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22–184 2017

OBAMACARE IMPLEMENTATION AND THE 

DEPARTMENT OF HEALTH AND HUMAN 

SERVICES FY16 BUDGET REQUEST 

HEARING 

BEFORE THE

COMMITTEE ON WAYS AND MEANS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

JUNE 10, 2015 

Serial No. 114–FC05 

Printed for the use of the Committee on Ways and Means 

( 

ii 

COMMITTEE ON WAYS AND MEANS 

PAUL RYAN, Wisconsin, Chairman 

SAM JOHNSON, Texas 

KEVIN BRADY, Texas 

DEVIN NUNES, California 

PATRICK J. TIBERI, Ohio 

DAVID G. REICHERT, Washington 

CHARLES W. BOUSTANY, JR., Louisiana 

PETER J. ROSKAM, Illinois 

TOM PRICE, Georgia 

VERN BUCHANAN, Florida 

ADRIAN SMITH, Nebraska 

LYNN JENKINS, Kansas 

ERIK PAULSEN, Minnesota 

KENNY MARCHANT, Texas 

DIANE BLACK, Tennessee 

TOM REED, New York 

TODD YOUNG, Indiana 

MIKE KELLY, Pennsylvania 

JIM RENACCI, Ohio 

PAT MEEHAN, Pennsylvania 

KRISTI NOEM, South Dakota 

GEORGE HOLDING, North Carolina 

JASON SMITH, Missouri 

ROBERT J. DOLD, Illinois 

SANDER M. LEVIN, Michigan 

CHARLES B. RANGEL, New York 

JIM MCDERMOTT, Washington 

JOHN LEWIS, Georgia 

RICHARD E. NEAL, Massachusetts 

XAVIER BECERRA, California 

LLOYD DOGGETT, Texas 

MIKE THOMPSON, California 

JOHN B. LARSON, Connecticut 

EARL BLUMENAUER, Oregon 

RON KIND, Wisconsin 

BILL PASCRELL, JR., New Jersey 

JOSEPH CROWLEY, New York 

DANNY DAVIS, Illinois 

LINDA SA ́ NCHEZ, California 

JOYCE MYER, Staff Director 

JANICE MAYS, Minority Chief Counsel 

iii 

C O N T E N T S 

Page 

Advisory of June 10, 2015 announcing the hearing .............................................. 2 

WITNESS 

The Honorable Sylvia Burwell, Secretary, U.S. Department of Health and 

Human Services ................................................................................................... 5 

SUBMISSIONS FOR THE RECORD 

A Submission of The Honorable Earl Blumenauer ............................................... 120 

Act No. 2015–279 ..................................................................................................... 123 

Foster Family-based Treatment Association (FFTA) ............................................ 130 

William Jefferson Terry, Sr., M.D., Member, American Urological Association, 

American Medical Association, and Medical Association of the State of 

Alabama ................................................................................................................ 138 

(1) 

OBAMACARE IMPLEMENTATION AND THE 

DEPARTMENT OF HEALTH AND HUMAN 

SERVICES FY16 BUDGET REQUEST 

WEDNESDAY, JUNE 10, 2015 

U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON WAYS AND MEANS, Washington, DC. 

The Committee met, pursuant to call, at 10:05 a.m., in Room 

1100, Longworth House Office Building, Hon. Paul Ryan [Chairman of the Committee] presiding. 

[The advisory announcing the hearing follows:] 

2 

ADVISORY 

FROM THE COMMITTEE ON WAYS AND MEANS 

FOR IMMEDIATE RELEASE CONTACT: (202) 225–3625 

Wednesday, June 3, 2015 

No. FC–05 

Chairman Ryan Announces Hearing on 

Obamacare Implementation and the 

Department of Health and Human 

Services FY16 Budget Request 

Chairman of the House Committee on Ways and Means Paul Ryan (R–WI) today 

announced that the Committee will hold a hearing on Obamacare Implementation 

and the Department of Health and Human Services FY16 Budget Request. The 

hearing will take place Wednesday, June 10, 2015, in Room 1100 of the 

Longworth House Office Building, beginning at 10:00 a.m. 

Oral testimony at this hearing will be from the invited witness only. However, 

any individual or organization may submit a written statement for consideration by 

the Committee and for inclusion in the printed record of the hearing. 

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS: 

Please Note: Any person(s) and/or organization(s) wishing to submit written comments for the hearing record must follow the appropriate link on the hearing page 

of the Committee website and complete the informational forms. From the Committee homepage, http://waysandmeans.house.gov, select ‘‘Hearings.’’ Select the hearing for which you would like to make a submission, and click on the link entitled, 

‘‘Click here to provide a submission for the record.’’ Once you have followed the online instructions, submit all requested information. ATTACH your submission as a 

Word document, in compliance with the formatting requirements listed below, by 

the close of business on Wednesday, June 24, 2015. For questions, or if you encounter technical problems, please call (202) 225–3625 or (202) 225–2610. 

FORMATTING REQUIREMENTS: 

The Committee relies on electronic submissions for printing the official hearing 

record. As always, submissions will be included in the record according to the discretion of the Committee. The Committee will not alter the content of your submission, 

but we reserve the right to format it according to our guidelines. Any submission 

provided to the Committee by a witness, any materials submitted for the printed 

record, and any written comments in response to a request for written comments 

must conform to the guidelines listed below. Any submission not in compliance with 

these guidelines will not be printed, but will be maintained in the Committee files 

for review and use by the Committee. 

1. All submissions and supplementary materials must be submitted in a single 

document via email, provided in Word format and must not exceed a total of 10 

pages. Witnesses and submitters are advised that the Committee relies on electronic 

submissions for printing the official hearing record. 

2. All submissions must include a list of all clients, persons and/or organizations 

on whose behalf the witness appears. The name, company, address, telephone, and 

fax numbers of each witness must be included in the body of the email. Please exclude any personal identifiable information in the attached submission. 

3. Failure to follow the formatting requirements may result in the exclusion of a 

submission. All submissions for the record are final. 

3 

The Committee seeks to make its facilities accessible to persons with disabilities. 

If you are in need of special accommodations, please call 202–225–1721 or 202–226– 

3411 TDD/TTY in advance of the event (four business days notice is requested). 

Questions with regard to special accommodation needs in general (including availability of Committee materials in alternative formats) may be directed to the Committee as noted above. 

Note: All Committee advisories and news releases are available online at 

http://www.waysandmeans.house.gov

f 

/. 

Chairman RYAN. The Committee will come to order. We know 

that the Secretary is on a tight timeline today with a hard deadline 

at noon. That is why the Ranking Member and I just discussed 

that we will limit Members’ questions to 4 minutes so as to accommodate as many Members as possible in the questioning. But first 

let me start off by thanking our witness, Secretary Burwell. 

I understand that you have to get going, so we are going to move 

this as quickly as we can. We were supposed to have this hearing 

earlier in the year, but events overtook us. So here we are today. 

I understand that the majority of your remarks are going to be 

about the budget. That is all well and good. But it shouldn’t surprise you, Secretary Burwell, that we are a little more interested 

in talking about ObamaCare, especially given the President’s remarks this week. 

I hope he gives you a medal for this job, because defending this 

healthcare law is no easy task. I think any objective observer 

would say that this law is on the fritz, by the law’s own standards. 

The whole point of ObamaCare was to make health care more affordable. But premiums aren’t going down, they are going up, way 

up all over the country. Insurers are proposing double-digit premium increases. In Maryland it is close to 30 percent; Tennessee, 

36 percent; South Dakota, 42 percent. 

Tax season was like a bad dream before. Now it is a total nightmare. People could never afford these plans on their own, so the 

law gave subsidies to some people. Well, now two-thirds of the people who got them had to pay the IRS back, on average over $700. 

That is not the kind of money that people just have laying around. 

And for all of this hassle, for all of this, what are we getting for 

it? The argument was that if people had insurance they would go 

to the doctor instead of the emergency room. But now even more 

people are going to the emergency room. 

So whatever the Supreme Court decides later this month, I think 

the lesson is absolutely clear: ObamaCare is just flat busted. It just 

doesn’t work. And no fix can change that fact. We are not talking 

about a ding or a dent or a fender-bender or a flat tire. The whole 

law is a lemon. Its very linchpin, its central principle, is government control. That means higher prices, fewer choices, and lower 

quality. 

So the answer isn’t just to tighten a few screws and everything 

will be fine. The answer isn’t just to tweak it here and tweak it 

there and we will all be okay. The answer is to repeal and replace 

this law with patient-centered reforms. 

And the truth is, I don’t have to convince this Administration 

that the law is broken. I know that you know it is broken, because 

4 

you keep trying to fix it. For several years now, HHS has delayed 

parts of the law, and sometimes, in some cases, they have rewritten it on the fly. 

We know the most egregious example, the subsidies. The law 

says that people who buy plans on State exchanges can get subsidies. It doesn’t say anything about Federal exchanges. And yet, 

HHS has sent millions of subsidies out the door, putting millions 

of people at risk. 

More and more it seems the Administration isn’t so much implementing the law as they are improvising it. We have already seen 

the evidence of the Administration using one account to pay for 

multiple programs—programs that Congress never funded. That is 

one of the main reasons that we are holding this hearing today. It 

is Congress that wields the power of the purse. And more and more 

the Administration is acting like a purse snatcher. 

So again, my kudos to you, Secretary Burwell, on a very difficult 

assignment. But the American people, they deserve better. They 

deserve a healthcare system that puts the patient first. They deserve lower prices. They deserve more choices. They deserve higher 

quality. And the Committee is going to do all it can to make those 

things happen. 

And with that, I would like to yield to the Ranking Member. 

Mr. LEVIN. Welcome. 

You know, I am glad we are having this hearing. And obviously 

the Republicans want to focus on ACA, and I think that is a good 

idea, because what is busted is not ACA, but your attacks on it, 

endless attacks, never coming up with a single comprehensive alternative in all these years. 

So you sit as armchair critics while millions of people have insurance who never had it before. Millions of kids have insurance who 

would not otherwise have had it. People who have preexisting conditions no longer are canceled or can’t even get insurance. The 

doughnut hole is gone. Millions of people in lower income categories are now insured through Medicare, millions and millions 

and millions. Cost containment is beginning to work. It is beginning to work. The increase in costs, that rate is going down. 

And so you are livid because it is getting better. That is why you 

are livid. And I am not surprised at your fervor. We will be glad 

to take it on. We will be glad to take it on. 

And I think you just need to understand what this experiment 

is all about. It was combining increased access to Medicare, to 

Medicaid, with an increased reliance on the private insurance sector. That is really what this is all about, an experiment. 

And you talk about government control? More and more people 

are getting insurance through the private sector. And the States 

that are denying their citizens further coverage under Medicaid are 

essentially telling people: Well, get lost when it comes to health 

coverage. Get lost. 

And you have a governor, Mr. Chairman, who is running around 

this country talking about the evils of health care, when millions 

of people are benefiting from what happened. 

So you decided to turn this from budget to ACA. Welcome. Welcome. Your frustration is millions and millions and millions of people are benefiting, have health care when they did not before. 

5 

So, Madam Secretary, I think they have thrown down the gauntlet. I don’t feel sorry for you. I think you love this job and you like 

being the person who is administering this experiment in greater 

health coverage after 70, 80 years of nothing being done in this 

town or throughout this country. So I happily welcome you because 

I think you are a very happy warrior. 

I yield back. 

Chairman RYAN. I would like to recognize the happy warrior 

now for your opening statement. The floor is yours, Secretary Burwell. 

STATEMENT OF THE HONORABLE SYLVIA BURWELL, 

SECRETARY, U.S. DEPARTMENT OF HEALTH AND HUMAN 

SERVICES 

Secretary BURWELL. Thank you. Chairman Ryan, Ranking 

Member Levin, and Members of the Committee, thank you for the 

opportunity to discuss the President’s budget for the Department 

of Health and Human Services. 

I believe firmly that we all share common interests and therefore 

we have a number of opportunities to find common ground. And we 

saw the power of common ground in the recent bipartisan SGR fix, 

and I appreciate all of your efforts to get that work done. 

The President’s budget proposes to end sequestration, fully reversing it for domestic priorities in 2016, matched by equal-dollar 

increases for defense funding. Without further congressional action 

the sequestration will return in full in 2016, bringing discretionary 

funding to its lowest level in a decade, adjusted for inflation. We 

need a whole-of-government solution, and I hope both parties can 

work together to achieve a balanced and commonsense agreement. 

The budget before you makes critical investments in health care, 

science, innovation, and human services. It maintains our responsible stewardship of the taxpayer’s dollar. It strengthens our work, 

together with Congress, to prepare our Nation for key challenges 

both at home and abroad. 

For HHS, the budget proposes $83.8 billion in discretionary 

budget authority. This is a $4.8 billion increase, which will allow 

our Department to deliver impact today and lay a strong foundation for tomorrow. It is fiscally responsible, which in tandem with 

accompanying legislative proposals would save taxpayers a net 

$250 billion over 10 years. In addition, it is projected to continue 

slowing the growth of Medicare by securing $423 billion in savings 

as we build a better, smarter, healthier delivery system. 

In terms of providing all Americans with access to quality, affordable health care, it builds upon our historic progress in reducing the number of uninsured and improving coverage for families 

who already had insurance. A recent example of this progress is 

the 10.2 million Americans who are currently enrolled in health insurance through the marketplaces in 2015. 

The budget covers newly eligible adults in 28 States, plus D.C., 

with expanded Medicaid, and an improved access to health care for 

Native Americans. To support communities throughout the country, the budget makes critical investments in health centers 

and our Nation’s health workforce, particularly in high-need areas. 

To advance our common interests in building a smarter, better, 

6 

healthier delivery system, it supports improvements to the way 

care is delivered, providers are paid, and information is used. 

To advance our shared vision for leading the world in science and innovation, the budget increases funding for NIH by $1 billion to 

advance biomedical and behavioral research, among other priorities. It invests $215 million for the Precision Medicine Initiative, 

which will focus on developing treatments, diagnostics, and prevention strategies tailored to the individual genetic characteristics of 

individual patients. 

To further our common interests in providing Americans with the 

building blocks of healthy and productive lives, this budget outlines 

an ambitious plan to make affordable, quality childcare available 

for working families. To keep Americans healthy, the budget 

strengthens our public health infrastructure with $975 million for 

domestic and international preparedness, including critical funds to 

implement the Global Health Security Agenda. It also invests in 

behavioral health services, including more than $99 million in new 

funding to combat prescription opioid and heroin abuse, dependence, and overdose. 

Finally, as we look to leave our Department stronger, the budget 

invests in our shared priorities of addressing waste, fraud, and 

abuse, initiatives that are projected to yield $22 billion in gross 

savings for Medicare over the next decade. 

We are also addressing our Medicare appeals backlog with a coordinated approach. We are pleased that the Senate Finance Committee last week passed bipartisan legislation, and we look forward 

to working with this Committee on it. I also want to assure you I 

am personally committed to responding promptly and thoroughly to 

the concerns of Members of the Committee. 

I want to close by taking a moment to say how proud I am of 

the HHS employees, from their work combating Ebola, to assisting 

unaccompanied children at the border, the commitment that they 

show day to day, day in and day out, as they work to help their 

fellow Americans have those building blocks of healthy and productive lives. 

I look forward to working closely with you to advance our common interests on behalf of the American people. Thank you. 

[The prepared statement of Secretary Burwell follows:] 

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Chairman RYAN. Thank you. 

Let me first start off by saying where we agree with the Administration we work with the Administration. This week’s action on 

trade is a perfect example. But on this healthcare law we could not 

be more opposed to what the Administration is doing. We really 

think this is doing a great harm to the healthcare system and to 

the people we all represent. 

So let me start by just addressing the big elephant in the room. 

Any day now the Supreme Court, as you well know, because your 

name is Burwell in King v. Burwell, is about to rule, and if the 

Court rules against the Administration then millions of people will 

be stuck with a government-designed health insurance that they 

cannot afford. 

So, I mean, the big question is, then what? What about the people who are going to lose their subsidies and possibly their coverage? Is the President going to dictate to us how to fix this flawed 

law or is the President, is the Administration going to be willing 

to work with us to give families greater freedom in choosing the 

health care that works best for them? 

Secretary BURWELL. With regard to the question of the courts, 

I think you know we believe that we are implementing the law as 

it was written, as the statute is written, as it was intended, as 

CBO has scored it for all these years, as recent articles have reflected, that those who were part of writing the law indicate that 

it should be. The idea that citizens in the State of New York should 

receive Federal subsidies that taxpayers contribute to and citizens 

in the State of Texas should not is not what we think the law intended—— 

Chairman RYAN. I understand your opinion on what the Court 

ought to do, but it stands to reason that there is a pretty decent 

chance that they may not go your way. So the question then is, 

then what? 

Secretary BURWELL. So if the Court does decide and if the 

Court would decide for the plaintiffs, and the idea that the Court 

would say that subsidies in the Federal marketplace are not eligible, those States that are part of the Federal marketplace, that 

those citizens can’t have those subsidies, if the Court makes that 

decision we are going to do everything we can, and we are working 

to make sure we are ready to communicate, to work with States, 

and do everything we can. But the critical decisions, if the Court 

says that we do not have the authority to give subsidies, the critical decisions will sit with the Congress and States and Governors 

to determine if those subsidies are available. 

Chairman RYAN. So here is the question I am trying to get at. 

Is the President going to stand up and wave, I have a one-page bill, 

I have a one-sentence fix, take it my way or the highway, is that 

going to be the Administration’s position? Or is the Administration 

going to be willing to work with Congress to find a way to give people more healthcare freedom? That is the question I am trying to 

get at. 

Secretary BURWELL. With regard to the question of healthcare 

freedom, I think it is important to reflect, the marketplace is a 

market. It uses private insurers. People that sign up in the marketplace are not on, so they have many choices. As a matter of fact, 

26 

in the marketplace this year there were 25 percent more plans. 

That is more choice. That is more competition. That is why 8 in 

10—— 

Chairman RYAN. Let me ask it this way, because I want to be 

kind to everybody’s time. Let me ask it this way. If the plaintiffs 

prevail, if the King side wins, and then the exchanges are deemed 

unconstitutional, not legal in the Federal-exchange States, and the 

individual mandate is effectively struck down for those taxpayers 

in those States, is the President going to say reinstate the individual mandate? I have to tell you; it is not real popular. And we 

here, at least on this side of the aisle, aren’t eager to reinstate the 

individual mandate. We would like to free people from some of 

these mandates. 

I would say that the Administration has kind of been a little twosided on this particular issue, mandates, where you have delayed 

the employer mandate twice. That goes away as well. 

So is the Administration going to take the position Congress 

must just reinstate this thing in all these 37 States, reinstate the 

individual mandate, reinstate the employer mandate, my way or 

the highway, or is the President going to be willing and flexible to 

work with Congress to fix this mess and negotiate with Congress? 

That is what I am trying to get at. 

Secretary BURWELL. So I think it is actually very important, 

though, with regard to the decision before the Court, the decision 

before the Court is who receives subsidies and whether or not those 

subsidies can be given in States that have a Federal marketplace 

versus a State marketplace. 

Chairman RYAN. Yes, we understand that. 

Secretary BURWELL. That is the decision, and that is the only 

decision before the Court right now. 

Chairman RYAN. Okay, so should—— 

Secretary BURWELL. And with regard to what happens if that 

decision occurs—— 

Chairman RYAN. Yes. 

Secretary BURWELL [continuing]. Three things occur. The first 

thing that occurs is, for the people—— 

Chairman RYAN. Secretary Burwell, we know what will occur. 

We all know this. The question is, what will the Administration do? 

Will they stand up with one piece of paper and say, ‘‘My way or 

the highway,’’ or will they work with Congress to address the situation? 

Secretary BURWELL. The problem that occurs if the Court decides against us is that they have made a decision that the subsidy 

isn’t available. 

Chairman RYAN. You are not going to answer the question, are 

you? 

Secretary BURWELL. No, the answer is, the problem that gets 

created is subsidies aren’t available. They aren’t available for millions of Americans. They lose their insurance. It drives up costs in 

the individual market. To solve that problem the critical decisions 

are going to sit with the Congress or States. 

Chairman RYAN. Okay. Right. So for a bill to become a law, it 

goes through the House, the Senate, then the person at the other 

end of Pennsylvania Avenue, the President, signs that bill into law. 

27 

Is the President going to come out and say, ‘‘Only my way or the 

highway,’’ one-sentence, one-page fix, or is that President of the 

United States going to be thinking less about digging in and defending his law as exactly written, or is he going to be willing to 

actually deal with the issue, which is affordable health care for millions of people who are losing their health insurance? Is he going 

to work with Congress to address this situation or is he going to 

put concrete around his ankles and say, ‘‘It is my law or nothing?’’ 

That is the question I am trying to get at. 

Secretary BURWELL. So the President and we have said, the 

Administration has said all along, with regard to improvements, 

and we believe that there are improvements that can be made, we 

look at three things and a fourth underlying: Affordability, access, 

quality, and the issue of how it affects the deficit and our economy. 

We will look at anything and have that conversation. 

Chairman RYAN. Okay. 

Secretary BURWELL. With regard to the specifics that you 

raised, I do think it is important, the issue of the individual mandate. That is related to a very fundamental part of the system, 

which is preexisting conditions. And it is our experience, at least 

in my conversations across the country, that most Americans believe that you shouldn’t be kept out of insurance or banned. If I 

have a child that has a condition, that is born with a particular 

condition, that I shouldn’t spend my time worrying that that child 

will never get insurance once they go off mine. 

Chairman RYAN. You are kind of going off topic. I am going to 

cut you off there. We both know that there are ways of dealing 

with those problems without having to impose an individual mandate. 

Let me leave it there, in the interest of everybody’s time. 

Mr. Levin. 

Mr. LEVIN. Well, I am not surprised at the tone, but I really 

think it is so counterproductive. Chairman, you talk about twosidedness. The two sides, when you say you worry about the millions who will lose their insurance, when it is your allies who 

brought the suit that would deprive them of insurance. You talk 

about concrete, having feet in concrete? That is exactly where you 

have been in terms of ACA. Your feet have been in concrete while 

you have brought up bill after bill to try to destroy ACA. And when 

you say will the President be my way or the highway, that is precisely what has been your approach to ACA. Precisely. You have 

never sat down with us to say, how could we make some changes? 

Instead, you have been out to destroy ACA. And you say, where is 

the President’s plan, when the President believes the Court will 

and should uphold the law. All you have done is issue op-eds. 

Chairman RYAN. And bills. 

Mr. LEVIN. And bills, contrary, contradictory bills. So you don’t 

have any plan. Like you haven’t had a plan for 60 years. So you 

can keep going after the Secretary and she will keep trying to spell 

out. 

I will ask you, and I finish, how many people have been receiving 

subsidies, Madam Secretary? 

Secretary BURWELL. Some 7.3 million people have received subsidies that are in the marketplace right now. 

28 

Mr. LEVIN. So when you shed tears about 7.3 million, remember—or about the law—it is 7.3 million. 

What has been the average subsidy? 

Secretary BURWELL. Two hundred and seventy-two dollars per 

month is the average subsidy in terms of those that are in the marketplace that are subsidized. That is the 7.3 million. So 10.2 million people are currently in the marketplace overall. About 85 percent of those receive subsidies. The average subsidy is $272 per 

month, which is what results in the affordability. 

Mr. LEVIN. And just quickly tell us, how many people have received additional care through expansion of Medicaid? 

Secretary BURWELL. The question of the total number, because 

there are people in terms of the expansion itself, about 10 million 

people are the estimates in terms of those States that have expanded. 

Mr. LEVIN. So add those two together and we are talking about 

individuals with families, and the Republicans come here and castigate you and this President. The shoe should really be on the other 

foot. 

I yield back. 

Chairman RYAN. Mr. Johnson. 

Mr. JOHNSON. Thank you, Mr. Chairman. I hardly know how 

to follow that. 

I guess I am supposed to thank you for being here. But I have 

to tell you, I am not in agreement with much of what you are saying. And let me just ask you, we are trying to get the health care 

back in shape, and it sounds to me like you want to go your way 

and not try to work with us. And let me just ask you if there are 

any proposals that HHS supports that will reduce costs for consumers without setting price controls or imposing other restrictions 

that will reduce access to care? 

Secretary BURWELL. Yes, there are a number of things that are 

part of our budget and that we are currently implementing that are 

reducing costs. We know that since the passage of the Act, the trajectory of Medicare—— 

Mr. JOHNSON. But it looks to me like everything is going up. 

Secretary BURWELL. Well, Medicare spending, if we look at 

what it was projected to be in terms of the previous 10 years up 

to 2008 to where it has been since 2009 through 2014, we saved 

$300 billion. With regard to per capita healthcare costs in the country, in 2011, 2012, and 2013 the cost growth is the lowest that it 

has been in 40 years. So that is taxpayer savings. That is also savings for providers. 

Mr. JOHNSON. Well, the insurance rates are going up, not 

down, and everybody is paying more for it. 

Secretary BURWELL. So insurance rates before the Affordable 

Care Act were going up often in the individual market well above 

double-digit numbers. And so what we have seen since the implementation is, while those rates are still continuing to go up, they 

are going up at a much lower rate. 

Mr. JOHNSON. Okay. Let me just change subjects for a second 

and ask you about an effort that my colleague, Lloyd Doggett, and 

I have been after for a number of years, and that is ending the use 

of Social Security numbers on Medicare cards. As you know, that 

29 

finally became law earlier this year as part of the Medicare Access 

and CHIP Reauthorization Act. So let me ask you, is HHS already 

implementing that, and how fast do you think you will be able to 

issue cards without Social Security numbers on them? 

Secretary BURWELL. First, let me say thank you. Having put 

this in the budget when I first arrived at OMB, I thought, as I told 

you in our call, it would take years. So thank you for your leadership and effort on this. We were pleased and I personally was very 

excited. 

So right now we are putting together the work plan to do that. 

We haven’t established the exact timetable, but as soon as it was 

passed, the next day, we asked the team for the work plans. We 

want to do it as quickly as possible in ways that will serve the consumer. As you know, there are a lot of Medicare consumers. We 

want to make sure that we are not disrupting them or their services, but we very quickly want to do it because, like you, we believe 

this is an important part of privacy and security. 

Mr. JOHNSON. Well, I thank Lloyd Doggett for helping me with 

that. But how easy do you think you can make it for seniors to get 

a new card? 

Secretary BURWELL. I think that is the part, in terms of understanding the timing, because we want it to be easy for seniors and 

we want to make sure they understand. One of the things we don’t 

want to do by making this improvement is create confusion. So figuring out the way that we can enter in the new people coming in 

very quickly with their cards, but we want to carefully plan for 

those with the existing cards, because we don’t want to have a confusing situation. So that is what we are working to do, and we look 

forward to staying in touch with you and your office about how we 

do that. 

Mr. JOHNSON. Thank you, ma’am. 

Thank you Mr. Chairman. 

Chairman RYAN. Thank you. 

Mr. Rangel. 

Mr. RANGEL. Thank you, Mr. Chairman. And I want to thank 

my colleague, Mr. Johnson, for not drinking all of that Kool-Aid 

that you had in the back against ObamaCare, and bringing forward 

something constructive that the people outside would know that we 

are trying to provide health care is very healthy. 

Chairman RYAN. Try the Kool-Aid. 

Mr. RANGEL. I can’t try that Kool-Aid, because I was a former 

altar boy, and I went to school and learned all the religions. And 

I just thought that the right thing for Americans to do was to believe that health care was a part of the pursuit of happiness. It 

doesn’t even seem like a political thing if a kid is sick and someone 

says that you can’t have health care. It should pain us as human 

beings if a person goes to a doctor and finds out that the child has 

an illness but he can’t get insurance. Maybe we can find a Good 

Samaritan on the side of the road. And we know that most people, 

middle class people, have insurance, but that poverty sometimes 

restricts people from getting this. 

It just seems to me that instead of tearing down a system where 

you know in your hearts people are getting health care, that you 

would say, ‘‘I don’t like the way you have done it, Mr. President. 

30 

I don’t like the way you Democrats have done it. Let us help you 

to do it better.’’ But to take some sense of pride that the Supreme 

Court will just strike down the opportunity for people to get just 

basic health care to me is not just mean-spirited—— 

Chairman RYAN. Will the gentleman yield? 

Mr. RANGEL. I don’t think so, Mr. Chairman, because you are 

on a roll now, and I don’t want to have you become a nice guy at 

this point in time, because I am glad that you have rehearsed the 

attack that you intend to do. And I don’t care who the Secretary 

is, if you are on the side of giving assistance to people that can now 

go see a doctor, that can now prevent going into intensive care because they have had preventive care, that can now get insurance, 

that they couldn’t have insurance, from a political point of view, I 

wouldn’t want to be in your shoes explaining it. 

Of course, those that are already covered, it is no problem there. 

I have mine, Jack. You get the best that you can. But I don’t care 

what religion you believe in and even if you don’t believe in any, 

it seems like compassion should override partisanship. And if we 

don’t like what is before us, we should work hard to repair and to 

fix it and to improve it. 

And so, you know, I am 85 years old. If I have to decide what 

moral side I am going to be raising issues on, I can’t find a better 

one than this. And it goes without saying, if you are crippled, if you 

are blind, if you are disabled, if you want help, and if money and 

insurance is what is keeping you from getting it, you cannot give 

a better political home run ball to the American people to decide 

a basic question, which side are you on? 

And so I am glad that politically my party would never put me 

in this position. The only position I would rather be in is where you 

are sitting, Madam Secretary, to be able to see that you are on the 

right side of the issue. You can see that people don’t really want 

to discuss the millions of people that are being helped and we are 

not talking about. We are talking about life and death in the true 

sense of the word. And if someone had a conscience that when a 

doctor said, ‘‘I wish you had seen me earlier,’’ and they said, ‘‘I 

wish I could have, but I didn’t have insurance to do it, Doctor,’’ or 

how many cases we have in intensive care saying, this woman, this 

man would never have had to be here if it was detected earlier and 

we have a mechanism for all of this. 

Chairman RYAN. The time of the gentleman has expired. 

Mr. RANGEL. Well, thank you, Mr. Chairman. I will turn back 

the balance of my time. 

Chairman RYAN. Okay, that is good. 

Mr. RANGEL. There was another minute there, but you cut that 

off. 

Chairman RYAN. We are doing 4 minutes so that we can get to 

Members of the other dais here. I would just ask Members, if you 

have a question, ask it earlier on so that the Secretary has a 

chance to respond. 

The gentleman from Texas is recognized. 

Mr. BRADY. Thank you, Mr. Chairman. 

And, Madam Secretary, health care is about patients, not politics. So I was really pleased to hear you answer Mr. Ryan that if 

the Court rules against the IRS in this case the Administration will 

31 

do everything we can. Can you give us some guidance here? Will 

the President sign legislation other than merely extending the subsidies to the Federal exchange? 

Secretary BURWELL. With regard to the question of legislation 

and the Affordable Care Act, that has been a question and a comment. And where we have been is when there is repeal of fundamental elements—— 

Mr. BRADY. But on going forward, I appreciate looking backward, but going forward, if the Court rules for the plaintiffs, will 

the President sign legislation other than extending subsidies to the 

Federal exchange? 

Secretary BURWELL. So the President has and I think will continue to sign legislation that we believe improves affordability, 

quality, access, and takes care of the deficit issues of the country. 

Mr. BRADY. So the answer is, and thank you for saying what 

I hear you say, the President will sign legislation other than simply 

extending the subsidies to the Federal exchange. Are you saying 

that is correct? 

Secretary BURWELL. The SGR bill that we just recently signed 

includes very important provisions that actually extend the Affordable Care Act’s effort to do delivery system reforms. 

Mr. BRADY. But as you know, that is not on the Supreme Court 

case. Specific to that, asking your guidance, the President will sign 

legislation—— 

Secretary BURWELL. Specific to the Supreme Court case—— 

Mr. BRADY [continuing]. Other than merely extending subsidies? 

Secretary BURWELL. Specific to the Supreme Court case, if the 

question is the Supreme Court case, I want to return to what the 

Supreme Court case is saying. 

Mr. BRADY. No, we are looking for your guidance in a bipartisan 

way. So your answer is, yes, the President will sign legislation 

other than extending the subsidies to the Federal exchange. 

Secretary BURWELL. With regard to the question of the Supreme Court case, that is an issue about subsidy. That is all that 

is about. 

Mr. BRADY. And your guidance to us would be—— 

Secretary BURWELL. If your question is, are we willing to consider things that would improve or enhance affordability, quality, 

and access, we are open to those things. 

Mr. BRADY. So yes. 

Secretary BURWELL. With regard to the Supreme Court case, 

though, I think it is very important for me to be clear. That is 

about one item. That is about one item. 

Mr. BRADY. The subsidy. I am very well aware. 

Secretary BURWELL. And that is the subsidy. 

Mr. BRADY. I just want to make sure, again, as we look to work 

together to put patients ahead of politics, you are saying, yes, the 

President would definitely sign legislation other than extending the 

subsidies to the Federal exchange. The answer is clearly yes. 

Secretary BURWELL. I want to distinguish between the question 

of how one resolves the problem that gets created. That doesn’t 

have anything to do with any other parts of the Affordable Care 

Act. 

32 

Mr. BRADY. But no, no, no. This is such an easy question. It can 

be, yes, the President will sign other legislation, or, no, he will sign 

only that legislation. 

Secretary BURWELL. Congressman, I think it is very hard for 

me to answer a question about hypothetical legislation. 

Mr. BRADY. No, it is actually not hypothetical. As we know, the 

Court is going to be ruling. Not hypothetical. If they rule for the 

plaintiffs, guiding us, you are saying the President would sign 

other legislation, he will not, as Mr. Ryan said, he will not say, ‘‘My 

way or the highway.’’ 

Secretary BURWELL. With regard to fixing, improving the Affordable Care Act, these are two different issues. The subsidy 

issue—— 

Mr. BRADY. No, no, Madam Secretary, I don’t mean to interrupt. 

I am really seeking your guidance. So the answer, though, to finalize it, is yes. 

Secretary BURWELL. My answer, Congressman, is we will review any legislation we get that has to do with the Affordable Care 

Act based on four things. 

Mr. BRADY. But I am asking about signing. So the answer is no? 

Secretary BURWELL. With regard to legislation that we sign, we 

will look at any piece of legislation and we will judge it by four 

things: Access—— 

Mr. BRADY. So would the President sign legislation to extend 

those subsidies temporarily while Republicans and Democrats and 

the President work toward a long-term solution? 

Secretary BURWELL. With regard to the subsidies, as I have 

said, the critical decision is with Congress. If the Congress writes 

legislation that makes sure that those subsidies are available, that 

is something that would fix the issue. 

Mr. BRADY. The answer is yes. Yes, he would sign legislation 

other than extending it, correct? 

Chairman RYAN. Time. 

Secretary BURWELL. Congressman, I apologize, but when you 

say ‘‘other,’’ I want to make sure—— 

Chairman RYAN. The time of the gentleman has expired. 

Mr. McDermott. 

Mr. MCDERMOTT. Mr. Chairman, thank you. 

Ms. Burwell, it is really nice out in Seattle. I am not sure you 

made the right choice coming back here to work. 

Secretary BURWELL. I am in the wrong Washington, is that 

what you are telling me? 

Mr. MCDERMOTT. I listen to this, and we are all talking about 

if the President does this and whatever. But let’s talk a specific, 

because I think that we haven’t heard a specific come out of the 

Republicans since the bill was passed. They have never put anything on the table. 

Now we have a bill, 1016, put in by Senator Johnson from Wisconsin, and it is his solution if the bill fails. And as I read it 

quickly, it repeals the individual mandate, it repeals the employer 

mandate, and it says that the States can continue the funding 

down, and the standard of benefits that people get are not the national standards, but whatever the State of Mississippi or Alabama 

33 

or Georgia or Texas or one of these States that has not had an exchange, whatever they set as a benefit. 

We know it will be lower, because it already is. They won’t cover 

people in Medicaid. So they clearly don’t care about the level of 

health care. 

But explain to me how you would respond to 1016. 

Mr. PRICE. Will the gentleman yield? Will the gentleman yield? 

Mr. MCDERMOTT. No, I am not going to yield. I am going to 

let her explain. 

Mr. PRICE. Will you take back the disparagement of the citizens 

of the State of Georgia? 

Mr. MCDERMOTT. She has the right to explain what the President would think of a particular piece of legislation that has been 

put forward as a serious thing by a Senator in the U.S. Senate. 

Secretary BURWELL. So with regard to the Johnson piece of legislation, that piece of legislation, from our perspective, is repeal, 

because it gets rid of preexisting conditions, it stops the funding for 

preventative services, it undoes that people up to 26 would be covered, and it actually takes away subsidies from all over time. 

And so with regard to that particular piece of legislation, that is 

a bill that, from our perspective, is repealing. And we have spoken 

to the issue of something that repeals the Affordable Care Act is 

something that the President will not sign. 

Mr. MCDERMOTT. So in answer to Mr. Brady’s question, will 

the President sign a bill that we pass, if we pass this bill, will the 

President sign that? 

Secretary BURWELL. As I have said, this bill, in its current 

form, is repeal, and the President has said that he will not sign 

something that repeals the Act. 

Mr. MCDERMOTT. Is there any place that you see where there 

is a proposal on the table by any Member of the House or Senate 

that looks at this point as though it deals with protecting the ACA 

in general and fixes the one specific problem? 

Secretary BURWELL. We have not seen anything. 

Mr. MCDERMOTT. And you have looked at all the legislation 

and read all of the press releases and everything else? 

Secretary BURWELL. At this point we have not seen something 

that addresses the specific issue of the question. Although I think 

there is also the issue, I think we are all very focused on the loss 

scenario. At some point I think it actually is important to focus on 

the win as well in terms of how we all go forward if there is a win. 

Mr. MCDERMOTT. Tell us about the costs of health care. We 

hear the Chairman say the President promised that there would be 

a reduction in premiums. Now, would you explain why that is a little bit misleading in that certainly everything is going up in the 

society, but they are not going up as much as was predicted. I 

would like you to talk about that. 

Secretary BURWELL. That is correct. And as we have seen, the 

premium increases that occurred in the individual market and even 

in the employer-based market, we are seeing smaller increases in 

those premiums than we saw before. And so while there are increases, the increases that we were historically seeing that were 

driving costs for individuals, for employers, and in terms of MediVerDate Sep 11 2014 06:46 Mar 13, 2017 Jkt 022184 PO 00000 Frm 00037 Fmt 6633 Sfmt 6602 I:\WAYS\WAYSPS\22184\22184.XXX 22184
34 

care and the costs to the government, that is what we have seen 

shrink and slow. 

Chairman RYAN. Thank you. 

Mr. Tiberi. 

Mr. TIBERI. Thank you, Mr. Chairman. 

Thank you, Secretary Burwell. 

The recent SGR repeal and Medicare reform bill that passed a 

couple months ago included a bipartisan bill that I sponsored to 

require binding bids from suppliers participating in the durable 

medical equipment and supplies competitive bidding program. The 

provision, supported by my Democrat colleagues, removes bad actors from the program, something I don’t have to, I know, go over 

with you, and ensures that seniors get quality medical equipment. 

In a compromise with the Administration, the law requires that 

CMS implement the provision not earlier than January 1, 2017, 

but not later than January 1, 2019. I think that 2019 is a very generous timeline to implement the bill and would hope, with your 

leadership, that we could move it closer to the January 1, 2017 

timeline. 

Because at the end of the day, as you know, again, there is bipartisan support for this concept. My good friend Bill Pascrell is all 

over this issue as well. We think that this will ultimately help separate the good from the bad and ultimately help our seniors. So 

your leadership would be critically important to moving that closer 

to the beginning than the end. 

Secretary BURWELL. So it is related to Mr. Johnson’s question 

too. As soon as the bill passed, which was such a very important 

bill—I don’t think I need to articulate to this Committee all the important things we have worked to put together so that we are specific and we do try to meet and beat deadlines. We have been able 

to do that on some bipartisan legislation in behavioral health that 

was supported both in the House and the Senate in terms of beating deadlines we were given, and where we can, we are going to 

try to. Thank you for your support in helping to do that. If we need 

further support and help I will come and ask. 

Mr. TIBERI. Thank you. 

Secretary BURWELL. But it is something that is a priority. 

Mr. TIBERI. Thank you. 

The other issues, Madam Secretary, are intellectual property 

rights, incentivizing the creation of innovative new medicines that 

improve people’s lives and supporting good U.S. jobs. We are talking about trade this week. 

I want to ask you specifically about India. Over the past couple 

of years, India’s intellectual property climate has unfortunately deteriorated pretty significantly and the U.S. IP-intensive industries 

have suffered, including pharmaceuticals, and they have expressed 

significant issues with respect to the Indian market. 

Most notably, courts in India have issued compulsory license, as 

well as denied or revoked several patents for popular medicines 

held by U.S. companies, citing an Indian law that many believe diverges from India’s international legal and international trade commitments. 

Have the compulsory license and denial, revocation of patents on 

medicines been part of any of HHS discussions with its Indian 

35 

counterparts? And I know this is kind of a question that might 

have come out of left field based upon what you prepared today, 

but would you agree it would be ill-advised for any U.S. Government employee to undermine the policy of the United States to promote strong international property rights in foreign markets? And 

if you aren’t prepared to answer that, would you mind looking into 

it and getting back to us as we have this trade debate this week? 

Secretary BURWELL. Yes, I am happy to get back to you. The 

USTR would probably lead in any of those conversations that were 

in that space. So I think what I will do is coordinate with the 

USTR so that we get back to you together. 

Mr. TIBERI. That would be great. 

Secretary BURWELL. Because I think you probably know those 

conversations—— 

Mr. TIBERI. Yep. 

Secretary BURWELL [continuing]. With the governments are 

being led by the USTR. We give our policy and programmatic input 

to them and they lead. 

Mr. TIBERI. Great. 

Secretary BURWELL. So we will make sure that one of the two, 

either HHS or the USTR, gets back to you. 

Mr. TIBERI. Thanks so much. I appreciate your leadership. 

I yield back. 

Secretary BURWELL. Thank you. 

Chairman RYAN. Thank you. 

Mr. Neal. 

Mr. NEAL. Thank you, Mr. Chairman. 

Madam Secretary, the opioid addiction issue is pronounced now 

across my congressional district, and there are all sorts of stories 

now that indicate a nationwide trend. And I am curious about the 

response of your Department, the agencies that you oversee, and 

I would also like to ask specifically about prescription drug misuse. 

Secretary BURWELL. Yes. 

Mr. NEAL. I would like to know about the evidence that you are 

coming across on that basis. 

Secretary BURWELL. So with regard to the issue that you have 

raised, thank you for raising it. In our budget there are 99 million 

additional dollars to implement an evidence-based strategy on the 

problem. 

Let’s just quickly touch on the problem. When we think about 

the problem, as you articulated, in your district, across the country, 

opioid and overdose deaths have exceeded the number of deaths 

from car accidents or any other accidental death. In the year 2012, 

there were 259 million prescriptions for opioids. That is more than 

one for every adult in the country. 

Mr. NEAL. Would you say that again? How many prescriptions? 

Secretary BURWELL. There were over 250 million prescriptions 

in 2012 for opioids. That is how many prescriptions there were. 

That is more than the number of adults in our country. So that 

was one prescription for every adult in the country in terms of 

where we are in the magnitude of the problem. 

Let’s go to the solution. We have worked and worked with States 

and worked with the Congress. There are a number of bills up on 

36 

the Hill right now. There are three basic areas on which we need 

to focus. 

One is prescribing. A big part of the problem, as you can see 

from that number, is prescribing. What we need to do there is we 

need to provide new prescribing guidelines for pain and pain medication that will help the problem. But also, in the prescribing 

States, States need to do what are called prescription drug monitoring plans. They are almost in all 50 States and they are the 

means by which a physician has the opportunity to look up and see 

that a controlled substance was already given to you, and control 

it that way. It works the same way with pharmacists. So prescribing is number one. 

Number two is the use of naloxone, which is a very important 

drug that actually stops death when there is an overdose, and making sure that first responders have access. That is a very important 

part of that picture. Nick Kristof even had a piece out about it this 

week. 

Number three is the issue of medicated assisted treatment combined with behavioral issues and making sure that we do treatment for those who are addicted. 

So those are the three things. The $99 million additional funding 

in our budget cuts across CDC and SAMHSA as we do this. We are 

doing this in conjunction with States. I have been in Massachusetts 

with your Governor, doing a joint event with your Governor. This 

is a bipartisan, bicameral, and statewide issue, whether it is Governors or both sides of the legislative body and both sides of the 

aisle. And certainly your colleague from Kentucky is leading in this 

effort in the House. 

So that is our plan. That is what we are trying to do. 

Mr. NEAL. And it is noted that in some places in New England heroin is selling for $3.50 a bag on the streets of some of our old 

industrial cities. And I have House bill 1821 that I would invite 

Members to take a hard look at. Senator Markey has a companion 

bill in the Senate. 

What specific actions should Congress be taking along these lines 

to assist you in noting, as you have, that there are now more 

deaths from overdose than from automobiles? 

Secretary BURWELL. So on the heroin point, we know that the 

second two elements, the nonprescribing elements of the strategy, 

we will work on. 

With regard to the places where we believe we need help from 

Congress to implement that strategy, one is in the area of buprenorphine, which is another drug that helps in this, and the question of prescribing. So we believe that that is an important place. 

The second place is in making sure people are trained with the 

guidelines. 

Chairman RYAN. Thank you. 

Dr. Boustany. 

Mr. BOUSTANY. Thank you, Mr. Chairman. 

Welcome, Secretary Burwell. 

Last fall the Administration proposed a child support enforcement rule, and former Chairman Dave Camp, along with Senator 

Hatch, sent a letter expressing concern about this. And the issues 

that were raised were that the Administration in this area was 

37 

usurping the authority of Congress to write law and was, in effect, 

writing law. 

And this has been a repetitive theme. I think Chairman Ryan 

raised this issue with regard to certain issues relating to ObamaCare. But we have seen this with immigration, with ObamaCare, 

other areas of the law, TANF waivers. So why, especially in this 

area where this Committee in a bipartisan way has been willing 

to work with the Administration on these child support policies, 

why does the Administration choose to trample on the Constitution 

and Article I powers in an area where we want to work together? 

I just don’t get it. 

I mean, I understand there is always tension where we disagree. 

I get it. And that is a fight that we are seeing being played out 

in the courts. But why in an instance where we do have willingness 

to work and cooperate on this important issue area? 

Secretary BURWELL. We would look forward to the opportunity 

to work in this space. In terms of that particular rule, there were 

some very important things that I know you are familiar with, the 

fact that some of these things were done in the 1990s. So people 

have to do paper applications with regard to child support. And so 

a lot of the rule was about things like improving the ability to use 

technology and other things, and improvements and simplifications 

to the rule. 

If there are specific policy areas that are of concern, we are listening to those comments that have come in. I think you know we 

have not finalized the rule. And we would welcome the opportunity 

to work on the issues and the substantive areas. 

Some of the things that have been mentioned in the release that 

happened yesterday are in areas where the States have advised 

us—in the State of Texas—in terms of we are following what the 

States have asked us to do in terms of things like using money for 

people to do job training, which is an issue that is important in a 

number of the States. 

Mr. BOUSTANY. Well, Chairman Ryan and I introduced legislation yesterday dealing with this in order to protect our constitutional right to write law. I know there is companion legislation in 

the Senate by Senator Hatch and Senator Cornyn. But we want to 

put the Administration on notice that this body, the legislative 

branch, writes law and that the executive branch executes. And we 

are getting tired of it, especially in an area where we have some 

agreement. Just be put on notice that we are going to continue to 

assert our constitutional prerogative. 

On a different issue, the employer mandate has not been implemented. There are a lot of complications with it. We know how 

complicated it is. We have heard testimony in the past on this. And 

I know it does not apply to small businesses, those with 50 or fewer 

full-time equivalents. But those individuals would still be subject 

to the individual mandate. 

Why has the Administration been reluctant to assist these kinds 

of small businesses? I questioned Secretary Lew when he was before this Committee earlier this year with regard to health reimbursement accounts, and there was a move, I think, for a 6-month 

reprieve on really onerous penalties for small businesses, but 6 

months. I just don’t get it. 

38 

I have legislation that would actually make it more effective for 

small businesses to use these health reimbursement accounts, 

which are completely legal under ACA, but yet for some reason 

your agency and the Administration have decided to close the door 

on these. I don’t get it. Shouldn’t we be helping small businesses 

and their employees at a troubled time? 

Secretary BURWELL. We agree with you and want to try to do 

more. In the budget right now, the budget proposal that is before 

the Congress right now for fiscal year 2016, we actually have proposed expanding the tax credit. It is available for those up to 25 

employees. We want to move it up to 50, to expand the access to 

tax credits that they can get. It sounds like similar kinds of ideas 

in terms of getting folks the access they need to the help they 

need—— 

Mr. BOUSTANY. Well, health reimbursement accounts are very 

effective, and it is a simple solution. 

Chairman RYAN. The time of the gentleman has expired. 

Mr. BOUSTANY. Thank you, Mr. Chairman. 

Chairman RYAN. Mr. Doggett, are you ready? 

Mr. DOGGETT. Thank you, Mr. Chairman. 

Thank you, Secretary Burwell, for being here. 

It seems to me that the focus of this hearing and the focus of all 

of our work should be on how we can make this healthcare system 

work better and deliver services and insure more families instead 

of speculating about some Court decision. 

As you know, Madam Secretary, I have a number of concerns 

about the way this law has been implemented, particularly in 

Texas. I am concerned about the fact that two out of three of our 

Texans who are market eligible for these marketplaces are not yet 

enrolled. 

And I think there are things that your office can do for more effective implementation. I would encourage you strongly to do the 

same kind of cost-benefit analysis that you did at OMB, and that 

is to look at these contractors and see if they are delivering on 

their services. As you know, I have a number of queries to you 

about those. I would hope to focus on how we can make it better 

and how we can make the implementation better. 

But when I hear you accused of being a purse snatcher, it does 

get my attention. You know, the easiest thing for this Court to do, 

and I think the right thing, is to not ignore the other 900 pages 

of the law and focus solely on four words. And if it is necessary to 

have a legislative fix, deleting four words solves the entire problem 

and allows this law to work the way the Congress intended for it 

to work. 

There are many other ways to address this problem, and in fact, 

apparently, some States are beginning to look at the possibility 

that the best way to fix the law, should the Court render the wrong 

decision, is to simply create their own exchange. 

It is also extremely impressive to me that of all the proposals 

that have come in here at the last minute of Republicans to deal 

with the possibility of an adverse Court decision, how many of 

those proposals attempt to include as much of the hated ObamaCare as possible—preserving the right of young people up to age 

39 

26 to participate in their family’s health insurance program, attempting to maintain exchanges and so on. 

If today we are asking you about how to make improvements to 

reach more people in our laws, that would be a reasonable thing, 

instead of the polemics that are going on here. Indeed, I think it 

is probably historic. I could not find another circumstance in which 

Members of the House and Senate ask a court to deny thousands, 

indeed, millions of people across the country an opportunity to get 

a Federal tax credit, to say please deny—in Texas, our two Senators—please deny our constituents $206 million every month in 

Federal tax relief, but let them keep paying taxes to finance the 

same kind of tax credits for people in California. 

Or someone from Wisconsin—since Chairman Ryan joined the 

same brief in the Court—who says, please have my constituents 

continue to pay taxes to fund tax credits in Connecticut, but deny 

thousands of people tax credits in Wisconsin. 

It is an unusual situation, to say the least, that that kind of approach would be taken. 

I believe we need to look for improvements in the law, to 

strengthen the law, but that the idea of denying relief to people 

who are receiving it right now is to take away from them Federal 

tax assistance and to take away from them the opportunity to get 

the insurance that is working for their family. 

To say that it is a lemon to provide families the relief with insurance for preexisting conditions that they never had before, something that is lifesaving in many cases, is truly a misstatement 

about the work of this legislation. Thank you very much. 

Chairman RYAN. Thank you. The time for the gentleman has expired. Mr. Roskam is recognized. 

Mr. ROSKAM. Thank you, Mr. Chairman. Secretary, thanks for 

your time today. There are two issues that I would like to use our 

couple of minutes together on. They are related. It is the discussion 

around cost-sharing reduction payments and then also the basic 

health program. So just to set the table, the cost-sharing reduction 

payments, the issue is whether the Administration has the authority to spend out of an account that hasn’t been appropriated. 

As you know, Chairman Ryan and Chairman Upton wrote to you 

and Secretary Lew on February 3. Your response back at a staff 

level, look, I mean, it was sort of predictable. It restates the obvious in terms of a number of truisms about the Affordable Care Act. 

And then it says go talk to the lawyers at the Department of Justice because there is pending litigation. A little bit of a cute response in my view. But it is your play. Now, where there is no litigation pending and the issue is exactly the same is on the issue 

of basic health programs. So it wouldn’t be satisfactory to say you 

have to check with Justice. Because they are not involved in any 

litigation because there is no litigation between us at this point in 

time. 

So here is my question. The law is really clear that you can’t 

spend money that hasn’t been appropriated. There is no ambiguity 

about that. The Constitution is clear. The GAO states this. Many, 

many, different entities say that money cannot be spent absent an 

appropriation. And, yet, there are a number of States that are anVerDate Sep 11 2014 06:46 Mar 13, 2017 Jkt 022184 PO 00000 Frm 00043 Fmt 6633 Sfmt 6602 I:\WAYS\WAYSPS\22184\22184.XXX 22184
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nouncing that, you know, Minnesota was a State that says they are 

going to be implementing the program. 

New York has announced that they will operate the basic health 

program starting in January of 2016. New York has estimated that 

they will receive $2.5 billion, B, billion. How is this possible since 

the money has never been appropriated? In other words, what 

extra-constitutional authority are you invoking that allows you to 

spend money that has not been appropriated? 

Secretary BURWELL. With regard to the issue of 1311 and 

where that is, I think 1311 is about States that want to choose and 

try to do things in ways that seek flexibility. And that is what we 

try to do is work with States when they do that. 

With regard to the authority, both for the cost-sharing and the 

issue of 1311, in the budget appendix, pages 1046 and 1047, is the 

place where we believe these authorities lie. 

Mr. ROSKAM. But there has been no appropriation, you will acknowledge that, won’t you? 

Secretary BURWELL. With regard to the authorities there, what 

we believe is the authorities for the APTC are the authorities because that is what the money—— 

Mr. ROSKAM. But you are conflating two concepts. You are 

conflating authorization, which I am not arguing with, and appropriation. There has been authorization. But there has been no 

appropriation. So how do you appropriate money that hasn’t been 

appropriated? 

Secretary BURWELL. But programs that are tax credits aren’t 

a part of our discretionary budget every year. In terms of discretionary programs, I mean, the Earned Income Tax Credit, other 

tax programs and tax credits are not a part of the discretionary 

process. 

Mr. ROSKAM. So just to follow up, would you be willing to come 

in and give a briefing to me and also to Chairman Tim Murphy, 

who chairs the Oversight Subcommittee at Energy and Commerce, 

to clear up these things when we have more time together? 

Secretary BURWELL. Congressman, we would look forward to 

the opportunity to try to clear this up and have the right people 

come and discuss these issues. 

Mr. ROSKAM. Thanks very much. I have just one other quick 

point. You mentioned in your opening statement that there was 

$22 billion in fraud savings, which is okay, not great. The problem 

is, and Mr. Lewis and I found this out together, along with all the 

Members of our Subcommittee, Medicare, by Medicare’s own admission, is wasting $1 billion a week, every single week in fraudulent and erroneous payments. 

So $22 billion over the decade is okay. But it is like turning it 

off halfway through the year and then letting 9.5 years go by without doing anything. So I think we really need to up the game. I 

yield back. 

Chairman RYAN. Thank you. Mr. Thompson. 

Mr. THOMPSON. Thank you, Mr. Chairman. Thank you for having the hearing. And thanks for helping to subsidize my California 

constituents and their health care. I appreciate that. 

Madam Secretary, thank you very much for coming out. I just 

want to say that I hear a lot from my constituents as well about 

41 

the ACA. I hear from people who are pleased that the preexisting 

conditions is no longer an issue for them, that their 26-year-old can 

stay on their policy, that they have access to quality preventive 

care, which I know for a fact will save us all money in the long 

run. But I also hear them say that they recognize there are problems with the ACA. And they want us to work together to fix those 

problems. 

I don’t know how it could be a lot different than in other parts 

of the country. My experience has been that folks want access to 

quality affordable health care. And we do have a responsibility to 

figure out how to make that happen. And I appreciate your effort 

in that regard. 

So I am all for fixing, making tweaks, making adjustments. Congresswoman Black and I are going to introduce legislation today, 

as a matter of fact, that falls into that category of making a tweak, 

making a fix. And we are going to introduce a bill that would ease 

the reporting requirements for employers offering coverage for their 

employees. And it would require that the exchanges use the most 

recent tax data to ensure that individuals and families will not 

have a large tax bill at the end of the year. 

As I am sure you know, Covered California in my home State of 

California, requires that the most recent tax data be used. And it 

has worked well. It has been beneficial. I am just wondering if you 

have any thoughts on requiring the more recent tax data to determine eligibility for subsidies, especially for auto renewals, and 

making that apply to all the exchanges? 

Secretary BURWELL. I think it is in our interest. And what we 

want to seek to do is get the most up-to-date information that we 

can possibly have which is why we encourage people to come in and 

update throughout the year. And we continue to do that. 

With regard to the specifics of this piece, I think we would have 

to look at the legislation. I am not sure if it sits with Treasury or 

with us. But we would work together to understand. Because I 

think what we want is actually to have the most up-to-date information. And that information for some people is an evolving and 

changing piece of information. For those who are self-employed, 

their incomes change throughout the year. And we do have means 

by which they can come in and update it. And we try to encourage 

them to do that. 

So, the most up-to-date information that we can implement is 

something that we do support. And so with regard to the specifics 

of the legislation, we would like to have the opportunity to look at 

it and understand between us and Treasury where we could be. 

Mr. THOMPSON. Thank you. I also had some questions regarding the RACs and the appeal process that I understand from your 

staff we are going to work together outside of the Committee hearing to deal with. So I appreciate that commitment. I am assuming 

it is shared by you. 

Secretary BURWELL. Yes, it is. And I would also use this just 

as an opportunity again to mention the piece of bipartisan legislation that Senate Finance just passed this past week on this issue, 

in terms of the strategic approach to help us get to a place where 

we can reduce that backlog of appeals. There are administrative 

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ator Hatch and Mr. Wyden have led an effort on that side. We are 

hopeful we can work with all of you too. 

Mr. THOMPSON. Great. And then Mr. Boustany had some questions about the HRAs. And we are working together on that legislation. I hope that we can have the help of your agency in making 

sure that this is the best legislation possible. 

Chairman RYAN. Thank you. 

Secretary BURWELL. We will work with you. 

Mr. THOMPSON. Thank you. I yield back. 

Chairman RYAN. Dr. Price is recognized. 

Mr. PRICE. Thank you, Mr. Chair. Madam Secretary, with respect, many of us here and many across the land sincerely believe 

that the principles that you outlined that all of us hold dear, accessibility, and affordability, and quality are all being harmed by the 

current path that we are on. 

And I want to highlight some of the problems in the system that 

are, I believe, we believe, harming patients and in many cases destroying the ability of those working as hard as they can to care 

for those patients. One of them is the Electronic Health Record and 

Meaningful Use. 

CMS is now dictating to physicians what must be documented 

and how it must be documented, without regard to what is truly 

important and necessary for taking care of patients. It is wasting 

money. It is wasting time. It is wasting resources. And, sadly, it 

is wasting the expertise of physicians, leading to further disgust on 

the part of physicians, many leaving practice. In fact, I know two 

individuals who said this was the last straw and they quit, at an 

age where they could be able to practice for years and years. 

There are positive solutions if we allow for flexibility and respect 

to those providing the care. ICD–10 is another example of CMS 

making it more difficult for physicians to care for patients. In some 

cases, in small and rural practices, as we have discussed, it will 

drive physicians out of business. So access is destroyed for those 

patients in those areas. 

The United States inappropriately combines and confuses clinical 

data, that is what is happening medically with a patient, with billing data, under the guise of wanting more information and saying 

that everybody else in the world is doing it. Well, the fact is that 

the United States will be the only country to use all 87,000 codes, 

the only country to use it in an outpatient setting, the only country 

to use it in a billing process, and the only country to put the cost 

on the shoulders of the physicians and those providing the care. 

This happens on October 1. If past is prologue, sadly, it holds real 

potential to be a significant disaster, further harming doctors and 

patients. I urge, I urge CMS to delay any penalty for coding errors 

for at least 2 years. It is only reasonable given the magnitude of 

the change coming. 

Durable medical equipment and a caring provider is oftentimes 

the only thing that stands between a patient’s quality of life and 

hospitalization or illness, exacerbation, or even death in the instance of the provision of oxygen. Yet, CMS has put in place a 

system of what they call competitive bidding, what you call competitive bidding. It doesn’t work. It is harming patients. And it is 

driving folks who have been wonderfully providing care and service 

43 

in communities all across this Nation out of business, further 

harming those patients. I urge, I plead with CMS to allow, at least 

allow a pilot demonstration to show there is a much better way to 

save money and also provide services to patients. 

Sadly, Madam Secretary, the President continues to shamelessly 

condemn and attack those standing up for patient-centered health 

care. As recently as yesterday, he ignored reality and cynically 

mocked those striving for positive solutions. We know that he has 

a pen and a phone. What he doesn’t seem to have is the knowledge 

or the humility or the concern or the desire to work together on behalf of those struggling to provide care and those receiving the 

care. 

Madam Secretary, I urge you, I urge you and your team to join 

with us in an open-minded way to end the oppression of meaningful use, to provide for flexibility with ICD–10 so that more practices aren’t destroyed, to allow for a pilot program to demonstrate 

that competitive bidding is hurting patients and that there is a 

much better way, and to give physicians the freedom to care for patients. 

If you are sincere in your desire for accessibility and affordability 

and quality, that would lead to your action working with us. And 

I look forward to that and hope that we will be able to move in a 

positive direction. Mr. Chairman, I yield back. 

Chairman RYAN. Thank you. Mr. Larson. 

Mr. LARSON. Thank you, Mr. Chairman. And thank you, 

Madam Secretary, thank you for your service. Hailing from the 

great State of Connecticut, we are so proud of the advances of the 

Affordable Care Act. And it is great to have a Governor that is 

hands on in terms of its implementation and all the progress that 

we know that has been made and will continue to be made under 

this Act. 

Mr. Chairman, I would like to submit for the record a 28-page 

report entitled ‘‘The Language of Healthcare 2009,’’ by Frank 

Luntz. Mr. Chairman, is there an objection? 

Chairman RYAN. No objection. 

[The submission of The Honorable John Larson follows:] 

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Mr. LARSON. No objection. And I think that, I have a great deal 

of respect for Mr. Luntz as well. He and Stan Greenberg, another 

pollster and someone who spends an awful lot of time on the 

science of language, in looking at, in detail, what people should say 

around subject matter areas, have studied this debate. Now, this 

is particularly of interest to me because it passed, you know, this 

was recommended in 2009. And, basically, Mr. Luntz describes the 

10 rules for stopping the Washington takeover of health care. And 

it is informative even to this debate today. 

For example, one of the things he says, that arguments against 

the Democratic healthcare plan must center around politicians, bureaucrats, and Washington, not free markets, tax incentives, or 

competition, is interesting. So we will hear a lot on that. It also 

goes on to underscore, you simply must be vocal and passionate on 

the side of the reform. The status quo is no longer acceptable. If 

the dynamic becomes President Obama is on the side of reform and 

Republicans are against it, then the battle is lost and every word 

of this 30-page document is useless. 

He goes on to say this, and this is the whole point, it is not 

enough just to say what you are against. You have to tell them 

what you are for. It is okay and even necessary for your campaign 

to center around why this healthcare plan is bad for America. But 

if you offer no vision for what is better for America, then you will 

be relegated to insignificance at best and labeled obstructionist at 

worst. What Americans are looking for in health care is what your 

solution is, what it will provide. The words of more access, more 

treatments, and more doctors are sure winners. I agree with Mr. 

Luntz there. And that is what this subject should be about, for us 

providing more access. 

Madam Secretary, may I ask you, are you aware of any Republican legislative proposals that reduce the number of uninsured in 

this country by more than 60 million and make sure that we continue to provide all the benefits of addressing preexisting conditions, keeping your children on the plan, and making sure we focus 

on prevention? 

Secretary BURWELL. I have not seen a proposal that does 

that. 

Mr. LARSON. I thank you, Madam Secretary. And with that, 

submitting this full report for the record, I think it is worth 

everybody’s reading. And we ought to get back to what this Committee should be doing. And that is to put Americans first and put 

Americans on the road to having the best access, more access, more 

accessibility, and more availability to health care. Thank you. 

Chairman RYAN. Thank you. Time for the gentleman has expired. We are now going to enter into the two-to-one phase, two on 

our side, one on the Democrats side, to keep it equal. Mr. Buchanan. 

Mr. BUCHANAN. Thank you, Mr. Chairman. And thank you, 

Madam Secretary. I appreciate you taking the time this week to 

give us a call, give me a call and make time for a chance to visit. 

My biggest concern, you made four points. At the top of the list, 

I was Chairman of the Florida Chamber. We had 137,000 businesses we represented. Most of them were 50 employees or less. So 

we have a lot of small businesses. But the biggest issue, and it is 

before the ACA, it goes back 15 years, is affordability. And there 

73 

was an expectation or hope that we could bend the curve on affordability. There is no question people who get the subsidies, they benefit. There are over a million in Florida. But there are many just 

above that line, the poverty line that don’t get the subsidies. 

And I want to talk on two bases first. Small business, their cost 

of trying to provide health care has gone up 20 to 30 percent in 

the last 3 or 4 years. I just talked to another person the other day 

who has 130 employees, and it went up 30 percent. But throughout 

Florida, throughout our region, we are not seeing any reduction or 

anything in terms of affordability from that standpoint. And many 

times, last week we had a town hall meeting, we had one woman, 

or a couple weeks ago, we had one woman who said it cost $2,000 

a month to get health care. She can get it for less. But then she 

has to pay some kind of a $10,000 penalty in terms of her health 

care if she has a claim. What is your thought on the affordability, 

where we are at as it relates to people who don’t get subsidies? 

Secretary BURWELL. When we think about the affordability, I 

think we think that some progress has been made. And as you appropriately reflect, what we were seeing before is we were seeing 

rising deductibles and we were seeing growth. And we have seen 

a slowdown in the premiums. The things that we have seen slow 

down, is we have seen a slowdown in premium growth across a 

number of categories. We have also seen Medicare savings that I 

mentioned earlier, over $300 billion in terms of where we are in 

our Medicare pricing. 

The other thing that is indicative is that we have seen the per 

capita healthcare costs grow. As a Nation, because we have so 

many people retiring and coming into Medicare, the overall costs 

of health care are probably going to go up because we have more 

elderly. So we do focus deeply on that per capita—— 

Mr. BUCHANAN. Well let me just mention, because we are short 

on time, we are not seeing the discounts, per se. I would love to 

have you come to Florida and talk to a lot of small businesspeople. 

We are not seeing those. We are not seeing any kind of discounts. 

Most of it is 20 to 30 percent increases. In the last couple of years, 

they were hopeful but they are not seeing it. And then, unfortunately, a lot of the costs get pushed to the employee. 

Secretary BURWELL. That is right. 

Mr. BUCHANAN. And so, many of the employees that were 

maybe picking up a couple hundred bucks a month, now they are 

paying $500 to $600 out of their pocket. If they don’t get a subsidy, 

many of them are being gutted. We like to talk up here a lot about 

the middle class. But this is, a lot of this is putting the middle 

class at risk in terms of healthcare costs. And what is your 

thoughts on that? 

Secretary BURWELL. I think this is why one of the things we 

need to focus on now deeply is delivery system reform. And that 

is the idea of better, smarter, healthier. And by that, it is both 

about quality and I think we have to be careful when we talk about 

this topic because people hear it and we need to make sure we preserve quality and improve quality. Why in our country do we have 

some of the lowest levels of quality offerings for health care? It is 

about improving quality and affordability. 

74 

And right now, one of the things that we did, in January we committed that the Federal Government, that Medicare payments, 30 

percent of them by 2016, 50 percent by 2018 will be based on value 

instead of volume as a part of working on this overall issue. Because we want to hear what you are hearing and that is important 

to us. And so that is a part of why we think this is so important. 

Mr. BUCHANAN. Let me close with the idea, because I have a 

few seconds, I hope we can focus more on affordability, all of us. 

Because it is bankrupting a lot of people that don’t get subsidies. 

That is the reality in Florida for small business and individuals. So 

the focus needs to be on affordability, finding a way to bend the 

curve on healthcare costs. Thank you, Madam Secretary. 

Secretary BURWELL. We look forward to the opportunity to 

actually work with you on some of these delivery system reform 

issues. 

Chairman RYAN. Thank you. Mr. Smith. 

Mr. SMITH OF NEBRASKA. Thank you, Mr. Chairman. And 

thank you, Madam Secretary, for being here today. There is limited 

time and a lot to cover here. As you know, as we spoke earlier 

about the consumer operated and oriented plan programs which 

were the alternative to the public option, I would argue, perhaps, 

these are somewhat quasi-public options, intended to be low-cost, 

government-subsidized healthcare plans. And to date, I believe 

HHS has awarded $2 billion in Federal loans to establish the 

plans. 

One plan, as you know, CoOpportunity, which served over 

100,000 people in Nebraska and Iowa, was seized by the State of 

Iowa and has since been liquidated. Folks who were on the plan 

have been left confused and frustrated and, again, looking for other 

plans. And I sent a letter on January 23 asking specific questions. 

I did receive a response on May 21. I would like to request unanimous consent to submit both of these letters for the record. 

Chairman RYAN. Without objection. 

[The submission of The Honorable Adrian Smith follows:] 

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Mr. SMITH OF NEBRASKA. Thank you. Now, quickly some questions. CoOpportunity received approximately $146 million in 

Federal loans. Will any of those dollars be paid back to the Federal 

Government? 

Secretary BURWELL. With regard to that, that is a question I 

will follow up on. 

Mr. SMITH OF NEBRASKA. Okay. I appreciate that. 

My understanding is Iowa and Nebraska were told they could not 

suspend enrollment within CoOpportunity and have it remain a 

qualified health plan. Yet, Tennessee was later allowed to do so. Do 

you know why that policy changed? 

Secretary BURWELL. So, per our conversation, I actually did follow up with CMS. And we didn’t have the record of that request 

in any way coming in. So I would love for our team to be able to 

follow up and understand if there was miscommunication. Because, 

based on your comment, it was something that was concerning to 

me when you mentioned it. And I went and followed up. So if we 

can work with your staff to understand what your staff understands happened, that would be helpful. 

Mr. SMITH OF NEBRASKA. Okay. Recent reports claim only 

one co-op didn’t have an operating loss in 2014. Is that accurate? 

Secretary BURWELL. I would have to go co-op by co-op. 

Mr. SMITH OF NEBRASKA. Okay. Are there any concerns 

about possible liquidation of any of the other plans in the near future or not so distant future? 

Secretary BURWELL. With regard to the co-ops, because they 

are all new businesses, they are start-ups, like the small businesses that we were just talking about before, you know, we are 

going to have failures in terms of the co-op system. That was a part 

of what was set up in terms of the original $5 billion that the Congress gave, but then through sequester and other means went to 

$1 billion. 

So I think that there will be co-ops that will have challenges and 

issues. I think we are working closely with the States and State 

insurance departments to make sure that we get in front of them 

and do the kinds of things that we attempted to do in the CoOpportunity situation, which was make sure as much as possible and 

where it was appropriate we would engage in supporting communication, offering a special enrollment period, and working with the 

State insurers to use our and any authorities we had to make sure 

that those consumers were taken care of. 

Mr. SMITH OF NEBRASKA. Okay. Will any of the consumers 

who lost coverage from the failed co-op be penalized by the individual mandate? 

Secretary BURWELL. I do not know how many are not still in 

the system. But I will check and will follow up on that. My understanding is no, but I want to confirm that before—— 

Mr. SMITH OF NEBRASKA. In that vein, I have introduced 

H.R. 954, which would exempt anyone who has lost health insurance from the failed co-ops from the individual mandate. Could the 

Administration support that approach and that piece of legislation? 

Secretary BURWELL. What I would love to do is have the opportunity to see if that is something that has already happened or not 

and then review the bill. 

81 

Mr. SMITH OF NEBRASKA. Okay. Now, in the bigger picture 

of obviously large sums of money being offered to these consumeroperated and oriented programs, what is the likelihood of those dollars being paid back? 

Secretary BURWELL. With regard to the loans that have gone 

out? 

Mr. SMITH OF NEBRASKA. Correct. 

Secretary BURWELL. I think with regard to a number of the coops, that will happen in terms of the successful co-ops and those 

that are gaining traction and working. As I said, there may be 

some that are not. And we will get back to you on that specific 

question. 

Mr. SMITH OF NEBRASKA. It seems to me also that the various States relevant to this issue might have a different approach 

for paying the claims that were submitted by—how on top of this 

are we? Because it is, in Nebraska, there is a fall back and, yet, 

it hurts more people. I apologize. My time has expired. 

Secretary BURWELL. State insurance law, as you know, is a big 

part of how that gets determined. But we try to work with and support the States with different options. 

Chairman RYAN. The time for the gentleman has expired. Mr. 

Blumenauer. 

Mr. BLUMENAUER. Thank you, Mr. Chairman. Madam Secretary, I appreciate your reluctance to deal with hypothetical legislation that hasn’t yet been written to deal with a legal decision 

that hasn’t yet been rendered. I think that is prudent. But if this 

occurrence takes place by the Court, it seems to me that it would 

not be rocket science, as some of my colleagues have mentioned, to 

make relatively minor changes, to conform statutes to the intent 

and text of the bill and move forward. I think the Committee could 

take one weekend and fix it and move on. 

I would like to shift gears slightly. We have had an ongoing series of conversations, it has been 6 years since a provision I authored was approved unanimously by this Committee, not just by 

part of it, unanimously by this Committee, dealing with end-of-life 

care. That provision, despite a kerfuffle and certain rhetorical 

flourishes, remained in the legislation. Unfortunately, it fell victim 

to the reconciliation process. And 6 years later, we are still trying 

to achieve those objectives. 

Although the world has moved on, in a best-selling book by Atul 

Gawande, Bill Frist, and Billy Graham, all agree that this is necessary. You recently received a letter from 65 notable national organizations calling on you to have Medicare reimbursement for advanced care planning. As you know, the AMA did the coding. It is 

all teed up, ready to go. We thought the Administration was going 

to be there. And, yet, it lingers. 

Published, peer-reviewed research shows that advance care planning leads to better care, better patient and family outcomes, fewer 

unwanted hospitalizations. The list, as you personally know, is 

compelling for this service. Is the Administration prepared to finally move forward and authorize it? 

Secretary BURWELL. With regard to this, as I think you just 

mentioned, the AMA has given us the guidance and the coding. 

And we are in the process of reviewing that. As we indicated in a 

82 

recent rulemaking, indicated in our preamble, that is something 

that we are working on and reviewing the current coding. 

Mr. BLUMENAUER. So it has been 6 years since Congress embraced it. The Committee approved it unanimously. We have had 

the research clear, the IOM dying in America. I am trying to understand what it is that is so hard to figure out whether or not this 

is part of the legacy of the Obama Administration, which has done 

some good things with health care. This seems to be a really terrific thing that is really simple, that would make a huge difference 

in people’s lives. Private insurance is moving. What is it that is 

hanging this up? Why can’t we just get to yes? 

Secretary BURWELL. Congressman, as we have said and in our 

conversations and our team’s conversations with you, this is an 

issue we are going to continue to work on. Because we want to 

make sure if we move that we do make the progress that we would 

intend to make. 

Mr. BLUMENAUER. Well, I find it mystifying that the rest of 

the world is aligned. This is one of the few things that this Committee agreed to unanimously and that we see the difference it 

makes in human lives. And the Administration continues to study. 

And I really hope that this could be part of the legacy and that it 

is part of the 2016 reimbursement. 

I find it frustrating beyond my ability to express. I am happy to 

walk, I have walked the plank for this Administration on things before. And this is really troubling. 

Chairman RYAN. Thank you. Time for the gentleman has expired. Ms. Jenkins. 

Ms. JENKINS. Thank you, Mr. Chairman. And thank you, 

Madam Secretary, for being here today. I want to echo the comments of Chairman Ryan and others on the Committee regarding 

the Supreme Court’s decision later this month on the constitutionality of this President’s healthcare law. Many Kansans are 

poised to lose their subsidies, which is the only thing that makes 

their insurance somewhat affordable. Many of my constituents will 

be facing increases over 30 percent next year, which, in addition to 

the loss of their subsidies, will make their insurance unaffordable. 

And I am extremely frustrated because I had an exchange with 

your predecessor, Secretary Sebelius, 3 years ago on February 28, 

2012, when she was a witness here before the Committee. And on 

that day, I expressed my concern that I did not see anything in the 

President’s healthcare law that would allow Federal subsidies to 

flow through non-State-based exchanges. And I told her the Administration didn’t have the authority to allow these subsidies to flow 

through federally-facilitated exchanges, even though the IRS at 

the time was telling Congress that the distinction didn’t matter. 

Because in the law, there is no mention of the term federallyfacilitated exchanges. 

Even though Secretary Sebelius promised me that HHS would 

give me a detailed answer in writing defending her interpretation 

of the law, she never did. And, obviously, this issue didn’t go away. 

And now the Supreme Court will finally weigh in on it. And I am 

equally concerned when you suggest that the decision before the 

Supreme Court is just about the subsidies. Because it isn’t. We 

have research here from the American Action Forum which talks 

83 

about all of the positive outcomes from a decision by the Supreme 

Court against the Administration. Over 11 million individuals freed 

from the individual mandate, over 260,000 businesses freed from 

the employer mandate, hundreds of thousands of new jobs, 1.2 million workers added to the labor force. 

With limited time, what I would like to do is turn my attention 

to a different topic. I have introduced legislation the past 3 years, 

along with my colleague, Representative Kind from Wisconsin, to 

repeal a provision in the healthcare law that allows folks to go to 

their doctor to get a note in order to purchase over-the-counter 

medicines with their HSAs or FSAs. And this presents patients 

with a maze of government redtape that they must navigate in 

order to purchase over-the-counter medicines, whose use saves the 

healthcare system money. 

Additionally, it presents physicians with the bizarre scenario of 

unnecessarily seeing patients in order to prescribe over-the-counter 

pain relievers or allergy medicines. This provision makes care less 

affordable, more confusing, clogs doctors’ offices, and makes patients less likely to use over-the-counter medicines. So, Madam Secretary, I was just wondering if you think that this is good policy 

and if you would support us in repealing this provision? 

Secretary BURWELL. As I have articulated, one of the things we 

are focused on is this idea of how we can improve quality and move 

toward affordability. The specific piece of legislation, I am sorry, I 

am not familiar with, I am not familiar in terms of the issue that 

I think you are trying to resolve. And so this is one I would want 

to understand. I also do want to return to where you began. 

Ms. JENKINS. Okay. But, in theory, would you support this if 

we could convince the Chairman to mark up the bill and move it 

over to the Senate? We have done that once. It has already passed 

with bipartisan support out of this Committee and out of the House 

once before. 

Secretary BURWELL. Congresswoman, I would want to look at 

the substance of the issue before I could comment specifically on 

that. It is not one, I am sorry, I am familiar with. 

Ms. JENKINS. Okay. All right. Thank you, I yield back. 

Chairman RYAN. Thank you so much. Mr. Paulsen. 

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

thanks for being here. In the limited amount of time, I want to address a couple of things. In Minnesota, unlike many States, we had 

a pretty low uninsured rate prior to the President’s healthcare law 

kicking into effect. You know, we had a high-risk pool for people 

who had preexisting conditions. It has been in existence since 1976. 

And it certainly wasn’t perfect but it worked pretty well. That 

high-risk pool was closed to make way for the new State exchange 

program that was set up. 

And now a lot of the headlines, similar to what we have heard 

from some of our colleagues and concerns about premiums rising, 

headlines over the last few weeks in Minnesota that have appeared 

in some of our papers, show the experience under the new exchange and the President’s healthcare law has been affecting their 

pocketbooks, right? And so it got here, you know, eight Minnesota 

healthcare plans propose premium hikes from 11 to 74 percent. 

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We have another story here, Blue Cross and Blue Shield of Minnesota, which is the largest insurer in the individual market, which 

you mentioned earlier about the individual market, having the 

marketplace work, they announced proposed average increases of 

54 percent. So certainly this is a pocketbook issue for families, for 

individuals, for small businesses alike. And that is why I really do 

hope, regardless of the court decision and how that goes, that we 

will be able to work with the Administration on addressing some 

of these affordability costs. Because I think when you are talking 

about premiums, this goes to the heart of affordability, as opposed 

to talking about, you know, per capita healthcare costs being lowered in Medicare and other areas like that. 

So just some commentary there, that I hope that cooperation will 

be coming forward. Because we need that. We need that on a host 

of issues if we are going to solve some of the challenges rather than 

just digging in and just protecting every provision of the law as it 

is intact right now. And I will just mention this. You know, my interest with medical devices and medical technology, which we 

talked about last week, is very important in my State. And America has been a leader in developing these technologies and cures. 

And innovation happens at a really rapid pace. But often the regulatory process does not keep pace. And I don’t think it is acceptable 

that American-made technology is available to citizens in other 

countries and it is not available to our patients here at home. 

And the number one concern that I hear now from patient 

groups, from doctors, from investors in new med-tech companies, 

from manufacturers isn’t the FDA. The biggest hurdle they now 

face is CMS and the lack of certainty surrounding coverage and 

coding and reimbursement. And these decisions take 2 or 3 years. 

And that is after the devices have already been approved. And they 

have already been approved. And this creates a lot of uncertainty 

for manufacturers and doctors that want to utilize the best available technology for their patients. 

So I guess my question is, you know, what can HHS do to oversee CMS, right, which is under your authority, to make sure that 

we are bringing certainty to the coverage, to the coding, and to the 

reimbursement process for medical technology that, quite honestly, 

can lead to less invasive procedures and a whole host of areas of 

health care that can actually save money? It is definitely an impediment right now. 

Secretary BURWELL. On the issue of the DME and CMS, we 

want to continue to work and would like to work. What we are trying to do is get that balance between making sure, we have all 

talked a lot about healthcare costs and growing healthcare costs, 

so making sure that the evidence-based decisions in terms of CMS 

saying they will pay for it. 

FDA determines its safety. And then CMS determines if we will 

pay, if, you know, the benefits are such that it should be a part of 

a payment scheme. And we will continue to move things through 

quickly. But we will also continue to try to figure out the ways that 

we balance it. If there are places and things that people, that you 

have ideas about faster, that is something that we would welcome 

in terms of what you are hearing from the companies. 

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The other thing I think it is important to touch on is the premium issue. What has been in the news recently is actually a part 

of the ACA’s effort to make sure that we have transparency and 

downward pressure on premiums. What has been in the news recently is any premium increase that is above 10 percent has to be 

reviewed. It has to be reviewed by State insurers. And so what you 

are seeing in the space right now in many of the articles, I am not 

sure of all the headlines you read, but a number of those headlines 

are about the fact that these are now their first submission. And 

last year we saw this come down because the review process works. 

Because there are conversations like this in public, that it creates 

downward pressure on those premium increases. 

So it is a part of the process. And it doesn’t reflect the whole 

base. Most insurers are saying that the majority of their people 

that they think will enroll next year in 2016 will have premium increases less than 10 percent. So we agree with you on the importance of that downward pressure. 

Chairman RYAN. Thank you. Mr. Kind. 

Mr. KIND. Thank you, Mr. Chairman. Madam Secretary, thank 

you for being here. Obviously, there is a lot of attention and focus 

on King v. Burwell and where that Court ultimately comes down. 

But in your opinion, how quickly or easily could this Congress, if 

it wanted to, enact legislation language to fix that overnight if it 

is an adverse decision from the Supreme Court? 

Secretary BURWELL. I think I would hesitate to say how 

quickly the Congress could act. 

Mr. KIND. Assuming there is a willingness. 

Secretary BURWELL. But I think the question of, the issue, if 

it is ruled that it is about the subsidy, that that is a relatively simple solution that one can do legislatively with regard to subsidies 

for those that are in the Federal marketplace. 

Mr. KIND. I come from a State, Wisconsin, I am very proud of, 

but I have never seen a greater act of fiscal malpractice by the current Governor than what has been perpetrated the last few years 

in his denial of the Medicaid expansion money. And his budget this 

year is proposing over $300 million of cuts to our university system. But if he took the Medicaid expansion money over the next 

2 years, that would bring into the State $350 million over the next 

2 years. 

It just seems to be basic math. And his denial of that is not only 

denying people who are tough to cover to begin with, but also denying getting that money into the State where it can do some good 

in Wisconsin. I know you especially and HHS have been working 

very closely with many other Republican Governors throughout the 

Nation to figure out a path forward on waivers, and modifications, 

and other things. I would encourage you to continue those lines of 

communication. Because we need help in Wisconsin. 

He also rejected the ability for us to form our own exchange. So 

we are in that box right now looking at the Supreme Court. And 

we could have done it the Wisconsin way and created our own 

health insurance exchange. He chose not to. So if we do get an adverse decision, 166,000 Wisconsonites would lose their premium tax 

credits. And my guess is insurance then would be rendered 

unaffordable to them too. So there is a lot riding on this decision. 

86 

And, hopefully, you will be able to continue to work with the States 

and convince them to do the right thing, especially in Wisconsin 

where we need help. But I also appreciate your focus, your sustained focus not only on delivery system reform, but payment reform, getting to a quality-based reimbursement system. 

And I agree with my colleague, Mr. Buchanan, that more needs 

to be paid to cost containment. And there is some good news. You 

have set up the new network on quality collaboration throughout 

the Nation. And I hail from the land of integration, coordination, 

quality measurements, best practices, value-based medicine and so 

forth. But in your estimation, how quickly can we pivot now from 

fee-for-service volume to a quality-based reimbursement system? 

Secretary BURWELL. When one considers that Medicare dollars 

are a large portion, we believe that we can move to 50 percent by 

2018. The goal for 2016, being 30 percent, was where we started 

out. Because, obviously, I won’t be here, we needed to set a goal, 

an achievement that would be there while we serve out. So we 

think that you can get to 50 percent of Medicare, at the point at 

which 50 percent of Medicare is based on value. And what we are 

trying to do is make that pass by this network. So I am meeting 

with the insurance, the CEOs, as well as CEOs of companies, because those are the other payers. 

In New York State, Medicaid has committed to doing the same 

thing we are. So I think the path that we have Medicare on is close 

to the trajectory for the Nation in terms of moving toward more 

value-based—— 

Mr. KIND. You mentioned New York. Why do you think more 

States aren’t taking up this challenge and converting Medicaid to 

that type of payment system too? 

Secretary BURWELL. I think that more States are interested. 

And in our conversations with States, I think a number of States 

are not wanting to have the public commitment. And so a number 

of States are a part of that network. 

And across all States, I can look around and have talked to Governors from a number of your States that are willing and thinking 

about this because they believe getting the value-based payments 

in Medicaid, which is a large expense for the States, is a very important thing. So I think there are more States that are interested 

but are not at the point of public commitment. 

Mr. KIND. Thank you. Thank you, Mr. Chairman. 

Chairman RYAN. Thank you. We are now going to move to 3 

minutes per person in order to try to fit in as many people as possible. Mr. Marchant. 

Mr. MARCHANT. Thank you, Mr. Chairman. Secretary Burwell, 

in the period of time in which the Affordable Care Act was being 

adopted, probably the most unpopular aspect of it and most debated in my district were the IPAB panels. Many names were 

given to those panels. And then last week, I think, I was able to 

cast a vote publicly that would abolish that panel. Yet, there is talk 

about strengthening the panel. There is talk about expanding the 

panel. Could you give us an explanation of what this talk is all 

about and what the purpose of it is? 

Secretary BURWELL. With regard to the changes in our budget 

around IPAB, it is to strengthen and increase the Medicare savVerDate Sep 11 2014 06:46 Mar 13, 2017 Jkt 022184 PO 00000 Frm 00090 Fmt 6633 Sfmt 6602 I:\WAYS\WAYSPS\22184\22184.XXX 22184
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ings. Because as we have all discussed, healthcare costs and the 

issue of healthcare costs, Medicare being a core element of that, are 

very important. What we are hopeful of, and in the budget, the $423 billion of 

Medicare savings that is specific in specific ways, that we can all 

have a discussion about, I know there are those who disagree with 

us about the balance we have of provider and beneficiary approaches to getting that money. But I think what we believe is that 

IPAB as a tool, and a tool that the Congress would still engage 

with, because you all would approve anything that was suggested 

by IPAB, Congress would have the opportunity to give it a thumbs 

up or a thumbs down, is an important tool to keep the pressure on 

all of us. 

Because I think we all know, Medicare expenditure is a tough 

issue. It is a very tough issue for everyone in terms of, even the 

issues we are talking about, about payments for DME or other 

things, that is what drives those costs upward. And so we believe 

it is a tool in the toolbox. We actually, in our budget, are depending 

though on specific issues that the Congress could review. 

And right now, IPAB would not kick in, in the President’s budget 

it would be 2019. If you don’t do any of the changes that we would 

do, it would be 2022. And that obviously is in another Administration. 

Mr. MARCHANT. And so why has the President not named anyone to the panel? 

Secretary BURWELL. With regard to the issue of panel members, it is something that we believe we should do in consultation 

with the Congress. And so that has been a place and I think it is 

because, as you were expressing, making sure if you were going to 

name a panel, there is appropriate congressional input. 

And the other thing is at this point, now that we see the numbers, and we have made improvements in terms of the Trust 

Fund’s viability over, you know, increased by many years, the need 

is not for now. And it would be in another Administration. So the 

question of us naming the panel now—— 

Mr. MARCHANT. So the President will not name a panel in his 

Administration? 

Secretary BURWELL. At this point, with regard to where we are 

in the budget, we have not yet done it. 

Chairman RYAN. The time of the gentleman has expired. Mrs. 

Black. 

Mrs. BLACK. Thank you, Mr. Chairman. And thank you for 

being here, Secretary Burwell. Mr. Chairman, I ask unanimous 

consent to insert this report from the Treasury Inspector for Tax 

Administration in the record. 

Chairman RYAN. Without objection. 

[The submission of The Honorable Diane Black follows:] 

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Mrs. BLACK. The Affordable Care Act requires the exchanges to 

determine if applicants were offered health insurance by their employer. And if they were offered that comprehensive and affordable 

coverage, then those individuals are not eligible for the premium 

tax credit. 

The Treasury Inspector General recently reported in this report, 

stated that neither the Federal nor the State exchanges were able 

to verify most individuals’ attestation that they were not offered 

health insurance by their employer. And this is happening despite 

the fact that the burden and the costly reporting requirements 

have been placed upon our employers. What is it that HHS is doing 

to ensure that people who receive these credits actually legally are 

eligible for them? 

Secretary BURWELL. So much of our, this is the APTC that you 

are referring to, correct? 

Mrs. BLACK. That is right. 

Secretary BURWELL. So with regard to that, we have a data 

matching process that we are doing. And it checks both immigration status, as well as income status. And that is one of the processes we are doing to make sure that people who are eligible, and 

we release numbers, I think you probably saw last week where 

over 100,000 people came off the rolls because we weren’t able to 

verify the information. 

And so that is a process, it is a process last year that took a 

longer period of time. And now we have improved to a 90-day period of time. 

Mrs. BLACK. So let me quickly go to the other part of this which 

involves the IRS. Because in their application, that is the individual’s application for this coverage, individuals are asked if their 

employer offered them health insurance. And the exchanges then 

are required to provide the applicant’s response to this question 

along with the information related to the employer to the IRS in 

a monthly data report. 

The Treasury found that neither the CMS nor many of the State 

exchanges were able to submit this information until well after the 

2015 filing season was complete. So it appears that two of those 

State exchanges have still not provided that required information. 

This is just one example of the numerous delays from CMS when 

it comes to Obamacare. 

So healthcare.gov alone took over $1 billion to build. And yet it 

is apparent that these systems are still not fully functioning based 

on this report. So CMS undertook this mammoth project without 

effectively planning for the development or the oversight. And this 

has led to hundreds of millions of dollars, these are taxpayer dollars, that are being wasted. 

So my question is, can you outline the oversight that is being 

conducted to ensure that the legal requirements that were set up 

by the law are actually met and the systems are properly developed 

to protect our taxpayer dollars? 

Secretary BURWELL. Congresswoman, I want to check because 

this report, I think, as you all probably know, there have been over 

50 audits of the Affordable Care Act, and I want to make sure that 

I am focused on the right one. 

116 

With regard to the one you are speaking about, if it is the one 

that I think it is, we are now in a place where the information is 

going from the Federal marketplace to the IRS on a monthly basis. 

And, you know, with all of these audits that we have received from 

both IGs and the GAO, we continue to work through their suggestions. And I think it is that one. But we will follow up, and if it 

is not the case, we are now in a monthly reporting—— 

Mrs. BLACK. I would really appreciate your following up. Because it is related to this report. Thank you very much. 

Chairman RYAN. Thank you. Mr. Pascrell. 

Mr. PASCRELL. Thanks, Mr. Chairman. And thank you, Madam 

Secretary. I am pleased that during your confirmation process, you 

expressed support for improving the safety of medical devices—a 

few of us have brought that up—by incorporating the FDA’s new, 

Unique Device Identifier, the UDI, to assist in health insurance 

claims. Myself and Chairman Brady have talked about this in the 

past. 

I am asking you today, despite this widespread support, that— 

some in the CMS, I am putting it mildly, have resisted this important public health and patient safety effort. So we need the tools. 

Could you commit to work with the Committee this summer to 

move the policy forward? 

Secretary BURWELL. I do commit. And I think we have made 

some progress by having FDA and CMS working together on something that will actually be more implementable. So we are working 

on it. And your comments and the Chairman’s comments and others are something that I recognized when I came in. And so we 

have been working on it, but would look forward to working with 

the Committee further. 

Mr. PASCRELL. Thank you. Let me shift a gear a little bit here. 

You would think that if my colleagues on the other side cobbled together all of the time they spent trying to undermine the ACA, 

they would have been able to come up with an alternative to this 

law. They can’t find anything good to say about anything. So in 

this Committee alone, we have had over a dozen hearings just on 

issues related to the individual and employer mandate. Many 

Members, in good faith I am sure, brought this up today. Not to 

mention nearly 64 votes to repeal or undermine the ACA. Make no 

mistake about it. That is what this is about. And how many have 

we had on this elusive Republican alternative I keep hearing 

about? Zero. 

The reality is that this Act is working. It has problems. Medicare 

has problems. Medicaid has problems. This is a very imperfect 

world, Madam Secretary. More than 10 million Americans have 

health coverage through the marketplaces. Eighty-five percent receive tax credits to help with the cost of coverage. So while we 

are waiting, I am interested in the answer to one question. Has 

the ACA impacted employer-sponsored insurance offering take-up 

rates? And does the ACA maintain the financial incentives for employers to cover and to offer coverage? That is my question. 

Secretary BURWELL. This past week, we have seen a piece of 

work by the Urban Institute with regard to the number of employer-base. The statistics that we have, certainly CBO’s changes 

to its numbers, most recent changes to its ACA numbers, have to 

117 

do with the fact that they now have lowered the number of people 

they think will switch from the employer-based market to the marketplace. 

And the Urban Institute numbers that came out this week said 

that there actually, on a percentage basis, has been a slight, very 

slight, so I would call it basically the same, no decrease, but the 

same. It is a slight tip up, but not numerically, I think, significant. 

Actual maintenance of those in the employer-based market. And so 

there has not been a decrease. 

Mr. PASCRELL. Thank you very much, Madam Secretary. I 

yield back, Mr. Chairman. 

Chairman RYAN. Thank you. Mr. Young. 

Mr. YOUNG. Madam Secretary, thank you for being here today. 

The President after the G–7 summit this week said the Affordable 

Care Act is working. I mean, part of what is bizarre about this 

whole thing is we haven’t had a lot of conversation about the horrors of Obamacare because none of them have come to pass. And 

he continued, somewhat oblivious, seemingly, to some of the things 

I am hearing in my own district, saying, ‘‘It hasn’t had an adverse 

effect on people who already had health insurance.’’ 

You know, I am frustrated. And I know many Hoosiers are frustrated by some of the adverse impacts they have experienced, from 

diminished coverage options, to lack of accessibility in their own 

communities for care. A lot of people are being squeezed when they 

go into the exchanges with price increases on premiums. And then 

there are the penalties, of course, the mandate taxes that exist if 

they can’t afford to buy health insurance. 

And so I just want to humanize this a little bit for you. Because 

I know you are quite conversant in the statistics and the goings on 

of much of this healthcare law. Patsy, from my district in Jeffersonville, Indiana, her premium went up $135 a month. She no longer 

has access to the family physician that has cared for her for over 

25 years. Brandon, from Greenville, signed up for health care his 

family can’t use because his family’s deductibles are too high. And 

they make just enough that they don’t qualify for assistance. Jason, 

from Georgetown, Indiana, had to seriously consider paying the 

individual mandate tax because he couldn’t afford to pay the 

increased premiums on the exchange and didn’t qualify for an exemption. Debra, from New Albany, had her monthly premium skyrocket to $800 a month, more than her mortgage payment. 

So these are just illustrative of what are larger problems in every 

State across the country, every congressional district. And, you 

know, to use the President’s own words, these horror stories 

haven’t come to pass. They are coming to pass. They are in existence right now. And I just want to know what you believe, Madam 

Secretary, I should tell my constituents who are trying to comply 

with this law? Are they merely collateral damage? 

Secretary BURWELL. With regard to the examples and stories, 

I think they are important. And they are important to combine 

with the numbers in terms of what we know, that, you know, 16.4 

million people in our country are no longer uninsured. And the stories, I hear those stories and respect those stories. But having traveled 22,000 miles and having been out amongst people, I heard the 

story from the woman in Texas who said you want to know how 

118 

to treat MS? I will tell you how to treat MS. You get sick enough 

to go to the emergency room, and they will treat you. And now she 

said I will know how. 

Mr. YOUNG. So in the near term, what do we do? I am sorry 

for interjecting but time is short. What do we do for these Hoosiers 

who don’t qualify for a hardship exemption? 

Secretary BURWELL. I think, first of all, we need to make sure 

they have exhausted that remedy. And, please, we are—— 

Mr. YOUNG. I have made sure they have. Our office has. 

Secretary BURWELL. And have worked through us. The other 

thing, on a number of the examples that you talked about, there 

is the issue of coverage to care and helping people understand how 

to select the right plan. The plans on the marketplace are very varied. There are many in terms of the questions of deductibility and 

that sort of thing. 

Chairman RYAN. Thank you. Thank you. Mr. Renacci. 

Mr. RENACCI. Thank you, Mr. Chairman. And thank you, 

Madam Secretary, for being here. Earlier on, you said the Administration is looking for fixes and improvements for the ACA. And I 

want to run through just a couple of them that I think would, it 

is disingenuous if you don’t help make some of those fixes. 

One of them deals with seasonal employees, the definition between seasonal workers and seasonal employees. I am not sure if 

you are aware of the conflict with that definition and some of the 

difficulty it is causing people in my district but also across the 

country. 

The other is the readmission, hospital readmission program. This 

program was aimed at reducing unnecessary hospital readmissions 

called the Hospital Readmission Reduction Program. The goal of 

the program was really something that I would support and probably many of my colleagues support. In fact, it is estimated that 

nearly $18 billion per year is wasted on avoidable readmissions of 

Medicare patients alone. However, the implementation of this program has been problematic, especially for those hospitals serving 

low-income populations. 

Evidence suggests that economically disadvantaged patients, especially patients eligible for both Medicare and Medicaid, are much 

more likely to be readmitted within 30 days of discharge regardless 

of physicians’ efforts to educate them on proper post-discharge care. 

Do you believe the readmission program criteria can be improved 

by adding clear adjustments for dual eligible status as well as for 

other planned readmissions such as those following trauma? 

Secretary BURWELL. So I agree with you on the issue of socioeconomic status and the difficulties that that can cause. We actually had a proposal and a rulemaking and a proposed rulemaking 

and a suggestion of how to make some of those kinds of changes. 

The remarks we received back were an important issue, but not the 

right way to go about it. 

The Congress, thankfully, has also given us money to actually do 

this specific study of how we can work through this issue. We look 

forward to working with you on how we correct it because we had 

a proposal that others didn’t. We believe it is an important issue. 

When I analytically understand how we can account for that but 

at the same time do what your beginning point was, which is we 

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know we have more readmissions than we should, both in terms of 

quality and price, I will discuss it in more detail. And so getting 

to that is something we would like to do. We have tried to propose 

it. We clearly didn’t get it there. 

Mr. RENACCI. Thank you. I have Ensuring Beneficiary Equity 

in Hospital Readmission Program, H.R. 1343, a bill that I have introduced which does have bipartisan support that I would hope the 

Administration would consider and support. 

Also, on seasonal employees, I have STARS Act, H.R. 863, really 

to clarify the conflicting definitions between seasonal workers and 

seasonal employees, which is causing compliance problems for both 

employers and individuals. Interactions between seasonal, seasonality, the employer mandate and the individual mandate really create opportunities for accidental noncompliance resulting in significant tax penalties for American workers and businesses alike. 

So that is another issue I would hope that we can work on. Because these are issues clarifying and fixing, as you said, fixing or 

improving the current law. So I thank you, and I yield back. 

Chairman RYAN. The gentleman yields back. I understand that 

the Secretary has a hard stop. I regret the fact that not every 

Member will be able to ask questions of the witness at this moment. I would like to invite any Member, particularly those who 

did not have the opportunity, to give us—the Committee their 

questions in writing. We will submit them to the Secretary, to the 

witness, and I ask the Secretary to respond in a very timely manner to these questions from the remaining Members. 

Secretary BURWELL. I would be happy to. I would be happy to 

and I think a number of you have my cell number, so feel free. 

Chairman RYAN. With that, and to honor your time, your deadline, the hearing stands adjourned. The Committee stands adjourned. 

[Whereupon, at 12:03 p.m., the Committee was adjourned.] 

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