 

So, we welcome the additional Medicaid money provided by the 

Affordable Care Act beginning in 2011, about $13 million per year. 

That new money kept our only hospital open when the local government had to stop its annual funding for our hospital because of 

the Great Recession and loss of tax revenues. 

That Affordable Care Act money is only available through 2019. 

What happens then? Does our hospital close? What about those 

now on Medicaid, do they lose coverage? I would like to give you 

the time to please explain to the committee about the President’s 

proposal and how we are going to make sure that Americans in my 

district get the same access to health care as Americans elsewhere, 

everywhere else in our Nation? 

Secretary BURWELL. So, our proposal is a proposal that we hope 

will address the issue of a cliff and not create further cliffs with 

regard to putting in place a proposal that will transfer away from 

a cap and create matches that are more aligned with the matches 

that other Americans receive, at the same time, the proposal includes steps to make sure that there are reforms and governance 

is put in place. 

So, it would happen over a period of time where steps would 

have to be met in order for the changes to occur. It is a proposal 

both about getting out of where we have a cliff and the problems 

that you have described in terms of the need, but do it in a way 

that is also encouraging high quality Medicaid performance and 

program integrity. 

So, the proposal combines those two things. We believe it is a 

reasonable and a very needed proposal, and we should get ahead 

of this issue, and that is why we have it in our budget. 

Mr. SABLAN. Thank you very much. It is very needed, not just 

for the Northern Marianas but for Puerto Rico, American Samoa, 

Guam, and the U.S. Virgin Islands. I yield back my time. Thank 

you. 

Chairman KLINE. I thank the gentleman. He yields back. Mr. 

Barletta? 

Mr. BARLETTA. Thank you, Mr. Chairman, and thank you, Secretary Burwell, for being here today. 

CEWDOCROOM with DISTILLER

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I was deeply disturbed by a recent Senate report that found the 

Centers for Medicare and Medicaid Services, which is part of your 

department, had billed out roughly $750 million in Obamacare subsidies to half a million people who were unable to prove their citizenship or lawful presence in our country. 

These tax credits are solely to be used to purchase health insurance by United States citizens and those lawfully residing here. Instead, they were improperly distributed, and the Federal Government will likely never see a cent returned. 

This report was just one of many reports that have recently come 

to light detailing the rapid fraud and waste under Obamacare mismanagement that hard working Americans have had to foot the bill 

for. 

I have been working to fight illegal immigration for more than 

a decade now, and I find it extremely troubling that, at a time 

when our national debt is $19 trillion and counting, the Federal 

Government continues to throw money away with no regard for the 

consequences. 

I would have a hard time explaining to families in my district, 

many of whom are struggling to put food on the table, as to why 

they should be helping to pay for the health expenses of someone 

who broke the law to get here and has no right to those Federal 

dollars. 

Secretary Burwell, whose decision was it to prioritize illegal immigrants over American citizens? 

Secretary BURWELL. So, with regard to the Senate report —I 

take the issues of program integrity and budgets very seriously. 

You probably know, it was during the years that I was at OMB 

that we actually had balanced budgets, close to the only time during my lifetime. So I take these issues of program integrity very 

seriously. 

With regard to the Senate report, I think what the Senate report 

reflects and says is that they were not able to provide—they did 

not provide—the documentation, we do not know whether they did 

or did not. 

I think with regard to the program integrity that you raised, as 

one looks at what happened in the first year of the Affordable Care 

Act, and there were about 250,000 people who were taken off last 

year, in terms of changes, both immigration and income, 1.6 million 

people in terms of when we reviewed and we were not able to receive the documentation, not knowing whether they could or could 

not, and that was both for immigration, the immigration number 

is about 500, and the other number is about— 

Mr. BARLETTA. Am I correct in that the tax credits are used, if 

somebody cannot produce legal documents at the time, the tax 

credits are used until they can come back, it gives them an opportunity to come back and prove their legal status? 

Secretary BURWELL. It is a 90-day period which is given by statute. 

Mr. BARLETTA. Right. So, my question is after the 90 days, why 

then did the Federal Government not go back, why did we not go 

back to those people after we gave them the tax credits to get the 

money back of the tax credits that could have been used for someone else? 

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50 

As the head of an agency that knows what it is like to scratch 

for every penny, please explain to me how the administration is 

going to make up to my constituents and ensure that three-quarters of a billion dollars is returned to the American taxpayers? 

Secretary BURWELL. With regard to that, that is the regular tax 

process. For any of these individuals, what will happen is they will 

owe those in taxes, in terms of reconciling, so the IRS in its processes— 

Mr. BARLETTA. We can count on that money coming back? 

Secretary BURWELL. So, what will happen is when they go in, 

this will be reconciled through the IRS process. That is the way the 

enforcement will occur because it is a tax matter, so it occurs on 

the IRS side of the house. 

Mr. BARLETTA. Thank you, Mr. Chairman. 

Chairman KLINE. The gentleman yields back. Ms. Bonamici? 

Ms. BONAMICI. Thank you, Mr. Chairman. Thank you, Secretary 

Burwell. Your work covers so many areas that affect the daily lives 

of Oregonians and Americans. I appreciate that. 

I want to thank my colleague and friend, Representative 

Stefanik, for bringing up the Older Americans Act. I want to ask 

you about the Home & Community-Based Supportive Services program that funds services like legal assistance, elder abuse and prevention, transportation and meal sites, medical appointments, referral assistance for seniors and their caregivers. 

Now, I am supporting the additional $10 million in the President’s request as well as many of my colleagues. Why is it important to increase funding for the Older Americans Act programs, especially the Home & Community-Based Supportive Services, given 

the rapidly rising population of older Americans? I do want to save 

time for another. 

Secretary BURWELL. I will just quickly say I think there are two 

elements. It is about what it means for the individuals in terms of 

these programs we know are making a difference in terms of supporting people to be able to have care at home, if that is what is 

appropriate for them. So, it is about the individual. 

It is also about the economics as well, in terms of the success of 

these programs contributes economically. 

Ms. BONAMICI. Keeping seniors in their homes, it is less expensive. Thank you. The Oregon Health Science University has been 

working in collaboration with Intel on genome mapping. That is especially useful in cancer research. The goal is to make personalized 

genomic analysis faster, less costly, more routine. 

What are some of the challenges that research institutions face 

regarding the collection and sharing of information, and what opportunities might the Cancer Moonshot provide to overcome some 

of these obstacles in advanced precision medicine? 

Secretary BURWELL. Some of the limitations are the fact that the 

areas of science do not work together, and you actually need an engineer to help deliver through the system. A biologist figures out 

what it needs, but an engineer actually delivers the delivery mechanism, and we have not broken down those silos as we think about 

the science. I think it can help with that. 

The other thing I think it can help with is data and information, 

because one of the things, and this is part of what precision mediCEWDOCROOM with DISTILLER

51 

cine is about, making sure data and information can be widely 

accessed in safe, secure ways. That is both about privacy and cybersecurity. That information can be used widely and broadly to 

discover and understand more quickly. 

It also in the end will save costs because how one accesses information for trials will become easier and less costly, which is a very 

important cost element to drugs. 

Ms. BONAMICI. Thank you. I look forward to working with my 

colleagues on those important issues. Finally, I think my colleagues 

brought up the issues with opioid overdose and abuse and all the 

resulting deaths, and we have had an explosion in my State as well 

as the country. 

I applaud your three-pronged evidence-based approach. Can you 

talk a little bit about the prong of improving prescribing practices? 

Secretary BURWELL. An extremely important part, and the Center for Disease Control and Prevention will be issuing new prescriber guidelines in terms of the issue of how we can talk about 

these issues and think about these issues. 

One of the problems is many physicians say I do not know, I was 

not trained in this way. We want to get those out and make sure 

people are using those. When you think that over 250 million prescriptions a year for opioids, we know we do not need that many 

as a country, so prescribing is an issue, so we are going to target 

that as an issue, get out new guidelines, and then we need to probably work with the Congress to make sure those guidelines are 

used. 

Ms. BONAMICI. Thank you. I know my State just received about 

$2.7 million to expand substance abuse services, particularly focused on treating opioid abuse. I know that is not enough. We still 

have more work to do. 

I had a fourth question but the Chairman asked already about 

preschool development grants, and I look forward to watching that 

and hope the transition is seamless as the HHS continues to manage those grants. 

I yield back. Thank you, Mr. Chairman. 

Chairman KLINE. The gentlelady yields back. Dr. Foxx? 

Ms. FOXX. Thank you, Mr. Chairman. Secretary Burwell, I want 

to follow up somewhat on what my colleague, Mr. Byrne, was talking about in his line of questioning, but first I want to say I have 

heard from employers who self-insure that this transitional reinsurance fee is particularly burdensome to them, depriving them of 

resources that could be used instead to create jobs. 

You asserted that HHS interpreted the law accurately and appropriately. You claim that the comment period for the NPRM resulted in no objections to the Department’s interpretation of the 

law. 

However, most of us believe that the NPRM was drafted in such 

a complicated way that no one could interpret it in the way your 

department did, where you used convoluted language to create a 

loophole to justify your reasoning. Given your dubious interpretation of the law thus far—you have heard members of this committee, and you will hear us say we think you have interpreted it 

wrong. I agree with Mr. Byrne, you have interpreted it wrong. You 

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are hearing directly from members of Congress that you have interpreted it wrong. 

I am now concerned that you are going to find a way to extend 

the transitional reinsurance program even though the law clearly 

states that it expires this year. So, could you expand in greater detail your legal interpretation of implementing the transitional reinsurance program contrary to the letter of the law? 

Can you commit to this committee that you will follow the letter 

of the law which states the program must cease collections for the 

program at the end of this year? Do you plan to distribute funds 

after 2016? 

Secretary BURWELL. With regard to the question of the reinsurance program, I think it is actually important to focus on what the 

substance of this program is about, and the substance of this is an 

issue that we have actually talked about in a number of places, 

which is pressure on costs, and you were indicating another space, 

in terms of this is about putting downward pressure on costs by 

creating an ability for the issuers in a new market. 

This is one of the transitional programs, and there are no plans 

to extend it beyond. 

Ms. FOXX. Okay. So, you consider the transition period time is 

over? 

Secretary BURWELL. We have no plans to change our reinsurance 

time table that was set out. Risk adjustment is the only program 

that will continue beyond right now. 

Ms. FOXX. Okay. When you say ‘‘we have no plans,’’ would you 

be a little more explicit, you will or you will not? 

Secretary BURWELL. I am being very clear, we have no plans. We 

just issued our rulemakings - our Proposed Notice, a Payment Notice—there is nothing that indicates anything that we do other 

than where we are. 

Ms. FOXX. Alright. Madam Secretary, I have some other questions, but Mr. Chairman, in the interest of time and my colleagues, 

I will yield back the balance of my time. 

Chairman KLINE. I thank the gentlelady. Mr. Pocan? 

Mr. POCAN. Thank you, Mr. Chairman. Thank you, Madam Secretary, for being here today. I am trying to get to three subjects 

in four minutes. I am going to try to go fast. 

Does the name Brent Brown from Wisconsin ring a bell to you? 

This is a gentleman who wrote a letter to the President, and I 

would like to ask unanimous consent to enter this letter into the 

record. 

Chairman KLINE. Without objection. 

Secretary BURWELL. I do know. 

Mr. POCAN. Yes. A gentleman who had spent his entire life savings on health care, he was literally a dead man walking, could not 

get health insurance because he had a preexisting condition, and 

because of the Affordable Care Act, he is alive today. 

What is unique about the letter, and I just want to read two or 

three of the paragraphs, this is in his letter, ‘‘I probably wore pins 

and planted banners to display my Republican loyalty. I was vocal 

in my opposition to you, particularly the ACA. Before I briefly explain my story, allow me to say this, I am very sorry. I understand 

written content cannot convey emotions very well, but my level of 

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conviction has me in tears as I write this. I was so very wrong, so 

very wrong.’’ He goes on to explain about his preexisting condition 

and had it not been for the Affordable Care Act, he would not be 

alive today. 

So, I just think that is a wonderful example and story, and more 

importantly, part of his appeal was to try to tell people maybe on 

the other side of the aisle who have been trying to repeal this for 

63–64 times, you know, maybe it is time to move on. I just wanted 

to mention that. 

One of the issues that came up was about the Affordable Care 

Act when it first came out, that on the employer rolls you were 

going to reduce employees because of the part-time hour commitment, do you very quickly have any updates on that, how we’re 

doing? 

Secretary BURWELL. We have seen no evidence, and we have continued the recovery in terms of involuntary part-time employment. 

The involuntary part-time employment increased as part of the recession, but we continue to see progress and a normal recovery, so 

there are no analytics that show there has been an impact in terms 

of part-time work. 

Mr. POCAN. Great. Thank you. I know a number of us talked 

about opioid abuse. I would like to talk about something different 

than behavioral health, mental health issues. 

I know that while the opioid issue is really getting a lot of attention right now, I think mental health issues, especially as someone 

who is a former legislator, 25 to 30 percent of the people in the 

prison system in Wisconsin are there for mental health. If they 

were there because they had cancer, people would be in the streets, 

but that is not how we are dealing with this issue and the amount 

of costs that go into it, very supportive of the President’s budget 

and the increases he is trying to do. 

I just want to make sure we are keeping the focus on mental 

health as we do this because not just the State government, in Wisconsin, that is $250 to $300 million a year just for the people who 

have mental health in the corrections system, but in the local jails, 

local government, et cetera. 

I think it is really sad commentary on how we treat the disease 

and not have enough efforts there, and anything we can do would 

be much appreciated. 

Secretary BURWELL. I think the Affordable Care Act together 

with the Mental Health Parity Act are the two most important 

steps we can make as a Nation to get parity in this space. 

Mr. POCAN. Great. The final issue I just want to raise in the last 

minute I have, prescription drugs. One of the issues that we have 

seen is prices are rising again, going up. I recently was at our VA, 

and he was telling me about what he had to do for one of his patients, a drug that was $125,000 a dose. 

We know that recently companies like Pfizer are trying to do tax 

inversions so they do not have to pay taxes here and go to Ireland, 

by buying a smaller company, yet at the same time, they are not 

going to charge us the prescription prices that they pay in Ireland, 

which is considerably less than they are paying here. 

I would just like to advocate for anything we can do and you can 

do within your department to help us look at that issue because I 

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think we may need to work with those folks working on inversions, 

because I think it is a real tragedy that we are paying more and 

more for prescription drugs, including 27 percent, I think, of mental health is on prescription drugs, and we need to do something 

more. 

Secretary BURWELL. High cost drugs is a priority, and there are 

a number of elements in the budget we think would help address 

it. 

Mr. POCAN. Thank you. I yield back. 

Chairman KLINE. The gentleman’s time has expired. Mr. Bishop? 

Mr. BISHOP. Thank you, Mr. Chairman. Thank you, Madam Secretary, for your testimony this morning. 

On February 19, as part of the Fiscal Year 2017 Medicare Advantage Rate Notice, CMS proposed a cut to Medicare Advantage 

employer group waiver plans, otherwise known as Medicare Advantage retiree coverage, 3.3 million seniors received their Medicare 

Advantage coverage through this plan. 

In fact, in Michigan alone, there are more than 300,000 retirees, 

including labor unions, State and local government, and private 

employer retirees who rely on Medicare Advantage retiree coverage. 

These proposed cuts would jeopardize the high quality care that 

they depend on for their health and financial security. That is why, 

last week, my colleague, Representative Debbie Dingell, and I, led 

a bipartisan Michigan delegation letter that included 11 of our colleagues in Michigan, to raise concerns with regard to the impact 

these proposed cuts would have on our constituents, and we also 

urged the agency to remove the cut to the Medicare Advantage retiree coverage from the final rate notice. 

Earlier this month, the UAW Retiree Medical Benefits Trust, 

which provides health coverage to retirees and their dependents of 

the United Auto Workers Union, who formerly worked for the 

Michigan Big Three (GM, Ford, and Chrysler) submitted comments 

to CMS expressing concerns with CMS’ proposed cuts to Medicare 

Advantage retiree coverage and the impact these cuts would have 

on their retirees. 

The Trust currently provides coverage to 719,000 people. Of this 

population, 534,000 are covered by Medicare. The Trust offers their 

retirees a choice of plans in which they can enroll. At the present 

time, 161,000 of these retirees have selected and are covered by 

Medicare Advantage plans. 

In comments submitted to CMS, the UAW Retiree Medical Benefits Trust expressed concerns that the proposed cuts to Medicare 

Advantage retiree coverage might result in diminishing the quality 

of care available to retirees and the proposal would lead to substantial reduction in payment to employer group waiver plans, 

thereby resulting in premium increases and/or benefit reductions. 

This leads me to my question. I did send you this letter, and I 

appreciate the fact that you have acknowledged receipt of that letter. Thank you very much for that. 

Having said what I just said, and the grave concerns they represent to in particular my constituents in the State of Michigan, 

can you tell me whether or not CMS considered the impact the cuts 

to the Medicare Advantage retiree coverage would have on the 3.3 

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55 

million seniors who depend on this form of coverage when developing the Advanced Notice? 

Secretary BURWELL. So, we did, and appreciate that, and appreciate the letter you have sent. We are in an open comment period, 

so welcome the comments and the concerns. We did consider this 

issue. 

We actually looked to our experience when we did this change in 

Part D. We did not see the impact that folks are saying could happen. We did not see that impact occur. We, like you, want to make 

sure affordability is an important part of it in our work, but we try 

to balance affordability for the individual as well as affordability 

for the taxpayer with the Medicare dollars, and feel it is a proposal 

that meets those, but we want to continue to hear the comments 

and see if there is something that would distinguish it from the experience we previously had. 

Mr. BISHOP. Have you responded to the UAW’s concerns? 

Secretary BURWELL. Probably because it is a part of the comment 

and the rulemaking process, most likely we took it in as a formal 

comment, but I am not sure how they did it, whether it was in the 

form of a letter or a comment. I do not know specifically, but it will 

most likely be a part of the record for the comment period. 

Mr. BISHOP. Thank you, Madam Secretary. I yield back. 

Chairman KLINE. The gentleman yields back. Mr. Takano? 

Mr. TAKANO. Thank you, Mr. Chairman. Madam Secretary, it is 

truly a pleasure to hear from you this morning about your department’s priorities. I am glad to hear about the administration’s continuing commitment to programs that support working families, 

educate our children, and keep Americans healthy. 

First, I would like to ask you about the Department’s work to 

support LGBT seniors. As you may know, the Congressional LGBT 

Equality Caucus, of which I am co-chair, has formed an LGBT 

Aging Issues Task Force. We sent a letter to Administrator 

Greenlee asking for ACL to require each State plan to assess 

whether State units on aging are meeting the needs of the LGBT 

community in their area. 

As you know, LGBT elders have poorer physical health, worse 

mental health, lower income, and fewer close ties on average than 

other seniors. 

Can you speak to whether ACL will be rolling out a guidance focused on LGBT older Americans, and if not, what will they be 

doing to assist this aging population? 

Secretary BURWELL. With regard to this population, which as you 

articulated has a higher level of challenges than other parts of our 

elderly populations as a nation, there have been a number of steps 

that we as an entire department have taken in this space. 

I think you are familiar with our LGBT Coordinating Committee, 

which is a part of what has led to another thing that will be coming to fruition, which I think is a very important part of understanding the problem better, which is data collection, a five-year 

data collection, that will be targeted, so we can better understand 

the specifics of both what is happening in terms of the results, but 

what is causing many of the things you talked about in terms of 

the discrepancies that we see among the elderly. 

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The third piece that I would actually mention is we have created 

a National Resource Center, specifically focused on LGBT issues, 

for communities to access so they can find out information and better serve the community. 

So, we are going to continue to work on these issues, appreciate 

your leadership, and look forward to continuing with the things you 

think we can do more in this space. 

Mr. TAKANO. Well, thank you, Madam Secretary. I wonder if you 

would be willing to have a meeting with the members of the LGBT 

Caucus to discuss these important issues? 

Secretary BURWELL. I am sure that we and our team can figure 

out how we can do that and the best way to get action taken. 

Mr. TAKANO. Wonderful. Madam Secretary, in your testimony 

you mentioned the administration’s commitment to growing our 

health care workforce by making continued investments in the National Health Service Corps, and graduate medical education. 

Ensuring that we have a robust health care workforce is one of 

my top priorities. In Riverside County, which I represent, there are 

only 34 primary care physicians for every 100,000 people. Half the 

number of doctors needed to provide adequate access to care. 

Can you share more about the administration’s efforts to guarantee we have the health care workforce that we are going to need? 

Secretary BURWELL. So, it has a number of different elements. 

You mentioned one in terms of the National Health Service Corps 

and our emphasis on the National Health Service Corps, and building that up, and continuing to add members to the Corps. 

In addition, the funding that we do for HRSA, our Health Resources Services Administration, is another important part of making sure that we are building up a Corps. 

I think the other thing is how we do the policies. Our graduate 

medical education funding proposal, we actually shifted to the 

mandatory side because we believe that funding should be a dependable, continual part of funding, so we are encouraging people 

to go into these fields and know they will have an ability to have 

help with their loans. 

The other thing that I would mention is the focus on primary 

care, because we believe that is at the center and core of 

transitioning our system to where people have primary care homes. 

So, it is both in policy and funding across the Department that 

we are working on the issue of making sure we have enough health 

providers. 

The other thing is people at the top of their licenses, right now, 

we want to make sure there is more access for nurses and others 

to be able to do certain types of functions, and lastly, telemedicine. 

There are three proposals on that. 

Mr. TAKANO. Mr. Chairman, I almost made it. I am sorry. 

Chairman KLINE. The gentleman’s time has expired. Mr. Rokita? 

Secretary BURWELL. I am sorry. That was me, sorry. 

Mr. ROKITA. I thank the Chairman. Thank you for coming, it is 

good to see you. On behalf of the Governor of the State of Indiana, 

Mike Pence, and many of us in the State, thanks for working with 

us on what we call ‘‘HIP 2.0,’’ consumer driven health care, that 

I think will be a model to help the Department and others around 

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the country really get at cost constraints while serving more people. Thank you for your cooperation and leadership in that regard. 

Secretary BURWELL. Thank you. 

Mr. ROKITA. I wanted to talk to you a little bit about the budget 

this morning. I thought I heard in your opening statement that you 

were able to get savings from Medicare and Medicaid, or did I misunderstand that? 

Secretary BURWELL. There are Medicaid proposals as well as 

Medicare proposals. 

Mr. ROKITA. I heard Medicaid and Medicare reforms. 

Secretary BURWELL. Yes. 

Mr. ROKITA. You did not mean spending reforms or did you mean 

spending reforms? What is the effect of the reforms? 

Secretary BURWELL. Savings. The effect is savings, $419 billion 

for Medicare, Medicaid, and other areas. 

Mr. ROKITA. Over the 10 year window? 

Secretary BURWELL. That is right. 

Mr. ROKITA. Thank you. In your written statement on page two, 

you say that taken together, there is an estimated savings of $242 

billion over 10 years. What is the difference in those numbers? 

Secretary BURWELL. We pay for our child care. We pay for the 

other mandatory issues, so we pay for. That is the savings in that 

space, the entitlement space. We use some of that for savings and 

we use some of that to do things like fund child care. 

Mr. ROKITA. Thank you. How do you save, in terms of Medicaid 

particularly, how do you save money when I thought CBO’s January report said Medicare spending will grow by $200 billion in 10 

years, what is your— 

Secretary BURWELL. Medicare or Medicaid? 

Mr. ROKITA. Medicaid. 

Secretary BURWELL. Medicaid spending. With regard to some of 

the proposals in the Medicaid space, one of the proposals, and I will 

have to see if this is one of the ones that scores into those numbers, 

but what we want to do is work with States so they can do purchasing for drugs together, help States do combined purchasing, 

which can drive down Medicaid costs for them and for us. That one, 

I have to check to see if it is one of the scorable ones, but those 

are the types of things that we are looking at. 

Mr. ROKITA. Okay. What do you think about flexibility grants or 

block grants or making finite—instead of an open-ending fee for 

service kind of structure—what about taking a finite amount of 

money and saying look, this is what you have to spend, State X, 

find out who really is poor, what the poor really need, and how the 

poor should get it? 

Secretary BURWELL. So, I think the question of capping Medicaid—the concerns we have with it are front and center right now 

in Puerto Rico, where we have almost 250 cases of Zika, we have 

over 10 cases of pregnant women who have tested for Zika, and you 

have a situation where you have a population whose needs were 

not being met before this started, and then you have a situation 

like Zika layered on top. 

So, having a program that is about the ability to be flexible with 

the needs of the people, to meet the needs, what— 

CEWDOCROOM with DISTILLER

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Mr. ROKITA. That example is a little extreme. That is what a 

supplemental funding measure could be for, something like that. 

We do not have to— 

Secretary BURWELL. I hope that is an expression of support for 

our Zika sup—— 

Mr. ROKITA. Well, it is an expression that Congress can act in 

emergencies, and you are describing an emergency. You are not describing day-to-day, in Puerto Rico. I am running out of time, so 

thank you. 

This is not meant to be a political ‘‘gotcha’’ in any way, but I 

clearly remember and see evidence where the President in 2008 

when he was running for office the first time said he would be able 

to lower insurance premiums with his Affordable Care Act at 

$2,500 per family on average. 

Your testimony describes the fact that we have slowed the 

growth in health care costs. What happened? What is different? 

Secretary BURWELL. I think in terms of that number, that is the 

projected growth, the amount of the projected growth, the— 

Mr. ROKITA. He said lower premiums. 

Secretary BURWELL. With regard to the specifics, I apologize, I 

am just— 

Chairman KLINE. I am sorry, the gentleman’s time has expired, 

and we are rapidly approaching—Ms. Clark? 

Ms. CLARK. Thank you, Mr. Chairman, and thank you, Secretary 

Burwell, for not only your testimony today but the incredible work 

that you are doing. I especially want to highlight your commitment 

to addressing the opioid crisis, coming from a State like Massachusetts where it has just been a devastating effect, we so appreciate 

your partnership and your commitment. 

I specifically want to ask you about adolescents and young 

adults. I have spoken with many experts who treat this population. 

They have been clear that this population needs special protocols 

to be able to tailor the treatment to their unique social and biological needs. They are also clear there has not been enough emphasis 

on programming or research in this area. 

Can you discuss any efforts that are underway to target action 

towards young adults and adolescents, and if you see this as an important area for fighting the opioid crisis? 

Secretary BURWELL. So, with regard to the fighting it in the here 

and now, a couple of elements and steps. One is you are right, because what happens is—I heard a story this past week of a young 

person at Cornell, an athlete injury, got on the opioids, overdosed 

and is dead. 

So, there is special need especially because of these athletic injuries, this gets to the prescribing guidelines, and making sure there 

are alternative approaches to helping these students and young 

people through their pain and their athletic injuries. That is one 

whole category. 

There is another category that we know sadly that while I think 

people think alcohol is an okay alternative for these young people, 

it is not, because I think what we know is that is a gateway often 

to the prescription. Those that are participating in those activities 

are more likely as they get older to participate in other activities. 

CEWDOCROOM with DISTILLER

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That is the here and now and things we need to focus on. The 

research that we need to do with regard to the question of opioids 

across the board is a broad part of the research. The questions of 

does it help for long-term pain and acute pain, that sort of thing, 

and making sure we are thinking about young people as we do the 

research is a more longer term issue but one we need to focus on. 

Ms. CLARK. And one we would love to work with you on. I want 

to quickly get back to Zika. You spoke about some startling numbers, even here in the United States. Every day we are seeing more 

of the connection being verified by research about the connection 

and danger for pregnant women. We are also seeing countries 

around the globe that have very restricted access to family planning for women saying do not become pregnant at this time. 

Can you elaborate on what is being done both here at home and 

abroad to make sure that women have access to a full range of 

health care options? 

Secretary BURWELL. So, three fundamental things as part of the 

strategy. Number one, a deep focus on pregnant women because of 

the concerns around microcephaly, and the very extreme birth defects that can occur with women who have Zika while they are 

pregnant. 

Number two, communication, making sure we are reaching as 

many people as possible who are either traveling to that region or 

have a partner who has traveled to the region, because we know 

sexual transmission is possible. So, communicating about the 

guidelines as much as we know as quickly as we know. 

And number three is making sure that we are focused on the research that we need to do to understand more about the disease, 

including how to do better vector control. This is a disease that is 

spread by a mosquito that can bite four people in one setting. It 

is an indoor mosquito. It can breed in a capful of water. It is a very 

difficult mosquito to control. 

We are continuing to use best practices, but more research on the 

disease, on the vaccine, and the vector need to be done. 

Ms. CLARK. Great. Thank you. 

Chairman KLINE. The gentlelady’s time has expired. We are 

shrinking the available time even more. I am telling my colleagues 

as we are moving towards the hard stop. Mr. Allen, you are recognized for three minutes. 

Mr. ALLEN. Thank you, Mr. Chairman, and thank you, Madam 

Secretary, and thanks for your call, by the way. I am sorry I did 

not get back to you. 

I wanted to just comment on a couple of things. One is you mentioned you have lowered the taxpayer growth in Medicare. I need 

some background on that, because I am not seeing that, so if you 

could get that to me. 

The other number that I am seeing is ‘‘totally insured.’’ I am not 

seeing that in my district. In fact, a very small percentage of my 

district is insured. In fact, doctors tell me at the emergency room 

that nothing has changed, many people are showing up without insurance as before. 

Also, on your comment about you do not pay more for preexisting 

conditions, I met a lady yesterday that told me about her son and 

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ten so high and his deductible was like $10,000. I said well, I will 

get an answer for you. I need you to get that to me. 

Last but not least, the President signed into law, and I voted for, 

the Hyde Amendment, which was an attachment to the appropriations bill. How are you monitoring your funding of these various 

claims that no taxpayer funds are being used for abortions? How 

do you monitor that, and what are you doing to oversee that? 

Secretary BURWELL. With regard to where that would occur, it 

would occur in HRSA, the Health Resources Services Administration, which are the clinics that we fund directly, and there are 

stringent guidelines with regard to that, that the clinics both know 

and are educated on, so it is not just a matter of telling the clinics, 

it is a matter of HRSA making sure they know and understand 

what those guidelines are so we can follow them. 

Mr. ALLEN. You are auditing these clinics? 

Secretary BURWELL. With regard to the specifics of how that 

goes, I will come back to you. 

Mr. ALLEN. Okay. Alright. The other thing, we have some States 

that are opting out of the Exchanges. I think Oregon and Kentucky 

is talking about getting out of the State Exchanges and going back 

to the Federal Exchange. 

Do you want to explain why that is going on? I mean our governor was criticized because he did not opt to go into the State Exchange, because he knew eventually the Federal Government was 

not going to fund it any more. Of course, in Georgia, we are required to balance our budget. He did not think the funds would be 

there. 

What is your take on this? 

Secretary BURWELL. With regard to either approach, I think it is 

about a State’s choice and a decision in terms of whether or not 

they want to do the setup of the piece that will attach their consumer to their ability to access it. 

In Kentucky, it is a system that is a well-integrated system that 

helps with and creates efficiencies for both their CHIP and Medicaid. I think they decided to do it because it creates that. Other 

States choose not to and use the Federal marketplace. 

Either way can work as a system. We just want to work with 

States to do what is their preference as a State. 

Mr. ALLEN. I yield back. 

Chairman KLINE. The gentleman yields back. Ms. Wilson? 

Ms. WILSON. Thank you, Mr. Chair. Welcome, Madam Secretary. 

Secretary BURWELL. Thank you. 

Ms. WILSON. Unfortunately, Florida, my State, is one of 19 

States that has failed to expand Medicaid under the ACA. Can you 

speak to why Medicaid expansion is so important for communities 

of color, especially in my home State, and across the country? 

Secretary BURWELL. So, while we have made great progress in 

terms of communities of color, 3 million uninsured reduction in the 

African American community, 4 million in the Latino community, 

we know that the uninsured rates are still disproportionately high. 

We know that if Medicaid expansion occurs, that a disproportionate 

number of folks that are minorities will be covered. 

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So, we are excited to continue pushing and pushing hard because 

we think it will have a disproportionate benefit to communities of 

color. 

Ms. WILSON. Our governor has repeatedly rejected expansion, citing budget restraints. Can you speak to how Florida and other 

States may actually see budgetary relief under Medicaid expansion? 

Secretary BURWELL. So, what we know, and the University of 

Louisville together with Deloitte has done a piece of work and a 

piece of research on their work and their expansion, and it led to 

the creation—it would lead to the creation by 2021 of 40,000 jobs, 

as well as $30 billion flowing into the State. 

We know we see reductions in uncompensated care for hospitals 

and communities across the State when expansion occurs. It is 

about the individual, but it is also about the economic impact. 

Ms. WILSON. How are we assured that our communities of color 

are getting the information they need to successfully enroll? 

Secretary BURWELL. One of the things we do during open enrollment, and I had the opportunity to spend a lot of time in your 

State, have gone to every place from beauty salons to barber shops, 

because we need to meet people where there are trusted voices. 

In Texas, actually in all States, we do second Sunday, where on 

Sundays, we work with the faith communities across the States to 

help people get information that is important information from 

trusted voices. 

Ms. WILSON. Just keep up the good work. I yield back. 

Chairman KLINE. The gentlelady yields back. Mr. Carter? 

Mr. CARTER. Thank you, Mr. Chairman. Thank you, Madam Secretary, for being here. Madam Secretary, as you know, I am a 

pharmacist, so I am very concerned about issues, obviously, dealing 

with patients and dealing with them getting their medications. 

Specifically, I wanted to ask you about compounding, 

compounding for office use only. I am very concerned about the 

FDA interpreting legislative intent, and certainly this is something 

that comes into play when we are talking about for office use only. 

I know the FDA continues to prevent medications to be compounded for office use only, and what this causes is for the patients 

to have to go back to the pharmacy, get a specific prescription, compound it for them, then go back to the doctor to have it applied. 

I am wondering where you are at in that process? Many States 

have already allowed for this to take place. Many States have already had regulations and laws in place that allow for office use 

only, for compounds to be made, and for the physician to have 

them there in the office where the physician has the ability to 

apply and use that medication instead of the patient having to go 

get a specific prescription filled for them as opposed to having it 

for office use only. 

I just want to know where we are at in that process. 

Secretary BURWELL. So, we do not have any guidance out preventing that, so maybe I can follow up with your staff to understand, that our team can follow up to understand. We welcome the 

input on the guidance on the issue. 

It does not exist, so right now, compounding should be occurring. 

Mr. CARTER. Compounding is occurring— 

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Secretary BURWELL. There is not a problem in terms of any guidance or any rules about it right now. 

Mr. CARTER. I beg to differ. The problem is you are requiring 

each specific patient to have a specific prescription for medication, 

for a compounded medication. What in the past we have been able 

to do is just to supply— 

Secretary BURWELL. In the doctor’s office? 

Mr. CARTER. Exactly, with a compound that is for office use only, 

in which they can apply that medication. 

Secretary BURWELL. It is my understanding that is able to be 

done—if there is something that is happening that is not, that is 

why I would like to follow up because what you are articulating is 

not my understanding. Let’s understand. 

Mr. CARTER. Absolutely. 

Secretary BURWELL. Is it a State issue or something else or 

maybe we are not communicating. 

Mr. CARTER. We are looking for guidance from the FDA on this, 

and this is an issue that we are very concerned with because again 

it has to do with patient care. We want to make sure that patients 

are getting the care they need. 

Secretary BURWELL. And we would like your input on any guidance that we would do in this space. 

Mr. CARTER. Okay, thank you. Mr. Chairman, I yield back. 

Chairman KLINE. I thank the gentleman. Ms. Adams? 

Ms. ADAMS. Thank you, Mr. Chair, and thank you, Madam Secretary, for being here. I am going to move along quickly. I just 

want to give a shout out to my police department in High Point for 

the work they are doing in opioid abuse, and I thank you for your 

work. 

Let me ask you about the health of our Nation’s most 

marginalized young people as it relates to sexual health services. 

A lot of data and research performed by CDC, American Academy 

of Pediatrics, and even your Office of Adolescent Health show that 

far too many young people in the U.S. face barriers accessing and 

receiving adequate health care services regarding sexual health 

education. 

So, can you please speak to existing efforts that HHS is leading 

to ensure that our Nation’s youth, especially those most vulnerable, 

have the education, skills, and access to sexual education services? 

Secretary BURWELL. So, across the board in terms of our tools, 

it is our community clinics that we have talked about. It is the 

CDC, as you mentioned. It is also our funding in terms of access 

through Title X. Those are three different ways we do that. 

Also, some of the most vulnerable that you are talking about are 

through our minority health issues as well, so that is the other 

place I would mention that we work on these issues. 

Ms. ADAMS. One follow up. So, what is the administration doing 

to address not only the Southern States that are disproportionately 

affected by HIV disease, but also the rural communities that are 

seeing the majority of the diagnoses? 

Secretary BURWELL. There is $54 million in minority health for 

HIV specifically proposed in our budget that we will hope will continue these efforts and work with those Southern States that have 

a disproportionate number, like North Carolina. 

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Ms. ADAMS. Okay. Thank you very much. Mr. Chairman, I am 

yielding back. 

Chairman KLINE. I thank the gentlelady. Mr. Thompson? 

Mr. THOMPSON. Thank you, Mr. Chairman. Secretary Burwell, 

thank you so much for the phone call, very much appreciate you 

reaching out. 

I just want to note the current crisis with the opioids, there is 

obviously some impact from infants to the elderly. We need to approach this from a broader perspective, this is symptomatic. I view 

it as a broader epidemic of substance abuse. It does not matter how 

large or how small the community is, it is present. 

This is kind of an all hands on deck for the Executive Branch, 

Legislative Branch, and all of the partners, we need to be working 

together. 

My question though is regarding access to health care. In your 

testimony, you state that through targeted investments, the administration’s budget expands access to health care, particularly for 

rural and underserved areas. I represent Pennsylvania’s Fifth Congressional District. It is the State’s most rural, largest congressional district, about 24 percent of the land mass. I know rural. I 

know it well. 

As a former health care provider for almost 30 years, access requires the presence of providers in our communities, first. I do not 

care how you pay for it or all the other moving parts of it. You have 

to have that access. There has to be a presence. 

Really, a tremendous concern considering the fact that more than 

45 rural hospitals have closed since 2010, and approximately 300 

others are in danger of closing. I struggle to understand how these 

facts support your conclusion that the Affordable Care Act is having a positive effect on the well-being of employers, employees, providers, health care professionals, and most importantly, patients in 

rural areas. 

Can you expand on your statement in regard to those facts? That 

is a trend line that is not good and it scares me. 

Secretary BURWELL. It is a trend line that started before the passage of the Affordable Care Act, and it is a trend line that has a 

number of different elements that contributed to it, and I think as 

you articulated, as you described your district, the issues of population density, the issue of providers being willing to go to places 

where there is not a lot of population density in terms of their 

choices they make, as well as one of the contributors I think we 

do see is uncompensated care in the form of Medicaid expansion. 

So, we do see a difference in the places where it has expanded, 

and the number of hospitals that are closing. We see a reduction 

in that because of the reduction in uncompensated care. 

Mr. THOMPSON. Obviously, I keep my finger on the pulse of this 

because that was my life, working to provide access to cost effective 

care. I see rapid expansion monopolies, that compounds it by raising costs, monopolies tend to do that, it takes the pressure off for 

increased quality. I think there are a lot of issues going on, and I 

would say they have been compounded since that time. 

Thank you so much. I look forward to continuing the discussion 

offline. 

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Chairman KLINE. The gentleman yields back. We have rapidly 

run out of time. Let me yield to Mr. Scott for any closing remarks 

he might have. 

Mr. SCOTT. Thank you, Mr. Chairman. Madam Secretary, I 

thank you particularly for your comments on the Affordable Care 

Act, where we have changed the situation from thousands of people 

every day losing their insurance to millions more being covered, 

and the cost savings, rather than often double digit increases to the 

lowest increases in modern history, showing a significant savings 

over what the costs would have been had it not for the Affordable 

Care Act. And people with preexisting conditions with no insurance 

to being able to get insurance at standard rates, and more progress 

could be made if Medicaid were expanded in those States, and 

those with insurance are actually picking up a lot of that cost, because of uncompensated care is cost shifted to those with insurance. 

I appreciate your response to the opioid situation. Finally, I 

think we are getting a consensus that early intervention and prevention is better than hospitalization and jails. 

We put all the money in the criminal justice system, and when 

have you ever heard a dealer tell a customer I could not get any 

heroin today because the police have cracked down, and a customer 

say, oh, my God, my dealer got busted, I cannot get any heroin. 

All that money spent on the criminal justice system could have 

been spent on research-based and evidence-based approaches that 

would actually reduce the amount of opioids being consumed. 

Appreciate your work with Head Start, homeless youth. We did 

not get into foster care. I do appreciate your request for additional 

resources in foster care to achieve permanent placements, to the 

extent that we can get young people on the right track and keep 

them on the right track, we will have fewer problems in the future. 

And finally, I express appreciation for your effective response to 

Zika, and the request you have made, I hope we can fund that, and 

to Flint, Michigan. 

So, thank you for your testimony, and look forward to continuing 

to work with you. 

Chairman KLINE. Madam Secretary, I want to thank you also. I 

want to thank you for your testimony, for your service, for your engagement with the members here, and for allowing us to go three 

minutes over the closing time. 

There being no further business, the Committee stands adjourned. 

[Additional submission by Mr. Carter follows:] 

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[Additional submission by Chairman Kline follows:] 

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[Additional submission by Mr. Pocan follows:] 

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[Questions for the record and their responses follow:] 

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

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