U.S. GOVERNMENT PUBLISHING OFFICE

30–005—PDF WASHINGTON : 2018

S. HRG. 115–229 

NOMINATION OF THOMAS PRICE 

HEARING 

BEFORE THE

COMMITTEE ON FINANCE 

UNITED STATES SENATE 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

ON THE

NOMINATION OF 

THOMAS PRICE, TO BE SECRETARY, 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

JANUARY 24, 2017 

( 

Printed for the use of the Committee on Finance 

COMMITTEE ON FINANCE 

ORRIN G. HATCH, Utah, Chairman 

CHUCK GRASSLEY, Iowa 

MIKE CRAPO, Idaho 

PAT ROBERTS, Kansas 

MICHAEL B. ENZI, Wyoming 

JOHN CORNYN, Texas 

JOHN THUNE, South Dakota 

RICHARD BURR, North Carolina 

JOHNNY ISAKSON, Georgia 

ROB PORTMAN, Ohio 

PATRICK J. TOOMEY, Pennsylvania 

DEAN HELLER, Nevada 

TIM SCOTT, South Carolina 

BILL CASSIDY, Louisiana 

RON WYDEN, Oregon 

DEBBIE STABENOW, Michigan 

MARIA CANTWELL, Washington 

BILL NELSON, Florida 

ROBERT MENENDEZ, New Jersey 

THOMAS R. CARPER, Delaware 

BENJAMIN L. CARDIN, Maryland 

SHERROD BROWN, Ohio 

MICHAEL F. BENNET, Colorado 

ROBERT P. CASEY, JR., Pennsylvania 

MARK R. WARNER, Virginia 

CLAIRE MCCASKILL, Missouri 

CHRIS CAMPBELL, Staff Director 

JOSHUA SHEINKMAN, Democratic Staff Director 

(II) 

(III) 

C O N T E N T S 

OPENING STATEMENTS 

Page 

Hatch, Hon. Orrin G., a U.S. Senator from Utah, chairman, Committee on 

Finance .................................................................................................................. 1 

Wyden, Hon. Ron, a U.S. Senator from Oregon .................................................... 4 

Isakson, Hon. Johnny, a U.S. Senator from Georgia ............................................ 6 

ADMINISTRATION NOMINEE 

Price, Hon. Thomas, M.D., nominated to be Secretary, Department of Health 

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

ALPHABETICAL LISTING AND APPENDIX MATERIAL 

Grassley, Hon. Chuck: 

‘‘Grassley Says Emory Psychiatrist Didn’t Report $500,000 in Payments,’’ 

by Jacob Goldstein, The Wall Street Journal, October 3, 2008 ................. 77 

‘‘Top Psychiatrist Didn’t Report Drug Makers’ Pay,’’ by Gardiner Harris, 

Money and Policy, October 3, 2008 .............................................................. 78 

Hatch, Hon. Orrin G.: 

Opening statement ........................................................................................... 1 

Prepared statement with attachments ........................................................... 80 

Heller, Hon. Dean: 

Letter From Hon. Aaron D. Ford and Hon. Jason Frierson to Senator 

Heller, January 10, 2017 .............................................................................. 89 

Isakson, Hon. Johnny: 

Opening statement ........................................................................................... 6 

McCaskill, Hon. Claire: 

Distribution of Federal Tax Change by Expanded Cash Income Level, 

2017, Summary Table, Tax Policy Center, December 15, 2016 ................ 91 

Nelson, Hon. Bill: 

‘‘A Premium Support System for Medicare: Analysis of Illustrative Options,’’ Congressional Budget Office, September 2013 ............................... 92 

‘‘GOP Split on Reforming Health Care,’’ by Jennifer Haberkorn, Politico, 

April 30, 2012 ................................................................................................ 138 

Price, Hon. Thomas, M.D.: 

Testimony .......................................................................................................... 9 

Prepared statement .......................................................................................... 139 

Biographical information ................................................................................. 141 

Responses to questions from committee members ......................................... 171 

Stabenow, Hon. Debbie: 

Statements and testimonials ........................................................................... 253 

Wyden, Hon. Ron: 

Opening statement ........................................................................................... 4 

Prepared statement with attachments ........................................................... 281 

COMMUNICATIONS

American Association of Hip and Knee Surgeons (AAHKS) ................................ 289 

Association of Web-Based Health Insurance Brokers (AWHIB) .......................... 289 

Brasch, Steven P., M.D. .......................................................................................... 292 

Choat, Lesli, MT (ASCP) ......................................................................................... 293 

Claybour, Richard and Jill ...................................................................................... 294 

Darrow, Robert K. .................................................................................................... 294 

Gyetvan, Angela Wilson .......................................................................................... 295 

Page

IV 

Human Rights Campaign ....................................................................................... 296 

LeadingAge ............................................................................................................... 298 

Murzyn, Debbie ........................................................................................................ 299 

National Center for Lesbian Rights (NCLR) ......................................................... 300 

Quinn, Marilyn D. ................................................................................................... 303 

Ravanesi, Stacey ...................................................................................................... 304 

Subaiya, Indu, M.D., MBA ...................................................................................... 305 

Treatment Action Group (TAG) .............................................................................. 307 

Vallance, Elizabeth .................................................................................................. 309 

(1) 

NOMINATION OF THOMAS PRICE, 

TO BE SECRETARY, DEPARTMENT OF 

HEALTH AND HUMAN SERVICES 

THURSDAY, JANUARY 24, 2017 

U.S. SENATE, 

COMMITTEE ON FINANCE, 

Washington, DC. 

The hearing was convened, pursuant to notice, at 10:02 a.m., in 

room SD–215, Dirksen Senate Office Building, Hon. Orrin G. Hatch 

(chairman of the committee) presiding. 

Present: Senators Grassley, Crapo, Roberts, Enzi, Cornyn, 

Thune, Burr, Isakson, Portman, Toomey, Heller, Scott, Cassidy, 

Wyden, Stabenow, Cantwell, Nelson, Menendez, Carper, Cardin, 

Brown, Bennet, Casey, Warner, and McCaskill. 

Also present: Republican Staff: Chris Campbell, Staff Director; 

Nicholas Wyatt, Tax and Nominations Professional Staff Member; 

Jay Khosla, Chief Health Counsel and Policy Director; Kimberly 

Brandt, Chief Health-care Investigative Counsel; Brett Baker, 

Health Policy Advisor; and Erin Dempsey, Health-care Policy Advisor. Democratic Staff: Joshua Sheinkman, Staff Director; Michael 

Evans, General Counsel; Elizabeth Jurinka, Chief Health Advisor; 

David Berick, Chief Investigator; Laura Berntsen, Senior Advisor 

for Health and Human Services; Beth Vrabel, Senior Health Counsel; Adam Carasso, Senior Tax and Economic Advisor; Matt Kazan, 

Health Policy Advisor; Anne Dwyer, Health-care Counsel; and 

Ryan Carey, Press Secretary and Speech Writer. 

OPENING STATEMENT OF HON. ORRIN G. HATCH, A U.S. 

SENATOR FROM UTAH, CHAIRMAN, COMMITTEE ON FINANCE 

The CHAIRMAN. The committee will come to order. I would like 

to welcome everyone to this morning’s hearing. Today we will consider the nomination of Dr. Tom Price to be the Secretary of the 

Department of Health and Human Services. 

I want to welcome Dr. Price to the Finance Committee. And I appreciate his willingness to serve in a position of this magnitude, especially at this particularly crucial time. 

When Obamacare was pushed through on a series of party-line 

votes, Republicans in Congress warned that the new health-care 

law basically would harm patients, families, and businesses. Not to 

put too fine a point on it, but we were right. And the next HHS 

Secretary will play a pivotal role as we work to repeal Obamacare 

and replace it with patient-centered reforms that will actually address costs, among other things. This will be an important endeavVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 R:\DOCS\30005.000 TIM
2 

or, one that will and should get a lot of attention here today, but 

it should not be the sole focus of the next HHS Secretary. 

HHS has an annual budget of well over $1 trillion. Let me repeat 

that: one department, $1 trillion. HHS encompasses the Centers for 

Medicare and Medicaid Services, the Centers for Disease Control 

and Prevention, the National Institutes of Health, the Food and 

Drug Administration, and many others. It is no exaggeration to say 

that HHS touches more of the U.S. economy and affects the daily 

lives of more Americans than any other part of the U.S. Government. 

I firmly believe that Dr. Price has the experience and qualifications necessary to effectively lead this large and diverse set of 

agencies, and many people share that view. He has had a wealth 

of experience in the practice of medicine, understands these problems, and has been a great member of the House of Representatives. 

For example, past HHS Secretaries Mike Leavitt and Tommy 

Thompson strongly support his nomination. Physician organizations that know Dr. Price’s work, including the American Medical 

Association and most surgical specialty groups, enthusiastically 

support him. The American Hospital Association and other healthcare stakeholder groups do as well. 

Perhaps the Healthcare Leadership Council, representing the 

broad swath of health-care providers, said it best in stating that, 

quote, ‘‘It is difficult to imagine anyone more capable of serving 

this Nation as the Secretary of HHS than Congressman Tom 

Price.’’ 

Unfortunately, in the current political environment, qualifications, experience, and endorsements from experts and key stakeholders sometimes do not seem to matter to some of our colleagues. 

At least that appears to be the case, since none of those who say 

they oppose Dr. Price’s nomination seem to be talking about whether he is qualified. Instead, we have heard grossly exaggerated and 

distorted attacks on his views and his ethics. On top of that, we 

have heard complaints and a series of unreasonable demands regarding the confirmation process itself. Of course, these tactics 

have not been limited to Dr. Price. 

My Democratic friends have taken this approach with almost all 

of President Trump’s Cabinet nominees, as Senate Democrats’ unprecedented efforts to delay and derail the confirmation process 

and apply a radically new set of confirmation standards has continued unabated. 

To that point, let me say this. I have been in the Senate for 40 

years, and I think my record for being willing to reach across the 

aisle is beyond any reasonable dispute. And I have certainly done 

it with my fellow Democrats here on this committee. In fact, from 

time to time I have taken lumps in some conservative circles for 

working closely with my Democratic colleagues. I have, on some occasions, voted against confirming executive branch nominees, but 

far more often than not I have opted to defer to the occupants of 

the White House and allowed them to choose who serves in their 

administrations. I have taken some lumps for that too. 

I am not bringing any of this up to brag or to solicit praise from 

anyone in the audience. I raise all of this today so that people can 

3 

know I am serious when I say that I am worried about what my 

colleagues on the minority side are doing to the Senate as an institution. While the overriding sense of comity and courtesy among 

Senators has admittedly been in decline in recent years, I have 

never seen this level of partisan rancor when it comes to dealing 

with a President from an opposing party. I have never seen a party 

in the Senate, from its leaders on down, publicly commit to not 

only opposing virtually every nomination, but to attacking and maligning virtually every single nominee. 

Now, let me be clear. I am not suggesting that the Senate start 

rubber-stamping nominees, nor am I suggesting that any member 

of the Senate should vote against their conscience or preferences 

simply out of respect for tradition or deference. What I am saying 

is that the same rules, processes, courtesies, and assumptions of 

good faith that have long been the hallmark of the Senate confirmation process, especially in this committee, should continue to 

apply regardless of who is President. If what we are seeing now is 

the new normal for every time control of the White House changes 

hands, the Senate, quite frankly, will be a much lesser institution. 

Unfortunately, our committee has not been entirely immune to 

the hyper-politicization of the nomination process. We saw that last 

week with the Mnuchin hearing. And I regret to say that I think 

we are likely to see more of it today. I hope not. 

Case in point: I expect that during today’s hearing, we are going 

to hear quite a bit about process and claims that Dr. Price’s nomination is being rushed and that the nominee has not been fully vetted. These allegations are simply untrue. 

President Trump announced his intent to nominate Dr. Price just 

3 weeks after the election. Dr. Price submitted the required tax returns and completed questionnaire on December 21st. That was 35 

days ago. And by any reasonable standard, that is sufficient time 

for a full and fair examination of the nominee’s record and disclosures. 

By comparison, the committee held a hearing on the nomination 

of Secretary Sebelius, the Democrat nominee, 16 days after she 

submitted her paperwork. For Secretary Burwell, it was 17 days. 

In other words, the time between the completion of Dr. Price’s file 

and his hearing has been more than that of the last two HHS Secretaries combined. And by the way, both of those nominees received 

at least a few Republican votes in this committee and on the floor. 

Outside of extraordinary process demands, Dr. Price has faced a 

number of unfair attacks on both his record as a legislator and his 

finances. On the question surrounding finances, I will defer on any 

substantive discussion and first allow Dr. Price to defend himself 

from what are, by and large, specious and distorted attacks. For 

now I will just say that I hope that my colleagues do not invent 

new standards for finances, ethics, and disclosure that are different 

from those that have generally applied in the past. There is a saying involving both stones and glass houses that might be applicable 

as well. 

With regard to Dr. Price’s views and voting record, I will simply 

say that virtually all the attempts I have witnessed to characterize 

Dr. Price’s views as being, quote, ‘‘outside of the mainstream’’ have 

been patently absurd unless, of course, the only ideas that are in 

4 

the, quote, ‘‘mainstream’’ are those that endorse the status quo on 

health care and our entitlement programs. 

In conclusion, I just want to note that the overly partisan treatment of nominees and distortions of their records is a relatively 

new development on this committee. My hope is that we can begin 

to set a new standard here that we can all be proud of, and that 

we will work to reverse recent trends and have a fair and open discussion of the nominee and his qualifications. 

So with that, I will turn to our distinguished ranking member, 

Senator Wyden. 

[The prepared statement of Chairman Hatch appears in the appendix.] 

OPENING STATEMENT OF HON. RON WYDEN, 

A U.S. SENATOR FROM OREGON 

Senator WYDEN. Thank you very much, Mr. Chairman. 

Colleagues, the American public heard many promises about 

health care from the new administration. No cuts to Medicare or 

Medicaid. Nobody hurt by ACA repeal. ‘‘Insurance for everybody 

. . . much less expensive and much better.’’ Congressman Price’s 

own record undercuts these promises. 

I am going to start with ethics and undisclosed assets. Congressman Price owns stock in an Australian biomedical firm called Innate Immunotherapeutics. His first stock purchase came in 2015 

after consulting Representative Chris Collins, the company’s top 

shareholder and a member of its board. In 2016, the Congressman 

was invited to participate in a special stock sale called a private 

placement. The company offered the private placement to raise 

funds for testing on an experimental treatment it intends to put up 

for FDA approval. Through this private placement, the Congressman increased his stake in the company more than 500 percent. He 

has said he was unaware he paid a price below market value. 

It is hard to see how this claim passes the smell test. Company 

filings with the Australia Stock Exchange clearly state that this 

specific private placement would be made at below-market prices. 

The Treasury Department handbook on private placements states, 

and I will quote: ‘‘They are offered only to sophisticated investors 

in a nonpublic manner.’’ The Congressman also said last week he 

directed this stock purchase himself, departing from what he said 

was his typical practice. 

Then there is the matter of what was omitted from the Congressman’s notarized disclosures. The Congressman’s stake in Innate is 

more than five times larger than the figure he reported to ethics 

officials when he became a nominee. He disclosed owning less than 

$50,000 of Innate stock. At the time the disclosure was filed, by my 

calculation, his shares had a value of more than $250,000. Today 

his stake is valued at more than a half-million dollars. Based on 

the math, it appears that the private placement was excluded entirely from the Congressman’s financial disclosure. This company’s 

fortunes could be affected directly by legislation and treaties that 

come before Congress. 

It also appears the Congressman failed to consult the House Ethics Committee following other trades of health-care stocks. That 

was required, as they are directly related to two bills he introduced 

5 

and promoted. Even if some of those trades were not made at his 

direction, he would have been made aware of them when he filed 

his Periodic Transaction Reports with the House of Representatives. 

Set aside the legal issues. It is hard to see this as anything but 

a conflict of interest and an abuse of position. 

Another key question on the Finance Committee’s biographical 

questionnaire is whether nominees have been investigated for ethics violations. The Congressman has been the subject of two investigations stemming from fundraising practices. This too was not 

disclosed. The committee needs to look into these matters before 

moving the nomination forward. 

Now to policy. On the Affordable Care Act specifically, and the 

scheme known as ‘‘repeal and run,’’ the secret replacement plan is 

still hidden away, but already the administration charges ahead 

with a broad executive order that endangers Americans’ health. 

As the Budget chairman, Congressman Price is the architect of 

repeal and run. If his repeal bill became law, 18 million Americans 

would lose their health care in less than 2 years. In 1 decade, you 

would go from 26 million uninsured to 59 million. Repeal and run 

raises premiums 50 percent in less than 2 years. Costs skyrocket 

from there. The market for individuals to buy health insurance collapses. No-cost contraceptive coverage for millions of women, gone. 

By defunding Planned Parenthood, nearly 400,000 women would 

lose access to care almost immediately, hundreds of thousands 

more would lose their choice to see the doctors they trust. The 

Price plan takes America back to the dark days when health care 

was for the healthy and the wealthy. 

His other proposals do not offer much hope that the damage will 

be undone. There is a big gap between the Trump pledge of ‘‘insurance for everybody and great health care’’ and the Congressman’s 

proposals. 

In another bill, the Empowering Patients First Act, the Congressman brings back discrimination against people with preexisting conditions such as pregnancy or heart disease. He gives insurers the power to deny care and raise costs on those with preexisting conditions if they did not maintain coverage. In effect, the 

bill said insurance companies could take patients’ money and skip 

out on paying for the care they need. 

The Price bill also gave insurers the okay to reinstate lifetime 

limits on coverage and charge women higher rates because they are 

women. It gutted the tax benefits that help working people afford 

high-quality coverage. It slashed the minimum standards that protect patients by defining exactly what health plans have to cover. 

All this from a bill called Empowering Patients First. I have seen 

a lot of bills with ironic titles. This one, colleagues, takes the cake. 

Here’s the constant. The Congressman’s proposals push new 

costs onto patients. Massive cuts to Medicare were proposed in the 

Price budget, as another example. In my view, the Congress has a 

duty to uphold the promise of Medicare. It is a promise of guaranteed benefits. 

The Congressman advocated privatizing Medicare, cutting it almost a half-trillion dollars. After his nomination, he said he wanted 

to turn the program into one with vouchers within the first 6 to 

6 

8 months of the administration. He supports ‘‘balance billing’’ so 

seniors would have to cover extra charges above what Medicare 

pays when they go to the doctor. More extra costs for seniors on 

a tight budget. In addition, the Congressman calls for block-granting and capping Medicaid, which would shred a vital safety net for 

our most vulnerable. 

Medicaid insures 74 million people. More Americans rely on Medicaid to pay for nursing home care and home-based care than any 

other program. The program pays for nearly half of all births and 

covers millions of children. It is a critical source of mental health 

coverage and substance abuse treatment, vital at a time when our 

communities are battling the opioid epidemic. 

I will close with just two additional points. If confirmed, the head 

of HHS, the Health and Human Services Department, is the captain of the Trump health-care team. Now the Congressman says 

patients should be at the center of care. I agree with that. When 

I look, however, at the Congressman’s proposals, I do not see the 

patient at the center of health care. I see money and I see special 

interests at the center of health care. 

Now finally, let me just make a point with respect to the process 

and the comments of my good friend, Chairman Hatch. 

Colleagues, the process here is exactly the same process to a ‘‘t’’ 

that this committee has used for 20 years. It is the process that 

applied, for example, to Tom Daschle; it applied to Ron Kirk. 

I will enter into the record a specific set of details about how this 

is the process that is exactly what was done on a bipartisan basis 

for 20 years. And I will make that a part of the record. 

[The information appears in the appendix on p. 278.] 

Senator WYDEN. Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator. 

[The prepared statement of Senator Wyden appears in the appendix.] 

The CHAIRMAN. I am pleased to hand over my normal witness introduction duties today to our colleague, the distinguished Senator 

from Georgia, Senator Isakson, who will introduce Dr. Price. 

And so, Senator Isakson, please proceed. 

OPENING STATEMENT OF HON. JOHNNY ISAKSON, 

A U.S. SENATOR FROM GEORGIA 

Senator ISAKSON. Well, thank you, Chairman Hatch, Ranking 

Member Wyden, and fellow members of the committee. I am proud 

to have a seat right up there on this committee and enjoy being 

a part of it. 

And I could not be prouder than to introduce Tom Price to you 

today. This is the second time I have had the occasion to introduce 

Tom in the last week. The first time I was called, it was to introduce him at the HELP Committee, which I also serve on, and I was 

proud to do that. And I gave what I hope was the best introduction 

I could possibly give for a man whom I have known for 30 years. 

I have known him as a family man, as a legislator, as a member 

of our community, as a great physician, and a great friend. 

And it was easy to do that one. But since that last week, things 

have changed. I feel like I have been asked to be a character witness in a felony trial in the sentencing phase of a conviction. 

7 

There are things that have been said the last week or so, just 

to me, that need to be refuted. So I am going to take all the positive things and say them at the end, but try and begin by saying 

there are a few things out there that need a perspective all the way 

around. 

I am very proud that Tom has submitted his income tax returns. 

A couple of things that the ranking member mentioned came from 

those submissions. Some of the things that came out in a memo 

last night about property taxes, those were de minimis items that 

came out, one late tax payment in Nashville, TN, one late tax payment in Washington, DC. Late, not unpaid—just late, and I have 

done that myself a couple of times. 

On Innate Immunotherapeutics, that was a disclosure that he 

made, and the valuation difference on a private placement is a normal thing. It is an eyes-of-the-beholder placement in terms of what 

you assess it at. And this was merely an assessment as to what you 

disclose in terms of its worth, not whether you disclose it or not. 

Tom is a good man. He is a family man. He is a physician. He 

is an honorable man. And I am proud to be here today, not to defend him, because he does not need defending, but to praise him 

for the things that he has done. 

You know, I think it is important for all of us to look at a Secretary nomination, whether it is Secretary of Defense, whether it 

is Health and Human Services, and say, ‘‘What am I really looking 

for in terms of this person?’’ 

Well, first and foremost, I am looking for a person who understands the American family. Tom is a great family man. In fact, 

his wife Betty is here. Raise your hand, Betty. 

Last week I told her to stand up, and she was in a crowd and 

I could not get her to do it, so I am going to get her to raise her 

hand this time around. Betty is a great lady and a great wife. 

Their son Robert, I guess, is still in Nashville, TN singing country 

music. Is that right? So he could not be here today, but Lamar 

Alexander appreciates that part very well. 

Tom is active in his church, active in his community, understands the needs of families, and understands the relationship of 

health care to a good family. 

Secondly, who would I ask to spend $1.1 trillion of my money? 

I do not have that much, of course, but that is how much Tom will 

oversee at HHS. What would I look for in a person to handle that 

much money? 

I would look for a little bit of experience. And Tom has it in 

terms of being a legislator. I would look for somebody who understood where that cost was going and what he needed to do to manage it. And Tom is that type of person. I would look for somebody 

I would trust with that amount of money, even though I do not 

have it, but if it were mine. 

Third, does he understand health care? Let me tell you a little 

bit about Tom and his medical practice. It is called Resurgens 

Orthopaedics. Resurgens Orthopaedics is the consolidation of a 

number of small orthopaedics firms around the State of Georgia 

into the largest orthopaedic provider in our State. 

Tom was one of the leading persons who pulled that together 

and, in fact, ran the practice for a while himself. They are my docVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6633 R:\DOCS\30005.000 TIM
8 

tors. In fact, 26 years ago Resurgens saved my young son Kevin’s 

right leg after a terrible automobile accident. And I have never forgotten what they did for him in a terrible crisis that we had in our 

family. 

But they are a great medical firm. He understands medicine. 

And he has run a comprehensive medical program. 

Fourth, I would want to understand if he knew the legislative 

process. You know, when the President calls Tom in and says, 

okay, we are going to go to the Senate and the House, we are going 

to sell our package, Tom has to have the ability to convince 535 

people that the President is right or that the administration is 

right. You do not want somebody going up there who has not 

walked into a legislative meeting before, somebody who has not 

been in the political process before. Tom has been there and done 

that. And he is the type of guy you could trust to make the sale 

and represent the administration and the people. 

Fifth, I would want somebody who is accountable. Tom is an accountable type of guy. In fact, I joked last week and said he is one 

of those rare ones of us who actually reads the bills. In fact, when 

I have a big question, I will usually come talk to Tom late at night 

and say, ‘‘Tom, what do you know about House Resolution 3742?’’ 

and he will tell me. 

He is not exciting. He is sometimes boring, but he is always 

right, because he is always prepared. But he understands you need 

to be accountable in this business. You need to be responsible for 

what you do and responsible for what you say. 

Now, there is a rumor that has been spread around by some people that Tom does not support the saving of Social Security. Let me 

tell you a little story. A few weeks ago, in fact at the end of the 

campaign in October, I was called by AARP and Tom was called 

by AARP. They said, will you two go on the road for us and do 

presentations around the State in your congressional districts 

about how you are going to save Social Security? 

And I guess Alpharetta, GA was the first place. Tom and I went 

one night and spent the whole night before a room full of seniors 

defending saving Social Security. So anybody who is passing that 

rumor around, hey, go ask AARP who is going to save Social Security, go ask the people who are active in that business who is going 

to do it. Tom Price understands the value of Social Security and 

the value of Medicare. And being eligible for both, I would not be 

up here promoting somebody who is going to take it away from me, 

I guarantee you that. 

Now, let me tell you one other thing. Four years ago, I sat in this 

committee room and in the HELP Committee and I questioned and 

I asked all that I could of Sylvia Burwell. And when it came time 

for a vote, I voted for her because she was the right person at the 

right time for the administration to put in as head of HHS. 

Dr. Tom Price is the right man at the right time for the right 

job. He is my friend. He is a man I have known for 30 years. He 

has unquestioned character and unquestioned ability. And he will 

be a great Secretary of HHS. 

I thank all of you for taking my calls earlier when I called before 

this meeting. I urge you to give him the courtesy of your time to 

listen to what he has to say, ask your thorough questions, and I 

9 

hope you will see fit to nominate an honorable man, an accountable 

man, and a good man to be the next Secretary of Health and 

Human Services. 

And I yield back, Mr. Chairman. 

The CHAIRMAN. Well, thank you, Senator Isakson. 

I tell you, Tom, you could not have a better introducer than Senator Isakson. I mean, he is not only highly respected by all of us 

in the Senate, Democrats and Republicans, but he is very, very articulate, as you can see. And I think he did a very good job talking 

about you and your future here in this committee. 

Now, I have some obligatory questions for the nominee. First, is 

there anything that you are aware of in your background that 

might present a conflict of interest with the duties of the office to 

which you have been nominated? 

Dr. PRICE. I am not. 

The CHAIRMAN. Do you know of any reason, personal or otherwise, that would in any way prevent you from fully and honorably 

fulfilling this responsibility? 

Dr. PRICE. I do not. 

The CHAIRMAN. Do you agree, without reservation, to respond to 

any reasonable summons to appear and testify before any duly constituted committee of the Congress, if you are confirmed? 

Dr. PRICE. I look forward to that. 

The CHAIRMAN. Finally, do you commit to provide a prompt response in writing to any questions that may be submitted to you 

or addressed to you by any Senator of this committee? 

Dr. PRICE. I do. 

The CHAIRMAN. Well, thank you. Those are the obligatory questions that we ask of everybody. 

Let us turn the time over to you, Dr. Price, Congressman Price, 

to state whatever you would like to state here for the committee 

this morning. 

STATEMENT OF HON. THOMAS PRICE, M.D., NOMINATED TO BE 

SECRETARY, DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON, DC 

Dr. PRICE. Thank you so much, Chairman Hatch and Ranking 

Member Wyden, and to all the members of this committee, for the 

opportunity to speak with you today and to engage in a discussion 

about the road ahead for our great Nation. 

I want to thank Senator Johnny Isakson so much for his incredibly gracious introduction. As he mentioned, we have known each 

other for 30 years or so. I am so grateful for his friendship and his 

kindness. Our State is so grateful for his leadership and his service. And we are blessed to have had it. 

I wish also to especially thank my wife Betty, of 33 years, who 

joins me here today. Her support and her encouragement and her 

advice—which I will remind you is always correct—and her love 

that she has given me over those past 33 years, I am more grateful 

for that than I could ever say. 

Over the past couple of weeks and months, I have met with 

many of you individually and gained a real appreciation for the 

passion that you all have for the critical work that is done at the 

Department of Health and Human Services. Please know that I 

10 

share that passion, which is why I am here today and why I am 

honored to have been nominated to serve as the next Secretary of 

Health and Human Services. 

We all come to public service in our own unique ways that inform who we are and why we serve. My first professional calling 

was to care for patients. That experience as a physician and later 

as a legislator has provided me a holistic view of the complex interactions that take place every single day across our communities. 

And today I hope to share with you how my experience has helped 

shape my understanding of and appreciation for the Department of 

Health and Human Services. 

From an early age, I had an interest in medicine. My earliest 

memories, though, were of growing up on a farm in Michigan, 

where I lived until I was 5 years old when our family moved to 

suburban Detroit. 

I spent most of my formative years being raised by a single mom. 

Some of my fondest memories as a child were those spent with my 

grandfather, who was a physician, and I would occasionally spend 

some weekends with him when he would make rounds, which 

meant that we got in a car and went to people’s homes and made 

house calls. And I will never forget the warmth and the love with 

which he was greeted at every single door. Those impressions are 

seared in my memory. 

After graduating from medical school from the University of 

Michigan, I moved to Atlanta, which I have called home for nearly 

40 years. It is where I met my wife Betty. It is where we raised 

our son. I did my residency at Emory University and Grady Memorial Hospital, where I would later return in my career to serve as 

the medical director of the orthopaedic clinic. 

Throughout my professional career, I cared for and treated patients from all walks of life, including many, many children. And 

anyone who has ever had the privilege of treating a child knows 

how fulfilling it is to look into the eyes of a mom or a dad and say 

how we helped heal their son or their daughter. My memories of 

Grady are filled with the gracious comments of parents and of patients for the team of health-care specialists with whom I had the 

privilege of working. 

After 25 years of school and training, I started a solo orthopaedic 

practice. Over the years, this practice grew, as Senator Isakson 

mentioned, and it eventually became one of the largest nonacademic group practices of orthopaedics in the country, for which 

I eventually served as chairman of the board. During 20 years as 

a practicing physician, I learned a good bit about not just treating 

patients, but about the broader health-care system and where it 

intersects with government. 

A couple of vivid memories stand out. One is the number of times 

when patients were remarkably angry about the individuals figuratively, not literally, standing between themselves and their physician in the clinic room, making it so that what the physician was 

recommending might or might not be possible, whether it was from 

insurance or regulators or government or the like. 

And then there was the day that I remember vividly when I realized there were more people in the office behind the door where we 

saw patients in the front clinic area trying to fight with insurance 

11 

and regulators and government than there were in front of the door 

actually caring and treating patients. And it became clear to me 

that our health-care system was losing focus on its number-one priority, and that is the patient. 

As a result, I felt compelled to broaden my role in public service 

and help solve the issues harming the delivery of medicine, and so 

I ran for the Georgia State Senate. 

I found Georgia’s State Senate to oftentimes be a remarkably bipartisan place where collegial relationships were the norm. This is 

the environment in which I learned to legislate, reaching across the 

aisle to get work done. 

In Congress, I have been fortunate to have been part of a collaboration that broke through party lines as well to solve problems. 

Just this past Congress, as you will recall, it was a bipartisan effort that succeeded in ridding Medicare of a broken physician payment system and which has now begun the creation of a system 

that, if implemented properly, will help ensure that seniors have 

access to higher-quality care. 

If confirmed, my obligation will be to carry to the Department of 

Health and Human Services an appreciation for the bipartisan, 

team-driven policymaking in what has been a lifetime of commitment to improving the health and well-being of the American people. That commitment extends to what I call the six principles of 

health care: affordability, accessibility, quality, responsiveness, innovation, and choices. 

But Health and Human Services is more than health care. There 

are real heroes at this department doing incredible work to keep 

our food safe and to develop drugs and treatment options driven by 

scientists conducting truly remarkable research. There are heroes 

among the talented, dedicated men and women working to provide 

critical social services, helping families and particularly children 

have a higher quality of living and the opportunity to rise up and 

achieve their American dream. 

The role of the Health and Human Services Department in improving lives means it must carry out its responsibilities with compassion. It also must be efficient and effective and accountable as 

well as willing to partner with those in our communities already 

doing remarkable work. Across the spectrum of issues and services 

this department handles, there endures a promise that has been 

made to the American people. And we must strengthen our resolve 

to keep the promises our society has made to senior citizens and 

to those most in need of care and support. 

That means saving and strengthening and securing Medicare for 

today’s beneficiaries and future generations. It means ensuring 

that our Nation’s Medicaid population has access to quality care. 

It means maintaining and expanding America’s leading role in 

medical innovation and of the treatment and eradication of disease. 

So I share your passion for these issues, having spent my life in 

service to them. And yet, there is no doubt that we do not all share 

the same point of view when it comes to addressing each and every 

one of these issues. Our approaches to policies may differ, but surely there exists a common commitment to public service and compassion for those whom we serve. 

12 

We all hope to improve the lives of the American people, to help 

heal individuals and whole communities. So with a healthy dose of 

humility and an appreciation for the scope of the challenges before 

us, with your assistance and with God’s will, we can make it happen. And I look forward to working with you to do just that. 

Mr. Chairman, I thank you for the opportunity to be with you 

today. 

[The prepared statement of Dr. Price appears in the appendix.] 

The CHAIRMAN. Well, thank you, Dr. Price. I cannot think of anybody who could give a better analysis of why this position is so important to them. 

Let me start with this question. The Department of Health and 

Human Services is one of the largest departments in government, 

employing, I think, nearly 80,000 employees and encompassing 

over 100 programs covering a large range of complex and diverse 

issues. 

Now, you have described to a degree, but if you could elaborate 

a little bit more, can you describe how you will prioritize and oversee the large array of issues for which you will be responsible? And 

tell us, what in your history has prepared you to lead the Department of Health and Human Services, such a multifaceted department? 

Dr. PRICE. Thank you, Mr. Chairman. As you and members 

know, the mission of the Department of Health and Human Services is to improve the health and the safety and the well-being of 

the American people. I am committed to that mission, but in order 

to do that, you have to put together teams of individuals in each 

sector of health and human services. And my history, wherever I 

was—whether it was in my clinical practice or in the State legislature or Congress or the work that I did in communities—was just 

to bring forward the greatest quality of talent that we could assemble. 

Second is to understand the scope and the issues. And clearly, 

having the experience both in the clinical arena as well as in the 

legislative arena, I understand the scope and the issues. 

And then finally, focusing on results. I think oftentimes it gets 

kind of muddy up here in Washington, what we do. We name the 

programs, we make certain that the resources are there to be able 

to provide money for the programs to be run, but oftentimes I think 

we drop the ball on whether or not we are actually accomplishing 

the mission. Are we truly improving the health and the safety and 

the well-being of the American people? 

So one of the major goals that I have is to look at the metrics 

that we are looking at at the department to make certain that we 

are accomplishing that mission and that goal. 

The CHAIRMAN. Thank you. The Center for Medicare and Medicaid innovation, CMMI, has begun numerous initiatives over the 

past few years, some of which have generated much controversy. 

Could you tell us your position on the work in CMMI and how it 

should or should not be continued in the future? 

Dr. PRICE. Thank you, Mr. Chairman. Innovation is so incredibly 

important to health care and the vibrant quality of health care that 

we need to be able to provide to our citizens. Innovation, in fact, 

is what leads quality health care. It is what expands the ability of 

13 

health-care professionals to be able to treat patients. So I am a 

strong supporter of innovation, and I think one of the roles that we 

as policymakers have is to incentivize innovation. 

The Center for Medicare and Medicaid Innovation is a vehicle 

that might do just that. I think, however, that CMMI has gotten 

off track a bit. I think that what it has done is defined areas where 

it is mandatorily dictating to physicians and other providers in this 

country, in certain areas, how they must practice. So whether it is 

a geographic area that includes 67 or 68 areas in our country that 

have to perform a certain procedure in a certain way and use a certain implant in a certain way because the government says they 

have to mandatorily, without exception, or whether it is 75 percent 

of the Part B Medicare drug demo, what is called a demonstration 

project, which dictates to physicians and other providers they must 

use an in-patient setting, that, to me, is no longer a trial, that is 

no longer an experiment, that is no longer a pilot project to determine whether or not an innovative solution might work. That is 

changing the way that American medicine is practiced by folks 

making decisions here in Washington as opposed to patients and 

families and doctors making those decisions. 

So I am a strong supporter of innovation, but I hope that we can 

move CMMI in a direction that actually makes sense for patients. 

The CHAIRMAN. Well, thank you so much. Medicare has lost more 

than $130 billion—that is with a ‘‘b’’—to improper payments over 

the past 3 years. The program has also been above the legal billing 

error rate threshold of 10 percent for the past 4 years. 

Given that Medicare trustees have issued grave concerns about 

looming Medicare insolvency if we stay at the current spending levels, will your administration actively champion our Medicare Integrity Program so that we can recover a much higher percentage of 

the billions of taxpayer dollars lost each year to billing mistakes 

and ensure that Medicare will be in place for future American seniors? 

And also, as a former practicing physician who has experience 

with Medicare and Medicaid programs, do you have any insights 

into steps you think should be taken to address the multi-billiondollar problem of waste, fraud, and abuse in these programs? 

Dr. PRICE. Yes, thanks, Mr. Chairman. Nobody supports care 

being billed that is not needed or has not been provided. And this 

is one of those areas that I think we need to be very, very focused 

on. 

I am certain that there are some bad actors out there. I think 

they are a minority, but there are some bad actors out there. And 

I am certain that if we were to focus specifically on those bad actors in real time—which is what happens in every other industry 

in our country where that real-time information is available and 

acted upon—instead of trying to determine whether every single incident of care is necessary, if we were to focus on those individuals 

who were the bad actors specifically, then I think we could do a 

much better job of not just identifying the fraud that exists out 

there, but ending that fraud. 

The CHAIRMAN. Well, thank you. 

Senator Wyden, we will turn to you now. 

Senator WYDEN. Thank you, Mr. Chairman. 

14 

Congressman, I am going to start with the trading in health-care 

stocks. Your position is that the trading was legal because, in your 

view, it complied with House rules. I think there are debatable 

legal questions, but there are other matters. 

Innate Immunotherapeutics is an obscure Australian company 

that develops a treatment for immune system disorders and plans 

to seek FDA approval. Innate’s fortunes are affected by congressional action. 

Today, the total value of your shares exceeds a half-million dollars. Yet on the Office of Government Ethics disclosure form you 

filed as a nominee, you significantly undervalued the stock. You 

failed to include the value of more than 400,000 shares you bought 

at a significant discount during a private stock sale made available 

to specially chosen investors around Labor Day. You also significantly underreported the value of this purchase to the committee. 

It is worth more than twice what you reported. 

You heard about the stock from a House colleague who is a board 

director of this Australian drug company and the largest shareholder. You got in on private placements not available to the public. In these private placements, you bought over 400,000 shares at 

discounts that were as much as 40 percent cheaper than the price 

on the Australian Stock Exchange. And you were sitting at the 

time on committees that have jurisdiction over major health-care 

programs and trade policy. 

‘‘Yes’’ or ‘‘no,’’ does this not show bad judgment? 

Dr. PRICE. Well, if what you said was true it might. But the fact 

of the matter is, that is not the case. 

Senator WYDEN. We have a paper trail, Congressman. We have 

a paper trail for every comment I have made. ‘‘Yes’’ or ‘‘no,’’ does 

this not show bad judgment? 

Dr. PRICE. No. 

Senator WYDEN. Well, I just—— 

The CHAIRMAN. Well, let him answer the question too. I mean, 

you have kind of indicated he did something wrong. Let him explain why it was not wrong. 

Senator WYDEN. It was a ‘‘yes’’ or ‘‘no’’ answer. 

The CHAIRMAN. No, I want him to be able to handle that problem. 

Dr. PRICE. Maybe it would be helpful if you laid out the accusation, sir. 

The CHAIRMAN. Be fair. 

Senator WYDEN. Well, you purchased stock in an Australian company through private offerings at discounts not available to the 

public. 

Dr. PRICE. If I may, they were available to every single individual who was an investor at the time. 

Senator WYDEN. Well, that is not what we learned from company 

filings. Company filings with the Australian Stock Exchange state 

that this specific private placement would be made at belowmarket rates. The Treasury Department says it is only offered to 

sophisticated investors in a non-public manner. We have a paper 

trail for every one of the statements that I have gone into. And 

trading in stocks while you sit on two committees introducing legislation that directly impacts the value of the stocks—— 

15 

Dr. PRICE. What legislation would that be, Senator? 

Senator WYDEN. We will take you through the various bills. But 

the reality is, this has been cited on a number of occasions. 

Dr. PRICE. The reality is that everything that I did was ethical, 

above-board, legal, and transparent. The reason that you know 

about these things is because we have made that information available in real time as required by the House Ethics Committee. 

So there is not anything that you have divulged here that has 

not been public knowledge. 

Senator WYDEN. Your stake in Innate is more than five times 

larger than the figure you reported to ethics officials when you became a nominee. 

Dr. PRICE. And if you had listened to your committee staff, I believe you would know that our belief is that that was a clerical 

error at the time that the 278E was filed. We do not know where 

it happened, whether it was on our end, whether it was on the end 

of the individuals of OGE. But there was not any malicious intent 

at all. 

Senator WYDEN. Congressman, you also reported it in the questionnaire to the committee, and you had to revise it yesterday because it was wrong. 

Dr. PRICE. And the reason for that is because I, when asked 

about the value, thought it meant the value at the time that I purchased the stock, not the value at some nebulous time when we 

supposedly made a specific gain. 

Senator WYDEN. I want to get in one other question, if I might. 

This weekend, the President issued an executive order instructing 

the Department and other agencies to do everything possible to roll 

back the Affordable Care Act. If confirmed, you will be the captain 

of the health team and in charge of implementing the order. 

‘‘Yes’’ or ‘‘no,’’ under the executive order, will you commit that no 

one will be worse off? 

Dr. PRICE. What I commit to, Senator, is working with you and 

every single member of Congress to make certain that we have the 

highest-quality health care and that every single American has access to affordable coverage. 

Senator WYDEN. That is not what I asked. I asked, will you commit that no one will be worse off under the executive order? You 

ducked the question. Will you guarantee that no one will lose coverage under the executive order? 

Dr. PRICE. I guarantee you that the individuals who lost coverage 

under the Affordable Care Act, we will commit to making certain 

that they do not lose coverage under whatever replacement plan 

comes forward. That is the commitment that I provide to you. 

Senator WYDEN. The question again is, will anyone lose coverage, 

and you answered something I did not ask. 

I will wrap up this round by saying, will you commit to not implementing the order until the replacement plan is in place? 

Dr. PRICE. As I mentioned, Senator, what I commit to you and 

what I commit to the American people is to keep patients at the 

center of health care. And what that means to me is making certain that every single American has access to affordable health coverage that will provide the highest-quality health care that the 

world can provide. 

16 

Senator WYDEN. I am going to close by way of saying that what 

the Congressman is saying is that the order could go into effect before there is a replacement plan. And independent experts say that 

this is going to destroy the market on which millions of working 

families buy health coverage. And on the questions that I asked, 

will the Congressman commit that nobody will be worse off, nobody 

will lose coverage, we did not get an answer. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Well, how can anybody commit to that? [Laughter.] 

Let me just say, Dr. Price, you have been accused here of investing in securities that you had a direct effect over in Congress and 

you disclosed the wrong value of shares you owned in Innate 

Immunotherapeutics. 

Now Dr. Price, let me just say this, has a diversified portfolio 

with Morgan Stanley in a broker-directed account. Correct me if I 

am wrong on any of this, Doctor. The portfolio includes both 

health-care and non-health-care stocks. His financial adviser designed the portfolio and directed all trades in the account. The advisers and not Dr. Price have the discretion to decide which securities to buy and sell. 

On March 17, 2016 in a rebalancing of the portfolio, the financial 

adviser directed the purchase of 26 shares in Zimmer Biomet worth 

under $3,000. The adviser notified Dr. Price of the purchase on 

April 4, 2016, and Dr. Price disclosed them on his House periodic 

transaction report on April 15th. 

Now, Dr. Price began his legislative effort related to the comprehensive joint replacement demonstration project in 2015. With 

one exception, all of Dr. Price’s stocks are held in three brokerdirected accounts. Neither he nor his wife direct or provide input 

regarding investments in these accounts. Innate Immunotherapeutics is the one exception. 

Now, Dr. Price decided to invest based on public information regarding his work on multiple sclerosis treatments as a disease. He 

has been intimately involved in treating for years. He directed the 

investments based on his own research into the company. He invested $10,000 in the company in January 2015 and reported the 

investments to House Ethics in February of that year. He made an 

additional investment in September 2016 and also disclosed that 

investment. 

He has corrected his filing regarding the value of his shares. He 

has agreed to divest all shares in the company. Is that a correct 

set of remarks? 

Dr. PRICE. I think your summation is correct, sir. And I just 

would point out that anybody who knows me well knows that I 

would never violate their trust. And I know the environment that 

we are in here—you mentioned it in your opening statement—but 

I appreciate you correcting the record. 

The CHAIRMAN. Well, thank you. 

Senator CARPER. Mr. Chairman? 

The CHAIRMAN. Yes, sir? 

Senator CARPER. Just an inquiry. You just consumed about 2 

minutes beyond your opening statement. And in the interest of fair 

17 

play, is it appropriate for someone to note that 2 minutes is also 

owed to Senator Wyden or somebody on our side? 

The CHAIRMAN. Well, he already did go over 2 minutes, so it is 

no problem. 

Senator CARPER. Okay. But as we go forward in this process, I 

would just ask you to keep that in mind. 

The CHAIRMAN. Well, I am not going to relinquish my role as 

chairman—— 

Senator CARPER. No, I understand. 

The CHAIRMAN [continuing]. To correct errors that are promulgated here. But I have always been good about giving time that 

you need, so I will try to do that. 

Senator CARPER. Thank you. 

The CHAIRMAN. But I am also not going to allow things that are 

false to go forward without some sort of comment. 

Senator CARPER. All right. 

The CHAIRMAN. We just cannot allow this to happen. 

Senator WYDEN. Mr. Chairman, just a unanimous consent request. 

The CHAIRMAN. Yes. 

Senator WYDEN. I have a bipartisan disclosure memo I would 

like to ask be made a part of the record, because it will document 

what I have stated. 

The CHAIRMAN. Without objection. 

[The memorandum appears in the appendix on p. 283.] 

The CHAIRMAN. Senator Roberts? 

Senator ROBERTS. Did you really wink at me and smile? Bless 

your heart, thank you. [Laughter.] 

Good Doctor, thank you for coming. I think it is important to 

make clear right off the bat that, even if Congress and the incoming administration were to do nothing, absolutely nothing amending or repealing parts of the Affordable Care Act, the law is not 

working. 

Dr. PRICE. Right. 

Senator ROBERTS. It is collapsing. The prices are unaffordable, 

the market is nearly nonexistent, with few options in several 

States and counties. This year, one out of every three counties in 

this country only has one insurer offering coverage on the exchange. 

What tools do you have, or will you have when you are confirmed, which could be utilized over the next couple of months to 

provide stability and improve the individual insurance markets, 

make them more appealing so that insurance carriers will want to 

come back and provide more coverage options as we transition 

away from the Affordable Care Act? 

Dr. PRICE. Well, thank you, Senator. I think it is incredibly important for us to admit here what the American people know, and 

that is that this law is not working. It certainly is not working for 

folks in the individual and small-group market. 

You have premiums that are up significantly; they were supposed to go down by 2,500 bucks; now they are up more than 2,500 

bucks on average. You have deductibles that have escalated to 

$6,000 to $12,000. You have, as you mentioned, States where there 

18 

is only one insurance provider. You have one-third of the counties 

in this country where there is only one insurance carrier. 

This is maybe working for government, maybe working for insurance companies, but it is not working for patients. And so what we 

need to do is make an effort to try to reconstitute the individual 

and small-group market. And that begins, I believe, by providing 

stability in our conversation and in our tone. 

And one of the goals that I have is to lower the temperature in 

this debate, to say to those providing the insurance products across 

this country, we understand; we heard the challenges that you 

have. 

They are already exiting the market. What we need to do is to 

say, there is help on the way to allow us to reconstitute the individual and small-group market and allow for folks to gain the kind 

of coverage that they want for themselves and for their family—not 

what the government forces them to buy—that allows them to purchase coverage at a reasonable amount, that makes it so that they 

do not have deductibles through the roof, where they have the ability to pay the premiums and the deductible as well. 

So there are so many things that we ought to be focusing on to 

make certain, again, that the American people have access to the 

highest-quality care that is affordable for them. 

Senator ROBERTS. Doctor, I have 84 critical access hospitals in 

my State. They are all part of the rural health-care delivery system, which is under great stress. As we have seen when I visit 

with hospital administrators all throughout Kansas—there was a 

time I knew every one of them—they are scratching their heads 

over regulations coming out of HHS, CMS, and all the other agencies that you will oversee when you are confirmed. 

I mention the meaningful use program for electronic health care 

records. Doctors used to spend, what, 10 to 15 minutes with patients. It is now down to about 2 or 3, and then they have to report 

immediately on what was going on. 

The 96-hour rule for critical access hospitals, numerous other 

documentation requirements—it seems to me there is a lack of understanding of our provider shortages in our rural areas. We are 

just hanging on by a thread, and these one-size regulations from 

Washington simply do not translate to rural Kansas or any other 

rural area as far as population—— 

My question is, how will you work to ensure an effective but 

smarter, less-burdensome rulemaking process? 

Dr. PRICE. Well, this is really critical, Senator, because, as you 

mentioned, in the rural areas—Georgia is the largest State geographically east of the Mississippi, and we have a large rural population, and critical access hospitals are so important to communities around our State and truly around this Nation. 

But the regulatory scheme that has been put in place is choking 

the individuals who are actually trying to provide the care, so 

much so that you have physicians and other providers who are 

leaving the practice, who are leaving the caring for patients, not 

because they have forgotten how to do it or they have grown tired 

of it, but because of the onerous nature of the regulatory scheme 

coming out of Washington, DC. 

19 

The meaningful use project that you mentioned makes it that 

much more difficult. We have turned physicians into data-entry 

clerks. And you just have to ask them what they are doing. And 

if you talk to patients, what they recognize is that, when they go 

in to see their doctor, they see the top of his or her head as they 

are punching the information, the data into a computer, as opposed 

to that sharing of information that is so vital and necessary between the physician and the patient for quality health care. 

So, one, a recognition of the problem is incredibly important, a 

recognition of the importance of rural health care in our Nation 

and how it needs to be bolstered up, and then looking at the consequences of what we do as government. 

As I mentioned earlier, oftentimes I do not think we look at the 

consequences. We pass the rule, we pass the regulation, we institute it, we think it is the greatest thing since sliced bread, but in 

fact what it is doing is harming the very individuals who are trying 

to provide the care. You do not get that information unless you ask. 

Senator ROBERTS. All right, I appreciate that. My time is up. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Senator Nelson? 

Senator NELSON. Thank you, Mr. Chairman. 

Congressman, I enjoyed our visit yesterday. We had a discussion, 

when you were kind enough to come visit me, about the fact that 

I have in the State of Florida 4 million-plus seniors on Medicare, 

and they are petrified of the idea of privatized Medicare. 

And I talked to you about this. And you talked about the premium support system that you are advocating. And you pointed to 

a study that was done by CBO. You mentioned that you would 

send me a copy, and we have not gotten it. So what I did, I went 

and got the copy myself, and it is from September of 2013. And 

what it concludes is opposite of what you said with regard to highcost States like Florida. 

Medicare is going to be spending 4 percent less under the proposal that you were talking about in this CBO report, lower than 

current law, and beneficiary costs will decrease by 6 percent on the 

average, which is what you said yesterday. But in high-cost regions 

like Florida, you are going to have a higher beneficiary cost than 

current law under your premium support proposal. 

Annual premiums in Florida would increase 125 percent according to the CBO chart on page 71. CBO says that the annual premium in a high-cost region like Florida would be $3,600 compared 

to the current law of $1,600. That is a 125-percent increase. So 

please help clarify what you were saying yesterday as it applies to 

Florida. 

Dr. PRICE. Yes, thank you, Senator. And I enjoyed our time together as well. 

When we talk about Medicare, it is important for everybody to 

appreciate, as I know that you and your colleagues do, that the 

Medicare trustees, not Republicans or Democrats, the Medicare 

trustees have told all of us that Medicare in a very short period of 

time, less than 10 years, is going to be out of the kind of resources 

that will allow us as a society to keep the promise to beneficiaries 

in the Medicare program. 

20 

What that means is—and it is important to appreciate what that 

means—it means that we will not be able to provide the services 

to Medicare patients at that time, which is very, very close, if nothing is done. 

So my goal is to work with each and every one of you to make 

certain that we save and strengthen and secure Medicare. I think 

it is irresponsible of us as policymakers to allow a program to continue, knowing—knowing—that in a few short years it is not going 

to be able to cover the services that we are providing. So that is 

the first point, that the current Medicare program, if nothing is 

done, as some have described it, goes broke. 

The second point is that my role, if I am confirmed and have the 

privilege of serving as the Secretary of Health and Human Services, my role will be one of carrying out the law that you all in Congress pass. It is not the role of a legislator, which I had when I was 

working to try to formulate ideas to hopefully generate discussion 

and get to a solution—— 

Senator NELSON. Okay. Let me be so rude as to stop you, because 

I am running out of time. Remember that Donald Trump in the 

campaign said that he was not going to cut Medicare spending. 

And I would also point out to you a legislative solution—one of 

the greatest examples on Medicare is 1983, when we were just 

about to go bust and it took two old Irishmen, Reagan and O’Neill, 

to agree to come to an agreement that made, in this case it was 

not Medicare, it was Social Security, actuarily sound for the next 

half-century. 

Let me ask you, Representative Price: you had made a statement 

that it was a terrible idea for people who had preexisting conditions to have the protection of insurance against those preexisting 

conditions. 

And what I would like to ask you is, if you please, in light of 

President Trump expressing his desire to retain this basic protection, do you think his proposal to continue the ban on discriminating against people with preexisting conditions is a terrible idea? 

Dr. PRICE. No, and I am not certain where you are getting that 

quote from. What I have always—— 

Senator NELSON. It came from a Politico talking points memo, 

May 1, 2012. 

Dr. PRICE. Well now, there is a reliable source. [Laughter.] 

What I have always said, Senator, is that nobody—nobody—— 

Senator NELSON. So you did not say it is a terrible idea? 

Dr. PRICE. I do not believe I ever made that statement. What I 

have always said about preexisting conditions is that nobody, in a 

system that pays attention to patients, nobody ought to be priced 

out of the market for having a bad diagnosis. Nobody. That is a 

system, again, that may work for insurance companies, may work 

for government, but it does not work for patients. 

So I believe firmly that what we need is a system that recognizes 

that preexisting conditions do indeed exist and that we need to accommodate them and make certain that nobody loses their insurance or is unable to gain insurance because of a preexisting condition. 

21 

Senator NELSON. Mr. Chairman, as I close, I would like to insert 

in the record the September 2013 Congressional Budget Office 

analysis of premium support systems for Medicare. 

[The analysis appears in the appendix on p. 92.] 

Senator NELSON. And I would invite you, Congressman, to please 

respond with the CBO report that you said yesterday supports your 

position, because this one does not. 

Dr. PRICE. I look forward to that. Thank you, sir. 

The CHAIRMAN. Senator Menendez? 

Senator MENENDEZ. Well, thank you, Mr. Chairman. 

Congratulations, Congressman Price. 

Let me ask you a series of questions. Given your medical training 

and time spent as a practicing physician, I have a couple of simple 

‘‘yes’’ or ‘‘no’’ questions to start off with. 

In your medical opinion, does HIV cause AIDS? 

Dr. PRICE. I think that the scientific evidence is clear that HIV 

and AIDS are clinically, directly related. 

Senator MENENDEZ. In your medical opinion, have immigrants 

led to outbreaks of leprosy in the United States? 

Dr. PRICE. I do not know what you are referring to, but I suspect 

that there are instances where individuals have an infectious disease, and they come to the United States and that that—— 

Senator MENENDEZ. I am not asking about an infectious disease. 

I am asking specifically about immigrants in the United States 

causing leprosy in the United States, in your medical opinion and 

scientific background. 

Dr. PRICE. Again, I do not know the incident to which you refer. 

Are you referring to a specific incident? 

Senator MENENDEZ. There are statements that have been made 

in the public domain that immigrants have led to outbreaks of leprosy in the United States. As the person who is going to be designated as the director of Health and Human Services, that is not 

only the national, but the world’s health epicenter, I want to know, 

in your medical opinion, is there such a causation? 

Dr. PRICE. Any time you get two individuals together in any relationship whatsoever, whether it is an immigrant or a visitor, and 

one individual has an infectious disease, then it is possible that 

that individual transmits that infectious disease—— 

Senator MENENDEZ. Including leprosy? 

Dr. PRICE [continuing]. Whether it is the flu or a cold. 

Senator MENENDEZ. Including leprosy? Including leprosy? 

Dr. PRICE. Any infectious disease whatsoever. 

Senator MENENDEZ. In your medical opinion, do abortions cause 

breast cancer? 

Dr. PRICE. I think the science is relatively clear that that is not 

the case. 

Senator MENENDEZ. In your medical opinion, do vaccines cause 

autism? 

Dr. PRICE. Again, I think the science in that instance is that they 

do not, but there are individuals across our country who are 

very—— 

Senator MENENDEZ. I am not asking about individuals; I am 

talking about science, because you are going to head a department 

in which science, not alternate universes of people’s views, is going 

22 

to be central to a trillion-dollar budget and the health of the Nation. 

Can you commit to this committee and the American people 

today that, should you be confirmed, you will swiftly and unequivocally debunk false claims to protect the public health? 

Dr. PRICE. What I will commit to doing is doing the due diligence 

that the Department is known for and must do to make certain 

that the factual information is conveyed to, obviously, the President 

and to the American people. 

Senator MENENDEZ. And that factual information will be dictated 

by science, I would hope? 

Dr. PRICE. Without a doubt. 

Senator MENENDEZ. Okay. So let me ask you about Medicaid specifically. And let me just say I am a little taken back about your 

answer on the question of immigrants and leprosy. I think the 

science is pretty well dictated in that regard too. 

Let me ask you this. One of the most beneficial components of 

the Affordable Care Act was the expansion of the Medicaid program that resulted in 11 million people nationwide and over half 

a million in New Jersey gaining coverage, many for the first time. 

It is one of the biggest programs on the Republican chopping block 

with proposals to not only repeal the Affordable Care Act’s Medicaid expansion, but going further and gutting billions in Federal 

funding to the States. 

There is no doubt that this would result in catastrophic loss of 

coverage for tens of millions of low-income families and lead to tens 

of billions in losses to safety-net and other health-care providers. 

Do you recognize Medicaid to be a valuable program and consider 

the coverage it provides to 74 million Americans to be comprehensive? 

Dr. PRICE. Medicaid is a vital program for health care for many 

individuals in this country, but one that has significant challenges. 

There is one out of every three physicians who should be seeing 

Medicaid patients who are not taking any Medicaid patients. There 

is a reason for that. 

If we are honest with ourselves, we would be asking the question, why? 

Senator MENENDEZ. Well, if that is the case that one in three 

does not treat Medicaid patients, you have to ask yourself, is that 

because Medicaid reimbursements are so low? And since provider 

reimbursements are set at a State level, will not cutting Federal 

funding and hitting States with higher costs only lead to lower provider rates? And how many doctors would actually treat former 

Medicaid beneficiaries when they no longer have any coverage or 

ability to pay? 

So, even if there is only one of three, there are still two of three 

who are providing the services; imagine if you do not have coverage. 

Which goes to my next question. You have advocated to, in essence, block-grant Medicaid. Now, the essence of Medicaid is an entitlement, which under the law means, if I meet these criteria, I 

have the right to have that coverage under the law. When you 

move to a block grant, you remove the right and you make it a possibility subject to whatever funding there is going to be. 

23 

Do you recognize that in doing so you risk the potential of millions of Americans who presently enjoy health-care coverage 

through Medicaid no longer having that right? 

Dr. PRICE. I think that it is important to appreciate that no system that the President has supported or that I have supported 

would leave anybody without the opportunity to gain coverage. Nobody. 

Senator MENENDEZ. Well, that is not my question, so let me reiterate my question. Medicaid, under the law as it exists today, is 

a right. Is that not the case, ‘‘yes’’ or ‘‘no’’? 

Dr. PRICE. It is an entitlement program—— 

Senator MENENDEZ. And as an entitlement, does that not mean, 

if you meet the criteria, that you are entitled to the services? 

Dr. PRICE. If one is eligible, that is correct. 

Senator MENENDEZ. One is eligible, meaning you have a right. 

When you move to a block grant, do you still have the right? 

Dr. PRICE. No. I think it would be determined by how that was 

set up if, in fact, that was what Congress did. Again, the role of 

the Department of Health and Human Services is to administer the 

laws that you pass, not to make the law. 

Senator MENENDEZ. Yes, but I would just simply say to you, I 

know in our private conversation—and I appreciate you coming by 

to visit me—you suggested that your role is that of an administrator of a large department. Well, that is not even what the Vice 

President said when you were nominated. He said he expected your 

experience, both medically and legislatively, to help drive policy. 

And even beyond the expectations of the Vice President in that regard, when we have the ability of the Secretary to dictate regulation, that is policy. 

So please do not say to me, I am here just to do what Congress 

says. I respect that you will follow the law and do whatever Congress says. But you will have an enormous impact. And based upon 

your previous opinion as it relates to Medicaid, ultimately blockgranting means a loss of a right. And then it is just a question of 

funding, and then we will have a bigger problem with a number 

of providers’ will to provide. 

And so I hope we can get to a better understanding of your commitment to Medicaid as it is, as an entitlement, as a right. 

Dr. PRICE. Thank you, sir. 

The CHAIRMAN. Senator, your time is up. 

We will go to Senator Carper now. 

Senator CARPER. Congressman Price, welcome to you and to your 

wife. 

There is a verse of scripture—you mentioned earlier that you are 

active in your church—in the New Testament, in Matthew 25, 

which speaks to the ‘‘least of these.’’ When I was hungry, did you 

feed me? When I was naked, did you clothe me? When I was 

thirsty, did you give me to drink? When I was sick and in prison, 

did you visit me? When I was a stranger in your land, did you take 

me in? It says nothing about, when my only access to health-care 

coverage was going into the emergency room of a hospital, did you 

do anything about it? 

What we sought to do with the ACA was to do something about 

it. And we did not, in this room, invent the Affordable Care Act. 

24 

The genesis of the Affordable Care Act goes back to 1993 when Hillary Clinton, first lady, was working on what was called Hillarycare. And a group of Senators, led by Senator John Chafee, a Republican from Rhode Island, developed legislation co-sponsored by, 

I think, 23 Senators, including, as I recall, Senator Orrin Hatch 

and Senator Grassley. 

And what he did in his legislation, what he proposed in his legislation, was to use really five major concepts. One, to create large 

purchasing pools for folks who otherwise may not have access to 

health-care coverage. He called them exchanges or marketplaces. 

He also proposed that there be a sliding scale tax credit to buy 

down the cost of people getting coverage in those exchanges within 

the different States. 

The third thing he proposed was the notion that there should be 

an individual mandate. He wanted to make sure people got covered, and he realized if they did not mandate coverage or people 

getting coverage, then you would end up with insurance pools that 

health insurance companies could not begin to cover; it just would 

be unworkable. 

He proposed, as well, employer mandates. And he proposed, as 

well, the notion that people should not lose their coverage because 

of preexisting conditions. 

Those are not Democratic ideas. Those were proposed by Republican leadership actually in the Congress at the time. And when 

Governor Romney developed his own plan in Massachusetts, I do 

not know, a decade or so later, he borrowed liberally from those 

ideas. 

When they instituted it, as you may recall—they instituted what 

I call, what others call, Romneycare—they found they were doing 

a pretty good job on covering people, but not such a good job on 

affordability. And what took place over time was, they found out 

they had insurance pools where a lot of the people were not young, 

they were not very healthy, they were older, and they needed more 

health care. And as a result, the insurance companies, in order to 

be able to stay in business, had to raise the premiums. 

I do not know if any of this sounds familiar to you, but it sure 

sounds similar to what we have seen in the last 6 years or so with 

the Affordable Care Act. 

To the ideas of Senator Chafee and the ideas of Governor Romney, we have added some things. We have encouraged States to increase the number of people they cover under Medicaid by raising 

to about 135 percent of the poverty level the eligibility under which 

people can receive health care. We have encouraged a focus on prevention and wellness: not just treating people when they are sick, 

but also trying to make sure that people stay healthy in the first 

place. We provide funding for contraception. We provide funding for 

programs that are intended to reduce obesity. We have programs 

that are intended to reduce smoking, the use of tobacco. 

This is not a ‘‘yes’’ or ‘‘no’’ question. What was wrong with that 

approach? What is wrong with that approach? 

And the last thing I will say is this, before you answer. The 

health insurance companies found it difficult to stay in business in 

the State group exchanges across the country. One of the reasons 

why they were unable to is because, I think—really we learned this 

25 

from Massachusetts—we did not raise the fine or, if you will, we 

did not have the incentive high enough to get young, healthy people, like my sons, into the exchanges across the country. 

S&P, I am told, has just put out, about a month ago, an update 

looking at the financial health of the health insurance companies 

in this country as they have tried to figure out how to price this 

product. And it seems like, according to S&P, believe it or not, they 

seem to have sort of figured it out, because the financial health of 

the health insurance companies has begun to stabilize. Your reaction to this, please? 

Dr. PRICE. Well, as I mentioned either in my opening or in response to a question, the principles of health care that all of us 

hold dear—affordability and accessibility and quality and choices 

for patients—I think are the things that we all embrace. 

The next step, how we get to accomplish and meet those goals 

and those principles, is where it takes working together to do so. 

The program that you outline has much merit, whether it is 

making sure that individuals with preexisting illness and disease 

are able to access coverage, whether it is the pooling mechanisms 

which I have actively and aggressively supported for years, there 

is a lot of merit there. 

So again, what I am hopeful that we are able to do is to, in a 

collegial, bipartisan way, work together to solve the remarkable 

challenges that we have. 

One of my physician colleagues used to tell me that he never operated on a Democrat patient or a Republican patient, he operated 

on a patient. And that is the way that I view the system. It is not 

a Republican system, it is not a Democrat system, it is a system 

where hopefully we are focusing on the patients to, again, make 

certain that they have the access to the highest-quality care possible. 

Senator CARPER. Thank you for that. Let me just conclude, Mr. 

Chairman, by saying I will use an analogy. There is a large building, and there are people in the large building. And there is a fire 

in the large building, but for some reason they cannot use the 

stairways and they cannot use the elevators. And they look out the 

windows and there are firefighters down in the street saying, ‘‘Go 

ahead and jump, we will save you,’’ but they do not have any safety 

nets. 

And my fear is, if we repeal what I have described, the system 

that I described, that we put in place, the Affordable Care Act, 

largely founded on Republican ideas which I think were good ideas, 

and we do not have something at least as good in place to catch 

those people as they fall from the building, we will have done a disservice to them and to our country. 

Thank you. 

Dr. PRICE. Thank you. 

The CHAIRMAN. Thanks, Senator. Your time is up. 

Senator Burr? 

Senator BURR. Thank you, Mr. Chairman. 

And a quick reminder that the Affordable Care Act was passed 

with not one Republican vote in the House or the Senate. 

So, Dr. Price, a couple of questions just to cut to the chase. Are 

all of your assets currently disclosed publicly? 

26 

Dr. PRICE. They are now and they always have been. 

Senator BURR. Okay. Are you covered by the STOCK Act legislation passed by Congress that requires you and every other member 

to publicly disclose all sales and purchases of assets within 30 

days? 

Dr. PRICE. Yes, sir. 

Senator BURR. Now, you have been accused of not providing the 

committee information related to your tax and financial records 

that were required of you. Are there any records you have been 

asked to provide that you have refused to provide? 

Dr. PRICE. None whatsoever. 

Senator BURR. So all of your records are in? 

Dr. PRICE. Absolutely. 

Senator BURR. Now, I have to ask you, does it trouble you at all 

that, as a nominee to serve in this administration, some want to 

hold you to a different standard than you were held to as a member of Congress, and I might say the same standard that they currently buy and sell and trade assets on? Does it burn you that they 

want to hold you to a different standard now that you are a nominee than they are held to as a member? 

Dr. PRICE. Well, we know what is going on here. 

Senator BURR. Well, we do. We do. 

Dr. PRICE. And I understand. And as my wife tells me, I volunteered for this. 

Senator BURR. So let us go to substance. You and I have a lot 

in common. We both spoke out in opposition to Obamacare early. 

We predicted massive premium increases. When the President 

promised, if you like your doctors, you can keep them, if you like 

your plan, you can keep it, we both said these promises would be 

broken, and, in fact, they were. 

Over the last 7 years, you and I, Senator Hatch, Congressman 

Upton, and others have actually written our own health-care plans 

because we were, I think, brave enough to say that, if you are 

going to be critical of something, then put your ideas on the table. 

In your opinion, was it clear to the American people that repeal 

of Obamacare was a promise that Donald Trump made before he 

was elected president? 

Dr. PRICE. Well, I have no doubt that it played a very prominent 

role in this past election and that the President is committed to fulfilling that promise. 

Senator BURR. And as the nominee and hopefully—and I think 

you will be—the Secretary of HHS, what are the main goals of an 

Obamacare replacement plan? 

Dr. PRICE. The main goals, as I mentioned, are outlined in those 

principles. That it is imperative that we have a system that is accessible for every single American, that is affordable for every single American, that incentivizes and provides the highest-quality 

health care that the world knows, and provides choices to patients 

so that they are the ones selecting who is treating them, when, 

where, and the like. 

So it is complicated to do, but it is pretty simple stuff. 

Senator BURR. I want to thank you for not only testifying here, 

but testifying in front of the HELP Committee when Johnny and 

I both had you over there. You are brave to go through this, but 

27 

the country will be much better off with your guidance and your 

knowledge in this slot. 

Mr. Chairman, I yield back. 

Dr. PRICE. Thank you, sir. 

The CHAIRMAN. Thank you. 

Senator Cardin? 

Senator CARDIN. Thank you, Mr. Chairman. 

Dr. Price, again, thank you for your willingness to serve in this 

position. And we also thank your family for being willing to put up 

with your voluntary choices. 

I want to talk about a few issues in the time that I have. One, 

yesterday the President by executive order reinstituted the global 

gag rule, but he also did it in a way that is more comprehensive 

than the previous. The new policy would prohibit any Federal aid 

to foreign organizations that provide or promote abortion. 

In the past, the policy only applied to organizations that got family planning funding; now it will apply to organizations that get 

global health funding, potentially including maternal health programs, anti-Zika efforts, and expansion of PEPFAR to stop HIV/ 

AIDS. 

My question to you is this: if confirmed, how will you make sure 

that the U.S. can fully participate in these global health efforts to 

help with maternal health, to help in stopping of the spread of and 

ending HIV/AIDS, to make sure that the next Zika virus is contained so it does not cause catastrophic effects, if the global gag 

rule is enforced in a way that prevents us from participating in 

international health organizations? 

Dr. PRICE. Okay. This is really important, Senator, and I appreciate the question. The Department is full of all sorts of heroes, as 

you well know, and incredibly talented individuals. And my goal, 

if I am confirmed and given the privilege of serving as the Secretary of Health and Human Services, is to gather the best minds 

and the best talent that we have within the Department and without and determine what is the wisest policy for this Nation to have 

as it relates to, in this instance, infectious disease. 

Germs no know geographic boundaries. And we do incredible 

work, the work that the CDC does and the work that is done by 

others in our Nation, to try to work to prevent infectious disease, 

work to detect the spread of infectious disease. And then providing 

a logical and methodical and aggressive response to the outbreak 

of any infectious disease is absolutely vital to protect the American 

people, and we are committed to doing so. 

Senator CARDIN. And I agree with that. I just hope that you will 

look at perhaps unintended consequences from these executive orders that could compromise our ability to be as effective as we need 

to, using all tools at our disposal. 

I want to get to tobacco regulation for one moment, an area that 

I think is now clear within the medical community, the impact that 

tobacco has, the fact that the Family Smoking Prevention and Tobacco Control Act of 2009 authorizes the HHS Secretary, through 

FDA, to regulate tobacco products, including restricting the sale of 

tobacco products to minors. It also has been expanded to include 

the selling of e-cigarettes, et cetera. 

28 

I know initially you did not support that legislation. If confirmed, 

can you commit to us that you would rigorously enforce that act to 

make sure particularly our children are not subjected to the new 

forms of tobacco products? 

Dr. PRICE. If I am confirmed, the responsibility that we will have 

is to enforce the law of the land, and we will do so. 

Senator CARDIN. It also requires keeping up with new technologies that are being used by the industry that may require 

modifications, as we see with e-cigarettes. Are you prepared to not 

only enforce the law, but to enforce our intent to make sure our 

children are protected? 

Dr. PRICE. Yes, I look forward to working with you, Senator, on 

just that. 

Senator CARDIN. I was listening to some of the exchanges related 

to the Affordable Care Act, and we will continue to debate the merits of the Affordable Care Act. I am a strong supporter of it. I think 

millions of people have coverage who did not have it before, the 

quality of coverage that Americans now have did not exist before, 

and the rate of growth of our health-care premiums is far lower 

than it would have been but for the Act. We will debate that later. 

The question is, what is coming along? I mean, we have heard 

you say several times the principles that the President has articulated as to what would be in place of the Affordable Care Act. 

I would like just to drill down a little bit, if I could, on essential 

health benefits. We have talked about preventive care now being 

available. We know that we have now mental health and addiction 

services that are available. We also know we have oral health, pediatric dental, that is now available, which is particularly important in my State because of the tragic loss of Deamonte Driver in 

2007. 

Can you assure us that, as you look at what will be the healthcare system moving forward, you are prepared to make sure that 

Americans have quality insurance coverage to deal with issues 

such as preventive care, mental health services, addiction services, 

and pediatric dental? 

Dr. PRICE. What I can commit to you, Senator, is that we will 

do all that we can within the Department with the incredible 

knowledge and expertise that is there to define whether or not the 

program is actually working as intended or not, if coverage equals 

care. In many instances, I would suggest that many individuals 

right now have ‘‘coverage.’’ They have a card, but they do not have 

any care, because they cannot afford the deductible that allows 

them to get the care. 

So we are committed to making certain that the program works, 

not just for government, not just for the insurance companies, but 

for the patients. 

Senator CARDIN. And as you know, we eliminated any copays on 

preventive care. But we can talk about the specifics going forward. 

I look forward to those discussions. Thank you, Mr. Chairman. 

Dr. PRICE. Thank you. 

The CHAIRMAN. Thank you, Senator. 

Senator Isakson? 

Senator ISAKSON. Thank you, Mr. Chairman. 

29 

Tom, as Secretary-to-be, let me ask you a few ‘‘yes’’ or ‘‘no’’ questions. You have been asked a lot of them with the intent of trying 

to get you to say ‘‘yes’’ that you are going to cut Medicare when 

you are not going to cut Medicare; you are going to try to improve 

it and reform it. 

But ‘‘yes’’ or ‘‘no’’ to these questions. Question number one: we 

have been hearing about the joint replacement program that Secretary Burwell launched in 2015. You and many others have raised 

concerns about this program saving money, that it could actually 

harm the quality of patient care. So in other words, was this an 

administrative action by HHS that actually cut a Medicare benefit? 

Dr. PRICE. Potentially, yes. 

Senator ISAKSON. Second: last year, HHS proposed a new way of 

paying for cancer drugs so as to reduce Medicare spending on these 

drugs. Many of us opposed this from our side of the aisle as well 

as the other. We were concerned it would cut cancer patients’ benefits and, more often, it would be a cut to the Medicare benefit to 

seniors. Is that correct? 

Dr. PRICE. I believe that is correct. Yes. 

Senator ISAKSON. Last one: what about all the recent changes 

HHS has made to cut Medicare payments to Medicare Advantage? 

Nearly one-third of all Medicare beneficiaries are on Medicare Advantage. Would these cuts not also break the pledge of not cutting 

Medicare? 

Dr. PRICE. I believe so. 

Senator ISAKSON. My point being, any one of us can sit at this 

dais and say give me ‘‘yes’’ or ‘‘no’’ answers and demonstrate the 

point we want to make, but that all of us, Republican and Democrat alike, are interested in saving Social Security for our seniors, 

making Medicare work, and saving the taxpayers’ money in the 

United States of America. Is that not true? 

Dr. PRICE. Absolutely. 

Senator ISAKSON. And one other point. Any one of us can take 

a financial disclosure, using something called disparate impact, 

where you take two facts, one over here and one over there, to 

make a wrong. Any one of us could do it to disrupt or misdirect 

people’s thoughts on somebody. It has been happening to you a lot 

because people have taken things that you have disclosed and tried 

to extrapolate some evil that would keep you from being Secretary 

of HHS when, in fact, it should not be true. 

For example, if you go to Senator Wyden’s annual report, he 

owns an interest in BlackRock Floating Rate Income Fund. The 

major holding of that fund is Valeant Pharmaceuticals. They are 

the people we jumped all over for 2,700-percent increases last year 

in pharmaceutical products. But we are not accusing the ranking 

member of being for raising pharmaceutical prices, but you could 

take that extrapolation out of that and then indict somebody and 

accuse them. Is that not true? 

Dr. PRICE. I think that is correct, yes, sir. 

Senator ISAKSON. So the point of that is, we ought to in the end 

be looking for the best person, man or woman, for the job and not 

trying to trick them into agreeing to something that is wrong, but 

in fact let them execute the programs that improve Medicare for 

the American people. 

30 

Dr. PRICE. Yes, sir. 

Senator ISAKSON. I thank you for your time. And I reserve the 

rest of my time. 

Senator WYDEN. A point of personal privilege, Mr. Chairman. 

The CHAIRMAN. Senator Wyden? 

Senator WYDEN. I do not trade in health-care stocks. 

The CHAIRMAN. Okay. Did you care to—— 

Senator ISAKSON. My only point to the Senator from Oregon is, 

you do have mutual funds like most of us have. The mutual funds 

have holdings in pharmaceuticals, many of them, one of them you 

own. But nobody should accuse somebody of holding pharmaceutical stocks if they have a mutual fund by pulling—— 

Senator WYDEN. Mr. Chairman, to continue on this point of personal privilege. Mutual funds in particular, by independent experts, ethics experts, are considered in a completely different category than personal trading in stocks. Even past Republican ethics 

experts make that same point, and they have never seen anything 

like what the Congressman has engaged in. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Senator Brown? 

Senator BROWN. Thank you, Mr. Chairman. 

And welcome, Congressman Price. 

Dr. PRICE. Thank you, Senator. 

Senator BROWN. I was troubled by your response to Senator 

Wyden when he asked the question, if you repeal the Affordable 

Care Act, will you commit that no one will lose insurance? That is 

22 million Americans, almost 1 million in my State. 

He asked, will you commit that no one will lose their insurance? 

And you ignored the question and responded that no one who lost 

their insurance under the Affordable Care Act—and to my knowledge that is 2 million to 4 million people, and almost all of them 

ended up getting reinsured—you said that no one who lost their insurance under the Affordable Care Act will basically lose it after 

they have been reinstated. 

So you pretty much ignored the 22 million, and that is the problem we all face. But I want to ask you about something else. 

If you are confirmed, obviously you will play a role in the repeal 

of the Affordable Care Act. I would like to ask you ‘‘yes’’ or ‘‘no’’ 

questions, and they really are ‘‘yes’’ or ‘‘no’’ questions; they are not 

meant as a trap. 

Marguerite is from Lyndhurst, OH. She suffers from a chronic 

condition. She was turned down by insurance companies for 25 

years before the ACA. She will lose her insurance if the ban 

against discrimination based on existing conditions is weakened. 

My question is, if you are confirmed, will you maintain the current scope of the law and continue to vigorously enforce the law’s 

ban against discriminating against individuals with preexisting 

conditions, ‘‘yes’’ or ‘‘no’’? 

Dr. PRICE. I commit to you that we will not abandon individuals 

with preexisting illness or disease. 

Senator BROWN. Thank you. Victoria is from Buckeye Lake, OH. 

As a senior on Medicare, she relies on free preventive services provided by the ACA. Will you commit to ensuring seniors like VicVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00034 Fmt 6633 Sfmt 6633 R:\DOCS\30005.000 TIM
31 

toria, who rely on Medicare, continue to get their preventive care— 

no copays, no deductibles, no out-of-pocket costs, ‘‘yes’’ or ‘‘no’’? 

Dr. PRICE. Preventive care and wellness care are absolutely vital 

for so many members of our population. 

Senator BROWN. That is part of ACA. You will commit to that? 

Dr. PRICE. And I believe it is a part of health care and health 

coverage, and it ought to be a priority. 

Senator BROWN. Yes, and we did that. Okay, I do not mean to 

be rude. We did that under the ACA. 

Grace is from Westlake, OH. She is 24. She was diagnosed with 

stage four metastatic melanoma in 2015. She is still on her parent’s health insurance, which was purchased through the ACA 

marketplace, and she benefits from the ACA’s ban on annual lifetime coverage maximums. Her first 3 months of treatment cost 

$800,000. As Secretary of HHS, if an insurer asks you for an exception to the current ban on out-of-pocket maximums as provided in 

Friday’s executive order, will you commit to stand up for patients 

like Grace and refuse to grant any insurer this exception? 

Dr. PRICE. As I mentioned, I think patients ought to be at the 

center, and our goal is to make certain that every single patient 

has access to the highest-quality care. 

Senator BROWN. I do not want it as your goal, I want you to commit that you will stand firm, as the ACA does, on this provision 

of canceling care, canceling insurance, because patients are too expensive. 

Dr. PRICE. As I said, nobody ought to lose their insurance because they get a bad diagnosis. 

Senator BROWN. Okay. Alice is from Bethel, OH. Prior to the 

ACA, she could not afford her preferred method of birth control. 

Now thanks to the law, she benefits from covered contraceptive 

coverage. Are you able to set aside any personal political views and 

protect the doctor/patient relationship by committing to ensure 

every woman’s right to access the form of contraception deemed 

best for her by her doctor at no cost, as currently provided in the 

ACA? 

Dr. PRICE. I think that contraception is absolutely imperative for 

many, many women. And the system that we ought to have in 

place is one that allows women to be able to purchase the kind of 

contraception that they desire, between their doctor and themselves. 

Senator BROWN. As the law is now with the ACA. Thank you. 

President Trump said he is working with you on a replacement 

plan for the ACA, which is nearly finished and will be revealed 

after your confirmation. Is that true? 

Dr. PRICE. It is true that he said that, yes. [Laughter.] 

Senator BROWN. So not that he has ever done this before, but did 

the President lie? Did the President lie about this, that he is working with you? He said he is working with you. I know we do not 

use the word ‘‘lie’’ here because we are polite when Presidents say 

statements that are not true. But did he lie to the public about 

working with you? 

Dr. PRICE. I have had conversations with the President about 

health care, yes. 

32 

Senator BROWN. Which is not quite an answer, so will you commit, with this President’s plan, to maintaining the protections for 

those Ohioans you just committed to in the replacement plan? 

Dr. PRICE. Our commitment is to make certain that every single 

American has access to the highest-quality coverage and care possible. 

Senator BROWN. I am still not sure if the President lied, not to 

you, but to us, the public, about whether he is actually working 

with you. It sounds like he did. 

Last series of questions briefly, Mr. Chairman. 

I want to find out about the Children’s Health Insurance Program. You said last week to staff that it has been a remarkably 

successful program. You once earlier had said it sounds like socialized medicine to you. I do not quite know what that means. 

Ninety-five percent of children in America are currently insured. 

I know about the chairman’s interest in CHIP, the Children’s 

Health Insurance Program. Ninety-five percent of American children are insured now, partly because of Medicaid expansion, partly 

because of CHIP. 

You discussed the importance of using the right metrics, so my 

question is this. Funding for CHIP, I think you know, is set to expire in September. If confirmed, would you advise the President to 

support an extension of CHIP and the Pediatric Quality Measures 

Program beyond September of this year? 

Dr. PRICE. Absolutely, but I want to expand a little bit because, 

after last week’s hearing in the HELP Committee, the same question was asked, quoting me as saying that CHIP was socialized 

medicine. And so I went back and looked at that article, and as so 

often happens, as you well know, though this may have never happened to you, it was a characterization in the article by the author 

of the article to push a political point of view. 

And I knew that was the case because I rarely, if ever, use that 

word. I talk about patients as being the focus. I do not talk about 

government being the focus. 

Senator BROWN. Okay. I am sorry. That is fine. I want to ask you 

specifically on CHIP. Last week, MACPAC submitted a report to 

Congress advising we extend the current CHIP program and the 

Quality Measures Program for 5 more years. Do you agree with 

this? 

Dr. PRICE. I think the CHIP program, with policymakers, has to 

be looked at, and I believe it ought to be extended. 

Senator BROWN. For 5 years? 

Dr. PRICE. Well, if we could extend it for 8, it would probably be 

better than 5. 

Senator BROWN. Okay. Thank you, Mr. Chairman. 

The CHAIRMAN. Well, thank you, Senator. 

Let us go to Senator Portman. 

Senator PORTMAN. Thank you, Mr. Chairman. 

I have a lot of questions, so I am glad you are letting people go 

a couple of minutes over, because I may need that time. 

Dr. PRICE. I am not. [Laughter.] 

The CHAIRMAN. We have been letting the other side go a couple 

of minutes over. We are not going to let our side go a couple of 

minutes over. 

33 

Senator PORTMAN. Okay, well I would like that time back. 

[Laughter.] 

First of all, Dr. Price, thank you very much for your willingness 

to serve. We need you. 

As you know, a couple of weeks ago Congress passed a budget 

resolution to set up a process that gives us the possibility of replacing the Affordable Care Act with policies that work better, particularly to reduce skyrocketing health-care costs that affect my constituents in Ohio. It is not just premiums. It is deductibles and 

copays, and also, people need more choices in health care. 

I did join with four of my colleagues, as you know—we talked 

about this—introducing an amendment that would have ensured 

we had enough time for the next step in the process. And I believe 

we got assurances for that to ensure that we have time to work 

with you, frankly. We need somebody at HHS in place who can 

work with us to be sure that the legislative and the administrative 

policies are working together and that this is done carefully. 

Prior to the Affordable Care Act, we had a very competitive insurance market in Ohio; now we do not. In fact, if you look at what 

has happened due to the increased regulations and mandates, we 

have a dramatically decreased competitive market. We went from 

having 17 insurers offering plans last year on the exchanges to 11 

now. We have 20 counties now in Ohio, over one-quarter of our 

counties, that only have one health-care insurance company offering plans. We used to have no counties in that situation. 

I know we are doing better than the rest of the country, actually, 

because about a third of the counties only have one insurer, and 

some of them have only one insurer in the entire State. 

Now that we have begun this process of replacement and the 

President has issued his executive order, what can we do, briefly? 

What actions can you take through your authority as Secretary to 

ensure that my constituents in Ohio have access to affordable 

health-care coverage with a healthy insurance market? 

Dr. PRICE. Well, what you laid out is the challenge that we have 

all across the Nation. And Ohio is doing better than other States, 

as you noted. 

But it is important to appreciate that things have gotten worse 

for the individual and small-group market, and we believe, I believe, that it is a direct result of policies that have come from 

Washington, DC, directly from the Affordable Care Act. 

So if we are honest with ourselves and honest with our constituents about trying to solve the challenges that they have to gain access to coverage that they want, then we ought to look at that and 

say, how do we fix that? And the way that you fix that is to make 

it so that individuals have the choices—one of the principles I mentioned—that we allow for pooling mechanisms that provide for individuals to have opportunities to recreate and reconstitute that individual and small-group market, which now does not exist. 

Senator PORTMAN. And by the way, I appreciate your response to 

my colleague from Ohio about protecting people who have preexisting conditions. And one way you do that, obviously, is through 

those risk pools, and, again, many States had good risk pools that 

were working before the Affordable Care Act to help in that regard. 

34 

As you know, Congress recently passed legislation authored with 

Senator Whitehouse called CARA, our Comprehensive Addiction 

and Recovery Act. And it is meant to address this opioid crisis we 

face—heroin, prescription drugs. 

We are now working to both fully fund—and the funding is there 

in place for this new program—and now to implement it. And a lot 

of the implementation goes through SAMHSA; almost half of the 

funding under new grant programs goes through HHS and 

SAMHSA. 

What should be done to ensure access to addiction treatment for 

those individuals currently getting insurance coverage through the 

exchanges or Medicaid expansion? And do you commit to us today 

to fully implement and implement promptly the new legislation? 

Dr. PRICE. Without a doubt. As you know, Senator, this is a 

scourge that has gone all across the country, and it is in communities large and small, destroying lives, destroying families, harming communities. And it is growing. 

And so what we must do is absolutely commit to carrying out the 

law as it was passed, but also—as I have talked about with some 

other challenges—make certain that we have the right metrics in 

place. Are we actually helping with what we are doing? 

There may be better things to do there, maybe things that we 

think we ought to do that in fact do not help, and we ought to be 

identifying those as much in real time as possible so that we can 

bring about a program that is actually making it work for the patients, for the individuals who are actually being harmed. 

Senator PORTMAN. One example of that, quickly. You are aware, 

I think, of the Institution for Mental Disease rule that says if you 

have an inpatient treatment center, it has to be limited to 16 beds. 

Would you be willing to look at that rule to see if we can get that 

number up to be able to provide more of this treatment? 

Dr. PRICE. I think that is one of the rules that has to be looked 

at. I think the 3-day stay rule in facilities is another, where oftentimes many of these individuals have some mental illness as well, 

and the limitation on being able to keep folks on an inpatient basis 

when all of the health-care professionals involved in their care say 

they ought to, but in fact that is not what is covered, makes no 

sense. And therefore, they are put back out on the street, and the 

challenge is, we just get in this revolving door. 

Senator PORTMAN. A final question, and maybe you could respond to this in writing, because my time is expiring based on the 

allocation here. 

With regard to the waivers, you know, Ohio applied for a waiver, 

and this was an 1115 waiver for Medicaid, to be able to better 

cover people under Medicaid. We were rejected by CMS. I know 

you have Seema Verma coming in who has worked on these over 

time. 

Do you believe that during this replacement time we should 

cover people under Medicaid expansion but then move to a program 

that is more flexible to provide better care under Medicaid? 

Dr. PRICE. I think there have to be better ways to provide care 

to the Medicaid population, because there are huge challenges right 

now, as I mentioned before. And the people whom we need to be 

listening to are the Governors and the State insurance commisVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00038 Fmt 6633 Sfmt 6633 R:\DOCS\30005.000 TIM
35 

sioners and the folks on the ground actually providing the care. 

And if we listen to them, I think they will guide us in the right 

direction in terms of policy. 

The CHAIRMAN. Senator, your time is up. 

Senator PORTMAN. Thank you, Mr. Chairman. 

The CHAIRMAN. Senator Bennet? 

Senator BENNET. Thank you, Mr. Chairman. 

I want to thank my colleague from Ohio for his graciousness in 

not going too over. 

Congressman Price, you have said a couple of times—I may misquote you a little, I hope not—that the goal here is access to the 

highest-quality coverage and the highest-quality health care for all 

Americans. Is that roughly where you would like to head? And I 

think that is a worthy goal. 

Dr. PRICE. Yes. 

Senator BENNET. And just piggybacking on what Senator Portman was asking you about, I am worried today—whether it is the 

Affordable Care Act or not the Affordable Care Act, whether it is 

the insurance market—that people, especially in rural parts of this 

country, in rural parts of my State, are not getting the access they 

need to high-quality health care, are not getting the access they 

need to high-quality choices in terms of insurance. 

I worry a little bit, and whether we are trying to repeal the Affordable Care Act or we are trying to fix the Affordable Care Act, 

I think it is incumbent on all of us not to make matters worse for 

rural America in doing what we are doing. And I know you share 

that goal. 

Dr. PRICE. Absolutely. 

Senator BENNET. And you talked about pooling as one solution. 

I wanted to talk a little bit or ask you a little bit about your projected quality of insurance in these markets, because one answer 

that I have heard from folks, including yourself, over the weeks has 

been making sure that people have the opportunity to buy coverage 

for catastrophic care. 

I wonder whether you also believe that it is essential that there 

be a floor for insurance providers. You know, some of the things 

that the Affordable Care Act requires for coverage include outpatient care, emergency services, hospitalization, maternity and 

newborn care, prescription drugs, rehab services, lab services, preventative care such as birth control and mammograms, pediatric 

services like vaccines, and routine dental exams for children younger than 19. 

I am not going to ask you to go through each one of those. But 

directionally, are we headed to a world where people in rural 

America have to settle for coverage for catastrophic care? Are we 

headed to a place where there is regulation of insurance providers 

that says if you are going to be in the insurance market, particularly if we are in a world where you are selling across State lines, 

there has to be a floor on the services you are willing to pay for? 

Dr. PRICE. I think there has to be absolutely credible coverage. 

And I think that it is important that individuals ought to be able 

to purchase the coverage that they want. 

Senator BENNET. I just do not want us to get to a place where 

people in America have to settle for something that no one else in 

36 

the industrialized world has to settle for. Why should they have to 

pay out of pocket month after month after month for something 

that is not going to cover something as basic as a hospitalization 

or maternity services or, you know, the rest of this list? There may 

be certain things on the list we disagree with. 

But I am worried that we are heading toward a place where 

somehow that choice is accepting a world that no one else in the 

industrialized world has to accept. And I applaud your goal, and 

I hope we can work together to make it so. 

Dr. PRICE. As do I. 

Senator BENNET. You mentioned that we should listen to the 

Governors, which brings me to my second question and your answer to Senator Portman. 

In Colorado—you may have heard of this—we have something 

called the Accountable Care Collaborative that is a unique approach to Medicaid. It connects members with coordinated primary 

care providers while reducing barriers to access. It also provides coordinated care for those with dual eligibility for Medicare and Medicaid. I do not have it today, but I could show you that the cost 

curve there is really starting to turn around because of the coordinated care that is happening out there. 

When asked about the need for more State flexibility, which is 

an argument that is made to carry out innovative programs like 

the one in Colorado, our Governor said that, quote, ‘‘Greater flexibility cannot make up for the lack of funding. Should the Federal 

Government pull back its financial commitments, we simply cannot 

afford to make up the difference.’’ 

So I would ask you whether you agree with our Governor’s assessment that while flexibility is helpful, it is not a replacement for 

critical funding needs. 

Dr. PRICE. I think so. And the decision for funding obviously is 

a legislative decision. 

Senator BENNET. But that is a very fundamental component of 

the Affordable Care Act, the expansion of Medicaid, would you not 

agree? 

Dr. PRICE. And that decision whether or not to change that is a 

decision that you and every member of the committee and Congress 

will be involved in. And if I am fortunate enough to serve as the 

Secretary of Health and Human Services, we will carry out the law 

that you pass. 

Senator BENNET. I appreciate that. In your mind, though, does 

the repeal of the Affordable Care Act include a repeal of the expansion of Medicaid that was part of the passage of the Affordable 

Care Act? 

Dr. PRICE. Any reform or improvement that I would envision for 

any portion of the Affordable Care Act would be one that would include an opportunity for individuals to gain coverage, the kind of 

coverage, again, that they want, the highest-quality health care. 

Senator BENNET. But that is not the question I asked. 

And I am sorry, Mr. Chairman; I realize I am at the end of my 

time. 

Do you believe that a repeal—I mean, this is what the President 

ran on—of the Affordable Care Act includes the repeal of the exVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00040 Fmt 6633 Sfmt 6633 R:\DOCS\30005.000 TIM
37 

pansion of Medicaid that was a fundamental part of the Affordable 

Care Act? 

Dr. PRICE. Again, that is a decision that you all would make. 

Senator BENNET. That is true. 

Dr. PRICE. What I believe is that any reform or improvement 

must include a coverage option and opportunity for every single 

American, including those who are either currently in or close to 

joining the Medicaid population in a given State, which changes depending on the State. 

Senator BENNET. Okay. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Well, thank you, Senator Bennet. 

Let us go to Senator Toomey. 

Senator TOOMEY. Thank you, Mr. Chairman. 

Congressman Price, thank you for joining us. 

Dr. PRICE. Thank you. 

Senator TOOMEY. Thanks for the great work you have done in 

the House and your willingness to serve in this extremely important post. I appreciate it, and I enjoyed the conversation that we 

had a little while back. 

I do think it bears reminding everyone as we talk about Obamacare that certainly the individual market is in a classic death spiral. The adverse selection is destroying that market. It is in a 

freefall. In Pennsylvania, 40 percent of all Pennsylvanians in the 

Obamacare exchanges have a grand total of one choice, and that 

very typically does not include whatever they had before and were 

promised they could keep, which, of course, was never true. 

So we have a system that is in collapse. And what we are trying 

to do is figure out what is a better way to go forward. Now, when 

we talk about repeal, sometimes I hear people say, well, but we 

have to keep coverage of preexisting conditions because, you know, 

we have to keep that. And when I hear that, I think that we are 

missing something here. 

And here is what I am getting at. There are obviously a number 

of Americans who suffer from chronic, expensive health-care needs. 

They have had these conditions sometimes all their lives, sometimes for some other period of time. And for many of them, the 

proper care for those conditions is unaffordable. 

I think we agree that we want to make sure those people get the 

health care they need. Now, one way to force it is to force insurance companies to provide health insurance coverage for someone 

as soon as they show up, regardless of what condition they have, 

which is kind of like asking the property casualty company to rebuild the house after it has burned down. But that is only one way 

to deal with this. 

And so am I correct, is it your view that there are other, perhaps 

more effective ways, since, after all, Obamacare is in a collapse, to 

make sure that people with these preexisting, chronic conditions 

get the health care that they need at an affordable price without 

necessarily having the guaranteed issue mandate in the general 

population? 

Dr. PRICE. I think there are other options. And I think it is important, again, to appreciate that the position that we currently 

find ourselves in with policy in this Nation is that those folks, in 

38 

a very short period of time, are going to have nothing because of 

the collapse of the market. 

Senator TOOMEY. Right. The second topic is, I think you and I 

share a goal of having health care that is much, much more driven 

by individuals, families, patients, consumers—consumer-centric 

rather than bureaucrat-centric, which is what Obamacare is. 

Do you agree with me that to get there we need to do more about 

the transparency of health-care outcomes so that informed consumers can evaluate among different physicians, different hospitals 

that really get the best outcomes? Do we need to do more there? 

Dr. PRICE. Absolutely. And this is an important point. And it is 

not just in outcomes. Outcomes are important, and we need to be 

measuring what actually makes sense from a quality standpoint 

and allow patients and others to see what those outcomes are. 

But it is transparency in pricing as well, and right now we do 

not have that. So if you are individual out there and you, in fact, 

want to know what something costs, it is virtually impossible to 

find out what that is. There are all sorts of reasons for that. 

But if we are honest with ourselves as policymakers and we want 

to make the system patient-friendly, not insurance-friendly or 

government-friendly, but patient-friendly, then we would make 

that a priority. And if I am confirmed, I hope to do so. 

Senator TOOMEY. I think Medicare and Medicaid, CMS, can play 

a big role in advancing that. Ultimately, I think the more we diminish dependence on third-party payers and allow the evolution 

of a market that responds to individuals, individuals will demand 

that information the way they do in every other market. 

Dr. PRICE. Right. 

Senator TOOMEY. The last point I want to touch on, if I could, 

has to do with NIH research and specifically Alzheimers. It is my 

view that we ought to think of Alzheimers as a disease in a category of its own. And I say that because there is no disease like 

it that we know of that afflicts Americans today. There are 5.2 million Americans with the disease right now. It is 100-percent fatal. 

It is the sixth-leading cause of death. There is no cure, there is no 

treatment; there is nothing. 

And yet, for fiscal year 2016, NIH spending is a grand total of 

$168 per diagnosed patient. It seems to me that the expenditures 

are wildly out of line with the severity and the breadth and the 

scope of this disease. And I wonder if you would commit to working 

with me and others who share this view to ensure that we have 

a better proportionality in terms of the allocation of resources in 

the breadth and severity of illnesses. 

Dr. PRICE. I think it is absolutely imperative, Senator, and I look 

forward to working with you. 

Senator TOOMEY. Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator. 

Senator Thune? 

Senator THUNE. Thank you, Mr. Chairman. 

Dr. Price, welcome, and thank you for your willingness to serve 

in this very important capacity. We have a lot of challenges ahead 

that we need to take on. 

As I met with you a couple of weeks ago, one of the issues that 

is of particular interest to me, which I conveyed to you, is this issue 

39 

of Indian Health Service. In 2010, there were some systemic problems that were uncovered in South Dakota. And an administrative 

action plan was set in motion to help remedy many of these findings. Similar issues popped up again throughout South Dakota in 

2015, and they continue to this day. And after oversight hearings, 

it became abundantly clear that, time and again, there was a lack 

of follow-through by the agency. 

And my question is, will you commit to follow up with me in 

writing that you will designate someone at HHS to be the point 

person that my staff and I can contact to ensure, one, that reforms 

are being implemented, and two, that we continue to collaborate on 

reform in the IHS? 

Dr. PRICE. Absolutely, Senator. This is an area that is of significant concern, because it appears to me, as I know you shared with 

me, that in the Indian Health Service there are so many areas 

where we are not meeting the goal of the highest-quality care being 

provided to individuals accessing that system. 

And so we are not doing what we ought to do in that system. 

And I am committed to making certain, should I be confirmed, to 

turn that system around. 

Senator THUNE. And as I shared with you, Senator Barrasso and 

I introduced a bill last year called the IHS Accountability Act 

which we believe will bring about a lot of structural changes within 

the IHS. And as I have said many times, that act, although we 

think it addresses a lot of the problems that have cropped up—and 

it was based upon consultation that we received from the tribes— 

really is merely a first step in the process that is necessary to improve that agency. 

If confirmed, what types of reforms could you see yourself supporting when it comes to the IHS and, obviously, starting perhaps 

with our legislation? I do not know, you probably have not had a 

chance to look carefully at that yet, so I will not ask you to comment specifically on it. But are there thoughts that you have with 

respect to the IHS when it comes to reforms that you could work 

with us on? 

Dr. PRICE. Yes, I appreciate that. I have had the privilege of visiting some IHS facilities in the State of Wisconsin and a couple of 

facilities that were doing remarkable work. And it appears to me 

that what we have not done—and if I am confirmed, I look forward 

to getting into this area within the Department itself—is identified 

best practices within the IHS system itself and shared those and 

incentivized the ability to move that kind of activity that is providing high-quality care for individuals in that system in certain 

areas to make certain that we are able to extend that across the 

country in the IHS. 

Senator THUNE. Okay. Well, we look forward to working with you 

on that. I think best practices is a good place to start. And obviously, those have not been employed in a lot of facilities in our 

State. 

In 2009, CMS issued a final rule that required all outpatient 

therapeutic services to be provided under direct supervision. Every 

year since then, the rule has been delayed, either administratively 

or legislatively, for critical access and small and rural hospitals. 

40 

And I shared this with you as well. In my State, obviously, we 

have a lot of critical access hospitals, a lot of very rural areas, big 

geography to cover, and it is sometimes difficult to get providers 

out to these areas. So the question is, if confirmed, will you work 

to permanently extend the nonenforcement of this regulation of 

these hospitals in order to remove this regulatory burden? 

Dr. PRICE. Yes, I look forward to working with you on it, Senator. 

I think there are areas, from a technological standpoint, where we 

are missing the boat, especially in our rural areas and the critical 

access hospitals. In every other industry out there, the information 

technology age has arrived and is moving across the land with 

rapid speed and has done so. 

However, it seems that in health care we have put roadblocks up 

to the expansion of technology, especially into the rural areas. And 

we ought to be incentivizing that so that, again, the patients are 

able to receive the highest-quality care. 

It is possible now, for example, in our State, if you are an individual who is suspected of having a stroke, you go to a critical access hospital in a rural area, it is possible by telemedicine to be 

able to access one of the world’s foremost specialists in stroke treatment by telemedicine at the university health center. So that is improving the lives and care of patients across our State. 

And I think there are so many things that we could do that 

would mirror that kind of technological expansion. 

Senator THUNE. Thank you. There is one final point I will make, 

because my time is expiring. But I know you have probably been 

questioned already a good amount about what happens next with 

respect to replacing Obamacare. I would simply say that I hope we 

can work with you in beginning to shift a lot of the—giving the 

States, I guess I would say, more flexibility when it comes to designing plans that work in our States. 

I think one of the problems that we have had with this is there 

is just too much dictation from Washington, DC and too much onesize-fits-all. And that is something I think that most States would 

probably agree with, and certainly, I think, most providers would 

agree with as well. 

So we look forward to working with you and designing programs 

that get that flexibility to our States and put them more in charge 

of some of these issues in a way that removes that power from 

Washington, DC, where I think too many of the problems have 

been happening. 

Thank you, Mr. Chairman. 

Dr. PRICE. Yes, sir. I look forward to it. 

The CHAIRMAN. Senator Casey? 

Senator CASEY. Thank you, Mr. Chairman. 

Dr. Price, good to be with you again. 

Dr. PRICE. Thank you. 

Senator CASEY. I want to ask you a couple of questions that center principally on children and individuals with disabilities. 

First, with regard to children, I think if we are doing the right 

thing, not only as a government, but as a society, if we are really 

about the business of justice and if we are really about the business of growing the economy, we should invest a lot and spend a 

lot of time making sure that every child has health care. The good 

41 

news is, despite a lot of years of not getting to that point, not moving in the right direction, we have made a lot of progress. 

The Urban Institute in an April 2016 report—I will not ask the 

report to be made part of the record, but I will read a line from 

this Urban Institute report ‘‘Uninsurance Among Children, 1997 to 

2015,’’ dated April 2016. It said as follows on page 3: the ‘‘decline 

in children’s uninsurance rate occurred at a relatively steady pace 

and includes a significant drop following implementation of the Affordable Care Act’s key coverage provisions from 7.1 percent in 

2013 to 4.8 percent in 2015.’’ 

So that is a significant drop, 7.1 percent to 4.8. Millions of kids 

have health insurance today who would not have it absent the Affordable Care Act and including the Medicaid provisions as well. 

That 4.8-percent uninsured rate for kids is an all-time low. That 

means we are at a 95-percent insured rate across the country for 

children. 

Kaiser Foundation, a separate authority, tells us that even with 

that, even with all that progress made in the last couple of years 

and even some progress before that, we still have more than 4.1 

million children uninsured. 

Would you agree with me, first of all, that we should get that 

number down, the number of uninsured children? 

Dr. PRICE. I think that throughout our population we ought to 

identify individuals who are uninsured and strive to make certain 

that they gain coverage. 

Senator CASEY. Right. And you would agree with me with regard 

to children especially? 

Dr. PRICE. Everybody in the population. Children are precious 

and are our future. 

Senator CASEY. Great. And just with regard to children, now that 

we have that number, we know the number that we have arrived 

at, we know the percentage, will you commit, if you are successful 

in your confirmation, to maintain or to even reduce that uninsured 

number even further—in other words, that you will be able to commit to us today that the number of uninsured children will not increase during your time as Secretary, were you to be confirmed, 

and the percentage of uninsured would not increase while you are 

Secretary? 

Dr. PRICE. Our goal is to decrease the number of uninsured individuals in the population under age 18 and over 18. 

Senator CASEY. Well, I hope you maintain that, because I think 

that is going to be critically important. 

The reason I ask that question is not just to validate that as a 

critically important goal for the Nation, but your answer seems to 

be contrary or in conflict with what you have advocated for as a 

member of the House of Representatives, not only in your individual capacity, but as chairman of the Budget Committee. 

Looking at now for reference an op-ed by Gene Sperling—you 

know who Gene Sperling is. He was head of the Council of Economic Advisers to two Presidents, both President Clinton and 

President Obama—Chair of that National Economic Council, I 

should say, is the proper title. 

In an op-ed on Christmas Day, the fifth paragraph, here is what 

he said in a pertinent part referencing you and your budget proVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00045 Fmt 6633 Sfmt 6633 R:\DOCS\30005.000 TIM
42 

posals. He said, quote, ‘‘Together,’’ meaning the two areas of policy 

that you have a long record on, full repeal of ACA and block-granting of Medicaid, which we now know is Trump administration policy, ‘‘they would cut Medicaid and the Children’s Health Insurance 

Program funding by about $2.1 trillion over the next 10 years, a 

40-percent cut.’’ 

How can you answer the questions that I just asked you about 

making sure that that number of uninsured children does not get 

worse under your tenure if that is the case with regard to your 

policies, the effect of what your policies would be—and now apparently, contrary to what was said during the campaign, it is now the 

policy of the Trump administration to block-grant Medicaid? 

Dr. PRICE. Yes. With respect to both you and to Mr. Sperling, it 

is because you all are looking at this in a silo. We do not look at 

it in a silo. We believe that it is possible to imagine, in fact put 

in place, a system that allows for greater coverage for individuals, 

in fact coverage that actually equals care. 

Right now, many of those individuals—the ACA actually increased coverage in this country. It is one of the things that it actually did. The problem is that a lot of folks have coverage, but they 

do not have care. So they have the insurance card, they go to the 

doctor, the doctor says, ‘‘This is what we believe you need,’’ and 

they say, ‘‘I am sorry, I cannot afford that.’’ 

Senator CASEY. A cut of a trillion dollars, a combined cut of a 

trillion dollars that would adversely impact the Children’s Health 

Insurance Program and the Medicaid program, is totally unacceptable, I think, to most Americans, Democrat, Republican, or otherwise. 

Dr. PRICE. And you are looking at that in a silo. You are not 

looking at what the reform and improvement would be. 

Senator CASEY. We will see the rebuttal to what not only Gene 

Sperling has said, but a whole long line of public policy advocates 

and experts. And I think the burden for you, sir, is to make sure 

that you fulfill your commitment to make sure that no children will 

lose health insurance coverage while you are Secretary. 

Dr. PRICE. I look forward to working with you. 

The CHAIRMAN. Okay. Senator Heller? 

Senator HELLER. Thank you, Mr. Chairman. 

And, Dr. Price, thank you for being here today. And thanks for 

your patience in working with us throughout this confirmation 

process. 

Mr. Chairman, as you can imagine, I am committed to ensuring 

that all Nevadans have access to high-quality and affordable health 

insurance. 

I have a letter here that came to my attention January 10th from 

the Nevada legislature. The letter comes directly from our majority 

leader of the State Senate and our Speaker of the Assembly. And 

they are good questions, five questions. Obviously, they want to get 

the same answers that all of us want here. 

We have about 88,000 Nevadans who have health insurance 

through the health exchange, 77,000 Nevadans who are eligible for 

Federal tax credits, 217,000 Nevadans who receive health-care coverage under Medicaid expansion. Basic questions. 

43 

Mr. Chairman, if I may, can I submit this letter for the record, 

and also, if I may, ask Dr. Price if he would respond to this particular letter, to these legislators? Again, I think they are very good 

questions. 

The CHAIRMAN. Without objection. 

[The letter appears in the appendix on p. 89.] 

Senator HELLER. Also, if I may add, if you could CC the Governor 

also. I think the Governor also would like answers to these questions. And I think you are in a great position to answer these particular questions. 

Dr. PRICE. Thank you, sir. 

Senator HELLER. Thank you. 

If I may, can I get your opinion on the Cadillac tax? 

Dr. PRICE. I think the Cadillac tax is one that has made it such 

that individuals who are gaining their coverage through their employer—there may be a better way to make it so that individuals 

gaining their coverage through their employer are able to gain access to the kind of coverage that they desire. 

Senator HELLER. The Cadillac tax would affect about 1.3 million 

Nevadans: school teachers, union members, senior citizens. And 

there is some disagreement as to whether or not these individuals 

are wealthy or not. There are some on this committee who believe 

that the $1.1-trillion tax increase in Obamacare does not affect the 

middle class. Do you agree with that? 

Dr. PRICE. I think it does affect the middle class. 

Senator HELLER. I do too. Do you believe that school teachers are 

wealthy? 

Dr. PRICE. Everybody has their own metric of what wealthy is, 

and some people use things to determine wealth that are not the 

greenbacks in—— 

Senator HELLER. I would argue that most school teachers do not 

think they are wealthy. 

Do you think most union members are wealthy? 

Dr. PRICE. I doubt that they think they are wealthy. 

Senator HELLER. Yes, I would agree with that. 

Do you think most senior citizens are wealthy? 

Dr. PRICE. Most senior citizens are on a fixed income. 

Senator HELLER. They would argue that they are not wealthy. 

And that is my argument on this particular tax. In fact, Obamacare as a whole is just another middle-class tax increase of $1.1 

trillion. 

I guess my request and question for you is if I can get your commitment to work with this committee and work with myself and 

the Treasury Secretary to repeal the Cadillac tax. 

Dr. PRICE. Well, we will certainly work to make certain that 

those who gain their coverage through their employer have the access to the highest-quality care and coverage possible in a way that 

makes the most sense for individuals from a financial standpoint 

as well. 

Senator HELLER. Does the Cadillac tax make the most sense? 

Dr. PRICE. As I mentioned, I think there are other options that 

may work better. 

Senator HELLER. And do you believe it is an increase, a health 

insurance increase, to middle-class America? 

44 

Dr. PRICE. I do. 

Senator HELLER. Okay. I want to go to Medicaid expansion for 

just a minute. Nevada was one of 36 States that chose to expand 

eligibility for Medicaid. We went from—I think the enrollment 

went from 350,000 to over 600,000. 

And I guess the concern, and I think it is part of the letter that 

I gave to the chairman, is whether or not that will have an impact 

and what we are going to do to see that those individuals are not 

impacted. Probably the biggest question that we have here for you 

today is, what are we going to do about those who are part of the 

Medicaid expansion and how that is going to impact them? 

Dr. PRICE. Yes. Again, as I mentioned to a question on the other 

side, I believe this is a policy question that needs to be worked out 

through both the House and the Senate. We look forward to working with you and others, if I am able to be confirmed, on making 

certain that individuals who are currently covered through Medicaid expansion either retain that coverage or in some way have 

coverage through a different vehicle. But every single individual 

ought to be able to have access to coverage. 

Senator HELLER. Dr. Price, thank you. Thank you for being here. 

Mr. Chairman, thank you. 

Dr. PRICE. Thanks, Senator. 

The CHAIRMAN. Thank you. 

Senator Warner? 

Senator WARNER. Thank you, Mr. Chairman. 

Good to see you again, Dr. Price. 

Dr. PRICE. Thank you. 

Senator WARNER. Let me start on something we discussed in my 

office. One of the issues I have been working on since I have been 

Governor, that I have been working on very closely with your 

friend, Senator Isakson, is the issue of how we as Americans address the end of life and sort through those issues. I think we both 

shared personal stories on that subject. 

Senator Isakson and I have legislation that we call the Care 

Planning Act that does not remove anyone’s choices, it simply allows families to have those discussions with their health-care provider and religious faith leader if needed or desired in a way to 

prepare for that stage of life. 

This year, CMS took a step by introducing a payment code into 

the fee schedule to provide initial reimbursement for providers to 

have these conversations with, as mentioned, a multidisciplinary 

case team. It also ran a pilot program that allowed hospice-type 

benefits to be given to individuals who were still receiving some 

level of curative services, called the Medicare Care Choices. 

I believe it is very important that we do not go backwards on 

these issues. And as I think we talked about, we are maybe the 

only industrial nation in the world that has not had this kind of 

adult conversation about this part of life. Again, it is not about limiting anyone’s choices. 

But would you, if you are confirmed, continue to work with Senator Isakson and me and others on this very important issue? 

Dr. PRICE. I look forward to doing so—— 

Senator WARNER [continuing]. And not be part of any effort to 

kind of roll back those efforts that CMS has already taken? 

45 

Dr. PRICE. I think it is important to look at the broad array of 

issues here. And one of the issues is liability. And I cannot remember whether we discussed that in your office. But the whole issue 

of liability surrounding these conversations is real. We need to be 

talking about it openly and honestly and working together to try 

to find a solution to just that. 

Senator WARNER. I would concur with that, but I also think this 

is something that more families need to take advantage of. 

On Friday, January 20th, President Trump issued an executive 

order that says Federal agencies, especially HHS, should do everything they can to, quote, ‘‘eliminate any fiscal burden on any State 

or any cost, fee, tax penalty, or regulatory burden on individuals 

and providers.’’ 

Dr. Price, if you are confirmed in this position, will you use this 

executive order in any way to try to cut back on implementation 

or follow the individual mandate before there is a replacement plan 

in place? 

Dr. PRICE. Well, I think that, if I am confirmed, then I am humble enough to appreciate and understand that I do not have all the 

answers and that the people at the Department have incredible 

knowledge and expertise, and that my first action within the Department itself as it relates to this is to gain that insight, gain that 

information, so that whatever decisions we can make with you and 

with Governors and others can be the most informed and intelligence decisions possible. 

Senator WARNER. I am not sure you answered my question. What 

I would not want to see happen as we take—I understand your 

concerns with the Cadillac tax. I know there are concerns you and 

others have raised about the individual mandate. There are some 

who are concerned about the income tax surcharges. 

It is just remarkable to me—and this is one of the reasons why 

I think so many of us are anxious to see your replacement plan— 

that the President has said he wants insurance for everybody, he 

wants to keep the prohibitions on preexisting conditions, he wants 

to keep young people on their parents’ policies until 26, and it 

seems like there is at the same time a rush to eliminate all of the 

things that pay for the ability of Americans to have those kind of 

services. 

And I would just want your assurance that you would not use 

this executive order prior to a legal replacement to eliminate the 

individual mandate, which I believe helps actually shore up the 

cost coverage and the shifting of costs that are required in an insurance system. 

Dr. PRICE. Yes. No, a replacement, a reform, an improvement of 

the program, I believe is imperative to be instituted simultaneously 

or at a time—— 

Senator WARNER. But you will not use this executive order as a 

reason to kind of, in effect, bypass the law prior to a replacement 

being in place? 

Dr. PRICE. Our commitment is to carry out the law of the land. 

Senator WARNER. I want to, in these last couple of minutes, go 

on. I know you have been in the past a strong critic of the Center 

for Medicare and Medicaid Innovation, CMMI. I believe in your testimony last week you saw great promise in it. 

46 

To me, if we are going to move towards a system that emphasizes quality of care rather than simply quantity of care, we have 

to have this kind of experimentation. There is one such program, 

the Diabetes Prevention Program, that last year CMS certified 

saved money on a per-beneficiary basis. 

And I know my time is running out, so let me just ask these 

questions. I think they can probably be answered ‘‘yes’’ or ‘‘no.’’ 

Do you support CMMI delivery system reform demonstrations 

that have the potential to reduce spending without harming the 

quality of care? 

Dr. PRICE. The second clause is the most important one. I support making certain that we deliver care in a cost-effective manner. 

But we absolutely must not do things that harm the quality of care 

being provided to patients. 

Senator WARNER. But if part of that quality of care—and I would 

agree with you—would mean bundled and episodic payment models 

that actually move us towards quality over volume, would you support those efforts? 

Dr. PRICE. For certain patient populations, bundled payments 

make a lot of sense. 

Senator WARNER. And if these experiments are successful, would 

you allow the expansion of these across the whole system? 

Dr. PRICE. I think that what we ought to do is allow for all sorts 

of innovation, not just in this area. There are things I am certain 

that have not been thought up yet, that would actually improve 

quality and delivery of health care in our country, and we ought 

to be incentivizing that kind of innovation. 

Senator WARNER. Well, I would simply say, Mr. Chairman, that 

CMMI seems to be one of the areas where I would like to have seen 

more, but I think it is a model and a tool we ought not to discard. 

Thank you. 

The CHAIRMAN. Well, thank you, Senator. 

Senator Scott? 

Senator SCOTT. Thank you, Mr. Chairman. 

Dr. Price, good to see you again. 

Dr. PRICE. Tim. 

Senator SCOTT. South Carolina launched the Nation’s first statewide pay-for-success project with Nurse Family Partnership with 

the use of Medicaid funds. Twenty percent of the babies born in 

South Carolina are born to first-time, low-income mothers. We also 

have a much higher than average infant mortality rate. 

Nurse Family Partnership is evidence-based and has already 

shown real results, both in the health of the mother and the babies, 

but also in other aspects of the mother’s life, such as high school 

graduation rates for teen moms and unemployment rates. 

What are your thoughts on incorporating a pay-for-success model 

to achieve success metrics? 

Dr. PRICE. Well, it sounds like a great program that actually has 

the right metric, and that is the quality of care and the improvement of lives. And as you state, if it is having that kind of success, 

it probably ought to be put out there again as a best practice for 

other States to look at and try to model. 

Senator SCOTT. Yes, sir. Thank you. 

47 

I believe you were the director of the orthopaedic clinic at Grady 

Memorial Hospital in Atlanta. 

Dr. PRICE. I was. 

Senator SCOTT. You just mentioned something that I think is 

very important. I believe Grady Hospital had the highest level of 

uninsured Georgians. You talked about having coverage, but really 

not access. Can you elaborate on how your experience at Grady 

may help inform you and direct you as it relates to the uninsured 

population? 

Dr. PRICE. Well, it was an incredible privilege to work at Grady 

for the number of years that I did. And we saw patients from all 

walks of life and many, many uninsured individuals. And they 

come with the same kinds of concerns, the same kinds of challenges 

that every other individual has. And they have an additional concern, and that is, is somebody going to be caring for me? Is somebody going to be able to help me? 

And that is why it was so incredibly fulfilling to be able to have 

the privilege of working at Grady and assisting people at a time 

when they were not only challenged from a health-care standpoint, 

but challenged from a concern about whether or not people were 

going to be there to help them. 

Senator SCOTT. Yes, sir. I know that you are aware of title I of 

the Every Student Succeeds Act. It allows for the population of 

Head Start to have access to resources. It seems to me that it 

would be imperative for the Secretary of HHS and the Secretary 

of Education to look at ways to synergize your efforts to help the 

underprivileged student, the underprivileged child. 

Can I get your commitment that you will look for ways to work 

with the Secretary of Education where it makes sense to help those 

students? You know, we have Head Start under you and other programs under ESSA. It would be wonderful for us to take the taxpayer in one hand, the child in the other hand, and look for ways 

to make sure that they both win. 

Dr. PRICE. Yes, you have identified an area that is a pet peeve 

of many of us, and that is that we do not seem to collaborate across 

jurisdictional lines, not just in Congress, but certainly on the administrative side. And so I look forward to doing just that and having as a metric how the kids are doing. 

Senator SCOTT. Yes. 

Dr. PRICE. Are they actually getting the kind of service and education that they need? Are they improving? Are we just being 

custodians? Are we just parking kids in a spot, or are we actually 

assisting and improving their lives? And are we able to demonstrate that? 

And if we are not asking the right questions, if we are not looking at the right metrics, then we will not get the right answer that 

allows us to either expand what is actually working or to modify 

it and move it in a better direction. 

Senator SCOTT. Thank you. I think that is one of the more important parts of your opportunity in this position: looking at those 

kids. I know that you know as well as anyone who is a doctor that 

those ages, before you ever get into pre-K or Kindergarten, the development of the child between those first 3 or 4 years is a powerVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00051 Fmt 6633 Sfmt 6633 R:\DOCS\30005.000 TIM
48 

ful opportunity for us to direct a child’s potential so that they maximize it. 

And sometimes we are missing those opportunities. We think 

that somehow the education system will help that child catch up. 

But there are things that have to happen before they ever get in 

the education system. So I thank you for your willingness to work 

in that direction. 

And my last question has to do with the employer-sponsored 

health-care system that we are so accustomed to in this country 

that provides about 175 million Americans with their insurance. In 

my home State of South Carolina, of course, we have about 2.5 million people covered by their employer coverage. 

If confirmed as HHS Secretary, how would you support American 

employers in their effort to provide effective family health coverage 

in a consistent and affordable manner? Said differently, there has 

been some conversation about looking for ways to decouple having 

health insurance through your employer. 

Dr. PRICE. I think the employer system has been absolutely a remarkable success in allowing individuals to gain coverage that they 

otherwise might not gain. I think that preserving the employer system is imperative. 

That being said, I think that there may be ways in which employers—I have heard from employers who say, if you just give me 

an opportunity to provide my employee the kind of resources so 

that he or she is able to select the coverage that they want, then 

that makes more sense to them. And if that works from a voluntary standpoint for employers and for employees, then it may be 

something to look at. 

Senator SCOTT. That would be more like the HRA approach 

where the employer funds an account and the employee chooses 

health insurance, not necessarily under the umbrella of the employer specifically. 

Dr. PRICE. Exactly—and gains the same tax benefit. 

Senator SCOTT. Yes. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator. 

Senator McCaskill? 

Senator MCCASKILL. At the risk, Mr. Chairman, of being way, 

way away from you and you being someone I have worked with and 

respected greatly, I do want to gently correct something in your 

opening statement. 

The first nominee of President Trump that this Senate considered was confirmed by a vote of 98 to one. I would not consider 

that a partisan vote. 

The second nominee of President Trump was confirmed by a vote 

of 88 to 11. Once again, I would not consider that a partisan vote. 

So I really do think we are all trying to look at each nominee individually. And I have had a chance to review Congressman Price’s 

questioning of Secretary Sebelius, and I can assure you, Mr. Chairman, it was no beanbag. It was tough stuff. 

So I think all of this looks different depending on where we are 

sitting. And I wanted to make that point. 

And as to passing Obamacare without one Republican vote, we 

are about to repeal Obamacare without one Democratic vote. This 

49 

will be a partisan exercise under reconciliation. It will not be a bipartisan effort. And what we have after the repeal is Trumpcare. 

Whatever is left after the dust settles is Trumpcare. 

Now, I know the President likes to pay close attention to what 

he puts his name on. And I have a feeling, Congressman, that even 

though you keep saying today that Congress will decide, you are 

not really believing, are you, that your new boss is not going to 

weigh in on what he wants Congress to pass? We are not going to 

have a plan from him? 

Dr. PRICE. Well, I think we look forward to working with you and 

other members of the House and Senate. 

Senator MCCASKILL. No, my question is, are we going to have a 

plan from the President? Will he have a plan? 

Dr. PRICE. If I have the privilege to be confirmed, I look forward 

to working with the President and brining a plan to you. 

Senator MCCASKILL. Great. So the plan will come from President 

Trump and you will have the most important role in shaping that 

plan as his Secretary of Health and Human Services, correct? 

Dr. PRICE. I hope I have input, yes, ma’am. 

Senator MCCASKILL. Yes. Okay. So whatever Trumpcare ends up 

being, you will have a role in it. And I think it is really important 

to get that on the record. 

Now, when we repeal Obamacare, we are going to do a tax cut. 

Does anybody in America who makes less than $200,000—are any 

of them going to benefit from that tax cut? 

Dr. PRICE. It’s a hypothetical, and you all are the ones who are 

going to—— 

Senator MCCASKILL. No, no, no, no, it’s not a hypothetical. When 

we repeal Obamacare, there are taxes in Obamacare. And when it 

is repealed, there is no question the taxes are going to be repealed. 

I promise you the taxes are going to be repealed. When those taxes 

are repealed, will anyone in America who makes less than 

$200,000 benefit from the repeal of those taxes? 

Dr. PRICE. I look forward to working with you on that plan, and 

hopefully that will be the case. 

Senator MCCASKILL. No, no, no, no, no. I am asking, the taxes 

that are in there now, does anybody who makes less than $200,000 

pay those taxes now? 

Dr. PRICE. It depends how you define the taxes. There are many 

individuals who are paying much more than they did prior to that 

point. The ACA—— 

Senator MCCASKILL. No, I am talking about taxes. 

Dr. PRICE. I understand. 

Senator MCCASKILL. Taxes, you know—the Cadillac tax has not 

been implemented, so that does not affect anybody. I am trying to 

get at the very simple question—and I do not think you want to 

answer it—that, in fact, when Obamacare is repealed, no one in 

America who makes less than $200,000 is going to enjoy the benefit 

of that. 

Dr. PRICE. As I say, I look forward, if I am confirmed, to working 

with you to make certain that that is the case. 

Senator MCCASKILL. That is not an answer, but we will go on. 

50 

Okay. We talked in my office. Ending Medicare as we know it, 

your plan that you have worked on for years is converting Medicare 

to private insurance markets with government subsidies. Correct? 

Dr. PRICE. Not correct. 

Senator MCCASKILL. Well, we talked yesterday, and we kind of 

went through this in my office. And by the end of our conversation, 

you admitted to me, and I am going to quote you, that your plan 

for Medicare in terms of people getting either tax credits or subsidies or however you are going to pay for the Medicare recipients 

would be them having choices on a private market. And you said 

yes, it was pretty similar to Obamacare with the exception of the 

mandate. Did you not say that to me yesterday? 

Dr. PRICE. That’s a fairly significant exception. 

Senator MCCASKILL. Well, but these people are old. They do not 

need to be mandated to get insurance. It is not like a 27-year old 

who does not think he is going to get sick. You do not need a mandate for people who are elderly; they have to have health insurance. So the mandate is not as relevant. But did you not admit to 

me that Obamacare and the private markets are very similar to 

what you are envisioning for Medicare? Did you not use the phrase 

‘‘pretty similar?’’ 

Dr. PRICE. There are some similarities. I think what I said, 

though, was that the mandate was significant. 

Senator MCCASKILL. Well, the mandate I get in Obamacare is 

significant. But we do not need a mandate for seniors. Would you 

agree with that, that you do not have to tell seniors they need 

health insurance? 

Dr. PRICE. What I hope is that we do not need a mandate for 

anybody so that they are able to purchase the kind of coverage that 

they want, not that the government forces them to buy. 

Senator MCCASKILL. Okay. Finally, you want to block-grant Medicaid for State flexibility and efficiency. Correct? 

Dr. PRICE. I believe that Medicaid is a system that is now not 

responding necessarily to the needs of the recipients, and consequently, it is incumbent upon all of us as policymakers to look 

for a better way to solve that challenge. 

Senator MCCASKILL. Are you in favor of block-granting Medicaid? 

Dr. PRICE. I am in favor of a system that is more responsive to 

patients in the Medicaid system. 

Senator MCCASKILL. Are you in favor of block-granting Medicaid? 

It is a really simple question, Congressman. I mean, you are at 

your confirmation hearing for the most powerful job in health care 

in the country. I do not know why you would not be willing to answer whether or not you are in favor of block-granting Medicaid. 

That is not complicated. 

Dr. PRICE. I am in favor of making certain that Medicaid is a 

system that responds to patients, not the government. 

Senator MCCASKILL. Okay. I do not understand why you will not 

answer that. And I do not have time. I know I am over. I will probably—I do not know if we are going to get another round, Mr. 

Chairman. Should I ask my last question, or are we going to get 

another chance? 

The CHAIRMAN. I am going to allow additional questions. I hope 

that not everybody will take the opportunity. [Laughter.] 

51 

Senator MCCASKILL. Okay. I will disappoint you; I am sorry. 

The CHAIRMAN. I will not call it a second round, however. 

Senator MCCASKILL. Not many, I just have one more. 

The CHAIRMAN. Let me just on that point say that Obamacare 

raised taxes on millions of American families across income levels. 

The nonpartisan Joint Committee on Taxation analysis in May 

2010 identified significant, widespread tax increases on taxpayers 

earning under $200,000 contained in the ACA. 

And then, for example, for 2017, 13.8 million taxpayers with incomes below $200,000 will be hit with more than $3.7 billion—with 

a ‘‘b’’—in Obamacare tax hikes from an increase in the income floor 

for the medical expense deductions. 

Obamacare has led to middle-class tax hikes, without question. 

It has led to fewer insurance options, higher deductibles and higher 

premiums. 

So I think those are facts that cannot be denied. 

Senator MCCASKILL. I will look forward to looking at those facts, 

because somewhere in this mix we have alternative facts. [Laughter.] 

Senator WYDEN. Well, and just on that—— 

The CHAIRMAN. Well, I think these are right, I can tell you that. 

Senator MCCASKILL. Well, I think mine are right. 

Senator WYDEN. Mr. Chairman, just a point of privilege to respond. 

The CHAIRMAN. Yes, sir. Yes, sir. 

Senator WYDEN. On this point, no alternative facts. The Republicans in last year’s reconciliation bill cut taxes for one group of 

people. They cut taxes for the most fortunate in the country. That 

is a matter of public record. It is not an alternative fact or universe. People making $200,000 and up got their taxes cut. That 

was in the reconciliation bill of the Republicans last year. 

The CHAIRMAN. Well, let us see who is next here. I do not agree 

with that, but we will see who is next. 

Senator Cassidy and then Senator Grassley. 

Senator CASSIDY. Thank you, Mr. Chairman. 

Dr. Price, how are you? 

Dr. PRICE. I am well, Senator. 

Senator CASSIDY. Let us talk a little about Medicaid, because we 

are getting this kind of rosy scenario of Obamacare and of the Republican attempt to replace it. It does seem a little bit odd. 

First, I want to note for the record that President Trump has 

said in various ways that he does not want people to lose coverage. 

He actually would like to cover as many people as under Obamacare. He wishes to take care of those with preexisting conditions 

and to do it without mandates and lower cost. Those will be your 

marching orders. Fair statement? 

Dr. PRICE. Absolutely. 

Senator CASSIDY. Now let us go to—you and I, we talked at a 

previous meeting. We have both worked in public hospitals for the 

uninsured and for the poorly insured, folks on Medicaid. 

Now, let us just talk a little bit about Medicaid. Why would we 

see patients on Medicaid at a hospital for the uninsured? If they 

wanted to see an orthopaedist in private practice, does Medicaid 

52 

pay a provider well enough to cover the cost of seeing an orthopaedic patient? 

Dr. PRICE. Oftentimes it does not. And in fact, as you well know 

and as mentioned before, one out of three physicians who ought to 

be able to see Medicaid patients in this Nation does not take any 

Medicaid patients. And there is a reason for that, whether it is reimbursement or whether it is the hassle factor or whether it is regulations or the like. 

But that is a system that is not working for those patients. And 

we ought to be honest about that and look at that and answer the 

question ‘‘why?’’ and then address that. 

Senator CASSIDY. I will note that when the House version of the 

ACA passed, Robert Pear in The New York Times wrote an article 

about a Michigan physician, an oncologist, who had so many Medicaid patients from Michigan Medicaid that she was going bankrupt. And she had to discharge patients from her practice. 

Now, the ranking member said we cannot have alternative facts. 

I agree with that. We also know that a New England Journal of 

Medicine article spoke about Medicaid expansion in Oregon, about 

how when they expanded Medicaid in Oregon outcomes did not improve. So I suppose that kind of informs you—as you say, we need 

to make Medicaid something that works better for patients. 

Dr. PRICE. Absolutely. And we need to look at the right metrics. 

Just gaining coverage for individuals is an admirable goal, but it 

ought not be the only goal. And we must have a goal in health care 

especially to keep the patient at the center and realize what kind 

of care and coverage we are providing for people on the ground, for 

real people in real lives, and whether or not we are affecting them 

in a positive way or a negative way. 

If we are affecting them in a negative way, then, again, we need 

to be honest with ourselves and say, how can we improve that? 

Senator CASSIDY. Now, a lot of times there is this kind of conflation of per-beneficiary payments to the States per Medicaid enrollee and block grants, which to me is a conflation. 

I will note that Bill Clinton on the left and Phil Gramm and Rick 

Santorum on the right proposed per-beneficiary payment some time 

ago. And that is actually how, would you agree with this, how the 

Federal Employees Health Benefits Program pays for these Federal 

employees? They pay a per-beneficiary payment to an insurer. Fair 

statement? 

Dr. PRICE. Correct. 

Senator CASSIDY. Would it not be great if Medicaid worked as 

well as the Federal Employees Health Benefits Program in terms 

of improved outcomes? 

Dr. PRICE. It would indeed. In fact, when you talk about the 

Medicaid population, it is not a monolithic population, as you well 

know. There are four different demographic groups within it: seniors, disabled, and then healthy moms, and kids, by and large. And 

we treat each one of those folks exactly the same under the Medicaid rules. 

Senator CASSIDY. So when you are pressed on whether, by golly, 

you believe in block grants, is there any nuance? I do not hear any 

of the nuances that we are discussing offered in that question. 

Dr. PRICE. Not at all. 

53 

Senator CASSIDY. But frankly, you cannot address that. Are you 

speaking about a per-beneficiary payment? Are you speaking about 

each of those four, one of those four? How do you dice that? New 

York is an older State, demographically. Utah is a very young 

State. Fair statement? 

Dr. PRICE. Absolutely. And those are the things that I think we 

tend not to look at, because they are more difficult to measure. 

They are more difficult to look at. But when we are talking about 

people’s lives, when we are talking about people’s health care, then 

it is imperative that we do the extra work that needs to be done 

to determine whether or not, yes, indeed, the public policy that we 

are putting forward is going to help you and not harm you. 

Senator CASSIDY. Now, let me ask, because there is also some 

criticism of your proposal about Health Savings Accounts. I love 

them because they activate the patient. I think we are both familiar with the Healthy Indiana Plan where, on a waiver, they gave 

folks of a lower income Health Savings Accounts and had better 

outcomes, decreased ER usage. Can you comment on that? 

Dr. PRICE. Just that when people do engage in their health care, 

they tend to demand more, they tend to demand better services. 

And individuals who have greater opportunity for choices of who 

they see, where they are treated, when they are treated, and the 

like have greater opportunity to gain better health care. 

Senator CASSIDY. So going back to not wanting to have alternative facts, if we contrast the experience in Healthy Indiana with 

the experience in Oregon where the National Bureau of Economic 

Research—I think, if I got that acronym correct—published in the 

New England Journal of Medicine that they found no difference in 

outcomes in those who are fulfilled through a Medicaid expansion 

program in Oregon, contrast that absence of good effect, if you will, 

in outcomes with that in which Indiana attempted to engage patients to become activated in their own care. ER usage actually fell, 

but outcomes improved. 

I think in our world of standard facts, I kind of like your position. Thanks for bringing a nuanced, informed view to the healthcare reform debate, Dr. Price. 

Dr. PRICE. Thank you, sir. 

The CHAIRMAN. Thanks, Senator. 

Senator Grassley? 

Senator GRASSLEY. Two statements before I ask a couple of questions. One is, it is kind of a welcome relief to have somebody of 

your profession in this very important role, particularly knowing 

the importance of the doctor/patient relationship. Because in my 

dealing with CMS and HHS over a long period of time, I think that 

the bureaucracy has been short of a lot of that hands-on information that people ought to have. 

And secondly, when you were in my office, we discussed the necessity of your responding to congressional inquiries. And you very 

definitely said you would. I tongue-in-cheek said maybe you ought 

to say ‘‘maybe’’ because a lot of times nominees do not do it. But 

since you said you would, I will hold you to that and appreciate 

anything you can do to help us do our oversight. 

As a result of oversight, I got legislation passed a few years ago 

called the Physicians Payment Sunshine Act. And the only reason 

54 

I bring this up is because it took Senator Wyden and me, last December, working hard to stop the House of Representatives from 

gutting that legislation in the Cures Act that passed. 

And I want to make very clear that the legislation I am talking 

about does not prohibit anything. It only has reporting requirements because it makes it very, very—well, it brings about the 

principle of transparency, brings accountability. 

And I have some studies here that we did and some newspaper 

reports on them, particularly one about a psychiatrist at Emory 

University who was not reporting everything that he should report, 

and even the president of Emory University came to my office and 

said, ‘‘Thank you for making us aware of this stuff.’’ 

I want to put those in the record. 

[The studies and reports appear in the appendix beginning on p. 

77.] 

Senator GRASSLEY. But since you are administering this legislation and since Senator Blumenthal and I will think about expanding this legislation to include nurse practitioners and physician assistants, I hope that I could get your commitment that you will enforce this act the way it was intended to be enforced, because even 

under the Obama administration, after we got it passed, it was 3 

years getting these regulations, getting it carried out. So effectively, it has only been working for about 2 or maybe 21⁄2 years. 

So I would like to know, if you are confirmed, would you and the 

Department of Health and Human Services work with me to ensure that this transparency initiative is not weakened? 

Dr. PRICE. We look forward to working with you, sir. I think 

transparency in this area and so many others is vital, again, not 

just in outcomes or in pricing, but in so many areas, so that patients are able to understand what is going on in the health-care 

system. 

Senator GRASSLEY. Thank you. Now, the last question deals with 

vaccine safety. You are a physician. I believe you would agree that 

immunization is very important for modern medicine and that we 

have been able to get rid of small pox way back in 1977, worldwide 

polio I think in 1991, at least in the Western Hemisphere, and all 

that. 

So as a physician, would you recommend that families follow the 

recommended vaccine schedule that has been established by experts and is constantly reviewed? 

Dr. PRICE. I think that science and health care have identified 

a very important aspect of public health, and that is the role of vaccinations. 

Senator GRASSLEY. Thank you very much. 

I yield back my time. 

The CHAIRMAN. Thank you, Senator. 

Senator Stabenow? 

Senator STABENOW. Thank you, Mr. Chairman. 

First, I would ask unanimous consent that a series of stories 

from individuals at a public forum that was held last week with 

my colleagues—people concerned about policies that our nominee 

has authored and about issues we are talking about today—be included in the record. 

The CHAIRMAN. Without objection. 

55 

[The information appears in the appendix beginning on p. 253.] 

Senator STABENOW. Thank you very much. 

Welcome, Congressman Price. 

Dr. PRICE. Senator. 

Senator STABENOW. And I appreciate our private discussion as 

well as the discussion this morning. I want to start right out—lots 

of questions—to see if we can move through some things quickly. 

You have said this morning that you would not abandon people 

with preexisting conditions. Is that basically what you are talking 

about with high-risk pools? Is that one of the strategies that you 

are thinking about? I have heard that talked about this morning. 

Dr. PRICE. I think high-risk pools can be incredibly helpful in 

making certain that individuals who have preexisting illness are 

able to be cared for in the highest-quality manner possible. 

I think there are other methods as well. We have talked about 

other pooling mechanisms. The destruction of the individual and 

small-group market has made it such that folks cannot find coverage that is affordable for them. And one of the ways to solve that 

challenge is to allow folks in the individual and small-group market to pull together. In fact, I think we talked about this in your 

office, with the Blue Shield model being the template for it—— 

Senator STABENOW. Yes, right. 

Dr. PRICE [continuing]. Where individuals who are not economically aligned are able to pool together their resources solely for the 

purpose of purchasing coverage. 

Senator STABENOW. But let me just stress that, for about 35 

years, we have tried high-risk pools. Thirty-five States had them 

before the Affordable Care Act. And frankly, they did not produce 

great results. 

In 2011, .2 percent of the people with preexisting conditions—.2 

percent—were actually in a high-risk pool. And the premiums were 

150- to 200-percent higher than standard rates for healthy individuals, and they had lifetime and annual limits on coverage and cost 

States money. So that was the reality before we passed the Affordable Care Act. 

So let me also ask you, when President Trump said last weekend 

that insurance was going to be much better, do you think that insurance without protections for those preexisting conditions or 

without maternity coverage or without mental health coverage or 

insurance that would reinstate caps on cancer treatments is better? 

Dr. PRICE. Well, I do not know that that is what he was referring 

to. I think that—— 

Senator STABENOW. Well, he said that it would be better. And if 

we in fact took away, if we went to high-risk pools instead of covering people with preexisting conditions, or if we stop the other 

coverage we have now, I am just wondering if you define that as 

better. 

Dr. PRICE. Well, I mean, you would have to give me a specific instance. What is better for you may not be better for me or somebody else. And that is the important thing that I am trying to get 

across, and that is that patients need to be at the center of this, 

not government. 

Should government be deciding these things, or should patients 

be deciding things? 

56 

Senator STABENOW. Prior to the Affordable Care Act, about 70 

percent of the private plans that a woman could purchase in a marketplace did not cover basic maternity care. Do you think that it 

is better not to cover basic maternity care? 

Dr. PRICE. And I presume that she would purchase that coverage 

if she needed it then. 

Senator STABENOW. She would have to pay more, just as in general for many women. Just being a woman was a preexisting condition. That is the reason why we have a basic set of services covered 

under health care. So it is just a different way of looking at this. 

This is something where, sure, if a woman wanted to pay a premium, wanted to pay more, she could find maternity care. We said 

in the Affordable Care Act, that is pretty basic. And for over half 

the population who are women, maternity care ought to be covered. 

Let me go to another one. Do you believe that mental health 

services should be a guaranteed benefit in all health insurance 

plans? 

Dr. PRICE. I have been a supporter of mental health parity inclusion, yes. 

Senator STABENOW. So mental health should be a defined benefit 

under health insurance plans? 

Dr. PRICE. I think that mental health illnesses ought to be treated with the same model as other physical illnesses. 

Senator STABENOW. I agree with you. On Medicare, there has 

been a lot of discussion—and I have to say also, with the nominee 

for the Office of Management Budget talking today about Medicare 

and Social Security, I personally believe people on Medicare should 

be very worried right now in terms of what we are hearing overall. 

But I did want—and my time is up—I did want, Congressman, 

just to relay a message from my mom who is 90 years old, who said 

she does not want more choices, she just wants to be able to see 

her doctor and get the medical care that she needs. She is not at 

all supportive of the idea of Medicare in some way being changed 

into premium support, into a voucher. 

So I am conveying to you this is somebody who is getting great 

care right now and is not interested in more choices, she just wants 

to keep her care. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator. 

Dr. PRICE. Well, if I may, Mr. Chairman, I would just convey to 

the Medicare population in this Nation that they do not have reason to be concerned. We look forward to assisting them in gaining 

the care and coverage that they need. 

Senator STABENOW. Thank you. 

The CHAIRMAN. Thank you. 

Senator Cantwell? 

Senator CANTWELL. Thank you, Mr. Chairman. 

Congressman Price, sorry we have not had a chance to talk. 

Dr. PRICE. I apologize. 

Senator CANTWELL. No, I think both of us have tried, and it is 

just a myriad of consequences. 

Dr. PRICE. Weather. 

Senator CANTWELL. But I wanted to ask you broadly, I know a 

lot of my colleagues have been asking you about Medicaid, but 

57 

what do you think is behind the rise in Medicaid costs? What is 

it due to? 

Dr. PRICE. Well, I think it is multifactorial. I think that we have 

a system that has many, many controls that are creating greater 

costs to the provision of the care that is being provided. 

I think that, oftentimes, we are not identifying the best practices 

in the Medicaid system so that patients move through the system 

in a way that is much more economical and much more efficient 

and effective, not just from a cost standpoint, but from a patient 

standpoint. There are so many things that could be done for, especially the sickest of the sick in the Medicaid population, where we 

could put greater resources and greater individual attention to individual patients. 

As you know, in a bell curve of patients in any population, there 

are those who are the outliers on the high side, where the resources spent to be able to provide their care is significant. And if 

you focus on those individuals specifically, then you oftentimes can 

provide a higher level of care and a higher quality of care for those 

folks and a more responsive care for those folks at a lower cost to 

move them down into the mainstream of the bell curve. 

Senator CANTWELL. Okay. Well, you have brought up a couple of 

interesting points, and I want to follow up on them. But specifically, if I started that conversation, I would start with two big phenomena: one, people living longer, because the longer they live, the 

more Medicaid they are going to consume. If they are living 10 or 

15 years longer than we have had in the past, they are going to 

consume more health care. And second, the baby boomer population is reaching retirement age. Those two things are ballooning 

the cost of health care in general, and specifically for the Medicaid 

population. 

And I want to make sure I understand where you are, because 

I feel like the administration is creating a war on Medicaid. You 

are saying that you want to cap and control the cost. And what we 

have already established in the Affordable Care Act are best practice incentives and ways to give the Medicaid population leverage 

in getting affordable health care. So I want to understand if you 

are for these things. 

For example, we provided resources in the Affordable Care Act 

to rebalance Medicaid patients out of nursing home care into 

community-based care. Why? Because it is more affordable. 

So, do you support that rebalancing effort? 

Dr. PRICE. I would respectfully, Senator, take issue with your description of a war on Medicaid. What we desire and want to do is 

to make certain that the Medicaid population is able to receive the 

highest-quality care. 

I have cared for thousands of Medicaid patients. The last thing 

that we want is to decrease the quality of care that they have access to. And clearly, the system is not working right now. So moving toward home-based care is something that is, if it is right for 

the patient, a wonderful thing to be able to do, and we ought to 

incentivize that. 

There are so many things we could do in Medicaid that would 

provide greater quality of care that we do not incentivize right now. 

58 

Senator CANTWELL. We did incentivize it in the Affordable Care 

Act, and your State and about 20 other States actually did it. They 

took the money from the Affordable Care Act. In fact, Georgia was 

approved for $57 million to make sure Medicaid beneficiaries got 

care in community-based care, and it has been able to shift 10 percent of its long-term costs from institutional care to that community-based care. So it is working. So are you for repealing that part 

of the Affordable Care Act? 

Dr. PRICE. What I am for is making certain, again, that the Medicaid population has access to the highest-quality care possible. 

And we will do everything to improve that, because right now so 

many in the Medicaid population do not have access to the highestquality care. 

Senator CANTWELL. I would hope you would look at this model 

and you would also look at the Basic Health Plan model. Again, 

what I think you are proposing and what the administration is refusing to refute is, when the President said, ‘‘I am going to protect 

these things,’’ and my colleague, Senator Sanders, brought this up 

and asked, ‘‘Are you going to protect this?’’ and then senior White 

House staff are now saying, ‘‘No, no, no, we are going to basically 

cap Medicaid spending,’’ it is a problem. 

What we want to do is, we want to give these individuals leverage in the marketplace. That is what the Basic Health Plan does. 

That is what the community-based care plan does. It gives them 

the ability to get more affordable care and better outcomes, and it 

is saving us money. 

So if you could give us a response—I see my time is expired— 

look at those two programs and tell me whether you support those 

delivery system reforms in the Affordable Care Act. 

Dr. PRICE. I would be happy to. 

Senator CANTWELL. Thank you. 

The CHAIRMAN. Well, thank you, Senator. 

That would end our first round. I would like to not go through 

a full second round, but we have some additional Senators here 

who would like to ask some more questions, so I guess we will start 

with Senator Wyden. 

Senator WYDEN. Thank you, Mr. Chairman. 

Congressman, I have several ideas on how to lower the price of 

medicine. But I would like to set those aside and start with the 

President’s idea: lower drug prices through bidding or negotiation. 

If confirmed, you are going to be the captain of the President’s 

health team, and you are going to have to persuade Republicans to 

change the law so that the President can fulfill his pledge: more 

affordable prices for medicine through bidding. 

As captain of the health team, will you do that? 

Dr. PRICE. As you know, Senator, we are committed to making 

certain that drug prices are affordable for individuals so they can 

have access to the high-quality care. Right now, that negotiation 

from a Part D standpoint, which I would remind folks is a real success story—the cost for medications for seniors is about half of 

what it was projected to be when Part D passed—the Pharmacy 

Benefit Managers are doing that negotiation right now. 

I think it is important to have a conversation about whether or 

not—— 

59 

Senator WYDEN. Congressman, I am asking about a specific idea, 

and it is not mine, it is the President’s. 

Dr. PRICE. I was going—— 

Senator WYDEN. And the question is, will you advocate to Republicans for authority to negotiate? It is ‘‘yes’’ or ‘‘no.’’ 

Dr. PRICE. What I was going to respond, Senator, if you will 

allow me, is to say right now the PBMs are doing that negotiation. 

I think it is important to have the conversation and look at whether or not there is a better way to do that. And if there is, then I 

am certainly open to it. 

Senator WYDEN. On Saturday, hundreds of thousands of women 

of all ages and backgrounds came to Washington to speak out in 

support of policies that you have opposed. This includes the Violence Against Women Act, provisions in the Affordable Care Act to 

prevent insurance companies from charging them more because 

they are women, access to no-cost contraceptive coverage, and the 

choice to see the provider they trust. 

Now, Speaker Ryan has publicly stated that no one will be worse 

off if the Affordable Care Act is repealed. But the nonpartisan Congressional Budget Office does not share that view. They have indicated nearly 400,000 women would lose access to care, including 

lifesaving cancer screenings, in the first year if Planned Parenthood is defunded and cut off from Medicaid. 

So again, Congressman, this is not my opinion as Democrat or 

Republican, this is the nonpartisan Congressional Budget Office. 

You are going to be the point person for health. Will you advise 

the President to reject any proposal that cuts coverage for or otherwise limits a woman’s ability to see the provider she trusts? 

Dr. PRICE. Well, there were multiple inaccuracies in your premise, Senator, and I would take significant issue with the Congressional Budget Office conclusion because, again, as I mentioned to 

a question over here, it looks at it in a silo, looks at it as saying, 

this is what you are doing without doing anything else to provide 

coverage for individuals. And that is simply—that is not anybody’s 

plan. 

Senator WYDEN. Well, again, this is what is in the bill you wrote. 

And these silos—you know, we keep hearing all kinds of happy talk 

about silos and dreams and the like. What we want to know is one 

thing above everything else: is there going to be a replacement before there is repeal? 

And you have been asked this now by a whole host of members. 

We have not been able to get any answers on it. It seems to me 

that your own bill is out of step with what the new President has 

said. The new President said the two were going to be intertwined. 

Your own bill was repeal and run, repeal it now, come back some 

other time. 

So I want to let my other colleagues have a chance to ask their 

questions. But when you talk about silos, that is the view of someone—I respect your right to state it—who would like to be confirmed. 

The nonpartisan Congressional Budget Office says women, who 

were speaking out in communities across this country, women are 

going to lose access to those vital cancer screenings. And that is not 

a partisan statement. That is from a nonpartisan agency. 

60 

Dr. PRICE. I respect—— 

Senator WYDEN. I hope you will reconsider your position. 

Dr. PRICE. I respectfully disagree with the conclusion. 

The CHAIRMAN. Okay, hopefully we can finish in the next 20 

minutes. 

Senator Cardin? 

Senator CARDIN. Thank you, Mr. Chairman. 

Again, thank you, Dr. Price, for your response to our questions. 

One of the major objectives of the Affordable Care Act was to 

deal with the historic discrimination against minority communities 

in our health-care system. And we can give you chapter and 

verse—the medical research that was done was very much not directed towards the priorities in the minority community. The access to providers was always challenging in minority communities. 

The affordability and quality of insurance products were not the 

same in minority communities. 

So there were various provisions included in the Affordable Care 

Act to deal with that. One was an amendment that I offered that 

elevated the National Institute for Minority Health and Health 

Disparities to a full institute, as well as creating offices for minority health and health disparities within the health-related agencies. 

Are you committed to continuing progress so that we have a focal 

point, so that we draw attention to the needs of minority communities? 

Dr. PRICE. Senator, this is a really important question, because 

there are many in our society in the minority community who, if 

you look at the right metrics, are not having the same outcomes 

or same quality of health that others in society are. 

And I believe that it is incumbent upon us as individuals administering these programs to ask the question why, why is that, and 

then reach a plan, a strategic plan, to be able to help correct that. 

Whether that is through the current offices or a different mechanism, you have my commitment to look at that and make certain—— 

Senator CARDIN. I appreciate that. The National Institute for Minority Health and Health Disparities funded a program in Maryland, in Baltimore, to show disparities, and that has been extremely helpful. And I would just encourage you to look at that institute as a real, valuable resource to you to carry out that commitment. 

The Affordable Care Act also increased dramatically the funding 

for Qualified Health Centers that allow access to care in minority 

communities. Are you committed to maintaining the support for 

Qualified Health Centers? 

Dr. PRICE. Qualified Health Centers play a vital role in our Nation’s health-care delivery system right now. And so I think it is 

imperative that we retain them or improve the delivery of care in 

that area. 

Senator CARDIN. So now I am going to get to the subject that has 

been talked about by many members: Medicaid. And the reason I 

mention Medicaid—and I appreciate your response that you do not 

want to disadvantage anyone who is currently on the Medicaid system—is blacks, Latinos, American Indians, and Native Alaskans 

61 

are almost twice as likely to be in Medicaid than the white population. In my State, 70 percent of our Medicaid population are people of color, so it is by far the dominant population that relies on 

Medicaid. 

So I hope you understand our concern, that when we talk about 

changing Medicaid, talk about block-granting Medicaid, talk about 

new approaches to Medicaid, it sends a signal that what we are 

going to do is cut the Federal Government’s commitment to access 

for minorities. And it is a major area of concern. 

We have seen budget rounds where cuts to Medicaid dollar-fordollar would have reduced access to minority communities for their 

health-care needs. We know States have challenged budgets, and 

the more you put on the State, the more likely it is that many 

States will not be able to meet their full commitments to the Medicaid population. 

Can you just share with me a little bit more your vision. When 

you look at the resources we are putting into health care—everybody wants to do it more efficiently—but if you just look at the 

Medicaid population, what you are doing is taking resources away 

from minority communities and making the problem even worse. 

How can you give me a comfort level that you are committed to 

the minority communities that depend so heavily on the Medicaid 

program? 

Dr. PRICE. Well, Senator, let me try to assuage your concerns. I 

think, of the individuals at the dais and at this table, I am the only 

one who has ever treated a patient in the Medicaid system, in fact 

treated thousands of patients in the Medicaid system. 

And when we as a society use as the only major metric for determining whether or not we are providing care for individuals in the 

Medicaid system, the amount of money that we are putting into the 

system instead of the outcome, whether or not people are getting 

covered, whether they are able to see the doctor they want to see, 

whether they are able to get the kind of care that they want—— 

Senator CARDIN. And I agree with that. I agree with what you 

are saying, but I would just make this point—— 

Dr. PRICE [continuing]. Then we are measuring the wrong thing. 

So my commitment to you is to make certain that we measure 

the right things. 

Senator CARDIN. I agree with you, but if you look at the relative 

resources that are going into the Medicaid population versus the 

general population, you will find in many cases it is less resources. 

And as we said on quality education, money is not the only thing, 

but it is part of the problem. 

I just really urge us to recognize, yes, we want a better outcome, 

we all want a better outcome in our health-care system. But you 

do not do that by taking money away from our most vulnerable. 

Dr. PRICE. Thank you. 

Senator CARDIN. Thank you, Mr. Chairman. 

The CHAIRMAN. Senator Nelson? 

Senator NELSON. Thank you, Mr. Chairman. 

Congressman, just to follow up our last conversation, you said 

that you did not recall having said it is a terrible idea. I quoted 

the source, Politico, and that was ‘‘Most Republicans support’’—and 

62 

I am quoting from the Politico article of 2002, April the 30th, ‘‘Most 

Republicans——’’ 

Dr. PRICE. 2002? 

Senator NELSON. 2012. 

Dr. PRICE. 2012. 

Senator NELSON. April 30th. ‘‘Most Republicans support the 

health law’s requirement that insurance companies accept all applicants. But the replacement plan on preexisting conditions put 

forth by the most prominent Republican ignores the idea’’—talking 

about preexisting conditions. 

Dr. PRICE. Yes, I would disagree. 

Senator NELSON. Quote, ‘‘ ‘It is a terrible idea,’ Representative 

Tom Price, the sponsor of the plan, told Politico.’’ 

So, Mr. Chairman, I would like to insert that Politico article into 

the record for clarification. 

The CHAIRMAN. Without objection. 

[The article appears in the appendix on p. 138.] 

Senator NELSON. You and I had the opportunity yesterday to talk 

about Puerto Rico. We do not know the origin of this, but they are 

not treated like the States where the poorer of the population that 

you have, the more Federal assistance for Medicaid that you get. 

Instead it is a block grant, and the block grant is going to run out 

this year. And they are in a heck of problem, not only financially 

on the island, but now with a third of the population, according to 

the CDC, being infected with the Zika virus. 

Do you want to comment on what you might do going forward? 

Dr. PRICE. Well, as we talked about in your office yesterday, Senator, we absolutely need to find the resources to be able to make 

certain that they have access to the care that they need. These are 

American citizens, and it is incumbent upon us to take that responsibility seriously. 

Senator NELSON. I mentioned earlier, and I did so yesterday, 

that senior citizens—we have 4 million in Florida on Medicare, but 

there are almost 2 million people in Florida who now get their 

health care through the ACA. 

And on Medicare Part D, the drugs, what we have tried to do is 

close the amount of money that seniors have to pull out of their 

own pocket, otherwise known as the doughnut hole. 

Do you want to comment, Congressman, about whether or not 

seniors should have retained that Federal ability to purchase their 

drugs? 

Dr. PRICE. Well, in view of the fact that two of those senior citizens in your State are my mother-in-law and my father-in-law, I 

need to tread very carefully here. 

One of the concerns that I have about drugs being available for 

seniors is the accessibility of the drugs that they need and desire. 

So we need to make certain that formularies are not limited, that 

we are not decreasing the access and availability of medications 

that seniors have available to them for the care that they receive. 

Senator NELSON. And so, the part of the ACA that closed that 

doughnut hole for senior citizens, you would support that part? 

Dr. PRICE. As I say, I think it is imperative that we provide the 

greatest amount of opportunity for individual seniors to be able to 

gain access to the drugs that they need. 

63 

So oftentimes in these discussions, we think that whatever we 

are doing right now is the only solution that is possible. And I just, 

again, I am humble enough to believe that there are better ideas 

out there. And if we find a better idea that actually provides greater coverage at a lower cost more efficiently and is more responsive 

to patients, then we ought to be able to admit to ourselves that we 

would embrace that if it were to come along. 

Senator NELSON. Congressman, as their Senator and as their 

protector of senior citizens in Florida, I cannot get away with an 

answer like that. I have to tell them that I am going to support 

their right to get drugs under Medicare Part D just like they are 

getting them now and not take that away from them. 

Dr. PRICE. And I understand that. And I would respectfully suggest that if we used, as a society, the line, we are going to maintain 

the kind of quality coverage that we have right now unless we are 

able to improve it, then we might just be able to do that for you. 

Senator NELSON. And if I gave them that answer, I would get 

run out of the room by a group of senior citizens. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Senator Menendez? 

Senator MENENDEZ. Thank you, Mr. Chairman. 

Congressman Price, one of the main policy priorities that you 

share with Speaker Ryan is to radically reform or alter, I should 

say, Medicare from its current structure to one where seniors 

would, in essence, receive a coupon to buy coverage. Now, despite 

the fact that President Trump has made repeated promises 

throughout the campaign that he will not touch Medicare, it seems 

that it is still one of your top agenda items. 

I have heard serious concerns about privatizing Medicare, not 

only from seniors worried about increased costs and decreased coverage, but also from providers in my State concerned about the serious negative impacts such underfunding will have on their ability 

to continue caring for Medicare seniors. 

So if the stated goal of Medicare privatization is to reduce Federal expenditures on health care for seniors, then does it not stand 

to reason that every dollar the Federal Government saves is going 

to have to come out of the pocket of seniors on Medicare? 

Dr. PRICE. Well, I disagree with the characterization of the program as you described it. I think it is inaccurate. 

Senator MENENDEZ. Okay. So let us go through the specifics. Do 

you not seek to privatize Medicare? 

Dr. PRICE. No. 

Senator MENENDEZ. Do you not seek to ultimately offer a voucher 

as your way of creating greater affordability? 

Dr. PRICE. No. 

Senator MENENDEZ. Well, it is interesting you say that, because 

studies that have been done on your and Speaker Ryan’s Medicare 

privatization plans have shown that an average 65-year old will 

pay more than twice what they pay now since the vouchers that 

you would give out are, by design, far short of what the current 

Medicare program covers. 

Dr. PRICE. Well, Senator, with respect, I have no reason to believe that the President, in his statement that he is not interested 

64 

in modifying Medicare, that that position of the President has 

changed. 

If you want to talk about what my role as a legislator was in 

fashioning legislation and trying to solve the challenges that we 

have in Medicare, I am happy to do that. But that is not the role 

that I would play if I am given the privilege of being confirmed to 

serve as the Secretary of Health and Human Services; that would 

be to administer the changes that you all come up with in the Congress of the United States and the programs that are—— 

Senator MENENDEZ. Well, let me respond to that, because I know 

I have heard you at various times, both here and before the HELP 

Committee, say that you are going to have more of an administrative role, not a legislative role. And I said to you privately, I think 

that that is a little disingenuous. 

I noticed last week, the day of the hearing before the HELP 

Committee, Vice President Pence was on TV, and he said, quote, 

‘‘I could not be more enthusiastic that someone with his background,’’ referring to yourself, ‘‘in medicine, but also his understanding of the President-elect’s vision for health-care reform and 

his ability to help us shape what that replace bill looks like once 

we repeal Obamacare. . . .’’ 

Clearly, they think, the President and the Vice President, that 

you are going to be playing a policy development role, not just simply the administration of whatever the Congress decides. 

So in your advocacy with the President as he deals with his desire to replace Obamacare, the reality is, you are going to have 

more than an administrative role; you are going to have a policy 

role. And if past is prologue, then your views as a legislator as to 

what you think is best for the American people is of concern to me 

because that, in essence, is a plan towards privatizing Medicare. 

So if that is not the case, would you commit to ensuring that, 

under your watch, Medicare will not increase costs or limit the coverage to current or future beneficiaries as a result of a change in 

the plan? 

Dr. PRICE. Senator, a couple of things. One, the comments that 

you referenced, I think, were related to the ACA, not to Medicare. 

Second, as I mentioned to you yesterday in our conversation in 

your office and as I have said before here, I am humble enough to 

understand and appreciate that the work that I did as a legislator 

is not necessarily the work that I would promote as Secretary of 

Health and Human Services. 

The work that has been done within the Department—the experts within the Department have significant knowledge and expertise in the work that they have done—— 

Senator MENENDEZ. Well, I appreciate that. But the essence of 

my question, then, if you dispute that your past views are going 

to be your future views, that your past views and legislative activity are not going to be your advocacy with the presidency, then I 

would ask you to go to the core of my question. Are you willing to 

commit that we will not see increased costs or less coverage for 

seniors under a revision of Medicare as you might advocate or the 

President might pursue? 

Dr. PRICE. What I can commit to you and will commit to you and 

have committed to you, sir, and others on this committee and in 

65 

other conversations, is that our goal is to make certain that seniors 

have access to the highest-quality health care possible at an affordable price. 

Senator MENENDEZ. Well, access without the ability to afford it— 

and I will end on this. 

Dr. PRICE. That is what I said: affordable price. 

Senator MENENDEZ. Well, affordability, still a question, is not 

just an affordable price; it is your ability to have the wherewithal 

even to access an affordable price. 

Medicare guarantees as a right, it guarantees care for seniors, 

like my late mother who worked in the factories of New Jersey as 

a seamstress, was not in a unionized factory, did not have private 

insurance. After working a lifetime of hard work to help her family 

achieve what they did, she faced an enormous struggle with Alzheimer’s that ultimately took her life. For her, her health-care security was Medicare. And without it, she would not have lived with 

the dignity that she deserved in the twilight of her life. 

So changing Medicare from a commitment and an entitlement to 

vouchers that might hope to create affordability but do not guarantee it, that is a fundamental shift in the nature of how we take 

care of seniors in this country. And that is why I am so passionate 

about it. 

I said this to you privately, and I just wanted to explore it with 

you publicly, but your answer does not assuage me that, in fact, 

you are committed to Medicare as we know it today in terms of the 

guarantee. Can we improve? I am always open to improving it, but 

the guarantee is what I am concerned about. 

Dr. PRICE. I share those concerns as well, but I disagree with 

your characterization and can also share with you a story of my 

mom, who, in the twilight of her years, had an illness that took her 

from us. And she enjoyed the benefits of Medicare and, without 

that, would not have been able to have the care that she received. 

Senator MENENDEZ. Well, I hope that will be compelling to you 

in the days ahead, that it will instruct you as to how we should 

pursue Medicare. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Senator Brown? 

Senator BROWN. Thank you, Mr. Chairman. 

I began with the comments of Congressman Price about not 

using the word ‘‘socialized medicine,’’ the term. In 2007 in the Congressional Record, debating CHIP, he talked about being eligible 

for government-run socialized medicine, referring to CHIP. But I do 

not want to debate that, I just want to point that out. You may 

have forgotten—it has been 10 years—I certainly understand that. 

I want to follow up on what Senator Menendez said about Medicare, with a slightly different twist. In December, you said you expected lawmakers to push forward an overhaul of Medicare, and I 

quote, ‘‘in the first 6 to 8 months of the Trump presidency.’’ 

Today, Congressman Mulvaney, the Budget Director designee, 

said that he would support raising the eligibility age for Social Security. He seemed to be open to raising the eligibility age for Medicare too, in his comments. And like you, he supported efforts to 

raise it in legislation, in Speaker Ryan’s so-called A Better Way 

plan. 

66 

That is in exact contradiction, I understand, of what President 

Trump has said; he said he opposes both cuts and raising the eligibility age. 

I would like you to—I asked you to clarify your position in a letter. I have not received a response yet. I know you are busy. But 

my question is this: if Congress passes legislation to raise the eligibility age for Medicare, as laid out in Speaker Ryan’s A Better Way 

plan, will you advise President Trump to veto that legislation? 

Dr. PRICE. I do not anticipate a single piece of legislation related 

to just that. So we would have to look at the constellation, if I am 

confirmed. 

Senator BROWN. So if something else is part of it, you would consider supporting raising the eligibility age? If you are not willing 

to say, no matter what else is in it—you stand firm on that? 

Dr. PRICE. If I am confirmed, it would be my responsibility to 

talk with the President about the various aspects of any piece of 

legislation, lay out the pros and cons and the consequences of the 

decisions that would be made by the Congress of the United States 

and make a recommendation. 

Senator BROWN. When I think about a barber in Warren, OH or 

a factory worker in Logan, OH or a woman who works in a diner 

in Mansfield, OH or someone working construction in Troy, OH 

and saying to them, you know, I know that you think Medicare’s 

eligibility age is 65, you have worked all your life, you do not have 

these jobs where we can work to older ages—you and I are close 

to the same age; unfortunately I am a bit older—but I just cannot 

imagine the morality of telling these people who have worked all 

their lives and their bodies have broken down more than ours do 

in these jobs, that we would even consider the possibility, as you 

all did in Congressman Ryan’s bill, you did, Budget Director 

Mulvaney did, raising the eligibility age for Medicare. It is just 

stunning to me. 

Let me talk about something—— 

Dr. PRICE. Senator, if I may, I struggle with the morality of a 

system that looks at Medicare, which is broken and is—— 

Senator BROWN. Yes, I know. I know what you are going to say. 

You have said that already. I appreciate that. I do not agree with 

that. I do not agree that Medicare is broken the way you say. 

Let me talk about something else. You said good things about innovation. I want to bring up one really quick issue and ask you to 

continue to work with us on it. 

Last summer, Secretary Burwell visited my hometown of Mansfield, OH to witness firsthand the effective and cost-efficient role of 

community health workers in reducing infant mortality rates. I will 

talk to you more privately—and thank you for trying to get together in the last few days—about working to ensure that community health workers are recognized and included in new payment 

and delivery system reforms. They have been very effective at 

bringing down the low birth weight baby rate and cutting back the 

rate of infant mortality. 

My State is, unfortunately, maybe last in black infant mortality 

and pretty bad overall in infant mortality. I just want a commitment from you to at least sit and work with us on what Secretary 

Burwell and I began for dealing with community health workers. 

67 

Dr. PRICE. Absolutely. 

Senator BROWN. Okay, thank you. 

Last question—and thank you for your indulgence, Mr. Chairman, on this second round. 

Do you support guaranteed health care for our Nation’s veterans? 

Dr. PRICE. I think the commitment that has been made by this 

Nation is that veterans should receive health care, yes. 

Senator BROWN. But we do not. I mean, not all veterans qualify 

for care through the VA. On Tricare they do and there are a lot 

of them in your State as in my State. But because of these gaps, 

additional coverage options, like those provided through the ACA, 

are critical to ensure that they are covered. 

So what is the answer? The VA does not do it alone; the ACA 

complements the VA. So if we repeal the ACA, how do you guarantee health care for my State’s thousands, your State’s thousands 

of veterans who served their country, but do not have real health 

care? 

Dr. PRICE. Right. Well, currently, as you know, Senator, there 

are real challenges in the VA system. Again, I think I am the only 

individual on the dais here who has ever taken care of a patient 

in a VA hospital. And I know the challenges. And I know—— 

Senator BROWN. Well, but you want to repeal—thank you—but 

you want to repeal the Affordable Care Act, and we have used the 

Affordable Care Act in such a way that these veterans now have 

guaranteed health care. Almost all veterans have guaranteed 

health care, yet you are going to repeal the Affordable Care Act 

with no plans that anybody has seen yet to make sure these veterans have guaranteed health care. 

Dr. PRICE. I understand and appreciate the promise that has 

been made to veterans. And sadly, in many instances, we are not 

keeping that promise right now. 

Senator BROWN. So is that part of your—— 

Dr. PRICE. And I look forward to working with you to put together a better system that will—— 

Senator BROWN. Well, I appreciate that. I appreciate that, Congressman. 

Dr. PRICE [continuing]. Allow us to care for veterans in the way 

that we should. 

Senator BROWN. Now, you had said when I asked you about 

President Trump saying he has been working with you on this repeal and replace plan, you said he has not really been working 

with you. So, I mean, you did not call the President a liar, but, you 

know, putting two and two together is pretty easy; it adds up to 

four. 

What does that mean? If you and he are working together, are 

you going to suggest to him that we find a way in repeal and replace to make sure there is guaranteed health care for our Nation’s 

veterans? 

Dr. PRICE. Well, I think it is vital, again, as I have mentioned 

before, that every single American have access to affordable coverage that is of high quality. And that is our goal, and that is our 

commitment. 

Senator BROWN. And so when we replace the Affordable Care Act 

after your party repeals it in this Congress, you will find a way for 

68 

all 22 million Americans, including a lot of those who are veterans, 

to have health insurance, so they do not lose it with the replace 

part of repeal and replace? 

Dr. PRICE. I look forward to working with you to make that happen, sir. 

Senator BROWN. That is not quite a ‘‘yes,’’ Congressman. 

Dr. PRICE. That is my answer. 

Senator BROWN. Okay. Inadequate, but thank you. 

The CHAIRMAN. Okay. Thank you. 

Senator Casey? 

Senator CASEY. Thank you, Mr. Chairman. Thanks for the additional round of questioning. 

Representative Price, I want to move to the topic I hoped I would 

have gotten to in the first round, which is individuals with disabilities, many of whom, I do not have the exact number, but many 

of whom rely upon Medicaid. 

One of them is actually a young child whom I just got a letter 

from his mother about—Pam Simpson, who is from Coatesville, PA, 

which is in southeastern Pennsylvania—talking about her son, 

Rowan Simpson, who was diagnosed in 2015 with autism. And 

among the things she said about the great care they get, that he 

gets in their family benefits from Medicaid, she says, without Medicaid, quote, ‘‘we would be bankrupt or my son would go without 

the therapies he sincerely needs.’’ 

Can you guarantee today that his family is going to benefit from 

and he, Rowan Simpson, will have that kind of coverage and protection that Medicaid provides, that he will have that if you are 

Secretary of Health and Human Services? 

Dr. PRICE. We are absolutely committed to making certain that 

that child and every other child and every other individual in this 

Nation has access to the highest-quality care possible. 

Senator CASEY. Okay, not access, he will have the medical care 

that he has right now, or better. If you can come up with a better 

level of care, that is fine. But he will have at least the coverage 

of Medicaid and all that that entails that he has right now? And 

that is either ‘‘yes’’ or ‘‘no,’’ that is not—— 

Dr. PRICE. No, it is not a ‘‘yes’’ or ‘‘no,’’ because the fact of the 

matter is that, in order for the current law to change, you all have 

to change it. If I am given the privilege of leading at the Department of Health and Human Services—— 

Senator CASEY. Yes. Here is why it is ‘‘yes’’—— 

Dr. PRICE [continuing]. And I am responsible for—— 

Senator CASEY. Look, you should stop talking around this. You 

have led the fight in the House, backed up by Speaker Ryan, for 

years—— 

Dr. PRICE. To improve Medicaid. 

Senator CASEY [continuing]. To block-grant Medicaid, okay? 

Dr. PRICE. To improve Medicaid. 

Senator CASEY. To block-grant Medicaid. What that means is, 

States will have to decide whether or not this child gets the Medicaid that he deserves. That is what happens. So you push it back 

to the States and hope it works out. 

One estimate by the Center on Budget and Policy Priorities, long 

before you were named, said that—here is the headline of a chart: 

69 

‘‘House budget chair’s plan would slash Medicaid by one-third by 

2026.’’ This was not developed because you are now in front of this 

committee. That is what they were saying, that Medicaid would be 

cut by a third and by a trillion dollars. 

So let me ask you this question. 

Dr. PRICE. May I respond? 

Senator CASEY. Let me just get this question in. Can you commit 

to us right now that no person with a disability who is currently 

covered by Medicaid, so that is everyone—that is Rowan and that 

is everyone else—that no person with a disability who is currently 

covered by Medicaid will lose health-care coverage, not access but 

coverage, under the block-granting plan that the administration 

now embraces as of Sunday? 

Dr. PRICE. What I can commit to you is that in our Medicaid system, if I am given the privilege of service, working with CMS administrators, the metrics that we will use for Rowan and every single other patient are the quality of care that they are receiving—— 

Senator CASEY. That is fine—— 

Dr. PRICE [continuing]. And whether or not they are receiving 

that care. The metric that you want to use—— 

Senator CASEY. Metrics are fine. What I am asking you again is, 

will you commit to ensure that Rowan and every other person in 

the country who has a disability, who benefits from Medicaid today, 

will they have that same coverage and the same health care and 

coverage they have today? 

Dr. PRICE. Our commitment is to make it so that they have that 

coverage or greater. 

Senator CASEY. That is a commitment you are making. 

Dr. PRICE. That is a commitment. 

Senator CASEY. For every person with a disability who benefits 

from Medicaid. 

Dr. PRICE. As I said, the goal is and our desire is to make sure 

that people have better health care, not less health care. And it is 

astounding to me—— 

Senator CASEY. Well, here is the problem with that. Here is the 

problem with your answer. Until Sunday, there was a question as 

to whether or not President Trump or his administration would 

fully embrace block-granting of Medicaid, because he said when he 

was campaigning that he would not cut Medicare and Medicaid and 

Social Security. As of Sunday, the administration has said on the 

record, in at least one and maybe two interviews, that they are 

going to pursue a block-granting policy with regard to Medicaid. 

What flows from that are the following: he has a majority in both 

houses, so what you have been working on in the House for years 

that you could vote for now may become the law of the land. So 

this is a live issue; this is not theory or some policy among House 

Republicans. This is a potential enactment of law to block-grant 

Medicaid. 

And I hope you can keep your promise to make sure that no one 

with a disability suffers any diminution of care or coverage. That 

is the promise you just made, and I hope you can keep that in light 

of a trillion-dollar cut in Medicaid pursuant to block-granting. 

The CHAIRMAN. Senator McCaskill, you are the last one. 

70 

Senator MCCASKILL. Thank you. And thank you for your patience 

in letting us have another round of questions, Mr. Chairman. We 

sincerely appreciate it. 

I would like to put in the record a table prepared by the Tax Policy Center on December 15, 2016 that lays out what happens with 

a repeal of all ACA taxes, including premium credits based on income level, if I could make that part of the record. 

The CHAIRMAN. Without objection, it will be placed in the record. 

[The table appears in the appendix on p. 91.] 

Senator MCCASKILL. You were chairman of the Budget Committee. I am going to try not to be—I get frustrated when people 

will not answer, especially when your record is so clear on this, 

Congressman. I do not really understand why you want to divorce 

yourself from your record. 

You were chairman of the Budget Committee, correct? 

Dr. PRICE. Yes. 

Senator MCCASKILL. And in that role, you had the most important—we all know the power of the chairman around here. You had 

incredible power to influence what was in that document, correct? 

Dr. PRICE. Which document do you refer to? 

Senator MCCASKILL. The budget that you prepared for 2017. 

Dr. PRICE. Absolutely, along with my colleagues. 

Senator MCCASKILL. Along with your colleagues. Was there anything in that document that you disagreed with on principle when 

you supported it? 

Dr. PRICE. Oh, absolutely. 

Senator MCCASKILL. Okay. What was in the document you disagreed with on principle when you supported it? 

Dr. PRICE. I would have to go back and look. 

Senator MCCASKILL. All right. 

Dr. PRICE. But it was a combined effort. But again, you know, 

as I mentioned before, if I am given the privilege of serving as Secretary of Health and Human Services, I appreciate and understand 

that that is a completely different role than as a legislator. 

Senator MCCASKILL. I know it is a completely different role. That 

is not what I am asking you, Congressman. I am not asking you 

about the difference. 

Dr. PRICE. Each of your questions refers to that role. 

Senator MCCASKILL. I am not asking you about the difference in 

your roles. What I am asking you is, what do you believe in? What 

do you believe in? You have been respected around these halls for 

a man of integrity because you believed in certain principles. And 

one of those was the principle that you embraced as chairman of 

the Budget Committee to block-grant Medicaid. 

Dr. PRICE. No, on the contrary. What I believe in is this great 

country and the people of this great country and the principles of 

health care that I defined earlier. And those are the principles that 

we all share, I believe, and they are that we need a system that 

is affordable for everybody, we need a system that is accessible for 

everybody. 

Senator MCCASKILL. I get that. 

Dr. PRICE. We need a system that is of the highest quality—— 

Senator MCCASKILL. You have said that over and over again—— 

71 

Dr. PRICE [continuing]. That is responsive to patients, not to insurance companies and government. 

Senator MCCASKILL. I am just trying to figure out—— 

Dr. PRICE. We need a system that incentivizes innovation, and a 

system that provides choices to patients. That is what I believe. 

Senator MCCASKILL. I understand. I understand the aspirational 

goal you have. But there is a record, Congressman. That is on 

record. And the record is that as chairman of the Budget Committee, controlled by your party, you put out a budget document, 

and you said over and over again that you favored block-granting 

Medicaid. 

In fact, your budget in 2017 when you were the chairman, you 

want to run away from that today as if it never happened, and I 

cannot figure out why. You are going to be influential. What you 

really believe matters. And you want to run away from that. 

You cut Medicaid by a trillion dollars in your 2017 budget. And 

yet today, you want to stand on some notion that, well, whatever 

you guys do is fine. And that is just not reality, Congressman. 

What is reality is, you have been chosen because of your beliefs, 

and your beliefs are reflected in your budget that you wrote as 

chairman of the Budget Committee. And that is the point I am trying to make. 

Dr. PRICE. Can I respond? 

Senator MCCASKILL. And I have a hard time understanding why 

you will not say, listen, it may not turn out the way I believe, but 

yes, I favored block grants to Medicaid. 

Dr. PRICE. What I believe in is a Medicaid system that is responsive to the patients and provides the highest-quality care possible. 

And I would respectfully suggest to you that that is not the Medicaid system that we currently have. So it is incumbent upon you, 

it is incumbent upon me, if I am given the privilege of serving in 

this capacity, to work together to find the solution so that we provide the highest-quality care for Medicaid patients and everybody 

else in this country. 

Senator MCCASKILL. And I understand. And by the way, the argument being made in favor of block grants is, they give more flexibility and efficiency to the States. That is the argument you have 

made before, that is the argument that was made around the budget that you crafted, that when you block-grant things to States, it 

gives them more efficiency. 

So I want to turn to a block grant that we have now, which is 

the Social Services Block Grant, which you have voted repeatedly 

to repeal. You have said that you wanted to zero it out. And you 

have voted that way as a member of Congress. And I want to make 

sure that you understand that that efficiency and effectiveness that 

you say you get with a block grant of Medicaid is what is happening in my State with the Social Services Block Grants, which, 

by the way, came about with Ronald Reagan. 

They are deciding where to use that money. And right now, just 

so you know where it is being used—in case you want to advise the 

President, the same way you voted—it is being used for residential 

treatment for detoxing off heroin, it is being used for daycare for 

seniors to keep them in their home so we are not paying the bill 

on Medicaid in a nursing home, it is being used for adoption servVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00075 Fmt 6633 Sfmt 6633 R:\DOCS\30005.000 TIM
72 

ices, and it is being used for case management to save money so 

that the cases are being managed effectively and efficiently in 

terms of accessing Federal safety net programs. 

Will you continue to advocate, as you have in Congress, for a repeal of the Social Services Block Grants? 

Dr. PRICE. Senator, with respect, I think there is likely a better 

way to provide those services in a much more efficient, effective, 

and economical way for the individuals receiving the care. And I 

would also respectfully suggest to you that another State flexibility 

model that is held up by many is the TANF program that has been 

extremely successful, and so there are different ways to do things. 

And again, it ought to be a collegial conversation that we have 

to lay out what the challenges are before us, working together to 

solve those challenges. And that is what I would like to do. 

Senator MCCASKILL. I just was trying to point out the inconsistency of saying block grants to Medicaid are good because of flexibility and efficiency and block grants to States on social services 

are bad. And that has been your record in Congress, Congressman, 

and that is why I brought it up. 

Dr. PRICE. And with respect, for individuals to say that State 

flexibility for Medicaid is bad, but State flexibility for TANF is fine, 

again, is a little bit inconsistent as well. 

Senator MCCASKILL. I understand. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Well, thank you. 

Now, we are going to close this, Senator Wyden and myself, so 

we will just ask Senator Wyden to make his closing remarks, and 

then I will make mine. 

Senator WYDEN. Thank you very much, Mr. Chairman. 

As we wrap up another quiet, subdued hearing in the Finance 

Committee [laughter], I just have a couple of thoughts. And the 

first is for you, Congressman. Despite our policy differences, I want 

you to know I very much respect your willingness to serve. As you 

know—we have talked about it—you and I have a lot of mutual 

friends, and I know they are very supportive of your career. And 

I want you to know I respect your willingness to serve. 

Here is where we are in terms of the substance. Several hours 

ago, I asked you, with respect to the executive order on the Affordable Care Act, will you commit that no one will be worse off? And 

you ducked it. I asked you, will you guarantee that no one will lose 

coverage? You ducked that. I asked you, would there be a replacement before all of this went into effect to avoid hurting working 

families? And that was ducked as well. 

And it just seems to me there is a big gap between the answers 

you have given on the executive order with respect to repealing the 

Affordable Care Act and what the new President said all through 

the campaign. Everybody was going to be okay, nobody would be 

worse off, there would be no gap between repeal and replace. 

My colleagues have gone through in great length the debate 

about the Medicaid block grant. Prediction? I think some of your 

biggest critics are going to be Republican Governors on this, because I think Republican Governors—and they will be probably 

more diplomatic than I—are going to see this as a Trojan horse to 

73 

cut spending. And that is why a lot of us are concerned about 

shredding the safety net. 

I asked you about women’s health care, and here the concern is 

that women all across the country are going to lose the choice of 

providers that they want and they have today and coverage. And 

you just said, ‘‘Hey, I disagree with the Congressional Budget Office.’’ 

I asked about drugs and how we are going to lower these pharmaceutical prices, and you told me about pharmaceutical benefit 

managers. You told me about Part D—I voted for Part D, one of 

the relatively few Democrats who did—but you did not answer the 

question about whether you would get Republicans to help you fulfill the President’s pledge on bargaining. So that is what concerns 

me about all of this. 

On the ethics questions, we want to correct one key point that 

was said earlier in the hearing, that the Congressman does not 

have control over his brokered accounts. First, the Congressman 

has not provided copies of the agreements that would clarify his 

level of control. 

Second, last week the Congressman told Senator Murray regarding the purchase of Innate, quote, ‘‘I did it through a broker, I directed the broker to purchase the stock, but I did it through a 

broker.’’ 

And third on this point, these are not blind trusts. I just want 

the record to reflect that. 

I am also going to put an article in the record, Mr. Chairman, 

that ran this morning about investments in other health-care 

stocks, specifically in four companies that manufacture products in 

Puerto Rico. 

The CHAIRMAN. Without objection. 

[The article appears in the appendix on p. 286.] 

Senator WYDEN. And so, Mr. Chairman, I will wrap up with just 

one last point. Ever since I was director of the Gray Panthers, the 

Oregon Gray Panthers—I did it for almost 7 years—I was interested in one thing: changing a system that was largely for the 

healthy and the wealthy. 

And as you and I have talked about, I had eight Democrats and 

eight Republicans on a bipartisan bill that would do that. I did not 

get my way. But the Affordable Care Act had many, many good 

features, and one of them was, it made clear all across this country 

we were not going to go back to the days when health care was for 

the healthy and wealthy. 

And I am especially troubled as we wrap up this morning—we 

have been at it close to 4 hours—that when you take all of these 

policies together that you have described this morning, that is really where we are headed, that is where we are going to be. And that 

is why I am so strongly opposed to these positions. 

My hope is—we still have some additional questions to look at 

with the ethics issues. I can just tell the Congressman that George 

W. Bush’s ethics lawyer was in the paper this morning talking 

about your stock trades, and he said ‘‘I have not seen anything like 

this before, and I have been practicing and teaching about securities law for 30 years.’’ 

74 

So I think there are very troubling questions that remain, Mr. 

Chairman, with respect to this. I know that we are being told that 

members have to get any written questions in by this evening. But 

with respect to what we have heard this morning and the lodestar 

that I see, that America will end up with health care that works 

for the healthy and wealthy, I am going to oppose it. I am very 

troubled by what we have heard today. And I appreciate the chance 

to make these closing remarks. 

The CHAIRMAN. Well, thank you, Senator. 

If we keep going the way we are going, there will not be any 

health care for anybody. We will not be able to afford it; we will 

not be able to provide for it. There are so many things that are 

wrong with the current system, but it is just pathetic, and it is 

gradually eating up the whole doggone Federal budget. 

Now, I have been around here only 40 years, but I will tell you 

I have never had a witness for any position in government who has 

performed as well as you have, who has an impeccable reputation 

in medicine and in the Congress. And to be treated like, if you do 

not agree with some concepts that some of my colleagues do, there 

is something wrong with you, is just beyond the pale. 

Like I say, you not only have a great deal of experience in medicine, but you have been a great Congressman, and you have been 

trying to get things under control around here. And you have found 

that it is almost impossible, because we have all these people saying we have to do everything in the world, and they do not care 

what the costs are. And that is why this country is broke. 

We have to find some way of delivering all these health-care benefits to people without totally ruining the country so nobody gets 

any health-care benefits, which is where we are headed. I do not 

know how in the world we can continue to buy into this liberal 

claptrap that you do not have to pay the piper. 

Now, what you have said is, we are going to try, within this current system, to make it work and to cover everybody and to help 

people, whether they be poor or whether they be rich. 

Now, I do not know if you can say much more than that. But I 

get a kick out of how many of these people are constantly blathering about, we have to do everything for everybody when we know 

we are $20 trillion in debt. And this money does not grow on trees, 

and yet every one of us wants to make sure health care works, 

every one of us wants to make sure every deserving person in our 

society is cared for. 

And I say that as a person who, over the last 40 years, almost 

every health-care bill that works has my name on it, starting with 

the Orphan Drug Act. How about Hatch-Waxman that created the 

modern generic drug industry? Name it all. 

The fact of the matter is that you have been very forthright, very 

honest, and you have indicated that, in spite of all the problems 

of trying to fund health care and all the problems around health 

care, you are going to do your doggone level best to make sure 

health care is delivered to our American people. 

You know, I wonder how many of my colleagues on the other side 

are going to vote for you. And if they do not, it kind of says something about what is happening in this country. 

75 

Now, I want to thank you for being here today. You know, I do 

not think you ducked any questions. You answered them forthrightly. It might not have pleased the individual Senators, but you 

did. And I look forward to Dr. Price being confirmed and assuming 

his position so he can begin working with us here in Congress to 

improve the Nation’s health and the whole health-care system and 

to ensure that taxpayer dollars are used efficiently and effectively. 

Now, we owe that to the dedicated taxpayers and citizens of this 

great country. And to that end, several groups and individuals 

have submitted letters of support for Dr. Price. And I would like 

to ask that those be entered into the record at this point, without 

objection. 

[The letters appear in the appendix beginning on p. 82.] 

The CHAIRMAN. In closing, this committee takes its responsibilities very seriously. As you can see, this is a very intelligent committee. We have a lot of really great people on both sides on this 

committee, and they are serious about what goes on. But that is 

why we have such a thorough review process for nominees. This is 

why the committee is following and will continue to follow our longstanding process in the future. 

Now, I would ask that any written questions for the record be 

submitted by 8 p.m. tonight, which is 2 hours more than what the 

Democrats gave us. This is a timeline that is consistent with the 

committee’s consideration of previous nominees for HHS Secretary. 

And that’s a direct quote, by the way. 

Now, I want to thank you and your family for sitting through 

this and for answering these questions. I think this was the best 

I have ever heard them answered, understanding that there are no 

answers to some of these problems. 

And I just want to personally thank you. My gosh, you could 

have such a great life without doing this kind of stuff, and you are 

willing to give your life to working for the American people and in 

trying to do what really needs to be done in the area of health care. 

And I want to commend you for it, because I just do not think there 

is a justifiable reason to vote against you. 

Dr. PRICE. Thank you, sir. 

The CHAIRMAN. Well, with that—— 

Senator WYDEN. Mr. Chairman, just a unanimous consent request. 

The CHAIRMAN. Yes, sir. 

Senator WYDEN. I would just like to put in a statement by me 

under this unanimous consent request—— 

The CHAIRMAN. That would be fine. 

Senator WYDEN [continuing]. On how important it is that Congressman Price respond to the questions he has been asked by the 

HELP Committee. It is a different committee, but it is something 

of great importance to me. And I appreciate it. 

The CHAIRMAN. Well, that is fine. But see, in my estimation, the 

HELP Committee should not have held a hearing to begin with. 

This is the committee of jurisdiction. This is the committee that 

has to stand up and vote on whether or not our congressional 

friend is going to serve this country in this great capacity. And I 

believe we will vote for him and get him out of here. And by getting 

him out of here, I do not mean out of this room, okay, we have to 

76 

get him out of the Congress and get him up there where he can 

really help with all this medical expertise that he has. 

And it is apparent that you have it. I mean, there is no question 

about that in my mind. And it is hard for me to understand why 

anybody would give you a rough time. It is good to ask tough questions, and we have had a lot of tough questions here today, but you 

have answered them very, very well, as far as I am concerned, 

much better than a lot of other people who have held this position. 

Many of the others, even recently, could not answer these questions that you have been asked. And it is wonderful that we have 

a doctor who has had a long life in medical practice willing to give 

up that life, give up the freedoms that you have to have to repeatedly come up here and justify everything you do down there. I 

think it is a wonderful thing, and I just personally want to congratulate you and your wife and family for giving so much to this 

country. 

With that, we will recess, and we will reconvene again to vote 

on you promptly. 

[Whereupon, at 1:54 p.m., the hearing was adjourned.] 

(77) 

A P P E N D I X 

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

SUBMITTED BY HON. CHUCK GRASSLEY

The Wall Street Journal, October 3, 2008 

GRASSLEY SAYS EMORY PSYCHIATRIST DIDN’T REPORT $500,000 IN PAYMENTS

By Jacob Goldstein 

For a while now, Senator Chuck Grassley has been writing to universities around 

the country to ask about ties between high-profile doctors and the drug industry— 

an interest related to a bill he’s sponsoring that would require drug makers to report payments to doctors. 

In the latest letter, Grassley says a prominent Emory psychiatrist failed to disclose 

a half-million dollars in payments from GlaxoSmithKline. 

Charles Nemeroff, the chair of Emory’s psychiatry department, was paid by Glaxo 

to give speeches to doctors around the country, the Grassley letter said. Nemeroff 

was also the main investigator on a federally funded trial of Glaxo drugs. 

Emory requires its doctors to disclose potential conflicts of interest when they receive payments of over $10,000. In a statement to the WSJ, Emory said the allegations made by Senator Grassley are ‘‘serious’’ and that the university is ‘‘working 

diligently to determine whether our policies have been observed consistently with 

regard to the matters cited’’ by Grassley. 

The New York Times posted a copy of a 2004 letter from Emory to Nemeroff telling 

him that he had to limit his Glaxo consulting fees to less than $10,000 a year to 

avoid a conflict that would violate federal regulations. This week’s letter from Grassley says Glaxo paid Nemeroff more than $70,000 in 2005 and more than $30,000 

in 2006, according to reports from the company. 

Nemeroff didn’t return a call from the WSJ, but the university said Nemerov told 

Emory officials that ‘‘to the best of my knowledge, I have followed the appropriate 

university regulations concerning financial disclosures.’’ Glaxo said it has ‘‘rigorous 

guidelines governing our interaction with healthcare professionals who participate 

in GSK-supported speaking events,’’ and that it requires them to disclose those relationships. 

Grassley has previously investigated similar issues regarding psychiatrists at Harvard, Stanford, the University of Cincinnati and the University of Texas Medical 

Branch. For more on Grassley’s investigations, check out the recent interview from 

the HealthCare Channel. 

The Physician Payment Sunshine Act, which Grassley sponsors, would require drug 

makers to report payments to doctors. The industry supports the bill—finding it 

preferable to a patchwork of state laws—which has been working its way through 

Congress for a while now. 

78 

Money and Policy, October 3, 2008 

TOP PSYCHIATRIST DIDN’T REPORT DRUG MAKERS’ PAY

By Gardiner Harris 

One of the nation’s most influential psychiatrists earned more than $2.8 million in 

consulting arrangements with drug makers from 2000 to 2007, failed to report at 

least $1.2 million of that income to his university and violated federal research 

rules, according to documents provided to Congressional investigators. 

The psychiatrist, Dr. Charles B. Nemeroff of Emory University, is the most prominent figure to date in a series of disclosures that is shaking the world of academic 

medicine and seems likely to force broad changes in the relationships between doctors and drug makers. 

In one telling example, Dr. Nemeroff signed a letter dated July 15, 2004, promising 

Emory administrators that he would earn less than $10,000 a year from GlaxoSmithKline to comply with federal rules. But on that day, he was at the Four Seasons Resort in Jackson Hole, WY, earning $3,000 of what would become $170,000 

in income that year from that company—17 times the figure he had agreed on. 

The Congressional inquiry, led by Senator Charles E. Grassley, Republican of Iowa, 

is systematically asking some of the nation’s leading researchers to provide their 

conflict-of-interest disclosures, and Mr. Grassley is comparing those documents with 

records of actual payments from drug companies. The records often conflict, sometimes starkly. 

‘‘After questioning about 20 doctors and research institutions, it looks like problems 

with transparency are everywhere,’’ Mr. Grassley said. ‘‘The current system for 

tracking financial relationships isn’t working.’’ The findings suggest that universities are all but incapable of policing their faculty’s conflicts of interest. Almost 

every major medical school and medical society is now reassessing its relationships 

with drug and device makers. 

‘‘Everyone is concerned,’’ said Dr. James H. Scully Jr., the president-elect of the 

Council of Medical Specialty Societies, whose 30 members represent more than 

500,000 doctors. 

Dr. Nemeroff is a charismatic speaker and a widely admired scientist who has written more than 850 research reports and reviews. He was editor-in-chief of the influential journal Neuropsychopharmacology. His research has focused on the long-term 

mental health risks associated with child abuse as well as the relationship between 

depression and cardiovascular disease. 

Dr. Nemeroff did not respond to calls and e-mail messages seeking comment. Jeffrey 

L. Molter, an Emory spokesman, wrote in an e-mail statement that the university 

was ‘‘working diligently to determine whether our policies have been observed consistently with regard to the matters cited by Senator Grassley.’’ 

The statement continued: ‘‘Dr. Nemeroff has assured us that: ‘To the best of my 

knowledge, I have followed the appropriate university regulations concerning financial disclosures.’ ’’ On Friday night, Emory announced that Dr. Nemeroff would ‘‘voluntarily step down as chairman of the department, effective immediately, pending 

resolution of these issues.’’ 

Mr. Grassley began his investigation in the spring by questioning Dr. Melissa P. 

DelBello of the University of Cincinnati after The New York Times reported her connections to drug makers. Dr. DelBello told university officials that she earned about 

$100,000 from 2005 to 2007 from eight drug makers, but AstraZeneca alone paid 

her $238,000 during the period, Mr. Grassley found. 

Then in early June, the Senator reported to Congress that Dr. Joseph Biederman, 

a renowned child psychiatrist at Harvard Medical School, and a colleague, Dr. Timothy E. Wilens, had reported to university officials earning several hundred thousand dollars each in consulting fees from drug makers from 2000 to 2007, when in 

fact they had earned at least $1.6 million each. 

Then the Senator focused on Dr. Alan F. Schatzberg of Stanford, president-elect of 

the American Psychiatric Association, whose $4.8 million in stock holdings in a drug 

development company raised concerns. 

79 

Mr. Grassley has sponsored legislation called the Physician Payment Sunshine Act, 

which would require drug and device companies to publicly list payments to doctors 

that exceed $500. Several states already require such disclosures. 

As revelations from Mr. Grassley’s investigation have dribbled out, trade organizations for the pharmaceutical industry and medical colleges have agreed to support 

the bill. Eli Lilly and Merck have announced that they would list doctor payments 

next year even without legislation. 

The National Institutes of Health have strict rules regarding conflicts of interest 

among grantees, but the institutes rely on universities for oversight. If a university 

fails, the agency has the power to suspend its entire portfolio of grants, which for 

Emory amounted to $190 million in 2005, although the agency rarely takes such 

drastic measures. 

Dr. Nemeroff was the principal investigator for a 5-year $3.9 million grant financed 

by the National Institute of Mental Health for which GlaxoSmithKline provided 

drugs. 

Income of $10,000 or more from the company in any year of the grant—a threshold 

Dr. Nemeroff crossed in 2003, 2004, 2005 and 2006, records show—would have required Emory to inform the institutes and take steps to deal with the conflict or 

to remove Dr. Nemeroff as the investigator. 

Repeatedly assured by Dr. Nemeroff that he had not exceeded the limit, Emory did 

nothing. 

‘‘Results from N.I.H.-funded research must not be biased by any conflicting financial 

interests,’’ John Burklow, a spokesman for the health institutes, said in the kind 

of tough statement that in the past has rarely been followed by real sanctions. ‘‘Officials at Emory are investigating the concerns.’’ 

‘‘Failure to follow N.I.H. standards’’ on conflict of interest, Mr. Burklow continued, 

‘‘is very serious, and N.I.H. will take all appropriate action to ensure compliance.’’ 

In 2004, Emory investigated Dr. Nemeroff’s outside consulting arrangements. In a 

14-page report, Emory’s conflict of interest committee detailed multiple ‘‘serious’’ 

and ‘‘significant’’ violations of university procedures intended to protect patients. 

But the university apparently took little action against Dr. Nemeroff and made no 

effort to independently audit his consulting income, documents show. 

Universities, too, can benefit from the fame and money the deals can bring—a point 

Dr. Nemeroff made in a May 2000 letter stamped ‘‘confidential’’ that he sent to the 

dean of Emory’s medical school. The letter, which was part of a record from a Congressional hearing, addressed Dr. Nemeroff’s membership on a dozen corporate advisory boards (some of the companies’ names have since changed). 

‘‘Surely you remember that Smith-Kline Beecham Pharmaceuticals donated an endowed chair to the department and that there is some reasonable likelihood that 

Janssen Pharmaceuticals will do so as well,’’ he wrote. 

‘‘In addition, Wyeth-Ayerst Pharmaceuticals has funded a Research Career Development Award program in the department, and I have asked both AstraZeneca Pharmaceuticals and Bristol-Meyers [sic] Squibb to do the same. Part of the rationale 

for their funding our faculty in such a manner would be my service on these 

boards.’’ 

Universities once looked askance at professors who consulted for more than one or 

two drug companies, but that changed after a 1980 law gave the universities ownership of patents discovered with federal money. 

The law helped give birth to the biotechnology industry and led to the discovery of 

dozens of life-saving medicines. Consulting arrangements soon proliferated at medical schools, and Dr. Nemeroff—who at one point consulted for 21 drug and device 

companies simultaneously—became a national model. 

He may now become a model for a broad reassessment of industry relationships. 

Many medical schools, societies and groups are considering barring doctors from giving lectures on drug or device marketing. 

For all his fame in the world of psychiatry, Dr. Nemeroff has faced ethics troubles 

before. In 2006, he blamed a clerical mix-up for his failing to disclose that he and 

his co-authors had financial ties to Cyberonics, the maker of a controversial device 

that they reviewed favorably in a journal he edited. 

80 

The Cyberonics paper led to a bitter e-mail exchange between Dr. Nemeroff and 

Claudia R. Adkison, an associate dean at Emory, according to Congressional records. 

Dr. Adkison noted that Cyberonics had not only paid Dr. Nemeroff and his coauthors but had also given an unrestricted educational grant to Dr. Nemeroff’s department. 

‘‘I can’t believe that anyone in the public or in academia would believe anything except that this paper was a piece of paid marketing,’’ Dr. Adkison wrote on July 20, 

2006. 

Two years earlier, unknown to the public, Emory’s conflict of interest committee discovered that Dr. Nemeroff had made more serious blunders, including failing to disclose conflicts of interest in trials of drugs from Merck, Eli Lilly and Johnson and 

Johnson. 

His continuing oversight of a federally financed trial using GlaxoSmithKline medicines led Dr. Adkison to write Dr. Nemeroff on July 15, 2004, that ‘‘you must clearly 

certify on your annual disclosure form that you do not receive more than $10,000 

from GSK.’’ 

In a reply dated August 4, Dr. Nemeroff wrote that he had already done so but 

promised again that ‘‘my consulting fees from GSK will be less than $10,000 per 

year throughout the period of this N.I.H. grant.’’ 

When he sent that letter, Dr. Nemeroff had already earned more than $98,000 that 

year from GlaxoSmithKline. Three weeks later, he received another $3,844.56 for 

giving a marketing talk at the Passion Fish Restaurant in Woodbury, NY. 

From 2000 through 2006, Dr. Nemeroff earned more than $960,000 from GlaxoSmithKline but listed earnings of less than $35,000 for the period on his university 

disclosure forms, according to Congressional documents. 

Sarah Alspach, a GlaxoSmithKline spokeswoman, said via e-mail that ‘‘Dr. Nemeroff 

is a recognized world leader in the field of psychiatry,’’ and that the company requires its paid speakers to ‘‘proactively disclose their financial relationship with 

GSK, and we believe that healthcare professionals are responsible for making those 

disclosures.’’ 

http://www.nytimes.com/2008/10/04/health/policy/04drug.html 

PREPARED STATEMENT OF HON. ORRIN G. HATCH, 

A U.S. SENATOR FROM UTAH

WASHINGTON—Senate Finance Committee Chairman Orrin G. Hatch (R–Utah) 

today delivered the following opening statement at a hearing to consider the nomination of Rep. Tom Price (R–Georgia) to head the Health and Human Services 

(HHS) Department: 

Today we will consider the nomination of Dr. Tom Price to be the Secretary of 

the Department of Health and Human Services. 

I want to welcome Dr. Price to the Finance Committee. I appreciate his willingness to serve in a position of this magnitude, especially at this crucial time. 

When Obamacare was pushed through on a series of party-line votes, Republicans 

in Congress warned that the new health law would harm patients, families, and 

businesses. 

Not to put too fine a point on it, but, we were right. And, the next HHS Secretary 

will play a pivotal role as we work to repeal Obamacare and replace it with patientcentered reforms that will actually address cost. This will be an important endeavor, 

one that will and should get a lot of attention here today, but it should not be the 

sole focus of the next HHS Secretary. 

HHS has an annual budget of well over $1 trillion. Let me repeat that: One department, $1 trillion. 

HHS encompasses the Centers for Medicare and Medicaid Services, the Centers 

for Disease Control and Prevention, the National Institutes of Health, the Food and 

Drug Administration, and many others. It is no exaggeration to say that HHS 

touches more of the U.S. economy and affects the daily lives of more Americans than 

any other part of the U.S. Government. 

81 

I firmly believe that Dr. Price has the experience and qualifications necessary to 

effectively lead this large and diverse set of agencies, and many people share that 

view. 

For example, past HHS Secretaries Mike Leavitt and Tommie Thompson strongly 

support his nomination. 

Physician organizations that know Dr. Price’s work—including the American Medical Association and most surgical specialty groups—enthusiastically support him. 

The American Hospital Association and other health-care stakeholder groups do as 

well. 

Perhaps the Healthcare Leadership Council, representing the broad swath of 

health-care providers, said it best in stating that, ‘‘It is difficult to imagine anyone 

more capable of serving this Nation as the Secretary of HHS than Congressman 

Tom Price.’’ 

Unfortunately, in the current political environment, qualifications, experience, 

and endorsements from experts and key stakeholders don’t seem to matter to some 

of our colleagues. At least, that appears to be the case, as none of those who say 

they oppose Dr. Price’s nomination seem to be talking about whether he is qualified. 

Instead, we’ve heard grossly exaggerated and distorted attacks on his views and 

his ethics. On top of that, we’ve heard complaints and a series of unreasonable demands regarding the confirmation process itself. 

Of course, these tactics haven’t been limited to Dr. Price. My Democratic friends 

have taken this approach with almost all of President Trump’s cabinet nominees as 

Senate Democrats’ unprecedented efforts to delay and derail the confirmation process and apply a radically new set of confirmation standards has continued unabated. 

To that point, let me say this: I have been in the Senate for 40 years and I think 

my record for being willing to reach across the aisle is beyond any reasonable dispute. In fact, from time to time, I’ve taken lumps in some conservative circles for 

working closely with my Democrat colleagues. 

I have, on some occasions, voted against confirming executive branch nominees, 

but far more often than not, I have opted to defer to the occupants of the White 

House and allow them to choose who serves in their administrations. I’ve taken 

some lumps for that too. 

I’m not bringing any of this up to brag or to solicit praise from anyone in the audience. I raise all of this today so that people can know I’m serious when I say that 

I am worried about what my colleagues on the minority side are doing to the Senate 

as an institution. While the overriding sense of comity and courtesy among Senators 

has admittedly been in decline in recent years, I have never seen this level of partisan rancor when it comes to dealing with a President from an opposing party. I 

have never seen a party in the Senate—from its leaders on down—publicly commit 

to not only opposing virtually every nomination, but to attacking and maligning virtually every single nominee. 

Let me be clear: I’m not suggesting that the Senate start rubber-stamping nominees. Nor am I suggesting that any member of the Senate should vote against their 

conscience or preferences simply out of respect for tradition or deference. What I am 

saying is that the same rules, processes, courtesies, and assumptions of good faith 

that have long been the hallmark of the Senate confirmation process should continue to apply regardless of who is President. If what we’re seeing now is the new 

normal for every time control of the White House changes hands, the Senate, quite 

frankly, will be a much lesser institution. 

Unfortunately, our committee has not been entirely immune to the hyperpoliticization of the nomination process. We saw that last week with the Mnuchin 

hearing, and I regret to say that I think we’re likely to see more of it today. 

Case in point: I expect that, during today’s hearing, we’re going hear quite a bit 

about process, with claims that Dr. Price’s nomination is being rushed and that the 

nominee hasn’t been fully vetted. 

This is simply untrue. 

President Trump announced his intent to nominate Dr. Price just 3 weeks after 

the election. Dr. Price submitted the required tax returns and completed questionnaire on December 21st. That was 35 days ago, and, by any reasonable standard, 

that is sufficient time for a full and fair examination of the nominee’s record and 

disclosures. 

82 

By comparison, the committee held a hearing on the nomination of Secretary 

Sebelius 16 days after she submitted her paperwork. For Secretary Burwell, it was 

17 days. In other words, the time between the completion of Dr. Price’s file and his 

hearing has been more than that of the last two HHS Secretaries combined. And, 

by the way, both of those nominees received at least a few Republican votes on this 

committee and on the floor. 

Outside of extraordinary process demands, Dr. Price has faced a number of unfair 

attacks on both his record as a legislator and his finances. 

On the questions surrounding finances, I’ll defer on any substantive discussion 

and first allow Dr. Price to defend himself from what are, by and large, specious 

and distorted attacks. For now, I’ll just say that I hope that my colleagues don’t invent new standards for finances, ethics, and disclosure that are different from those 

that have generally applied in the past. 

There is a saying involving both stones and glass houses that might be applicable 

as well. 

With regard to Dr. Price’s views and voting record, I’ll simply say that virtually 

all the attempts I’ve witnessed to characterize Dr. Price’s views as being ‘‘outside 

of the mainstream’’ have been absurd, unless, of course, the only ideas that are in 

the ‘‘mainstream’’ are those that endorse the status quo on healthcare and our entitlement programs. 

In conclusion, I just want to note that the overly partisan treatment of nominees 

and distortions of their records is a relatively new development on this committee. 

My hope is that we can begin today to reverse recent trends and have a fair and 

open discussion of the nominee and his qualifications. 

AMERICAN ACADEMY OF DERMATOLOGY ASSOCIATION

1445 New York Avenue, NW, Suite 800 

Washington, DC 20005–2134 Main: 202–842–3555 

Fax: 202–842–4355 

Website: www.aad.org 

January 30, 2017 

The Honorable Orrin Hatch The Honorable Ron Wyden 

Chairman Ranking Member 

U.S. Senate U.S. Senate 

Committee on Finance Committee on Finance 

104 Hart Senate Office Building 221 Dirksen Senate Office Building 

Washington, DC 20510 Washington, DC 20510 

Dear Chairman Hatch and Ranking Member Wyden: 

The American Academy of Dermatology Association (Academy), which represents 

more than 13,500 dermatologists nationwide, wishes to express its support for the 

nomination of Representative Tom Price, M.D., for the position of U.S. Secretary of 

the Department of Health and Human Services (HHS). 

Dr. Price, in his active role in health care policy in Congress as well as his years 

of service at the state level of government, has demonstrated a proven understanding of the intricate complexities of our nation’s health care system. Additionally, as someone who has worked as a practicing physician, Dr. Price would bring 

to the position of Secretary a personal understanding of how the policies enacted 

in Washington impact the practice of medicine and delivery of care to patients 

across the country. 

Specifically, Dr. Price understands the importance of the physician-patient relationship and recognizes the critical role that physicians play in the delivery of care to 

their patients. He has often supported dermatology’s position on integrated electronic health care records and the challenges of meaningful use. Dr. Price has also 

been a leading voice to reduce burdensome regulations which have limited the time 

physicians can devote to caring for and treating patients. 

During his time in Congress, Dr. Price worked with colleagues on both sides of the 

aisle to enact a new Medicare physician payment system that streamlines multiple 

reporting requirements for physician practices within Medicare. More recently, with 

the roll out of the new Medicare Quality Payment Program (QPP), Dr. Price sought 

input regarding proposed regulations and their potential impact on physicians and 

83 

patients, working with stakeholders and advocating with the Centers for Medicare 

and Medicaid Services (CMS), to help provide flexibility for physician practices both 

small and large. 

The Academy appreciates your consideration of Dr. Price’s nomination as Secretary 

of Health and Human Services, and supports his nomination as Secretary. At this 

important time in health care for our nation, Dr. Price’s experience as a physician 

and his in-depth understanding of health care policy will provide HHS and our nation the direction needed to guide our health care system as it addresses the needs 

of a growing and diversifying patient population. Should you have any questions or 

need additional information, please contact Shawn Friesen, the Academy’s Director, 

Legislative, Political and Grassroots Advocacy at sfriesen@aad.org or (202) 712- 

2601. 

Sincerely, 

Abel Torres, M.D., JD, FAAD 

President, American Academy of Dermatology Association 

AMERICAN ASSOCIATION OF NEUROLOGICAL SURGEONS

Kathleen T. Craig, Executive Director 

5550 Meadowbrook Drive 

Rolling Meadows, IL 60008 

Phone: 888–566–AANS 

Fax: 847–378–0600 

info@aans.org 

AND

CONGRESS OF NEUROLOGICAL SURGEONS

Regina Shupak, CEO 

10 North Martingale Road, Suite 190 

Schaumburg, IL 60173 

Phone: 877–517–1CNS 

FAX: 847–240–0804 

info@1CNS.org 

January 4, 2017 

The Honorable Orrin Hatch 

Chairman 

Committee on Finance 

U.S. Senate 

Washington, DC 20510 

SUBJECT: Rep. Tom Price Nomination for HHS Secretary 

Dear Chairman Hatch: 

On behalf of the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS), representing more than 4,000 practicing neurosurgeons in the United States, we are writing in strong support of Representative 

Tom Price, M.D. (R–GA) to become the next Secretary of the U.S. Department of 

Health and Human Services (HHS). 

Throughout his time in Congress, Dr. Price, an orthopaedic surgeon, has been a 

staunch advocate for the preservation of the doctor-patient relationship, a fierce protector of private practice, and a stalwart supporter of academic medicine. As a practicing physician, and because of his work on key congressional committees with jurisdiction over health care issues, he understands all aspects of the health care system, which is essential to run HHS effectively. 

We have every confidence that Dr. Price will work tirelessly to create a health care 

delivery system that promotes high-quality, high-value, and better-coordinated care 

for our nation’s patients. We, therefore, urge the Senate Finance Committee to favorably report Dr. Price’s nomination to the full Senate vote swiftly. 

Thank you for considering our views. 

Sincerely, 

Frederick A. Boop, M.D., President Alan M. Scarrow, M.D., President 

American Association of Neurological 

Surgeons 

Congress of Neurological Surgeons 

84 

Staff Contact: 

Katie O. Orrico, Director 

AANS/CNS Washington Office 

725 15th Street, NW, Suite 500 

Washington, DC 20005 

Direct: 202–446–2024 

Email: korrico@neurosurgery.org 

AMERICAN PODIATRIC MEDICAL ASSOCIATION (APMA) 

9312 Old Georgetown Road 

Bethesda, Maryland 20814–1621 

Tel: 301–581–9200 

Fax: 301–530–2752 

https://www.apma.org/ 

January 11, 2017 

The Honorable Orrin Hatch 

Chairman 

Committee on Finance 

U.S. Senate 

219 Dirksen Senate Office Building 

Washington, DC 20510 

The Honorable Ron Wyden 

Ranking Member 

Committee on Finance 

U.S. Senate 

219 Dirksen Senate Office Building 

Washington, DC 20510 

Dear Chairman Hatch and Ranking Member Wyden: 

The American Podiatric Medical Association (APMA) respectfully requests your 

Committee affirmatively recommend Representative Thomas Price, M.D., to the full 

Senate for Secretary of Health and Human Services (HHS). Founded in 1912, the 

APMA is the leading organization and represents the majority of the estimated 

15,000 podiatrists in the country. 

Dr. Price is highly qualified for this position and brings years of experience as a 

physician and the leading health policy expert in Congress. Dr. Price has been supportive of policies that will free providers of overly burdensome regulations which 

hinder the delivery of care to patients and has encouraged additional pathways for 

providers to play a more significant role in regulatory decision-making. He has consistently provided healthcare solutions that are patient-centered and emphasize consumer choice, which will be critical as Congress moves forward with changes to the 

Patient Protection and Affordable Care Act. 

Again, we support the nomination of Congressman Tom Price as HHS Secretary and 

ask for your favorable consideration. 

Sincerely, 

R. Dan Davis, DPM 

President 

CORINTHIAN MEDICAL IPA 

5030 Broadway, Suite 821 

New York, NY 10034 T 212–740–8294 

F 212–740–8246 www.corinthianmedicalipa.com 

January 16, 2017 

The Honorable Lamar Alexander 

Chairman, 

Committee on Health, Education, Labor, and Pensions 

U.S. Senate 

Washington, DC 20510 

85 

Re: Letter in support of Dr. Tom Price 

Dear Honorable Lamar Alexander: 

I have practiced medicine in the United States for 25 years. Throughout that time, 

I have focused my practices exclusively on improving outcomes for lower-income 

communities, who face extreme health disparities in our current system. Many of 

my patients are immigrants; and I am proudly an immigrant myself. 

Today, I head a nonprofit network, Advocate Community Providers. We consist of 

over 2,000 physicians and healthcare providers and are responsible for over 700,000 

lives across four boroughs in New York City. To put this population in perspective, 

this is larger than the populations of all but the seventeen largest cities in the country. Nearly all of our patients are Medicaid recipients; most are concentrated in the 

Hispanic and Asian communities. Our network came together as a result of New 

York’s transformative Delivery System Reform Incentive Payment program, or 

DSRIP, which uses state and federal dollars to cut costs stemming from unnecessary 

hospital usage by lower-income patients by switching to a community-based preventative care system as opposed to one that depends on emergency room visits, and 

switching a value-based system instead of one based on exorbitant fee-for-service. 

I have had the opportunity to meet with Congressman Tom Price last year in New 

York; Dr. Price was particularly interested in knowing about health-care issues and 

care-enhancing, cost-saving methods that are showing promise in lower-income communities in New York, especially regarding the DSRIP initiative. 

I sincerely support his nomination and I hope that after his confirmation as Secretary of Health and Human Services, he will look closely at our work and this 

model and that we can work together to discuss support and scalability. The reforms 

that my network and the 24 other similar networks in New York are pioneering can 

and should be thoughtfully considered in urban areas and rural states alike with 

heavy Medicaid populations. We stand ready to work with him. 

There is no question that a new Administration taking office presents a key opportunity. Hopefully, it will be a historic moment for a renewed national dialogue on 

health-care reform that is apolitical and places patients first. The eventual outcome 

is uncertain, but there is no doubt that the Affordable Care Act will undergo significant changes. No matter the changes, I hope that Dr. Price and President-Elect 

Trump will be as committed to raising outcomes and creating healthier, stronger 

and more prosperous communities through better quality care and lower expenditures as the previous administration. I trust that they share that goal, and as a doctor who has worked in the Medicaid network, I can confirm that using this system 

as the place to make change is where the strongest potential exists. 

I look forward to welcoming Dr. Price back to New York this year and convening 

a round table of providers who are leading on care-enhancing, cost-saving reforms 

that can flourish anywhere. I hope to serve as a laboratory for results that will have 

positive national implications and that Dr. Price and the Department of Health and 

Human Services will take every advantage of under his leadership. 

With regards, 

Dr. Ramon Tallaj 

Chairman, Corinthian Medical IPA (CMIPA) (ACP) 

STATE OF GEORGIA

Office of the Governor 

Atlanta 30334–0090 

Nathan Deal 

Governor 

The Honorable Orrin Hatch The Honorable Ron Wyden 

Chairman Ranking Member 

Committee on Finance Committee on Finance 

U.S. Senate U.S. Senate 

Washington, DC 20510 Washington, DC 20510 

January 23, 2017 

Dear Chairman Hatch and Senator Wyden: 

86 

It is with great pride that I write to you to support the nomination of Congressman Tom Price, M.D. as the Secretary of Health and Human Services. As an orthopaedic surgeon, in private practice for twenty years, Rep. Price knows firsthand the 

intricacies of the healthcare landscape. Representative Price has served in both the 

State Senate and as a Representative for Georgia’s 6th District. During this time, 

he has become a champion for healthcare. As such, he is uniquely situated to serve 

as the Secretary for Health and Human Services. Representative Price has been 

working for the past several years to craft a solution to the many woes of the Affordable Care Act, passed and signed into law in 2010. 

As a Governor, charged with balancing a state budget, I know the many challenges that the Affordable Care Act has brought to states like Georgia. Since taking 

office, we have seen the portion of our state budget consumed by health expenses 

continue to grow. Continued growth in healthcare expenses means that other critical 

spending areas like education, transportation, and public safety are put at risk. 

I look forward to the confirmation of Representative Price so that Georgia can 

craft a Medicaid program that is sustainable and best suited to fit the needs of our 

unique population. 

Sincerely, 

Nathan Deal 

GRADY HEALTH SYSTEM

80 Jesse Hill Jr. Drive, SE 

Atlanta. GA 30303 

(404) 616–1000 

www.gradyhealth.org 

January 20, 2017 

The Honorable Orrin Hatch 

Chairman 

Committee on Finance 

U.S. Senate 

Washington, DC 20510 

The Honorable Ron Wyden 

Ranking Member 

Committee on Finance 

U.S. Senate 

Washington, DC 20510 

Dear Chairman Hatch and Ranking Member Wyden: 

It is an honor to submit these comments as you deliberate the confirmation of Dr. 

Tom Price, M.D. as this country’s next Secretary of Health and Human Services. 

I am Chairman of the Grady Health System Board of Directors (Grady Memorial 

Hospital) in Atlanta, Georgia, one of the largest, essential safety net health systems 

in the country. Grady has a vital stake in the future of this Nation’s healthcare policy. 

Grady was founded with a mission to care for the underserved and is celebrating 

its 125th anniversary this year. Our health system consists of the 953-bed Grady 

Memorial Hospital, 6 neighborhood health centers, Crestview Health and Rehabilitation Center, and Children’s Healthcare of Atlanta at Hughes Spalding, which is 

operated as a Children’s affiliate. In 2016, Grady had over 620,000 patient visits, 

including more than 130,000 emergency room visits. Over 28% of our patients are 

uninsured, 28% are covered by Medicaid, and 24% are enrolled in Medicare. The remainder have other forms of coverage, including commercial insurance. 

With its nationally acclaimed emergency medical services, Grady has the premier 

level I trauma center in all of North Georgia and serves as the 911 ambulance provider for the city of Atlanta and six rural counties. Grady’s American Burn Association /American College of Surgeons verified Burn Center is one of only two in the 

State. And the Marcus Stroke and Neuroscience Center is a Joint Commission designated Advanced Comprehensive Stroke Center. 

Other key services include Grady’s Regional Perinatal Center with its Neonatal Intensive Care Unit, Georgia’s first Cancer Center for Excellence, The Avon Breast 

87 

Health Center, the Georgia Comprehensive Sickle Cell Center, and the Ponce de 

Leon Center—one of the top three HIV/AIDS outpatient clinics in the country. 

As the cornerstone of healthcare in Atlanta, Grady serves Americans from every 

walk of life in every possible circumstance and does it with limited resources. Grady’s funding, like other safety net hospitals in the country, is often determined by 

the changing priorities of government—local, State or Federal. And it’s the place 

where changes in public policy can have an immediate and direct impact on the 

lives of our patients and the hospital’s ability to meet the demand for services. 

Dr. Price completed his residency program in orthopedics at Grady and later returned to serve as Medical Director of the Orthopedics Clinic. We believe there is 

no better training or opportunity to gain personal perspective on the health-care 

needs of all Americans than working at a safety net institution like Grady. While 

at Grady, Dr. Price trained the next generation of clinicians and provided care to 

the vulnerable—particularly the uninsured and Georgia’s Medicaid recipients. 

No clinician has been in charge of our Nation’s health-care system since Dr. Louis 

Sullivan, a former board member of Grady. With so much change being contemplated and considered in both houses of Congress, it reassures us to know that 

Dr. Price will view changes in policy with Grady and the community we serve in 

mind. 

As our Nation continues to discuss how best to deliver health care to all Americans, 

but especially to the indigent and uninsured, we believe Dr. Price’s experience as 

a physician at Grady will serve him well. We are grateful for Dr. Price’s work with 

us throughout his time in public office. We look forward to working with him in this 

important role to improve access to care for all Americans. 

Sincerely, 

Francis S. Blake 

Chairman 

NATIONAL CONFECTIONERS ASSOCIATION (NCA) 

1101 30th Street NW, Suite 200 

Washington, DC 20007 

(202) 534–1440 

https://www.candyusa.com/ 

January 13, 2017 

The Honorable Orrin G. Hatch The Honorable Ron Wyden 

Chairman Ranking Member 

Committee on Finance Committee on Finance 

U.S. Senate U.S. Senate 

219 Dirksen Senate Office Building 219 Dirksen Senate Office Building 

Washington, DC 20510 Washington, DC 20510 

The Honorable Lamar Alexander The Honorable Patty Murray 

Chairman Ranking Member 

Committee on Health, Education, Labor, 

and Pensions 

Committee on Health, Education, Labor, 

and Pensions 

U.S. Senate U.S. Senate 

428 Dirksen Senate Office Building 428 Dirksen Senate Office Building 

Washington, DC 20510 Washington, DC 20510 

Dear Chairmen Hatch and Alexander, Senator Wyden, and Senator Murray: 

I am writing to you to express support from the National Confectioners Association 

in regard to the nomination of Representative Tom Price as Secretary of the Department of Health and Human Services. 

The National Confectioners Association is the trade organization representing the 

$35 billion U.S. chocolate, candy, gum and mints industry. Confectionery is manufactured in all 50 states, directly employing 55,000 workers in more than 1,000 facilities. In addition to these jobs in manufacturing, the industry supports an additional 410,000 U.S. jobs in fields like retail, transportation and agriculture. The confectionery industry generates more than $10 billion in U.S. taxes and more than $2 

billion in exports annually. 

Dr. Price’s experiences as a surgeon and his significant legislative background at the 

state and federal levels have uniquely positioned him to lead the Department. His 

88 

considerable experience will also have a positive influence on the Food and Drug Administration, an agency with significant oversight on regulations that impact the 

confectionery industry. Dr. Price is a principled man and strong leader who will underscore the importance of making policy using the best science available after thorough and practical deliberation. 

NCA respectfully asks for Dr. Price’s prompt consideration by both of your committees and confirmation by the United States Senate as our next Secretary of the Department of Health and Human Services. 

Sincerely, 

John H. Downs, Jr. 

President and CEO 

SMALL BUSINESS AND ENTREPRENEURSHIP COUNCIL (SBE COUNCIL) 

301 Maple Avenue West, Suite 100 

Vienna, VA 22180 

(703) 242–5840 

January 23, 2017 

The Honorable Orrin Hatch The Honorable Ron Wyden 

Chairman Ranking Member 

Committee on Finance Committee on Finance 

U.S. Senate U.S. Senate 

The Honorable Lamar Alexander The Honorable Patty Murray 

Chairman Ranking Member 

Committee on Health, Education, Labor, 

and Pensions 

Committee on Health, Education, Labor, 

and Pensions 

U.S. Senate U.S. Senate 

Dear Chairmen Hatch and Alexander, and Ranking Members Wyden and Murray: 

On behalf of the Small Business and Entrepreneurship Council (SBE Council) and 

our more than 100,000 members nationwide, I am writing to express our strong support for the confirmation of U.S. Representative Tom Price, M.D. as Secretary of the 

U.S. Department of Health and Human Services (HHS). 

Congressman Price is a serious and successful physician, legislator, and policy 

thought leader who naturally transferred his Hippocratic Oath to policymaking and 

legislative initiatives across many areas. Over the course of his career in Congress, 

he has worked hard to propose and fight for policies that empower and help all 

Americans, while warning against those that do harm and undermine opportunity. 

Congressman Price is a great friend of entrepreneurs and small business America, 

and understands that government policies and actions—if not carefully thought 

through—can take a disproportionate toll on the ability of small businesses to compete, grow, innovate and create jobs. Regarding health care policy, his insights and 

experience have been invaluable in developing positive solutions, while also correctly warning about the unintended consequences of poor policy or actions. 

Congressman Price has been a leader on common sense reforms to lower health 

costs, improve quality, drive more choice and innovation in the market, and create 

true access for all health care consumers. His ‘‘do no harm’’ ethic is extraordinarily 

important now as the Congress and policymakers carefully unwind a health care 

law that has undermined people’s health, access to health coverage, as well as their 

personal finances. Small businesses and the self-employed have especially been burdened by the higher costs and limited choices that have resulted from the Affordable 

Care Act. 

Congressman Price is the right person, with the precise set of skills, experience and 

temperament to guide us to a system where all people have access to high quality, 

affordable care, and a system that is innovating for the future. This is a system— 

a market—that desperately needs more entrepreneurial ideas, but excessive regulation and government control are barriers that prevent the type of rapid innovation 

we are benefitting from in other industries and sectors. 

SBE Council strongly supports Congressman Price’s confirmation, and we urge the 

Senate to move quickly on a full vote to ensure HHS has the leadership it needs 

in many important areas, including navigating the type of reforms we need to make 

health coverage more affordable and competitive for the self-employed, small busiVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00092 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
89 

nesses and their employees. Please do not hesitate to contact me if you have questions about SBE Council’s support for Congressman Price’s confirmation as HHS 

Secretary. 

Sincerely, 

Karen Kerrigan 

President and CEO 

SCOTT WALKER

Office of the Governor 

State of Wisconsin 

P.O. Box 7863 

Madison, WI 53707 

www.wisgov.state.wi.us 

(608) 266–1212 

Fax: (608) 267–8983 

January 17, 2017 

The Honorable Orrin Hatch The Honorable Ron Wyden 

Chairman Ranking Member 

Committee on Finance Committee on Finance 

U.S. Senate U.S. Senate 

The Honorable Lamar Alexander The Honorable Patty Murray 

Chairman Ranking Member 

Committee on Health, Education, Labor, 

and Pensions 

Committee on Health, Education, Labor, 

and Pensions 

U.S. Senate U.S. Senate 

Dear Chairmen Hatch and Alexander, and Ranking Members Wyden and Murray: 

I write today in support of President-elect Trump’s nomination for Secretary of the 

U.S. Department of Health and Human Services, Dr. Tom Price. 

Secretary-designee Price is uniquely positioned to work with Wisconsin and other 

states to reform health care and help curb years of federal overreach. In addition 

to his leadership roles in congress, he spent more than 20 years caring for patients 

in Georgia as an orthopaedic surgeon and medical professional. If confirmed, Dr. 

Price will bring years of medical knowledge and federal lawmaking experience to 

the department. 

In Wisconsin, we share Dr. Price’s commitment to quality healthcare as we rank one 

of the best states in the nation for health insurance coverage and our reforms allowed us to cover everyone living in poverty under Medicaid. His decades of medical 

knowledge and firsthand experience as a licensed physician and orthopaedic surgeon, combined with his years as a lawmaker make him the perfect candidate to 

begin tackling critical reforms to empower the states. 

Again, I strongly support the confirmation of Dr. Price as the next U.S. Health and 

Human Services Secretary. I look forward to working with him in this new role. 

Sincerely, 

Scott Walker 

Governor of Wisconsin 

SUBMITTED BY HON. DEAN HELLER, A U.S. SENATOR FROM NEVADA

Nevada Legislature 

January 10, 2017 

The Honorable Dean Heller 

324 Hart Senate Office Building 

Washington, DC 20510 

Dear Senator Heller: 

90 

We are writing to express our concern regarding plans to repeal the Affordable Care 

Act. Specifically, we are concerned that Republicans in Congress are pushing ahead 

with a repeal of the Affordable Care Act despite having no viable replacement legislation ready to enact. 

Failure to immediately enact replacement legislation risks creating uncertainty in 

the insurance marketplace. Such uncertainty will likely result in higher out-ofpocket costs and fewer insurance options for Nevada’s families while simultaneously 

placing an increased burden on our State budget. 

As you are aware, Governor Sandoval worked closely with the Legislature and ultimately signed legislation creating the Silver State Health Exchange in 2011. Subsequently, more than 300,000 Nevadans have gained access to health care coverage, 

either by purchasing it on the exchange or by meeting the expanded Medicaid eligibility requirements. 

In light of these facts, we hope that you will address the following questions regarding the planned repeal of the Affordable Care Act: 

1. What steps do you plan to take to ensure that the more than 88,000 Nevadans 

who have purchased health insurance through the Silver State Health Exchange continue to have the ability to purchase health insurance with adequate coverage in a transparent marketplace? 

2. What steps do you plan to take to ensure that the more than 77,000 Nevadans 

who are eligible for Federal tax credits under the Affordable Care Act to help 

purchase private insurance will continue to have access to affordable health insurance options with adequate coverage? 

3. What steps do you plan to take to ensure that the 217,000 Nevadans who are 

receiving health care under the Medicaid expansion remain covered? 

4. The Affordable Care Act guarantees coverage vital to preventative services for 

women, including cancer screenings and birth control. What steps do you plan 

to take to ensure that the Affordable Care Act’s coverage guarantees remain 

intact for women’s health? 

5. The Affordable Care Act guarantees that Nevadans with pre-existing conditions will not be denied health care and ends lifetime minimums on coverage. 

It also allows younger people, many of whom are saddled with college debt and 

cannot afford insurance, to stay on their parents’ insurance until they are 26. 

What steps do you plan to take to preserve those coverage guarantees? 

The lack of clarity regarding viable alternatives to the Affordable Care Act from the 

incoming administration and Republican congressional leadership is troubling. 

While Congress has expended considerable time and energy over the past several 

years talking about the law, hundreds of thousands of Nevadans have relied in good 

faith on the Affordable Care Act to obtain health insurance. Repealing the law without implementing an adequate replacement will put those Nevadans’ health and 

well-being at risk. 

Further, any congressional action that creates a large gap in insurance coverage will 

likely result in more Nevadans relying on state-funded social service programs. 

Most of these programs are already under resourced. Nevada cannot afford to shoulder this new financial burden created by politicians in Washington failing to live 

up to guarantees that the Federal Government previously made to our citizens. 

We hope you will use your position as Nevada’s senior U.S. Senator and a member 

of the majority party to protect the thousands of Nevada families who are now at 

risk of losing their health insurance. We also hope you will take steps to ensure that 

our State does not bear any unfair and unnecessary costs of caring for people who 

stand to lose that coverage in the near future. 

We look forward to your prompt reply. 

Sincerely, 

Aaron D. Ford Jason Frierson 

Majority Leader Speaker 

Nevada State Senate Nevada State Assembly 

91 

SUBMITTED BY

HON. CLAIRE

MCCASKILL, A U.S. SENATOR

FROM

MISSOURI

Table T16–0285 

Repeal all ACA Taxes, Including Premium Credits 

Baseline: Current Law 

Distribution of Federal Tax Change by Expanded Cash Income Level, 2017 1

Summary Table 

http://www.taxpolicycenter.org/ 

Expanded Cash Income 

Level 2

Tax Units with Tax Increase or Cut 3

Percent 

Change in 

After-Tax 

Income 4

Share of 

Total Federal 

Tax Change 

Average 

Federal Tax 

Change ($) 

Average Federal Tax Rate 5

With Tax Cut With Tax Increase 

Change 

(% Points) 

Under the 

Proposal Pct. of Tax 

Units Avg. Tax Cut Pct. of Tax Units Avg. Tax Increase 

Less than 10 7.3 ¥1,150 0.0 7,140 1.6 3.5 ¥80 ¥1.5 5.3 10–20 6.6 ¥1,210 4.2 3,850 ¥0.5 ¥5.8 80 0.5 2.6 

20–30 7.2 ¥960 9.9 4,020 ¥1.3 ¥22.1 320 1.3 4.4 30–40 41.6 ¥170 9.2 4,600 ¥1.1 ¥18.2 350 1.0 7.7 40–50 83.9 ¥90 6.1 5,630 ¥0.6 ¥11.2 260 0.6 10.4 

50–75 93.6 ¥100 3.1 6,400 ¥0.2 ¥8.3 100 0.2 13.1 

75–100 97.3 ¥140 1.3 5,840 0.1 3.1 ¥60 ¥0.1 15.6 

100–200 98.8 ¥190 0.4 6,540 0.1 14.8 ¥160 ¥0.1 18.8 

200–500 99.8 ¥540 0.0 8,320 0.2 18.0 ¥540 ¥0.2 23.0 

500–1,000 99.9 ¥4,590 0.0 0 0.9 17.9 ¥4,580 ¥0.7 28.0 

More than 1,000 99.9 ¥50,200 0.0 0 2.2 108.4 ¥50,130 ¥1.5 32.6 

All 60.0 ¥600 3.8 4,720 0.3 100.0 ¥180 ¥0.2 19.6 

Source: Urban-Brookings Tax Policy Center Microsimulation Model (version 0516–2). Number of AMT taxpayers (millions). Baseline: 5.5; proposal: 5.5. * Non-zero value rounded to zero; ** Insufficient data. 1 Calendar year. Baseline is current law. Proposal would repeal all ACA taxes: the 3.8 percent Net Invest Income Tax, the 0.9 percent additional HI tax, the Cadillac Tax, the excise tax 

on employers offering inadequate health insurance coverage, the excise tax on individuals without adequate health insurance, the increase in threshold for medical expense deductions, and the excise taxes on health insurance providers, pharmaceutical manufacturers and importers, and medical device manufacturers and importers. Analysis includes the Premium Tax Credit which is not treated as a tax in the TPC baseline due to its similarity to a spending program. Simulations of Premium Tax Credit calibrated to match results from Urban Institute’s Health Insurance Policy Simulation Model (HIPSM). For a description of TPC’s current law baseline, see http://www.taxpolicycenter.org/taxtopics/Baseline-Definitions.cfm. 2 Includes both filing and non-filing units but excludes those that are dependents of other tax units. Tax units with negative adjusted gross income are excluded from their respective income class but are included in the totals. For a description of expanded cash income, see http://www.taxpolicycenter.org/TaxModel/income.cfm. 3 Includes tax units with a change in federal tax burden of $10 or more in absolute value. 

4 After-tax income is expanded cash income less: individual income tax net of refundable credits, corporate income tax, payroll taxes (Social Security and Medicare), estate tax, and excise 

taxes. 5 Average federal tax (includes individual and corporate income tax, payroll taxes for Social Security and Medicare, the estate tax, and excise taxes) as a percentage of average expanded 

cash income. 

92 

Notes: Unless otherwise indicated, the years referred to in this report are calendar years. The 

estimates for the next 10 years were generated using the Congressional Budget Office’s March 

2012 baseline projections of Medicare spending, and the analysis of longer-term effects was 

based on the agency’s June 2012 long-term projections of Medicare spending. (Those were the 

most recent projections available when much of the analysis was performed.) 

Numbers in the text, figures, and tables may not add up to totals because of rounding. 

SUBMITTED BY HON. BILL NELSON, A U.S. SENATOR FROM FLORIDA

Congressional Budget Office 

September 2013 

A Premium Support System for Medicare: 

Analysis of Illustrative Options 

Summary 

Over the past two decades, numerous proposals have been advanced for the establishment of a premium support system for Medicare. Under such a program, beneficiaries would purchase health insurance from one of a number of competing plans, 

and the federal government would pay part of the cost of the coverage. The various 

proposals have differed in many respects, including the way in which the federal 

contribution would be set and how that contribution might change over time. 

This Congressional Budget Office (CBO) report presents a preliminary analysis of 

the ways two illustrative options for a premium support system would affect federal 

spending and beneficiaries’ choices and payments. The agency has developed significant new tools to analyze such a system in greater depth than in the past; the specifications of the options examined here also differ from those CBO analyzed previously. As the agency refines its modeling approach and considers alternative options for a premium support system, its findings could change. CBO’s analysis to 

date indicates the following: 

■ Both options for premium support considered here would reduce federal spending 

for Medicare net of beneficiaries’ premiums and other offsetting receipts. 

■ Under the second-lowest-bid option, the option with the greater reduction in net 

federal spending, beneficiaries’ premiums and total payments for Medicare’s Part 

A and Part B benefits would each be higher on average than they would be under 

current law. (Total payments consist of premiums and out-of-pocket costs for 

deductibles, copayments, and coinsurance.) Under the average-bid option, the option with the smaller reduction in net federal spending, those amounts would 

each be lower on average than they would be under current law. 

■ Under both options, combined spending by the federal government and by beneficiaries (that is, premiums and out-of-pocket costs) would be less than that if 

current law remained in place. 

■ Under both options, effects on premiums and total payments for some beneficiaries would differ greatly from the national averages. In particular, in most 

regions, the premiums and total payments of beneficiaries enrolled in the fee-forservice (FFS) program would be higher than they would be under current law. 

■ Alternative specifications for key features of a premium support system would 

yield different results. 

What Premium Support Options Did CBO Analyze? 

The two premium support options analyzed in this report differ in terms of the formula by which the federal contribution would be determined. Otherwise, they are 

very similar. The nation would be divided into regions within which competing private insurers would submit bids indicating the amounts they would accept to provide Medicare benefits to a beneficiary of average health. The FFS program would 

be part of the system as a competing plan, and its ‘‘bid’’ would be based on the projected FFS spending for an enrollee of average health in a given region. Insurers 

would bid to provide a benefit package that would encompass the same services covered by Part A (Hospital Insurance) and Part B (Medical Insurance) of Medicare 

under current law and that would have the same actuarial value as Parts A and 

B combined (that is, each package would cover the same percentage of total expenses for a given population that Medicare’s FFS program would cover under current law). Beneficiaries who were eligible for the premium support system would not 

93 

be permitted to enroll in Part C (the current Medicare Advantage system, offered 

by private insurers that contract with Medicare to provide Part A and Part B benefits). Part D (Medicare’s prescription drug benefit program), which is now delivered 

through a competitive system, would continue as it is under current law and would 

be administered separately from the new program. 

The federal government would pay insurers for each enrollee who was in average 

health an amount that was equal to a ‘‘benchmark’’ set for that region minus the 

standard premium paid by enrollees; insurers would receive larger or smaller government payments for beneficiaries whose health was worse or better than average. 

Beneficiaries who enrolled in a plan with a bid that equaled the benchmark would 

pay the plan a standard premium, which would equal one-quarter of the estimated 

cost of providing the Part B portion of benefits and would be the same across the 

nation (set by the same formula as that used under current law for the Part B premium). Beneficiaries who chose a plan with a bid less than the benchmark would 

pay a premium that was lower by the full amount of the difference between the bid 

and the benchmark, and those who chose a more expensive plan would pay a premium that was correspondingly higher. 

The benchmarks that would be used to set the federal contribution are the defining 

features of the two options CBO examined: 

■ Under the second-lowest-bid option, the benchmark in a region would be the 

lower of a pair of bids—the region’s second-lowest bid submitted by a private insurer and Medicare’s FFS bid. 

■ Under the average-bid option, the benchmark in a region would be the weighted 

average of all bids, including the FFS bid. Each bid would be weighted by the 

proportion of beneficiaries enrolled in that plan in the year immediately preceding. 

CBO assumed that no cap would be imposed on the amount or the rate of growth 

of the federal contribution and that insurers would be required to provide coverage 

to all beneficiaries who selected a particular plan. 

The agency made detailed assumptions about many other specifications of the premium support system. Some were chosen to illustrate the potential for savings from 

a highly competitive system; others were chosen for feasibility of implementation or 

to simplify the analytical process. The specifications adopted for this analysis are 

not recommendations, and many alternative specifications are possible. 

For this analysis, CBO assumed that dual-eligible beneficiaries—people who are simultaneously enrolled in Medicare and Medicaid—would be excluded from the premium support system and that federal spending for their health care would continue as it would under current law. Anyone else who was enrolled in Medicare 

when the premium support system was implemented (assumed to be 2018 for this 

report) would enter the system immediately, and anyone other than dual-eligible 

beneficiaries who became eligible subsequently would enroll in the new system. (See 

below for a brief discussion of policy alternatives that would exclude certain other 

Medicare beneficiaries from a premium support system.) The starting date of 2018 

was chosen to allow for a period during which the federal government could develop 

the necessary administrative structures and beneficiaries and insurers could learn 

about and prepare for the new system. 

How Would the Premium Support Options Affect Federal Spending? 

CBO estimates that the second-lowest-bid option would reduce net federal spending 

for Medicare by about $45 billion in 2020 and that the average-bid option would reduce such spending in that year by about $15 billion (see Table 1). For this analysis, 

CBO reports those effects as a percentage of two different measures of spending projected under current law: net federal spending on Medicare as a whole and net federal spending on Medicare’s Part A and B benefits for beneficiaries who would be 

affected by the options (that is, everyone other than dual-eligible beneficiaries who 

would have enrolled in Medicare under current law). 

■ Net federal spending for Medicare is total Medicare spending, including spending 

on dual-eligible beneficiaries and prescription drugs covered by Part D, minus 

beneficiaries’ premiums and other offsetting receipts. The second-lowest-bid option would reduce that spending in 2020 by 6 percent and the average-bid option 

would reduce that spending by 2 percent, CBO estimates. 

■ Net federal spending on Medicare Part A and B benefits for affected beneficiaries 

includes amounts that would be paid for hospital and medical benefits provided 

by the FFS program and private plans under current law and the premium supVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00097 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
94 

port options, but excludes net spending for dual-eligible beneficiaries, Part D benefits, and certain items and services that are not covered by the bids of Medicare 

Advantage plans under current law. Beneficiaries’ premiums and other offsetting 

receipts are subtracted from that amount to arrive at net spending. The secondlowest-bid option would reduce such spending in 2020 by 11 percent and the average-bid option would reduce such spending by 4 percent, CBO estimates. Those 

percentages are larger than the percentages for total Medicare spending because 

the savings are measured relative to the portion of Medicare spending that would 

be for the beneficiaries who are directly affected by the premium support system 

rather than to total Medicare spending. 

Federal savings under either option would be substantially lower over an extended 

period if all current beneficiaries stayed in the existing Medicare system and only 

new enrollees participated in the premium support system. 

The savings to the federal government would stem, in part, from greater price competition. Because all plans would offer a basic benefit package covering the same 

services and having the same actuarial value and because the government’s contribution within a region would not vary from plan to plan (except to adjust for differences in the health status of enrollees), the full difference between plans’ bids 

would be reflected in the premiums that enrollees would pay. Thus, the two options 

would generate more price competition among private insurers than would be the 

case under current law, which would induce insurers to offer plans with lower premiums as a way to attract more enrollees. To reduce premiums, private insurers 

could, for example, strengthen utilization management (which insurers use to control costs by influencing the quantity and type of services provided) or tighten provider networks (that is, limit the number of providers to be covered by a plan). In 

most regions, the benchmark would be lower under the second-lowest-bid option 

than under the average-bid option, so the federal contribution for a plan with a 

given bid would be lower, and the premium would be higher under the secondlowest-bid option. 

Heightened price competition would probably restrain the growth of Medicare 

spending over the long term by curtailing demand for costly new technologies and 

treatments and by boosting demand for technologies that reduced costs—although 

the magnitude of any such changes is highly uncertain. Those effects on the growth 

of spending would be larger under the second-lowest-bid option than under the average-bid option, CBO anticipates, because the higher premiums under the secondlowest-bid option would cause a larger fraction of beneficiaries to choose private 

plans with lower bids. 

Under current law, the growth of Medicare spending will be restrained in other 

ways during the next two decades, thus limiting the potential for the government 

to realize further savings from a premium support system. For example, updates to 

Medicare’s payment rates for most providers in the FFS program are generally 

scheduled to be smaller than the increases in the costs of their inputs (such as labor 

and equipment), and the federal government has broad authority under current law 

to make regulatory changes to expand demonstration projects that successfully reduce spending for Medicare. How effective the various incentives and possible administrative actions under current law ultimately will be at restraining growth in 

spending, however, is not known. 

CBO estimates that the rate of growth in Medicare spending in the 2020s under 

the two premium support options would be similar overall to the rate under current 

law. Thus, the estimated savings relative to current law would be roughly the same 

in percentage terms throughout that period as in 2020, although the dollar amount 

of the savings would increase. That estimate is subject to considerable uncertainty 

but, in CBO’s judgment, lies in the middle of the distribution of possible outcomes. 

Beyond the next two decades, the federal savings from the premium support system 

would probably increase slightly in percentage terms, but CBO has not quantified 

the amounts because the uncertainties are even greater for that longer period. 

How Would the Premium Support Options Affect Beneficiaries’ Premiums? 

CBO estimates that the premiums that affected beneficiaries would pay for Medicare Part A and B benefits under the second-lowest-bid option in 2020 would be 

about 30 percent higher, on average, than the current-law Part B premium projected for that year. CBO expects that much of the increase would occur because 

many beneficiaries would remain in the FFS program and pay much higher premiums than would be the case under current law. Two-fifths of the beneficiaries 

who chose the FFS program would spend at least 6 percent of their household inVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00098 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
95 

come on premiums for each beneficiary, CBO estimates. (For comparison, CBO estimates that under current law about one-fifth of FFS enrollees would do so.) 

In contrast, under the average-bid option, affected beneficiaries would pay premiums that were 6 percent lower, on average, than the current-law Part B premium 

in 2020. Because of the higher federal contribution, premiums would be substantially lower under the average-bid option than they would be under the secondlowest-bid option. The impact of either option on premiums would vary geographically, depending on regional differences in plans’ bids. 

Because CBO estimates that total Medicare spending would be reduced under either 

option, and the standard premium would equal the same share of spending that the 

Part B premium equals under current law, the standard premium under either premium support option would be lower than the current-law Part B premium. In each 

region, beneficiaries would be offered at least one plan at or below the standard premium (given the manner in which the regional benchmarks would be calculated), 

and in most cases, at least one plan with a premium that is below (not just at) the 

standard premium would be offered, CBO anticipates. Beneficiaries who chose such 

a low-cost plan would pay a lower premium than they would under current law. 

(Beneficiaries subject to the income-related premium under current law—that is, the 

additional Part B premium required of beneficiaries whose income exceeds specified 

thresholds—would still be required to pay that additional amount.) 

Under both options, most beneficiaries who wanted to remain in the FFS program 

would face higher premiums than they would for private plans. In addition, in many 

regions, the bid for the FFS program would exceed the benchmark, so beneficiaries 

who chose to remain in the FFS program would pay higher premiums than they 

would under current law. Although many beneficiaries would switch to lowerbidding private plans, CBO estimates, a substantial proportion of beneficiaries 

would still prefer to remain in the FFS program. 

How Would the Premium Support Options Affect Beneficiaries’ Total Payments for Medicare Services? 

CBO’s analysis of beneficiaries’ total payments focuses on premiums and out-ofpocket costs for deductibles, copayments, and coinsurance for Medicare’s Part A and 

B benefits for affected beneficiaries. The analysis accounts for the loss of the federally subsidized supplemental benefits that enrollees in Medicare Advantage plans 

would receive under current law (projected to average about $400 per enrollee annually in 2020), which would not be available under the options analyzed here. In 

2020, beneficiaries’ total payments would be about 11 percent higher, on average, 

under the second-lowest-bid option and about 6 percent lower, on average, under the 

average-bid option than they would be under current law (see Table 2). 

Under the second-lowest-bid option, the premiums that beneficiaries would pay generally would be higher than current-law premiums, but out-of-pocket costs generally 

would be lower than under current law because more beneficiaries would enroll in 

lower-bidding private plans, which would tend to reduce the total costs of care while 

maintaining the required actuarial value. The lower out-of-pocket costs would offset 

part, but not all, of the increase in premiums. (On average, according to CBO’s estimates, out-of-pocket costs would account for a higher share of beneficiaries’ total 

payments than premiums would, but under the second-lowest-bid option, they would 

decline by a smaller percentage than premiums would increase relative to amounts 

under current law.) 

Under the average-bid option, the estimated reduction in beneficiaries’ total payments results from the combination of lower average premiums and lower out-ofpocket costs. As with the second-lowest-bid option, the difference in out-of-pocket 

costs would be attributable primarily to increased enrollment in lower-bidding private plans. 

Under both options, the change in total payments for particular beneficiaries could 

differ markedly from the national average. For example, those who chose to remain 

in the FFS program would generally face higher premiums and would not see a reduction in out-of-pocket costs. 

How Would the Premium Support System Affect Combined Spending by the 

Government and by Beneficiaries? 

The sum of net federal spending for Medicare and beneficiaries’ total payments as 

discussed above would be about 5 percent lower in 2020 under the second-lowestbid option than under current law, CBO estimates. Under the average-bid option, 

combined payments would be about 4 percent lower than under current law. The 

96 

estimated effects under both options are measured as a percentage of projected net 

federal spending and beneficiaries’ total payments for benefits covered by Parts A 

and B, in each case focusing on the beneficiaries who would be affected by the premium support system. The second-lowest-bid option would yield slightly more savings overall than would accrue from the average-bid option because the smaller federal contribution under the second-lowest-bid option would increase competitive 

pressure. The federal savings under the second-lowest-bid option would be much 

larger than those under the average-bid option, but beneficiaries’ payments would 

be higher. 

What Are the Implications of a ‘‘Grandfathering’’ Provision in a Premium 

Support System? 

Under some premium support proposals, all beneficiaries who became eligible for 

Medicare before the system took effect would remain in the current-law Medicare 

program and only those who became eligible after that time would enroll in the premium support system. Such an arrangement would substantially reduce federal savings relative to a system without a grandfathering provision—for an extended period—because, in the early years, only a small portion of the Medicare population 

would be covered under the new system. Moreover, because newly eligible beneficiaries entering the system would have health care costs that were lower than the 

average for Medicare beneficiaries as a group, the potential savings would be limited even more. 

CBO estimates that if a premium support system began in 2018 and existing Medicare beneficiaries remained in the current system, only about 25 percent of the 

Medicare population would be covered under the new system after five years (assuming dual-eligible beneficiaries were excluded), and those beneficiaries would account for only about 15 percent of net Medicare spending in total for that year 

under current law (including spending for dual-eligible beneficiaries and for Part D). 

After 10 years, about 45 percent of the Medicare population would be covered, accounting for about 30 percent of net Medicare spending in total. 

Although in order to simplify the modeling, CBO decided for this analysis not to 

consider grandfathering provisions, the agency expects to complete such a study 

soon. A very rough approximation (made on the basis of the estimated share of 

Medicare spending that would be covered each year) suggests that federal savings 

after five years of operation under a system with grandfathering would be about 15 

percent of the savings achieved if all beneficiaries other than those with dual eligibility entered the new system in 2018; after a decade, about 30 percent of those savings would be realized. 

Thus, the cumulative savings would be substantially less than would be possible if 

all beneficiaries entered a premium support system immediately. Grandfathering 

also would reduce, for an extended period, the incentives to modify the development 

and adoption of new technologies, so the restraint in the growth of Medicare spending that would probably occur under a premium support system would be substantially smaller for many years. 

What Key Specifications of a Premium Support System Would Affect Federal Spending and Beneficiaries’ Payments? 

On the basis of its preliminary analysis, CBO identified several important features 

of premium support proposals that would significantly affect federal spending and 

beneficiaries’ payments: 

■ A smaller federal contribution would yield greater federal budgetary savings; on 

average, beneficiaries’ premiums would be higher, however. 

■ Including the FFS program as a competing plan would boost federal savings, both 

because the rates the program pays providers (which generally are below rates 

paid by commercial plans) would serve to hold down the rates paid by competing 

private insurers and because in some regions the FFS program would be the 

lowest-bidding plan and therefore could lower the benchmark relative to what it 

would be otherwise. 

■ Excluding some groups of beneficiaries from the premium support system—say, 

people born before a particular year or dual-eligible beneficiaries—would reduce 

federal savings; however, including certain groups could pose additional challenges for administering the system and could have unintended consequences for 

members of those groups. (Dual-eligible beneficiaries, for example, might face 

limited provider networks and complex issues of care coordination.) 

97 

1See House Committee on the Budget, The Path to Prosperity: A Responsible Balanced Budget: 

Fiscal Year 2014 Budget Resolution (March 2013), http://go.usa.gov/bAAV (PDF, 7 MB); Pete 

Domenici and Alice Rivlin, Domenici–Rivlin Protect Medicare Act (Bipartisan Policy Center, 

June 2012), http://tinyurl.com/nherwb4; and Ron Wyden and Paul Ryan, Guaranteed Choices 

to Strengthen Medicare and Health Security for All: Bipartisan Options for the Future (House 

Committee on the Budget, December 15, 2011), http://go.usa.gov/bAsz. 2See Congressional Budget Office, Dual-Eligible Beneficiaries of Medicare and Medicaid: 

Characteristics, Health Care Spending, and Evolving Policies (June 2013), www.cbo.gov/publication/44308. 

■ Features that make beneficiaries more responsive to differences in premiums 

would boost enrollment in plans with lower bids and thus increase the incentive 

for plans to submit lower bids. 

Many other aspects of a premium support system also would significantly affect federal spending and enrollees’ payments. CBO will continue to develop its capacity to 

estimate the effects of varying those features. 

Two Illustrative Options for a Premium Support System for Medicare 

In designing a premium support system for Medicare, lawmakers would confront 

many choices affecting federal costs, beneficiaries’ payments, and, perhaps, beneficiaries’ access to care and the quality and nature of the care that they would receive—both in the short term and over the longer term. To project the potential effects of such a system, CBO developed detailed illustrative specifications regarding 

eligibility for the program and the timing of its implementation, the structure of the 

market for Medicare benefits, and the determination of federal contributions and 

beneficiaries’ payments. 

CBO analyzed two illustrative options, both of which would require insurers to submit bids specifying the payment they would accept to provide a basic package of 

Medicare benefits for an enrollee of average health. Under each option, the federal 

contribution toward beneficiaries’ health care costs would be determined on the 

basis of a benchmark set for each region of the country. The two options differ in 

that under the first, determination of the benchmark would involve the secondlowest bid in each region; under the second, the benchmark would be set on the 

basis of a weighted average of bids in the region. For this analysis, CBO adopted 

a variant of the second-lowest-bid approach that is similar to those included in several recent proposals.1 Under such an approach, the benchmark would equal the 

lower of two bids: the second-lowest bid from a private insurer and Medicare’s FFS 

bid. Thus, in any region, the benchmark could be no higher than the bid of the FFS 

program. (For a summary of the program’s operations under the second-lowest-bid 

option, see Figure 1. The operations under the average-bid option would be the same 

except for the determination of the benchmark.) 

Medicare would continue to be divided into Parts A, B, and D under both options, 

and financing for federal outlays would come mostly from the same sources as under 

current law (see Box 1). 

The specifications outlined in this report are not recommendations. Some were chosen to illustrate the potential for savings from a premium support framework; others were chosen for feasibility of implementation or to simplify the modeling approach. Many other variants of these options are possible. (For additional discussion, see the section ‘‘Implications of Key Specifications and Alternatives.’’) 

Eligibility and Timing 

CBO assumed that dual-eligible beneficiaries would be excluded from the premium 

support system and that gross federal spending for their health care would continue 

as it would if current law remained in place. (In 2009, those beneficiaries made up 

19 percent of the Medicare population and accounted for 29 percent of total spending for Medicare’s Part A and Part B benefits.) 2 CBO made that assumption because of the additional complexity of specifying how the system would work if such 

beneficiaries were included, although alternative systems could be designed to include them. CBO did not make any explicit assumptions about the system of care 

that would be in place for dual-eligible beneficiaries, and it assumed that their exclusion from the premium support system would not affect the number of Medicare 

beneficiaries who enrolled simultaneously in Medicaid. 

Everyone else who was enrolled in Medicare when the premium support program 

took effect in 2018 would enter the new system at once, and people who reached 

eligibility after 2018 (other than dual-eligible beneficiaries) would enter the new sysVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00101 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
98 

tem when they became eligible. The Medicare Advantage program would not be 

available as an option after 2017 for beneficiaries in the premium support system. 

The Structure of the Market for Medicare Benefits 

CBO made several assumptions about the structure of the market for Medicare coverage, including the required scope of benefits, the bidding process, and the process 

by which beneficiaries would choose a plan. 

Scope of Benefits. Under each premium support option, insurers would offer a 

basic package of benefits with services and an actuarial value that matched those 

provided by Medicare’s FFS program under Parts A and B. CBO assumed that hospice services and certain services provided to beneficiaries with end-stage renal disease would not be included in the basic benefit package and that spending for those 

services would continue as it would under current law. Those services were excluded 

so that the plans’ benefits would be identical to those that are included in the bids 

of Medicare Advantage plans under current law. That assumption simplified CBO’s 

modeling. 

Insurers would be permitted to offer an additional package with enhanced benefits, 

however, and would submit separate bids for providing prescription drug benefits 

through Medicare’s Part D, as under current law. Enrollment in Part D would remain voluntary. 

Bids. To simplify the choices for beneficiaries (and thereby heighten competition 

based on differences in premiums), private insurers would be allowed to submit bids 

for just one or two plans for the basic Medicare package in each region. (The two 

plans could have different features—offering a larger or smaller provider network, 

for example—but both would need to have the same actuarial value.) Insurers would 

submit bids reflecting their costs for a combined package of Part A and Part B benefits (as insurers do for Medicare Advantage) and not separate bids for Parts A and 

B. Bids would be the amount that insurers would charge to provide care for a beneficiary of average health. Insurers also could offer one package of enhanced benefits 

(with a single, fixed higher actuarial value that would be the same for all insurers) 

to go along with each basic package offered. Enrollees would pay the full additional 

cost of the enhanced packages through higher premiums. Under such rules regarding packages with enhanced benefits, beneficiaries would find it easier to compare 

plans, and thus competition would be heightened. 

Bidding Regions. Regional boundaries would be determined by the government 

and designed to coincide with health care markets within states. Regions would be 

the same for all prospective bidders, and insurers would be required to serve the 

entire regions for which they submitted bids. 

Fee-for-Service Medicare. Medicare’s FFS program would act as a competing 

plan. Its bid in each region would be based on the amount it would cost the program 

in that region to provide care for a beneficiary with average health as projected by 

the Medicare program. Support for disproportionate-share hospitals (whose share of 

low-income patients exceeds a specified threshold) and spending for medical education, hospice benefits, and certain benefits for patients with end-stage renal disease would be excluded from that projection. CBO assumed that such spending 

would continue outside the premium support system at the amounts projected under 

current law. The government’s administrative costs for the FFS program, however, 

would be included in the bid. The FFS program would be required to maintain a 

contingency reserve fund equal to a specified percentage of projected expenses, and 

if the program’s actual expenses differed from its projected expenses, future bids 

would be adjusted to maintain adequate reserves. CBO assumed that there would 

be no changes to current law concerning either the mechanisms for setting the rates 

paid to providers or the tools available to the FFS program to help it contain costs. 

As under current law, enrollees in the program could purchase supplemental 

(medigap) coverage from private insurers. CBO assumed that the same standard 

medigap plans that are currently available would be available under the two premium support options. 

Coverage for Retirees. CBO assumed that employers and unions that provide coverage for retirees who are Medicare beneficiaries would make cash payments to 

their retirees to be applied toward the purchase of a basic package offered in the 

bidding region, an enhanced-benefit package (on top of a basic package) from any 

of the private plans in that region, or supplemental coverage for the FFS program. 

In that way, the choices of beneficiaries with retiree coverage would be the same 

as those of other beneficiaries, and they would have no additional incentives to select a particular plan (as typically occurs now when employers pay part of the preVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00102 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
99 

3That approach to enrollment of beneficiaries who are not enrolled in both Parts A and B 

of Medicare was adopted to simplify the modeling for this analysis. In fact, including such beneficiaries in a premium support system would raise complex issues that are not addressed in this 

report. 4 CBO assumed that a risk adjustment mechanism comparable to that used for the Medicare 

Advantage program would be used for a premium support system. That mechanism assigns each 

beneficiary a risk score, based on the person’s medical conditions and demographic characteristics, that represents the expected spending in the FFS program relative to the national average 

for the Medicare population. A beneficiary with a risk score of 1.0 has average expected spending. To simplify the discussion, this report refers to beneficiaries with risk scores that are less 

than or greater than 1 as being in better or worse than average health—although personal characteristics other than health also influence spending for Medicare services. 

mium if retirees enroll in a plan offered by the employer). CBO assumed that the 

premium support system would be implemented so as to not affect the percentage 

of beneficiaries with retiree coverage. Those assumptions simplified CBO’s modeling. 

Requirement Regarding Issuance. Insurers would be required to issue insurance 

to all Medicare beneficiaries who applied and to charge the same premium for all 

enrollees in a particular plan within a bidding region. 

Plan Selection. Beneficiaries would receive information about premiums, cost sharing, and other plan attributes to help them compare plans. Enrollees would choose 

a plan during an annual enrollment period and would be required to remain in that 

plan for a year. Once beneficiaries chose a plan, they would automatically remain 

in that plan in subsequent years unless they chose a different one. 

Initial Choice. Beneficiaries would not automatically remain in their current plan 

when the premium support system began in 2018. In 2018 and later years, beneficiaries who entered the premium support system and did not make an affirmative 

choice for enrollment would be assigned (with equal probability) to plans that presented bids at or below the benchmark, including the FFS program if it met that 

criterion. (If more than four plans in a region did so, beneficiaries would be assigned 

to one of the four lowest-bidding plans.) After their first year in the system, beneficiaries who were initially assigned to a plan would remain in that plan unless they 

chose a different plan during a future enrollment period or the plan to which they 

were assigned was no longer one of the lowest-bidding plans in their region (in that 

case, the beneficiaries would be assigned to one of the new low-bidding plans in 

their region). Beneficiaries who had been assigned to a plan and then subsequently 

chose another plan, as well as beneficiaries who affirmatively chose a plan when 

they entered the premium support system, would remain in that plan in subsequent 

years unless they chose a different one. 

Enrollment in Part A and Part B. For this analysis, CBO assumed that enrollment in Part B would remain voluntary and that beneficiaries with coverage under 

Part A or Part B (or both) could enroll in any plan within a bidding region. Federal 

payments to plans for enrollees with Part A coverage only would be reduced proportionately on the basis of the share of total Medicare spending nationally for Part 

A services, and federal payments to plans for people covered under Part B only 

would be reduced in a similar manner.3

Federal Contributions and Beneficiaries’ Payments 

CBO also made assumptions about the determination of the amounts the federal 

government would pay insurers for providing Medicare coverage and the amounts 

beneficiaries would pay for that coverage under the illustrative premium support options. 

Federal Contributions and Risk Adjustment. The benchmarks for setting the 

federal contribution would be based on the bids for the basic package of benefits. 

A benchmark would be calculated in each bidding region for a beneficiary of average 

expected health. For each enrollee of average health, the federal government would 

pay insurers an amount that was equal to the regional benchmark minus the standard premium. To compensate for a higher or lower cost implied by an individual 

beneficiary’s ‘‘risk score,’’ insurers would receive a larger or smaller payment for a 

beneficiary whose health was worse or better than average—as is the case under 

current law for Medicare Advantage and Part D.4 Neither the amount nor the rate 

of growth in federal payments would be capped. 

Beneficiaries’ Payments. Medicare beneficiaries who joined plans with bids that 

equaled the regional benchmark and were enrolled in Parts A and B would pay the 

insurer a standard premium, which would be set at 25 percent of total costs for covered services in Part B (physicians’ services, hospital outpatient care, durable medVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00103 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
100 

ical equipment, and other services, including some home health care)—using the 

same formula as that for the standard Part B premium under current law. The premium for beneficiaries with Part A coverage only would be proportionately smaller 

than the standard premium based on the share of total Medicare spending nationally for Part A services (about half); a similar calculation would be used to set the 

premium for enrollees in Part B only. 

Beneficiaries who joined plans with bids that were higher than the benchmark 

would pay the insurers the standard premium plus the difference between the bid 

and the benchmark. Those who selected plans below the benchmark would pay the 

insurers the standard premium minus the difference between the benchmark and 

the bid. In contrast to the rules for the current Medicare Advantage program, insurers with bids below the benchmark could not use such differences to enhance benefits or reduce premiums for Part D prescription drug insurance and the result would 

be heightened competition based on differences in premiums for the basic benefit 

package. 

For the most part, premiums would be paid directly to insurers, as is generally the 

case for Part D, rather than withheld from Social Security benefits, as is generally 

the case under current law for Parts A and B. Income-related premiums for Part 

B specified in current law would continue and would be withheld from Social Security benefits. 

Hypothetical Examples of Determining Premiums 

Several examples show how premiums would be determined under the illustrative 

premium support options considered here. The hypothetical bids for regions with 

high and low levels of FFS spending per beneficiary are roughly consistent with the 

bids CBO has projected for such regions under the two options. In regions where 

FFS spending is high, premiums under the second-lowest-bid option would generally 

be higher than those under the average-bid option because the benchmark would 

be set at a low bid rather than at the average bid, and low bids would be much 

lower than the average bid. In regions where FFS spending is low, the low bids and 

the average bid would be closer and premiums under the two options would be more 

similar. 

The Second-Lowest-Bid Option. Consider a region with high FFS spending in 

which the FFS program’s bid in 2020 was $14,000 and the bids from the region’s 

five private plans were in the range of $11,000 to $11,800 (see Table 3). Under the 

second-lowest-bid option, the regional benchmark would be $11,200, equal to the bid 

of the second-lowest-bidding private plan. The annual premium for enrollees in that 

plan would be $1,500, the standard premium nationwide. Premiums for the other 

plans would differ from that amount depending on how the bids compared with the 

benchmark. Because the FFS bid would be $2,800 more than the benchmark, the 

premium for FFS enrollees would be $4,300 ($1,500 plus $2,800). The annual premium for the lowest-bidding private plan would be $1,300. 

Next, consider a low-spending region in which the FFS program’s bid was $9,900 

and the bids of the five private plans ranged from $9,300 to $10,100. The regional 

benchmark would equal that of the second-lowest-bidding private plan ($9,500), and 

enrollees in that plan would pay the standard premium of $1,500. Because the bid 

of the FFS program would be $400 more than the benchmark, FFS enrollees would 

pay an annual premium of $1,900. 

The Average-Bid Option. Consider again the high-spending region in which the 

FFS bid was $14,000. The private plans’ bids would be slightly higher in this region—ranging from $11,200 to $12,000—because the share of income that beneficiaries would spend on premiums would be lower, on average, thus reducing the 

sensitivity of beneficiaries’ choice to differences in premiums and reducing competition among plans to lower bids. As a simple example, assume that, in the previous 

year, 25 percent of the people in the region enrolled in the FFS program and 75 

percent enrolled in private plans, with an equal number enrolled in each private 

plan. Then the benchmark (the enrollment-weighted average bid) would be $12,200. 

Under this option, the standard premium would be $1,500 nationwide. Because the 

FFS program’s bid would be $1,800 more than the benchmark, the FFS premium 

would be $3,300. The annual premium for the lowest-bidding private plan would be 

$500 because that plan’s bid would be $1,000 less than the benchmark. 

Finally, consider the low-spending region in which the FFS program’s bid would be 

$9,900. The bids of private plans would be about the same as that for the secondlowest-bid option in this region, ranging from $9,500 to $10,300. Assume that, because FFS spending is low, in the previous year 75 percent of the region’s beneVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00104 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
101 

5This description reflects the method of determining Medicare Advantage benchmarks that 

will be fully phased in by 2017. The benchmark for each county will be set at a specified share 

(ranging from 95 percent to 115 percent) of local FFS costs. 6See Michael Levine and Melinda Buntin, Why Has Growth in Spending for Fee-for-Service 

Medicare Slowed? Working Paper 2013–06 (Congressional Budget Office, August 2013), 

www.cbo.gov/publication/44513. 7The Affordable Care Act comprises the Patient Protection and Affordable Care Act and the 

health care provisions of the Health Care and Education Reconciliation Act of 2010. 

ficiaries enrolled in the FFS program and 25 percent enrolled in private plans, with 

an equal number enrolled in each private plan. The benchmark would be the 

enrollment-weighted average bid of $9,900. Because the FFS bid would be the same 

as the benchmark, the FFS premium would be the standard premium of $1,500. The 

annual premium for the lowest-bidding private plan would be $1,100. 

Comparison With the Current Medicare Program 

Although some aspects of a premium support system would make it similar to the 

current Medicare program, there also would be significant differences. Under both 

illustrative options analyzed here, insurers would be required to provide a benefit 

package that encompassed the same services that were covered under Parts A and 

B of Medicare (with the few exceptions noted above) and that had the same actuarial value as Parts A and B combined. However, under both options, the federal 

contribution per beneficiary in each bidding region would be determined prospectively each year on the basis of the bids submitted by participating insurers. In contrast, except for Part D, federal spending for Medicare under current law is either 

on a fee-for-service basis or, in the case of Medicare Advantage enrollees, is tied to 

spending in the FFS program. 

Under current law, the premium paid by enrollees in the FFS program is the same 

regardless of where a beneficiary lives. That premium has two components, both for 

enrollment in Part B: the standard amount (referred to in this report as the Part 

B premium), and the income-related amount. Under either illustrative option, by 

contrast, the FFS program would be one of the bidders, and its premium would vary 

by region depending on how its bid compared with the benchmark. 

Although the current Medicare Advantage program is similar in some ways to a premium support system, several features limit the extent of price competition among 

private insurers, and the FFS program is not a bidder in Medicare Advantage. For 

example, benchmarks for Medicare Advantage (which determine the maximum federal payment for an enrollee) are set by law as a specified percentage of the average 

FFS spending in a given county and are announced before insurers submit bids (see 

Box 1).5 In contrast, benchmarks for the premium support options would be determined from plans’ bids. Another difference concerns the incentives offered to beneficiaries to enroll in plans with lower bids. Under Medicare Advantage, beneficiaries 

who enroll in a plan with a bid below the benchmark receive some of the difference 

between the two, generally in the form of additional benefits. Under the two premium support options, by contrast, beneficiaries who enrolled in a plan with a bid 

below the benchmark would receive the entire difference between the two in the 

form of a lower premium. 

Effects on Federal Spending 

Projecting the effects of a premium support system in the first several years after 

implementation is difficult, given the substantial changes to the Medicare program 

that such a system would entail, the lack of historical experience with similar systems, the rapid evolution of health care and health insurance, and the significant 

changes in the Medicare program occurring under current law. (For additional details about the methods used in the analysis, see Appendix A.) Projections are even 

more uncertain for the period following the first several years of implementation. 

One reason is that growth in Medicare spending—and for health care more generally—has slowed markedly over the past several years, although it is not clear 

how much of the slowdown is attributable to persistent changes in the health care 

system.6 Moreover, spending for Medicare is projected to be restrained by provisions 

of the Affordable Care Act that will change the ways and amounts that health care 

providers and insurers are paid.7 The implications of those changes for long-term 

growth in Medicare spending are difficult to assess, thus adding to the uncertainty 

concerning the difference in spending that might occur as a result of policy 

changes—including the adoption of a premium support system. 

102 

8This analysis presents estimated changes in net federal spending because the allocation of 

financial flows to the budget categories of gross outlays and offsetting receipts would differ from 

those under current law in complicated ways. The two options would eliminate withholding of 

basic premiums from Social Security benefits; instead, beneficiaries would pay the basic premium directly to a plan. The reduction in gross spending attributable to that change in the way 

premiums were collected would be accompanied by a corresponding reduction in the government’s collections of offsetting receipts. However, the proposals also would establish a new 

source of offsetting receipts consisting of the premiums paid by beneficiaries who enrolled in the 

FFS program—that is, the basic premiums plus the amount by which the FFS program’s bid 

exceeded the benchmark (or minus the amount by which the benchmark exceeded the FFS program’s bid). 9See Congressional Budget Office, ‘‘Medicare—March 2012 Baseline’’ (March 13, 2012), 

www.cbo.gov/publication/43060, and ‘‘Medicare—May 2013 Baseline’’ (May 14, 2013), 

www.cbo.gov/publication/44205. 10The ratios also differ because of small effects on net spending for dual-eligible beneficiaries. 

Although CBO assumed that gross federal spending for dual-eligible beneficiaries would not 

change, net spending would increase by a small amount relative to that under current law because premiums for dual-eligible beneficiaries would decrease. Those premiums would be linked 

to total Part B spending in Medicare, which would decline under the premium support options. 

Effects in the First Several Years 

CBO assumed that the premium support system would be implemented in 2018. 

This analysis reflects the assumption that dual-eligible beneficiaries would be excluded from the premium support system and that federal spending for their health 

care would continue as projected under current law. Everyone else enrolled in Medicare in 2018 would enter the new system in that year, and people who became eligible for Medicare subsequently (other than dual-eligible beneficiaries) would enter 

the new system. For this analysis, CBO chose 2020 as an illustrative year shortly 

after implementation for which to report results about federal spending. Additional 

information—both about the bids of private plans and about the uncertainty in the 

estimates—provides context for understanding those results. 

In 2020, the second-lowest-bid option would reduce net federal spending for Medicare by about $45 billion, or 6 percent, from the approximately $700 billion projected under current law, CBO estimates (see Figure 2). The average-bid option 

would reduce net spending in that year by about $15 billion, or 2 percent, the agency estimates.8 Those percentage savings were estimated relative to net federal 

spending on all services covered by Parts A, B, and D, including spending on benefits for dual-eligible beneficiaries. (The estimated savings in percentage terms were 

generated using CBO’s March 2012 baseline projections of Medicare spending—because the agency’s work on the estimates in this report began in earnest in early 

2012—and the estimated savings in dollar terms were obtained by applying the percentages to the agency’s latest baseline projections of Medicare spending, which 

were released in May 2013.) 9

The second-lowest-bid option would reduce net federal spending on Parts A and B 

of Medicare in 2020 by about 11 percent for beneficiaries who would be affected and 

the average-bid option would reduce such spending by about 4 percent, CBO estimates. Those savings are larger than the savings for net federal spending on all of 

Medicare because the amount of spending to which the savings are compared is restricted here to include only the beneficiaries and the portions of Medicare that 

would be covered by the new system. (The ratios of the two estimates for each premium support option are nearly identical, and the difference reported here is attributable primarily to rounding.) 10

For either option, during the first several years of a premium support system, Medicare savings would be similar in percentage terms to the savings estimated for 2020, 

with one main exception. Under the average-bid option, the federal savings estimated for 2018 would be much smaller than the amount estimated for 2020 in percentage terms because the FFS bid would receive a greater weight in constructing 

benchmarks in the first year of the new system than it would in later years. (CBO 

assumed that the weight would equal the proportion of enrollment in the FFS program under current law in 2017.) Thus, under the average-bid option, most regions 

would have higher benchmarks in 2018 than they would later. 

Federal savings would be greater under the second-lowest-bid option than under the 

average-bid option because the benchmarks that determine the federal contribution 

would be lower. Under either option, CBO projects, the benchmarks in most regions 

would be lower than the FFS program’s bid. 

Although federal costs would decrease if more people declined Medicare coverage 

under either option than did so under current law, CBO projects that few people 

103 

would do so. Beneficiaries would have plans available that cost less than, or about 

the same as, Medicare under current law. Also, beneficiaries who did not actively 

choose a plan would be assigned to one, and CBO expects that few would choose 

to drop out of the Medicare program rather than remain in an assigned plan for 

the required one-year period. 

Effects on Private Plans’ Bids. The options’ effects on federal spending would be 

determined in part by how they influenced the bids of private plans. Various factors, 

such as competition and the reduced importance of the administratively determined 

payment rates of the FFS program, would affect the bids that determined the benchmarks. CBO used its projection of the bids that Medicare Advantage plans would 

submit under current law as a starting point in estimating the bids of private insurers under premium support. On net, CBO’s analysis indicates that private insurers’ 

bids in 2020 under the two options would be below the current-law bids for Medicare Advantage by about 4 percent, on average, and that the differences between 

those types of bids would vary regionally. That outcome would be the net result of 

different types of downward and upward pressures on bids. 

On the one hand, CBO expects, both options would create more competitive pressure 

than the Medicare Advantage program, encouraging insurers to reduce their costs 

(primarily by constraining the volume and intensity of health care services provided 

and to a lesser extent by reducing administrative costs and profits) and thus to be 

able to lower their bids. The greater competition relative to the current Medicare 

program would arise because insurers with lower bids would expect to achieve larger increases in enrollment, because more Medicare beneficiaries would choose plans 

affirmatively and those beneficiaries would face larger differences in premiums 

among different plans. The specification adopted for this report that insurers could 

submit no more than two bids for the basic benefit package per bidding region also 

would increase competitive pressure to submit lower bids, in CBO’s view. (Under the 

Medicare Advantage program, insurers often submit more than two bids in their 

service areas.) Given the competitive structure of the two premium support options, 

CBO expects that restricting insurers to a maximum of two bids would cause insurers to eliminate some of the higher-bidding plans that would exist under the current-law Medicare Advantage program. Another smaller but notable force also 

would tend to lower private plans’ bids: The enrollees in private plans would be 

healthier (on average, after accounting for characteristics included in the risk adjustment mechanism) than enrollees in the FFS program, and such ‘‘favorable selection’’ would occur to a greater extent in a premium support system than under current law, CBO expects. That relatively greater favorable selection would occur because private plans would face greater pressure under premium support to contain 

costs (for example, by narrowing provider networks), and as a result, they would be 

less attractive to beneficiaries who use more health care services than do other 

beneficiaries with the same risk score. 

On the other hand, reductions in the share of Medicare beneficiaries enrolled in the 

FFS program would cause private insurers participating in a premium support system to pay higher rates to health care providers. Two main mechanisms would be 

at work. First, although the rates private insurers pay now under the Medicare Advantage program are similar to those for Medicare’s FFS program, CBO expects that 

a lower FFS market share would reduce the importance of the FFS program’s rates 

in determining how much private insurers would pay providers for treating Medicare enrollees. Second, to accommodate an influx of enrollees, some private plans 

might need to expand their networks to include health care providers who would 

be more costly, on average. (CBO assumed in this preliminary analysis that all 

plans would be required to serve all beneficiaries who wished to enroll.) The resulting payment rates negotiated between insurers and health care providers would 

probably rise toward commercial rates for people under age 65 (which, adjusted for 

differences in average health status by age, are generally higher than Medicare’s 

rates), especially where the market share of the FFS program declined substantially. However, even in areas where the FFS market share would be very low, CBO 

expects, the rates private insurers paid providers for their premium support enrollees would be somewhat lower than the rates they would pay for commercial enrollees under current law for several reasons: The FFS provider payment rates would 

serve as a reference point for negotiations, the competitive structure of a premium 

support system would tend to constrain rates, and the commercial rates existing 

alongside a premium support system would be lower because the extent to which 

relatively low Medicare FFS rates led providers to charge more to treat privately 

insured enrollees would abate as the FFS market share declined. 

104 

11 CBO varied the following parameters to construct the ranges: bids of Medicare Advantage 

plans relative to FFS spending as projected under current law, the amount by which private 

insurers would reduce their bids relative to Medicare Advantage bids under current law in response to the increased competitive pressure created by the premium support system, the higher 

rates that private insurers would need to pay providers (with corresponding increases in bids) 

that CBO projects would result if the market share of the FFS program fell significantly, the 

responsiveness of beneficiaries to differences in premiums when choosing among plans, and the 

percentage of beneficiaries who would not actively choose a plan in the first year of premium 

support and that therefore would be assigned to a plan with a bid at or below the benchmark. 12For the second-lowest-bid option, the reported range is not symmetric about the central estimate because of rounding. 

Although CBO projects that bids would be similar under the two premium support 

options, the agency expects that they would be just slightly lower under the secondlowest-bid option than under the average-bid option because private insurers would 

have a stronger incentive to bid low under the former. However, factors that would 

tend to increase private plans’ bids—the reduced importance of the provider payment rates in the FFS program and the broadening of provider networks—also 

would be stronger under the second-lowest-bid option than under the average-bid 

option and would partially offset the stronger incentive to bid low. 

Uncertainty in the Estimates. CBO’s estimates of the effects on Medicare spending of the two illustrative premium support options depend on numerous parameters 

and other factors used in predicting the responses of insurers, health care providers, 

and beneficiaries—all of which are subject to considerable uncertainty. To characterize that uncertainty, the agency specified ranges of values for five key parameters 

in its analysis and determined the effects of varying those parameters, focusing on 

estimates for 2020.11 The ranges for the parameters’ values were chosen to represent CBO’s judgment that, accounting not only for uncertainty about those parameters but for many other sources of uncertainty, there would be about a two-thirds 

chance that the effect on federal spending would be within the range reported 

(under an assumption that the premium support system was implemented as specified here). 

The results indicate that for the second-lowest-bid option, net federal spending in 

2020 on Parts A and B for beneficiaries who would be covered under the premium 

support system analyzed would probably be reduced by between 9 percent and 14 

percent (CBO’s central estimate is 11 percent), and for the average-bid option, federal spending would probably be reduced by some amount between 1 percent and 

7 percent (the central estimate is 4 percent). (See Table 2.) 12 The range is smaller 

for the second-lowest-bid option mainly because a higher or lower proportion of 

beneficiaries enrolled in lower-bidding plans under that option would not directly affect the benchmarks that determined the federal contribution. By contrast, spending 

under the average-bid option would be directly sensitive to the fraction enrolled in 

lower-bidding plans, and the range of estimates incorporates the greater uncertainty 

from that additional factor. (For additional discussion of factors affecting the ranges, 

see Appendix B.) 

Effects After the First Several Years 

After the initial years of a premium support system, the percentage savings from 

either illustrative option would remain roughly constant for about a decade, CBO 

estimates. At that point, heightened price competition would probably reduce the 

growth of Medicare spending over the long term relative to that under current law, 

and that effect would probably be larger under the second-lowest-bid option than 

under the average-bid option. However, the longer-term effects are even more uncertain than are the short-term effects of a premium support system on Medicare 

spending. And if other health care or health insurance policies changed as well, the 

effects of such a system on spending could differ significantly from those presented 

here. 

Effects of the Two Illustrative Options. During the decade following the first 

several years of implementation, CBO expects that the growth in bids of private 

plans under either option would be close to the growth in per capita costs in the 

FFS program under current law, contributing to the roughly constant percentage 

savings over that period. Over the longer term, CBO expects that the growth in 

Medicare spending under the options would probably be somewhat less than the 

growth of Medicare spending under current law. 

The increased competition created by either option would tend to restrain growth 

in Medicare spending by reducing demand for costly new technologies and treatments and by increasing demand for cost-reducing technologies. A crucial factor unVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00108 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
105 

13See Congressional Budget Office, Technological Change and the Growth of Health Care 

Spending (January 2008), www.cbo.gov/publication/41665. 14For example, see Sarah L. Krein and others, ‘‘Preventing Hospital-Acquired Infections: A 

National Survey of Practices Reported by U.S. Hospitals in 2005 and 2009,’’ Journal of General 

Internal Medicine, vol. 27, no. 7 (July 2012), pp. 773–779, http://go.usa.gov/DbQC; and Centers 

for Medicare and Medicaid Services, ‘‘Readmissions Reduction Program,’’ http://go.usa.gov/ 

DbQW. 15 A list of ongoing demonstration projects is available at Centers for Medicare and Medicaid 

Services, ‘‘Innovation Models,’’ http://go.usa.gov/DbQd. 

derlying the rise in spending for health care in recent decades has been the emergence, adoption, and widespread diffusion of new medical technologies and services.13 Although such advances can sometimes reduce costs, in medicine they and 

the accompanying changes in clinical practice have generally had the opposite effect. 

By strengthening price-based competition in Medicare, a premium support system 

could change that dynamic within the program and perhaps in the broader health 

care system. Moreover, relative to outcomes under current law, the potential for cost 

savings from managing utilization and limiting provider networks would be greater 

under a premium support system with a larger share of Medicare beneficiaries enrolled in private plans that have the flexibility to manage care. The magnitude of 

that effect is highly uncertain, however, and it would take a number of years before 

it became fully apparent. CBO anticipates that the effect on spending would be larger under the second-lowest-bid option—because of greater competitive pressure— 

than under the average-bid option. 

However, the provisions of current law that will restrain growth in Medicare spending limit the potential for additional savings to result from a premium support system. In particular, CBO anticipates, private insurers would not be able to hold down 

payments to health care providers to the extent required in the FFS program under 

the sustainable growth rate mechanism for physicians or under the provisions of the 

Affordable Care Act that apply to other providers (the consequences of those provisions are discussed below). More generally, current law offers incentives to providers 

and beneficiaries to help reduce growth in federal spending, and it allows some 

flexibility for the Centers for Medicare and Medicaid Services in managing the program. Beneficiaries’ demand for Medicare services will be constrained as the program’s premiums and cost sharing consume a larger portion of their income. For 

providers, whose updates to Medicare’s payment rates are generally scheduled to be 

smaller than the increases in the costs of inputs, the pressure to adopt cost-reducing 

procedures and technologies will be significant. Other changes in the structure of 

Medicare payments to providers—such as financial incentives to reduce hospitalacquired infections and readmissions—also might help to constrain federal spending.14 The Centers for Medicare and Medicaid Innovation, like many state Medicaid 

agencies and private insurance companies and providers, is hoping to achieve cost 

savings by testing promising ideas for modifying rules and payment methods and 

by expanding the use of ideas that prove effective.15 Whether any of the several 

demonstrations currently in process will succeed and be applied more widely is still 

uncertain. 

Another factor limiting the potential for cost savings under a premium support system is that the Medicare program is required by law to cover items and services 

that are judged to be medically necessary and reasonable. Private insurers participating in the premium support options analyzed for this report would be required 

to cover the same services as those covered by the FFS program. The options would 

cause less restraint on the development of costly new technologies than would be 

the case if private insurers (or the Medicare program as a whole) had the authority 

to refuse coverage for certain services if, for example, less costly alternatives were 

available that were at least as effective. Under the options analyzed in this report, 

however, private insurers would have some flexibility to reduce beneficiaries’ use of 

costly services through tools such as utilization management, higher cost sharing, 

and exclusion of providers from an insurer’s network on the basis of practice style. 

By contrast, the FFS program does not have the authority to apply such methods 

to influence beneficiaries’ use of services but, rather, must pay for any services that 

are used as long as they meet Medicare’s criteria for coverage. That feature of the 

FFS program would remain in place under the two premium support options and 

might limit the extent to which either option could reduce the growth in Medicare 

spending. (Removing the FFS program as a competitor in the premium support system would tend to push up Medicare spending in other ways, as discussed earlier.) 

In quantifying the effects of the illustrative premium support options relative to outcomes under current law, CBO recognized that current law provides for three apVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00109 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
106 

16 Before the enactment of the Affordable Care Act, payment updates for most providers (except for physicians, whose payments have been controlled by the sustainable growth rate mechanism since 1998) generally were set to equal the estimated percentage change in the average 

cost of providers’ inputs. Under current law, however, the updates will equal those percentage 

changes in costs minus the 10-year moving average of growth in productivity in the economy 

overall—a measure that seeks to capture, for the economy as a whole, how much more output 

is produced from a given amount of inputs. Under current law, payment rates for physicians’ 

services in Medicare will be reduced by about 25 percent in January 2014 and, CBO projects, 

will be increased by small amounts in most subsequent years. The Independent Payment Advisory Board will be required to submit a proposal to reduce Medicare spending in certain years 

if the rate of growth in spending per enrollee is projected to exceed specified targets. 17For more discussion, see Congressional Budget Office, The 2012 Long-Term Budget Outlook 

(June 2012), pp. 56–57, www.cbo.gov/publication/43288. 

proaches to restraining cost growth in Medicare that could be difficult to sustain 

over the long term: the ongoing reductions in payment updates for most providers 

in the FFS program, the sustainable growth rate mechanism for payment rates for 

physicians, and the process associated with the Independent Payment Advisory 

Board.16 It is unclear whether the long-term restraint of Medicare spending envisioned to occur through those provisions can be accomplished through greater efficiency in the delivery of health care or whether it would lead to reductions in beneficiaries’ access to care or the quality of care they received. Accordingly, CBO’s extended baseline reflects the assumption that the growth rate of Medicare spending 

after 2029 will not be affected by those provisions but that the percentage reduction 

in Medicare spending in 2029 achieved through those provisions will continue in 

later years.17 In the analysis in this report, CBO anticipates that beneficiaries will 

respond to concerns regarding access and quality in the FFS program by showing 

some additional preference for private plans relative to the FFS program when payment rates for providers in private plans increase relative to those paid by the FFS 

system. 

Under the assumptions of its extended baseline, CBO anticipates that growth in 

Medicare spending per beneficiary (after removing the effects of demographic 

changes on health care spending—in particular, changes in the population’s age distribution) would exceed growth in spending per beneficiary for all forms of private 

health insurance combined because the private sector has more flexibility to respond 

to the pressures created by rising health care spending than administrators of Medicare have under current law. The growth rate of federal spending for Medicare 

under the two illustrative premium support options—which involve a mixture of features of Medicare and private health insurance—would probably be lower than that 

for the existing Medicare program but above that for private health insurance. 

Uncertainty in the Estimates. Estimates of the longer-term effects of the premium support options on Medicare spending are subject to the same sources of uncertainty that are described above for the shorter-term effects, but the magnitude 

of the uncertainty is increased by the longer time horizon. Uncertainty in projecting 

federal spending for Medicare over the long term under current law adds to the uncertainty of such estimates. 

In particular, CBO’s assessment—that the growth rate of federal spending for Medicare under the two options would probably be lower than that for the existing Medicare program but above that for private health insurance—is highly uncertain. It 

is possible, for instance, that over the long term, the bargaining power of health 

care providers relative to private insurers could increase to such an extent that 

spending growth under the options would exceed that for the existing Medicare program. Alternatively, private health insurers could be more successful than CBO 

projects in developing processes for delivering care in ways that would reduce costs, 

in which case spending growth under the options could be further below that for 

the existing Medicare program than CBO anticipates. 

Effects of Modifying the Illustrative Premium Support Options or of Combining a Premium Support System With Other Changes to Medicare. The 

longer-term effects of the two illustrative options on Medicare spending could differ 

significantly from the estimates presented here if either option was modified or if 

policies for setting payment rates in the FFS program were revised. For example, 

imposing a cap on federal contributions under a premium support system could have 

an important effect on federal savings, and changes in the way provider payment 

rates in the FFS program were set could have complex interactions with a premium 

support system. Although CBO has not estimated the consequences of such policies, 

the following observations provide some relevant information. 

107 

18See Congressional Budget Office, The 2012 Long-Term Budget Outlook (June 2012), 

www.cbo.gov/publication/43288. 

Effects of a Cap on Federal Contributions. The effects of a cap on federal contributions under a premium support system would depend in part on how the cap was 

specified. CBO expects that if a premium support system limited the growth rate 

of federal contributions per beneficiary to match the growth of gross domestic product (GDP) per capita plus, say, 1.5 percentage points per year, in most years such 

a cap probably would not be binding. Under last year’s extended baseline, which 

largely follows current law and which CBO used for the analysis in this report, the 

agency projected that the growth rate of Medicare spending per beneficiary between 

2020 and 2032 (after adjusting for demographic changes) would be, on average, 0.8 

percentage points greater than the growth rate of GDP per capita.18 As a result of 

the offsetting factors just described, CBO estimates that the growth rate for Medicare spending during those years under both premium support options would be 

similar to that under current law. 

A cap of per capita GDP plus 1.5 percentage points could be binding regularly, however, if CBO’s long-term projection underestimates growth in Medicare spending. 

And that cap could be binding in some years but not in others even if the projection 

is generally accurate because of volatility in the growth of health care costs and 

GDP. Moreover, the prospect of a cap’s taking effect could alter the behavior of insurers in any year, thus increasing or decreasing the likelihood that such a cap 

would take effect. The effects of a cap would also depend on the details of how it 

was specified and enforced. For the current report, CBO has not attempted to estimate the effects of imposing a cap on federal contributions. 

Effects of Alternative Policies for Setting Payment Rates for Providers in Fee-forService Medicare. Under CBO’s extended alternative fiscal scenario (included in The 

2012 Long-Term Budget Outlook), the reduced payment updates would expire and 

the Independent Payment Advisory Board process would cease to be effective after 

2022, and payments to physicians would be maintained at 2012 rates rather than 

declining as scheduled. Under that scenario, CBO projected, net Medicare spending 

in 2030 would be about 0.5 percent of GDP higher than it would be under CBO’s 

extended baseline. CBO has not estimated the effects of combining a premium support system with the changes to current law that are assumed under its extended 

alternative fiscal scenario. 

Instead, if current-law policies restraining cost growth were retained through the 

2030s or longer, then spending in the existing Medicare program would be below 

that projected under CBO’s extended baseline. CBO has not estimated the long-term 

effects of a premium support system under such restraints either. 

Effects on Beneficiaries’ Premiums 

The premiums that beneficiaries would pay under the two premium support options 

would depend on the premiums charged by the plans in their region and on the 

beneficiaries’ choice of plan. Under each option, at least one plan would be available 

in every region that charged the standard premium or less, and in most regions 

other plans would be available that charged premiums that were higher or lower 

than that amount (depending on whether the bid was above or below the benchmark). For each option, CBO estimated the premiums that would be charged by the 

array of plans offered, and the agency summarized that information by estimating 

the average premiums charged by three plans—the second-lowest-bidding private 

plan in the region, the median-bidding private plan (that is, the plan with a bid in 

the middle of the distribution among private plans), and the FFS program. To arrive 

at the average premium charged by each plan, CBO computed a weighted average 

of region-specific premiums, with each region weighted by the proportion of affected 

beneficiaries. 

CBO next estimated the premiums that beneficiaries would pay under each option 

by estimating their choice of plan, based on the differences in the premiums charged 

and on beneficiaries’ sensitivity to those differences. For that analysis, CBO computed a weighted average of the premiums charged, weighting plans by the number 

of beneficiaries each one enrolled. CBO compared average premiums charged by 

plans and average premiums paid by beneficiaries with the Part B premium under 

current law. 

Background on Premium Determination 

Under either premium support option analyzed in this report, beneficiaries would 

pay the standard premium if they chose a plan with a bid that was equal to the 

108 

regional benchmark. That premium would be the same everywhere in the country 

and would be determined by the same formula used under current law for the Part 

B premium: The federal government allocates spending under Medicare Advantage 

to Parts A and B on the basis of the share of total spending in the FFS program 

for Part B services and then sets the Part B premium equal to 25 percent of all 

Part B spending, divided by the number of beneficiaries. In this report, the standard 

premium equals 25 percent of the estimated amount of total Medicare spending attributable to Part B services under a premium support system. 

Under current law, the Part B premium will be $1,600 in 2020, CBO projects. Because total Medicare spending would be slightly less than it would be under current 

law under either premium support option, CBO estimates, the standard premium 

for each would be slightly lower than the Part B premium under current law— 

$1,500 per year under either option. (All estimates of annual premiums in this report are rounded to the nearest $100; although CBO projects that the standard premium under the average-bid option would be higher than that under the secondlowest-bid option, those amounts round to the same number.) 

If a beneficiary chose a plan with a bid that differed from the regional benchmark, 

the premium would depend on the plan chosen. Someone who enrolled in a plan 

with a bid above the benchmark would pay the standard premium plus the amount 

by which the plan’s bid exceeded the benchmark, and someone who enrolled in a 

plan with a bid below the benchmark would pay a correspondingly lower premium. 

CBO expects that, depending on how bidding regions were defined, there might be 

some sparsely populated regions in which no private plans would participate under 

either option. In those regions, the FFS program would be the only plan available, 

and beneficiaries who enrolled in the program would pay the standard premium. 

CBO focused on standard premium amounts that did not include income-related adjustments. In addition, the agency analyzed premiums only for the basic package 

of Medicare benefits, excluding additional amounts that enrollees in private plans 

might pay for enhanced benefits or that enrollees in the FFS program might pay 

for supplemental coverage. 

Enrollees in private plans under the options would forgo the federal subsidies for 

supplemental benefits that would be provided by many Medicare Advantage plans 

under current law. CBO estimates that the annual value of those supplemental benefits (under current law) will be about $400, on average, per Medicare Advantage 

enrollee in 2020. The loss of those subsidies would make private plans less attractive under the options, all else being equal. For this analysis, CBO compared premiums for both options with the $1,600 current-law premium projected for Part B. 

The agency did not make any adjustment in that analysis for the loss of supplemental benefits under the Medicare Advantage program. Those forgone benefits are 

included in the analysis presented below concerning the effects of the two options 

on beneficiaries’ total payments. 

Premiums by Region. The range of premiums around the standard premium 

would vary geographically. CBO’s analysis focused on four groups of regions— 

ranked from highest to lowest average FFS spending—with equal numbers of beneficiaries in each group. In regions with high FFS spending, CBO estimates, the bid 

for the FFS program would be higher than the private plans’ bids and higher than 

the benchmark under either option. Medicare beneficiaries enrolled in the FFS program in such regions tend to use certain health care services at a higher-thanaverage rate, so private plans would have greater potential to achieve savings relative to the FFS program by reducing that use. In contrast, CBO estimates, the FFS 

program’s bid would be similar to or lower than the bids of private plans in many 

regions with low FFS spending. People enrolled in the FFS program in those regions 

tend to use less care, so private plans would have less potential to achieve savings 

by reducing the quantity of care; savings from reducing the price of care also would 

be difficult to achieve because of the restraints in provider payment rates that are 

scheduled for the FFS system under current law. Thus, the range of premiums 

would be narrower in regions with low FFS spending. 

Premiums for Beneficiaries Who Do Not Actively Choose a Plan. CBO 

projects that many beneficiaries would not actively choose a plan in the first year 

of a premium support system—perhaps because they were unaware of the new system, did not understand how to enroll, were hampered by a health problem, or for 

some other reason. Under the options considered for this report, beneficiaries who 

did not choose a plan would be assigned to a plan with a bid at or below the benchmark. CBO projects that about 15 percent of beneficiaries would not choose a plan 

in the first year of premium support under the second-lowest-bid option and about 

109 

19 CBO expects that some beneficiaries who were assigned to a low-bidding plan in the first 

year would later switch to the FFS program or to another plan that would have, on average, 

a higher premium. 

20 percent would not choose a plan in the first year under the average-bid option.19

Those beneficiaries would pay premiums less than or equal to the standard premium, but there would be no guarantee that the assigned plan would include all 

of their current providers. 

Under an alternative approach, which CBO has not yet analyzed, beneficiaries who 

did not make a choice would remain in the plan most similar to their current plan 

(or be transferred to the FFS program if a similar plan was no longer available). 

In particular, beneficiaries who had been in the FFS program when the premium 

support system began would remain in that program unless they chose a private 

plan. In that sort of system, FFS beneficiaries would retain access to their current 

providers but, depending on the region, their premiums could be substantially higher. In addition, insurers would have less incentive to reduce their bids because they 

would anticipate that being a lower-bidding plan would result in a smaller gain in 

enrollment than they would achieve if all beneficiaries were required to affirmatively choose a plan. 

Premiums Charged by Plans in 2020 

Under either illustrative premium support option, CBO anticipates, beneficiaries 

would be offered at least one plan at or below the standard premium and most people would have access to at least one other plan with a premium below that amount. 

In most regions, the plans with premiums at or below the standard amount would 

be private. Overall, CBO estimates, the premiums charged by plans would generally 

be lower under the average-bid option than under the second-lowest-bid option because the benchmarks would be higher under the average-bid option, so the federal 

government would contribute more for each plan. 

The Second-Lowest-Bid Option. Under this option, CBO estimates, the average 

premium for the second-lowest-bidding private plan across all regions would be 

about $1,500 per year in 2020, or 6 percent below the Part B premium projected 

under current law for that year (see Table 4). In regions with low FFS spending, 

however, the premium for the second-lowest-bidding private plan would tend to be 

higher than in other regions because of the role of FFS spending in determining the 

benchmark. Specifically, in some regions with low FFS spending, the bid for the 

FFS program would be lower than that of the second-lowest-bidding private plan, 

so the FFS program’s bid would become the benchmark, and the premium for the 

second-lowest-bidding private plan would be above the standard amount. CBO estimates that the average premium for the second-lowest-bidding private plan would 

be $1,600 in regions with the lowest FFS spending (see Figure 3). 

The average premium for the median-bidding private plan available would be 

$1,800 in 2020 under the second-lowest-bid option, CBO estimates. That amount 

would be 13 percent above the current-law Part B premium. 

The average premium for the FFS program under the second-lowest-bid option 

would be about $3,100, or almost twice the projected Part B premium under current 

law, CBO estimates. That increase would occur because, in most regions, the FFS 

program’s bid would be substantially above that of the second-lowest-bidding private 

plan, and thus the bid for the latter would become the benchmark. The premium 

for the FFS program would be highest in regions with the highest average FFS 

spending. CBO estimates that in those regions, the average premium for the FFS 

program would be $4,600, or almost triple the projected current-law Part B premium. Even in regions with the lowest FFS spending, the average FFS premium 

would be $1,900, or almost 20 percent above the projected current-law Part B premium. (In some regions, the FFS program’s bid would be lower than that of the second-lowest-bidding private plan, and the premium would equal the standard premium.) 

The Average-Bid Option. Premiums would generally be lower under the averagebid option than under the second-lowest-bid option. For the second-lowest-bidding 

private plan, the national average premium in 2020 would be $900 under the average-bid option, CBO estimates—more than 40 percent below the projected currentlaw Part B premium for that year. That amount would be less than the premium 

for that plan under the second-lowest-bid option because, in most areas, the benchmark would be higher and the plan’s bid would be below the benchmark, which determines the government’s contribution. Under the average-bid option, the average 

110 

20Two opposing considerations led CBO to project similar—but not identical—enrollment patterns for the two options. In most regions, the FFS premium would be higher relative to private 

plans’ premiums under the second-lowest-bid option than under the average-bid option. That difference would arise because the second-lowest bid would be lower than the average bid, resulting in a larger gap between the federal contribution and FFS costs under the second-lowestbid option. As a result, enrollment would tend to be higher in private plans under the secondlowest-bid option. CBO expects, however, that the prospect of paying higher premiums under 

the second-lowest-bid option would prompt more beneficiaries to choose a plan in the first year 

of the program. Thus, a smaller proportion of beneficiaries would be assigned to a plan at or 

premium of the second-lowest-bidding private plan would be the smallest (at $600) 

in regions with the highest FFS spending because that plan’s bid would be lower 

relative to the benchmark (which would be influenced by the bids of the FFS program and the higher-bidding private plans). The average premium of the secondlowest-bidding private plan would be substantially greater (at $1,400) in regions 

where FFS spending is lowest because, in most of those areas, that plan’s bid would 

be close to the bid of the FFS program. 

For the median-bidding private plan, CBO estimates that the average premium 

would be $1,200. That amount would be 25 percent below the current-law Part B 

premium in 2020. 

The FFS program’s bid under the average-bid option would be above the benchmark 

in most areas. CBO estimates that the national average premium for the FFS program would be $2,400, 50 percent higher than the projected current-law Part B premium. 

Premiums Paid in 2020 

The average premiums that beneficiaries would pay under a premium support system would depend not only on the premiums charged by plans as just discussed, 

but also on the plans beneficiaries chose to enroll in. Under the second-lowest-bid 

option, CBO estimates, the average annual premium paid by beneficiaries in 2020 

would be $2,100—about 30 percent higher than the current-law Part B premium for 

that year (see Figure 4). Under the average-bid option, CBO estimates, the average 

premium paid by beneficiaries in 2020 would be $1,500, or 6 percent below the 

current-law Part B premium. 

The Second-Lowest-Bid Option. CBO estimates that about half of the beneficiaries included in the premium support system would enroll in private plans 

under the second-lowest-bid option and about half would enroll in the FFS program. 

The average premium paid by beneficiaries for private plans across all regions 

would be $1,800 and the average premium paid for the FFS program would be 

$2,500. The percentage of household income that beneficiaries would spend on the 

premium for the FFS program would vary substantially. The premium for the FFS 

program would amount to less than 2 percent of household income for about onefourth of enrollees in that plan and to 6 percent or more for about two-fifths of the 

plan’s enrollees. In comparison, under current law that premium would amount to 

less than 2 percent of household income for about two-fifths of beneficiaries in the 

FFS program and to 6 percent or more of household income for about one-fifth of 

beneficiaries in that program. (Those estimates focus on the standard premium and, 

in the case of premium support, on any reduction or increase in that premium that 

would result when a beneficiary enrolled in a plan with a bid below or above the 

benchmark. The estimates do not include amounts paid for the income-related premium.) 

Under the second-lowest-bid option, average premiums would vary regionally. Beneficiaries in regions with the highest FFS spending would pay an average of $2,300 

(compared with the nationwide average of $2,100). The higher average premium estimated for the regions with highest FFS spending is largely a reflection of CBO’s 

estimate that about one-fifth of the beneficiaries would enroll in the FFS program. 

In those regions, roughly half of all beneficiaries enrolled in the FFS program would 

spend at least 6 percent of their household income on the FFS premium. Beneficiaries in regions with the lowest FFS spending would pay an average premium 

of $1,800, according to CBO’s estimates. About 80 percent of beneficiaries in regions 

with the lowest FFS spending would enroll in the FFS program. 

The Average-Bid Option. CBO estimates that slightly fewer than half of all beneficiaries would enroll in private plans under the average-bid option in 2020 and 

slightly more than half would enroll in the FFS program—proportions that are similar to those CBO projects for the second-lowest-bid option.20 For all regions comVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00114 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
111 

below the benchmark, and that would tend to decrease enrollment in private plans under the 

second-lowest-bid option. 21This report does not provide estimates of the total effects of the premium support options 

on beneficiaries’ payments for Medicare services because the analysis did not include premiums 

that beneficiaries would pay for supplemental coverage. (CBO has not yet modeled such coverage as part of a premium support system.) However, by including total out-of-pocket costs for 

Medicare services, whether paid by the beneficiary or by supplemental insurance, the analysis 

captures, in the aggregate, most of the costs beneficiaries would incur for premiums for supplemental insurance. 22 CBO expects that lower-bidding plans would generally have lower rates of health care utilization. As a result, enrollees would pay less out of pocket than they would with higher-bidding 

plans. Under the options in this report, the actuarial value of all plans would match the value 

of current-law Medicare; that is, every plan would cover the same percentage of the total expenses of a given population that is covered by the current Medicare benefit package. For general information on the actuarial value of health plans, see Chris L. Peterson, Setting and Valuing Health Insurance Benefits, Report for Congress R40491 (Congressional Research Service, 

April 6, 2009). 

bined, the average premium paid by beneficiaries in the FFS program would be 

$2,000 and the average premium paid by enrollees in private plans would be $1,000, 

compared with $2,500 and $1,800, respectively, under the second-lowest-bid option. 

Under the average-bid option, the average premium would be approximately equal 

for beneficiaries in all four groups of regions classified by FFS spending, CBO estimates. Where FFS spending is highest, the estimated $1,500 average premium reflects the anticipated choice of some beneficiaries to enroll in private plans with bids 

below the benchmark (about three-fourths of that group; their average premium 

would be less than $1,500) and of others to enroll in the higher-bidding FFS program (about one-fourth; their average premium would be more than $1,500). In 

areas with the lowest FFS spending, the $1,500 average premium reflects much 

smaller differences between the bids of private plans and the FFS program. In those 

regions, about three-fourths of beneficiaries would enroll in the FFS program, by 

CBO’s estimate. 

Effects on Beneficiaries’ Total Payments 

CBO has estimated the effects of the two illustrative premium support options on 

beneficiaries’ total payments for covered services. The total consists of premiums 

and out-of-pocket payments for deductibles, coinsurance, and copayments. In this 

analysis, out-of-pocket payments include all such obligations for beneficiaries, 

whether paid directly by beneficiaries or covered by supplemental insurance.21 The 

premiums included in CBO’s estimates are the average premiums that beneficiaries 

would pay as presented above and are based on CBO’s projections of the distribution 

of beneficiaries among plans. Income-related premiums for Part B also were included in the total payments the agency estimates under current law and for both 

options. In addition, the estimates account for the value of the forgone federally subsidized supplemental benefits that would have been available to enrollees in Medicare Advantage plans under current law but that would not be available under the 

two options. As discussed below, the estimated effects of the two premium support 

options on beneficiaries’ total payments are subject to considerably greater uncertainty than are the estimated effects on federal spending and the premiums charged 

by plans. 

Effects in 2020 

CBO estimates that beneficiaries’ total payments in 2020 would be about 11 percent 

higher, on average, under the second-lowest-bid option than they would be under 

current law. The premiums paid by beneficiaries would be higher, on average, than 

under current law, but beneficiaries’ out-of-pocket costs would be lower—even 

though the actuarial value of the Medicare benefit would be unchanged—because of 

a decline in the total cost of covered services, which would be a result primarily of 

greater enrollment in lower-bidding private plans.22 (On average, a larger share of 

beneficiaries’ total payments is in out-of-pocket costs than in premiums, so, in the 

calculations of the change in total payments, the percentage change in out-of-pocket 

costs receives a greater weight than the corresponding change in premiums.) The 

projected savings in out-of-pocket costs would offset part, but not all, of the increase 

in premiums. 

CBO’s analysis implies that beneficiaries’ total payments would be about 6 percent 

lower, on average, under the average-bid option than under current law. That reduction results from the combination of the lower average premiums paid discussed 

above and a reduction in average out-of-pocket costs, which would result primarily 

from higher enrollment in lower-bidding private plans. 

112 

Under both options, the effect on total payments for particular beneficiaries could 

differ greatly from the nationwide average and would depend partly on the region 

and the choice of plan. In particular, beneficiaries who chose to remain in the FFS 

program would generally face higher premiums and would not experience a reduction in out-ofpocket costs. 

Uncertainty in the Estimates 

To characterize the uncertainty of the estimated effects of the options on beneficiaries’ total payments, CBO applied the same type of analysis reported above for 

the effects of the premium support options on federal spending. Specifically, it varied the same five parameters, with ranges chosen to generate lower and higher estimates of the effects on beneficiaries’ payments for each option. In CBO’s judgment, 

there is a two-thirds chance under the second-lowest-bid option that beneficiaries’ 

total payments in 2020 would, on average, be within a range extending from a reduction of 2 percent to an increase of 24 percent relative to payments under current 

law (CBO’s central estimate is that total payments would increase by 11 percent). 

For the average-bid option, the corresponding range of likely average effects on 

beneficiaries’ total payments extends from no effect to a reduction of 12 percent (the 

central estimate is a reduction of 6 percent.) (See Table 2.) The range under the 

average-bid option is narrower than that under the second-lowest-bid option mainly 

because the changes in beneficiaries’ premiums from varying those parameters are 

smaller under the average-bid option and because the variation in responsiveness 

to smaller changes in premiums results in a smaller range of effects on total payments. (For additional discussion of factors affecting the ranges, see Appendix B.) 

Beneficiaries’ total payments would be unlikely to rise, on average, under the 

average-bid option relative to those under current law, for two main reasons. First, 

because use of health care services tends to be higher for enrollees in the FFS program than for those in private plans, out-of-pocket costs would probably be lower 

under the average-bid option than they would be under current law as long as the 

percentage of beneficiaries in the FFS program did not increase. According to CBO’s 

central estimates, the share of beneficiaries in private plans would be about 20 percentage points greater than under current law, and a reduction in that share would 

be unlikely. Second, average premiums paid under the option would be closely tied 

to the standard premium, which would be set using the same formula as the Part 

B premium under current law, so those average premiums would not differ greatly 

from the Part B premium. And even if premiums were slightly higher under the average-bid option than under current law, the effect probably would not offset the decline in out-of-pocket costs. 

Effects on Combined Federal Spending and Beneficiaries’ Total Payments 

The combined payments of the federal government and beneficiaries constitute the 

total amount paid for health care services covered by Medicare. They consist of the 

federal government’s payments to plans, beneficiaries’ premiums, and beneficiaries’ 

out-of-pocket payments. CBO estimates that those payments would be about 5 percent lower under the second-lowest-bid option and about 4 percent lower under the 

average-bid option than they would be under current law. Those percentages are a 

combination of the effects on net Medicare spending and on beneficiaries’ total payments discussed above. 

CBO expects that the decrease in combined payments would probably be slightly 

larger under the second-lowest-bid option than under the average-bid option mainly 

because the former would result in lower bids by private plans and a larger share 

of beneficiaries enrolled in those plans. CBO did not quantify the uncertainty of 

those estimates but it did reach two conclusions about ranges that would cover twothirds of the possible outcomes for the two options: First, such ranges would clearly 

overlap; that is, CBO is not confident that combined payments under the secondlowest-bid option would be lower than combined payments under the average-bid option. Second, based on the separate ranges for federal spending and for beneficiaries’ 

total spending, ranges for combined payments would extend only over reductions in 

payments; that is, it is likely that either option would result in reductions in combined federal spending and beneficiaries’ total payments. 

The sum of federal spending and beneficiaries’ payments examined here is a significant component of total national spending on health care, and this analysis suggests 

that total national spending would probably decline under either of the two illustrative premium support options. However, a premium support system would interact with other parts of the health care system in complex ways that CBO has not 

quantified. 

113 

23For example, see Congressional Budget Office, The Long-Term Budgetary Impact of Paths 

for Federal Revenues and Spending Specified by Chairman Ryan (March 2012), www.cbo.gov/ 

publication/43023; Long-Term Analysis of a Budget Proposal by Chairman Ryan (attachment 

to a letter to the Honorable Paul Ryan, April 5, 2011), www.cbo.gov/publication/22085; Budget 

Options, Volume 1: Health Care (December 2008), pp. 120–121, www.cbo.gov/publication/41747; 

and Designing a Premium Support System for Medicare (December 2006), www.cbo.gov/publication/18258. 24See Congressional Budget Office, Updated Estimates for the Insurance Coverage Provisions 

of the Affordable Care Act (March 2012), www.cbo.gov/publication/43076. 

Comparison With CBO’s Previous Analyses of a Premium Support System 

CBO has previously estimated the budgetary effects of revamping Medicare as a 

premium support system.23 But those earlier analyses were limited in at least two 

key respects: They did not include detailed modeling of beneficiaries’ choices among 

alternative insurance plans, and they did not include detailed modeling of insurers’ 

behavior regarding bids or payments to health care providers. Thus, none of those 

analyses captured the full effects of a competitive system on federal spending or 

payments by beneficiaries. The analysis in this report incorporates such modeling. 

In addition, this report differs from some previous analyses by CBO in considering 

different illustrative options for a premium support system instead of a specific proposal. 

The treatment in this report is substantially different from the rough analysis of 

a specific premium support proposal published by CBO in April 2011. Not only have 

there been substantial improvements in CBO’s modeling of the behavior of beneficiaries and insurers, but the options examined in this report differ in important 

ways from that earlier proposal. For example, the earlier proposal included a 

grandfathering provision, and CBO estimated that only 4 percent of Medicare 

spending in 2022 would be accounted for by premium support payments under that 

proposal. The proposal also specified a federal contribution that was initially fixed 

(rather than determined through bidding) and that would keep pace with the consumer price index for all urban consumers (at a rate that CBO estimated would be 

substantially slower than the rate of growth in Medicare spending under current 

law). Moreover, because of the simple formula for determining federal spending in 

that proposal, CBO projected such spending over a longer period than it does in this 

report. 

CBO’s estimates of the total payments by beneficiaries and of combined federal 

spending and beneficiaries’ payments for the 2011 proposal were much higher than 

the estimates for the two options in this report primarily because CBO projected for 

that earlier report that health care spending covered by private plans would be 

much higher initially and would grow faster than the agency currently estimates. 

The difference arose from two main factors: First, the earlier proposal did not include the Medicare FFS program as a bidding plan in the premium support system. 

Because that program was not present to put downward pressure on the rates paid 

to providers by private insurers, CBO projected, the premiums of private plans 

would be substantially higher than they would be under the premium support options discussed in this report. Second, more recent information has led CBO to make 

a downward revision in its projections of the future growth rate of private health 

insurance premiums.24

Implications of Key Specifications and Alternatives 

Although policymakers would need to determine many specific characteristics of a 

premium support system, several choices would be particularly important from a 

federal budgetary perspective: setting the formula for the government’s contributions, determining whether the traditional FFS program would be included as a 

competing plan, setting rules of eligibility for the system, delineating bidding regions, and designing the program features that would influence beneficiaries’ choice 

of a plan. Policymakers would also need to address many other design and operational issues to implement such a system. 

Note again that the illustrative premium support options analyzed here are anchored in basic features of the current Medicare system: Both would guarantee insurance for all beneficiaries; adjust payments to private insurers to account for the 

health of their enrollees (that is, use risk adjustment); and, under what is called 

community rating, require that insurers charge everyone in a region the same premium for the same coverage. Changes to those features also could have important 

consequences for a premium support system. 

114 

In addition, changes in the broader health care and health financing systems would 

affect a premium support system and change the way it affected federal spending 

and beneficiaries’ payments. For example, if more people outside of the Medicare 

market purchased health insurance plans with narrower networks of providers and 

lower premiums than CBO expects under current law, the willingness of Medicare 

beneficiaries to purchase similar plans in a premium support system would probably 

increase—although the opposite could occur if people’s experiences with those plans 

left them dissatisfied. Legislative changes affecting the broader health care market 

also could have consequences for the effects of a premium support system in Medicare. For instance, repealing the tax exclusion for employment-based health insurance would heighten pressure to restrain the growth of health care costs outside of 

Medicare. The resulting changes in practice patterns of health care providers would 

probably decrease private plans’ bids under a premium support system, although 

CBO has no basis for estimating the magnitude of such an effect. 

Federal Contributions 

In this analysis, CBO focused on two possible approaches to determining federal 

contributions, but many other methods could be used. For example, capping the 

growth rate of federal contributions could generate additional federal savings relative to an uncapped proposal, although CBO has not yet estimated the effects of 

such a cap. In general, federal budgetary savings would increase as federal contributions declined, but beneficiaries’ premiums would be higher. 

The Fee-for-Service Program 

CBO assumed that Medicare’s FFS program would continue to be offered within the 

premium support options analyzed here. If, instead, the FFS program was eliminated, the savings produced for the government under a premium support system 

would be less (or federal spending could be even more than under current law) because the rates that private insurers would pay health care providers for treating 

Medicare enrollees would probably be higher than CBO estimates for either premium support option. In general, the rates that private insurers now pay providers 

for Medicare Advantage enrollees are similar to those Medicare pays under the FFS 

program but substantially below the rates paid for enrollees who are in commercial 

plans and are not Medicare beneficiaries. 

CBO anticipates that competition from the FFS program within a premium support 

system would constrain the rates that private insurers paid for premium support 

enrollees in the same way that the FFS program now appears to constrain the rates 

that insurers pay for Medicare Advantage enrollees. If a system did not offer the 

FFS program as a choice, the result probably would be higher payment rates, higher 

bids, and higher costs for the government. CBO also expects that, under the options 

analyzed here, in some regions the FFS program would submit the lowest bid, so 

eliminating the program would directly reduce federal savings by raising the benchmark in those regions. 

Eligibility 

If fewer people were included in a premium support system, federal savings generally would be lower, all else being equal. For this analysis, CBO assumed that the 

premium support systems would not include a grandfathering provision (thus including more beneficiaries than if such a provision were part of the system) and 

would exclude dual-eligible beneficiaries. 

A Grandfathering Provision. Under some premium support proposals, all beneficiaries who became eligible for Medicare before the system took effect would remain in the current-law Medicare program and only those who became eligible after 

that time would enroll in the premium support system. Several important questions 

would arise about the structure of such a program (see Box 2). Clearly, however, 

grandfathering some beneficiaries would limit the savings that could be achieved 

over an extended period because only a subset of the Medicare population would enroll in the new system and (because the grandfathered beneficiaries would be older) 

the cost of health care for the eligible population would tend to be lower than average. 

CBO estimates that if a premium support system implemented in 2018 excluded 

beneficiaries who entered the program before 2018 and dual-eligible beneficiaries, 

only about 25 percent of the Medicare population would be covered under the new 

system after 5 years, and spending for those beneficiaries would represent only 

about 15 percent of net Medicare spending in total in that year under current law 

(where such spending includes that for dual-eligible beneficiaries and for Part D). 

After a decade, approximately 45 percent of the Medicare population would be covVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00118 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
115 

25See Congressional Budget Office, Dual-Eligible Beneficiaries of Medicare and Medicaid: 

Characteristics, Health Care Spending, and Evolving Policies (June 2013), www.cbo.gov/publication/44308. 26Such effects are not included in CBO’s estimates in this report. 

ered, and spending for that group would represent about 30 percent of net Medicare 

spending in total under current law. 

Because the share of the Medicare population and the share of Medicare spending 

covered would rise gradually under a grandfathering provision, federal savings 

would be substantially smaller over an extended period than would be the case if 

all beneficiaries entered the new system immediately. A very rough approximation 

(made on the basis of the estimated share of Medicare spending covered each year) 

for a system that also excluded dual-eligible beneficiaries suggests that of the total 

savings achieved if all eligible beneficiaries entered in 2018, federal savings would 

be about 15 percent as much after 5 years and about 30 percent as much after 10 

years. 

Moreover, the savings under a grandfathering provision could be slightly smaller 

than the rough estimates would suggest, for two reasons. First, CBO anticipates 

that the gradual rise in the proportion of Medicare beneficiaries and Medicare 

spending covered under such a system would give private insurers less incentive to 

reduce their bids, over an extended period, than would be the case if all eligible 

beneficiaries entered the system immediately. Second, the reduction in the growth 

of Medicare spending likely to occur under a premium support system as a result 

of changes in the demand for new technologies would be substantially smaller for 

many years if that system included a grandfathering provision. 

Dual-Eligible Beneficiaries. Medicare covers some services for dual-eligible beneficiaries and Medicaid covers others, thus creating conflicting financial incentives for 

the federal and state governments and for health care providers.25 Recent federal 

and state efforts have focused on integrating the Medicare and Medicaid funding 

streams and coordinating the often-complex care of many of those beneficiaries—and 

including that group in a premium support system would pose substantial additional challenges. For instance, it would be difficult to give dual-eligible beneficiaries 

incentives to choose low-bidding plans in a premium support system while also 

minimizing their total payments for medical services. Despite that, excluding such 

beneficiaries would reduce the potential savings that could be achieved from a premium support system. In addition, that exclusion might create incentives for private 

plans to encourage lower-income beneficiaries with higher health care costs than 

predicted by their risk scores to seek Medicaid eligibility and thereby leave the 

plan.26

Bidding Regions 

CBO assumed that bidding regions for both options would reflect health care markets within states. The precise definition of those markets would involve trade-offs. 

For example, defining regions to include large numbers of beneficiaries would make 

insurers’ projections of average spending within the region more reliable. However, 

regions that included areas that varied greatly in their spending would make it 

more difficult for insurers to project spending for their enrollees because those enrollees could be concentrated in certain areas within the region. As another example, because CBO assumed that a premium support system would require any insurer that submitted a bid for a region to serve the entire region, some local and 

regional insurers might decline to participate if a region included areas they could 

not serve effectively, thus reducing competition. And in some regions, those firms 

could be among the insurers offering the lowest-cost health care, the highest-quality 

health care, or both. However, if regions were small, some insurers might decline 

to participate even though they would have served those same areas if they had 

been included in larger regions. That result could occur, say, if the costs to carriers 

of developing networks of providers in those areas were higher than in nearby areas 

and if those costs would have been worth incurring to serve a larger region. 

Features of a System That Could Influence Enrollment 

Features of a premium support system that made beneficiaries more sensitive to differences in plans’ premiums would tend to reward plans that bid low with higher 

enrollment and thus encourage more plans to submit lower bids. 

In the illustrative premium support options analyzed here, CBO assumed that differences in bids would be translated dollar for dollar into differences in premiums. 

116 

If, instead, the government retained some of the difference between the benchmark 

and bids below that amount, two effects would occur: First, the government would 

reduce its spending by the amount retained, all else being equal. Second, however, 

by retaining some of the difference between the benchmark and the bids, the government would reduce the incentive for beneficiaries to enroll in low-bidding plans 

and thus reduce the incentive for plans to submit low bids—which would increase 

the benchmark and federal spending. The net effect of those two factors on government spending would depend partly on beneficiaries’ responsiveness to premiums 

and partly on the extent to which private insurers raised their bids. Moreover, if 

the difference between the benchmark and bids below that amount was provided as 

additional benefits rather than as cash, beneficiaries would tend to have more difficulty comparing plans. 

CBO assumed that beneficiaries who did not choose a plan when they entered the 

premium support system would be assigned to a plan that submitted a bid that was 

at or below the benchmark (or assigned to one of the four lowest-bidding plans if 

more than four were at or below the benchmark). If, instead, beneficiaries were 

automatically placed into their original plan (if they had already been enrolled in 

Medicare) or into the FFS program, insurers would probably have less incentive to 

submit low bids, and beneficiaries’ total payments would be higher because low-bidding plans would have lower enrollment. Conversely, if those beneficiaries were assigned to plans that had especially low bids (rather than being assigned equally to 

all plans bidding at or below the benchmark), insurers would probably have a greater incentive to submit low bids, and beneficiaries’ total payments would be lower. 

Alternatively, if beneficiaries were required to choose a plan if they wished to enroll 

in the premium support system and thus to maintain or obtain Medicare coverage, 

some would not do so and the fraction of the eligible population not covered by 

Medicare would increase—particularly in the first few years after implementation. 

In this analysis, CBO assumed that the basic packages that plans would be required 

to offer would consist of health care services and an actuarial value that matched 

those provided by Medicare’s FFS program under Parts A and B—although the 

plans could vary in other dimensions, such as the breadth of provider networks or 

the structure of coinsurance. If that basic package was only a minimum requirement 

and plans could supplement a package in unrestricted ways without offering the 

basic package itself, comparisons would be more difficult for beneficiaries, enrollment in low-bidding plans would be reduced, and plans’ bids would rise. Conversely, 

if the deductibles and copayments of the basic package were made standard, comparisons would be simpler. The drawback of standardization, however, is that it 

could dampen the ability of insurers and providers to develop more cost-effective approaches to providing health care and for beneficiaries to choose those approaches 

rather than more expensive ones. 

Appendix A: 

Basis for CBO’s Findings 

The preliminary findings presented in this report regarding the effects of two illustrative options for a premium support system for Medicare (one called the secondlowest-bid option and the other called the average-bid option) are based on detailed 

modeling of the behavior of buyers and sellers of health insurance policies. In its 

analysis, the Congressional Budget Office (CBO) focused particular effort on estimating private insurers’ bids under those options. 

CBO reviewed the research literature and consulted a variety of experts who represented a broad span of views about premium support systems. In addition, some 

insights about the potential responses of beneficiaries and insurers are possible from 

observing current experience with the Medicare Advantage program (which provides 

benefits through private insurance), Medicare Part D (the prescription drug program), the Federal Employees Health Benefits program, and various employmentbased insurance plans. The usefulness of those systems to inform the analysis of a 

premium support system is limited, however, because the competitive structure of 

a premium support system would be quite different from that of Medicare Advantage or the federal employees’ program, and the array of health care services covered would be broader than that under Part D. Moreover, information about the 

small number of employers whose experiences with similar systems have been studied in depth may not be broadly generalizable—particularly to the Medicare population, which is likely to be less responsive than the nonelderly population to difVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00120 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
117 

27For examples of earlier analyses, see Congressional Budget Office, Long-Term Analysis of 

a Budget Proposal by Chairman Ryan (attachment to a letter to the Honorable Paul Ryan, April 

5, 2011), www.cbo.gov/publication/22085, and Designing a Premium Support System for Medi- care (December 2006), www.cbo.gov/publication/18258. 28This discussion applies to local Medicare Advantage plans, which account for the bulk of 

enrollment in the Medicare Advantage program. By contrast, the federal government defines 

service areas for regional preferred provider organizations—or PPOs—as consisting of one or 

more states; each PPO must serve one or more of those designated service areas. 

ferences in health insurance premiums. Finally, the changes that are occurring in 

private health care and in health insurance could affect federal spending on Medicare in complicated and unpredictable ways—either under current law or under a 

premium support system. And the adoption of a premium support system for Medicare could have spillover effects on private health care and health insurance systems. 

The current analysis incorporates a range of significant improvements in the modeling of a premium support system for Medicare compared with CBO’s earlier analyses of such systems.27 The agency has devoted considerable time and effort to 

strengthening its analytical capabilities in this area. Nonetheless, it is extremely 

difficult to know how beneficiaries or insurers would respond to a premium support 

system for Medicare, and the actual outcomes would surely differ from the estimates 

presented in this report—which, according to CBO’s current judgment, represent the 

middle of the distribution of possible outcomes. The agency’s modeling effort is not 

complete; further analysis and additional consultation with outside experts may 

alter the findings, perhaps in significant ways. One potential area of inquiry that 

CBO has not analyzed concerns the ways a premium support system might affect 

the coordination of care or the quality of care that beneficiaries receive; the agency 

does not currently have the tools necessary to study such effects, nor does it anticipate having them in the near future. 

Estimating Private Insurers’ Bids 

To estimate the bids that private insurers would submit in 2020 under the two illustrative premium support options considered in this report, CBO analyzed insurers’ 

2012 bids for Medicare Advantage, projected those bids to 2020, and adjusted them 

to account for the differences in competition that CBO anticipates private insurers 

would face under the two options as compared with the current Medicare Advantage 

program. 

In adjusting the projected Medicare Advantage bids to develop estimates of what 

private insurers would bid under a premium support system, CBO concluded that 

some factors would tend to lower bids and others would tend to raise them (see Figure A–1). The net effect is that the projected bids under the two premium support 

options considered in this report are lower, by an average of about 4 percent under 

each option, than those projected for the current-law Medicare Advantage program. 

(Bids would be slightly lower under the second-lowest-bid option than under the average-bid option, but the differences relative to bids under the Medicare Advantage 

program are rounded to the nearest percentage point.) The difference between private insurers’ bids under the two options and average spending in Medicare’s feefor-service (FFS) program would remain fairly constant in the decade after the first 

few years of implementation, CBO anticipates. 

Projecting Medicare Advantage Bids 

Under current law, each Medicare Advantage plan generally can define its service 

area as consisting of one or more counties.28 CBO based its estimates on the bids 

submitted by insurers for their service areas, using the county as the unit of analysis. The agency developed simulated distributions of bids for counties based on the 

view that insurers would participate in a premium support system and would offer 

insurance plans with a range of prices, just as is the case for the current Medicare 

Advantage program. 

CBO estimated benchmarks for counties under the two premium support options on 

the basis of the agency’s projected distributions of private insurers’ bids, which were 

combined with projected per capita Medicare FFS spending for each county. The use 

of the county as the unit of analysis simplified the modeling and provides a foundation for subsequent analyses of a system with other types of bidding regions. The 

results of the analysis could change if different types of regions were specified. 

Under current law, Medicare Advantage insurers submit a bid for a beneficiary in 

average health (defined as a beneficiary with a risk score of 1.0). CBO projects that 

the average bid from current-law Medicare Advantage plans in 2020 will be 6 perVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00121 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
118 

29For this analysis, CBO divided counties into quartiles on the basis of average FFS spending 

in the county, with the same number of counties in each quartile. This differs from the approach 

elsewhere in the report for the analysis of beneficiaries’ premiums, which divides groups of regions into quartiles constructed such that the same number of beneficiaries is in each quartile. 30Those estimates incorporate factors affecting bids that are related to the risk adjustment 

mechanism, discussed below. For this analysis, CBO excluded three types of Medicare Advantage plans that differ substantially from plans that would probably be offered under a premium 

support system: private FFS plans, special needs plans, and employment-based group plans. The 

FFS program’s costs used for the comparisons in this report exclude certain types of spending 

because it is not covered by the bids that Medicare Advantage plans submit under current law— 

namely, the additional payments to disproportionate-share hospitals (whose share of low-income 

patients exceeds a specified threshold) and spending for medical education, hospice benefits, and 

certain benefits for patients with end-stage renal disease. CBO included in its calculations the 

government’s cost of administering the FFS program. The analysis was based on CBO’s projections of Medicare expenditures and Medicare Advantage enrollments in March 2012. See Congressional Budget Office, ‘‘Medicare—March 2012 Baseline’’ (March 13, 2012), www.cbo.gov/ 

publication/43060. 31Zirui Song, Mary Beth Landrum, and Michael E. Chernew, ‘‘Competitive Bidding in Medicare: Who Benefits From Competition?’’ American Journal of Managed Care, vol. 18, no. 9 (September 2012), pp. 546–552, http://tinyurl.com/odtwf87. 

cent below the average FFS spending for a beneficiary with the same reported risk 

score. For the one-quarter of the nation’s counties with the highest average FFS 

spending, CBO estimates, the average Medicare Advantage bid will be 12 percent 

below that amount.29 For the one-quarter of counties with the lowest average FFS 

spending, CBO projects that the average Medicare Advantage bid will be 6 percent 

above that amount.30

CBO expects that Medicare Advantage bids will be higher relative to average FFS 

spending in the same areas in 2020 than in 2012 because Medicare Advantage plans 

will be able to achieve some—but not all—of the restraint in provider payment rates 

that is scheduled for the FFS system under current law. As a result, the agency 

projects higher growth in the bids of Medicare Advantage plans than it does for 

growth in per capita spending under the FFS system. 

Factors That Would Tend to Reduce Bids 

CBO anticipates that two main mechanisms would tend to lower bids under either 

option relative to Medicare Advantage bids under current law: increased competition 

that would result from stronger incentives for beneficiaries and insurers to focus on 

reducing health care costs and the slightly greater favorable selection for private 

plans than exists under the Medicare Advantage program. 

Increased Competition. Differences in the plans’ bids under either option would 

translate directly into differences in beneficiaries’ premiums. Under current law, a 

Medicare Advantage plan with a bid below the benchmark receives a federal payment that equals the bid plus a rebate that is a percentage of the difference between 

the bid and the benchmark. (Beginning in 2014, the rebate will range from 50 percent to 70 percent, depending on the plan’s performance on certain measures of 

quality.) Plans now return most of that difference in the form of supplemental benefits (rather than as reduced premiums), which consumers generally find harder to 

evaluate than a cash amount. Under the illustrative premium support options, plans 

with bids below the benchmark would return the entire difference between the two 

in the form of lower premiums. Beneficiaries would therefore be more sensitive to 

differences in plans’ bids in deciding on a plan than they would be under the Medicare Advantage program, so the insurers would have more incentive to lower their 

bids under the two premium support options. 

Insurers also would face more competition under both options because of changes 

in market structure. Under the Medicare Advantage program, the benchmarks are 

announced before insurers submit their bids. Under the two premium support options, the benchmarks would be determined from the bids themselves. Some evidence suggesting that competition among Medicare Advantage plans is limited 

under the current approach comes from a study that concluded that a $1.00 increase 

in a benchmark, with all other factors (including health care costs) held constant, 

results in a $0.49 increase in the average bid.31 In a highly competitive system (for 

example, one in which each dollar that a bid was below the bid of another plan 

within a region would correspond to a dollar’s difference in the premiums between 

the two plans), the insurers’ bids would primarily reflect their costs rather than the 

benchmarks. 

119 

32For related research, see Thomas C. Buchmueller, ‘‘Consumer-Oriented Health Care Reform 

Strategies: A Review of the Evidence on Managed Competition and Consumer-Directed Health 

Insurance,’’ Milbank Quarterly, vol. 87, no. 4 (December 2009), pp. 820–841, http://tinyurl.com/ 

nsaff32, and ‘‘Does a Fixed-Dollar Premium Contribution Lower Spending?’’ Health Affairs, vol. 

17, no. 6 (November 1998), pp. 228–235, http://tinyurl.com/puwqjaz; David M. Cutler and 

Sarah J. Reber, ‘‘Paying for Health Insurance: The Trade-Off Between Competition and Adverse 

Selection,’’ Quarterly Journal of Economics, vol. 113, no. 2 (May 1998), pp. 433–466, http:// 

tinyurl.com/ mycqvem; and Steven C. Hill and Barbara L. Wolfe, ‘‘Testing the HMO Competitive 

Strategy: An Analysis of Its Impact on Medical Care Resources,’’ Journal of Health Economics, 

vol. 16, no. 3 (June 1997), pp. 261–286, http://tinyurl.com/nvvz76c. 33 Estimates of the difference vary considerably, however. For example, see Joseph P. 

Newhouse and others, ‘‘Steps to Reduce Favorable Risk Selection in Medicare Advantage Largely Succeeded, Boding Well for Health Insurance Exchanges,’’ Health Affairs, vol. 31, no. 12 (December 2012), pp. 2,618–2,628, http://tinyurl.com/naps2jl; Medicare Payment Advisory Commission, Report to the Congress: Medicare and the Health Care Delivery System (June 2012), pp. 

100–101, http://go.usa.gov/DXbF; Gerald F. Riley, ‘‘Impact of Continued Biased Disenrollment 

From the Medicare Advantage Program to Fee-for-Service,’’ Medicare and Medicaid Research 

Review, vol. 2, no. 4 (2012), pp. E1–E17, http://go.usa.gov/DXbd; and Jason Brown and others, 

How Does Risk Selection Respond to Risk Adjustment? Evidence From the Medicare Advantage 

Program, Working Paper 16977 (National Bureau of Economic Research, April 2011), 

www.nber.org/papers/w16977. 

Insurers would be expected to respond to increased competition by reducing their 

costs and lowering their bids.32 The reductions might occur partly as a result of reduced administrative costs or smaller profit margins. But they also could result 

from cuts in spending for services, perhaps made possible by insurers’ combining improvements in management of care with development of more restrictive provider 

networks, slower adoption of expensive technological advances, faster adoption of 

methods to compensate providers that demonstrated cost-effective care, or changes 

in benefit design (for example, tying cost-sharing requirements to evidence of the 

cost-effectiveness of specific services). 

Under the specification of the two options that restricts insurers to submitting a 

maximum of two bids for the basic benefit package in any bidding region, CBO also 

expects that insurers would eliminate some of the higher-bidding plans that would 

exist under the Medicare Advantage program—reducing average bids. (Under the 

Medicare Advantage program, insurers often submit more than two bids in their 

service areas.) 

Increased Favorable Selection. Under both premium support options, all private 

insurers in a region would submit bids indicating the payment they would accept 

to provide Medicare benefits for a beneficiary of average health, and those standardized bids would be used to establish regional benchmarks. Payments to insurers 

would be adjusted to reflect the health status of their enrollees, using a risk adjustment mechanism that CBO assumed would be comparable to that of the Medicare 

Advantage program. 

It is difficult to adjust payments to reflect health status, and the system used for 

Medicare Advantage is unavoidably imperfect. Medicare beneficiaries in poor health 

tend to prefer to enroll in the FFS program because it generally places fewer restrictions on the use of health care services. That tendency is in evidence even among 

beneficiaries with the same risk scores because risk scores incorporate only limited 

information about health status. When a beneficiary who enrolls in a private plan 

is healthier than someone with the same risk score enrolled in the FFS program, 

the private plan experiences ‘‘favorable selection’’ beyond that captured by risk 

scores. Some research indicates that current Medicare Advantage enrollees who 

have a given risk score would have had lower costs, on average, under the FFS program than people enrolled in the FFS program with that same score.33

CBO expects that, under either premium support option, private plans would experience greater favorable selection (beyond that captured by risk scores) than they will 

experience under the Medicare Advantage program. That is, people who enrolled in 

private plans—under either option—would use fewer health care services, on average, than people with the same risk score enrolled in Medicare Advantage. CBO anticipates that outcome because increased competition would prompt insurers to take 

more aggressive steps to control costs (by enhancing utilization management or 

using tighter provider networks, for example), thus rendering private insurers less 

attractive to beneficiaries who would, on average, use more health care services 

than would other beneficiaries with the same risk score. 

Because of the increased favorable selection, costs per enrollee would be lower for 

private plans under a premium support system than for Medicare Advantage plans 

under current law if the average risk scores in the two sets of plans were the same. 

120 

34 Information about those rates is based on interviews conducted by CBO staff with industry 

sources and is consistent with reports in the research literature. See Robert A. Berenson and 

others, ‘‘The Growing Power of Some Providers to Win Steep Payment Increases From Insurers 

Suggests Policy Remedies May Be Needed,’’ Health Affairs, vol. 31, no. 5 (May 2012), pp. 973– 

981, http://tinyurl.com/ntyyudv. 35Sections 1866(a)(1)(O) and 1876(i)(1) of the Social Security Act contain the relevant provisions for hospitals and physicians, respectively. 

Reflecting those lower costs, private plans competing for additional enrollees under 

either option would tend to reduce their bids for a beneficiary of average health relative to those of Medicare Advantage plans, CBO anticipates. 

Factors That Would Tend to Raise Bids 

CBO estimates that in most counties the percentage of beneficiaries enrolled in the 

FFS program would decline once either premium support option took effect. In 

CBO’s assessment, the reduced market share of the FFS program would tend to 

boost the rates that private insurers paid to health care providers and thereby lead 

them to raise their bids. That reduction in market share, and thus the effect on private insurers’ bids, would be greater in areas where average FFS spending was 

high. (CBO’s methodology for estimating the proportion of beneficiaries who would 

select the FFS program is discussed below.) 

Declines in the FFS program’s market share would affect payment rates for private 

insurers through two main mechanisms. First, the importance of payment rates 

from the FFS program would diminish as a determinant of the amounts private insurers would pay health care providers for treating Medicare enrollees (those FFS 

payment rates are generally a good deal lower than the rates private insurers pay 

to providers of health care for people with commercial insurance—that is, employment-based coverage). Second, some private insurers would need to broaden their 

provider networks to accommodate additional enrollees. Both mechanisms would 

cause insurers to raise their bids to cover additional costs, CBO projects. 

The Reduced Importance of FFS Provider Payment Rates. CBO’s assessment 

of the importance to private plans of FFS payment rates is based on the observation 

that, on balance, the rates paid for Medicare Advantage enrollees are similar to or 

slightly above those that Medicare pays for FFS patients’ care—even though providers receive substantially higher amounts when they offer the same services to patients in commercial plans focused on the under-65 population.34 The exact cause 

of the difference is not known, but it appears to arise in part because private insurers that offer Medicare Advantage plans can exclude from their networks any providers who are unwilling to accept Medicare’s rates, thus reducing those providers’ 

volume of Medicare patients; those same providers would generally end up being 

paid the lower rates for treating Medicare patients in the FFS system. Moreover, 

when Medicare Advantage enrollees go outside their plan’s provider network to obtain care that the plan either must cover by law (emergency care, for example) or 

that it covers as a matter of choice (such as certain highly specialized services), federal law requires providers to accept Medicare’s FFS rates as payment in full.35

Thus, a hospital that might anticipate providing a certain amount of emergency care 

to enrollees in a Medicare Advantage plan would not receive higher commercial 

rates for treating those patients simply because it refused to join the plan’s network. 

The relationship between private insurers and providers is much different for plans 

that serve commercial enrollees. Although there are dominant insurers in many 

commercial markets, they appear to have less leverage than the Medicare FFS program has with providers—in part, at least, because FFS payment rates are established by law and are not subject to negotiation. If providers are unwilling to accept 

rates for their commercial enrollees that are similar to Medicare’s rates, they can 

be reasonably confident that other insurers will pay them more—particularly because private insurers typically try to satisfy consumers’ desire for broad provider 

networks. In addition, when enrollees in commercial plans go outside the plan’s network to receive care, the providers who treat them generally charge more than they 

would have charged had they been in the plan’s network. Insurers often limit their 

payments for such care to predetermined amounts, but patients are often responsible for some or all of the differences between those payments and the provider’s 

charges. 

In regions where the role of the FFS program diminished under a premium support 

system, CBO expects, the relationship between private insurers and health care providers would become less similar to the relationship in Medicare Advantage under 

121 

36 CBO expects that the rates private insurers will pay providers under Medicare Advantage 

plans will rise over time relative to Medicare’s FFS rates because private insurers are not likely 

to obtain all of the reductions in payment updates that are scheduled for the FFS program 

under current law. The adjustments to bids discussed in this section were applied to projected 

Medicare Advantage bids, developed under the expectation that private insurers’ payment rates 

would be higher relative to Medicare FFS rates than they are now. 

current law and more similar to the relationship in the commercial market for people under age 65. 

Broadening of Provider Networks. Another reason bids would increase as the 

share of beneficiaries in the FFS program fell is that private insurers, on average, 

would need to expand their networks to accommodate increased enrollment. As a 

result, private insurers would probably need either to pay higher rates or to contract 

with providers with higher-cost practice styles. Bids would rise as a result of including higher-cost health care providers that private insurers would tend to have excluded when their networks could be narrower. The expansion would be greater for 

lower-bidding plans, CBO projects, because those plans would experience greater increases in enrollment. 

The Magnitude of the Resulting Adjustments to Bids. CBO did not adjust its 

projections of private insurers’ bids in counties in which it expects that the FFS program would maintain the share that it currently holds (or its nationwide market 

share, if that is lower). The agency anticipates that, in those counties, the forces 

that now allow private insurers to obtain payment rates for their Medicare Advantage plans that are similar to those for Medicare’s FFS program would continue to 

prevail under a premium support system.36 However, where the market share of the 

FFS program is projected to fall below its current level—and where that share 

would be below the current national market share—CBO expects that private insurers would pay higher rates to providers for their premium support enrollees than 

they would pay under current law for Medicare Advantage enrollees. CBO adjusted 

its projections for insurers in those counties, and the adjustment was greater for 

counties where larger reductions are anticipated in the FFS program’s market 

share. CBO also adjusted the bids upward slightly for plans at or near the bottom 

of the bid distribution to account for the expected broadening of provider networks. 

The size of the adjustment for private plans’ bids was made partly on the basis of 

the agency’s assessment of the average difference between the rates paid by Medicare and the rates paid by private insurers to hospitals, physicians, and other providers for enrollees in commercial plans. However, the adjustment was smaller than 

that average difference as a way to account for four main factors: 

■ The observed difference in payment rates now is more informative about the rise 

in rates that might occur under a premium support system in which the FFS program was eliminated; rates would generally rise much less under a system in 

which the FFS program was a competing plan—particularly in regions where the 

FFS program retained a significant market share. 

■ Medicare’s FFS payment rates would be used as a reference point in negotiations 

between private plans and providers for their premium support enrollees, which 

would tend to keep those rates below commercial rates even in regions where the 

FFS program had a very low market share. 

■ The competitive structure of a premium support system would tend to push rates 

below commercial rates. In particular, current tax-based subsidies to health insurance for commercial enrollees result in less competitive pressure on provider 

payment rates than would occur under the premium support options analyzed 

here. 

■ A reduction in the FFS market share would lower commercial rates, reducing the 

difference between FFS rates and commercial rates. Because of the reduction in 

the FFS market share, fewer health care services would be paid for at relatively 

low Medicare FFS rates. As a result, fewer costs associated with Medicare beneficiaries would probably be shifted to private insurers through higher rates for 

hospital services, thus reducing commercial rates. 

After considering all of those factors, CBO made separate adjustments to its estimates of the bids in each county, depending on the projected changes in the FFS 

program’s market share. The relationship between the FFS market share and private plans’ bids is subject to considerable uncertainty, but CBO regards its estimates as being in the middle of the distribution of possible outcomes. 

122 

Differences Between the Options’ Effects on Bids 

The combined effects of the factors that would tend to lower bids would be slightly 

larger under the second-lowest-bid option than under the average-bid option. In 

2020, those effects would reduce bids by about 7 percent, on average, under the 

second-lowest-bid option and by about 6 percent under the average-bid option. In 

either case, the amount by which bids were reduced would vary considerably from 

one region to another. 

The effects of the factors that tended to increase bids also would be slightly larger 

under the second-lowest-bid option than under the average-bid option because the 

increased competition, and the resulting changes in enrollment among the plans, 

would be greater. In 2020, that effect would boost bids by about 3 percent, on average, under the second-lowest-bid option and by about 2 percent under the averagebid option. 

The largest difference in the effects of the two options on bids by private insurers 

would result from a difference in the degree of competition. That difference would 

occur for two main reasons. 

First, and more important, the benchmark would be lower under the second-lowestbid option than under the average-bid option in most regions, so the premiums for 

a plan with a given bid would be higher. In CBO’s judgment, insurers would expect 

those higher premiums to increase beneficiaries’ sensitivity to differences in costs 

because premiums would consume a greater share of enrollees’ discretionary income. 

Second, bids for plans that wanted to attract automatically assigned beneficiaries 

would tend to be lower under the second-lowest-bid option than under the averagebid option. Under either option, according to specifications outlined in this report, 

beneficiaries who made no affirmative choice would be assigned with equal probability to an available plan that had submitted a bid that was at or below the regional benchmark (or to one of the four lowest-bidding plans if more than four met 

that criterion). Although such beneficiaries would be comparatively less attractive 

to plans than those who made an active enrollment choice, some plans would nevertheless seek to obtain them through assignment. Because no more than two plans 

would receive automatically assigned beneficiaries under the second-lowest-bid option in most instances, compared with as many as four under the average-bid option, the plans that wanted to enroll such beneficiaries would have greater incentives to submit lower bids under the second-lowest-bid option. 

Changes Over Time in Effects on Bids 

Under either option, the combined effects of the factors that tended to reduce bids 

would increase over time, as would the combined effects of the factors that tended 

to increase bids. On balance, CBO anticipates, the difference between private insurers’ bids under the two options and average FFS costs would remain fairly constant 

for the decade following the first few years of implementation. 

CBO expects that the increased competition in particular would lead insurers to reduce costs even more after 2020 so they could keep their bids as low as possible 

in subsequent years. However, for three reasons, the incremental reductions would 

probably be smaller than the initial drop: First, one assumption of this analysis is 

that the legislation that created a new premium support system would provide private insurers with several years to determine how to reduce their costs before the 

system was implemented with the result that many changes would probably be undertaken in the first few years. Second, because many beneficiaries would probably 

remain in the first plan they chose without thoroughly evaluating their options in 

subsequent years, insurers would have an especially strong incentive to submit low 

bids in the first year of the new system. Third, insurers would tend to undertake 

the easier reductions first, and additional reductions would probably involve more 

difficult actions. 

However, CBO also projects that Medicare Advantage bids under current law will 

rise more rapidly than average spending in the FFS program. As a result, greater 

cost reduction under the premium support options would be necessary in future 

years to maintain the percentage savings relative to FFS spending projected for 

2020. By CBO’s estimate, the additional cost reductions would roughly offset the 

trends in Medicare Advantage bids projected under current law through the 2020s. 

Estimating Federal Spending for Medicare and Beneficiaries’ Total Payments 

The methods for estimating combined federal spending and beneficiaries’ total payments were similar for both options CBO analyzed. CBO projected bids for a given 

123 

37See, for example, Thomas C. Buchmueller and others, ‘‘The Price Sensitivity of Medicare 

Beneficiaries: A Regression Discontinuity Approach,’’ Health Economics, vol. 22, no. 1 (January 

2013), pp. 35–51, http://tinyurl.com/oo2rrk4; Steven D. Pizer, Austin B. Frakt, and Roger Feldman, ‘‘Nothing for Something? Estimating Cost and Value for Beneficiaries From Recent Medicare Spending Increases on HMO Payments and Drug Benefits,’’ International Journal of Health 

Care Finance and Economics, vol. 9, no. 1 (March 2009), pp. 59–81, http://tinyurl.com/p7xjtvh; 

Thomas C. Buchmueller, ‘‘Price and the Health Plan Choices of Retirees,’’ Journal of Health Economics, vol. 25, no. 1 (January 2006), pp. 81–101, http://tinyurl.com/m6p93dz; Adam Atherly, 

Bryan E. Dowd, and Roger Feldman, ‘‘The Effect of Benefits, Premiums, and Health Risk on 

Health Plan Choice in the Medicare Program,’’ Health Services Research, vol. 39, no. 4 (August 

2004), pp. 847–864, http://tinyurl.com/o4wl339; Bryan E. Dowd, Roger Feldman, and Robert 

Coulam, ‘‘The Effect of Health Plan Characteristics on Medicare+Choice Enrollment,’’ Health 

Services Research, vol. 38, no. 1, part 1 (February 2003), pp. 113–135, http://tinyurl.com/ 

p34m69r; Anne Beeson Royalty and Neil Solomon, ‘‘Health Plan Choice: Price Elasticities in a 

Managed Competition Setting,’’ Journal of Human Resources, vol. 34, no. 1 (Winter 1999), pp. 

1–41, http://tinyurl.com/o2m3br7; David M. Cutler and Sarah J. Reber, ‘‘Paying for Health Insurance: The Trade-Off Between Competition and Adverse Selection,’’ Quarterly Journal of Economics, vol. 113, no. 2 (May 1998), pp. 433–466, http://tinyurl.com/mycqvem; and Thomas C. 

Buchmueller, ‘‘The Health Plan Choices of Retirees Under Managed Competition,’’ Health Services Research, vol. 35, no. 5, part 1 (December 2000), pp. 949–976, http://tinyurl.com/lajxa4w. 

year as described in the previous section. The agency used those bids (and, for the 

average-bid option, past enrollment) to estimate benchmarks in each county and 

premiums for each plan in each county. It then simulated the enrollment of a large 

sample of beneficiaries in different plans on the basis of premiums and previous patterns of enrollment, calculated federal spending as the sum of the risk-adjusted federal contribution for each beneficiary, and compared total federal spending with the 

baseline projection. To project beneficiaries’ total payments, CBO used claims data 

to estimate cost-sharing payments by each beneficiary for the services covered by 

Medicare and combined those estimates with the plans’ premiums. 

The estimates incorporated data from administrative records for a sample of about 

600,000 Medicare beneficiaries, along with county-level projections of the FFS program’s bid and the bids of private plans. CBO adjusted the estimates of out-of-pocket spending to match the actuarial value of the plans and current distributions of 

health spending by age, health risk, and other factors. 

The enrollment simulations were based in part on estimates of two especially important aspects of beneficiaries’ choices of plans: their sensitivity to premiums and the 

likelihood that they would actively choose to enroll in a plan. The analysis also incorporated the effects of CBO’s expectation that patients who enrolled in private 

plans would have their diagnoses coded more intensively than would patients in the 

FFS program. Possible spillover effects on Medicare FFS spending from increased 

enrollment in private plans were not considered in the estimates. 

Sensitivity to Premiums 

To develop its projections of the plans that Medicare beneficiaries would choose 

under different premium support proposals, CBO conducted its own analysis and it 

examined findings from the research literature concerning beneficiaries’ sensitivity 

to premiums in selecting health plans.37 In the agency’s judgment, there are two 

main reasons that beneficiaries’ sensitivity under either option would be greater 

than is generally reported in the literature for the Medicare population. First, they 

would face larger differences in premiums under the options than those that have 

been studied previously. Second, beneficiaries would receive information on the features of available plans—including premiums—in ways that would make comparison among plans simpler than is generally the case under current law. Moreover, 

CBO anticipates, beneficiaries who are new Medicare enrollees in the future will be 

more sensitive, on average, than current beneficiaries are to differences in premiums. CBO expects those beneficiaries to be healthier generally (and thus less 

likely to have strong ties to providers who might not be in some plans’ networks) 

and, because of their experience in the health insurance marketplace, to be more 

conversant than many current enrollees are with the process of choosing among 

plans that offer different premiums and packages of benefits. 

In most regions, under either option, beneficiaries would be able to choose from several private plans that are likely to be more similar to one another than to the FFS 

program in terms of the size of provider networks and approaches to utilization 

management. Therefore, CBO anticipates, beneficiaries would be more sensitive to 

premiums when choosing among private plans than they would be when choosing 

between any private plan and the FFS program. Additionally, CBO expects, beneficiaries would become somewhat less sensitive to the cost of premiums after the 

first few years; once beneficiaries are in a plan, they generally do not seem to switch 

124 

38For related discussion, see Benjamin R. Handel, ‘‘Adverse Selection and Inertia in Health 

Insurance Markets: When Nudging Hurts,’’ working paper (University of California at Berkeley, 

March 2013, http://emlab.berkeley.edu/bhandel/index.shtml; Peter J. Cunningham, Few Americans Switch Employer Health Plans for Better Quality, Lower Costs, Research Brief 12 (National 

Institute for Health Care Reform, January 2013), www.nihcr.org/Health-Plan-Switching; Jonathan D. Ketcham and others, ‘‘Sinking, Swimming, or Learning to Swim in Medicare Part D,’’ 

American Economic Review, vol. 102, no. 6 (October 2012), pp. 2639–2673, http://tinyurl.com/ 

ow8luxd; Keith M. Marzilli Ericson, Consumer Inertia and Firm Pricing in the Medicare Part 

D Prescription Drug Insurance Exchange, Working Paper 18359 (National Bureau of Economic 

Research, September 2012), www.nber.org/papers/w18359; and Kathleen Nosal, ‘‘Estimating 

Switching Costs for Medicare Advantage Plans,’’ working paper (University of Arizona, June 

2012), www.u.arizona.edu/∼nosal/research.html. 39The Centers for Medicare and Medicaid Services has estimated that reported risk scores for 

Medicare Advantage enrollees are 3.4 percent higher than they would have been in the FFS sector, and the agency adjusts the reported risk scores downward by 3.4 percent when it calculates 

payments to the plans. Under current law, beginning in 2014 and continuing until 2018, the 

agency must increase the adjustment until the downward adjustment reaches at least 5.9 percent. The Government Accountability Office has estimated that the difference in coding boosts 

risk scores for Medicare Advantage enrollees by between 5 percent and 6 percent relative to likely scores in the FFS system and that the difference has widened over time. See Government 

Accountability Office, Substantial Excess Payments Underscore Need for CMS to Improve Accuracy of Risk Score Adjustments, GAO–13–206 (January 2013), www.gao.gov/products/GAO-13- 

206. 

readily.38 Nevertheless, the possibilities of attracting new enrollees each year and 

of losing existing enrollees to competitors would provide incentives for private plans 

to continue to keep bids low. 

The constraints on Medicare payment rates for providers embodied in current law 

may result in diminished access to care and in reduced quality of care for beneficiaries in the FFS program, although the timing and extent of such changes are 

very difficult to predict. In this analysis, CBO anticipates that beneficiaries would 

respond to the possibility of reduced access or quality by being somewhat more inclined to choose a private plan than to choose the FFS program when the FFS rates 

for health care providers fell relative to those of private plans. 

Active Choice of a Plan 

In CBO’s assessment, a significant proportion of beneficiaries would not actively 

choose a plan in the first year that a premium support system was implemented. 

Under the specifications adopted for this report, beneficiaries who did not make a 

choice would be assigned randomly to a plan with a bid at or below the benchmark 

(or to one among the four lowest-bidding plans, if more than four bid at or below 

the benchmark). To project that share of beneficiaries, CBO analyzed the behavior 

of Medicare Advantage enrollees whose plans had left the market, and it reviewed 

research on enrollment in the Part D program. 

CBO expects that a higher percentage of beneficiaries would choose a plan under 

the second-lowest-bid option than under the average-bid option because the higher 

average premiums would be more likely to impel beneficiaries to learn about the 

new program and choose a plan. CBO projects that, on average, about 15 percent 

of beneficiaries would not choose a plan in the first year of premium support under 

the second-lowest-bid option and about 20 percent would not choose a plan in the 

first year under the average-bid option. The percentages would be expected to vary 

according to certain demographic characteristics and health status identified in 

CBO’s analyses and in its review of related research. The agency also projects that 

most beneficiaries who were assigned to a plan in 2018 would still be in that plan 

by 2020 (the reference year for the analysis of beneficiaries’ premiums) but that 

some beneficiaries who did not choose a plan in the first year would switch from 

the low-bidding plan to which they were assigned to a higher-bidding plan later. 

More Intensive Diagnostic Coding by Private Insurers 

Evidence suggests that private insurers in the Medicare Advantage program record 

a larger number of diagnoses than FFS providers do, so a given beneficiary would 

be expected to have a higher risk score in a Medicare Advantage plan than in the 

FFS program. Because higher risk scores result in larger payments, private insurers 

have a financial incentive to ensure that every appropriate diagnosis is coded for 

each enrollee; such an incentive does not generally exist in the FFS sector. Although 

the Medicare program adjusts the risk scores of Medicare Advantage enrollees 

downward to attempt to account for the difference—and that adjustment was incorporated in the risk scores used in this analysis—there is recent evidence that the 

adjustment is probably insufficient.39 CBO expects that under the two options private insurers would code diagnoses more intensively than providers treating FFS 

125 

40See Katherine Baicker, Michael Chernew, and Jacob Robbins, The Spillover Effects of Medicare Managed Care: Medicare Advantage and Hospital Utilization, Working Paper 19070 (National Bureau of Economic Research, May 2013), www.nber.org/papers/w19070; Michael 

Chernew, Philip DeCicca, and Robert Town, ‘‘Managed Care and Medical Expenditures of Medicare Beneficiaries,’’ Journal of Health Economics, vol. 27, no. 6 (December 2008), pp. 1,451– 

1,461, http://tinyurl.com/qxfh4h9; and Laurence C. Baker, ‘‘The Effect of HMOs on Fee-forService Health Care Expenditures: Evidence From Medicare,’’ Journal of Health Economics, vol. 

16, no. 4 (July 1997), pp. 453–481, http://tinyurl.com/kf28hus. The study of Baicker and others 

presented estimates of the effects of Medicare Advantage plans’ market share on hospitals’ resource costs of treating Medicare beneficiaries, which do not directly determine Medicare’s payments for FFS beneficiaries under the prospective payment system. The two other studies estimated the effects of Medicare Advantage plans’ market share on Medicare spending for FFS 

beneficiaries. 41The Affordable Care Act comprises the Patient Protection and Affordable Care Act and the 

health care provisions of the Health Care and Education Reconciliation Act of 2010. 

patients to the same extent that they would do so in the Medicare Advantage program under current law and that the Medicare program would adjust the risk scores 

of enrollees in private plans to the same extent that is projected for Medicare Advantage under current law. Thus, no adjustments to plans’ projected bids in Medicare Advantage were needed to account for those practices. 

However, CBO expects that the more intensive coding of diagnoses would affect federal spending under a premium support system even though it would not affect the 

bids of private plans relative to those under current law. In particular, under both 

options, a larger fraction of the Medicare population would be covered by private 

plans, and thus more of the population would be subject to more intensive coding, 

on average, than is the case under current law. Therefore, CBO accounted for differences in coding in its projections of payments to insurers. CBO expects that beneficiaries who switched from the FFS program to a private plan would end up with 

higher risk scores and that the Medicare program would adjust for only part of that 

difference in calculating payment amounts for the insurers. As a result, the federal 

government would pay more for such beneficiaries under a premium support system, all else being equal, than it would if there was no difference in coding or if 

the Medicare program adjusted the risk scores of private plans to completely remove 

the effects of coding differences. 

Possible Spillover Effects on Medicare FFS Spending 

There is evidence that increases in the proportion of beneficiaries enrolled in Medicare Advantage plans lead to lower federal spending for beneficiaries in the FFS 

program and in a lower intensity of their treatment.40 Such spillover effects could 

occur through at least two pathways: Increased managed care penetration could 

change the way physicians treat all of their patients, not just those enrolled in managed care plans, and it could influence investment decisions and the adoption of new 

technology in local markets. For this report, CBO did not incorporate such spillover 

effects on the FFS program. 

In CBO’s estimation, such effects would be very small or even negligible in 2020, 

although the agency will explore the issue more in future analyses. The sustainable 

growth rate mechanism for physicians and the provisions of the Affordable Care Act 

that restrain payment updates for most other FFS providers also will restrain federal spending in Medicare’s FFS program, suggesting that any additional reductions 

in Medicare spending on the FFS program that might result from a spillover effect 

would be smaller than has been estimated in the past.41

Over the longer term, the size of spillover effects would depend in part on whether 

the restraints on payment updates in the FFS program specified under current law 

are maintained. However, as discussed in the section of the text on ‘‘Effects After 

the First Several Years,’’ stronger price-based competition under a premium support 

system would probably affect the emergence and diffusion of new technology and 

services in ways that might reduce FFS spending (for a beneficiary of average 

health, relative to that under current law) in the longer term. 

Appendix B: 

Analysis of Uncertainty in the Estimates 

To characterize uncertainty in the estimated effects of the two illustrative options 

for a premium support system (one called the second-lowest-bid option and the other 

126 

called the average-bid option) on federal spending for Medicare and on beneficiaries’ 

total payments, the Congressional Budget Office (CBO) determined ranges of values 

for five key parameters and estimated the effects of varying those parameters. 

Those estimates focused on results for 2020, which CBO used as a reference year 

in the analysis. The ranges for the parameters’ values were chosen to represent 

CBO’s judgment that, accounting not only for uncertainty about those parameters 

but also about most of the sources of uncertainty in the analysis (assuming that a 

premium support system was implemented as specified here), there would be about 

a two-thirds chance that CBO’s central estimate for the effect on federal spending 

would be within the range reported. 

CBO varied the following parameters to construct the ranges: 

■ Bids of Medicare Advantage plans relative to Medicare fee-for-service (FFS) 

spending as projected under current law, 

■ The amount by which private insurers would reduce their bids relative to Medicare Advantage bids under current law in response to the increased competitive 

pressure created by the premium support system and other factors, 

■ The higher rates that private insurers would need to pay providers (with corresponding increases in bids) that CBO projects would result if the market share 

of the FFS program fell significantly, 

■ The responsiveness of beneficiaries to differences in premiums when choosing 

among plans, and 

■ The percentage of beneficiaries who would not actively choose a plan in the first 

year of premium support and who therefore would be assigned to a plan with a 

bid at or below the benchmark. 

Effects on Federal Spending 

CBO estimated a range of effects on federal spending by simultaneously varying all 

five key parameters in ways that would result in higher or lower spending under 

the premium support options. To do so, the agency examined how varying each parameter would affect spending. 

Bids by Medicare Advantage Plans Relative to Fee-for-Service Spending 

If Medicare Advantage bids under current law were lower than those in CBO’s projections and FFS spending was as CBO projects, then federal savings under both 

options would be greater, according to CBO’s estimates, because the benchmarks 

under the options would be lower than projected. Conversely, if Medicare Advantage 

bids under current law were higher than those in CBO’s projections and FFS spending was as CBO projects, federal savings would be smaller than projected. Although 

CBO’s estimates of the effects of a premium support system are sensitive to changes 

in the bids of Medicare Advantage plans relative to FFS spending, those estimates 

are not directly sensitive to equal percentage changes in Medicare Advantage bids 

and FFS spending—that is, to an across-the-board increase or decrease in Medicare 

spending relative to the amounts that CBO projects—because the difference between 

the benchmarks under the options and federal spending for Medicare under current 

law would not be affected. However, if such an across-the-board change occurred, 

it could affect the amount by which private insurers under a premium support system reduced their bids relative to Medicare Advantage bids (as discussed below). 

Reduction of Bids of Private Plans in Response to Increased Competitive 

Pressure and Other Factors 

If private insurers responded to increased competitive pressure by reducing their 

bids by more than the amounts in CBO’s central estimates, federal savings would 

be correspondingly greater under both options because the benchmarks would be 

lower than estimated. But federal savings would be lower if private insurers reduced their bids by less than the central estimates. 

In addition, if FFS and Medicare Advantage costs were higher across the board (because of greater systemwide growth in costs), there might be more opportunity for 

cost savings, depending on the underlying drivers of that growth, and the amounts 

by which private insurers reduced their bids under the premium support options 

would probably be greater than they are in the agency’s central estimates. Similarly, if costs were lower across the board, the amounts by which private insurers 

reduced their bids under the premium support options would probably be smaller 

than they are in the agency’s central estimates. 

127 

Rates That Private Insurers Would Pay to Providers 

If the decline in the market share of the FFS program under a premium support 

system resulted in higher payment rates for health care providers and therefore in 

higher bids from private insurers than in CBO’s central estimates, federal savings 

would be correspondingly smaller because both those bids and the benchmarks 

would be higher, all else being equal. If that effect was smaller than in the central 

estimates, however, federal savings would be correspondingly greater. 

Beneficiaries’ Sensitivity to Premiums 

Departures from the central estimates in beneficiaries’ responsiveness to differences 

in premiums would influence federal spending both through the effects on plans’ 

bids and through the effects on the share of beneficiaries enrolled in private plans. 

If beneficiaries were more responsive to differences in premiums than is predicted 

in CBO’s central estimates, private insurers’ bids would be lower than they are in 

those estimates (because insurers would have a stronger incentive to reduce their 

bids if such reductions led to larger increases in enrollment); those lower bids would 

result in greater federal savings. Conversely, if beneficiaries were less responsive to 

differences in premiums than in the central estimates, the private insurers’ bids 

would be higher and federal savings would be lower. Regarding enrollment shares, 

if beneficiaries were more responsive to differences in premiums than in the central 

estimates, a larger proportion would switch to lower-bidding plans under premium 

support, causing several indirect effects on federal savings (as discussed below). If 

they were less responsive, the opposite would occur. 

Active Choice of a Plan 

If a larger percentage of beneficiaries did not actively choose a plan in the first year 

of premium support than is predicted in CBO’s central estimates and if those beneficiaries were assigned to plans with bids at or below the benchmark, a larger percentage of beneficiaries would be enrolled in low-bidding plans, all else being equal. 

Conversely, if a smaller percentage of beneficiaries did not actively choose a plan, 

a smaller percentage would be enrolled in low-bidding plans. The implications for 

federal savings under the two premium support options would be similar to the indirect effects (discussed below) that would occur through changes in the shares of enrollment in private plans when beneficiaries were more, or less, sensitive to differences in premiums than is predicted in the central estimates. (Although one 

might expect that having a higher share of beneficiaries not actively choosing a plan 

would have effects similar to beneficiaries’ being less sensitive to premiums, that 

is not the case because the beneficiaries who did not choose a plan would be assigned to a low-bidding plan.) 

Effects of Changes in the Proportion of Beneficiaries in Lower-Bidding 

Plans 

A greater responsiveness of beneficiaries to differences in premiums when choosing 

among plans and a larger percentage of beneficiaries not actively choosing a plan 

in the first year would both lead to a larger proportion of beneficiaries being enrolled in lower-bidding plans. Similarly, less responsiveness to differences in premiums and a smaller percentage of beneficiaries not actively choosing a plan would 

lead to a smaller proportion of beneficiaries being enrolled in lower-bidding plans. 

Those differences in enrollment would have indirect effects on federal savings 

through three main mechanisms: 

■ Under the average-bid option, having a greater proportion of beneficiaries in 

lower-bidding plans would result in lower benchmarks (because benchmarks are 

constructed by weighting each plan’s bid by its enrollment in the prior year) and 

thus would result in greater federal savings. And if a smaller proportion were 

enrolled in lower-bidding plans, higher benchmarks and lower federal savings 

would result. Under the second-lowest-bid option, however, having a higher or 

lower proportion of beneficiaries enrolled in lower-bidding plans would not directly affect benchmarks. 

■ In most regions, the lower-bidding plans would be private plans, and higher enrollment in those plans would be accompanied by a lower market share for the 

FFS program, which would increase bids of private plans for reasons discussed 

above, all else being equal. Lower enrollment in private plans would have the opposite effect. 

■ For any given set of bids, CBO expects, greater enrollment in private plans would 

result in smaller federal savings because diagnostic coding by private insurers 

would be more intensive than that by FFS providers under a premium support 

system (as is now the case under the Medicare Advantage program) and federal 

128 

payments to private plans would be adjusted to account for only part of that difference in coding. Again, lower enrollment in private plans would have the opposite effect. 

Effects on Beneficiaries’ Total Payments 

CBO estimated a range of effects on beneficiaries’ total payments by simultaneously 

varying all five key parameters in ways that would result in higher and lower payments under the premium support options. In CBO’s assessment, the uncertainty 

of the estimated effects on beneficiaries’ total payments is greater than that concerning the estimated effects on federal spending because there are especially broad 

ranges of plausible values for the two parameters that would affect beneficiaries’ 

payments the most: their sensitivity to premiums and the percentage who would not 

initially choose a plan. Varying other parameters also affects the estimates. 

If beneficiaries were more sensitive to premiums than CBO’s central estimates indicate, more of them would enroll in lower-bidding plans, and their total payments 

would be lower, on average, than the central estimates indicate (because enrollees 

in low-bidding plans would pay lower premiums and use fewer medical services and 

therefore pay less out of pocket for services). The opposite also is true: If beneficiaries are less sensitive to premiums, fewer would enroll in lower-bidding plans, 

and their total payments would be higher, on average. 

By the same logic, if the proportion of beneficiaries who did not choose a plan in 

the first year of a premium support system was larger than that indicated by the 

central estimates, their total payments would be lower, on average, than predicted 

(because those who did not choose a plan would be assigned to one with a bid at 

or below the benchmark). And if the proportion of beneficiaries who did not choose 

a plan was smaller than in the central estimates, their total payments would be 

higher, on average. 

Beneficiaries’ payments under the premium support options also would depend on 

other factors that contribute to the uncertainty of CBO’s estimates. Private plans’ 

bids could differ from the agency’s central estimates if the current-law bids for 

Medicare Advantage were higher or lower than they are in CBO’s estimates, if private insurers reduced their bids under a premium support system by more or less 

than the amounts in those estimates, or if the adjustment to plans’ provider payment rates (and thus their bids) reflected a decline in the FFS market share that 

was smaller or larger than that in the estimates. For example, if the bids of private 

plans were below the central estimates, then payments would be lower for enrollees 

in those plans (because of lower premiums and reduced cost sharing) and higher for 

those who enrolled in the FFS program (because the lower cost of private plans 

would reduce benchmarks and raise FFS premiums). As a result, beneficiaries 

would have a greater incentive to switch from the FFS program to private plans, 

and beneficiaries’ total payments would be lower than CBO’s central estimates 

would indicate (assuming that the number of beneficiaries enrolled in the FFS program was not so large that the increase in payments for those beneficiaries outweighed the reduction in payments for enrollees in private plans and the reduction 

in the standard premium for all beneficiaries as a result of the lower benchmarks). 

If private plans’ bids were higher than predicted by the central estimates, beneficiaries’ total payments would rise relative to the central estimates. 

About This Document 

This Congressional Budget Office (CBO) report was prepared in response to interest 

expressed by Members of Congress. In keeping with CBO’s mandate to provide objective, impartial analysis, the report makes no recommendations. 

Jessica Banthin, James Baumgardner, Tom Bradley, Melinda Buntin (formerly of 

CBO), Holly Harvey, Paul Jacobs, Jeffrey Kling, Paul Masi, Eamon Molloy, Lyle 

Nelson, Romain Parsad, and Andrew Stocking contributed to the analysis and prepared the report with guidance from Linda Bilheimer and Peter Fontaine. Additional assistance was provided by numerous analysts in CBO’s Budget Analysis Division and in its Health, Retirement, and Long-Term Analysis Division. 

Henry Aaron of the Brookings Institution, Joseph Antos of the American Enterprise 

Institute, Thomas Buchmueller of the University of Michigan, Michael Chernew of 

Harvard University, Mark Duggan of the University of Pennsylvania, Alain 

Enthoven of Stanford University, Roger Feldman of the University of Minnesota, 

129 

Amy Finkelstein of the Massachusetts Institute of Technology, Paul Ginsburg of the 

Center for Studying Health System Change, Mark McClellan of the Brookings Institution, Mark Miller of the Medicare Payment Advisory Commission, Joseph Newhouse of Harvard University, Patricia Neuman of the Kaiser Family Foundation, 

and Robert Reischauer of the Urban Institute provided comments about CBO’s analytical approach. (The assistance of external experts implies no responsibility for the 

final product, which rests solely with CBO.) 

Kate Kelly edited the report, and Maureen Costantino and Jeanine Rees prepared 

it for publication. An electronic version is available on CBO’s website (www.cbo.gov/ 

publications/44581). 

Douglas W. Elmendorf 

Director 

September 2013 

Table 1. 

Change in Net Federal Spending for Medicare Under Illustrative Premium Support Options, 

Relative to That Under Current Law, 2020 

Second-Lowest-Bid Option Average-Bid Option 

In Billions of Dollars a ¥45 ¥15 

As a Percentage of Net Federal Spending for Medicare ¥6 ¥2 

As a Percentage of Net Federal Spending for Parts A and B for 

Affected Beneficiaries b ¥11 ¥4 

Source: Congressional Budget Office. 

Note: Although estimates of percentage changes are based on CBO’s March 2012 baseline projections (which are the projections underlying 

the analysis in this report), the dollar savings are based on applying those percentages to CBO’s most recent projections (see Updated Budget Projections: Fiscal Years 2013 to 2023, May 2013, www.cbo.gov/publication/44172). 

a Rounded to the nearest $5 billion. 

b Affected beneficiaries include everyone who would have enrolled in Medicare under current law, except dual-eligible beneficiaries (people 

who are simultaneously enrolled in Medicare and Medicaid). Spending for affected beneficiaries includes all spending for Part A (Hospital 

Insurance) and Part B (Medical Insurance) except spending that was excluded because it is not covered by the bids that Medicare Advan- tage plans submit under current law—namely, the additional payments to disproportionate-share hospitals (whose share of low-income patients exceeds a specified threshold) and spending for medical education, hospice benefits, and certain benefits for patients with end- stage renal disease. Spending for Part D prescription drug insurance is excluded. 

Table 2. 

Change in Net Federal Spending for Medicare and in Beneficiaries’ Payments Under 

Illustrative Premium Support Options, Relative to Amounts Under Current Law, 2020 

(Percent) Second-Lowest-Bid Option Average-Bid Option 

Net Federal Spending for Parts A and B for Affected Beneficiaries a

Central Estimate ¥11 ¥4 

Range ¥9 to ¥14 ¥1 to ¥7 

Total Payments by Affected Beneficiaries b

Central Estimate 11 ¥6 

Range ¥2 to 24 0 to ¥12 

Net Federal Spending for Parts A and B for Affected 

Beneficiaries Plus Total Payments by Affected Beneficiaries a, b, c

Central Estimate ¥5 ¥4 

Memorandum: 

Premiums Paid by Affected Beneficiaries c, d

Central Estimate 31 ¥6 

Source: Congressional Budget Office. 

Note: Affected beneficiaries include everyone who would have enrolled in Medicare under current law, except dual-eligible beneficiaries (people who are simultaneously enrolled in Medicare and Medicaid). 

130 

a The reported range for the second-lowest-bid option is not symmetric around the central estimate because of rounding. Spending for affected beneficiaries includes all spending for Part A (Hospital Insurance) and Part B (Medical Insurance) except spending that was excluded because it is not covered by the bids that Medicare Advantage plans submit under current law—namely, the additional payments 

to disproportionate-share hospitals (whose share of low-income patients exceeds a specified threshold) and spending for medical education, hospice benefits, and certain benefits for patients with end-stage renal disease. Spending for Part D prescription drug insurance 

is excluded. 

b Payments include premiums and out-of-pocket costs for deductibles, copayments, and coinsurance for services and supplies covered by 

Part A and Part B. Payments include the standard Part B premium and the income-related premium (applicable for beneficiaries whose 

income exceeds specified threholds) but exclude any additional amounts paid for enhanced benefits or supplemental (medigap) coverage. 

c Range has not yet been estimated. 

d Under current law and under the options, premiums are for the basic package of Medicare benefits covered under Parts A and B. They 

exclude any additional amounts paid for enhanced benefits or supplemental (medigap) coverage and any amounts paid for the 

incomerelatedpremium. 


012417.001
131 

Box 1. 

The Medicare Program 

In 2013, Medicare will provide federal health insurance for 52 million people who are elderly (age 65 or 

older) or disabled or who have end-stage renal disease. Of that group, about 85 percent are elderly. 

Medicare’s Part A (Hospital Insurance) primarily covers inpatient hospital, skilled nursing facility, and 

hospice care. Part B (Medical Insurance) mainly covers services provided by physicians and other practitioners and by hospital outpatient departments. Home health care may be covered by Part A or by Part 

B. Medicare’s Part D is the prescription drug program. Nearly 30 percent of Medicare beneficiaries receive care through the Medicare Advantage program, or Part C, in which private health insurers assume 

responsibility for, and the financial risk of, providing Medicare benefits. Almost all of the remaining 

beneficiaries receive care in the traditional fee-for-service (FFS) program. In 2012, gross spending for 

Medicare was $557 billion. Net of offsetting receipts (mostly premiums paid by beneficiaries), federal 

spending for the program was $472 billion. 


012417.002
132 

Box 1.—Continued 

Medicare’s Financing 

The various parts of Medicare are financed in different ways. Part A is financed primarily by a payroll tax. 

Beneficiaries’ premiums (including income-related adjustments paid by higher-income beneficiaries) 

cover just over one-quarter of the outlays for Part B, and general funds from the U.S. Treasury cover 

nearly all of the rest. The government’s payments to Medicare Advantage plans are financed by funds 

from Parts A and B. For Part D, enrollees’ premiums cover about one-quarter of the cost of the basic 

prescription drug benefit, the federal government receives payments from states for dual-eligible beneficiaries (who are enrolled simultaneously in Medicare and Medicaid), and general funds cover most of 

the remaining cost. In fiscal year 2012, payroll taxes financed about 37 percent of Medicare outlays, 

beneficiaries’ premiums covered about 13 percent, and most of the rest came from general funds of the 

Treasury. 

Medicare’s Traditional Fee-for-Service Program 

Enrollees in the traditional FFS program are covered for services delivered by any participating provider, 

and both the package of benefits and the rates paid to providers are set by law. Medicare beneficiaries 

share those costs through deductibles and coinsurance, but because cost-sharing liabilities can be substantial (in part because traditional Medicare does not include an annual cap on what beneficiaries 

spend), about 90 percent of beneficiaries in the FFS program have supplemental insurance that covers 

most or all of their cost sharing, often through retiree plans offered by former employers or through individual insurance policies (known as medigap plans) or Medicaid. 

Medicare Advantage 

In most places in the United States, Medicare beneficiaries may choose among competing private insurers—through the Medicare Advantage program—instead of the traditional FFS program. Participating 

insurance companies submit bids indicating the per capita payment they are willing to accept for providing Part A and B benefits to a beneficiary of average health. (A separate bidding process determines 

payments for Part D.) The federal payment per enrollee then depends on what the insurance company 

bids and on how that amount compares with a ‘‘benchmark’’ that is announced by the federal government before those bids are submitted. Under a system set to be fully phased in by 2017, benchmarks 

will be based on per capita spending in the FFS program at the county level, and they will range from 

95 percent of FFS spending per capita in the one-quarter of counties where such spending is highest to 

115 percent of FFS spending per capita in the one-quarter of counties where such spending is lowest. 

Plans with quality ratings above a specified threshold will have bonus amounts added to their benchmarks. 

Plans that submit a bid below the benchmark for a service area receive federal payments that equal their 

bid plus a rebate that is a percentage of the difference between the bid and the benchmark. (Beginning 

in 2014, the rebate will range from 50 percent to 70 percent, depending on the plan’s performance on 

certain quality measures.) Plans must return the rebate to enrollees in the form of reduced cost sharing 

for benefits, coverage for items not covered by Medicare, or reduced Part B or Part D premiums. Plans 

with a bid that equals or exceeds the benchmark receive federal payments that equal the benchmark 

and must charge enrollees a premium for their Medicare coverage equal to the amount by which their 

bid exceeds the benchmark. Plans’ payments from Medicare are larger or smaller, respectively, for enrollees who are in worse- or better-than-average health. 

Table 3. 

Examples of Determining Premiums Under Illustrative Premium Support Options, Using 

Hypothetical Bids and Enrollment 

Region With High Fee-for-Service Spending Region With Low Fee-for-Service Spending 

Bid Annual 

Premium 

Proportion 

Enrolled Bid Annual Premium 

Proportion 

Enrolled 

Second-Lowest-Bid Option 

Fee-for-Service Program 14,000 4,300 0.25 9,900 1,900 0.75 

Private Plans 

A 11,800 2,100 0.15 10,100 2,100 0.05 

B 11,600 1,900 0.15 9,900 1,900 0.05 

C 11,400 1,700 0.15 9,700 1,700 0.05 

133 

Table 3.—Continued 

Examples of Determining Premiums Under Illustrative Premium Support Options, Using 

Hypothetical Bids and Enrollment 

Region With High Fee-for-Service Spending Region With Low Fee-for-Service Spending 

Bid Annual 

Premium 

Proportion 

Enrolled Bid Annual Premium 

Proportion 

Enrolled 

D 11,200 1,500 0.15 9,500 1,500 0.05 

E 11,000 1,300 0.15 9,300 1,300 0.05 

Benchmark 11,200 n.a. n.a. 9,500 n.a. n.a. 

Standard Premium n.a. 1,500 n.a. n.a. 1,500 n.a. 

Average-Bid Option 

Fee-for-Service Program 14,000 3,300 0.25 9,900 1,500 0.75 

Private Plans 

A 12,000 1,300 0.15 10,300 1,900 0.05 

B 11,800 1,100 0.15 10,100 1,700 0.05 

C 11,600 900 0.15 9,900 1,500 0.05 

D 11,400 700 0.15 9,700 1,300 0.05 

E 11,200 500 0.15 9,500 1,100 0.05 

Benchmark 12,200 n.a. n.a. 9,900 n.a. n.a. 

Standard Premium n.a. 1,500 n.a. n.a. 1,500 n.a. 

Enrollment-Weighted Average 12,200 1,500 n.a. 9,900 1,500 n.a. 

Source: Congressional Budget Office. 

Notes: Under the second-lowest-bid option, the benchmark would equal the lower of the second-lowest bid from a private plan and the bid 

of the fee-for-service program. Under the average-bid option, the benchmark would equal the enrollment-weighted-average bid 

among all plans, including the fee-for-service program. 

Proportion enrolled is for the previous year. Equal proportions among private plans are used to simplify the example. (According to 

CBO’s estimates, enrollment would be higher in low-bidding plans.) 

Under both options, premiums would equal the standard premium plus the bid minus the benchmark, and federal contributions for 

a beneficiary of average health would equal the benchmark minus the standard premium. Those federal contributions would be 

$9,700 and $8,000 under the second-lowest-bid option in regions with high and low fee-for-service spending, respectively, and 

$10,700 and $8,400 under the average-bid option in such regions, respectively. 

n.a. = not applicable. 

134 

Table 4. 

Average Annual Premiums Charged by Plans for Medicare Part A and B Benefits Under 

Illustrative Premium Support Options, Weighted by Population, 2020 

Second-Lowest-Bid Option Average-Bid Option 

Annual Premium (Dollars) 

Change From 

Part B Premium 

Under Current Law (Percent) 

Annual Premium (Dollars) 

Change From 

Part B Premium 

Under Current Law (Percent) 

Second-Lowest-Bidding Private Plan 1,500 ¥6 900 ¥44 

Median-Bidding Private Plan 1,800 13 1,200 ¥25 

Fee-for-Service Program 3,100 94 2,400 50 

Source: Congressional Budget Office. 

Note: Premiums charged by plans are averages weighted by the Medicare population in each region. (Those averages differ from the average premiums paid by beneficiaries, which are based on CBO’s projections of enrollment in plans.) Under current law and under the 

options, premiums are for the basic package of Medicare benefits covered under Part A (Hospital Insurance) and Part B (Medical Insurance). They exclude any additional amounts paid for enhanced benefits or supplemental (medigap) coverage and any amounts 

paid for the income-related premium (applicable for beneficiaries whose income exceeds specified threholds). Under current law, for 

most beneficiaries, Part A will have no premium and the premium for Part B (excluding income-related adjustments) will be $1,600 

in 2020, CBO projects. Amounts are rounded to the nearest $100. 


012417.003
135 


012417.004

Figure 3. Return to Reference 

Average Annual Premiums Charged by Plans for Medicare Part A and B Benefits Under Illustrative 

Premium Support Options, by Fee-for-Service Spending in a Region, Weighted by Population, 2020 

(Dollars) 

Fee-for-Service 

Program 

Median· Bidding 

Private Plan 

Secondlowest-Bidding 

Private Plan 

Second-Lowest-Bid Option 

·~\ 

"~ 2,600 

2,000 

---------------1,800 

~,900 1,800 

---------------1,600-::::::-1,600 

1,5oo---1,5oo----1,5oo 

Highest Second-Highest Third-Highest 

Quartile Quartile Quartile 

Lowest 

Quartile 

Average-Bid Option 

600 600 

Highest Second-Highest Third-Highest 

Quartile Quartile Quartile 

Quartiles of Beneficiaries Grouped by Fee-for-Service Spending in Their Region 

Source: Congressional Budget Office. 

Lowest 

Quarti le 

Note: Premiums charged by plans are averages weighted by the Medicare population in each region. (Those averages differ from the average 

premiums paid by beneficiaries, which are based on CBO's projections of enrollment in plans.) Under current law and under the 

options, premiums are for the basic package of Medicare benefits covered under Part A (Hospital Insurance) and Part B (Medical 

Insurance). They exclude any additional amounts paid for enhanced benefits or supplemental (medigap) coverage and any amounts 

paid for the income-related premium (applicable for beneficiaries whose income exceeds specified thresholds). Under current law, for 

most beneficiaries, Part A will have no premium and the premium for Part B (excluding income-related adjustments) will be $1,600 in 

2020, CBO projects. Amounts are rounded to the nearest $100. Quartiles are groups of regions classified by per capita fee-for-service 

spending; each contains a quarter of the Medicare population. 
136 

Box 2. 

Grandfathering of Beneficiaries Under a Premium Support System 

Under one type of proposal for a premium support system, current beneficiaries and those who became eligible for Medicare before the new system took effect would continue to receive coverage under the existing Medicare program; only those beneficiaries who became newly eligible on or after a specified date 

would enroll in the premium support system. Such an arrangement would require the federal government 

to address several important design questions-some are unique to such a system and others are relevant for any premium support system but have added significance if grandfathering is part of the design. Although policymakers might also consider changing the existing Medicare program if it remained 

in operation, this discussion focuses on design issues specifically related to a grandfathering provision 

in a premium support system, and it assumes that beneficiaries who remained in the existing system 

could choose Medicare’s fee-for-service (FFS) program or a Medicare Advantage plan and that private 

insurers could participate in the premium support system, the Medicare Advantage program, or both. 

Enrollment in Part B 

An important question for any premium support system is whether enrollment in Medicare’s Part B (Medical 

Insurance) would remain voluntary, and if so, how beneficiaries who declined that coverage would be 

treated by the system. About 8 percent of Medicare beneficiaries are not enrolled in Part B currently, 

generally because either they or a spouse are still working and have employment-based coverage as primary insurance with Medicare as a secondary insurer. 

Among the Medicare population age 65 or older, younger beneficiaries are more likely to decline Part B 

coverage, and the percentage that does so has increased as more people have stayed in the workforce 

past age 65. (The late-enrollment penalty for Part B is waived for active workers in larger companies 

that offer employment-based coverage. If such workers were to enroll, Medicare would be a secondary 

payer for their health care costs, which would reduce the value of the coverage.) Some 19 percent of 

65-year-old Medicare beneficiaries were not enrolled in Part B in 2011, up from 15 percent in 1999. If a 

premium support program included grandfathering, the question of whether Part B enrollment would remain voluntary would be especially important because the younger segment of the retirement-age population would constitute a substantial fraction of the beneficiaries covered in the first few years. 


012417.005
137 

Box 2.—Continued 

Bidding Regions 

Depending on how the regions were defined, in many regions the number of beneficiaries in a premium 

support system with a grandfathering provision could initially be very small. If dual-eligible beneficiaries 

also were excluded from the new system, the Congressional Budget Office (CBO) projects, just 5 percent 

of the Medicare population would be covered by the system after the first year, and only 25 percent 

would be covered after the fifth year. 

Some proposals would have bidding regions correspond to health care markets within states. In that case, 

grandfathering would result in some regions’ enrolling very small numbers of people in the new system 

in the first few years. Because personal health care expenditures vary widely, the actual costs of enrollees in private plans and the FFS program could differ greatly from those plans’ bids for their regions. 

That uncertainty could make participation less attractive to private insurers, cause them to raise their 

bids if they chose to participate, and create significant year-to-year variation in the amounts of the 

bids. In regions with few beneficiaries, private insurers also would have less incentive to modify health 

care plans to contain costs. 

Bids and Risk Adjustment 

Under the illustrative premium support options analyzed for this report, insurers would submit a bid for a 

beneficiary with average expected health care costs (that is, a beneficiary with a risk score of 1.0), and 

federal payments to insurers would be adjusted to account for differences between their enrollees’ expected costs and those of the average beneficiary. CBO assumed that the risk adjustment would be 

comparable to that for the Medicare Advantage program, in which federal payments to insurers are adjusted on the basis of enrollees’ medical conditions and demographic characteristics. 

In the initial years of a system with grandfathering, a substantial proportion of covered beneficiaries would 

not have the history of past Medicare claims data necessary to compute a risk score. For those beneficiaries, payments to plans could be adjusted using a version of the risk adjuster based entirely on demographic characteristics. That approach lacks the completeness of the standard risk adjuster, which 

includes information on medical conditions, so pursuing it would raise questions about the adequacy of 

risk adjustment in the first few years. 

Under a grandfathering provision, the bidding and risk adjustment mechanism could reflect average expected costs for a beneficiary in the premium support system. That approach would necessitate ‘‘rescaling’’ the risk adjustment factors to correspond to the segment of the Medicare population enrolled in 

the premium support system or reestimating those factors (because particular risks are associated with 

costs in ways that would differ between that segment and the Medicare population as a whole). If the 

existing risk adjustment mechanism was used instead, insurers would base their bids on a population 

that differed from the population served under the premium support system. An analogous set of issues 

would confront the Medicare Advantage program. Once the premium support system began, the proportion of beneficiaries eligible to enroll in a Medicare Advantage plan would decline each year as new 

people entered the premium support system. 

Beneficiaries’ Premiums 

For both illustrative options, CBO assumed that beneficiaries who enrolled in a plan with a bid equal to 

the benchmark would pay a standard premium determined using the same formula used to calculate 

the Part B premium under current law. With grandfathering, that premium could be determined in various ways. One approach would be to compute a single standard premium for the entire Medicare population that would apply both to beneficiaries in the premium support system and to those who were 

grandfathered into Medicare in its current-law form. In a second approach, separate computations could 

be made for a standard premium under the premium support system and for the Part B premium that 

would apply to the grandfathered population; a standard premium could be computed as one amount, or 

standard premiums could differ by beneficiaries’ age. Each approach would involve a different distribution of health care costs and of potential savings from a premium support system among age groups. 

138 

Politico, April 30, 2012 

GOP SPLIT ON REFORMING HEALTH CARE

By Jennifer Haberkorn 

Ask the 242 House Republicans what kind of health policy they’d like to enact instead of President Barack Obama’s health care reform law and you might get 242 

different answers. 

Even after 3 years of railing against Obama’s plan, Republicans have coalesced 

around only a few basic tenets of health policy—let alone a full replacement plan. 

They are even divided over whether some of the popular pieces of Obama’s health 

law are a good idea. For example, most Republicans support the health law’s reVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00142 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM

012417.006
139 

quirement that insurance companies accept all applicants—but the replacement 

plan put forward by the most prominent Republican ignores that idea. 

‘‘It’s a terrible idea,’’ Rep. Tom Price (R–GA), the sponsor of the plan, told Politico. 

He said Democrats only enacted the provision in order to require exactly what kinds 

of insurance Americans must have. He would rather expand coverage voluntarily. 

The wide range of GOP opinions could make it hard for the party to come together 

behind a single plan to replace Obama’s health care law if it’s overturned by the 

Supreme Court this summer. 

A ruling against all or part of the legislation has the potential to reopen the health 

care wars of 2009, putting the differences among Republicans on full display. It’s 

a divide Democrats would try to exploit as they press Republicans on how they’re 

going to solve the country’s health care problems. 

‘‘If the Supreme Court throws out the president’s plan, we’re going to have to have 

something on the table,’’ said Rep. Paul Broun (R–GA), a physician. 

House Republicans won’t be the only ones with replacement plans. Gov. Mitt Romney’s health agenda relies more on state-level reforms and private competition than 

Obama’s law. 

On Capitol Hill, there are a handful of pending Republican health bills. 

Days before the Supreme Court heard oral arguments over the health law, Broun 

introduced a plan that allows Americans to deduct all of their health care costs; encourages the use of health savings accounts; converts Medicare to a ‘‘premium support’’ model that subsidizes private coverage; allows consumers to buy insurance 

across state lines; and encourages the use of association health plans, which allow 

groups of people or co-workers to buy health care together. 

Broun said he’s trying to drum up support among lawmakers and outside groups 

and already has the backing of FreedomWorks, the conservative group led by Dick 

Armey. 

The plan that’s likely to get the closest look from Republicans is sponsored by Price, 

an orthopedic surgeon and one of the House’s leading voices on health care. He released a video on Wednesday touting the plan, which he originally introduced in 

2009. 

PREPARED STATEMENT OF HON. THOMAS PRICE, M.D., NOMINATED TO BE SECRETARY, DEPARTMENT OF HEALTH AND HUMAN SERVICES

Thank you, Chairman Hatch, Ranking Member Wyden, and all the members of 

this committee, for the opportunity to speak with you today and engage in a discussion about the road ahead for our great Nation. These proceedings, and this entire 

process, would not be possible without the work of your staff, and so I want to extend my appreciation to them as well for the great service they provide. Thanks so 

much to Senator Johnny Isakson for his generous introduction. We’ve known each 

other for nearly 30 years—and I’m so grateful for his friendship and kindness, and 

our State is blessed to have had his service and leadership. I wish also to especially 

thank my wife of 33 years, Betty. Her support, encouragement and advice (which 

is always correct) mean more than I could ever say. 

Over the past few weeks, I have had the chance to meet with many of you individually and have gained a real appreciation for the passion you all have about the 

critical work of the Department of Health and Human Services. Please know that 

I share that passion. That is why I am here today—and why I’m honored to have 

been nominated by the President to serve as the next Secretary of HHS. 

We all come to public service in our own unique ways that inform who we are 

and why we serve. My first professional calling was to care for patients. That experience as a physician and later as a legislator has provided a holistic view of the 

complex interactions that take place every day across our communities and across 

this country that, when done correctly, are in service to the greater good we seek 

to achieve. Today, I hope to share with you how my experience has helped shape 

my understanding of and appreciation for the work of the department and its team, 

which I hope to lead. 

From an early age, I had an interest in medicine. My earliest memories are of 

a farm in Michigan where my family and I lived before moving to suburban Detroit 

at the age of five. I spent most of my formative years being raised by a single 

140 

mom—and I assumed a lot of responsibility since there were 5 of us. Some of my 

fondest memories were spending time with my grandfather—a physician—as he 

made house calls to see patients. Having both a father and grandfather as physicians surely influenced my path toward medicine. And it was very likely that the 

orthopedist who treated my many broken bones in my youth gave me a particular 

fascination for fixing things—and not just broken bones. 

After graduating with a medical degree from the University of Michigan, I went 

south to Atlanta, GA—which I’ve called home for nearly 40 years. It’s where I met 

my wife Betty and where we raised our son. I did my residency at Emory University 

and Grady Memorial Hospital in downtown Atlanta. I would return to Grady later 

in my career to serve as Medical Director of the Orthopedic Clinic. Throughout my 

professional career I treated patients of every age—from all walks of life—including 

many children. Anyone who has ever treated a child knows how fulfilling it is to 

look into the eyes of a parent and tell them our team has helped heal their son or 

daughter—to give them peace of mind. My memories of Grady are filled with the 

gracious comments from parents and patients for the team of health care specialists 

with whom I had the privilege of working. I cherished my time there. 

After 25 years of school and training, I hung out my shingle to start a solo private 

orthopedic practice. Over the years, this practice grew and eventually became one 

of the largest, non-academic orthopedic groups in the country—a group I would 

eventually serve as Chairman of the Board. Whether as part of that team or on staff 

at a hospital, it was apparent early on that every person involved in the delivery 

of care, no matter their role—doctors, nurses, lab techs, orderlies—all had one goal 

in mind—and that was to get our patients well again, to heal them. It was always 

a team effort and wherever you fit into that team, you appreciated the value of 

those working with you. 

During 20 years as a practicing physician—both in office and hospital setting— 

I learned a good bit about not just treating patients but about the broader health 

care system and where it intersects with government—local, State and Federal. A 

couple of lessons stand out. One—many patients I knew or treated were never more 

angry and frustrated than when they realized that there was someone other than 

themselves and /or their physician making medical decisions on their behalf—when 

there was someone not involved in the actual delivery of care that was standing between them and their doctor or treatment. 

Another lesson came the day I noticed that there were more individuals within 

our office who were dealing with paperwork, insurance filings, and government regulations than there were individuals actually seeing and treating patients. It was 

in those moments that it became crystal clear that our health care system was losing focus on the number one priority—the individual patient. Having had no greater 

joy than taking care of patients, I felt compelled to broaden my role in public service, and help solve the issues harming the delivery of medicine—so I ran for the 

State Senate in Georgia. 

Anyone here who has ever served at the State level knows that State government 

has a different feel to it—a different pace. In Georgia, I found the State Senate to 

be a remarkably bipartisan place where collegial relationships were the norm. This 

is the environment in which I learned to legislate—reaching across the aisle to get 

the work done—needing the buy-in and the support of more than just one party. 

I worked with Democrats including then State senator, now-Atlanta Mayor, Kasim 

Reed. He and I did not see eye to eye on everything, for sure, but we were successful 

in finding our way together through some really challenging issues for our State. 

In Congress, I have been fortunate to have been a part of collaborations that 

broke through party lines to solve problems including those pertaining to health 

care. Early in my congressional career, I was privileged to work alongside thenrepresentative, now Senator, Tammy Baldwin to introduce legislation that would 

have empowered States to come up with new ideas to provide health care coverage 

to their uninsured populations. Just this past Congress, it was a bipartisan, bicameral effort that actually succeeded in ridding Medicare of a broken physician 

payment system and which has now begun the creation of a new system that, if implemented properly, will help ensure that seniors have better access to higher quality care. 

If confirmed, my obligation will be to carry to the Department of Health and 

Human Services both an appreciation for bipartisan, team-driven policymaking and 

what has been a lifetime commitment to work to improve the health and well-being 

of the American people. That commitment extends to what I call the six principles 

141 

of health care—six principles that, if you think about it, all of us hold dear: affordability, accessibility, quality, choices, innovation, and responsiveness. We all want 

a health care system that’s affordable, that’s accessible to all, of the highest quality, 

with the greatest number of choices, driven by world-leading innovations, and responsive to the needs of the individual patient. 

But HHS is more than just health care. There are real heroes at this department 

doing incredible work to keep our food safe, to develop new drugs and treatment 

options—driven by scientists conducting truly remarkable research. The Centers for 

Disease Control and Prevention—which we in Atlanta are proud to have headquartered in our city—is the first place the world turns to when there’s a health 

care threat that requires the greatest, most capable minds to solve. 

There are heroes among the talented, dedicated men and women working to provide critical social services—helping families and, particularly, children have a higher quality of living and the opportunity to rise up and strive to achieve their American Dream—something we all want for ourselves and our loved ones. 

The role of HHS in improving lives means it must carry out its responsibilities 

with compassion. It also must be efficient, effective and accountable, as well as 

being willing to partner with those in our communities already doing remarkable 

work. In every aspect of the department, across the spectrum of issues and services 

it handles, there is embedded a promise that has been made to the American people. 

Governor Michael Leavitt, during his confirmation hearing in 2004 to take on this 

task, spoke of our highly regarded ‘‘brands’’—the CDC, FDA, NIH, and others—and 

how they must be preserved and strengthened because they guarantee that those 

promises are kept. 

Today’s challenges make it even more important that we strengthen our resolve 

to keep the promises we, as a society, have made to our senior citizens and to those 

among us who are most in need of care and support. That means saving, strengthening, and securing Medicare for today’s beneficiaries and future generations. It 

means ensuring that our Nation’s Medicaid population has access to quality care. 

It means maintaining, and expanding, America’s leading role in medical innovation 

and the treatment and eradication of disease. 

As I noted at the outset, I share your passion for these issues—having spent my 

life in service to them. And yet, there’s no doubt that we do not all share the same 

point of view when it comes to addressing each and every one of them. Our approaches to policies may differ, but there surely exists a common commitment to 

public service and compassion for those we serve. We all hope, by our actions, to 

help improve the lives of the American people, to help heal individuals and whole 

communities. With a healthy dose of humility and appreciation for the scope of the 

challenges before us, with your assistance and with God’s will, we can make it happen. I look forward to working with you to do just that. 

Thank you very much for the privilege of appearing before you today. 

SENATE FINANCE COMMITTEE 

STATEMENT OF INFORMATION REQUESTED 

OF NOMINEE 

A. BIOGRAPHICAL INFORMATION 

1. Name (include any former names used): Thomas Edmunds Price, M.D. 

2. Position to which nominated: Secretary of the Department of Health and 

Human Services. 

3. Date of nomination: January 20, 2017. 

4. Address (list current residence, office, and mailing addresses): 

5. Date and place of birth: October 8, 1954, Lansing, Michigan. 

6. Marital status (include maiden name of wife or husband’s name): 

7. Names and ages of children: 

142 

8. Education (list secondary and higher education institutions, dates attended, degree received, and date degree granted): Dearborn High School, 1969–1972, Diploma; University of Michigan, 1972–1979, Bachelor’s Degree and Doctor of 

Medicine. 

9. Employment record (list all jobs held since college, including the title or description of job, name of employer, location of work, and dates of employment): Surgical Intern, Emory University School of Medicine/Grady Health System, Atlanta, GA, 1979–1980; Orthopaedic Surgical Resident, Emory University School 

of Medicine/Grady Health System, Atlanta, GA, 1980–1984; Orthopaedic Surgeon, solo and group practice (North Fulton Orthopaedic Clinic, Compass Orthopaedics, Resurgens Orthopaedics), Roswell/Atlanta, GA, 1984–2002; Assistant 

Professor, Orthopaedic Surgery, Emory University School of Medicine/Grady 

Health System, Atlanta, GA 2002–2004; Georgia State Senator, State of Georgia, Atlanta, GA, 1997–2005; Member of Congress, GA06, House of Representatives, Washington DC, 2006–present. 

10. Government experience (list any advisory, consultative, honorary, or other parttime service or positions with Federal, State, or local governments, other than 

those listed above): See Appendix A. 

11. Business relationships (list all positions held as an officer, director, trustee, 

partner, proprietor, agent, representative, or consultant of any corporation, company, firm, partnership, other business enterprise, or educational or other institution): Founder/owner, North Fulton Orthopaedic Clinic, Roswell, GA; cofounder/president, Compass Orthopaedics, Roswell, GA; Director/chairman of 

board, Resurgens Orthopaedics, Atlanta/Roswell, GA; managing partner, Chattahoochee Associates, Roswell, GA (owns medical office building); member and 

co-owner, Diagnostic Ventures of Roswell, LLC, Roswell, GA (owns medical office building); member and co-owner, RMC3, LLC, Roswell, GA (owns stake in 

Diagnostic Ventures of Roswell, LLC, which owns medical office building); limited partner, Carolina Properties, Ltd., (owns apartment buildings in North 

Carolina, South Carolina, and Virginia). 

12. Memberships (list all memberships and offices held in professional, fraternal, 

scholarly, civic, business, charitable, and other organizations): Roswell Rotary 

Club, 1985–present, president 1996–1997; American Academy of Orthopaedic 

Surgeons; American Medical Association; Medical Association of Georgia; Medical Association of Atlanta; Atlanta Orthopaedic Society; Kelly Orthopaedic Society; Georgia Orthopaedic Society; American College of Surgeons; Chattahoochee 

Nature Center; Georgia Ensemble Theatre; Georgia Arthritis Foundation. 

13. Political affiliations and activities: 

a. List all public offices for which you have been a candidate. 

Georgia State Senate District 56; U.S. House of Representatives GA06. 

b. List all memberships and offices held in and services rendered to all political 

parties or election committees during the last 10 years. 

Member of Congress, GA06, Republican. 

c. Itemize all political contributions to any individual, campaign organization, 

political party, political action committee, or similar entity of $50 or more for 

the past 10 years. 

See Appendix B. 

14. Honors and awards (list all scholarships, fellowships, honorary degrees, honorary society memberships, military medals, and any other special recognitions 

for outstanding service or achievement): 

See Appendix C. 

15. Published writings (list the titles, publishers, and dates of all books, articles, 

reports, or other published materials you have written): 

Saving the American Miracle: The Destruction and Restoration of American Values. Paperback—self-published, January 20, 2011. 

In addition, a listing of all requested Op-Eds authored by Dr. Price has been 

attached as Appendix D. 

143 

16. Speeches (list all formal speeches you have delivered during the past 5 years 

which are on topics relevant to the position for which you have been nominated): 

See Appendix E. 

17. Qualifications (state what, in your opinion, qualifies you to serve in the position 

to which you have been nominated): 

My strengths are commitment, passion, and expertise. My entire adult life has 

been dedicated to service—professionally as an orthopaedic surgeon, politically 

as a State Senator and member of Congress, and in our community through numerous volunteer and charity activities. As a third-generation physician, I am 

well aware of the challenges of caring for patients and the societal needs of populations. For over 20 years, I had the privilege of practicing orthopaedic surgery 

in both private and public settings, training in an urban medical center including service in a veterans hospital, and treating folks of all ages and all walks 

of life. I founded North Fulton Orthopaedic Clinic and over time co-founded 

Resurgens Orthopaedics—reputed to be the largest private group practice of 

orthopaedic surgeons in the country. While serving as a Georgia State Senator, 

I was responsible for training students, interns, and residents in a large, major 

urban hospital in Atlanta. Those experiences coupled with being a legislator at 

both the State and Federal levels has given me a comprehensive understanding 

of the complex interactions taking place every day between patients and their 

families, physicians, providers, insurers, as well as local, State, and Federal 

Governments. It is a perspective that has reinforced my belief that the individual patient must always be at the center of health-care policy decisions. Having examined many systems and collaborated with many individuals and groups 

to bring improvements to our health-care financing and delivery, my breadth of 

experience and understanding has uniquely qualified me for this post. I have 

a deep passion for finding positive solutions to improve the human condition 

and allowing each member of our society to realize their full potential. I am not 

daunted by the challenge before us and have confidence in the promise that 

HHS may bring with its many agencies and broad jurisdiction to assist our communities and citizens. As a student of scientific principles, I have a profound 

appreciation for the role of basic scientific research, for the development of innovative treatments and cures, and for the imperative that America remains a 

leader in those pursuits. 

B. FUTURE EMPLOYMENT RELATIONSHIPS 

1. Will you sever all connections with your present employers, business firms, associations, or organizations if you are confirmed by the Senate? If not, provide 

details. 

Yes, any and all necessary. 

2. Do you have any plans, commitments, or agreements to pursue outside employment, with or without compensation, during your service with the government? 

If so, provide details. 

No. 

3. Has any person or entity made a commitment or agreement to employ your 

services in any capacity after you leave government service? If so, provide details. 

No. 

4. If you are confirmed by the Senate, do you expect to serve out your full term 

or until the next presidential election, whichever is applicable? If not, explain. 

Yes. 

C. POTENTIAL CONFLICTS OF INTEREST 

1. Indicate any investments, obligations, liabilities, or other relationships which 

could involve potential conflicts of interest in the position to which you have 

been nominated. 

None. The nominee will comply with all Office of Government Ethics recommendations for current and future personal investment holdings. 

144 

2. Describe any business relationship, dealing or financial transaction which you 

have had during the last 10 years, whether for yourself, on behalf of a client, 

or acting as an agent, that could in any way constitute or result in a possible 

conflict of interest in the position to which you have been nominated. 

None. The nominee will comply with all Office of Government Ethics recommendations for personal business relationships, dealings, and financial transactions. 

3. Describe any activity during the past 10 years in which you have engaged for 

the purpose of directly or indirectly influencing the passage, defeat, or modification of any legislation or affecting the administration and execution of law or 

public policy. Activities performed as an employee of the Federal Government 

need not be listed. 

Only as a member of Congress. 

4. Explain how you will resolve any potential conflict of interest, including any 

that may be disclosed by your responses to the above items. 

I intend to operate as I always have during all of my years in public service: 

by making ethical compliance a cornerstone of my public service and operating 

without reproach. Any personal holdings or positions which could conceivably 

present a potential conflict of interest have been disclosed to the Office of Government Ethics, and appropriate resolution of any potential conflict of interest 

will be resolved prior to my confirmation. 

5. Two copies of written opinions should be provided directly to the committee by 

the designated agency ethics officer of the agency to which you have been nominated and by the Office of Government Ethics concerning potential conflicts of 

interest or any legal impediments to your serving in this position. 

6. The following information is to be provided only by nominees to the positions 

of United States Trade Representative and Deputy United States Trade Representative: 

Have you ever represented, advised, or otherwise aided a foreign government 

or a foreign political organization with respect to any international trade matter? If so, provide the name of the foreign entity, a description of the work performed (including any work you supervised), the time frame of the work (e.g., 

March to December 1995), and the number of hours spent on the representation. 

N/A. 

D. LEGAL AND OTHER MATTERS 

1. Have you ever been the subject of a complaint or been investigated, disciplined, 

or otherwise cited for a breach of ethics for unprofessional conduct before any 

court, administrative agency, professional association, disciplinary committee, or 

other professional group? If so, provide details. 

The nominee was the subject of an investigation by the Office of Congressional 

Ethics in 2010 for matters involving fundraising activities associated with his 

principal campaign committee. Although the matter was referred for further 

consideration by the House Committee on Standards of Official Conduct, the 

committee dismissed the matter finding no wrongdoing and recommending that 

no further action was necessary. The public record associated with this investigation is available at the following link: https://oce.house.gov/january-26- 

2011-oce-referral-regarding-rep-tom-price/. 

2. Have you ever been investigated, arrested, charged, or held by any Federal, 

State, or other law enforcement authority for a violation of any Federal, State, 

county or municipal law, regulation, or ordinance, other than a minor traffic offense? If so, provide details. 

No. 

3. Have you ever been involved as a party in interest in any administrative agency 

proceeding or civil litigation? If so, provide details. 

No. 

4. Have you ever been convicted (including pleas of guilty or nolo contendere) of 

any criminal violation other than a minor traffic offense? If so, provide details. 

145 

No. 

5. Please advise the committee of any additional information favorable or unfavorable, which you feel should be considered in connection with your nomination. 

N/A. 

E. TESTIFYING BEFORE CONGRESS 

1. If you are confirmed by the Senate, are you willing to appear and testify before 

any duly constituted committee of the Congress on such occasions as you may 

be reasonably requested to do so? 

Yes. 

2. If you are confirmed by the Senate, are you willing to provide such information 

as is requested by such committees? 

Yes. 

APPENDIX A 

Leadership Positions and Standing Committee Assignments 

1997–1998—Georgia Senate 

• Health and Human Services 

• Insurance and Labor 

• Reapportionment 

• Special Judiciary 

• Youth, Aging, and Human Ecology 

1999–2000—Georgia Senate 

• Minority Whip 

• Consumer Affairs 

• Education 

• Health and Human Services 

• Reapportionment 

• Special Judiciary 

2001–2002—Georgia Senate 

• Minority Whip 

• Education 

• Health and Human Services 

• Reapportionment 

• Rules 

• Veterans and Consumer Affairs 

2003–2004—Georgia Senate 

• Majority Leader 

• Appropriations 

• Economic Development and Tourism, Vice-chair 

• Education, ex-officio 

• Ethics 

• Health and Human Services 

• Insurance and Labor ex-officio 

• Reapportionment and Redistricting, Secretary 

• Rules, Secretary 

2005–2009—U.S. House of Representatives 

• Financial Services 

• Education and Workforce/Labor 

2009–2011—U.S. House of Representatives 

• Chair—Republican Study Committee 

• Financial Services 

• Education and Labor 

• Ranking Member—Workforce Protections Subcommittee 

• Ranking Member—HELP Subcommittee 

• Franking Commission 

2011–2013—U.S. House of Representatives 

• Chair—Republican Policy Committee 

• Ways and Means 

146 

• Budget 

• Franking Commission 

2013–2015—U.S. House of Representatives 

• Ways and Means 

• Vice-Chair—Budget Committee 

• Education and Workforce 

• Franking Commission 

2015–2017—U.S. House of Representatives 

• Chair—Budget Committee 

• Ways and Means 

APPENDIX B 

Contributions Made By Thomas and Elizabeth Price 

Contributor Name Committee Name Transaction Date Amount 

Clark-Price, Elizabeth Norwood, Charlie via Norwood for Congress August 23, 2000 $250 

Clark-Price, Elizabeth Gingrey, J. Phillip via Gingrey for Senate Inc. July 27, 2002 $1,000 

Clark-Price, Elizabeth Isakson, John Hardy via Georgians for Isakson June 6, 2003 $200 

Price, Elizabeth Handel, Karen Christine via Handel for Senate Inc. June 29, 2013 $1,000 

Price, Elizabeth Handel, Karen Christine via Handel for Senate Inc. December 18, 2013 $1,000 

Price, Elizabeth Georgia Republican Party, Inc. March 21, 2013 $250 

Price, Elizabeth Georgia Republican Party, Inc. March 10, 1999 $200 

Price, Elizabeth Georgia Republican Party, Inc. June 9, 1997 $500 

Price, Elizabeth Gingrey, J. Phillip via Gingrey for Senate, Inc. August 28, 2002 $1,000 

Clark-Price, Elizabeth Romney, Mitt/Paul D. Ryan via Romney for President, 

Inc. 

June 28, 2012 $1,000 

Price, Thomas E., M.D. Georgia Republican Party, Inc. May 4, 1999 $295 

Price, Thomas E., M.D. Gingrey, J. Phillip via Gingrey for Senate, Inc. July 27, 2002 $1,000 

Price, Thomas E., M.D. Gingrey, J. Phillip via Gingrey for Senate, Inc. August 28, 2002 $1,000 

Price, Thomas E., M.D. Republican National Committee October 23, 2000 $250 

Price, Thomas E., M.D. Bush, George W. via Bush-Cheney ’04 (Primary) Inc. January 22, 2004 $2,000 

Price, Thomas E., Mrs. Republican National Committee October 23, 2000 $250 

Price, Thomas E., M.D. Political Action Committee of the American Association 

of Orthopaedic Surgeons—PAC of AAO 

June 6, 2002 $250 

Price, Thomas E., M.D. Dole, Elizabeth via Elizabeth Dole for President Exploratory Committee Inc. August 24, 1999 $1,000 

Price, Thomas E., M.D. Georgia Republican Party, Inc. May 24, 2000 $300 

Price, Thomas E., M.D. Biggert, Judy via Judy Biggert for Congress September 23, 2012 $2,000 

Price, Thomas E., M.D. NRCC December 11, 2008 $220 

Price, Thomas E., M.D. Gingrich, Newton L., via Friends of Newt Gingrich January 22, 1998 $1,000 

Price, Thomas E., M.D. Price, Thomas Edmunds via Price for Congress—Loan, 

since repaid 

July 28, 2004 $99,000 

147 

Contributions Made By Thomas and Elizabeth Price—Continued 

Contributor Name Committee Name Transaction Date Amount 

Price, Thomas E., M.D. Price, Thomas Edmunds via Price for Congress—Loan, 

since repaid 

August 6, 2004 $150,000 

Joint Fundraising Contributions 

These are contributions to committees who are raising funds to be distributed to other committees. 

The breakdown of these contributions to their final recipients may appear below. 

Contributor Name Committee Name Transaction Date Amount 

Price, Mrs. Elizabeth Trump Make America Great Again Committee September 15, 2016 $1,000 

Recipient of Joint Fundraiser Contributions 

These are the Final Recipients of Joint Fundraising Contributions. 

Contributor Name Committee Name Transaction Date Amount 

Price, Mrs. Elizabeth Trump, Donald J./Michael R. Pence via Donald J. 

Trump for President, Inc. 

September 15, 2016 $800 

Georgia Contributions 

Recipient Contributor’s Name PAC Affiliation/Occupation/ 

Employer Date Received Type Amount 

Georgia Republican Party, 

Inc. 

Hon. Thomas E. 

Price 

Physician Self-Employed April 25, 2006 Monetary 

General 

$4,863 

Georgia Republican Party, 

Inc. 

Hon. Thomas E. 

Price 

Physician Self-Employed April 25, 2008 Monetary 

General 

$4,956 

Georgia Republican Party, 

Inc. 

Hon. Thomas E. 

Price 

Physician Self-Employed April 27, 2010 Monetary 

General 

$5,220 

Georgia Republican Party, 

Inc. 

Hon. Thomas E. 

Price 

Physician Self-Employed January 5, 2010 Monetary 

General 

$5,220 

Karen Handel for Governor, 

Inc. 

Elizabeth Price Councilwoman, City of 

Roswell 

January 5, 2010 Monetary 

Primary 

$1,000 

Georgia Republican Party, 

Inc. 

Elizabeth Price Physician Compass 

Orthopedics 

March 21, 2013 Monetary 

General 

$250 

Keep Judge Tom Campbell; 

Thomas Ralph Campbell Jr. 

Elizabeth Price Physician Compass 

Orthopedics 

April 16, 2014 Monetary 

General 

$500 

Fulton County Republican 

Party, Inc. 

Elizabeth Price Homemaker 

N/A 

January 22, 2009 Monetary 

General 

$150 

Fulton County Republican 

Party, Inc. 

Elizabeth Price Homemaker 

N/A 

February 13, 2009 Monetary 

General 

$50 

Fulton County Republican 

Party, Inc. 

Elizabeth Price Homemaker 

N/A 

April 29, 2010 Monetary 

General 

$150 

Fulton County Republican 

Party, Inc. 

Elizabeth Price City Councilman, City of 

Roswell 

October 7, 2011 Monetary $10 

Fulton County Republican 

Party, Inc. 

Elizabeth Price City Councilman, City of 

Roswell 

October 7, 2011 Monetary $180 

148 

Georgia Contributions—Continued 

Recipient Contributor’s Name PAC Affiliation/Occupation/ 

Employer Date Received Type Amount 

Friends to Elect Todd Tyson, 

Inc., Todd Tyson 

Thomas E. Price, 

MD 

Congressman United 

States 

October 25, 2013 Monetary 

Special 

$1,000 

Georgia Medical Political 

Action Couunittee 

(GAMPAC) 

Thomas E. Price, 

MD 

Physician Self-Employed December 3, 2014 Monetary 

Primary 

$250 

APPENDIX C 

Awards Received by Dr. Thomas Price 

1988 In Appreciation—Chairman, Bylaws Committee—North Fulton Regional Hospital 1988 

In Appreciation—American Cancer Society 

1990 In Appreciation—Chairman, Department of Surgery—North Fulton Regional 

Hospital 

1993 President’s Award—‘‘Rx for Georgia’’—Medical Association of Georgia 

President’s Award—Medical Association of Atlanta—Chairman, Health Care 

Reform Committee 

1994 President’s Award—Medical Association of Atlanta—Chairman, Health Systems Reform Committee 

President’s Award—Medical Association of Atlanta—Chairman, Health Care 

Reform Committee 

1996 Partners in Education—Fulton County Schools 

In Appreciation—1st Vice President—Medical Association of Georgia 

1997 In Appreciation—Northside Alliance for Mentally Ill 

Recognition—Support of Georgia Rotary Student Program—Georgia Rotary 

Student Endowment 

Distinguished Service Award—Medical Association of Atlanta 

1998 Rotarian of the Year—Roswell Rotary Club 

Outstanding Rotarian—Past Service—Roswell Rotary Club 

Legislative Service Award—Association of County Commissioners of Georgia 

Certificate of Achievement—Georgia Emergency Management Agency 

1999 Outstanding work as a friend of medicine and demonstrating dedication to 

patients of Georgia—Medical Association of Georgia 

In Appreciation—Kiwanis Club of Historic Roswell 

Senator of the Year—Georgia Republican Party 

Legislative Leadership Award—Georgia Hospital Association 

In Appreciation—Honorable and Holy Calling to Public Service—Presbytery 

of Greater Atlanta 

2000 Will Watt Fellow—Rotary International 

In Appreciation—Member of Governing Council—Organized Medical Staff 

Section, American Medical Association 

In Appreciation—Medical Team—Roswell High School 

Legislative Leadership Award—Georgia Hospital Association 

2001 In Appreciation—Georgia Alcohol Policy Partnership 

In Appreciation—North Georgia Community Action, Inc. 

In Appreciation—Coalition for Hospital Choice 

In Appreciation—Friends of Scouting, North Fulton Team 

Family Practice Legislator of the Year—Leadership in Health Care—Georgia 

Academy of Family Physicians 

2002 Aven Citizenship Cup—Medical Association of Atlanta 

Nathan Davis Award—Outstanding State Senator—American Medical Association 

In Appreciation—Keep Roswell Beautiful 

2003 President’s Award—National Republican Legislators Association 

149 

Champion of 2003 Legislative Session—Perimeter Community Improvement 

Districts 

Cottage School—commencement speaker 

In Appreciation—Northside Baptist Church dedication 

2005 NWYC Constituent Communication Award 

Rotary Club of Roswell East 

Civil Air Patrol 

University of Phoenix Award 

Consulate General of Israel—Friend of Israel Award 

New South Energy Award 

Governor’s Office of Highway Safety 

National Health Museum Charter Membership Award 

College of American Pathologists Award 

Americans for Tax Reform—2005 Hero of the Taxpayer Award 

Spirit of Enterprise Award—U.S. Chamber of Commerce 

2006 U.S. Chamber—Spirit of Enterprise Award 

Tommy Nobis Center—Award Presentation 

Adopt a Road Award 

ATR Hero of the Taxpayer Award 

60 Plus Association of the Guardian of Senior’s Rights Award 

Association of Builders and Contractors—Champion of Merit Shop 

JWOD Congressional Champion Award 

Club for Growth Defender of Economic Freedom Award 

National Tax Limitation Committee Tax Fighter Award 

National Museum of Patriotism—Patriotism Award 

All Saints Catholic Church—Community Fellowship Award 

Cobb Chamber Award 

National Society of Sons of the American Revolution 

Armor Troops Foundation, Inc. Award 

National Hemophilia Foundation Award 

National Taxpayers Union—Taxpayers’ Friend 

International Foodservice Distributors Association—Thomas Jefferson Award 

2007 U.S. Chamber—Spirit of Enterprise Award 

Georgia Ensemble Theater—Legacy Award 

National Taxpayers Union—Taxpayers’ Friend 

NAPUS Georgia Chapter Award 

2008 North Fulton Chamber of Commerce Pioneer Award 

U.S. Chamber of Commerce Spirit of Enterprise Award 

U.S. English Award 

Medicare Choices Award 

A in English Award 

Americans for Tax Reform Award—Hero of the Taxpayer 

National Association of Mutual Insurance Companies—Benjamin Franklin 

Public Policy Award 

Club for Growth’s Defender of Economic Freedom Award 

American Legion—Certificate of Appreciation 

Oglethorpe Student Body and Phi Delta Epsilon’s Thank You Award 

GA Civilian Aide to Secretary of Army—Appreciation Award 

Coalition for Medicare Choices—The Medicare Choices Leadership Award 

IFDA—Thomas Jefferson Award 

National Taxpayers Union Taxpayers’ Friend 

2009 National Association of Manufacturers—Manufacturing Legislative Excellence 

National Orthopedic Leadership Conference—leadership on musculoskeletal 

diseases and conditions 

American Conservative Union Defenders of Liberty Award 

National Taxpayers Union—2008 Taxpayers’ Friend Award 

60 Plus Association—Ben Franklin Award to thank you for working against 

the death tax 

AAOS—Congressional Leadership Award 

Club for Growth Defender of Economic Freedom Award 

Weyrich Awards Reception—You are receiving an award 

U.S. Chamber—Spirit of Enterprise Award 

Fulton County Republican Party—Leadership and Service Award 

Cherokee County Volunteer Aging Council Award 

150 

FHL Bank—Key to Homeownership Award 

American Academy of Orthopedic Surgeons—Congressional Leadership 

Award 

Doctors for Patient Freedom—Ed Annis Award for Medical Leadership 

Logisticare Appreciation Award for Presentation to Logisticare Operations 

2010 National Taxpayers Union—Friend of the Taxpayer Award 

U.S. Chamber of Commerce Spirit of Enterprise Award 

AAOS Advocacy Communications Award 

National Association of Mutual Insurance Companies—Benjamin Franklin 

Public Policy Award 

American Conservative Union Defenders of Liberty Award 

U.S. English Award 

ProEnglish—American Unity Award 

GM Executive Retirees Club of GA 

GA GOP 6th District—Ronald Reagan Freedom Fighter Award 

American Academy of Orthopedic Surgeons Advocacy—Communications 

Award 

International Foodservice Distributors Association—Thomas Jefferson Award 

Club for Growth’s Defender of Economic Liberty Award 

2011 Institute for e-Health Policy—leadership award on HIT policy issues 

National Association of Manufacturers—Manufacturing Legislative Excellence 

National Taxpayers Union’s—Taxpayers’ Friend Award 

Emory Board of Trustees—GA Delegation Award 

60 Plus Association’s Guardian of Seniors’ Rights Award 

American Conservative Union Defender of Liberty Award 

Club for Growth’s Defender of Economic Liberty Award 

Health Care Leadership Council—Champion of Healthcare Innovation 

GA Association of Physicians of Indian Heritage Award 

2012 Cobb County Republican Women—Trumpet Award 

U.S. Chamber of Commerce Spirit of Enterprise Award 

Rotary International’s Polio Eradication Champion Award 

Healthcare Leadership Council—Champion of Healthcare Innovation 

Small Business Council of America’s 2012 Congressional Award 

IFDA—Thomas Jefferson Award 

RetireSafe—2012 Standing Up for America’s Seniors Award 

Freedomworks Award 

NFIB Guardian of Small Business Award 

Fulton County JRTOC’s Coin of Excellence Award 

National Society of Daughters of the American Revolution 

NASA-Space Shuttle Discovery GA flag 

American Congress of Obstetricians and Gynecologists—Public Service Award 

2013 National Association of Manufacturers—Award for Excellence 

American Conservative Union Foundation Award 

American Congress of Obstetricians and Gynecologists—Public Service Award 

U.S. Chamber of Commerce Spirit of Enterprise Award 

Dearborn High School Hall of Fame 

Senior Connections—Summer 2013 Champion of Senior Award 

America’s Essential Hospitals Essential Physician Leader Award 

National Taxpayers Union—2012 Taxpayers’ Friend Award 

Doctors for Patient Freedom—Ed Annis Award for Medical Leadership 

Southern Ortho Association’s Award 

American Urological Association—Presidential Lecturer Award 

2014 U.S. Chamber of Commerce Spirit of Enterprise Award 

America’s Essential Hospital Essential Physician Leader Award 

ACU Annual Award 

Association of Builders and Contractors—Champion of Merit Shop 

National Retail Federation—Hero of Main Street Award 

International Foodservice Distributors Association—Thomas Jefferson Award 

Virginians for Quality Healthcare—Healthcare Freedom Guardian Award 

National Association of Manufacturers—Award for Excellence 

National Taxpayer Union—National Taxpayers Union’s Taxpayers’ Friend 

Award for 2013 

Association of Mature American Citizens—Friend of AMAC Award 

National Active and Retired Federal Employees Award 

151 

Rx Drug Abuse Summit 

American College of Cardiology—President’s Award for Distinguished Public 

Service Award 

ACC President’s Award for Distinguished Public Service 

International Foodservice Distributors Association—Thomas Jefferson Award 

2015 FRC Action True Blue Award 

National Association of Manufacturers—Award for Excellence 

American Society of Transplantation—Organ Transplantation and Donation 

Legislative Leaders of the Year Award 

American Academy of Ophthalmology—Academy’s Visionary Award 

American Conservative Union—Award for Conservative Excellence 

60 Plus Association—Member Tax Reform Award 

U.S. Chamber of Commerce Spirit of Enterprise Award 

Alliance for Patient Access and National Association of Nutrition and Aging 

Services Programs—2015 Medicare Part D Patient Access Champion 

Award 

ACU Annual Award 

Rotary Club of Dunwoody—Certificate of Appreciation 

GA Ortho Society—James Funk Distinguished Service Award 

GA Association of College Republicans—Order of Reagan 

FRC Action True Blue Award 

2016 AMRPA Chairman’s Award 

ACU—Award for Congressional Excellence 

American Medical Rehab Providers Association—Chairmen’s Award 

American Transaction Processor Coalition—Legislative Champion Award 

ATPC Friend of Industry Award 

U.S. Chamber of Commerce Spirit of Enterprise Award 

Healthcare Leadership Council—Champion of Healthcare Innovation IFDA— 

Thomas Jefferson Award 

Campaign to Fix the Debt—Fiscal Hero Award 

National Retail Federation—Heroes of Main Street Award 

GA Life Alliance—Advocate for Life Award 

HME—Congressional Leadership Award 

World Harvest Church Award 

Campaign to Fix the Debt Fiscal Hero Award 

National Retail Federation—Heroes of Main Street Award 

No Year Coalition for Medicare Choices—Leadership Award 

SIRPAC 

Alliance for Patient Access Medicare Part D—Patient Access Champion 

Award 

Veterans Issues—William Cobb VFW of Roswell Award 

Republic of Korea 

Naval Academy—Certificate of Appreciation 

American’s Essential Hospital—Essential Physician Leader 

NFIB Guardian of Small Business (111th Congress) 

NFIB Guardian of Small Business (113th Congress) 

NFIB Guardian of Small Business (114th Congress) 

Associated Builders and Contractors Champion of the Merit Shop (111th Congress) 

Theodore Roosevelt American Unity Award (111th Congress) 

Associated Builders and Contractors Champion of the Merit Shop (110th Congress) 

NFIB Guardian of Small Business (112th Congress) 

Associated Builders and Contractors Champion of the Merit Shop (112th Congress) 

APPENDIX D 

Op-Eds Authored by Dr. Tom Price—May 2011 to the Present 

The listing of pertinent Op-Eds begins on the table below and contains 

website addresses for direct access to the specified publications. In instances 

where a particular Op-Ed is not available via an internet source, a copy of 

the actual publication is attached for the committee’s reference. 

152 

Date Publication Title Link 

May 13, 2011 Health Reform 

Report 

Empowering America’s 

Seniors 

http://tomprice.house.gov/op-ed/empowering-americas-seniors 

May 14, 2011 The Daily Caller Debt Limit and 

Spending Reforms 

are Inextricably 

Linked 

http://tomprice.house.gov/op-ed/debtlimit-nnd-spending-reforms-are-inextricably-linked 

June 28, 2011 TownHall.com Cutting What Washington Has Yet to 

Spend and Cannot 

Afford 

http://tomprice.house.gov/op-ed/cutting-what-washington-has-yet-spendand-cannot-afford 

October 10, 2011 Human Events Empowering Patients 

First Act: The Solution to Obamacare 

http://tomprice.house.gov/op-ed/empowering-patients-first-act-solutionobamacare 

November 15, 2011 Cobb Medical 

Society 

H.R. 3000—Empowering Patients Not 

Government 

Attached 

November 16, 2011 Big Government Patient Centered 

Healthcare is Possible 

http://tomprice.house.gov/op-ed/patient-centered-healthcare-possible 

November 26, 2011 The Washington 

Times 

PRICE: Preserving the 

promise to patients 

http://tomprice.house.gov/op-ed/pricepreserving-promise-patients 

December 1, 2011 Reporter Newspapers Republicans, Democrats see different 

fixes to fiscal 

stalemate 

http://tomprice.house.gov/op-ed/republicans-democrats-see-different-fixesfiscal-stalemate 

December 12, 2011 Chicago Tribune Getting America out of 

deep debt 

http://tomprice.house.gov/op-ed/getting-america-out-deep-debt 

December 16, 2011 The Oregonian/ 

McClatchy 

Medicare pro: Reasonable reforms can 

provide fair fees for 

physicians and ensure patients receive quality treatment 

http://www.oregonlive.com/opinion/in 

dex.ssf/2011/12/medicare_pro_rea 

sonable_reform.html 

February 15, 2012 The Hill President obviously 

doesn’t grasp the 

seriousness of fiscal situation 

http://tomprice.house.gov/op-ed/president-obviously-doesn%E2%80%99tgrasp-seriousness-fiscal-situation 

May 31, 2012 The Daily Caller Obamacare Medical 

Device Tax: Hazardous to America’s 

Health 

http://tomprice.housc.gov/op-ed/ 

obamacare-medical-device-tax-hazardous-america%E2%80%99s-health 

June 5, 2012 The Hill IPAB is not the way to 

lower Medicare 

costs 

http://tomprice.house.gov/op-ed/ipabnot-way-lower-medicare-costs 

July 1, 2012 Marietta Daily 

Journal 

Try Principled Solutions to Health 

Care Fix 

http://tomprice.house.gov/op-ed/tryprincipled-solutions-health-care-fix 

July 26, 2012 USA Today Plenty of Alternatives 

to Government 

Health Care 

http://tomprice.house.gov/op-ed/plenty-alternatives-government-healthcare 

153 

Date Publication Title Link 

Fall 2012 Jewish Policy 

Center 

A Principled Health 

Care 

https://www.jewishpolicycenter.org/ 

2012/08/31/health-care-empowerpatients/ 

July 30, 2012 The Washington 

Times 

Regulations Are Choking Small Business 

Engine of Growth 

http://tomprice.house.gov/op-ed/regulations-are-choking-small-business-engine-growth 

December 6, 2012 AJC House Republicans 

Stand by Taxpayers 

http://tomprice.house.gov/op-ed/houserepublicans-stand-taxpayers 

February 6, 2013 Red State Require A Plan http://tomprice.house.gov/op-ed/require-plan 

March 12, 2013 FoxNews.com Introducing a responsible, reasonable 

plan to balance the 

federal budget 

http://tomprice.house.gov/op-ed/introducing-responsible-reasonable-planbalance-federal-budget 

April 19, 2013 The Hill President’s budget ignores the will of 

the people 

http://origin-nyi.thehill.com/blogs/ 

congress-blog/economy-a-budget/ 

295025-presidents-budget-ignores-thewill-of-the-people 

May 20, 2013 Real Clear 

Politics 

The Unserious Senate 

Budget 

http://tomprice.house.gov/op-ed/ 

unserious-senate-budget 

May 30, 2013 Washington 

Examiner 

President Obama is 

Responsible for His 

Administration 

http://tomprice.house.gov/op-ed/president-obama-responsible-his-administration 

May 31, 2013 AJC Stop the Obamacare 

train wreck 

http://tomprice.house.gov/op-ed/stopobamacare-train-wreck 

July 17, 2013 The Hill How to Replace 

Obamacare 

http://tomprice.house.gov/op-ed/howreplace-obamacare 

July 31, 2013 The Daily Caller We can’t trust the IRS 

to enforce 

Obamacare 

http://tomprice.house.gov/op-ed/wecan%E2%80%99t-trust-irs-enforceobamacare 

October 8, 2013 Marietta Daily 

Journal 

All Republicans want 

is fairness for all 

Americans, and 

that’s why we fight 

http://tomprice.house.gov/op-ed/all-republicans-want-fairness-all-americans-and-thats-why-we-fight 

December 5, 2013 National Review Empowering Patients 

First 

http://tomprice.house.gov/op-ed/empowering-patients-first 

February 10, 2014 ConservantiveUSA.org Let’s Begin Again— 

Patients First 

http://www.conservativeusa.org/updates/lets-begin-again-patients-firstrep-tom-price-md-ga-06-reptompricefeb-10-2014 

February 19, 2014 Red Alert Politics A Better Prescription 

for Millenials 

http://tomprice.house.gov/op-ed/betterprescription-millenials 

March 7, 2014 Maryland State 

Medical Journal 

There’s No Code for 

Quality Care 

Attached 

March 20, 2014 AMA SE New Challenges Mean 

New Opportunities 

Attached 

154 

Date Publication Title Link 

March 24, 2014 Medical Association of Georgia 

E-Newsletter 

Modernizing Medicare 

to Protect Seniors 

Attached 

August 11, 2014 Roll Call Save Medicare’s Home 

Health Benefit 

http://tomprice.house.gov/op-ed/savemedicares-home-health-benefit 

January 23, 2015 Real Clear 

Politics 

A Healthy Economy for 

All 

http://tomprice.house.gov/op-ed/ 

healthy-economy-all 

March 17, 2015 USA Today Balance the budget 

for a prosperous 

America 

http://tomprice.house.gov/op-ed/balance-budget-prosperous-america 

April 1, 2015 AMA SE Prepared to Act on 

Patient-Centered 

Reform 

Attached 

April 6, 2015 SC Times House budget plan 

would set U.S. on 

right fiscal path 

http://www.sctimes.com/story/opinion/2015/04/05/house-budget-planset-us-right-fiscal-path/25277905/ 

July 30, 2015 Independent 

Journal 

Review 

Medicare and Medicaid Turn 50 

Today. Let’s Keep 

Them Healthy 

http://tomprice.house.gov/op-ed/medicare-and-medicaid-turn-50-todaylet%E2%80%99s-keep-them-healthy 

February 2, 2016 Medical Association of Georgia 

E-Newsletter 

A Step in the Right 

Direction 

Attached 

March 10, 2016 Medical Association of Georgia 

E-Newsletter 

Keep the focus on the 

patient 

Attached 

April 5, 2016 AMA SE Focused on Solutions Attached 

April, 13, 2016 Real Clear Politics How and Why We 

Budget 

http://tomprice.house.gov/op-ed/howand-why-we-budget 

September 7, 2016 Roll Call Obamacare Agency 

Escapes Congressional Oversight 

http://tomprice.house.gov/op-ed/ 

obamacare-agency-escapes-congressional-oversight 

October 13, 2016 JAMA Forum Three Congressmen’s 

Views on ACA’s 

Flaws, Alternatives 

for Health System 

Reform 

http://tomprice.house.gov/op-ed/3- 

congressmen%E2%80%99s-viewsaca%E2%80%99s-flaws-alternativeshealth-system-reform 

October 17, 2016 FoxNews.com Reps. Burgess, Price, 

Roe: Our diagnosis 

as doctors— 

ObamaCare is 

about to collapse 

http://www.foxnews.com/opinion/ 

2016/10/17/reps-burgess-price-roeour-diagnosis-as-doctors-obamacareis-about-to-collapse.html 

November 1, 2016 TownHall.com Obamacare is failing. 

Let’s try a Better 

Way 

http://tomprice.house.gov/op-ed/ 

obamacare-failing-let%E2%80%99stry-better-way 

155 

A STEP IN THE RIGHT DIRECTION

By Congressman Tom Price, M.D. (GA–06) 

On December 28th of last year, President Obama signed into law the Patient Access 

and Medicare Protection Act (S. 2425)—legislation that included several health-care 

reforms that had bipartisan support in Congress. Included in that package of reforms was a provision addressing electronic health record (EHR) meaningful use requirements—specifically hardship exceptions for physicians who would be unable to 

comply with the Centers for Medicare and Medicaid Services’ (CMS) final Stage 2 

modification rule. At issue was the fact that CMS released its rule with less than 

the requisite 90 days left to comply in 2015. 

The hardship exceptions provisions in S. 2425 are based on a bill that I had introduced, the Meaningful Use Hardship Relief Act (H.R. 3940), almost 2 months prior. 

We acted because it was clear that many physicians would likely be unfairly penalized due to CMS’s failure to offer health-care providers adequate time to comply 

with new requirements pertaining to the electronic health records program. Under 

the new law, physicians are able to more easily obtain a hardship exception due to 

insufficient time in the 2015 reporting period. Additionally, CMS is now also able 

to batch process hardship exception applications for groups of physicians, rather 

than strictly on a more burdensome individual case-by-case basis. 

On January 22nd, CMS released guidance on the updated hardship exception application, and our office is continuing to closely monitor this issue as well as the meaningful use and electronic health records program. We would encourage you to apply 

for the hardship exemption. You can do so by going to CMS.gov. This is a small 

step but a step nonetheless toward protecting the critical doctor-patient relationship. Patients and physicians face many challenges in today’s health-care system. 

Anything that can be done to allow physicians to focus more of their time and energy on the practice of medicine ought to be done so that we can further improve 

the quality and responsiveness of care. 

THERE’S NO CODE FOR QUALITY CARE

By Congressman Tom Price, M.D. (GA–06) 

Physicians are used to dealing with complex systems—the human body being the 

most obvious example. They devote their years of education and their craft to finding answers to tough questions, solutions to difficult and—for patients and their 

families—very personal challenges. The eagerness of physicians, scientists, and 

other health-care providers to tackle the complex and at times unknown is driven 

by the knowledge that their time and commitment is in service to the health and 

well-being of others. Providing the best care for patients is the motivation. 

So it is with particular concern and consternation that today physicians are being 

inundated with a new set of complex problems to solve. The purveyor of these new 

challenges is, generally speaking, the regulatory state. It’s the folks who are not so 

much in charge of actually caring for patients but the ones who have taken it upon 

themselves to be in charge of telling physicians more and more how to care for patients. 

Their more widely known mandates and regulations center most recently on the implementation of electronic health records (EHRs) and meaningful use requirements. 

The sorts of items that can justifiably be applied to improving quality care if physicians have the flexibility, the time and the resources to comply in an orderly fashion. That’s a big ‘‘if.’’ 

But then you have the complexities being handed down from upon high that have 

at best a tangential relationship to serving the needs of patients. Perhaps none will 

be more frustrating and costly to the delivery of care than the new ICD–10 diagnosis coding system that American physicians, hospitals, and other health-care providers are being told to adopt. 

The ICD–10 system has already earned a reputation as a bridge a bit too far—a 

sign that the regulatory state has become far too prescriptive to the point of being 

comical. You’ve likely heard of some of the more humorous new diagnosis codes. 

ICD–10 applies specific codes to injuries related to burning water skis, injuries sustained through an accident with a military vehicle while riding an animal, or being 

struck by any number of different animals for example, an orca. 

156 

Could those examples and any of the others listed in the ICD–10 system occur? One 

supposes almost anything is possible. But the ‘‘more is better’’ mentality that sits 

behind the drafting and implementation of this system portends a very arduous and 

in many cases financially perilous environment for physicians and their practice. 

Resources that might be applied to new innovative technologies, expanded capacity 

to serve new patients, or even charitable payment scenarios will be diverted to pay 

for the adoption and implementation of ICD–10. Those most likely to be squeezed 

are the private practices—particularly those caring for patients in rural or underserved communities—that operate on narrow margins. That shifts the delivery of 

care to hospitals where the quality can be equal but the costs disproportionately 

higher. 

As an orthopaedic surgeon who practiced medicine for over 20 years in the Metro 

Atlanta area, I know firsthand about practicing medicine both in a private and hospital setting. There are benefits and drawbacks to both. But what makes our healthcare system most beneficial to patients is the flexibility and diversity of care. The 

regulators are on schedule to continue destroying that flexibility and diversity of 

care. 

We see it in the manner in which the Affordable Care Act (ACA) is defining quality 

care based on a Washington-centric point of view. And, we see it with the unwillingness on the part of the Centers for Medicare and Medicaid Services (CMS) to consider a delay in the implementation of ICD–10 coding requirements. CMS Director 

Marilyn Tavenner recently confirmed that Washington would consider no more 

delays and that it was ‘‘time to move on.’’ 

Thankfully, Congress has taken action—albeit in a limited capacity. Legislation recently signed into law included a 1-year delay of the ICD–10 deadline. It pushes 

back the date at which medical providers must adopt the new coding system from 

October 1st of this year to October 1, 2015. 

So where does that leave physicians trying to practice their profession and care for 

patients? According to a February 2014 report commissioned by the American Medical Association (AMA), a small medical practice will be on the hook for anywhere 

between $56,639 to over $226,000 in costs associated with the transition. For a medium size practice, AMA estimates pre- and post-implementation costs rising to as 

high as $824,735. And, the ‘‘typical large practice’’ can expect to pay anywhere in 

the range of $2 million to $8 million. 

Perhaps in Washington that’s not considered a lot of money. But in the real world 

where the cost of health-care delivery is already rising due to any number of other 

forces—including innovation and other regulations—adding hundreds of thousands 

to millions of dollars to the cost of care is incredibly troubling. 

It should come as no surprise that an overwhelming majority of physicians were not 

ready for this year’s October 1st deadline. A survey by the Medical Group Management Association found that slightly fewer than 10 percent of medical practices 

claim to have made significant progress on implementing the overhaul of the ICD 

system. In other words, if you were to put aside the argument about whether or not 

shifting to the new coding system was wise or necessary, folks still are not ready. 

In Congress, there’s a broader effort underway to avoid this coming train wreck altogether. H.R. 1701, the Cutting Costly Codes Act of 2013—of which I’m a cosponsor—would prohibit the Secretary of Health and Human Services from moving 

forward with the ICD–10 implementation. 

What happens if a year passes, no action is taken to prohibit the implementation, 

and further delays are not forthcoming? If Washington ignores the facts and the 

frustration shared by many in the medical community? The initial costs associated 

with adopting ICD–10 will likely seem like a drop in the bucket over the longer 

term as medical practices struggle to familiarize themselves with the new litany of 

codes. It is expected that the number of codes will grow from roughly 20,000 to over 

150,000. 

Any failures to properly apply the right diagnostic label may be met with rejection 

or withholding of payment for services already rendered. Furthermore, fines and 

other costly legal proceedings could be incurred by physicians and medical practices 

whose only crime may be that they had unwittingly failed to comply properly with 

this complex new system. 

Were the new ICD–10 diagnosis codes coming online in otherwise relatively calm 

waters in the Nation’s health-care system, the disruption could perhaps have been 

157 

contained. But that’s not the reality physician’s face today. With the implementation 

of the Affordable Care Act, America’s health-care system and those participating in 

it have been thrown one curve ball after another—told to get on board or get out 

of the way. 

Far too often that’s how a bureaucracy functions, and it is the strongest argument 

against endowing regulators with the type of prescriptive power they are now preparing to wield. For the sake of patient access to quality, affordable care, we must 

continue to search for solutions that will let physicians do what they are trained 

to do—care for those in need. To be successful, physicians must engage in the public 

debate. 

NEW CHALLENGES MEAN NEW OPPORTUNITIES

By Congressman Tom Price, M.D. (GA–06) 

There is no shortage of issues these days competing for our attention. We have turmoil and upheaval around the world. There are long-running disagreements and 

troubles here at home. And while it can all be a tad overwhelming, it’s important 

to find within these challenges the opportunity to affect positive change. Of note 

right now are five key areas that do deserve our focus—all of which, coincidentally, 

have emerged either from action or inaction on the part of your government. 

As a physician, I have watched with particular concern the troubled rollout or unraveling of the President’s health-care law. Frankly, what we have is the expected 

outcome of truly disastrous policymaking. The law is not working—at least not as 

advertised. It is not working for patients, families or physicians. And, its failures 

are not merely the result of incompetence on the part of the Obama administration. 

They are the product of a fundamental conflict between the law and those principles 

of health care we hold dear: affordability, accessibility, choices, innovation, quality, 

and responsiveness. 

Premiums are rising. Provider networks made available through the new exchange 

plans are smaller. Folks are losing the coverage they had and access to the doctors 

they trusted. Less access and less affordability mean choices are being taken away 

from Americans. The law taxes innovation—literally a tax on life-saving medical devices. All of this will contribute to diminished quality of care as the system becomes 

more responsive to the needs of bureaucrats and less so to the needs of patients, 

families and doctors. 

So what can be done? Anyone who has taken care of patients knows that the status 

quo that existed prior to the passage of Obamacare was not working either. So no 

one should pretend we can simply uproot the current law and that will solve everything. We need a set of reforms that serve patients and those who care for them. 

Patient-centered solutions—like those I’ve introduced in H.R. 2300, the Empowering 

Patients First Act—would expand access to more health care choices by making it 

financially feasible for folks to purchase the coverage they want. 

We’d solve the insurance challenges of portability and pre-existing conditions by allowing folks to own their coverage no matter who’s paying for it and to pool together 

and gain the purchasing power of millions. That way we can make sure no one is 

priced out of the insurance market due to a pre-existing injury or illness. 

To go after the rising costs of care in America, H.R. 2300 would enact medical malpractice reforms. Our plan would deter the practice of defensive medicine by giving 

physicians an affirmative defense in a court of law built on standards agreed upon 

and established by physicians—not Washington. 

Just as we need broader health-care reform, we also need to once and for all rid 

Medicare of its current payment formula. The sustainable growth rate (SGR) formula is not working for patients or doctors. The effort to repeal and replace it with 

one that does work has gone on too long. Thankfully, some encouraging steps have 

been taken in recent weeks. 

In the House of Representatives, we have passed a bill to repeal the SGR and modernize the payment system—giving physicians time to adjust to new rules that will 

hopefully provide the type of certainty and flexibility needed to increase the quality 

of care. The ball is now in the Senate’s court. Our hope is that they will work with 

us so that there is a credible plan to move forward. We need to get this specific 

issue resolved in a way that protects seniors and respects American taxpayers. 

158 

It is out of respect for American taxpayers that we must also keep our eye on the 

tremendous fiscal challenges we are facing as a Nation right now. As vice-chairman 

of the House Budget Committee, I’ve had the opportunity to work with many of my 

colleagues on different budget proposals over the years—plans that would balance 

the Federal Government’s books, save and strengthen critical programs like Medicare and Social Security, and enact pro-growth policies like fundamental tax reform 

to get this economy moving. A budget is a blueprint for the positive direction we 

can take our Nation if we have the courage to make real, tough decisions on behalf 

of this generation and the next. Right now the committee is working on the next 

budget for fiscal year 2015. With the President offering his plan that taxes more 

in order to spend more, there’s a real opportunity and obligation to provide that better, alternative vision. 

Another pro-growth area we ought to be focused on is America’s ongoing energy revolution. Whether one is talking about the growth in our ability to safely harvest 

more and more of America’s abundant natural resources or the growth in new energy technologies, there are exciting opportunities here that will truly benefit our 

Nation. A robust energy market means more direct and indirect jobs and economic 

freedom. Internationally, a lessening of dependence on foreign sources of energy and 

a growing of America’s impact on the global energy markets means we have greater 

influence in diplomatic and national security affairs. 

One doesn’t have to look farther than the recent events in Ukraine to see an opportunity to leverage an all of the above energy strategy. With Russia exercising power 

in that part of the world thanks to their prolific energy production and distribution 

we can directly undermine their coercive powers by expanding our production and 

sale of energy resources to allies in the region. 

Lastly, what contributes to the disgust many feel watching Russia invade and annex 

a piece of another country is that this action flies in the face of democratic values 

we hold sacred here in America. Those values were written into our Constitution 

and made explicit when our founders declared our rights came from God, not man. 

Chief among them is the First Amendment’s right to freedom of speech. 

Unfortunately, that fundamental freedom has been under assault from an overactive regulatory environment in Washington. We know that the IRS unfairly targeted 

and abused certain Americans whose only crime was attempting to speak up for 

their beliefs. Now, the IRS is attempting to codify that level of abuse through new 

regulations affecting groups—including veterans’ organizations and those engaged 

in civic education—that file as nonprofits under the tax code’s 501(c)(4) designation. 

Under that section of the code, activities by these nonprofits that are for the purposes of ‘‘social welfare’’ are tax exempt. The IRS wants to rewrite the rules after 

55 years to essentially force these nonprofits—many of which hold political views 

in conflict with the current administration—to re-classify under a different section 

of the code or become subject to taxation. Either way, the end result would be to 

silence voices and expose more Americans to further abuse and unfair treatment. 

All of these issues—whether foreign, domestic or both—impact our lives in some 

form or another. We should not shy away from these challenges because with them 

comes opportunity to improve our lives and that of our families, friends, and neighbors. If we can find a way to bridge differences, reinforce time-honored principles, 

and show leadership, I’m confident we will find positive solutions that build a 

stronger future for our Nation. 

MODERNIZING MEDICARE TO PROTECT SENIORS

By Congressman Tom Price, M.D. (GA–06) 

The Medicare program is a vital life-line for millions of American seniors. Unfortunately, the current program is not working as well as it should for either those in 

retirement or the physicians who care for them. In addition to the real financial 

challenges the program as a whole faces in the next few years—challenges that 

ought to be addressed with broader reforms to Medicare—we have an even more immediate concern as it relates to Medicare’s current payment formula. 

Efforts to address the broken sustainable growth rate formula (SGR) have been underway for years. In the meantime, Congress has acted to avoid the SGR’s looming 

large cuts in physician reimbursements by enacting a series of delays—some longer 

than others. This has been done to buy time for policymakers to coalesce around 

159 

a responsible solution that will repeal the SGR permanently and replace it with a 

system that makes sense. The cost of those delays has been substantial, but it has 

also been necessary in order to protect access to care for seniors. 

Thankfully, promising steps have been made in the last several months to forge a 

consensus on a real plan to modernize the Medicare payment system. Introduced in 

February, the SGR Repeal and Medicare Provider Payment Modernization Act of 

2014 (H.R. 4015) enjoys bipartisan, bicameral support. On March 14th the House 

of Representatives passed the bill and sent it to the Senate for its consideration. 

In order to ensure these solutions both protect seniors and respect taxpayers, the 

legislation endorsed by the House of Representatives included a delay in the Affordable Care Act’s individual mandate to offset the costs associated with a repeal of 

the SGR. The Obama administration has already implemented a de facto delay to 

this provision of the President’s health-care law through executive fiat. We thought 

it better to do so through the normal and constitutional lawmaking process. 

The latest projections show cuts to physician reimbursement rates in the range of 

24% if nothing is done. Temporary patches will continue to buy more time but in 

the aggregate over the years they also prove more costly than a full repeal and replace scenario. More importantly, the level of uncertainty and anxiety that will persist so long as this issue remains unresolved exacts its own costs on physicians and 

seniors that cannot be measured in dollars and cents. 

It is rare in Washington these days that you can find an issue that secures both 

bipartisan support and action. We should not miss this opportunity to enact a positive set of solutions that will modernize Medicare’s payment system. Our hope is 

that the Senate will come to the table with the House of Representatives so we can 

work together to protect seniors’ access to health care. 

PREPARED TO ACT ON PATIENT-CENTERED REFORM

By Congressman Tom Price, M.D. (GA–06) 

This summer the Supreme Court of the United States will render a verdict in the 

case of King v. Burwell, which could have a lasting impact on whether the Affordable Care Act or ‘‘Obamacare’’ remains the law of the land. The fundamentals of 

the case are fairly straightforward: should the Obama administration be allowed to 

offer subsidies to help Americans purchase health-care coverage through Obamacare 

exchanges established by the Federal Government? The text of the law states that 

subsidies are to be made available to those who have enrolled in an insurance plan 

through an exchange established by the State. Since the enactment of Obamacare, 

37 States have chosen not to establish their own exchanges or have partnered with 

the Federal Government in some fashion—meaning millions of Americans have 

gained health-care coverage with the help of subsidies through a Federal exchange. 

If the Court rules in favor of the actual text of the law, which does not explicitly 

provide financial assistance to those purchasing coverage through the Federal exchange, those millions of Americans who purchased that insurance coverage would 

lose access to subsidies and face even higher health-care costs. For its part, the 

Obama administration has claimed it has no strategy in place to handle the aftermath of such a ruling—despite being complicit in the creation of the law itself and 

its, quite possibly soon to be ruled illegal, interpretation. 

Conversely, in March, I introduced the Medical Freedom Act (H.R. 1234)—legislation to allow States the freedom to offer within their jurisdiction health plans, 

health savings accounts, and other arrangements that are currently restricted under 

Obamacare, and the Medicare Patient Empowerment Act (H.R. 1650)—allowing patients and physicians to voluntarily contract for a service outside of the dictates 

from CMS. This type of flexibility within States to regulate their markets and ensuring doctors may practice as they see most appropriate would be strong first steps 

toward mitigating the fallout from the King v. Burwell ruling. At the same time, 

committees of jurisdiction in the House of Representatives and the Senate have 

been hard at work putting together policy proposals of their own that would be 

needed to respond should the court rule that the Federal exchange subsidies are indeed illegal. No matter the makeup of our response, Congress is aiming to be prepared so that the American people are not made to suffer any more than they already have from Obamacare. 

160 

Even if the Court rules in favor of the Obama administration’s interpretation and 

keeps the subsidies flowing on the Federal exchanges, there still remains real, fundamental concerns with how this law has been implemented, the impact it is having 

on the quality and affordability of health care in America, on access to physicians 

and on innovation. 

Those of us who believe we ought to have a health-care system less geared toward 

Washington and more in the hands of patients, families and physicians have to continue to push our colleagues and Congress and take our case to the American people. We have to keep the conversation going, and make clear that there are positive, 

patient-centered solutions out there that are far better for the health of our Nation 

than what Obamacare has to offer. 

For several years now, I have introduced legislation each Congress called the Empowering Patients First Act—a set of solutions that would expand access to quality 

affordable health-care choices and put patients, families and doctors in charge of 

health-care decisions, not Washington, DC. We have offered patient-centered reforms like Individual Member Associations so folks can pool together for the purpose 

of purchasing affordable coverage; lawsuit abuse reform to end the practice of defense medicine that adds hundreds of billions of dollars to America’s health-care bill 

each year; health-care tax credits so folks have the financial wherewithal and incentive to purchase the sort of coverage that meets their individual needs. 

There are many other aspects of the Empowering Patients First Act that would enhance the quality, affordability and accessibility of care in our country. Indeed, 

there are a myriad of positive, promising ideas that my colleagues in Congress have 

put forward and each of those ideas should continue to be a part of an honest and 

open debate on a broader reform effort. 

Depending on its decision, the Supreme Court’s ruling later this year may initiate 

an unraveling of Obamacare or it may have no real impact. Either way, policymakers need to be prepared to respond. Physicians and other health-care practitioners across the country need to be ready as well to play a constructive role in 

ensuring that not only in the near term but in the long run, we protect and preserve 

the sanctity of the doctor-patient relationship. 

FOCUSED ON SOLUTIONS

By Congressman Tom Price, M.D. (GA–06) 

America’s Founding Fathers wisely chose to give Congress—the branch of government closest and most accountable to the people—the power to write laws, determine how many hard-earned tax dollars are necessary to administer those laws, and 

to ensure the executive branch is faithfully carrying out those laws. For our Nation’s 

experiment in self-government to work, those roles and responsibilities must be respected. 

At the Committee on the Budget in the U.S. House of Representatives—on which 

I am honored to serve as chairman—we have been hard at work doing just that. 

The House Budget Committee is tasked with putting together an annual budget. We 

provide lawmakers a blueprint for how Congress can assert the spending and oversight authorities given it under the Constitution and do so in a responsible, responsive manner. 

In March, the House Budget Committee introduced and approved our fiscal year 

2017 budget resolution which we call A Balanced Budget for a Stronger America. 

This proposal would balance the Federal budget within 10 years without raising 

anyone’s taxes. It keeps the Federal Government’s books in balance beyond the coming decade which puts us on a path to pay off the national debt. If the policies we 

advocate were enacted, we would achieve over $7 trillion in deficit reduction 

through a combination of savings and economic growth. Those savings come from 

common sense reforms we propose to make government more efficient, effective, and 

accountable. 

Some of the more critical reforms are in the area of health care. We put forward 

a plan to save and strengthen the Medicare program. We advocate for an improved 

system that enhances quality, gives seniors more choices, and ensures that traditional Medicare is always available to Americans when they reach retirement age. 

Under current law, if nothing is done, Medicare will go insolvent in 2030. This will 

result in a significant reduction in benefits for seniors’ health care. We believe this 

161 

would be irresponsible. Our plan would prevent this from happening with patientcentered reforms, and ensure this program, which millions have paid into, will be 

there for them when they need it. 

For the brave men and women of our armed forces, for our veterans, and for our 

military families, our budget encourages additional health-care reforms at both the 

Department of Veterans Affairs (VA) and the Department of Defense (DoD). Those 

who protect and defend our Nation must have access to the care they need when 

they need it. 

For those Americans who are struggling to afford health-care coverage, our budget 

rejects the broken status quo and calls for innovative solutions. We would give 

States the flexibility to design and implement their Medicaid programs to meet the 

unique needs of their communities. At the same time, we would get rid of the topdown, Washington-knows-best model that is currently in place in private-sector 

health care and implement patient-centered solutions to ensure every American has 

access to the health coverage they want, not the one Washington forces them to buy. 

What these solutions ultimately comprise is part of a conversation currently being 

held in Congress and, specifically, among those of us on the House Task Force on 

Health Care Reform. We are developing a package of reforms that would create a 

patient-centered health-care system where Americans have access to quality, affordable choices, the doctor-patient relationship is respected, and real insurance challenges like pre-existing conditions are solved through policies that protect and empower individuals, not government mandates. 

The task force is committed to building these solutions from the ground up. However, we do not come to this challenge empty handed. Numerous health care policy 

ideas—including H.R. 2300, the Empowering Patients First Act which I have introduced for the past several congresses—have been circulating for years, both before 

and after passage of the President’s health-care law. 

The Task Force on Health Care Reform is one pillar of a larger effort to advance 

a positive, proactive agenda. A perfect partner in that effort is the annual budget 

resolution which is why the House Budget Committee has been committed to bringing this positive proposal forward. We are focused on getting results and solving the 

numerous challenges facing our country—from the economy to national security— 

so we have a more secure and more prosperous Nation. 

EMPOWERING PATIENTS NOT GOVERNMENT

By Congressman Tom Price, M.D. (GA–06) 

While practicing orthopaedic surgery for over 20 years, my focus was, as it should 

be, on the patients and serving their needs to the best of my ability. Unfortunately, 

during the early 1990s under then-President Clinton’s attempt to overhaul America’s health-care system, it became clear that policy decisions were continuing to be 

made in Washington that would have a profound, and oftentimes, negative impact 

on the practice of medicine. Many of those decisions were being made by individuals, probably with good intentions, but who knew little to nothing about the practice of medicine—who had never cared for patients or understood what it took to 

do so. 

While President Clinton’s efforts were unsuccessful, last year President Obama 

signed into law a massive health reform law that is destructive and fails to protect 

and promote the principles of health care we cherish, including affordability, accessibility, quality, responsiveness, innovation, and choices. The challenge to improve 

our health-care system and make it accessible to more Americans still stands; i.e., 

the status quo is unacceptable, which makes it incumbent upon those of us who disagree with the overhaul enacted in the previous congress to propose positive solutions in line with health-care principles that protect the rights of patients and doctors. 

In order to ensure health-care choices in America, Congress must repeal the President’s health-care law first and foremost and then reform the system in a common 

sense manner. As one of a growing number of physicians in the House of Representatives, we understand that changes must be made. In order to move the debate forward, I recently introduced legislation to repeal and replace the President’s healthcare law. 

162 

The Empowering Patients First Act (H.R. 3000) encourages individuals to obtain 

health coverage and makes it financially feasible for individuals and families to do 

so. It addresses the issue of lawsuit abuse and defensive medicine, which was completely ignored in last year’s health-care law, and it keeps Washington out of the 

way of health-care decisions. At its core, it advances patient-centered solutions to 

the challenges we face. 

Many of us in the medical profession have seen firsthand the distortions and disruptions that defensive medicine and excessive bureaucracy have on the practice of 

medicine. Inserting misguided government controls and regulations will lead to the 

denial of care and the elimination of health-care choices and personal decisionmaking. Under current law, there is even an unaccountable, unelected board of 15 

bureaucrats—the Independent Payment Advisory Board (IPAB)—that will have the 

power to deny health care to America’s seniors. That is wrong and does not have 

to happen in order to make our health-care system stronger. It will only weaken 

the quality of medicine for seniors and all Americans. 

Since physicians know the best care for their patients, the Empowering Patients 

First Act establishes doctor-led quality measures. And we encourage healthier lifestyles by allowing employers more flexibility in offering discounts to their employees 

through wellness and prevention programs. 

The health-care system in America needs to be reformed and improved—there is no 

doubt about that—but this must be done without handing over greater authority to 

the Federal Government. As a physician and someone who spent years caring for 

patients, the damage that can be done to the health of our great Nation by government interference is clear and unacceptable. The current situation demands that we 

advance a plan not only to halt that interference, but also one to improve access 

to quality, affordable health care. That solution is H.R. 3000! 

KEEP THE FOCUS ON THE PATIENT

By Congressman Tom Price, M.D. (GA–06) 

A patient-centered health-care system is built upon six principles: accessibility, affordability, quality choices, responsiveness, and innovation. Today, there are many 

instances where those principles are being violated—more often than not through 

rules and regulations handed down from bureaucratic agencies in Washington, DC. 

For an example, we need only look at how physicians and hospitals have had to go 

about adopting electronic health records (EHR). 

As part of the economic stimulus package that became law in the early days of the 

Obama administration, there was a concerted effort to help spur adoption of EHR 

among physicians and hospitals. The law states ‘‘the Secretary [of Health and 

Human Services] shall seek to improve the use of electronic health records and 

health-care quality over time by requiring more stringent measures of meaningful 

use.’’ 

From this text was born a complex and burdensome set of requirements known as 

Meaningful Use (MU) Stage 1, 2, and 3. Although well-intentioned, the MU requirements have chiefly missed the mark by focusing more on data entry and less on patients and their doctors. 

Physicians face a number of impediments to meeting the MU requirements, many 

of which are outside of their control. These include the lack of usability and interoperability among EHR, significant data exchange fees, interference with face-toface patient care, time-consuming data entry, the degradation of clinical documentation, and in inflexible metrics. 

A total of 209,000 physicians will face penalties in 2016 for failing to meet EHR 

MU criteria. While 80 percent of physicians have adopted EHR in their practices, 

less than 10 percent of physicians have successfully participated in MU Stage 2 so 

far. If we want higher quality care, healthier patients, and a more efficient use of 

time and resources, then the MV program needs to be reevaluated so it moves in 

the direction of our health-care principles. 

This past October, the Centers for Medicare and Medicaid Services (CMS) released 

its modified Stage 2 rule of the MU program. CMS issued its directive with less 

than the requisite 90 days remaining in the 2015 program year. That meant it was 

virtually impossible for doctors to meet the requirement deadlines. 

163 

Anticipating this challenge, I introduced H.R. 3940—the Meaningful Use Hardship 

Relief Act—to provide physicians with much-needed relief by ensuring they would 

be granted a hardship exception to avoid penalties stemming from the delayed rulemaking. Working with colleagues in Congress, physicians and various stakeholders, 

we were able to get language based on the solutions that we introduced included 

in a larger package of reforms—S. 2425, the Patient Access and Medicare Protection 

Act—which was signed into law just prior to the new year. 

On January 22, CMS released a hardship application for physicians and hospitals 

to use when filing an exception to the MU penalty for the 2015 program year. In 

the past, providers and hospitals had separate application forms. Under the new 

law, the application is now streamlined and can be used by both. Providers may file 

as individuals or in groups—while before each individual provider would have had 

to submit a separate application to be considered by CMS on a case-by-case basis. 

This new streamlined process also allows CMS to process hardship applications 

more efficiently in batches. 

All physicians are encouraged to go to CMS.gov and apply for a hardship exception 

under the category ‘‘EHR Certification/Vendor Issue (CEHRT Issues),’’ which references ‘‘insufficient time’’ in accordance with CMS’s delayed rulemaking. Applications must be submitted to CMS by March 15. 

Sadly physicians know all too well that the work of defending the principles of patient-centered care never ends. While MU penalties affect physicians and hospitals 

nationwide, here in Georgia our laboratories and physician groups were facing a 

more unique threat at the beginning of this year. Under a blatantly prejudiced reimbursement policy related to new codes for drug testing. CMS was threatening a 33 

percent cut from the national payment rate for Georgia labs and doctors. Thanks 

to the Medical Association of Georgia and others, we were able to get this serious 

discrepancy repaired and ensure that Georgia health-care providers were treated 

fairly. 

With solutions to improve our health-care system that adhere to our principles, we 

can protect the doctor-patient relationship from undue influence and interference, 

and put patients, families, and doctors in charge. 

APPENDIX E 

Speeches and Remarks Made by Dr. Tom Price—2012 to the Present 

Date Name Topic Location 

2016 Speeches and Remarks by Dr. Tom Price 

January 13, 2016 REMARKS: Brookings Event What, If Anything Congress is Likely to Accomplish in This Election Year DC 

January 23, 2016 REMARKS: Georgia Medical Directors Association Winter Symposium Washington Update GA 

January 30, 2016 REMARKS: Conservative Policy Leadership 

Institute 

Healthcare Update, Emphasis on H.R. 2300 GA 

February 24, 2016 REMARKS: NAHU Meeting Health Care—ACA replacement DC 

March 1, 2016 REMARKS: AMRPA Leadership Forum Congressional Update and Gratitude for 

the AMRPA Chairman’s Award 

DC 

March 22, 2016 REMARKS: Pete Sessions Medical Professionals Fly-in General Healthcare Overview DC 

March 24, 2016 REMARKS: Emory College Republicans The State of the GOP and H.R. 2300 GA 

April 11, 2O16 REMARKS: Healthcare Symposium with 

Berry College 

Issues of Healthcare Economics and Policy 

in the U.S. 

GA 

April 13, 2016 REMARKS: Idea Forum on Healthcare Reform No topics listed DC 

April 14, 2016 REMARKS: Georgia Society of Ophthalmology Breakfast Washington Update DC 

164 

Date Name Topic Location 

April 19, 2016 REMARKS: NASS Event General/Broad Update on Healthcare as it 

Stands in the House and From his Perspective as Chairman of the Budget 

Committee 

DC 

May 4, 2016 REMARKS: Emory Science Advocacy Network Federal Funding for Biomedical Research, 

Particularly for the National Institutes of 

Health (NIH) and National Science Foundation (NSF) 

GA 

June 27, 2016 REMARKS: Roundtable Lunch Event with 

Market News International Connect 

Washington Update With a Focus on Budget Committee Activity and Dr. Price’s 

Work on Health Care 

NY 

July 13, 2016 REMARKS: Health on Wednesday Your Perspective as a Leader in the House 

on Finalizing Health Initiatives in the 

2nd Session of Congress; Standard 

Healthcare Speech 

DC 

July 21, 2016 REMARKS: Washington Post Panel on 

Healthcare 

Future of Health Care and Health Policy 

Issues the Next President Will Face 

OH 

August 7, 2016 REMARKS: GPLA; Perspectives on Physician 

Leadership Communication 

Perspectives on Physician Leadership Communication GA 

August 13, 2016 REMARKS: Concierge Medicine Conference The Current State of Healthcare and 

Emerging Entrepreneurial Forms of 

Healthcare Delivery in America 

GA 

August 25, 2016 REMARKS: MVP Vets Event With Elekta and 

AdvaMed 

Your Work in Washington and How It’s Essential to the Medical Technology Community (Medical Device Tax or Even the 

Breakthrough Pathways legislation, 

e.g.) 

GA 

August 25, 2016 REMARKS: AARP Financial Forum With Senator Isakson Social Security (Challenges to, the Future 

of, Possible Solutions) and any Other Financial Initiatives at the Federal Level 

You Would Like to Highlight 

GA 

September 10, 2016 REMARKS: AKSM Medical Director Meeting Washington/Healthcare Update GA 

September 13, 2016 REMARKS: PhRMA Board CMMI and 2017 Agenda DC 

September 20, 2016 REMARKS: AAMC Present Information About Mr. Trump’s 

Platform, Especially as it Related to 

Health Care 

DC 

September 28, 2016 REMARKS: U.S. Chamber’s E8 Committee Better Way Health Care Plan DC 

October 10, 2016 REMARKS: Emory School of Business’s 

Speaker Series: Medical Technology 

(Health IT and Medical Devices) 

Future of Health, Healthcare, and Congressional Roll GA 

October 17, 2016 REMARKS: Seniors for Trump Conference 

Call 

Senior’s Healthcare (Medical and Supplementary Coverage) Call 

October 20, 2016 REMARKS: Eastern Orthopedic Society Federal Healthcare and How it Affects 

Orthopaedic Surgeons 

LA 

November 1, 2016 REMARKS: Healthcare Event With Trump Healthcare PA 

November 2, 2016 REMARKS: Medtrade Conference AAHomecare Washington Update GA 

November 12, 2016 REMARKS: RIPON: PANEL 4 National Health Service vs. Obamacare DC 

November 21, 2016 REMARKS: Panel Discussion With U.S. 

Global Leadership Coalition 

Importance of U.S. Global Leadership and 

to Highlight the Positive Impacts America’s Development and Diplomatic Programs Have on Georgia 

GA 

2015 Speeches and Remarks by Dr.Tom Price 

January 12, 2015 REMARKS: Heritage Action Policy Summit Vision for the House Budget Committee + 

Upcoming Fiscal/Economic Deadlines 

(ex: SGR) 

DC 

165 

Date Name Topic Location 

January 30, 2015 REMARKS: American Society of General 

Surgeons Conference 

Affordable Care Act Update DC 

January 31, 2015 REMARKS: Conservative Policy Leadership 

Institute 

Empowering Patients First Act GA 

February 9, 2015 REMARKS: MASA Conference SGR, ICD–10 and How the Doctor’s Caucus 

Can Have More Influence in Congress as 

Far as Medical Issues 

DC 

February 12, 2015 REMARKS: ASCO Oncology Meeting SGR Reform and How it is Impacted by the 

Budget Process 

DC 

February 18, 2015 REMARKS: Panel Discussion With Senator 

Isakson: NFIB/GA Small Business Day 

Obamacare/Healthcare Reform GA 

February 24, 2015 REMARKS: AMA National Advocacy Conference Budget, Medicare, etc. DC 

February 28, 2015 REMARKS: CPAC What Have His Former Colleagues in Medicine Told Him About How Obamacare is 

Affecting Their Practices, and What Effect Might This Have on Federal Spending? 

MD 

March 2, 2015 REMARKS: American Academy of Neurology 

Reception 

General Update on Healthcare DC 

April 16, 2015 REMARKS: American Academy of Ophthalmology Medicare Payment Outlook DC 

April 27, 2015 REMARKS: GNFCC’s Healthcare Technology 

Roundtable 

Your Health Care Plan and Obamacare Repeal and Replacement GA 

April 27, 2015 REMARKS: Emergency Department Practice 

Management Association’s Solutions 

Summit 

Repeal of the SGR and Interested in What 

Will Happen Moving Forward 

FL 

April 28, 2015 REMARKS: Big Cities Health Coalition 

Breakfast Briefing With John Lewis 

Opening Remarks—Share Your Personal 

Story 

DC 

April 30, 2015 REMARKS: Laffar Associates 55th Washington Conference Discuss What Your View Is as to the Most 

Important Economic Legislative Agenda 

Items and Current Events 

DC 

May 1, 2015 REMARKS: American Association of 

Orthopaedic Surgeons 

What It’s Like to Be a Member of Congress 

and Former Surgeon; Budget Outlook; 

Healthcare Landscape—Post-SGR 

DC 

May 6, 2015 REMARKS: Lecture With the Princeton Tory A Balanced Budget for a Stronger America: 

Federal Spending, Obamacare, and 

Other Washington Updates 

NJ 

May 13, 2015 REMARKS: American Tax Reform Meeting H.R. 23OO DC 

May 19, 2015 REMARKS: National Association of Spine 

Specialists: (NASS) Capitol Hill Day 

2015 

Primary Focus: Dr. Price’s Patient Shared 

Billing Legislation—H.R. 1650, Medicare 

Patient Empowerment Act 

DC 

June 8, 2015 REMARKS: SE Breakfast at AMA Healthcare IL 

June 15, 2015 REMARKS: American Society of Actuaries H.R. 2300 GA 

June 23, 2015 REMARKS: Healthcare Leadership Council 

Luncheon 

Brief Overview of Work in the Ways and 

Means Committee 

DC 

July 20, 2015 REMARKS: Town Hall Meeting With AMA 

President Stack 

Meaningful Use—Town Hall Is Focused on 

Electronic Health Records and Looming 

Regulations 

GA 

August 1, 2015 REMARKS: Concierge Medicine Conference Current State of Healthcare and Emerging 

Entrepreneurial Forms of Healthcare Delivery in America 

GA 

August 9, 2015 REMARKS: GPLA Perspectives on Physician Leadership GA 

166 

Date Name Topic Location 

August 14, 2015 REMARKS: South Atlantic Region Architecture for Health Annual Conference Policy and the Impact on Healthcare Delivery GA 

August 17, 2015 REMARKS: UCB Politics and Pizza Luncheon Healthcare Related Topics—Vision for the 

U.S. Healthcare System—FDA Reform, 

etc. 

GA 

August 21, 2015 REMARKS: WellStar Board Meeting—Reception and Dinner Healthcare/Budget Update GA 

September 24, 2015 REMARKS: University of Michigan Young 

Americans for Freedom 

Your Specialty in Medicine and Perhaps 

Touch on Some Important Legislative 

Issues (Obamacare) 

MI 

September 28, 2015 REMARKS: Chairman’s Council Policy Conference Health Reform and Budget DC 

October 3, 2015 REMARKS: GOS No topics listed GA 

November 16, 2015 REMARKS: AMA Southeastern Delegation 

Breakfast 

Personal Experience in Medicine and Transition to Government GA 

December 3, 2015 REMARKS: First Quality Forum Health Policy and Related Budget Issues DC 

December 9, 2015 REMARKS: AEI Speech No topics listed DC 

2014 Speeches and Remarks by Dr. Tom Price 

January 15, 2014 REMARKS: Healthcare Policy Briefing MMP Bill Completive Bidding (They May 

Bring Up SGR, ACA, etc.) 

DC 

February 10, 2014 REMARKS: Heritage Action Panel H.R. 2300 DC 

February 22, 2014 REMARKS: Tea Party Patriots Healthcare 

Event 

Healthcare Update—H.R. 2300 GA 

February 27, 2014 REMARKS: Lone Star Leadership PAC 

Breakfast 

Healthcare Roundtable—E&C, W&M Perspective DC 

February 27, 2014 REMARKS: Galen Institute Health Solutions 

Conference 

Healthcare Reform Proposals DC 

February 28, 2014 REMARKS: AEI Symposium Healthcare Reform DC 

March 6, 2014 REMARKS: CPAC Panel The New Medical Realities We All Face: 

Rationing, Denial of Care, Doctor Shortages and a Loss of Religious Liberty 

Under Obamacare 

MD 

March 7, 2014 REMARKS: AEI Panel The Health of America’s Health Policy DC 

March 9, 2014 REMARKS: RJC—Atlanta Healthcare Update, Emphasis on H.R. 2300 GA 

March 12, 2014 REMARKS: The Commonwealth Fund’s 

Harkness Fellows 

Affordable Care Act, its Prospects for Expanding Coverage, Transforming the 

U.S. Health Care System and Containing 

Costs 

DC 

March 24, 2014 REMARKS: American Psychiatric Association 

Advocacy Leadership Conference (annual 

fly-in) 

Current Major Healthcare Issues in Congress DC 

March 27, 2014 REMARKS: American Association of Physicians of Indian Origin (AAPI) Healthcare: SGR, ACA, etc. DC 

March 27, 2014 REMARKS: NASS Washington Conference Importance of Physician Advocacy and Visiting Washington, DC, to SGR DC 

April 1, 2014 REMARKS: Obamacare: What to Watch in 

2014 

Health Care and the Economy Between 

Now and November 

DC 

April 3, 2014 REMARKS: Tax Council Your Thoughts on the Comprehensive Reform Process, SGR, Highways, and Other 

Items. 

DC 

April 9, 2014 REMARKS: Las Vegas Metropolitan Chamber of Commerce Conference Healthcare and the Impact on American 

Employers Both Large and Small 

DC 

April 10, 2014 REMARKS: PDMA Healthcare in 2014 and Beyond MD 

167 

Date Name Topic Location 

April 11, 2014 REMARKS: Heritage Conference If You Like This Session, You Can Keep 

it—Real Health Care Solutions As 

Obamacare Unravels 

DC 

April 14, 2014 REMARKS: Forsyth County Tea Party Tax 

Day Rally 

The Un-Affordable Care Act/Obamacare— 

‘‘0ne Giant Tax’’ 

GA 

April 23, 2014 REMARKS: National Rx Abuse Summit Drug-Related Legislation He Has Supported 

and any Stories He Could Tell About the 

Epidemic in Georgia 

GA 

April 23, 2014 REMARKS: St. Louis Orthopaedic Society 

Dinner 

The Future of Health Care Reform: A Physician’s Perspective on Policy Making MO 

April 26, 2014 REMARKS: Alabama Orthopaedic Society 

Meeting 

Navigating the ACA and the Battle for 

Patient-Centered Solutions 

AL 

May 8, 2014 REMARKS: Virginians for Quality Healthcare 

Forum 

Concern That is Percolating Among the Republican Base and the Media That the 

Leadership Actually Has no Intention to 

‘‘Repeal and Replace’’ 

VA 

May 12, 2014 REMARKS: St. Joe’s General Medical Staff 

Meeting 

Healthcare Update GA 

May 17, 2014 REMARKS: Atlanta International Trauma 

Symposium 

Healthcare Update from DC—Emphasis on 

Reform 

GA 

June 17, 2014 REMARKS: Government Health Information 

Technology Conference 

Crafting Health Innovation That Works for 

Patients and Doctors 

DC 

June 17, 2014 REMARKS: ASCA Dinner An Update on Healthcare DC 

August 12, 2014 REMARKS: Medical Forum: ‘‘Federal Issues 

Facing the Medical Community in NC’s 

3rd Congressional District’’ 

Healthcare Problems Confronting Doctors, 

Nurses, Administrators, and Patients 

NC 

August 13, 2014 REMARKS: Roundtable Lunch with Congressman Walter Jones and Special 

Guest Congressman Tom Price 

Federal Issues that Will Affect Eastern 

NC’s Medical Community 

NC 

August 17, 2014 REMARKS: Leadership Session—GPLA Perspectives on Physician Leadership GA 

September 30, 2014 REMARKS: Keynote Speaker, AHIP Medicare 

and Medicaid Conference 

Sustaining Medicare for Future Generations: Views From the Hill DC 

November 20, 2014 REMARKS: Speech/Panel With Benjamin 

Rush Institute, Georgetown Chapter 

General Discussion on How One Goes From 

Medicine to Congress 

DC 

2013 Speeches and Remarks by Dr. Tom Price 

January 10, 2013 REMARKS: Florida Healthcare Reception Update on What is Happening in DC on 

the Health Care Front Since Election 

Day—Federal Viewpoint 

FL 

February 27, 2013 REMARKS: Call With Coalition or State 

Medical and National Specialty Societies 

Reintroduction of the Medicare Patient Empowerment Act. (Dr. Price)—Medicare 

Patient Empowerment Act in the New 

Congress and Strategies to Get it 

Passed 

Call 

March 4, 2013 REMARKS: AWARD American Congress of 

Obstetricians and Gynecologists (ACOG) 

31st Annual Congressional Leadership 

Conference 

Physician Payments: Cuts, Bumps, and 

Bruises 

DC 

March 4, 2013 REMARKS: AAMC Government Relations 

Conference 

Current Climate on Capitol Hill as it Relates to Federal Health Care Spending 

(Particularly, Medicare, Medicaid, Public 

Health Service Programs Like the National Health Service Corps, and the 

NIH) 

DC 

168 

Date Name Topic Location 

March 6, 2013 REMARKS: Meeting With Commonwealth 

Fund’s Fellows 

U.S. Health Reform and the Sustainability 

of Medicare and Medicaid, the Challenge of Improving the Quality of Care 

and Access to the Latest Technologies 

and Medications While Containing Spiraling Health Care Costs 

DC 

March 17, 2013 REMARKS: American Urological Association Impact of the Affordable Care Act on Physicians VA 

April 7, 2013 REMARKS: Self-Insurance Institute of 

America, Inc. (SIIA) 

Perspectives on Implementation of the ACA 

and any Future Actions Being Taken by 

the House Affecting Healthcare Reform 

DC 

May 3, 2013 REMARKS: National Orthopaedic Leadership 

Conference (AAOS) 

Entitlement Reform: Long-Term Economic 

Projections and the Outlook for Medicare 

Reform 

DC 

May 6, 2013 REMARKS: RADPAC Specifics on Healthcare and Comments on 

Radiology Bill—H.R. 846—and H.R. 

3269 Last Congress That Had More 

Than 270 Co-Sponsers 

DC 

May 15, 2013 REMARKS: PPO Capital Caucus Impact of Obamacare and the Next Steps 

as We Look Ahead to 2014 

DC 

May 22, 2013 REMARKS: American Association for 

Homecare Washington Legislative Conference 

Problems With Medicare’s Competitive Bidding Program and Benefits of the Market Pricing Program (MPP) HME Provider 

Compliance and Audit Issues; Power 

Mobility Issues; and Efforts to Eliminate 

Medicare Fraud and Abuse 

DC 

June 15, 2013 REMARKS: Becker’s ASC Review Panel Orthopaedic, Spine, and Pain Management 

Practices and ASCs—6 Defining Issues 

IL 

June 17, 2013 REMARKS: AMA SE Delegation Breakfast Status of Obamacare IL 

June 24, 2013 REMARKS: National Association of Health 

Underwriters’ Annual Convention 

Obamacare and Your Plan on Reducing 

Costs, From the Provider Side of Business 

GA 

July 9, 2013 REMARKS: Alliance of Specialty Medicine Healthcare DC 

July 16, 2013 REMARKS: 2013 Health Care Payments and 

Policy Conference 

What Representative Price Thinks About 

Emerging Health Reform Issues in the 

113th Congress 

DC 

July 20, 2013 REMARKS: Southern Orthopaedic Association Obamacare Current Perspective 

August 10, 2013 REMARKS: GA Physicians Leadership Academy Perspectives on Physician Leadership GA 

August 17, 2013 REMARKS: American Society of General 

Surgeons 

How Will The Affordable Care Act Influence 

the Practice of Surgery in the Near Future? 

MD 

August 20, 2013 REMARKS: GNFCC’s Healthcare Panel ACA GA 

September 23, 2013 REMARKS: Elekta Learning and Innovation 

Center (LINC) Grand Opening/Ribbon 

Cutting 

Importance of Elekta to Georgia and the 

Health Care Industry 

GA 

October 9, 2013 SPECIAL GUEST: U.S. Oncology Network PAC 

Board 

Talk About SGR, Government Shutdown, 

and Thoughts of What Happens Over the 

Next Couple of Months; Anything Physician Related 

DC 

October 21, 2013 REMARKS: GA/Cobb Chamber Healthcare 

Summit 

Affordable Care Act—The Story, The Politics and Policy, and the Future GA 

October 24, 2013 REMARKS: CA Lincoln Club Fly-in Panel of GOP members Who Are Working 

on a GOP Plan/Alternative to Obamacare—Very Casual/Informal Discussion 

169 

Date Name Topic Location 

November 16, 2013 REMARKS: Keynote address Medical Student Section at the AMA–MSS Interim 

Assembly Meeting 

As the Largest Medical Student Organization in the Country the AMA–MSS is 

Dedicated to Representing Medical Students, Improving Medical Education, Developing Leadership, and Promoting Activism for the Health of America 

DC 

November 16, 2013 REMARKS: 4th Edward Annis Medical Freedom Awards Dinner/Give Award to Dr. 

Carson 

Current Republican Health Reform Proposals MD 

November 17, 2013 REMARKS: International Medical Graduates 

Section 

Physicians as Leaders and Legislators MD 

November 18, 2013 REMARKS: AMA SE Delegation Breakfast Developments on ACA and Some on SGR DC 

December 4, 2013 REMARKS: Ripon Society Breakfast The Health Care Debate: Reform vs. Reality DC 

December 11, 2013 REMARKS: ATR Wednesday Meeting to Roll 

Out H.R. 2300 Score 

H.R. 2300 DC 

2012 Speeches and Remarks by Dr. Tom Price 

January 23, 2012 REMARKS: 39th Annual March for Life March for Life DC 

February 21, 2012 REMARKS: Cushman and Wakefield 

Healthcare CFO Roundtable 

Healthcare Update GA 

February 23, 2012 REMARKS: Southeast Permanente Medical 

Group Board of Directors Meeting 

Healthcare Update, Including the Revolving 

Status of the ACA Legislation and What 

SPMG Can Do to Best Position Itself for 

the Future 

GA 

February 29, 2012 REMARKS: Luncheon for the American Association of Clinical Endocrinologists Physician Payment Reform and the Prospects of Passing H.R. 1700 Given the 

Inability of Congress Thus Far to Enact 

Permanent Medicare Physician Payment 

Reform 

DC 

March 5, 2012 REMARKS: American Urological Association Perspective on Where Medicine is Going, 

Implementation of the Health Reform 

Bill, etc. 

DC 

March 7, 2012 REMARKS: Academic Health Centers Fly-in Conference Committee Outcome; What Will 

the 2012 Election Mean for Teaching 

Hospitals, Payroll Tax Conference, and 

SGR? 

DC 

March 13, 2012 REMARKS: Colorado School of Medicine 

Benjamin Rush Society 

The Nexus of Medicine and Politics . . . 

Closer Than you Think! 

CO 

March 16, 2012 REMARKS: RPA Reception Future of Healthcare DC 

March 22, 2012 REMARKS: Townhall Meeting With Athena 

Health 

Athena’s Innovative Approach to Incentivizing Meaningful Health Information 

Exchange and a Recent OIG Opinion the 

Company Successfully Obtained That 

Has the Potential to at Last Unleash the 

Technological Innovation in the Health 

Care Sector That Has Eluded Policy 

Makers for Decades 

DC 

March 22, 2012 REMARKS: National Association of Chain 

Drug Stores 

Medication Adherence: How Important it Is 

for Patients to Take Their Medications, 

and Take Them Correctly; One of the 

Items in our MTM Bill That We Stress is 

That Patients in Transition of Care Need 

Extra Help to Make Sure They Take Their 

Meds, Take Them Properly, and Continue 

to Take Them Until the Physician Has 

Determined They Stop 

DC 

March 27, 2012 REMARKS: Hands Off My Healthcare Rally Hands Off My Healthcare DC 

170 

Date Name Topic Location 

April 12, 2012 REMARKS: Lunch With AMA Students Health Care Reform From the Perspective 

of a Physician in Congress 

DC 

April 12, 2012 REMARKS: Speaking at the Commons Seminar Healthcare in America: Where Have We 

Come From and Where Are We Going? 

DC 

April 13, 2012 REMARKS: Medical Association for State of 

Alabama Annual Meeting 

Physician Leadership: Critical for Preserving the Profession; Why Physicians 

Should be More Involved in the Political 

Process 

AL 

April 23, 2012 REMARKS: North Fulton Hospital (SemiAnnual Medical Staff Meeting) A Washington/Healthcare Update GA 

April 26, 2012 REMARKS: National Journal Keynote Interview Discussion on How Congress Can Act in 

the Interest of the American Public and 

the Policy Issues Americans Want Their 

Elected Officials to Focus on for the Remainder of the 112th Congress 

DC 

April 26, 2012 REMARKS: American Association of Orthopaedic Surgeons No Topic Listed DC 

April 30, 2012 REMARKS: To Hilldale Students A Principled Prescription for America’s 

Health: The Perspective of DoctorTurned-Lawmaker 

May 8, 2012 REMARKS: College of American Pathologists Breakfast Outlook in Congress for the Rest of the 

Year; What’s the GOP View on Health 

Care and Medicare Reform? What Happens Next in Health Care if ACA is Repealed or is Not Repealed? 

DC 

May 21, 2012 REMARKS: University of Missouri Medical 

School 

Health Care Financing in General and Financing of Graduate Medical Education MO 

May 22, 2012 REMARKS: Richmond County Medical Society Healthcare Update; Status of Healthcare 

Reform Legislation 

GA 

June 3, 2012 REMARKS: GA/SC Radiology Societies Joint 

Chapter Meeting 

Our Bill, H.R. 3269; How We Can Get it 

Into End of Year Package, etc.; SGR; 

Your Bill to Repeal and Replace ACA 

SC 

June 15, 2012 REMARKS: Faith and Freedom Coalition Panel: Obamacare: Repeal, Replace, and 

Reform 

DC 

June 18, 2012 REMARKS: AMA Southeastern Breakfast No topic listed IL 

June 22, 2012 REMARKS: Stand Up for Religious Liberty 

Rally 

Your/House Perspective on HSS Mandate; 

Role the Federal Government is Playing 

to Infringe on the Rights of Religious 

Organizations; Any Updates From the 

House on These Issues 

GA 

June 26, 2012 REMARKS: American Orthopaedic Association Personal Story of How You Got Involved in 

Politics 

MD 

July 10, 2012 REMARKS: American Action Network and 

Crossroads GPS Healthcare Panel 

Repealing and Replacing Obamacare DC 

July 10, 2012 REMARKS: American Association of Neurological Surgeons Fly-in Price/Boustany Medicare Physician Payment Bill and Private Contracting DC 

July 20, 2012 REMARKS: Smart Girl Politics Healthcare, Next Steps VA 

July 27, 2012 REMARKS: Lincoln Day Dinner with Ross Obamacare FL 

July 31, 2012 REMARKS: B26 Romney Breakfast Healthcare NC 

August 3, 2012 REMARKS: ASCRS/ASOA Retreat (via teleconference) Medicare Physician Payment Reform, the 

SGR, IPAB Repeal 

Call 

August 7, 2012 REMARKS: GAMES Legislative Breakfast Healthcare: Home Health Care: Medicare 

Competitive Bidding and the Current 

Audit Environment 

GA 

171 

Date Name Topic Location 

August 7, 2012 REMARKS: Brunswick Medical Community 

Event 

Healthcare/Washington Update GA 

August 12, 2012 REMARKS: Georgia Physicians Leadership 

Academy 

Perspective on Physician Leadership GA 

August 24, 2012 REMARKS: Strathspey Crown: A New Model 

for Healthcare 

The Opportunity for Reforms to the ACA CA 

August 25, 2012 REMARKS: Government Affairs Panel: Creating a New Era in Healthcare No topic listed CA 

August 28, 2012 REMARKS: Bipartisan Conversation on 

Healthcare 

Healthcare Panel FL 

August 29, 2012 REMARKS: The Hill Healthcare Panel No topic listed FL 

September 9, 2012 REMARKS: Docs 4 Patient Care U.S. Congressional Solutions for Obamacare VA 

September 10, 2012 REMARKS: American Academy of Dermatology The Outlook for Health Care Legislation 

and Legislation Impacting Physicians 

Broadly and, More Specifically, Dermatologists 

DC 

September 13, 2012 REMARKS: American Congress of Obstetricians and Gynecologists Government Relations Committee 

Providing an Assessment of the PostSCOTUS Health Reform Landscape Call 

September 13, 2012 REMARKS: SC–04 Chambers of Commerce 

National Issues Fly-in 

Healthcare, General Ideas and Thoughts 

About PPACA, the Supreme Court Ruling 

on PPACA, and Healthcare Issues in 

General as it Relates to the Business 

Community 

DC 

November 10, 2012 REMARKS: Mount Vernon Towers Retirement 

Facility 

Obamacare’s Impact on Seniors GA 

November 11, 2012 REMARKS: Emory Johns Creek Hospital Healthcare Update; H.R. 3000 GA 

November 16, 2012 REMARKS: Medtrade Expo (Power for Funding Welcome Reception) H.R. 6490—Why That Would be Better 

Than the Current Competitive Bidding 

Methodology 

GA 

November 22, 2012 REMARKS: SCI Solutions Healthcare Meeting Healthcare Update/Legislative Trends in 

Healthcare Policy 

GA 

November 24, 2012 REMARKS: National Association of Spine 

Specialists 

Health Policy Issues Facing Congress TX 

QUESTIONS SUBMITTED FOR THE RECORD TO HON. THOMAS PRICE, M.D. 

QUESTIONS SUBMITTED BY HON. RON WYDEN

BROKERAGE ACCOUNT DOCUMENTATION

Question. In the hearing, you were asked to reaffirm that trades in your brokerage accounts were controlled by your stock broker and not by yourself. 

Please provide the management and brokerage agreements for all accounts that 

hold individual health-care stocks including but not limited to the Morgan Stanley 

account labeled Morgan Stanley #1 in your 2015 House of Representatives Financial 

Disclosure and the Morgan Stanley account labeled Morgan Stanley #2 in your 2015 

House of Representatives Financial Disclosure. 

Answer. I previously provided the Senate Finance Committee (‘‘SFC’’) with substantial information regarding the nature of the brokerage accounts described in 

this inquiry and have no further information to provide at this time. Additional information regarding Morgan Stanley’s management and brokerage policies is also 

readily available in the public domain. 

172 

MANAGEMENT OF SHARES IN INNATE IMMUNOTHERAPEUTICS

Question. As discussed in the disclosure memo, which was made part of the record 

of the hearing, you purchased shares in Innate Immunotherapeutics in private 

placements in 2016. 

In what account and in what form were those shares held at the time you filed 

your financial disclosures, as a nominee, with Federal ethics officials and your response to the committee’s questionnaire? In what account and in what form are 

those shares currently held? If shares were transferred between accounts, when 

were they transferred and at whose direction? 

Answer. I previously provided the SFC with substantial information regarding the 

issues raised in this question. As the committee is fully aware, the shares of Innate 

Immunotherapeutics (‘‘Innate’’) purchased in 2016 through private placement were 

held with the company in electronic certificate format up until recently. In the process of gathering information to respond to committee questions (posed on January 

17, 2017) in the wake of due diligence meetings with committee staff, I learned that 

these electronic certificate holdings have now been transferred to his Wells Fargo 

Joint Brokerage Account #1. The desire to transfer this holding from electronic certificate form to a brokerage account was discussed during the due diligence meeting 

with SFC staff. Both the SFC and OGE were appropriately notified of the transfer 

upon its completion. 

BROKERAGE TRADES

Question. In testimony to the Senate HELP Committee, you stated that you directed your broker to purchase shares in Innate Immunotherapeutics. 

During your time in Congress, have you ever directed your broker to make any 

other transactions in stock of specific companies? If so, please identify the companies, the date, and volume of the transaction. 

Answer. To the best of my knowledge, I have not undertaken such actions. 

Throughout my time as a member of the U.S. House of Representatives, I have abided by and adhered to all ethics and conflict of interest rules applicable to me. 

TRANS-PACIFIC PARTNERSHIP NEGOTIATIONS

Question. Did you or your staff consult with the House Ethics Committee at any 

time concerning the possibility or appearance of a conflict of interest or other ethics 

concern arising from your ownership of shares in Innate Immunotherapeutics and 

your role as a member of the House Ways and Means Committee concerning negotiations related to the Trans-Pacific Partnership, or the receipt of any information 

that you received in that capacity or as a member of the House concerning such negotiations? 

Answer. To the best of my knowledge, neither I nor my staff has had such consultations. Throughout my time as a member of the U.S. House of Representatives, 

I have abided by and adhered to all ethics and conflict of interest rules applicable 

to me. 

INNATE IMMUNOTHERAPEUTICS PURCHASES

Question. The nominee owns 461,238 shares of Innate Immunotherapeutics Ltd. 

(‘‘Innate’’), a small Australian biopharmaceutical firm developing a multiple sclerosis therapy. The nominee acquired the stock in four separate purchases on January 8, 9 and 23 of 2015 (‘‘2015 tranche’’), and in a pair of private stock placements 

on August 31, 2016 (‘‘2016 tranche’’). Regarding Innate: 

Please describe how and when the nominee first learned about Innate. 

Answer. I previously answered this question for the SFC. I learned about Innate 

during the course of a conversation in the fall of 2014 with Representative Chris 

Collins regarding their respective personal backgrounds. I cannot recall the specific 

date of that conversation. During that exchange, Representative Collins told me that 

he sat on a number of public company boards including Innate, which was developing a treatment for multiple sclerosis (MS). 

Question. Did the nominee or his staff ever meet or otherwise communicate with 

current or former employees, directors, consultants, or other officials affiliated with 

Innate? If so, please describe the communication, including who it involved, the 

date, subject, place and form (e.g., in person, by phone) of communication. 

173 

Answer. I previously answered this question for the SFC. 

I communicated with Representative Collins, who is a director of Innate. As noted 

above, I learned about Innate through a general conversation with him in the fall 

of 2014. I also communicated with Simon Wilkinson of Innate regarding my interest 

in participating in the 2016 private placement of company stock. According to 

Innate’s website, Mr. Wilkinson is currently the Managing Director and CEO of Innate. 

My congressional staff has not met or otherwise communicated with current or 

former employees, directors, consultants or other officials affiliated with Innate. 

Question. Please describe any communication between the nominee and Congressman Collins regarding Innate Immunotherapy, including the date, subject, place 

and form. 

Answer. I previously answered this question for the SFC. 

I had a conversation with Representative Collins in the fall of 2014 that brought 

Innate, as a company, to my attention. The nature of that conversation did not, 

however, influence my decision to invest in the company in either 2015 or 2016. 

I believe I had subsequent general communications with Representative Collins 

regarding Innate. I do not have a specific recollection of when those conversations 

occurred or their substance. Any such communications did not impact my investment decisions, however, because my purchases of Innate stock were based solely 

on my own research. 

Question. The nominee bought 400,316 shares in the 2016 tranche in a private 

stock sale that included two placements at two prices. Please provide the number 

of shares bought in each placement, and the price at which the shares were bought. 

Answer. I previously answered this question for the SFC. I purchased 250,000 

shares of Innate in Private Placement 1 at US$0.18/share—the same price offered 

all participants in this private placement. I purchased 150,613 shares of Innate in 

Private Placement 2 at US$0.26/share—the same price offered all participants in 

this private placement. 

ZIMMER BIOMET STOCK HOLDING

Question. Did you or your staff meet with Zimmer Biomet employees or representatives, including but not limited to lobbyists, executives, or board members, between 

July 14, 2015 and April 1, 2016? If so, please describe the communication, including 

who it involved, the date, subject, place and form (e.g., in person, by phone) of communication. 

Answer. To the best of my knowledge, neither I nor any members of my staff met 

with or attended an event with a lobbyist or representative from Zimmer Biomet 

during the specified dates. 

HOUSE ETHICS COMMITTEE CONSULTATION

Question. House rule 3, clause 1, provides that members of the House ‘‘shall vote 

on each question put, unless having a direct personal or pecuniary interest in the 

event of such question.’’ However, the House Ethics Manual (House Ethics Manual, 

U.S. House of Representatives Committee on Standards of Official Conduct, 110th 

Cong, 2d Sess. (2008), pp. 233–37) makes a sharp distinction between, on one hand, 

voting on the House floor, and, on the other, more active advocacy. The House Ethics Manual states: 

The provisions of House Rule 3, clause 1, as discussed in this section apply 

only to members voting on the House floor. They do not apply to other actions that members may normally take on particular matters in connection 

with their official duties, such as sponsoring legislation, advocating or participating in an action by a House committee, or contacting an executive 

branch agency. Such actions entail a degree of advocacy above and beyond 

that involved in voting, and thus a member’s decision on whether to take 

any such action on a matter that may affect his or her personal financial 

interests requires added circumspection. Moreover, such actions may implicate the rules and standards, discussed above, that prohibit the use of one’s 

official position for personal gain. Whenever a member is considering taking 

any such action on a matter that may affect his or her personal financial 

interests, the member should first contact the [Ethics] Committee for guidance. 

174 

Before, or any time after, you introduced H.R. 4848, the Healthy Inpatient Procedures Act of 2016 (HIP Act) in the 114th Congress, did you consult with the House 

Ethics Committee concerning the possibility of, or appearance of, a conflict of interest or other ethics concern arising from your ownership of shares in ZimmerBiomet? 

If so, when? 

Answer. My investment accounts, particularly the Morgan Stanley Portfolio Management Program account wherein the noted stock transaction occurred, were established so as to place trading discretion in the hands of my broker/financial advisor. 

No conflict of interest existed and no consultation was necessary. Throughout my 

time as a member of the U.S. House of Representatives, I have abided by and adhered to all ethics and conflict of interest rules applicable to me. 

Question. Before, or at any time after, you introduced H.R. 4185, the Protecting 

Access through Competitive-pricing Transition Act of 2015 (the PACT Act) in the 

114th Congress, did you consult with the House Ethics Committee concerning the 

possibility of, or appearance of, a conflict of interest or other ethics concern arising 

from your ownership of shares in health-care stocks? If so, when? 

Answer. My investment accounts, particularly the Morgan Stanley Portfolio Management Program account wherein the noted stock transactions occurred, were established so as to place trading discretion in the hands of my broker/financial advisor. No conflict of interest existed and no consultation was necessary. Throughout 

my time as a member of the U.S. House of Representatives, I have abided by and 

adhered to all ethics and conflict of interest rules applicable to me. 

Question. Before, or at any time after, you introduced H.R. 5400, an Act to amend 

the Internal Revenue Code of 1986 to make permanent the deduction for income attributable to domestic production activities in Puerto Rico in the 114th Congress, 

did you consult with the House Ethics Committee concerning the possibility of, or 

appearance of, a conflict of interest or other ethics concern arising from your ownership of shares in Eli Lilly, Bristol Myers Squibb, and Amgen? If so when? 

Answer. My investment accounts, particularly the Morgan Stanley Portfolio Management Program account wherein the noted stock transactions occurred, were established so as to place trading discretion in the hands of my broker/financial advisor. No conflict of interest existed and no consultation was necessary. Throughout 

my time as a member of the U.S. House of Representatives, I have abided by and 

adhered to all ethics and conflict of interest rules applicable to me. 

Question. Before, or at any time after, you introduced H.R. 5210, the Patient Access to Durable Medical Equipment (PADME) Act of 2016 in the 114th Congress, 

did you consult with the House Ethics Committee concerning the possibility of, or 

appearance of, a conflict of interest or other ethics concern arising from your ownership of shares in Blackstone, Inc. or any other company that markets or manufacturers durable medical equipment? If so, when? 

Answer. My investment accounts were established so as to place trading discretion in the hands of my broker/financial advisor. No conflict of interest existed and 

no consultation was necessary. Throughout my time as a member of the U.S. House 

of Representatives, I have abided by and adhered to all ethics and conflict of interest rules applicable to me. 

RESURGENS ORTHOPAEDICS

Question. Do you have any financial or business relationship including an equity 

or ownership stake in Resurgens Orthopaedics, and/or do you derive any financial 

interest or benefit from the company? If so, please detail the type of financial or 

business relationship you have, and any income you do or may derive related to 

Resurgens. In addition, if you answered ‘‘yes,’’ please describe your plan to divest 

your financial interest in the company. 

Answer. I have no current financial stake or interest in Resurgens Orthopaedics. 

LGBTQ HEALTH CARE

Question. LGBTQ individuals often experience exceptional barriers to care; health 

disparities associated with gender identity are partially driven by lower rates of insurance. Under the ACA, the LGBTQ population cannot be excluded from health 

plans due to pre-existing conditions such as HIV. Discrimination based on sex and 

gender identity is also prohibited for programs receiving Federal funds. Additionally, all insurance plans must offer the same coverage to married same-sex couples 

as is offered to opposite-sex couples. In terms of national health surveys, the ACA 

175 

changed data collection requirements to include sexual orientation and gender identity, which supports future advocacy and research. 

Will you maintain health-care protections for the LGBTQ community? Please explain. 

Answer. It is essential that health-care services be available to all people with the 

highest level of quality, affordability, and respect for their human dignity. If confirmed, I will ensure that HHS follows Congress’s lead in defining and enforcing 

nondiscrimination laws, and that HHS will comply with all statutory and judicial 

requirements in doing so. 

MEDICAID AND DISABILITY SERVICES

Question. Medicaid serves as the primary health insurance program for Americans 

with disabilities, especially those with limited income. A lack of adequate health and 

long-term care coverage is often cited as a primary barrier to the ability to live in 

the community and the ability to succeed in employment. Many of the most important Medicaid-funded services for people with disabilities can be the most expensive. 

States must offer three of these services: inpatient hospital care, home health care, 

and Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). State Medicaid programs currently have the option to cover the remaining services important 

to Americans with disabilities including: many home-and-community based services; 

prescription drugs; private duty nursing, physical therapy, occupational therapy; 

speech, hearing, and language therapy; prosthetic devices; intermediate care facilities; and personal care services. 

Since the enactment of the Americans with Disabilities Act (ADA) in 1990, there 

has been a concerted effort at the State, Federal, and community levels to transform 

the Medicaid program from institutional-care focused financing mechanism into a 

comprehensive and flexible community-based long-term services and supports program. Examples of such congressional efforts can be seen in the Affordable Care 

Act, which strengthened and expanded the Money Follows the Person program and 

created the State Balancing Incentive Program and Community First Choice Option. 

How will the administration ensure Medicaid supports the protections of the 

Americans with Disabilities Act? 

Answer. The coordination of two complex laws such as Medicaid and the Americans with Disabilities Act requires the close interaction of those who are expert in 

each. At some level the protections referred to are best supported by allowing States 

the flexibility to approach them in a way that makes sense for their program, so 

long as Federal requirements are met. As to those Federal requirements, there may 

be a need for close coordination with the Department of Justice or the Equal Employment Opportunity Commission as well as the Department’s own Office for Civil 

Rights. 

Question. How will you ensure that Federal dollars are not used in a way that 

promotes unnecessary institutionalization of individuals with disabilities? 

Answer. Community integration, beneficiary autonomy in decision making, and 

person-centered planning are central tenets articulated in CMS’ approach to Home 

and Community Based Services and the HCBS Settings Rule with a compliance date 

in March 2019, and I support each of those principles. It is also important to note 

that many residential, disability-specific settings have long provided a safe and integrated community alternative to institutional placement for individuals with disabilities, and appropriate weight should be given to the preferences of families and individuals with disabilities because they are in the best position to decide what type 

of setting best meets their individualized needs and circumstances. 

Question. How will you work to ensure States have sufficient resources to fund 

home- and community-based services? 

Answer. As with any program or initiative relying on States, the central question 

for the State is often one of funding. If confirmed, I would work to see that the Department is a helpful resource to the States with respect to these services at least 

by providing clarity regarding their flexibility, technical assistance and support as 

needed, and sharing best practices. 

Question. Will you direct CMS in its approval of waivers to encourage States to 

expand home- and community-based services and shift away from waiting lists and 

institutional care? 

176 

Answer. Every State is unique in their specific approach to the provision of services for the population eligible to receive HCBS, and we stand ready to assist States 

as they develop strategies to meet their particular goals. 

MEDICAID EQUAL ACCESS RULE

Question. Congressman Price, as you have previously stated, some providers do 

not accept Medicaid. Studies show that provider payment rates are a leading reason 

that some providers choose not to participate in Medicaid. 

Recently, the Centers for Medicare and Medicaid Services (CMS) has finalized two 

major rules to help address this issue—the ‘‘equal access’’ rule and the Medicaid 

managed care rule. 

Congressman Price, given that this is an issue you seem particularly concerned 

about, will you commit to ensuring successful enforcement of the Medicaid Equal 

Access rule, the Medicaid managed care rule, and other Federal standards that help 

ensure States set appropriate payment rates as required under the Medicaid statute’s equal access provision? 

Answer. If confirmed as Secretary, I will faithfully implement laws written by 

Congress and the regulations issued by the Department. This includes enforcement 

action as appropriate. As a doctor who has actually treated thousands of Medicaid 

patients, I do care deeply about the Medicaid program and the access of Medicaid 

patients to actual care, not just a card they can carry with them. 

MEDICARE BALANCE BILLING

Question. Congressman Price, you have championed legislation to allow providers 

participating in Medicare to enter into private contracts with Medicare beneficiaries, 

meaning that those providers would be permitted to balance bill seniors and other 

Medicare beneficiaries for the difference between what Medicare pays and what the 

provider decides to charge—potentially putting seniors and other Medicare beneficiaries on the hook for high medical bills. More than 30 years ago, Congress passed 

legislation to protect against exactly that situation. One study found that out-ofpocket medical spending declined by 9% in Medicare households as a result of these 

protections. 

Those who want balance billing in Medicare often claim that doctors are fleeing 

the Medicare program, but evidence demonstrates this is simply not true. Provider 

participation in Medicare remains strong. In fact, 9 in 10 primary care physicians 

accept Medicare, and 96 percent of people with Medicare report having regular access to a physician’s care. Allowing balance billing would essentially create two tiers 

of Medicare beneficiaries—those who can afford to access needed care and those who 

cannot. 

Will you commit to the more than 55 million Americans who rely on Medicare 

that, if confirmed as HHS Secretary, you will advise the President to veto any legislation that would undermine these decades-old protections and allow providers participating in Medicare to balance bill seniors and other Medicare beneficiaries? 

Answer. In considering Medicare, it is important to appreciate that the bipartisan 

Medicare Trustees have told everyone that Medicare, in less than 10 years, is going 

to be out of the kind of resources that will allow us as a society to keep the promise 

to beneficiaries of the Medicare program. My goal, if confirmed, is to work with Congress to make certain that we save and strengthen Medicare. It is irresponsible for 

us to do anything else. If I am confirmed, my role will be one of carrying out the 

laws Congress passes and as to that I would convey to the Medicare population that 

we look forward to assisting them in getting the care they need. 

Question. Do you believe low- and middle-income seniors can afford to pay more 

for Medicare services than they currently do? 

Answer. In previous legislation, I have proposed giving our seniors more flexibility 

within the Medicare Program and providing the opportunity to make decisions with 

their physicians without interference from Washington. The measure would help ensure that Medicare beneficiaries maintain adequate access to health-care professionals by increasing the number of physicians who will accept Medicare patients 

and addressing physician shortages by attracting new professionals to the field of 

medicine. In addition, the bill provides safeguards to Medicare beneficiaries. More 

importantly, it would allow a provider to see a Medicare patient pro-bono or charge 

minimal cost (below the standard fee schedule) without prosecution. 

177 

RAISING THE MEDICARE ELIGIBILITY AGE

Question. Congressional Republicans support increasing the Medicare eligibility 

age from 65 to 67 to generate savings for the Federal Government. It is well documented that these savings ultimately shift costs to the American people, States, and 

employers. According to 2014 estimates, increasing the Medicare eligibility age 

would result in a $11.4 billion shift to individuals, States, and employers. The Federal savings would amount to only half of this cost, or $5.7 billion. 

Most Americans retire well before age 67. By age 63, nearly half of the population 

is no longer working. Advocacy groups argue that increasing the Medicare eligibility 

age is an across the board benefit cut that undercuts a promise made to working 

families and seniors more than 50 years ago. 

Would you recommend President Trump veto legislation that would increase the 

Medicare eligibility age? 

Answer. In considering Medicare, it is important to appreciate that the bipartisan 

Medicare Trustees have told everyone that Medicare, in less than 10 years, is going 

to be out of the kind of resources that will allow us as a society to keep the promise 

to beneficiaries of the Medicare program. My goal, if confirmed, is to work with Congress to make certain that we save and strengthen Medicare. It is irresponsible for 

us to do anything else. If am confirmed, my role will be one of carrying out the laws 

Congress passes and as to that I would convey to the Medicare population that we 

look forward to assisting them in getting the care they need. 

Question. If implemented, would Federal savings from a higher eligibility age be 

shifted onto Medicare beneficiaries, States, or employers instead? 

Answer. If such a change is made and the savings do not accrue to beneficiaries 

and the Trust Fund, then we may be right back where we started without the 

change. However, the allocation of savings from such a change, whether to the 

Medicare Trust Fund or to other budgetary priorities, will be a decision for the Congress. 

MENTAL HEALTH

Question. As you must know, mental illness is highly prevalent in the United 

States. Over 43 million adults, just over 18 percent of the population, had any mental illness in 2014. In the past year, over 68 million Americans, representing 20 percent of the population, experienced a psychiatric or substance use disorder. 

Medicaid is the country’s primary payer for all mental health services and is an 

important source of funding for mental health services that would otherwise be out 

of reach for low-income people. Under Medicaid, children and adults with mental 

illness receive vital services and supports that are not typically covered by private 

insurance. Medicaid accounted for 25% of all mental health spending in the United 

States in 2014. 

Thanks to Medicaid expansion under the Affordable Care Act (ACA), an additional 

3.8 million Americans have access to mental health coverage. Furthermore, due to 

consumer protections under the ACA, it is now required that health insurers provide mental health and substance use disorder services as an essential health benefit. 

In your 2017 budget and 2015 reconciliation bill, you call for a full-out repeal of 

the Medicaid expansion; do you still support full repeal? 

Answer. This is a matter for the legislative branch to consider. If confirmed, I will 

work to ensure that HHS (appropriately) implements the statutes within its purview. 

Question. In 2015 you voted to eliminate important coverage protections for Medicaid beneficiaries in alternative benefit plans so they can access the treatment they 

need. 

Do you still support eliminating these protections? 

Answer. This is a matter for the legislative branch. I remain committed to making 

sure health care is affordable and accessible for all Americans. And if confirmed, I 

will work to ensure that HHS (appropriately) implements the statutes within its 

purview. 

Question. In your Empowering Patients First Act you call for full repeal of the 

ACA including important protections such as mental health parity that help to enVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00181 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
178 

sure that a person receives the same level of mental health coverage that they 

would for any physical illness. 

Do you still support repeal of these protections? 

Answer. I believe it is important that we as a nation make sure that every American has access to the kind of mental health and substance abuse care that they 

need. This is a matter for the legislative branch, however, and if confirmed, I will 

work to ensure that HHS (appropriately) implements the statutes within its purview. 

Question. The Office of the Assistant Secretary for Planning and Evaluation 

(ASPE), which will be your principal advisor as HHS Secretary should you be confirmed, reported that in States that didn’t expand Medicaid nearly 2 million lowincome adults with mental health and substance use disorders are uninsured. 

How do you plan to work with States to expand Medicaid coverage to these individuals? 

Answer. Every State has different demographic, budgetary, and policy concerns 

that shape their approach to Medicaid and Medicaid expansion. That is one of the 

reasons I devoted so much time working to help identify creative solutions, and why 

I believe a one-size-fits-all approach is not workable for a country as diverse as the 

United States. If I am confirmed, I will work with CMS and SAMHSA to help the 

population of uninsured low-income adults with mental health and substance use 

disorders. 

I note that the conversation and focus in these topics has been the question of 

coverage rather than true access to care. For many Americans, they might have an 

insurance card and yet not be able to afford care or it might not be available to 

them for other reasons. 

OPIOIDS AND MEDICAID EXPANSION

Question. In November, I released a report describing the consequences of not 

adequately funding treatment and prevention services for opioid addiction. However, 

as we both know, the effects of opioid crisis go far beyond mere statistics. People 

all across the country end up struggling with opioid addiction simply because they 

got into a car accident, or had a painful surgery. Medicaid expansion has provided 

millions of Americans an opportunity to get the treatment they need to get back on 

their feet. 

Congressman Price, in your 2017 budget you call for ending the Medicaid expansion, can you confirm whether you still support getting rid of the Medicaid expansion? 

Answer. This is a matter for the legislative branch. If confirmed, I will work to 

ensure that HHS (appropriately) implements the statutes within its purview. 

Question. In your role as a cabinet Secretary, would you advise the President to 

veto a bill that repeals the Medicaid expansion? 

Answer. I am committed to making sure all Americans have access to affordable 

health care that is of the highest quality. Every State has different demographic, 

budgetary, and policy concerns that shape their approach to Medicaid. That is one 

of the reasons I devoted so much time to working with States to help them to identify creative solutions, and why I believe a one-size-fits-all approach is not workable 

for a country as diverse as the United States. I would encourage anyone to keep 

this principle front and center in considering any changes to Medicaid, which themselves might well be part of a greater context that further informs the best approach. In the meantime, I look forward to faithfully executing whatever law that 

Congress passes and the President signs, if I am confirmed. I will promise you this: 

Regardless of the final legislative outcome, I would work as HHS Secretary to ensure that the Medicaid program is well administered, effective, and available for eligible beneficiaries and that the States/Governors are given the flexibility to pursue 

innovative approaches that fits the needs of their States. 

Question. Would you advise the President to support ending coverage for the 1.6 

million Americans struggling with substance use disorders who gained access to coverage for treatment under the Medicaid expansion? 

Answer. It is important that we as a nation make sure that every American has 

access to the kind of mental health and substance abuse care that they need. If I 

am confirmed, I am committed to ensure that access is not diminished. 

179 

Question. Will you promise that people dealing with opioid addiction will not lose 

their Medicaid expansion coverage that has provided them with the treatment they 

need and deserve? 

Answer. Opioid addiction has had a severe and devastating impact to communities and families across the country. If I am confirmed, I am committed to ensure 

that access to treatments is not diminished and will work with CMS and SAMHSA 

to help low-income adults with mental health and substance use disorders. 

NETWORK ADEQUACY RULES FOR SPECIALTY PHARMACIES

Question. Pharmacy Benefit Managers (PBMs) may or may not own the pharmacies in their pharmacy networks. Recently, PBMs have been criticized for using 

aggressive tactics to restrict access to pharmacies that they do not own. If pharmacy 

networks are narrowed, then individuals will have limited access to pharmacies and 

necessary medications. 

I have heard from Oregon pharmacies that pharmacy benefit managers (PBMs) 

are using aggressive tactics to, in the pharmacies’ opinion, restrict access to pharmacies not owned by the PBM. 

This issue was described in a January 9, 2017 New York Times article: (https:// 

mobile.nytimes.com/2017/01/09/business/specialty-pharmacies-say-benefit-manag 

ers-are-squeezing-themout.html?_r=0&referer=https%3A%2F%2Fwww.google.com% 

2F). 

I am concerned that if pharmacy networks are narrowed, access to needed medications will be limited. 

Can you explain if practices described in the New York Times article are permitted under Medicare Part D and the Exchanges established under the Affordable 

Care Act (ACA)? 

Answer. Part D plans are required to accept any pharmacy willing to participate 

in the plan under the terms of its standard contract. Qualified health plans do not 

have such a requirement though State insurance commissioners may consider such 

practices in their regulatory oversight. 

Question. What minimum standards regarding network adequacy for specialty 

pharmacies exist for both Part D plans and plans offered on the ACA Exchanges? 

Question. For Part D plans, network adequacy requirements are set forth in 42 

CFR 423.120 and in subregulatory guidance. The requirements vary by the type of 

drug. For home infusion drugs, they vary by State. See https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Adequate-Access-to-HI-Pharmacies-Rewrite-012610.pdf. 

For Qualified Health Plans, network adequacy requirements are set forth at 45 

CFR 156.230, 45 CFR 156.122(e), and QHP application and attestation materials, 

as well as in State laws. 

PREVENTIVE CARE

Question. Countless studies have proven that early detection of disease saves lives 

and improves quality of life. Early detection, through preventive screenings, can 

save the health-care system the expense of more costly treatments that may be necessary with a later stage diagnosis. However, early detection of disease is often not 

possible without preventive screenings, for both acute conditions like cancer and 

chronic conditions like diabetes. High copays and high deductibles can be a deterrent to patients utilizing these preventive screenings, regardless of socioeconomic 

status. 

The ACA included a provision requiring private health plans to cover recommended preventive services without any co-payments or cost-sharing. It also 

added coverage of an annual wellness visit and eliminated cost-sharing for recommended preventive services under the Medicare program. 

As HHS Secretary, how will you guarantee that Americans will retain their current level of coverage for preventive screenings and ensure early detection screenings are preserved? 

Answer. I would convey to the Medicare population that we look forward to assisting them in getting the care they need and the caregivers that they need too. 

180 

As we consider what to do with regards to the Affordable Care Act, my hope is 

to move in a direction where insurers can offer products people want and give them 

the coverage they want. Getting to that kind of system requires changes that will 

inevitably involve working with Congress and considering the tradeoffs of various 

proposals to achieve our shared objective of the best and highest quality care being 

available to Americans. 

SPOUSAL IMPOVERISHMENT PROTECTIONS

Question. In the 1980s, married couples commonly were driven into complete poverty when one spouse developed a need for nursing home care. The couple often had 

to spend down their joint resources to just a few thousand dollars before Medicaid 

could provide assistance. Congress addressed this problem in 1988 legislation signed 

by President Reagan. Beginning in October 1989, the spouse of a nursing home resident has been allowed allocations of income and resources in determining the resident’s Medicaid eligibility. These allocations allow the at-home spouse to retain adequate but not lavish amounts of income and savings. To allow for State flexibility, 

the Federal Government sets a range for these allocations, and indexes those ranges 

to inflation. Each State sets its own income allocation and resource allocation, as 

long as the allocation falls within the Federal range. 

Spousal impoverishment protections are mandatory for nursing home residents 

and were optional for people receiving home and community-based services (HCBS). 

Due to the Affordable Care Act, people receiving HCBS are also entitled to spousal 

impoverishment protections. 

Do you support the requirement for State spousal impoverishment protections? 

Answer. I support the flexibility of States to make decisions about eligibility so 

that they can ensure the broadest set of people get access to the highest quality care 

on the budget available to the State. Spousal impoverishment protections allow 

States to delay or prevent the impoverishment of spouses lest they too need to be 

added to the Medicaid rolls. 

Question. Should a person be required to receive long-term care in a nursing home 

in order to protect a spouse from poverty? 

Answer. My hope is that we can move to a system where States can make decisions like this with their population, values, dynamics, and funding in mind. 

Question. How will HHS ensure spouses are protected from living in poverty when 

a loved one reaches a stage of fragility that requires long-term care? 

Answer. I have seen that the best solutions to seemingly intractable problems like 

this rely on States to find the right approach for that State. If confirmed, I look forward to working with Governors (and Congress) to help States chart their course 

in this regard. 

WOMEN’S HEALTH

Question. Congressman Price, in the past, when asked whether birth control 

should have to be covered, you’ve stated that not a single woman has been left behind. 

Will you reject any proposals that limit a women’s access to contraceptive care or 

make it cost more for her? 

Answer. Women should have the health care that they need and want. The system we ought to have in place is one that equips women and men to obtain the 

health care that they need at an affordable price. 

Question. As a cabinet adviser to the President, will you advise the President to 

veto any bill that reduces guaranteed access to affordable contraceptive coverage? 

Answer. As we consider what to do with regards to the Affordable Care Act, my 

hope is to move in a direction where insurers offer products people want and give 

them the coverage they want. Getting to that kind of system requires changes that 

will inevitably involve working with Congress and considering the tradeoffs of various proposals to achieve our shared objective of the best and highest quality care 

being available to Americans. 

Question. In your hearing last week, you were asked about your vote against the 

DC Council’s efforts to protect employees from being fired for taking birth control. 

Congressman Price, to clarify for the record, do you or do you not think an employer 

should be able to fire or discriminate against an employee for taking birth control? 

181 

Answer. I do not believe so. My vote regarding the DC Council law you mentioned 

does not relate to this particular issue or question. 

Question. Will you advise the President to veto any bill that rips access to care 

away from hundreds of thousands of women by defunding Planned Parenthood? 

Answer. Deciding whether to sign any particular law, particularly one that involves as many different moving parts as one to replace the Affordable Care Act, 

inevitably involves considering many competing, complementary, or countervailing 

issues. If Congress passes a law that makes certain that every single American has 

access to the coverage they want for themselves and ensures the individuals who 

lost coverage under the Affordable Care Act get or maintain coverage, that is something I would hope would be strongly considered for signature. 

Question. You sponsored the 2015 reconciliation bill (H.R. 3762) that would repeal 

key components of the Affordable Care Act (ACA) and rescind Federal funding for 

Planned Parenthood for 1 year. Please provide the names of providers other than 

Planned Parenthood health centers that H.R. 3762 would prohibit from participating in Medicaid? 

Answer. H.R. 3762 restricts the availability of Federal funding to a State for payments to any entity that is a 501(c)(3) tax-exempt organization, is an essential community provider primarily engaged in family planning services and reproductive 

health; provides abortions other than in cases of rape, incest or life of the mother, 

and receive a total of more than $350 million under Medicaid in FY 2014. 

It should also be noted that H.R. 3762 would increase funding available to the 

Community Health Center Program (CHC) by $470 million over 2 years. As I said 

in my hearing before the Senate Health, Education, Labor, and Pensions (HELP) 

Committee last week, community health centers are a vital part of the health care 

delivery system, filling a void in so many areas across the county. We need to do 

all we can to strengthen them, ensuring they are staffed with the highest quality 

providers and providing the highest quality care, and look forward to working with 

you on this if confirmed. 

WORK REQUIREMENTS FOR MEDICAID SERVICES

Question. Your Budget Plan for 2017 proposes work requirements for so called 

‘‘able-bodied’’ adults in order to qualify for Medicaid coverage. Specifically, these individuals must be actively seeking employment or participating in an education or 

training program in order to qualify for health-care coverage under Medicaid. 

According to independent evaluations of programs that have imposed work requirements, imposition of work requirements found only modest, short-term increases in employment with families living in deep poverty rising under such programs. The evidence also shows that over the long-term, those in programs with 

work requirements were as likely to find employment as enrollees in Medicaid programs that did not have strict work requirements. 

How do you define an ‘‘able-bodied’’ adult? 

Do you support work requirements in order for these ‘‘able-bodied’’ adults to qualify for Medicaid? 

Given you’re interest in employment, how do you plan on working to support local 

economies to ensure that those looking for work regardless of income are actually 

able to obtain jobs? 

Answer. One major lesson learned from welfare reform signed into law by President Clinton is that the American people, when given the opportunity, work exceptionally hard. This view is also shared by President Trump and reflected in his commitment to job creation and the dignity of work. Encouraging work allows more 

families to realize the American dream, earn their success and rise out of poverty. 

I will faithfully execute any laws passed by Congress to institute work requirements 

and if given the opportunity to serve I will allow States greater flexibility for determining how to care for their most needy citizens. 

AMA RECUSAL

Question. Congressman Price, in your January 11th letter to the Associate General Counsel for Ethics at HHS, you said you would resign from your position as 

a Delegate of the American Medical Association (AMA) if confirmed as HHS Secretary. You also promised that—for 1 year after your AMA resignation—you would 

‘‘not participate personally and substantially in any particular matter involving speVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00185 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
182 

cific parties in which (you know) the American Medical Association is a party or represents a party, unless (you are) first authorized to participate.’’ 

In 2016 alone, the AMA submitted 21 formal comment letters to HHS and CMS— 

almost two per month on average—covering a wide range of issues, including, for 

example, the implementation of the Medicare physician payment reforms in MACRA 

(the Medicare Access and CHIP Reauthorization Act) and key provisions of last 

year’s Comprehensive Addiction and Recovery Act (CARA). 

In this context, what criteria would you use to determine what constitutes participating ‘‘personally and substantially’’ in a matter? 

Answer. I view the term ‘‘personally and substantially’’ in the context of its statutory and regulatory definitions. To the extent necessary, I will seek advice from his 

designated agency ethics official and other appropriate parties when assessing 

whether participation in a matter is indeed personal and substantial. 

Question. In this context, what criteria would you use to determine whether the 

level of AMA’s involvement means that it is a party or represents a party in a particular matter? 

Answer. I will abide by the actions agreed to in my publicly available ethics agreement with the Office of Government Ethics, and seek advice (when necessary) from 

the designated agency ethics official and other appropriate persons. 

Question. Will you recuse yourself from any matter in which the AMA has submitted formal comments to HHS or CMS? 

Answer. This matter has already been addressed with the OGE and designated 

agency ethics official, and I will abide by the obligations agreed to in my publicly 

available ethics agreement. 

Question. For example, will you recuse yourself from any decision-making regarding the implementation of the physician payment reforms in MACRA—given how 

actively engaged AMA has been with HHS and CMS on that issue? 

Answer. This matter has already been addressed with the OGE and designated 

agency ethics official, and I will abide by the obligations agreed to in my publicly 

available ethics agreement. 

Question. Will you also recuse yourself from any matter about which the AMA 

sent correspondence to HHS or CMS? 

Answer. This matter has already been addressed with the OGE and designated 

agency ethics official, and I will abide by the obligations agreed to in my publicly 

available ethics agreement. 

Question. Do you think an HHS Secretary can effectively do his job if he cannot 

participate in any of the above described matters? 

Answer. Adherence to all applicable ethics and conflict of interest obligations 

under Federal law is an essential component of being an effective HHS Secretary, 

and in no way limits the ability of an individual to successfully carry out his or her 

responsibilities within the Department. 

AUTOMATIC CUTS TO ENTITLEMENTS

Question. The day after you were nominated for HHS Secretary, you rolled out 

a set of budget process changes that would force automatic cuts to almost all Federal programs—including Social Security, Medicare, and Medicaid—if the national 

debt exceeds targets specified by Congress. If the Trump tax plan is signed into law, 

but Congress cannot agree on how to pay for its cost of more than $6 trillion over 

10 years, your budget process would automatically cut Social Security by $1.7 trillion and Medicare by $1.1 trillion over 10 years. This would cut the average Social 

Security benefit by $168 per month. President Trump has pledged not to cut Social 

Security, Medicare, and Medicaid; but your budget process seems to provide a way 

to cut these programs without President Trump having to sign any specific cuts into 

law. 

If Congress passed your budget changes today, would you recommend he veto that 

legislation? 

Answer. Should the budget pass, I will carefully review the legislation and communicate the health-care implications of that budget to the President. 

183 

Question. The sequester, under current law, shields vulnerable populations from 

across the board cuts. Why do you believe the sequester should be expanded to programs that serve the most vulnerable Americans? 

Answer. It is my belief that the Federal Government needs to strengthen mandatory programs if we are going to ensure future generations have access to the programs. 

CHILDREN’S HEALTH COVERAGE

Question. Congressman Price, you once remarked that low-income children already have access to all the health care they need. You’ve publicly said that you, 

‘‘know of no study that shows these individuals have no access,’’ and that uninsured 

children are already treated by doctors and hospitals even though they often do not 

pay for the care they receive. 

Do you still believe that all children had adequate access to health care before 

the ACA? 

Answer. Though programs like CHIP have made substantial progress in the availability of health-care coverage to children, there has always been more work to do 

in this regard. I should add that what is most important in this regard is not just 

that children have coverage but also actual access to care that is affordable and 

available to them. 

Question. Do you agree that maintaining these coverage gains and not taking a 

step back on children’s health is vitally important? 

Answer. With regards to health care for children, our goal is to make certain that 

every single American has access to the coverage they want for themselves and their 

children and ensures the individuals and children who lost coverage under the Affordable Care Act get or maintain coverage. 

Question. Congressman Price, according to independent reports, repeal of the ACA 

would mean over 4 million children would become uninsured. As advisor to the 

President, will you advise the President to veto any bill if the result is fewer children have coverage? 

Answer. Deciding whether to sign any particular law, particularly one that involves as many different moving parts as one to replace the Affordable Care Act, 

inevitably involves considering many competing, complementary, or countervailing 

issues. I look forward to working with the Congress to ensure that fewer children 

having coverage is not one of those tradeoffs, but rather that every single American 

has access to the coverage they want for themselves and their children and ensures 

the individuals and children who lost coverage under the Affordable Care Act get 

or maintain coverage. 

CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)

Question. Today, the bipartisan Children’s Health Insurance Program provides 8 

million children with access to comprehensive, affordable health care including 

thousands of children in Oregon’s Healthy Kids program. Yet you’ve publicly referred to CHIP as ‘‘government-run socialized medicine’’ and put forth proposals 

that would have denied families with access to more affordable care for their children through this successful bipartisan health program. 

Congressman Price, in your role as a cabinet Secretary, would you advise the 

President to support an extension of the Children’s Health Insurance Program? 

Answer. It is important that every child has access to high-quality health coverage, and CHIP plays an important role in accomplishing this objective. 

Question. Will you commit to ensuring that not a single child under Oregon’s 

Healthy Kids program gets left behind under any CHIP extension? 

Answer. If confirmed as Secretary, my goal would be to ensure that no child in 

Oregon or anywhere else is left behind. CHIP plays a major role in this, but there 

is also a need for coordinated family coverage in the private market and employer 

plans, and giving States the needed flexibility to accomplish this. 

Question. As a cabinet-level advisor to the President, will you advise the President 

to veto any bill that results in coverage being stripped away from a single child in 

Oregon benefiting from our Healthy Kids program? 

184 

Answer. Deciding whether to sign any particular law inevitably involves considering many competing, complementary, or countervailing issues. I look forward to 

working with the Congress to ensure that fewer children having coverage is not one 

of those tradeoffs, but rather that every single child in Oregon and America has access to high-quality care. That means not just having a card, but being able to access the care it covers. 

COST SHARING IN MEDICAID

Question. Your 2017 budget used the Healthy Indiana Plan as an example of an 

innovative State program that is reducing State Medicaid costs. However, the 

Healthy Indiana Plan has not worked as intended in some important ways and has 

created access barriers for some. In fact, studies show that the required premiums 

for many low-income people depress participation and make it harder for people to 

access the coverage they need. According to an independent evaluation of the program, thousands of individuals in the program were penalized or kicked off and 

locked out of coverage under the complicated structure. 

If these types of complicated structures used in a State’s Medicaid program is 

shown to keep eligible people from getting the health care they need, will you disallow it as not meeting the objectives of the Medicaid statute? 

Answer. The Healthy Indiana Plan has long been and continues to be a national 

model for State-led Medicaid reforms pertaining to the low-income, able-bodied adult 

population. It is important that Medicaid’s design helps its members to transition 

successfully from the program into commercial health insurance plans, as HIP’s 

consumer-driven approach and underlying incentive structures encourage. HIP 

members are more engaged with their providers, less reliant on the emergency 

room, and more satisfied with their coverage than traditional Medicaid members. 

HIP is achieving Indiana’s objective to increase access to consumer-driven coverage 

as well as the broader objectives of the Medicaid program, and I support the use 

of HIP’s reforms in future 1115 demonstration requests by other States. 

DELIVERY SYSTEM REFORM

Question. Congressman Price, you have been an outspoken critic of the delivery 

system reforms included in the Affordable Care Act (ACA), particularly the Center 

for Medicare and Medicaid Innovation (CMMI) and the movement away from traditional fee-for-service payments for providers and toward value-based payment models such as bundled payments. 

Do you agree that the traditional fee-for-service payment system—in which providers are paid based on volume instead of value—creates incentives for overutilization of health-care services? 

Answer. Our health-care system is complex, and we cannot attribute overutilization trends to a single cause. For instance, efforts to curb overutilization in emergency rooms have been unsuccessful. Overutilization is a complex issue that needs 

to be carefully addressed. 

Question. Do you also agree that the successful implementation of the bipartisan 

Medicare Access and CHIP Reauthorization Act (MACRA) will require the continued 

development of value-based payment models? 

Answer. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) 

is built on the principle of encouraging providers to develop Alternative Payment 

Models (APMs) that can ultimately be adopted by CMS and commercial payers. 

Question. Will you commit to supporting the continued development of valuebased payment models in Medicare and increasing the percentage of provider payments made through those models? 

Answer. We share the goal of improving Medicare by empowering providers to be 

creative and develop payment models that best suit the unique needs of their patients to ultimately improve patient care. 

MEDICARE-MEDICAID COORDINATION OFFICE

Question. ‘‘Dual eligibles’’ receive benefits under the Medicare and Medicaid programs. Full benefit dual eligibles suffer from serious health care needs including debilitating physical and mental disabilities, often requiring complicated and expensive long-term services and supports. The ACA created the Medicare-Medicaid Coordination Office, also called the Medicare-Medicaid Coordination Office, to coordiVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00188 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
185 

nate and address the needs of dual eligibles. The office has led Federal efforts to 

improve how programs are delivered to this high need, high cost population. 

Will the administration continue to support the Medicare-Medicaid Coordination 

Office? 

Answer. If confirmed as Secretary, and if legislation regarding this Office changes, 

I will work with the CMS Administrator to consider how best to deploy the tremendous resources of CMS against the enormous challenge of ensuring access to the 

highest quality care for dual beneficiaries. In the meantime, I will implement the 

law as passed by Congress. 

Question. Does the administration plan to continue the financial alignment demonstration currently underway in several States? 

Answer. Commenting on specific potential models is premature at this point. 

These models go through a lengthy development and modeling process, as well as 

internal review and approval at CMMI and OMB. If confirmed, as HHS Secretary, 

I plan to work closely with CMS to ensure that CMMI—after appropriate consultation with Congress, the States, health-care stakeholders, and Innovation Center 

staff—tests innovative models that reduce costs and improve quality for Medicare 

and Medicaid beneficiaries. 

FEDERAL DATA COLLECTION

Question. The Department of Health and Human Services (HHS) collected valuable data related to the Affordable Care Act (ACA). This includes rate filings, enrollment data, and analytical reports on the efficacy of the law in different sectors of 

the health system. Additionally, the ACA invested in the implementation of a new 

health data collection and analysis strategy. Section 4302 of the Affordable Care Act 

contains provisions requiring all national Federal data collection efforts collect information on race, ethnicity, sex, primary language and disability status. The law also 

provides HHS the opportunity to collect additional demographic data to further improve our understanding of health-care disparities. 

Will health-care data collected by the government continue to be publicly available to promote government transparency? 

Answer. If confirmed as Secretary, I would implement the law regarding these 

topics as written and passed by the Congress. 

Question. Will health-care data continue to require the collection of information 

on race, ethnicity, sex, primary language, and disability status? 

Answer. If confirmed as Secretary, I would implement the law regarding these 

topics as written and passed by the Congress, including with respect to the data 

points required to be collected. 

Question. How does CMS plan to leverage this data to address health disparities? 

Answer. Any data that can inform CMS’s approach to understanding where people’s needs are not being met will help us understand how best to move towards 

a system where every single American has access to the coverage they want for 

themselves. 

BAN ON HEALTH AGENCY COMMUNICATIONS

Question. News reports on January 24th indicate that Trump administration officials have issued what amounts to a gag order essentially muzzling external communications by employees of the Department of Health and Human Services (HHS) 

and the National Institutes of Health between now and February 3. This ban on 

external communications reportedly includes correspondence with public officials including members of Congress as well as press releases and social media posts. 

What communications are covered by the Trump administration’s restriction of external communications? 

Are there any exceptions allowed for releases of information about matters of public health or safety? 

If a public health or safety matter arises between now and February 3rd, will the 

agencies be prevented from communicating with public officials or the general public 

about these matters? 

Under what circumstances would external communications be allowed? 

186 

Who within the Department is authorized to allow communications in a public 

health or safety situation or otherwise? Please provide the criteria that has been 

developed to determine if and when external communications are permitted. 

What impact will this restriction have on whistleblowers who are exercising rights 

protected by law? 

What is the reason for this action? 

Is it possible the restriction will be extended beyond February 3rd? Under what 

circumstances could it be extended? 

Does the restriction apply to Federal employees’ personal use of social media or 

only use of official agency accounts? 

Will the restriction prevent HHS employees from responding to outstanding questions from members of Congress including letters or other communications awaiting 

answers? If so, when will such questions be answered? 

Will questions submitted by members of the Finance Committee be answered in 

a timely manner and in any case before February 3rd notwithstanding the restriction on external communications? 

Answer. The Acting Secretary Memo to Department of Health and Human Services operating and staff division heads is straightforward and consistent with Chief 

of Staff Memo issued on behalf of President Trump with regard to regulatory review 

of new or pending regulations and guidance. As noted in the HHS memo, the purpose of the directive is to ensure ‘‘President Trump’s appointees and designees have 

the opportunity to review and approve any new or pending regulations or guidance 

documents.’’ Furthermore, the Chief of Staff memo provides explicit exceptions for 

‘‘emergency situations or other urgent circumstances relating to health, safety, financial, or national security matter. . . .’’ This request is standard for a new administration. With regard to correspondence to public officials, such as members of Congress, the memo outlines a clear and expedited process for adequate review and is 

by no means intended to impede the agencies or staff divisions from continuing their 

important work on behalf of the American people, including routine constituent 

service communications. 

COST-SHARING REDUCTIONS

Question. Under the Affordable Care Act, individuals and families with incomes 

between the Federal poverty level and 250 percent of the poverty level are eligible 

for cost-sharing reductions (CSRs) if they are eligible for a premium tax credit and 

purchase a silver plan through the health insurance exchange. The cost-sharing reductions reduce the deductibles, copayments, and other out-of-pocket costs for these 

lower- and moderate-income Americans. 

In House v. Burwell, House Republicans challenged the legality of Federal funding 

of CSR subsidies. In a May 2016 ruling, U.S. District Judge Rosemary Collyer ruled 

in favor of the House Republicans, although she stayed implementation of the ruling. The previous administration appealed the decision, but the case was stayed 

until after the 2016 presidential election. 

If confirmed as HHS Secretary, will you recommend that the administration continue to reimburse insurers for the cost-sharing reductions that reduce deductibles, 

copayments and other out-of-pocket costs for lower- and moderate-income Americans? 

Answer. The agency is currently involved in litigation related to this matter, and 

it would be inappropriate for me to comment at this time. 

Question. If confirmed as HHS Secretary, will you recommend that the administration protect the Federal Government’s authority to make payments for cost-sharing reductions, which was challenged in House v. Burwell, and move forward with 

its appeal of the lower court’s ruling? 

Answer. The agency is currently involved in litigation related to this matter, and 

it would be inappropriate for me to comment at this time. 

Question. If confirmed as HHS Secretary, will you recommend that the administration seek an appropriation from Congress for the cost-sharing reductions? 

Answer. It will be up to the President and Congress to determine the appropriate 

policy on this issue. My job, if confirmed, would be to faithfully execute that law. 

187 

RISK CORRIDOR PAYMENTS

Question. The Affordable Care Act’s temporary risk corridor program was intended to promote accurate premiums in the early years of the exchanges (2014 

through 2016) by cushioning insurers from extreme gains and losses. It was modeled 

after the Medicare Part D prescription drug program’s successful risk corridor program. The Federal Government currently owes insurers approximately $8.3 billion 

under the risk corridor program to offset losses from 2014 and 2015. This is largely 

due to a rider attached to the 2015 and 2016 appropriations bills requiring the risk 

corridor program to be revenue neutral, meaning that the Centers for Medicare and 

Medicaid Services (CMS) can only pay out funds under the program that it collected 

under the program. 

Under the previous administration, HHS and CMS acknowledged that risk corridor payments are an obligation of the government and that full payment must be 

made to insurers. The Department of Justice defended the lawsuits brought by insurers for the full risk corridor payments, but also expressed a willingness to engage 

in settlement discussions. 

If confirmed as HHS Secretary, will you also acknowledge that risk corridor payments are an obligation of the government and that full payment must be made to 

insurers? 

Answer. The agency is currently involved in litigation related to this matter, and 

it would be inappropriate for me to comment at this time. 

Question. If confirmed as HHS Secretary, will you recommend that the administration engage in settlement discussions with insurers on overdue risk corridor payments? 

Answer. The agency is currently involved in litigation related to this matter, and 

it would be inappropriate for me to comment at this time. 

GENDER RATING

Question. Before the Affordable Care Act, insurance companies were able to 

charge women more for their health insurance compared to men. This practice was 

widespread, as 92 percent of the best-selling plans on the individual market used 

gender rating in setting their premiums. This cost women approximately $1 billion 

in additional costs each year that men did not have to pay. 

Do you believe that insurance companies should be required to charge men and 

women the same rate for premiums? 

Answer. The setting of premiums is something that has historically been a matter 

of State law and regulation, so that the dynamics of that State and its population 

and risk pool and consumer behavior can be taken into account. Nevertheless, of 

course, if confirmed as HHS Secretary, my role would be to implement the law as 

it is now written. 

1332 WAIVERS

Question. The ACA included a provision known as the State Innovation Waiver 

(SIW), or 1332, that provides States the opportunity to tailor their own health care 

system in a way that best aligns with the individual State’s needs. This waiver was 

written to give States a chance to implement the ACA better; it was not written 

as a tool to undermine the law. States may apply to use these waivers beginning 

January 1, 2017. 

As a reminder, a waiver must meet the following requirements: 

• Ensure that individuals get insurance coverage that is at least as comprehensive as provided under the ACA. 

• Ensure that insurance coverage offered to individuals is at least as affordable 

as it would be under the ACA. 

• Ensure that as many people are covered as would be under the ACA. 

• Not increase the Federal deficit. 

Please respond to the following questions. 

What opportunities do you see for States to use the SIW? Are there particular reforms that you think would enhance access to affordable, quality coverage? 

Answer. These waivers present an opportunity for CMS to encourage State innovation and allow for adaptation of national requirements to the needs of individual 

188 

States. If confirmed, I would work with CMS to enable States to utilize this—and 

other—authority provided by Congress to ensure access to high-quality, affordable 

health insurance. 

Question. How do you envision the SIW working in conjunction with Medicaid and 

any corresponding Medicaid waivers? What checks would you put in place to ensure 

that those individuals entitled to Medicaid receive the full benefits and protections 

afforded them under title XIX? 

Answer. There is a tremendous opportunity to allow States to innovate with respect to the intersection of their Medicaid programs and qualified health plans and 

the risk pools within each. State fair hearing processes (as well as the Medicaid 

waiver process and CMS oversight) provide substantial procedural and other protections that would address concerns regarding Medicaid beneficiaries not getting benefits due to them. 

Question. What precautions would you put in place to ensure consumers are protected in States that choose to move forward with a 1332 waiver application? 

Answer. The statute itself has protections in place relating to the findings that 

must be made that would protect consumers in States that move forward with a 

1332 waiver application. Furthermore, the democratic process in each State, where 

government is even closer to the people, provides substantial protection with regards to any 1332 waiver application and its implementation. Such protection may 

well be even more effective than that available to consumers vis-a`-vis the Federal 

Government. 

Question. What steps would you take, as Secretary of HHS, to implement this provision, as intended by congressional drafters, to ensure it is not used to undermine 

the ACA? 

Answer. As part of the ACA, the use of section 1332 to allow States to innovate 

would not undermine the ACA. In fact, failing to successfully use this important tool 

to allow States flexibility with regards to the ACA as allowed by the law would undermine the ACA. 

RURAL HEALTH

Question. Americans living in rural areas often have difficulty accessing quality 

care due to physical and economic barriers. The Health Resources and Services Administration estimates that 65 percent of primary care health professional shortage 

areas are in rural areas. These challenges translate into significant health disparities for rural populations, including higher rates of chronic disease and disability 

as well as lower life expectancy. Rural Americans have also historically experienced 

lower rates of insurance. The Affordable Care Act provided new access to coverage 

for people living in rural areas through the Health Insurance Marketplaces and 

Medicaid expansions, as well as critical consumer protections. 

If confirmed how will you protect access to quality health care in rural areas? 

Answer. Too often rural health care is overlooked in the broader discussion of national health-care issues. Significant health disparities exist for rural populations 

for a variety of reasons, including challenges with access to affordable coverage and 

health-care services. Rural Americans are acutely aware of the dire need for expanded health insurance options. If confirmed, I will work tirelessly to address the 

health-care needs of all Americans, rural or urban. 

PRE-EXISTING CONDITIONS AND CONTINUOUS COVERAGE REQUIREMENT

Question. The Affordable Care Act prohibits insurers from denying coverage to individuals with pre-existing conditions, charging them higher premiums, or refusing 

to cover benefits related to a pre-existing conditions. 

Your Empowering Patients First Act (H.R. 2300 in the 114th Congress) repeals 

the Affordable Care Act in its entirety (including the protections for those with preexisting conditions) and instead puts in place a ‘‘continuous coverage requirement,’’ 

meaning that individuals with pre-existing conditions must maintain continuous 

health insurance coverage for at least 18 months in order to qualify for protections 

against discrimination by insurers. Under your legislation, insurers would once 

again be allowed to exclude coverage of a pre-existing condition for lengthy periods 

of time or charge much higher premiums unless individuals had maintained continuous coverage for at least 18 months. 

189 

1http://www.bigstory.ap.org/article/12658e69b70148fc8d4743fa631fa9f9/5-states-strugglesurging-numbers-foster-children. 2https://www.acf.hhs.gov/media/press/2016-number-of-children-in-foster-care-increases-forthe-third-consecutive-year. 

According to a recent report from the HHS Office of the Assistant Secretary for 

Planning and Evaluation (ASPE), up to 133 million non-elderly Americans may 

have a pre-existing condition, and nearly one-third (44 million) went uninsured for 

at least 1 month during the 2-year period beginning in 2013. 

If any of these individuals were to face difficult circumstances that resulted in a 

temporary loss of coverage—such as losing a job or being unable to work due to serious illness—your legislation would allow insurers to refuse to cover services related 

to the pre-existing condition or charge a much higher premium than many of these 

individuals would likely be able to afford. 

Do you agree that individuals with pre-existing conditions who experience a loss 

of coverage—for example, due to the loss of a job or being unable to work due to 

a serious illness—should not be denied coverage for their condition or charged high, 

unaffordable premiums as a result of that temporary loss of coverage? 

Under the continuous coverage requirement included in your Empowering Patients First Act, what would prevent insurers from doing exactly that to any individual with a pre-existing condition who experiences a temporary loss of coverage? 

Answer. I believe it is important that we as a nation make sure that every American has access to the kind of mental health care and health coverage that best 

meets their need. Additionally, it is imperative that all Americans have access to 

affordable coverage and that no one is priced out of the market due to a bad diagnosis. This is a matter for the legislative branch, however, and if confirmed, I will 

work to ensure that HHS appropriately implements the statutes within its purview. 

HUMAN SERVICES PROGRAMS

Question. In recent years, there has been an increasing focus on using evidence 

to make policy decisions. 

What is your view on this? 

Answer. There is no question we must use available evidence when making governmental decisions. 

Question. What evidence would you use to decide whether policies or program 

changes that you have championed are successful? 

Answer. When championing policy or program changes, outcomes should always 

be a top indicator when determining whether or not those changes are successful. 

Question. What evidence leads you to believe that TANF was a success? 

Answer. Since the passage of TANF, we have seen employment rates of single 

mothers increase, lower poverty rates among female-headed households with children and African-American households, a reduction in child poverty overall, and a 

sharp decline in the number of families receiving cash assistance. 

Question. The annual data from HHS through the Adoption and Foster Care Analysis Reporting Systems (AFCARS) released in fall 2016 show a third consecutive annual increase in foster care to 427,910 children. This represents an 8-percent increase since 2012. Your home State is no exception. A recent AP story stated that, 

‘‘the most dramatic increase has been in Georgia, where the foster-care population 

skyrocketed from about 7,600 in September 2013 to 13,266 last month. The State 

is struggling to provide enough foster homes for these children and keep caseloads 

at a manageable level for child-protection workers.’’ 1 HHS recently indicated that: 

A rise in parental substance use is likely a major factor driving up the 

number of children in foster homes. Citing opioid and methamphetamine 

use as the most debilitating and prevalent substances used, some State officials expressed concern that the problem of substance use is straining their 

child welfare agencies.2

Clearly, substance use is having a big impact on children, families, and child welfare systems. I am particularly concerned about the strain the epidemic is placing 

on grandparents and other relatives who often unexpectedly take on the role of caretaker for children in foster care and at risk of entering foster care. Thankfully, there 

are programs that work and can even save taxpayer dollars over the long run. For 

190 

3https://www.ncbi.nlm.nih.gov/pubmed/11291901 and https://www.ncbi.nlm.nih.gov/ 

pubmed/11291900. 4http://www.cwla.org/discussion-on-plans-of-safe-care/. 

5http://www.oecd.org/els/family/PF2_5_Trends_in_leave_entitlements_around_childbirth. 

pdf. 

example, research shows that when parents are able to get into substance use treatment programs that permit them to live with their children, two-thirds of these parents successfully complete the program. That compares with only one-fifth of parents when their children aren’t allowed to stay in the treatment facility with them.3

The results achieved by these model programs have saved millions of dollars every 

year in the costs of keeping kids in foster care. 

What will you do to ensure that drug treatment and services will be both maintained and coordinated to target these families that need treatment and whose children could end up in foster care without the appropriate services? 

Answer. There needs to be better coordination between Federal departments, 

State governments, and local governments to ensure we are meeting the challenges 

of one of the great crises of our times: the opioid epidemic. A top agenda of all levels 

of government is to ensure innocent children, including those in foster homes, are 

protected from the scourge of this epidemic. As a strong proponent of the Comprehensive Addiction and Recovery Act of 2016, I will do all I can to effectively administer and implement this law should I be confirmed as Secretary. 

Question. How will you help grandparents and other family members receive the 

supportive services they need in the event that parents cannot safely retain custody 

of their children? 

Answer. Should I be confirmed as HHS Secretary, I will do all within my power, 

under the laws passed by Congress, to help grandparents and other family members 

receive supportive services. 

Question. Will you pledge to me that, if confirmed, you will work with me to provide Federal support for effective programs, and to ensure that the children and 

grandparents caught up in the opioid epidemic get support from your Department? 

Answer. I absolutely pledge to work with you to ensure support for effective programs and to see that children and grandparents get appropriate support from HHS 

to deal with the tragic opioid epidemic. 

Question. As part of the Comprehensive Addiction and Recovery Act of 2016, Congress required States to have plans of ‘‘safe care’’ for infants born exposed to substances.4 This requirement, along with numerous existing requirements, is a condition of State receipt of grants under the Child Abuse Prevention and Treatment Act, 

or CAPTA. Grants to States under CAPTA total $26 million per year. Discretionary 

spending for child welfare services under CAPTA, the Adoption/Kinship Incentives 

Program, the Promoting Safe and Stable Families Program and Child Welfare Services have all faced significant reductions in appropriations over the past 5 years. 

What is your position on proposals that would move mandatory funding to discretionary funding (thus limiting the committee’s ability to fund both child welfare and 

other vital services)? 

Answer. This is a legislative matter. Should I be confirmed as HHS Secretary, I 

will implement the laws passed by Congress. 

Question. How will you ensure adequate funding for these services that have suffered significant reductions over the recent past despite a backdrop of increasing 

foster care numbers? 

Answer. Should I be confirmed as HHS Secretary, I will strive to make effective 

use of all dollars appropriated by Congress in order to provide the most effective 

services possible. 

Question. The United States is the only industrialized country without paid maternity leave.5 The President has endorsed such leave for new mothers. 

If confirmed, how might you lead the Department to help support this goal? 

Please be specific about resources and expertise that may be available at HHS, including in such areas as benefit design, eligibility determination, IT systems, and 

program access. 

Answer. If I am so honored as to be confirmed as HHS Secretary, I will implement 

the laws passed by Congress and support the President’s initiatives as they fall 

191 

6https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2842802&download=yes. 

within HHS’s authorities. I will do so in a way that is as effective and as efficient 

as possible, drawing on the expertise and experience of the fine men and women 

currently working at HHS. 

Question. Access to high-quality child care is fundamental to the economic security of families and too many parents cite lack of dependable child care as a key 

barrier to finding and maintaining employment. The President’s child care tax proposals would primarily benefit high-income families through tax deductions, while 

providing little or no help to low- and middle-income families.6 The most significant 

Federal child care program for families of modest means is the Federal Child Care 

and Development Block Grant (CCDBG) which provides funds to States to help lowincome families afford child care of their choice. Yet the CCDBG serves only one 

out of seven children eligible for assistance. 

If confirmed, under your leadership how might the Department improve access to 

high quality child care? Please be specific about resources and expertise that may 

be available at HHS, including in such areas as benefit design, eligibility determination, IT systems, and program access. 

Answer. Should I be confirmed as HHS Secretary, I will implement the laws 

passed by Congress. I will do so in a way that is as effective and as efficient as 

possible, utilizing the ample and exemplary expertise available by the fine men and 

women currently working at HHS. 

Question. As Budget Chairman, you proposed eliminating funding for the Social 

Services Block Grant (SSBG), a flexible funding stream for social services programs 

such as substance use disorder treatment services, child protection, elder protection, 

services for the elderly like Meals on Wheels, and other critical safety net programs. 

It also helps fill in financial gaps for overburdened State foster care systems which 

are facing an increased strain in light of the opioid epidemic. 

In light of increased demands on State human services programs brought on by 

the opioid epidemic, has your position on the SSBG changed? 

Answer. During my time in Congress, I have been acutely aware of the need to 

eliminate duplicative programs and strengthen those programs that work. However, 

as SSBG continues to be a program authorized by Congress, I will do all I can to 

effectively administer this law should I be so honored as to be confirmed as HHS 

Secretary. 

Question. If not, where do you suggest States turn to make up for the loss of these 

flexible SSBG dollars if funding is eliminated? Please be specific in terms of which 

programs you believe would fill the void left by SSBG. 

Answer. Given the nature of our Federal system, there is not a one-size fits all 

approach to how States might react should there be an elimination of any Federal 

program. 

Question. Can you explain what makes the flexibility in the Social Services Block 

Grant inherently different and worse than either existing or proposed block grants 

(such as TANF as it exists or Medicaid as you have proposed)? I’d be especially interested in why you consider SSBG to be a failure while you consider TANF to be 

a success. 

Answer. As a 2011 GAO report pointed out, SSBG is a program of fragmentation, 

overlap, and duplication. SSBG essentially offers a no-strings-attached approach 

whereas TANF, while maintaining a great deal of flexibility for the States, has been 

successful in moving recipients off of welfare and on to work. That being said, SSBG 

continues to be a program authorized by Congress, I will do all I can to effectively 

administer this law should I be confirmed as HHS Secretary. 

Question. One of the most significant sources of assistance on the human services 

side of the Department of Health and Human Services is Temporary Assistance for 

Needy Families, or TANF. During the hearing, in your response to Senator McCaskill, you touted the success of TANF. However, according to HHS data, between 

1996—when the welfare reform law was enacted—and 2015, the number of poor 

families in Georgia receiving support through TANF dropped from 82 per 100 to just 

5 families per 100 while the population of poor Georgia families increased by over 

192 

7http://www.cbpp.org/sites/default/files/atoms/files/tanf_trends_ga.pdf and http://www. 

cbpp.org/research/family-income-support/how-states-use-funds-under-the-tanf-block-grant. 8http://www.cbpp.org/research/family-income-support/tanf-continues-to-weaken-as-a-safety- net and http://poverty.ucdavis.edu/faq/what-deep-poverty. 9http://www.cbpp.org/research/family-income-support/tanf-cash-benefits-have-fallen-by-morethan-20-percent-in-most-states and https://fas.org/sgp/crs/misc/RL32760.pdf. 10http://www.cbpp.org/blog/tanfs-worsening-track-record-shows-why-its-not-a-model. 11https://www.aei.org/publication/welfare-reform-progress-states-step-up/. 12https://waysandmeans.house.gov/event/39841647/ and http://mlwiseman.com/wp-content/uploads/2016/05/Profiles-in-Courage.052216.pdf. 

50 percent.7 While Georgia is one of the most drastic examples, this overall trend 

is not unique to your home State. Nationally, TANF reached 68 percent of poor families when the 1996 law passed. It now reaches just 23 percent of such families, despite the fact that extreme poverty has more than doubled.8 Moreover, TANF has 

faced effective cuts of over 30 percent since its creation in 1996 and benefit levels 

have also declined.9

Do you believe TANF has been a success both across the Nation and in your home 

State of Georgia? 

Answer. Yes. Since the passage of TANF, we have seen employment rates of single mothers increase, lower poverty rates among female-headed households with 

children and African-American households, a reduction in child poverty overall, and 

a sharp decline in the number of families receiving cash assistance. 

Question. What metrics do you use in making this determination? Please specifically address time periods beyond 2005 in describing your views. 

Answer. I think the best way to measure the success of the law is to see where 

the Nation was prior to its passage and where we are now. As I’ve pointed out, since 

passage of TANF, we have seen employment rates of single mothers increase, lower 

poverty rates among female-headed households with children and African-American 

households, a reduction in child poverty overall, and a sharp decline in the number 

of families receiving cash assistance. 

Question. Can you provide a commitment that Medicaid will not see cuts like 

what you’ve proposed in your budget and what has happened to TANF? 

Answer. I will provide a commitment that if I am honored to be confirmed as HHS 

Secretary, I will faithfully implement and administer all the laws passed by Congress. 

Question. President George H.W. Bush’s welfare advisor and one of the conservative architects of the 1996 law, Ron Haskins, has said, ‘‘States did not uphold their 

end of the bargain,’’ and argued that TANF is not a model for other programs, asking ‘‘So why do something like this again?’’ 10 A recent piece published by the conservative think-tank, American Enterprise Institute came to a similar conclusion 

noting that unfortunately, ‘‘some States have abandoned their responsibility to provide support to poor families and help them get jobs,’’and that enough States have 

stopped spending money on core services that, ‘‘it tarnishes the entire program.’’ 11

However, you resisted recent Republican-authored legislation that aimed to ensure States met even the most basic TANF spending obligations.12 You insisted on 

changes that essentially would grandfather in practices that let Georgia and other 

States continue to, to use the AEI publication’s words, ‘‘abandon their responsibility 

to provide support to poor families and help get them jobs.’’ 

If confirmed, will you continue to oppose efforts to ensure States hold up their 

end of the bargain with respect to investing their own dollars into the TANF program? 

Answer. States should contribute their part in State-Federal human services programs, even if we don’t always agree on the method for getting there. I have an 

open mind and welcome proposals to improve State-Federal human services programs to achieve the goal to reduce low-income families’ dependence on government 

aid through high levels of paid work, especially those that are well supported by 

evidence. We have a duty to the American taxpayers, and the people these programs 

were created to help, to find workable solutions to problems within these programs. 

If I am privileged to serve as the HHS Secretary, I will follow the policies adopted 

by the Congress and signed into law by the President that reform State-Federal 

human services programs. 

193 

13https://www.gpo.gov/fdsys/pkg/BILLS-114hr2959ih/pdf/BILLS-114hr2959ih.pdf. 

Question. Specifically, will you advise the President to oppose legislation, like H.R. 

2959 as introduced in the 114th Congress, that would phase out the practice of 

States being able to count third party spending towards their TANF maintenance 

of effort requirements? 13

Answer. The ultimate objective of human services programs is to help people 

stand on their own again after they have fallen down. Certain interpretations cut 

against this objective by keeping people down even when they want to stand up. 

I have a broad and open mind and welcome proposals to improve programs like 

TANF that would help people stand on their own again, especially those that are 

well-supported by evidence. If I am privileged to serve as the HHS Secretary, I will 

follow the policies adopted by the Congress and signed into law by the President. 

Question. In your testimony and meetings with committee staff, you stressed the 

need to establish better measures by which to evaluate the effectiveness of Federal 

human services programs. As you know, timely, accurate and relevant evaluations 

rely on: modern, efficient and integrated State and Federal data systems; effective 

data use agreements; and transparent and strong privacy and data security measures. Moreover, system modernization cannot only improve client services but reduce waste, fraud, and abuse. However, much of the funding currently being used 

to modernize and integrate systems comes through ACA and the OMB A–87 waiver. 

Will you commit to working, if confirmed, with Congress and the administration 

to sustain the current efforts to improve State and Federal health and human services data systems? 

Answer. Good data is an essential element for ensuring that we have accurate information and are able to effectively manage the programs under our charge. While 

funding decisions ultimately rest with Congress, if I am privileged to serve as the 

HHS Secretary, I will follow the policies adopted by the Congress and signed into 

law by the President to modernize State and Federal human services data systems. 

Question. The Maternal, Infant, and Early Childhood Visitation program 

(MIECHV) is a program that members on both sides of the aisle have championed 

due to the demonstrated success of its models in improving the health and wellbeing mothers and children. MIECHV’s innovative model has well-established goals, 

outcomes and metrics. 

MIECHV is due for reauthorization this year. At current funding levels ($400M/ 

year), the Department of Health and Human Services (HHS) estimates that only 3% 

of the eligible population receives MIECHV services. To me, reauthorization represents an opportunity to increase access to the program and improve the life course 

of children born into low-income households, while also reducing preventable government spending in the short and long term. 

In your home State of Georgia, the Great Start Georgia program receives 

MIECHV funds. The program’s aim is to provide evidence-based home visiting services to those families who are most in need of support and has met all 6 program 

benchmarks, including maternal and newborn health, family economic self-sufficiency, improving at-risk students’ school readiness, and reducing crime and domestic violence. 

If confirmed, how do you plan on continuing the successful MIECHV program? 

Answer. I share your goal of increasing access to affordable, quality health coverage. While I cannot comment specifically on legislation that would reauthorize 

MIECHV, I look forward to working with you on examining this program’s funding 

and working on ways to improve rural and child health using evidence-based approaches. 

QUESTIONS SUBMITTED BY HON. BILL NELSON

Question. Your health proposal would remove protections for individuals with preexisting conditions, allowing insurers to charge them higher premiums or denying 

them coverage altogether, unless an individual has maintained coverage for 18 

months. Your bill would expand high-risk pools as an option to individuals with preexisting conditions. In Florida, more than 7.8 million people have pre-existing conditions. 

194 

Please explain how you believe high-risk pools will provide quality coverage to the 

7.8 million people in my State who have pre-existing conditions. 

Answer. Pooling mechanisms that allow individuals to come together for the purchase of coverage, like the traditional Blue Cross Blue Shield Plan, have been successful in bringing down the cost of insurance for Americans. I believe this same 

concept could be successful in pooling the risk among those Americans with preexisting conditions. 

Question. Have high-risk pools been successful in providing adequate and affordable coverage in populous, high-costs States like New York or Florida? 

Answer. If confirmed, I look forward to working with you to implement commonsense solutions that prioritize flexibility for States like New York and Florida to design and operate their own high-risk pools or other risk-mitigation programs that 

suit their citizens’ unique needs. 

Question. You introduced the 2015 reconciliation bill, which would have repealed 

key parts of the Affordable Care Act, had it not been vetoed. The nonpartisan Congressional Budget Office released a report on the effects of your bill, including increased numbers of uninsured Americans and increased premiums. 

Last week, President Trump said the Republican replacement plan is ‘‘coming 

down to the final strokes.’’ He said that as soon as the HHS Secretary is confirmed, 

a repeal and replace plan will be submitted, ‘‘essentially simultaneously.’’ 

Is there a nearly fully formed replacement plan? 

If yes, what’s in the replacement plan? 

Does it provide insurance coverage for everyone as President Trump said? 

Does it protect individuals with pre-existing conditions from paying higher premiums or being denied coverage altogether? 

Does it allow children to stay on their parents’ insurance until age 26? 

Does it ensure that individuals struggling with substance use disorders or diagnosed with behavioral health conditions have adequate access to quality treatment? 

Answer. Plans for real health-care reform are a work in progress, but the President and I share the same goal: to provide relief to all Americans from Obamacare. 

Obamacare has raised premiums and deductibles, narrowed doctor networks, reduced choices of plans, limited Americans’ liberty, and undermined the doctor patient relationship. The goal is to make certain that every single American has access 

to the coverage they want for themselves. 

Question. What will you do to provide coverage to the more than 800,000 Floridians that could have been covered by Medicaid expansion? 

Answer. I look forward to faithfully executing whatever law that Congress passes 

and the President signs, if I am confirmed. I will promise you this: Regardless of 

the final legislative outcome, I would work as HHS Secretary to ensure that the 

Medicaid program is well administered, effective, and available for eligible beneficiaries and that the States/Governors are given the flexibility to pursue innovative 

approaches that fit the needs of their States. 

Question. Can you explain how, under a Medicaid block grant program, States like 

Florida would cover the unforeseen costs associated with public health crises, like 

Zika virus, or high cost prescription drugs, or unexpected sudden changes in demographics without harming another population? 

Answer. My work in the Congress has been focused on how to improve Medicaid 

and provide additional flexibility. If I have the privilege of being confirmed as Secretary, I would look forward to the opportunity to work with States and Congress 

using the tools and authorities given by Congress in legislation. The mechanics of 

any new Medicaid program along the lines described would be a legislative decision 

that would need to account for how to encourage States to save for such eventualities or how the Federal and State governments do so together. 

Question. Florida is currently in the process of renegotiating its section 1115 Medicaid managed care waiver. 

What safeguards and beneficiary protections do you believe HHS should keep in 

place when reviewing Medicaid waivers? 

195 

Answer. The 1115 waivers are an important tool for States to innovate within the 

Medicaid program, as they have for many years prior to the ACA becoming law. The 

statute itself has requirements for certain procedures. Furthermore, the democratic 

process in each State, where government is even closer to the people, provides substantial protection with regards to any 1115 waiver application and its implementation. 

Question. You introduced a bill to allow practitioners to enter into private contracts with their Medicare patients and charge higher fees than what is currently 

allowed under the Medicare program. Currently, when seniors in Medicare see their 

doctors, they are responsible for a set amount of costs and don’t encounter any surprise bills. Under current law, physicians who choose to participate in Medicare are 

not allowed to bill their patients for any costs that remain once Medicare pays their 

share of the bill, a practice that is commonly known as balance billing. 

Did you know that half of all Medicare beneficiaries had incomes of less than about $24,000 and savings below $63,350 in 2014? Is this the population that your 

bill targets? 

Answer. The Medicare Patient Empowerment Act is one approach to giving our 

seniors more flexibility within the Medicare Program and providing the opportunity 

to make decisions with their physicians without interference from Washington. The 

measure would help ensure that Medicare beneficiaries maintain adequate access to 

health-care professionals by increasing the number of physicians who will accept 

Medicare patients and addressing physician shortages by attracting new professionals to the field of medicine. In addition, the bill provides safeguards to Medicare 

beneficiaries. More importantly, my legislation would allow a provider to see a 

Medicare patient pro-bono or charge minimal cost (below the standard fee schedule) 

without prosecution. Without this legislation, a physician can be charged with fraud 

for failure to attempt to collect the full coinsurance amount under Medicare. 

Question. The Medicare Advantage program provides quality care to over 1.6 million Floridians and over 18 million seniors across the United States. 

Do you have any ideas about how to strengthen and build upon this vital and 

proven part of the Medicare program? In your role as Secretary of HHS, will you 

commit to supporting Medicare Advantage and protecting the Nation’s seniors as 

they age? 

Answer. Medicare Advantage provides an important option for Medicare beneficiaries to access coordinated care and greater benefits. If confirmed as Secretary, 

I would seek to ensure Medicare Advantage remains a stable option for beneficiaries 

and that Medicare Advantage plans are afforded the flexibility to design plans that 

beneficiaries want and give them the coverage they want. 

Question. Today, I joined a bipartisan group of Senators in reintroducing the Public Health Emergency Response and Accountability Act, which would fund the nearly empty Public Health Emergency Fund through mandatory appropriations designated as emergency spending, a proposal modeled after FEMA’s disaster relief 

fund. 

As HHS Secretary, would you work with me to protect my constituents from the 

Zika virus and other public health emergencies? Do you support the creation of an 

emergency health fund to provide mandatory appropriations to fight Zika and other 

infectious diseases? 

Answer. If confirmed as HHS Secretary, I give you my word I will do all within 

my power to protect your constituents, and the constituents of every Senator, from 

the Zika virus and other public health emergencies. Should Congress create a new 

program or alter an existing program, I will work to ensure the program is as effective as it can be in fighting Zika and other infectious diseases. 

Question. The increased use of generic drugs results in real savings due to their 

lower costs as compared to brand name drugs. Senator Collins and I asked GAO 

to examine the factors behind recent spikes in some generic drugs. GAO found that 

Part D generic drug prices declined overall since 2010—they fell about 59 percent. 

Additionally, GAO found that 300 of the more than 1,400 established generic drugs 

analyzed had at least one price increase of 100 percent or more between 2010 and 

2015. 

What do you believe should be done to keep generic drugs affordable? 

Answer. I appreciate that generic drugs play an important role in meeting many 

American’s health-care needs. If confirmed, I look forward to focusing on how we 

196 

can make health care more affordable, including prescription drugs, and build on 

policies that have helped to empower patients in meeting their health-care needs. 

Question. Amyotrophic lateral sclerosis (ALS) usually strikes people between the 

ages of 40 and 70, and for unknown reasons, military veterans are approximately 

twice as likely to be diagnosed with ALS. There is currently one FDA approved drug 

that modestly slows the progression of ALS in some people. While there is no cure 

or treatment that that halts or reverses ALS, scientists have made significant 

progress in learning more about this disease. 

The Centers for Disease Control and Prevention operate a National ALS Registry, 

which is a critical resource for (1) providing data to researchers focused on developing treatments and prevention strategies; and (2) matching patients to potential 

clinical trials. 

Please advise how the administration will support this work in fiscal year 2018 

and work with Congress to make the registry even more effective at confronting 

ALS. 

Answer. ALS is a devastating disease with far-reaching consequences for both 

those afflicted and their families, and as a physician I understand the hardships 

these individuals must endure. If confirmed, I plan to work to advance patientfocused health care, which will support efforts to better serve those suffering from 

ALS. 

Question. The ACA reauthorized the Minority Centers of Excellence (COE) program, housed within the Department of Health and Human Services. The Florida 

Agricultural and Mechanical University (FAMU) Pharmacy, located in Florida, is a 

grantee. COE supports curriculum-based initiatives for increasing minority and 

underrepresented individuals to become health professionals. 

Do you support preserving important programs like COE, Health Careers Opportunities Program, and Area Health Education Centers? 

Answer. As a physician, I understand the critical importance of diversity among 

health-care practitioners in order to meet the varied health-care needs of the American people. If confirmed, I look forward to working with you and others to ensure 

that we are supporting efforts to increase diversity within our Nation’s health-care 

workforce as part of advancing patient-focused health care. 

Question. CT colonography (CTC), also known as virtual colonoscopy, are diagnostic medical tests, which produce detailed images of the colon by using a combination of 2-dimensional x-rays and a 3-dimensional computer views. They have the 

ability to identify lesions and tumors on the kidneys and other organs and blockages 

in the coronary arteries. 

Currently, Tricare and private payers in 21 States and the District of Columbia 

cover virtual colonoscopies for colorectal cancer screening, but Medicare does not. 

Will you use your authority as Secretary to consider the addition of virtual colonoscopies as a colon cancer screening option for Medicare beneficiaries? 

Answer. As you know, CMS has a detailed process for making determinations regarding whether items and services are reasonable and necessary, if they can be 

considered eligible for Medicare coverage given other restrictions and prohibitions. 

I understand CMS’s decision to cover CT colonography only for diagnostic testing 

but not screening was based on the state of the technology at the time and the possible need for a confirmation colonoscopy in so many cases. If confirmed as Secretary, I would look forward to working with you to understand if revisiting this 

issue is appropriate and warranted. 

Question. On July 16, 2015, Proposed/Draft Local Coverage Determination for 

Lower Limb Prostheses (DL33787) (Draft LCD) was published by the four Durable 

Medical Equipment Medicare Administrators (‘‘DME MACS’’). Last year, the Coverage and Analysis Group, headed by CMS, was created to review the DME MAC 

recommendations. That Group continues to deliberate. 

Can you speak to what actions as an administrator you would take on finalizing 

this Draft LCD? 

Answer. Medicare coverage for prostheses can be a particularly challenging topic 

given the role this durable medical equipment plays in the lives of many Medicare 

beneficiaries. I understand CMS has stated it is committed to providing high quality 

care to Medicare beneficiaries in need of a prosthesis, that it has committed to a 

Workgroup the task of making recommendations concerning the best and most relVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00200 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
197 

evant measures in this realm, and that CMS will ensure there is opportunity for 

public comment and engagement. If confirmed as Secretary, I would be pleased to 

work with you to look into the timing of this matter and see what can be done to 

either expedite it or further support the work so there is assurance of its comprehensiveness and objectivity. 

Question. Representative Price, I know you are very familiar with the Centers for 

Medicare and Medicaid Service’s (CMS) Home Health pilot program known as the 

‘‘Pre-Claim Review Demonstration (PCRD)’’ which affects five States, including Florida. I am concerned that the PCRD may restrict beneficiary access to timely services, divert clinical resources to paperwork management, and incur high administrative costs. These concerns were amplified after hearing what the State of Illinois 

had been dealing with when PCRD began there in August 2016. 

In response to my concerns, CMS delayed PCRD in Florida until April 2017. 

While I understand the concern, CMS has with needing to tackle the improper payment rates, PCRD may not get to the root of the problem. 

As Secretary, how do you plan to tackle the problem of improper payments? Do 

I have your commitment that you will work with me to alleviate the concerns raised 

by the PCRD? 

Answer. The topic of improper payments is one of concern in the Medicare program—both overpayments and in some cases underpayments. Tackling them requires close support for the payment integrity team within CMS and close cooperation with the Office of the Inspector General and the Department of Justice. But 

it also involves a definition of scope and a prioritization—which improper payments 

are ones that reflect services not rendered and which involve a missing signature 

on a form. With that prioritization in mind, I am hopeful we can align resources 

to those areas of highest risk. 

As to the Pre-Claim Review Demonstration (PCRD), if confirmed, I would be 

pleased to work with you to address your concerns. For example, we may want to 

explore the experience of the Prior Authorization of Repetitive Scheduled NonEmergent Ambulance Transport demonstration to understand if there are applicable 

lessons for PCRD or vice-verse. 

Question. During the public comment period for the FDA’s tobacco deeming rule, 

the Small Business Administration’s Office of Advocacy filed concerns that the economic impact analysis conducted by FDA was ‘‘deficient’’ and should be recalculated. 

Small business premium cigar retailers and manufacturers in my State have expressed the same concern to me. Unfortunately, FDA took no action to address these 

concerns. 

Do you believe additional review of the costs of this regulation should be conducted before any additional implementation? 

Answer. Whenever the Federal Government implements its regulatory responsibilities, it is important to consider the costs, especially those imposed on small 

businesses. Any time economic impact analyses are conducted, I believe they must 

be fact-based. If I am confirmed, I would seek to better understand the SBA’s views 

of the regulation in question, which is consistent with the President’s commitment 

to reduce the overall regulatory burden on American businesses. 

QUESTIONS SUBMITTED BY HON. THOMAS R. CARPER

Question. The number one concern I hear from my constituents about health care 

is affordability. I was pleased to hear the President say that under his plan, health 

insurance will be better and less expensive for all Americans. Americans cannot afford to pay more for their health care. Even supporters of the President value the 

health benefits they have gained through the Affordable Care Act and could not 

bear the higher deductibles and decreased benefits that your earlier plans have 

called for. 

Can you ensure that under the President’s health-care plans, health insurance 

premiums, deductibles, and co-pays will decrease for all Americans? How exactly 

will you do this? 

Answer. President Trump and I have the same goals for health-care reform and 

the same general approach to meeting those goals. Neither one of us is wedded to 

a particular plan to the exclusion of all others. We see eye-to-eye on this, and are 

looking forward to giving the American people what they’ve been longing for, for 7 

198 

long years: real health-care reform. But they have never wanted Obamacare: It has 

raised premiums and deductibles, narrowed doctor networks, reduced choices of 

plans, limited Americans’ liberty, and undermined the doctor patient relationship. 

Question. The Congressional Budget Office (CBO) has found that repealing the 

ACA will cause more than 30 million Americans to lose their insurance and increase 

premiums by more than 20 percent. 

Do you agree that the President’s executive order to begin repealing the Affordable Care Act while there is no alternative plan creates instability and uncertainty 

that will only drive up costs in our health-care system? 

Answer. The insurers are deciding right now as they come forward in March and 

April what the premium levels will be for 2018. What they need to hear from us 

is a level of support and stability in the market, the kinds of things that are able 

to provide stability. There are counties in the State where there is only on provider. 

We must, as policymakers, ask what is going on. Where are the problems out there? 

The President’s Executive order is directed towards exactly that—reducing costs and 

the other burdens on the American people imposed by Obamacare. The initial reactions to the order from plans and others indicate this is something they anticipated 

based on the President’s promises and that the recent and current discussions regarding how to address the issue of costs have been productive. In fact, it is the 

costs of inaction which are not acceptable. 

Question. Do you believe that all Americans, regardless of income, should have 

health insurance and does the President share your views on this? Have you told 

the President that repealing the ACA without a replacement means 32 million 

Americans will lose their health insurance and add $9 trillion to our national debt? 

Have you had direct discussions with members of the Transition Team or the President’s current health-care advisers since your nomination? Would you insist that 

Congress hold multiple bipartisan hearings on the President’s health care proposal? 

Will you commit to, should you be confirmed, to answer our questions when such 

a proposal is sent to Congress and evaluated by the non-partisan, independent Congressional Budget Office? 

Answer. I think the conversation and focus in these topics has been the question 

of coverage rather than true access for too long. By that I mean that Americans 

might have an insurance card and yet not be able to afford care or it might not be 

available to them for other reasons. And so when we talk about coverage we ought 

to make clear what we really mean and want to have happen. In any case, the 

President has made clear his hope and plan for a replacement to Obamacare. The 

goal is to make certain that every single American has access to the coverage they 

want for themselves. 

Question. Sixty percent of the children born outside of marriage are from unplanned pregnancies. This is a major public health challenge, as children born from 

unintended pregnancies and raised in single parent households have a higher rate 

of mental health problems, a lower rate of high school graduation, earn less income 

than their peers, and cost more to taxpayers. Because of the Affordable Care Act, 

millions of American women can now afford contraception, without co-pay or costsharing, and the rate of unplanned pregnancies has dropped. 

Will the President’s plan to replace the ACA ensure these women will not have 

to pay more for contraception and put birth control out of reach for millions of young 

women and families? 

Answer. Women should have the health care that they need and want. The system we ought to have in place is one that equips women and men to obtain the 

health care that they need at an affordable price. 

Question. Health-care experts have found that obesity, smoking, and mental 

health challenges are the ‘‘root causes’’ of our country’s most persistent public health 

challenges. Together, tobacco, obesity, and mental health lead to more than a million deaths and cost us more than half a trillion dollars each year. It’s critical that 

all health insurance plans fully cover the treatment for these conditions. If the ACA 

is repealed, Americans would lose access to treatment for mental health care, smoking cessation, and obesity treatment. 

Under the bills and proposals you have championed, would the treatment and cost 

of insurance coverage for obesity, smoking cessation, and mental health care remain 

the same or decrease? 

199 

Answer. It has been the goal, for any legislation I have championed, for the treatment and cost of insurance coverage for all Americans to decrease. 

Question. The obesity epidemic has had a devastating impact on our health-care 

system, increasing the prevalence of nearly every major chronic condition, including 

heart disease, hypertension, diabetes, and cancer, and costing our country hundreds 

of billions of dollars every year to treat the variety of conditions attributable to this 

increasingly prevalent disease. A critical step in combating obesity was the decision 

by the AMA in 2013 to designate obesity as a disease. This designation is an important step towards ensuring the best medical care is provided to those suffering from 

this disease. 

Will you, as Secretary of Health and Human Services, follow the leading medical 

association and declare obesity as a disease and will you assist us in maximizing 

the use of all the medical interventions currently available to combat this crisis? 

Answer. Obesity is a chronic condition that takes its toll over many years and in 

many quiet ways. I agree it is an important priority for all involved in the healthcare system to address this toll. This is particularly the case because obesity is generally a preventable condition and can be controlled through changes in behavior. 

Fundamental to that is the relationship between patient and doctor which our current system has undermined in many ways. I can tell you that I will consider the 

legal framework within which any decision regarding the formal designation of any 

disease ought to take place and come to any decision with these considerations in 

mind. 

Question. Have you ever been a member of the Association of American Physicians and Surgeons? This group has said that the government poses a greater threat 

to patients than tobacco use, drug addiction, and excessive alcohol intake, and that 

patients should seek doctors who do not participate with Medicare, Medicaid, and 

private health insurers. When you were a member of this group, did you agree with 

this position? Do you agree with this position now? This group has also compared 

the use of advance directives—the process by which patients and their health-care 

providers plan for end of life care decisions in advance and when they are of sound 

mind and body—as ‘‘population control.’’ Do you agree with this comparison? 

Answer. My work has been focused on making sure that physicians and patients 

are ones making medical decisions, rather than the government. Once that relationship is undermined and patients do not trust their doctors or doctors do not think 

first about their patients then no other medical or public health goal can be 

achieved. This is important when it comes to chronic disease, preventive care and 

healthy choices, and life and death decision-making. For all these reasons, I have 

fought alongside many to ensure patients have these choices to make for themselves 

and with their doctors. 

Question. As you know, the Affordable Care Act prohibits health insurance companies from limiting coverage to individuals on the basis of sexual orientation and gender identity. But a number of your previous statements regarding lesbian, gay, bisexual, and transgender people indicate that you don’t support these consumer protections. 

As HHS Secretary would you support reversing these protections and jeopardizing 

the LGBT population’s access to health care? As Secretary of Health and Human 

Services, would you uphold the department’s efforts to ensure that health insurance 

companies do not deny or limit health-care coverage to LGBT people? 

Answer. If confirmed, my efforts and work as Secretary will be to seek the availability of the highest quality care for all Americans. The goal is to make certain that 

every single American has access to the coverage they want for themselves. Of 

course, consumer protections at Federal and State levels ought to be available to 

all consumers, not just certain ones who meet certain criteria. 

Question. Data has shown repeatedly that Federal resources devoted to fighting 

health-care fraud is well worth the investment. The Health and Human Services 

Department has found that for every dollar that is invested to fight fraud, the government recovers $5. On January 23, 2017, the President announced a hiring freeze 

on government workers, which would include a freeze on hiring investigators and 

attorneys devoted to protecting Medicare and Medicaid from criminals. The GAO 

has repeatedly listed Medicare and Medicaid as two of the Federal Government programs most vulnerable to fraud, waste, and improper payments. Unfortunately, this 

freeze only leaves Medicare and Medicaid more vulnerable to fraud. 

200 

Do you agree with these concerns and if confirmed, will you recommend to the 

President that the hiring freeze should be lifted for Federal workers fighting criminal activity, waste, and fraud in Medicare and Medicaid? 

Answer. The President’s memorandum is not for time immemorial. It provides 

that within 90 days of its issuance, the Director of OMB, in consultation with the 

Director of OPM, shall recommend a long-term plan to reduce the size of the Federal Government’s workforce through attrition and that the ‘‘freeze’’ will expire upon 

implementation of the OMB plan. If confirmed as Secretary, I will take into account 

in weighing in with OMB and OPM the clearly important role our fraud fighters 

play which you outline. 

Question. During your time in Congress, you have supported proposals that would 

block grant Medicaid or put a per capita cap on Medicaid spending. The Congressional Budget Office has found that reversing the Medicaid expansion under the Affordable Care Act would lead to the loss of health care for millions of Americans 

and would lead to State funding shortfalls of $1 to $2 trillion. 

Do you support proposals to block grant or cap Medicaid? Do you agree that block 

granting or capping Medicaid would save the Federal Government as much as $1 

to $2 trillion? 

Answer. Every State has different demographic, budgetary, and policy concerns 

that shape their approach to Medicaid. That is one of the reasons I devoted so much 

time to working with States to help them to identify creative solutions, and why I 

believe a one-size-fits-all approach is not workable for a country as diverse as the 

United States. Of course, the specifics of any particular proposal to provide more 

flexibility to States will determine its budgetary consequence. 

Question. The American Association of Actuaries has pointed to risk corridors and 

other risk mitigation programs as important mechanisms for stabilizing our insurance markets. These programs were also included in the Medicare Part D program 

and remain in place today. Please just give us a yes or no answer to the following 

questions. 

Do you support the use of these programs in Medicare Part D? Did you support 

these programs as a part of the State insurance marketplaces created by the Affordable Care Act? Do you think these types of programs should be included in any plan 

to improve on the ACA or to replace the ACA? 

Answer. Risk adjustment is used to adjust payments to health plans based on the 

relative risk of plan participants. Reinsurance has been used to reimburse insurers 

for the cost of individuals who have unusually high claims. And risk corridors are 

used to mitigate the pricing risk that insurers face when they lack data on health 

spending for potential enrollees. Part D has successfully deployed these mechanisms 

consistent with the underlying direction of Congress. The issue with any of these 

programs is often in the way they are implemented and the direction Congress gives 

with respect to them. In any current or future legislation, it would be important to 

consider these issues closely. 

Question. You have expressed concerns with delivery system reforms and in particular, bundled payments. 

Please talk about your recommendations for how we can move away from fee for 

service reimbursement to a health care payment system that rewards better health 

outcomes and reduced costs. 

Answer. For certain populations, bundled payments make a lot of sense. And they 

can often lead to both better health outcomes and reduced costs. But it is important 

we not get fixated on one of those two outcomes. That is, I support making certain 

that we deliver care in a cost-effective manner but we absolutely must not do things 

that harm the quality of care being provided to patients. What we ought to do is 

allow for all sorts of innovation. Not just in this area. There are things that haven’t 

been thought up yet that would actually improve health-care delivery in our country 

and we ought to be incentivizing that kind of innovation. And in finding our way 

to those innovations, we ought to remember we are not talking about science experiments in a lab or a computer simulation, but about experiments involving real patients’ lives. 

Question. During your time in Congress, how have you worked to strengthen and 

improve community health centers in your district and in the country? Do you think 

we should increase the presence of community health centers to increase Americans’ 

access to health care? 

201 

Answer. Community health centers are a vital part of our medical infrastructure. 

They fill a void in so many States and are often times the entry point if not the 

main source of health care. I have sought to support them to make sure they can 

provide the highest quality care and will continue to do so if confirmed. 

Question. I have always felt that we can’t manage what we can’t measure. You 

point to having good metrics as an important tool for ensuring we’ve made good 

progress. I agree with you wholeheartedly. 

With your wealth of experience as a physician, a State legislator, a Congressman, 

and the chairman of a major House committee writing major legislation, please 

share with me the metrics we should use to measure our progress towards a more 

just and equal health-care system that ensures affordable and high quality health 

care for all Americans. If you cannot name any specific metrics, can you outline the 

process by which we should determine what metrics we should use to measure 

progress towards increasing access to health care? 

Answer. The fundamental metric for knowing that our system is on the right 

track is the centrality of the patient in the system and their ability to make choices 

about their care in consultation with their doctor. Without that, the most impressive 

facilities and technology are not serving our people’s needs, nor is the most efficient 

system doing what is most important. With the patient at the center of the system 

as a foundation, all else is possible and achievable. 

Question. During the debate over the Affordable Care Act, Congress held more 

than 100 bipartisan hearings, roundtable discussions, and negotiations, which were 

predominantly open and transparent to the public. The legislation was open to 

amendment by both parties in lengthy committee markups and by the full Senate, 

completely evaluated by the Congressional Budget Office, and reported on extensively by the news media before Congress voted on final passage. I understand that 

you place a high premium on transparency and honesty. 

Will you commit to having the same level of bipartisan discussion, transparency, 

and honesty in putting together the President’s proposal for reforming our country’s 

health-care system and ensuring that all Americans will have affordable and high 

quality health care? 

Answer. The President has made clear his hope and plan for a replacement to 

Obamacare. At the same time, many in Congress have their own ideas. And the conversation about how those will play out is ongoing. That is the nature of our democracy. I certainly hope we will have bipartisan support for any approach to fixing the 

current system, which we must all agree is broken. If confirmed, I look forward to 

working with anyone in Congress willing to work with me and the administration 

generally to come up with the best replacement plan under the procedures and involving the processes the Congress considers appropriate so as to make available the 

highest quality care to all Americans. 

Question. Do you agree with the President that the sale of health insurance over 

State lines will increase competition and lower the cost of health insurance? Section 

1333 of the Affordable Care Act already allows States to form interstate compacts 

to allow for the sale of health insurance over States lines? The States of Georgia, 

Maine, Kentucky, and Wyoming allow for out-of-state insurance sales, but virtually 

no out-of-state insurers have tried to sell insurance in these States. How would you 

increase the sale of insurance over State lines while maintaining consumer protections such as insurance coverage for contraception, preventive screenings, maternity 

care, and mental health treatment? 

Answer. The idea of allowing interstate sale of insurance may take many different 

forms. I agree with the President that it is an important option to increase competition and lower the cost of insurance. While the details of any such proposal would 

have to consider the extent to which benefit design varies among States, it is important that individuals be able to purchase the coverage that they want and there has 

to be a floor of creditable coverage. 

QUESTIONS SUBMITTED BY HON. CHUCK GRASSLEY

Question. As someone who is being considered to lead the Department of Health 

and Human Services, and as a physician, do you have any doubts about safety and 

effectiveness of vaccines? 

202 

Answer. I understand the significant impact vaccines have had on our Nation’s 

public health, as well as the importance of patients having confidence in the therapies they receive as part of their care. 

Question. As a physician would you recommend that families follow the recommended vaccine schedule that has been established by experts and is constantly 

reviewed? 

Answer. As a physician, I encourage individuals and families to consult with their 

physician on the most appropriate care for them and their loved ones. 

QUESTIONS SUBMITTED BY HON. ROBERT MENENDEZ

CLAMPDOWN ON COMMUNICATIONS WITH THE PUBLIC AND CONGRESS

Question. Shortly after your hearing concluded, press reports came out that a 

memo was issued to employees of the Department of Health and Human Services 

and the National Institutes of Health prohibiting any external communication 

throughout the entire Department. Specifically, the press accounts quote the memo 

as stating ‘‘[f]or your additional awareness, please note that (HHS employees) have 

been directed not to send any correspondence to public officials (to include Members 

of Congress and State and local officials) between now and February 3, unless specifically authorized by the Department[.]’’ 

I find this to be an unconscionable clampdown of information and a rejection of 

basic transparency and accountability standards that should seriously concern all 

Americans. This is made all the more concerning given the health-care, public safety, research, and biodefense programs that operate within HHS. 

Do you support this directive or any other department-wide order to suppress the 

flow of information between the Department of Health and Human Services, the 

public and Congress? 

If confirmed, do you commit to never imposing such restrictions on any agency, 

office, or employee at HHS that limits their ability to communicate with the public 

and Congress? 

During your hearing today you agreed ‘‘to provide a prompt response in writing 

to any questions that may be submitted to you or addressed to you by any Senator 

of this committee[.]’’ Do you believe this directive prohibits you from fulfilling that 

commitment to the committee? 

Were you aware this directive was going to be issued prior to the time of your 

hearing on January 24, 2017? 

Answer. The Acting Secretary Memo to Department of Health and Human Services operating and staff division heads is straightforward and consistent with the 

Chief of Staff Memo issued on behalf of President Trump with regard to regulatory 

review of new or pending regulations and guidance. As noted in the HHS memo, 

the purpose of the directive is to ensure ‘‘President Trump’s appointees and designees have the opportunity to review and approve any new or pending regulations 

or guidance documents.’’ Furthermore, the Chief of Staff memo provides explicit exceptions for ‘‘emergency situations or other urgent circumstances relating to health, 

safety, financial, or national security matters. . . .’’ This request is standard for a 

new administration. With regard to correspondence to public officials, such as members of Congress, the memo outlines a clear and expedited process for adequate review and is by no means intended to impede the agencies or staff divisions from 

continuing their important work on behalf of the American people, including routine 

constituent service communications. 

FIDELITY TO SCIENCE AND TO DEBUNKING DANGEROUS FALSEHOODS

Question. During the hearing I raised a series of debunked and fake health and 

science claims, all of which have been perpetrated and advanced by the Association 

of American Physicians and Surgeons, a group to which you currently, or previously, 

have been a member. These debunked and factually inaccurate claims include linking undocumented immigrants to a spike in leprosy, connecting abortions to breast 

cancer, and claiming that the HIV virus doesn’t lead to AIDS. This group has also 

promoted widely debunked and untrue claims that vaccinations lead to the development of autism spectrum disorder. These are dangerous claims made all the more 

toxic for being promoted by a group comprised of medical professionals. What’s even 

203 

more dangerous is that the President himself has a long history of promoting falsehoods linking vaccinations to autism. 

Will you state unequivocally that vaccines do not have any link to the development of an autism spectrum disorder and confirm that such all claims are fraudulent and have been widely debunked? 

Answer. General scientific consensus at this time is that vaccines do not lead to 

autism spectrum disorder. As always, this is an area where patients and the parents of patients should consult with their doctor. 

Question. Will you, if confirmed to be the Nation’s highest ranking health care official, actively work to debunk these types of false health-care and scientific claims? 

Answer. If confirmed, I will work to hold HHS to the highest scientific standards. 

Question. Do you ensure that no political appointee within any agency, department or office in the Department of Health and Human Services believes in, or has 

promoted, demonstrably false statements about health-care practices or debunked 

scientific claims? 

Answer. As a physician, I understand the importance of patients having confidence in the therapies they receive as part of their care. When confirmed, I commit 

to conducting the due diligence HHS must to ensure that factual, science-based information is clearly communicated to the American people. 

Question. Will you advise that the President not appoint anyone to the staff of 

the Executive Office of the President who believes in, or has promoted, demonstrably false statements about health-care practices or debunked scientific claims? 

Answer. As a physician, I understand the importance of patients having confidence in the therapies they receive as part of their care. When confirmed, I commit 

to conducting the due diligence HHS must to ensure that factual, science-based information is clearly communicated to the American people. 

AUTISM POLICY

Question. Since I first learned that New Jersey has the highest incidence of autism in the country, I have been Congress’s leading advocate for advancing Federal 

policy to help individuals and families with autism and other developmental disabilities. Recently, the CDC released updated numbers showing that 1 in just 41 children in New Jersey are diagnosed with an autism spectrum disorder by the age of 

8. This is the highest rate in the Nation. 

In 2014, I authored the Autism Collaboration, Accountability, Research, Education, and Support Act of 2014, known as Autism CARES. Among the several key 

policies included in this law was the continuation of the Interagency Autism Coordinating Committee and the elevation of a senior Health and Human Service official 

to serve as the HHS Autism Coordinator. 

Do you commit to ensuring individuals appointed to these key positions maintain 

a fidelity to science, and will you ensure that they will have the ability and freedom 

to debunk false claims linking autism to vaccines (or any other similar demonstrable 

falsehoods) without fear of retribution from you or the White House? 

Do you commit to promoting, through your capacity as Secretary and through the 

President’s annual budget, increased funding for autism research and supports and 

services programs? 

What specific steps will you take as Secretary to promote and support a robust 

environment throughout the Department that focuses on research into diagnosis, 

treatments, supports and services, specifically those targeting adolescents and 

adults with autism and other developmental disabilities? 

The Centers for Disease Control and Prevention report that a child with an autism spectrum disorder can be diagnosed as early as age 2, yet children are frequently much older at the time of diagnosis. List the specific steps will you take 

to promote early diagnosis and early intervention? 

Answer. As a physician, I understand the importance of patients having confidence in the therapies they receive as part of their care. If confirmed, I commit 

to conducting the due diligence HHS must to ensure that factual, science-based information is clearly communicated to the American people. HHS is involved in a 

number of autism-related initiatives with the important goal of helping the individVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00207 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
204 

uals and families living with autism. When confirmed, I look forward to continuing 

this important work on behalf of these individuals and families. 

Question. The Affordable Care Act, as part of the Essential Health Benefit Package for plans sold on the Marketplace, requires that all carriers provide coverage 

for behavioral health-care services, including those for autism. This was an amendment that I had included into the ACA, and it has provided families across the Nation with assurances that their children’s coverage will provide them with the care 

they need. 

Do you commit to maintaining nationwide access to behavioral health care by preserving the Essential Health Benefits package? 

Answer. My hope is to move in a direction where insurers offer products people 

want and give them the coverage they want. And in so doing, we want to not lose 

sight of our shared objective of the best and highest quality care being available to 

every American. I refer to care because ultimately, having maternity or other coverage is not meaningful if one cannot access the care they need or the quality of 

care leaves them worse off. So we must work towards both coverage and care. 

Question. Do you strongly disavow any attempt to weaken this coverage standard 

or any attempt at the Federal level to preempt States, like New Jersey, that have 

a long-standing State requirement that insurance provides benefits that cover services for autism? 

Answer. I am respectful of the role of States and, if confirmed as Secretary, will 

work to provide States with flexibility along the lines described and consistent with 

President Trump’s Executive order Minimizing the Economic Burden of the Patient 

Protection and Affordable Care Act Pending Repeal. 

Question. Medicaid is a literal lifeline to those with autism and other developmental disabilities. Every year, 50,000 of these individuals age out of school-based 

services and need access to home and community-based care to ensure they live as 

active and integrated a life as possible. This is largely accomplished through Medicaid. 

List the specific policies will you promote as Secretary to expand access to home 

and community-based services for individuals with autism and other developmental 

disabilities? 

Answer. Every State is unique in their specific approach to the provision of services for the population eligible to receive HCBS, and we stand ready to assist States 

as they develop strategies to meet their particular goals. 

Question. List the specific steps will you take to improve outcomes for transitionaged youth and ensure that they maintain access to services and supports? 

Answer. If confirmed, I would work as HHS Secretary to ensure that the Medicaid 

program is well administered, effective, and available for eligible beneficiaries and 

that the States/Governors are given the flexibility to pursue approaches that fit the 

needs of their States. 

Question. The Autism CARES Act of 2014 requires the Secretary of Health and 

Human Services to submit to this committee a report concerning young adults with 

autism and the challenges related to the transition from existing school-based services to those services available during adulthood. This report is long overdue. 

When will this report be finalized? Will you prioritize the finalization and submission of this report to Congress before March 31, 2017? 

Answer. If confirmed, I would be pleased to work with you on the status and finalization of this report. 

COMMUNITY HEALTH CENTERS

Question. Federally Qualified Health Centers (FQHCs) are the health-care home 

for more than 25 million patients nationwide with 494,912 Community Health Center patients in New Jersey. In New Jersey, FQHCs save the State and hospitals millions of dollars when patients are seen at health centers rather than in emergency 

rooms. FQHCs cost of care is substantially lower than other types of providers, even 

though they provide a wide range of ancillary services not offered in other healthcare settings. As an example, FQHCs in New Jersey have a lower average perepisode cost than health centers nationally, and almost half that of hospitals. 

205 

Further, community health centers are essentially one-stop shops for health care, 

providing medical, oral health, mental health, substance abuse, and other critical 

services at the same location. The 23 New Jersey Community Health Centers make 

up the largest primary care network in the State, providing care to almost half a 

million patients in over 131 sites of care including in schools, homeless centers, and 

public housing. Beyond just providing health care, our State’s FQHCs employ more 

than 180,000 individuals, and generate over $26 billion annually in economic impact 

to some of the Nation’s most distressed communities. 

What is the specific dollar amount that Community Health Centers stand to lose 

as a result of ACA repeal and the repeal of Medicaid expansion funding? 

Answer. I am not aware of the specific dollar amount. 

Question. How many fewer patients will not get health-care services at Community Health Centers as a result of ACA repeal and the repeal of Medicaid expansion 

funding? 

Answer. I do not have this figure. 

Question. What will be the impact on any ongoing Community Health Center expansion project that will be halted as a result of ACA repeal and the repeal of Medicaid expansion funding? 

Answer. We are committed to supporting Community Health Centers, providing 

increased access to care for patients across the Nation. 

Question. Please provide an economic impact, including lost jobs and diminished 

economic impact, that will occur as a result of ACA repeal and the repeal of Medicaid expansion funding? 

Answer. To my knowledge, repeal of the ACA is projected to have a positive impact on the labor market and the economy. 

Question. If the ACA is repealed, list the specific steps you will take to further 

promote the importance of seeking preventative care rather policies which encourage patients to wait until they have to go to the emergency room? 

Answer. Our goal is to ensure that all Americans have access to affordable coverage that best meets the needs of them and their families so that they can receive 

preventative care from the doctor of their choice in a primary care setting. 

Question. Do you commit to maintaining current funding levels for Community 

Health Centers, not only in the Department’s annual budget submission to Congress, but in ongoing operations that will be financially damaged by the repeal of 

the Affordable Care Act? 

Answer. I support Community Health Centers, however, funding levels are determined by Congress. If confirmed, I will uphold the law as passed by Congress and 

signed by the President. 

INTERSTATE SALE OF HEALTH INSURANCE

Question. One of the policies that you and President Trump often refer to in your 

talks about an ACA ‘‘replace’’ plan is to allow insurance to be sold across State lines. 

As you must be aware, the ACA already allows for this, and several States—including your home State of Georgia—have passed State laws to allow for it too. 

In the 5 years since Georgia started allowing out-of-state insurance to be sold, 

how many insurance companies have started selling out-of-state plans? 

How has allowing out-of-state plans impacted consumer choice in available health 

insurance plans, what has been the impact on insurance costs, and what has been 

the impact on access to care in Georgia? 

How many States have indicated they want to form a compact to allow out-ofstate plans, under the current law? 

How would this lack of interest on the part of States and insurance companies 

change under the plan you’ve previously proposed (e.g., title III of H.R. 3200, the 

Empowering Patients Act)? 

As a former physician who had to negotiate with insurance companies to be in 

their networks, wouldn’t you prefer to work with an insurance company that knew 

you and your patients, or would you prefer one from across the country that knows 

nothing about you, your practice, or your patient population? 

206 

Answer. It’s no surprise that an overwhelming majority (85%) of Americans support the ability to purchase insurance across State lines. More important than insurance companies’ views about more competition or State regulators’ views about 

greater regulatory competition is the fact that American families are desperate for 

more affordable health-care choices. It’s our job to make certain that every American has access to the highest quality care and coverage that is possible. Opening 

up more health options for American families by allowing them to purchase a plan 

from another State will do just that. Understandably, insurance companies and 

States have been reluctant to take bold action to sell products across State lines 

with the heavy burden of Obamacare already on the books. Removing Obamacare’s 

insurance mandates and regulations combined with the ability to reach more customers will ultimately reward American families with more choices at lower costs. 

Question. One of the consistent arguments you’ve made against the ACA is that 

it was a Federal takeover of health care and that oversight of the health industry 

is better left to States. 

If you do in fact believe that, how does undermining States and their insurance 

commissioners by imposing interstate sale of health insurance follow that same 

logic? 

Answer. If confirmed, I look forward to working with States to increase access to 

affordable coverage. 

RECUSAL FROM AMA-RELATED ACTIVITIES

Question. The American Medical Association’s (AMAs) House of Delegates is, to 

quote their website, the ‘‘principal policy-making body of the AMA.’’ You’ve been a 

Delegate for more than a decade and have presumably been involved in the development of the organization’s policies relating to key issues before both Congress and 

HHS during that time. You’ve stated that if confirmed you intend to recuse yourself 

from any issues the AMA has worked on for 1 year. 

How did you determine that a year is a sufficient period of time for your recusal 

from all AMA-related activity? 

Answer. This matter has already been addressed with the OGE and designated 

agency ethics official, and I will abide by the obligations agreed to in my publicly 

available ethics agreement. 

Question. Does the clock on this year start on the day you assume the role of Secretary or do you currently consider that year to have already started? 

Answer. The terms of my publicly available ethics agreement, which I entered 

into in consultation with the Office of Government Ethics and my designated agency 

ethics official, make clear that the 1-year recusal window begins on the day of the 

confirmation. 

Question. If the Department’s General Counsel, Office of Inspector General or any 

other authority within the HHS determines that a year recusal is insufficient to 

properly distance yourself from your previous work with the AMA, will you commit 

to extending the recusal period for the remainder of your tenure as Secretary? 

Answer. I will abide by the obligations agreed to in my publicly available ethics 

agreement, which I entered into in consultation with the OGE and my designated 

agency ethics official. 

Question. A quick search on the AMA’s website shows that the organization has 

formally commented on issues as varied as Medicare Advantage, the physician fee 

schedule, FDA oversight of laboratory developed tests, Medicaid and CHIP, CMS 

quality measures, Medicare prescription drug benefits, electronic health record 

meaningful use requirements, guidelines for opioid prescribing, and the comprehensive joint replacement model you’ve spoken out against so frequently. Obviously the 

group representing doctors has myriad interests in the workings of virtually every 

agency and office within HHS. 

Please provide me with documentation outlining exactly how you will recuse yourself from all AMA-related activities, which includes specific details on the HHS policies this recusal impacts. Further, please provide a list of all personnel within the 

Department that will be designated to act on your behalf for all the listed polices 

for which you will be recused. 

207 

Answer. This matter has already been addressed with the OGE and designated 

agency ethics official, and I will abide by the obligations agreed to in his publicly 

available ethics agreement. 

I have not yet been confirmed or hired any personnel to assist efforts in the Department of Health and Human Services. 

Question. As a member of the AMA’s House of Delegates for more than a decade, 

it’s safe to presume that you are familiar with, and supportive of, their policies. One 

of these policies states that the ‘‘AMA recognizes that uncontrolled ownership and 

use of firearms, especially handguns, is a serious threat to the public’s health’’ because they are the leading cause of premature death in the country. 

Do you agree that guns are a top cause of intentional and unintentional death, 

as the AMA states? 

As a member of the AMA’s House of Delegates, at any point did you fight against 

the AMA taking a stance declaring guns to be a public health issue? 

Do you oppose government prohibitions on studying how gun violence affects the 

public health? If confirmed, will you commit to not imposing government prohibitions on any agency, department or office from conducting gun-related health research to improve public health? 

Answer. Violence is a challenge in our society that deserves greater attention. All 

Americans want our communities to be safe places to live, learn, work and play. To 

my best recollection, I have not taken an individual stance on this matter. To the 

question of how best to prevent the tragic loss of innocent lives, I believe we must 

take a hard look at the underlying issues contributing to these tragic events, including too often unmet mental health needs among our citizens. A proper diagnosis and 

treatment as part of patient-focused care are critical to ensuring we are identifying 

indicators of violent behavior that may contribute to tragic events. 

EVIDENCE-BASED HOME VISITING PROGRAMS

Question. I have been a strong supporter of the Maternal, Infant, and Early Childhood Visitation program (MIECHV), which has always enjoyed bi-partisan support. 

MIECHV was enacted as part of the Affordable Care Act to help States build capacity to provide in-home visits to at-risk mothers and families with the stated goals 

of improving maternal and child health, preventing child abuse and neglect, encouraging positive parenting, and promoting child development and school readiness. 

The Medicare Access and CHIP Reauthorization Act (MACRA), passed in 2015, 

reauthorized the program for 2 years. This reauthorization maintains current funding, which unfortunately is only enough resources to provide services to only 3 percent of the eligible population who are currently receiving MIECHV services. This 

points to a missed opportunity to improve the life course development of children 

born into low-income households, while also reducing preventable government 

spending in the short and long term. 

Do you commit to supporting continuation of funding for the MIECHV program 

in the Department’s annual budget submission? Do you recognize the value of the 

MIECHV program and its evidence-based design by proposing increases in funding 

to capture more than just 3 percent of those children and families who could greatly 

benefit through the program’s services? 

Answer. I share your goal of increasing access to affordable, quality health coverage for rural America. While I cannot comment specifically on legislation that 

would reauthorize MIECHV, I look forward to working with you on examining this 

program’s funding and working on ways to improve rural and child health using evidence-based approaches. 

DIVERSITY IN HIRING

Question. The Affordable Care Act expanded health-care coverage to millions of 

Americans who were previously uninsured. Because of the greater demands on the 

health-care industry, the ACA has also become an engine for job growth in the 

health related fields. This is especially true for women and people of color. 

For example, women represent 75% of the health-care workforce. Nearly half of 

workers in the long-term/residential and home health-care services are people of 

color. The future of our American workforce in the health industry promises increasing diversity. Between 2003–2004 and 2013–2014 the number of doctoral degrees 

conferred in health profession fields increased by 61 percent (from 41,900 to 67,400 

208 

14https://nces.ed.gov/programs/coe/indicator_svc.asp. 15https://nces.ed.gov/programs/digest/d15/tables/dt15_324.25.asp. 16Mitchel, D.A. and Lassiter M.A. (2006) Addressing health care disparities and increasing 

workforce diversity: The next step for the dental, medical, and public health professions, American Journal of Public Health, 96 (12), pp. 2093–2097. 17https://www.hhs.gov/sites/default/files/asa/ohr/spd/di/newsletter/dinewsletterfallwinter 

15.pdf. 18https://minorityhealth.hhs.gov/assets/pdf/checked/1/ANDERSON.pdf. 19https://minorityhealth.hhs.gov/assets/pdf/FINAL_HHS_Action_Plan_Progress_Report_11_2 _2015.pdf. 

degrees).14 In 2013–2014, one-third of those doctoral degrees were awarded to people of color.15 The importance of a diverse workforce in the health industry has been 

well-documented in scientific literature. One of the more significant outcomes of a 

diverse workforce is greater access to and quality patient care.16 Diversity in the 

workforce also increases career opportunities for people of color. 

Given the fact that the current administration intends on gutting the Affordable 

Care Act, which, along with leaving millions of Americans uninsured, will also leave 

thousands of women and minorities without an opportunity to build a career in their 

field of study: 

Will you commit to minimizing the impact of leaving thousands of incoming 

women and minority health-care professionals without a career path to look forward 

to? 

Answer. Workforce issues are a major challenge in health care. We should work 

together to expand career options and paths for all health-care professionals. 

Question. The Department of Health and Human Services is among the most diverse agencies to work for within the government, except when it comes to its Hispanic labor force. In FY 2015, Hispanics comprised 3.08% of HHS’s workforce compared to 9.96% of the National Civilian Labor Force.17

What concrete steps does the Department of Health and Human Services plan to 

take to increase diversity and inclusion in its agency, especially at its Senior and 

Executive levels? 

Answer. If confirmed, I would be pleased to work with you to identify steps that 

could be taken to ensure the Department is drawing upon the widest and most diverse pool of applicants possible in the hopes of it resulting in an even more diverse 

workforce. 

DIVERSITY IN HEALTH OUTCOMES

Question. Eliminating health-care disparities among Americans from minority racial and ethnic backgrounds has long been a bipartisan issue. In 1985 under President Reagan, then Secretary of Health a Human Services Margaret Heckler commissioned a report on Black and Minority Health where she noted that there was 

a ‘‘continuing disparity in the burden of death and illness experienced by [. . .] minority Americans as compared with our Nation’s population as a whole.’’ The report, 

as she envisioned, should have marked ‘‘the beginning of the end of the health disparity that has, for so long, cast a shadow on the otherwise splendid American track 

record of ever improving health.’’ 18

Unfortunately that shadow is still cast over our country. There is a significant 

body of literature that indicates that disadvantaged populations, such as racial and 

ethnic minorities, still face systemic barriers to achieving ideal health. For example, 

African Americans are 50% more likely to die from heart disease or stroke; Asian/ 

Pacific Islanders are 60% more likely to have acute Hepatitis B, which causes liver 

disease; and African-American, Native Hawaiian/Other Pacific Islander, and Hispanic adults all have rates of HIV infection diagnosis that range from three to nine 

times the rate of non-Hispanic Whites. 19 To that end, the Affordable Care Act established Offices of Minority Health within six agencies, thus expanding the work 

begun by President Reagan 30 years ago. The purpose of creating these offices was 

to have greater interagency coordination when it comes to eliminating minority 

health disparities. 

To the extent that this administration has taken and will continue to take concrete steps to repeal the ACA, which created the Offices of Minority Health within 

the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease 

Control and Prevention (CDC), the Food and Drug Administration (FDA), the 

Health Resources and Services Administration (HRSA), the Centers for Medicare 

209 

and Medicaid Services (CMS), and the Substance Abuse and Mental Health Services 

Administration (SAMHSA): 

Will you commit to prioritizing the elimination of minority health disparities in 

America a priority? Please provide specifics of how you plan to make this a priority. 

Answer. Health outcome disparities are a challenge and prioritizing work in this 

area is important. Using the proper metrics may provide important insight into new 

solutions. 

QUESTION SUBMITTED BY HON. ROB PORTMAN AND HON. SHERROD BROWN

Question. HHS, through CMS, has a long tradition of supporting nursing education. Our State of Ohio is home to 12 facilities that receive Medicare pass-through 

funding for nursing education. Over the past few years, CMS support for nursing 

education funding has been under threat due to accreditation changes. We have authored a bill, the MEND Act that would ensure CMS support of nursing education 

through pass-through funding continues and that we can continue educating high 

quality nurses. 

If you are confirmed, will you commit to work with us in Congress to provide technical assistance and ensure that the MEND Act is quickly implemented if passed? 

Answer. I look forward to working with you on this issue and sharing both feedback and assistance regarding the important policy and technical issues in nursing 

education funding, an issue related to and similar to the challenges with physician 

shortages but broader in geographic scope and impact. If the law is implemented, 

and if confirmed, I will ensure it is implemented on the timeline Congress imposes. 

QUESTION SUBMITTED BY HON. ROB PORTMAN AND HON. ROBERT P. CASEY, JR. 

Question. Section 154 of MIPPA 2008 specifically excludes from the Medicare 

DME competitive bidding program (CBP) CRT power wheelchairs, as well as the accessories that consumers use with those wheelchairs. Consistent with the law, Congress did not include those CRT items in Rounds 1 or Rounds 2 of the DME bidding 

program and has repeatedly expressed to CMS that it was not the intent of the law 

to apply bid rates to accessories used with CRT wheelchairs. Unfortunately, CMS 

has interpreted MIPPA contrary to congressional intent and in December 2014 CMS 

posted on-line a ‘‘Frequently Asked Questions’’ (FAQ) document stating that starting 

in January 2016 CMS intended to use bid pricing information obtained from the 

CBP for standard wheelchair accessories to reduce the payment amounts for CRT 

wheelchair accessories. 

At the end of 2015, Congress included in the Patient Access and Medicare Protection Act (PAMPA) a 12-month delay (through December 31, 2016) of CMS’s planned 

application of CBP prices based on standard accessories to CRT accessories that 

share the same HCPCS code. In December 2016, as part of the 21st Century Cures 

Act, Congress included an additional 6-month delay that will expire on June 30, 

2017. 

Based on your support for this non-application of CBP prices to CRT accessories 

as a member of Congress, if confirmed as Secretary of HHS, can you commit to work 

with Congress to correct this CMS policy and adhere to the intent of Congress in 

MIPPA? 

Answer. As a member of Congress, I have been engaged in understanding and improving the competitive bidding program. If confirmed, I will continue this work but 

with the different role of carrying out the law for the benefit of the American people. 

If confirmed, I fully expect to work with Congress on this issue and many others 

that arise when Congress’s intent encounters the details of implementation. I also 

hope to bring to that role, if confirmed, the informative and valuable perspective of 

serving as a member of Congress writing and voting on these laws. 

210 

QUESTIONS SUBMITTED BY HON. BENJAMIN L. CARDIN

CMMI AND HEALTH CARE DELIVERY INNOVATION

Question. What are your views of State demonstrations, State innovation, and 

Centers for Medicare and Medicaid Innovation (CMMI) authority? 

Answer. I believe these authorities can be important ways to ensure there is flexibility in CMS programs and activities for the individual and varying needs of 

States. 

DRUG PRICES

Question. Last year the country was shocked by a series of price-hikes on older, 

off-patent drugs by manufacturers who had played no part in the research and development that produced them. The Senate debated numerous solutions last Congress to prevent price gouging behavior, and many put the ball squarely in HHS’s 

court. 

What is your view on HHS’s role in preventing price-gouging, and if confirmed, 

how do you propose to use the Office of Secretary to ensure Americans have access 

to affordable prescription drugs? 

Answer. The issue of drug pricing and drug costs is one of great concern to all 

Americans. You have my commitment to work with you and others to make certain 

that Americans have access to the medications that they need. If confirmed, I look 

forward to focusing on how we can make health care more affordable, including prescription drugs. I share your concern regarding the importance of individuals and 

families being able to afford the prescription drugs they need. 

EMERGENCY HEALTH SERVICES

Question. The Balanced Budget Act of 1997 requires Medicaid managed care organizations (MCOs), and others, to cover emergency services without prior authorization and established a Federal ‘‘prudent layperson standard.’’ This standard defines 

an ‘‘emergency medical condition’’ as one that manifests itself by acute symptoms 

of sufficient severity (including severe pain) such that a prudent layperson, who possess an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy, serious bodily functions, or serious dysfunction of any 

bodily organ or part. 

Do you support this Federal policy? 

Answer. I appreciate the aim of this Federal policy is to ensure a minimum level 

of emergency room coverage for Medicaid managed care organizations. Every State 

has different demographic, budgetary, and policy concerns that shape their approach 

to Medicaid and potential Medicaid managed care coverage requirements. While I 

believe that in the long run a one-size-fits-all approach is not workable for a country 

as diverse as the United States, my hope is to make sure that Medicaid beneficiaries 

need not rely on the emergency room to reliably access care because they have a 

doctor they trust in their community and a strong relationship and reliable access 

to that doctor. 

Question. Will you ensure the Centers for Medicare and Medicaid Services continues to enforce the prudent layperson standard for all Medicaid MCOs? 

Answer. If confirmed as Secretary, I will faithfully implement laws written by 

Congress and the regulations issued by the Department. This includes enforcement 

action as appropriate. As a doctor who has actually treated thousands of Medicaid 

patients, I do care deeply about the Medicaid program and the access of Medicaid 

patients to actual care, not just a card they can carry with them. 

FEDERAL WORKERS

Question. Do you believe that the Office of the Actuary’s actuarial and economic 

projections should be based on ‘‘best professional estimates’’ and remain as free as 

possible from political considerations? Why or why not? 

Answer. In getting advice from any professional it is important that advice be objective and consistent with relevant professional standards. Just as I would expect 

that from any doctor I visit I would expect the same from an actuary. 

211 

GLOBAL HEALTH SECURITY AGENDA

Question. What are your views on President Obama’s Global Health Security 

Agenda? 

Answer. In an interconnected world, no nation is safe from the risks posed by infectious diseases. I agree that the international community must continue to work 

together towards the common goal of a world safe from infectious diseases. I also 

agree that the international community must build-up our capacities in order to 

achieve this goal. If confirmed I will meet with the Office of Global Affairs and CDC 

to review the progress we have made on this agenda. 

Question. For decades the U.S. Government has been a leader in strengthening 

health systems around the world to prevent, detect, and minimize the impact of 

emerging infectious diseases. The United States is one of over 50 countries that 

have committed to the Global Health Security Agenda, which aims to help countries 

improve their capacity to prevent, detect, and respond to infectious disease outbreaks. 

As Secretary, how would you support and enhance global efforts to detect, prevent, and respond to diseases internationally to prevent them from becoming a 

threat to the United States? 

How will you ensure that we effectively address emerging crises and maintain our 

leadership role in global health? 

Answer. No global effort to detect, prevent, and respond to diseases internationally can be successful without an active and engaged United States. Rapid response 

in fighting infectious diseases is essential. Oftentimes, we can ensure these diseases 

do not spread to our shores if we do what we can to stop them spreading abroad. 

Few responsibilities are more important than keeping the public safe from potential 

public health pandemics and if confirmed I will make this a top priority. 

Question. America’s approach to global health has been extremely successful, including the effort to move toward ending the epidemics of AIDS, tuberculosis and 

malaria. The hallmark of America’s work against the three diseases has been to 

support results-oriented, accountable and transparent programming through the 

Global Fund and bilateral programs including PEPFAR, PMI and the USAID tuberculosis program. The Global Fund and our bilateral programs closely coordinate 

their work and depend on each other to implement comprehensive programming. 

As Secretary, will you be committed to continuing America’s leadership against 

AIDS, TB and malaria through Global Fund investments? 

Answer. United States leadership has been crucial in fighting AIDS, TB and malaria. Should I be confirmed, I fully expect these efforts to continue as we build upon 

and learn from our past and current initiatives. HHS and CDC are critical to fighting a range of global health security threats from Ebola and Zika to polio and HIV/ 

AIDS. Yet, as was made clear during the Ebola epidemic, severe shortages of health 

workers greatly hamper efforts for infectious disease prevention, detection and response. 

Question. HHS and CDC are critical to fighting a range of global health security 

threats from Ebola and Zika to polio and HIV/AIDS. Yet, as was made clear during 

the Ebola epidemic, severe shortages of health workers greatly hamper efforts for 

infectious disease prevention, detection and response. 

In your view, what is the role of the Department of Health and Human Services 

in growing and developing a better-trained health workforce worldwide? 

Answer. If confirmed as HHS Secretary, I look forward to working with the health 

secretaries of other nations in helping the world community train an international 

health workforce capable of tackling the myriad public health challenges of the 21st 

century. 

GRADUATE MEDICAL EDUCATION (GME)

Question. The current Medicare GME system is not producing enough doctors who 

will practice in rural America. Data show less than 5% of all graduates practice in 

rural areas. When Congress set limits on the number of Medicare funded GME slots 

(BBA 1997) there was clear intent in both the statute and the report language to 

treat rural training differently and provide special consideration to meet the needs 

of underserved rural areas. Unfortunately, the technicalities of the statute, and the 

regulations deriving from it, have not succeeded in achieving this intent. 

212 

What will you do as Secretary of HHS, specifically, to support changes to Medicare GME to increase the production of physicians practicing in rural areas? 

Answer. I have always been a strong supporter of efforts to support medical education. Congress has used the Medicare program from its inception to invest in future generations of doctors. Regardless of what we do in Washington, health care 

should always be about that one to one relationship of a patient to a doctor. That 

relationship of course requires a doctor. And so I am hopeful we can continue to find 

ways to remove disincentives to the practice of medicine and its rewards as well as 

support the profession in other ways. This issue is all the more important in the 

case of a rural area, where there is already an ongoing physician shortage and difficulty in recruiting talent and capital for medical infrastructure. If confirmed as 

Secretary, I would look for opportunities to address these situations through GME 

but also through programs administered by the Health Resources Services Administration and by taking a closer look at telemedicine. 

MEDICARE

Question. Your ACA replacement proposal, the Empowering Patient’s First Act, 

eliminates benefit expansions for beneficiaries such as free preventive benefits 

(blood pressure screenings, colorectal screenings and immunizations) and closing the 

Part D donut hole which helped with out-of-pocket prescription drug costs. 

If confirmed as HHS Secretary, how will you prevent any care reductions for or 

our-of-pocket health-care cost increases to Medicare beneficiaries? 

Answer. In considering Medicare, it is important to appreciate that the bipartisan 

Medicare Trustees have told everyone that Medicare, in less than 10 years, is going 

to be out of the kind of resources that will allow us as a society to keep the promise 

to beneficiaries of the Medicare program. My goal, if confirmed, is to work with Congress to make certain that we save and strengthen Medicare. It is irresponsible for 

us to do anything else. If I am confirmed, my role will be one of carrying out the 

laws Congress passes and as to that I would convey to the Medicare population that 

we look forward to assisting them in getting the care they need. 

MENTAL HEALTH WORKFORCE

Question. Mental health professions face chronic workforce shortages, and the future for many of these professions remain grim. For example, a recent survey from 

the American Association of Medical Colleges found that almost 60% of psychiatrists 

are aged 55 or older, making psychiatry the fourth oldest medical specialty in terms 

of practitioner age. 

Along with the overall shortage, the distribution of mental health practitioners 

heavily favors key urban and suburban areas of the country over rural regions. The 

21st Century Cures Act requires the Substance Abuse and Mental Health Services 

Administration to develop a strategic plan every 4 years to identify strategies to improve the recruitment, training, and retention of a mental health and substance use 

disorder workforce. 

While this provision and similar provisions are steps in the right direction, the 

numbers clearly suggest that growing a robust workforce to meet the mental health 

and substance use needs of nearly 70 million Americans will be of paramount importance in the coming years. Please describe in detail how you, if confirmed, will support the growth of the next generation of mental health practitioners. 

What strategies will you use to encourage medical students and others to pursue 

careers in these fields? 

Answer. It is important that we as a nation make sure that every single individual has access to the kind of mental health and substance abuse care that they 

need. If I am confirmed, I look forward to working closely with you and the other 

members of Congress to faithfully execute the 21st Century Cures Act, which aims 

to ensure that the mental health profession is adequately staffed for current and 

the future generations. 

MINORITY HEALTH

Question. In Maryland, the ethnic minorities make up roughly 41% of the State’s 

population. This is important because the health outcomes of minority populations 

are significantly lower and morbidity rates are higher than that of majority populations. Your Department, HHS, recognized this when it produced with what is commonly called the Heckler Report back in the 1980s, under President Ronald Reagan, 

213 

looking at what are now commonly called ‘‘health disparities’’ and the need for more 

health professionals coming from minority and underrepresented backgrounds. 

Racial and ethnic communities suffer disproportionate higher rates of illnesses, 

disabilities and preventable deaths. In fact, according to Johns Hopkins and University of Maryland researchers, racial health disparities cost the United States $229 

billion between 2003 and 2006. 

The Affordable Care Act is allowing communities coverage and access to much 

needed care, treatment, and prevention services from diabetes, to cancer, to asthma, 

and more. Specifically, how do you plan to further the elimination of racial and ethnic health disparities? 

Answer. I am committed to ensuring that minorities in this country have access 

to the highest quality care. To address these challenges, we need to examine what 

is happening on the ground in these communities. From there, we can establish better metrics and better accountability, and I look forward to working with you on this 

when I am confirmed. 

NATIONAL INSTITUTES OF HEALTH (NIH)

Question. Young scientists in the United States are finding it more difficult—and 

more time-consuming—to secure stable funding to launch their research careers, 

which stifles America’s competitiveness. More and more talented young people are 

dropping out of the scientific workforce or choose not to enter in the first place. 

What do you plan to do to ensure barriers facing young scientists are addressed 

and can we count on your leadership to implement the recommendations that come 

out of the National Academies report? 

Answer. If confirmed, I will look at flexibilities given to us through the 21st Century Cures Act and the focus on ‘‘young emerging scientists’’ to better recruit and 

retain top talent in order to help us achieve our mission of promoting innovation 

in order to benefit patients and their families across the country. 

Question. What do you see as the future roadmap for NIH over the next four 

years? 

Answer. If confirmed, I will work with NIH leadership to map out a forwardleaning NIH agenda. As I mentioned in my testimony, NIH is a true treasure for 

our country. With the increased resources provided in the Cures Act and the President’s commitment to innovation and patient-centric health care, great opportunities 

lie ahead for the NIH. 

PEDIATRIC DENTAL

Question. According to the CDC, tooth decay (cavities) is one of the most common 

chronic conditions of childhood in the United States and if left untreated, tooth 

decay can cause pain and infections that may lead to delays in important cognitive 

skills, such as eating, speaking, playing, and learning. 

How will you plan to ensure that children will continue to have access to early 

prevention services for oral health? 

Answer. If confirmed as Secretary, I would hope to work with you to revisit the 

current CMS’ ‘‘Oral Health Strategy’’ for children (https://www.medicaid.gov/medicaid/quality-of-care/downloads/cms-oral-health-strategy.pdf). I would also aim to 

provide States with flexibility in their Medicaid programs to provide both coverage 

and access to these services. Lastly, there may be opportunities to encourage innovation in both the coverage and payment for these services as well as the actual 

technology and even the relevant public health education strategies. 

SOCIAL SERVICES BLOCK GRANT (SSBG)

Question. This important program funds a variety of social services programs, 

from child protection to elder abuse to Meals on Wheels. I see every day in Maryland how this grant program helps our neediest and most vulnerable citizens. You 

proposed eliminating this $1.7 billion a year program as the chairman of the House 

Budget Committee. 

What was your rationale for trying to eliminate this program, and what would 

you put in its place? 

Answer. During my time in Congress, I have been acutely aware of the need to 

eliminate duplicative programs and strengthen those programs that work. As a 2011 

214 

GAO report pointed out, SSBG is a program of fragmentation, overlap, and duplication. SSBG essentially offers no-strings attached approach and a blank check to 

States. However, as SSBG continues to be a program authorized by Congress, I will 

do all I can to effectively administer this law should I be so honored as to be confirmed as HHS Secretary. 

SUBSTANCE USE DISORDERS

Question. The United States currently faces a growing epidemic in the form of 

prescription drug misuse, abuse, addiction and overdose. The numbers are disquieting. One person dies every 19 minutes from a drug overdose, now the leading 

cause of death among those ages 25–44, according to Johns Hopkins experts. 

In Maryland in 2015, fatal overdoses in the State were up 21 percent from the 

year before, and nearly twice the number in 2010. There is an urgent need for evidence-informed solutions ready for rapid implementation. 

How will HHS balance the twin-priorities of preventing new cases of opioid addiction and expanding access to effective addiction treatment while safely meeting the 

needs of patients experiencing pain? 

Answer. The opioid epidemic is real. This epidemic is a rampant crisis that is 

harming families and communities across the Nation. I firmly believe it is vital that 

those suffering from substance abuse have continued access to addiction treatment. 

If confirmed, I am committed to working closely with you and the other members 

of Congress to ensure that the Substance Abuse and Mental Health Services Administration (SAMHSA) fulfills its duty of treating those who are in addiction recovery, 

and prioritizes prevention efforts to keep America’s families and communities 

healthy. 

Question. Last month, the Centers for Medicare and Medicaid Services (CMS) 

granted Maryland a Medicaid section 1115 waiver to implement initiatives to address substance use disorders throughout the State. This is great news for my home 

State and a first step to addressing opioid abuse and heroin use. Now, Medicaid enrollees will have access to residential treatment for substance use disorders, putting 

them on the road to recovery. 

If confirmed as HHS, will you commit to ensuring States’ ability to use Medicaid 

section 1115 models to provide life-saving care, including addiction treatment and 

recovery services covered by Medicaid, to Americans in need? 

Answer. If I am confirmed, I will work with CMS and SAMHSA to help lowincome adults with mental health and substance use disorders. With respect to 

Medicaid specifically, every State has different demographic, budgetary, and policy 

concerns that shape their approach to Medicaid. That is one of the reasons I devoted 

so much time to working with States to help them to identify creative solutions, and 

why I believe a one-size-fits-all approach is not workable for a country as diverse 

as the United States. Waivers are an important tool for States to innovate within 

the Medicaid program. If confirmed, I would work with CMS to ensure that it evaluates waivers like Maryland’s on their merits, taking into account the desirability of 

States charting their own course, and ensure that they are compliant with the law. 

TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF)

Question. I am concerned that, while the TANF caseload had declined by over 60 

percent over the last 2 decades, the number of children in poverty and deep poverty 

(meaning income below half the poverty line) has increased. 

What steps would you take to reverse this trend? 

Answer. If confirmed as HHS Secretary, I am going to do all I can to effectively 

and efficiently administer the laws passed by Congress to address and alleviate the 

very real problem of children living in varying levels of poverty. 

Question. Do you agree that TANF is not succeeding as a program even if caseloads are declining while the number of persons in poverty and deep poverty are 

increasing? 

Answer. Respectfully, I must disagree with this assessment of TANF’s success. 

Since passage of TANF, we have seen employment rates of single mothers increase, 

lower poverty rates among female-headed households with children and AfricanAmerican households, a reduction in child poverty overall, and a sharp decline in 

the number of families receiving cash assistance. 

215 

THERAPY CAPS

Question. As you know, the therapy cap exceptions process expires in less than 

a year—on December 31, 2017. We have all heard from constituents whose therapy 

needs exceeded the cap and their conditions have deteriorated, necessitating more 

expensive medical intervention. 

As Secretary of HHS, how will you support the repeal of these arbitrary and discriminatory limits and maintain access to rehabilitation therapy that Medicare 

beneficiaries clearly need? 

Answer. If confirmed as Secretary, I will look into this issue and seek to understand the competing objectives and issues motivating the current CMS policy. Part 

of the frustration with the current health-care system is rules like this that do not 

make sense to many people. However, that is not surprising when one considers 

that Medicare Parts A, B, C, and D have each developed in silos and that even payment for particular types of services sometimes reflect silos within the silos. It may 

be that other approaches to therapy provide greater quality care at reduced cost 

with more respect for the individual needs of each patient in consultation with their 

doctor. If confirmed as Secretary, I would hope to break down these silos and encourage approaches based on a broader perspective. 

Question. Given the problems associated with monitoring the therapy cap, are the 

Centers for Medicare and Medicaid capable of achieving a timely uniform and defensible streamlined, responsive, and transparent process for manual medical review 

of Medicare records by Medicare administrative contractors? 

Answer. Any time there is manual review of anything in an organization with the 

scale of Medicare, there is a recipe for something to go wrong. If confirmed as Secretary, I would be pleased to work with you to confirm whether the staffing and 

other resources needed would be up to the challenge you describe. 

QUESTIONS SUBMITTED BY HON. DEAN HELLER

MEDICAID EXPANSION

Question. Do I have your commitment to working with Congress, and members 

of this committee, to protect access to care for all patients in Nevada, particularly 

the over 600,000 Nevadans currently covered under Medicaid? 

Answer. I am committed to ensuring that Medicaid is available for eligible beneficiaries, and working with States to ensure they are able to make the most use of 

available resources to serve their citizens, if confirmed as Secretary of Health and 

Human Services. Each State has different needs, and I believe CMS needs to work 

with States to ensure that, consistent with those needs, the Medicaid and CHIP programs provide the best possible coverage to their residents. 

Question. Under your leadership, how will the U.S. Department of Health and 

Human Services work with States likes Nevada, who expanded Medicaid, to ensure 

that they are successful in protecting access to health care, particularly the 200,000 

newly eligible Nevadans, as we transition out of Obamacare? 

Answer. I look forward to faithfully executing whatever law that Congress passes 

and the President signs, if I am confirmed. I will promise you this: Regardless of 

the final legislative outcome, I would work as HHS Secretary to ensure that the 

Medicaid program is well administered, effective, and available for eligible beneficiaries and that the States/Governors are given the flexibility to pursue innovative 

approaches that fits the needs of their States. 

DOCTOR SHORTAGE

Question. Nevada is 47th in the Nation for doctor-to-patient ratio. What can Congress and HHS do to attract more health-care providers to practice medicine in 

rural and underserved areas in States like Nevada that are facing a significant doctor shortage? 

Answer. If confirmed, I would work closely with the Center for Medicare within 

CMS to see that critical access hospitals are able to serve rural populations well. 

I would also work with the HRSA (Health Resources and Services Administration) 

Administrator to consider how CMS and HRSA can best cooperate with regards to 

community health centers and other issues. I would also consider how we can allow 

216 

for reimbursement of telehealth in general and to further help address provider 

shortages. 

Question. Do you believe that tele-medicine would be helpful for predominantly 

rural States like Nevada expand access to care for patients in underserved areas? 

Answer. Telemedicine is an exciting innovation that will allow for individuals to 

access resources that are otherwise not available. In the State of Georgia, we have 

a program that is a spoke and wheel program. There is a neurologist who works 

with a network of clinics and hospitals around the State. If somebody comes in with 

symptoms of a stroke, that neurologist is able to see the patient in real time and 

determine if they are having a stroke, whether they can be treated in the community or ought to be transferred. Innovations like this have been particularly helpful 

for rural areas. 

FINANCIAL DISCLOSURE

Question. To the best of your knowledge, as a member of the House of Representatives, did you fully comply with the Stop Trading on Congressional Knowledge Act 

(STOCK Act, Pub. L. 112–105) and the Office of Government Ethics (OGE) to publicly disclose your personal financial transactions? 

Answer. To the best of my knowledge, I have met all compliance obligations for 

the disclosure of personal financial transactions by members of the House of Representatives. 

Question. If confirmed, do you commit to fully complying with the law that would 

require you to sell stock in companies regulated by HHS? 

Answer. If confirmed, I commit to fully comply with all applicable ethics and conflict of interest obligations required by law, including the divestment of all applicable securities identified for sale in my publicly disclosed ethics agreement with the 

Office of Government Ethics (‘‘OGE’’). 

NEVADA STATE LEGISLATURE

Question. Please see the attached questions from the Nevada State Legislature. 

I respectfully ask that you respond to these important issues in the State, and cc 

Governor Sandoval. 

Answer. I look forward to writing to you and the Governor regarding these important issues. I expect my response will include the following. 

Q. What steps do you plan to take to ensure that the more than 88,000 Nevadans 

who have purchased health insurance through the Silver State Health Exchange 

continue to have the ability to purchase health insurance with adequate coverage 

in a transparent marketplace? 

A. I think the conversation and focus in these topics has been the question of coverage rather than true access for too long. By that I mean that Americans might 

have an insurance card and yet not be able to afford care or it might not be available to them for other reasons. And so when we talk about coverage we ought to 

make clear what we really mean and want to have happen. In any case, the President has made clear his hope and plan for a replacement to Obamacare. The goal 

is to make certain that every single American has access to the coverage they want 

for themselves. 

Q. What steps do you plan to take to ensure that the more than 77,000 Nevadans 

who are eligible for Federal tax credits under the Affordable Care Act to help purchase private insurance will continue to have access to affordable health insurance 

options with adequate coverage? 

A. I think the conversation and focus in these topics has been the question of coverage rather than true access for too long. By that I mean that Americans might 

have an insurance card and yet not be able to afford care or it might not be available to them for other reasons. And so when we talk about coverage we ought to 

make clear what we really mean and want to have happen. In any case, the President has made clear his hope and plan for a replacement to Obamacare. The goal 

is to make certain that every single American has access to the coverage they want 

for themselves. 

Q. What steps do you plan to take to ensure that the 217,000 Nevadans who are 

receiving health care under the Medicaid expansion remain covered? 

217 

A. Regardless of the final legislative outcome, I would work as HHS Secretary to 

ensure that the Medicaid program is well administered, effective, and available for 

eligible beneficiaries and that the States/Governors are given the flexibility to pursue innovative approaches that fits the needs of their States. 

Q. The Affordable Care Act guarantees coverage vital to preventative services for 

women, including cancer screenings and birth control. What steps do you plan to 

take to ensure that the Affordable Care Act’s coverage guarantees remain intact for 

women’s health? 

A. My hope is to move in a direction where insurers can offer products people 

want and give them the coverage they want. Getting to that kind of system requires 

changes that will inevitably involve working with Congress and considering the 

tradeoffs of various proposals to achieve our shared objective of the best and highest 

quality care being available to Americans. And note that I refer to care because ultimately, having maternity or other coverage is not meaningful if one cannot access 

the care they need or the quality of care leaves them worse off. So we must work 

towards both coverage and care. 

Q. The Affordable Care Act guarantees that Nevadans with pre-existing conditions will not be denied health care and ends lifetime minimums on coverage. It also 

allows younger people, many of whom are saddled with college debt and cannot afford insurance, to stay on their parents’ insurance until they are 26. What steps do 

you plan to take to preserve those coverage guarantees? 

A. Nobody ought to lose insurance because they get a bad diagnosis. As to coverage until age 26, the insurance industry has applied that across the board. In any 

case, if confirmed as HHS Secretary, my role would be to implement the replacement passed by Congress and signed by President Trump. Regardless of my own 

ideas, it is Congress that will ultimately decide what a replacement bill will look 

like, and my job would be to faithfully execute the law as passed by Congress. 

QUESTIONS SUBMITTED BY HON. MICHAEL F. BENNET

Question. The Medicare Advantage program has been used to provide quality, affordable health care to about 18 million seniors and individuals with disabilities. 

Many of these seniors indicate that they are satisfied with their choice of Medicare 

Advantage program. In fact, 36% of Coloradans are in Medicare Advantage plans. 

In your role as Secretary of HHS, how do you plan to support Medicare Advantage 

plans? What other steps do you plan to take to ensure that seniors have access to 

coordinated care plans? 

Answer. Medicare Advantage provides an important option for Medicare beneficiaries to access coordinated care and greater benefits. If confirmed as Secretary, 

I would seek to ensure Medicare Advantage remains a stable option for beneficiaries 

and that Medicare Advantage plans are afforded the flexibility to design plans that 

beneficiaries want and give them the coverage they want. 

Question. According to the Medicare Boards of Trustees, the Affordable Care Act 

(ACA) has extended the solvency of the Medicare hospital insurance trust fund by 

11 years in total. The Committee for a Responsible Federal Budget estimates that 

a full repeal of the ACA would push up the insolvency date to 2021 and more than 

triple the program’s 10-year deficit. 

How would you structure an ACA replacement bill that does not reduce the solvency of the Medicare Hospital Insurance Trust Fund? 

Answer. Neither President Trump nor I are wedded to a particular plan to the 

exclusion of all others. We are looking forward to giving the American people what 

they’ve been longing for, for 7 long years: real health-care reform. But they have 

never wanted Obamacare: It has raised premiums and deductibles, narrowed doctor 

networks, reduced choices of plans, limited Americans’ liberty, and undermined the 

doctor patient relationship. A replacement need not affect the Medicare trust fund 

if the provisions related to Medicare are ones that are carefully considered. 

Question. Do you plan to advise the administration to advocate for premium support as a means of extending the Medicare trust fund? 

Answer. One of my goals in discussing these matters is to lower the temperature 

regarding what we are talking about. These issues have real-life impact for folks 

in their lives and so, if confirmed, I would advise the administration that we convey 

218 

to the Medicare population that they do not have reason to be concerned and that 

we look to assisting them in getting the care they need and the caregivers that they 

need too. 

Question. Colorado has 2.3 million people living with a pre-existing condition that 

rely on the protections of the ACA to receive coverage. 

How would your plan keep coverage for pre-existing conditions and control costs 

while dissolving other parts of the ACA such as the individual mandate, the exchanges, and Medicaid expansion? 

Answer. Our goal is to ensure every single American has access to the coverage 

they want for themselves and ensures the individuals who lost coverage under the 

Affordable Care Act get or maintain coverage. If we preserve the patient-doctor relationship and put the patient at the center, then we will see quality go up and costs 

go down. In any case, I look forward to faithfully executing whatever law that Congress passes and the President signs, if I am confirmed. 

Question. I have heard from rural hospitals in Colorado that may lose significant 

funding if the ACA is repealed. The Medicaid Expansion provided some financial 

stability to hospitals that were on the brink of closure before the bill was passed. 

In fact, hospitals in Colorado saw a 30% drop in uncompensated care. 

What metrics would you use to ensure that an ACA replacement does not hurt 

rural or critical access hospitals? 

Answer. Our goal is to ensure every single American has access to the coverage 

they want for themselves and ensures the individuals who lost coverage under the 

Affordable Care Act get or maintain coverage. This of course includes individuals 

who access care at rural or critical access hospitals. And so the best metric in the 

end is one that measures the extent of access to actual care, not just coverage and 

the quality of that care as determined by patients working individually with their 

doctors. 

Question. You have included health savings accounts in previous proposals to replace the ACA. As you know, health savings accounts are essentially a way for people to save their own money that they can then spend on health care. They are not 

a substitute for quality coverage and are paired with a high deductible, making it 

difficult to obtain health care. 

How can a middle-class family making $60,000 a year successfully use a health 

savings account if they live paycheck to paycheck and can’t afford to set aside thousands of dollars to pay for their health-care bills? 

Answer. Our goal is to ensure every single American has access to affordable coverage they want for themselves and their families. Health savings accounts are powerful tools that can be used to help lower costs and empower individuals, providing 

greater flexibility to spend health-care dollars as they see fit. 

Question. The ACA took steps to enhance price transparency of health-care services by requiring health plans to be more explicit about what they cover. A knee 

replacement in the United States could cost $11,000 in one area of the country and 

nearly $70,000 in another area. Consumers are still largely unaware of what they 

will be billed after a certain test or procedure. 

What steps do you plan to take as HHS Secretary to improve price transparency 

for consumers? 

Answer. If confirmed as HHS Secretary, I would work to improve price transparency to foster and facilitate patient choice. In so doing, I would be focused on 

actual costs and not costs billed to insurance companies or from a master price list 

no one uses. At the end of the day though, until patients rather than government 

are making the purchasing decisions, the price transparency information we might 

aim to provide is of limited utility because it does not reflect the patients’ collective 

choice and willingness to pay but the government’s. 

Question. I worked with Senator Portman to introduce the Medicare PLUS Act 

which would set up a pilot program to help the top 15% of the highest-cost Medicare 

beneficiaries by coordinating their health care needs. As you may know, 15% of 

Medicare beneficiaries have six or more chronic conditions and account for 50% of 

total Medicare spending. 

What steps will you take as HHS Secretary to pilot this program and ensure that 

these patients get the coordinated care they need? 

219 

Answer. If confirmed as Secretary, I would explore what voluntary options we can 

make available to the Medicare beneficiaries with the greatest needs and their physicians. I think many will appreciate the opportunity to work with a care manager 

and possibly others who will spend the time and effort needed to help the patient 

make different choices to manage their own care. I would seek to work with you 

on your proposal to explore how it and others like it can be a path to empowering 

those who are subjected to the most uncoordinated and challenging aspects of our 

health-care system. 

Question. Congress and the last administration have made it a priority to pursue 

delivery system reforms that improve quality and lower costs. The Advancing Care 

for Exceptional (ACE) Kids Act, on which I worked with Senator Grassley, aims to 

coordinate care for vulnerable children with complex medical conditions. 

What steps will you take as HHS Secretary to promote increased emphasis on reforms that target the needs of children with complex medical conditions? 

Answer. If confirmed as Secretary, I would look across the Department to identify 

all the ways in which HHS aims to help these children in need. And I would hope 

to encourage our use of existing authorities and funding to better align resources 

to meet this challenge. I would also work with members of Congress on their ideas 

on this important topic. 

Question. Over 500,000 children in Colorado are enrolled in Medicaid. Nationally, 

the program covers over 30 million kids. 

If Medicaid is transformed from an entitlement program to a block grant, can you 

guarantee that those children will maintain coverage? What metrics will you use to 

ensure that those children are covered and have access to the same services that 

they do today? 

Answer. It is important that every child has access to high-quality health coverage, and Medicaid plays an important role in accomplishing this objective. If confirmed as Secretary, my goal would be to ensure that no child in Colorado or anywhere else is left behind. 

Question. The Children’s Health Insurance Program (CHIP) currently covers 

60,000 children in Colorado, increasing access to routine check-ups, prescriptions, 

and emergency services for vulnerable kids. Extension of the program needs to occur 

early this year in order for States to plan and have budget certainty. 

What is your position on CHIP? What reforms would you recommend as HHS Secretary before supporting extending the program? 

Answer. It is important that every child has access to high-quality health coverage, and CHIP plays an important role in accomplishing this objective. CHIP 

plays a major role in this, but there is also a need for coordinated family coverage 

in the private market and employer plans, and giving States the needed flexibility. 

Question. The National Health Service Corps Loan Repayment Program has been 

vital in supporting primary care providers who then practice in Health Professional 

Shortage Areas (HPSAs). The ACA expanded this program and it has added necessary primary care providers in Colorado. 

If confirmed as HHS Secretary, will you recommend that Congress support this 

program to increase the number of primary care providers in rural and underserved 

areas? 

Answer. As a physician, I understand the value and importance of the National 

Health Service Corps (NHSC) and the NHSC Repayment Program. I have included 

loan forgiveness for primary care providers in past legislative proposals, and I look 

forward to working with Congress on this issue when I am confirmed. 

Question. The Pharmacy and Medically Underserved Areas Enhancement Act recognizes pharmacists as health-care providers in underserved areas in order to expand access to care. In areas with a shortage of primary care providers, pharmacists 

may play a key role in helping patients manage their diseases to avoid Emergency 

Department visits and hospitalizations. These services are especially important for 

patients with multiple chronic conditions who may be taking several medications at 

a time. As HHS Secretary, would you support this approach as a way to increase 

care in rural and underserved areas? 

Answer. We ought to step back and say, ‘‘What are we doing wrong?’’ as one out 

of every eight physicians no longer sees Medicare patients. Therefore, if confirmed 

as Secretary, I would be open to all options to address the impact of the ongoing 

220 

physician shortage in rural areas. Paying pharmacists in underserved areas to engage in certain medical services could work well in those States where pharmacists 

have such licensure and a setting appropriate to the services, where primary care 

doctors continue to be involved in care, and where there is a patient and consumer 

demand for such services. 

QUESTIONS SUBMITTED BY HON. SHERROD BROWN

MEDICAID EXPANSION

Question. During your testimony in front of the Senate HELP Committee last 

week, you told Senator Murkowski that Medicaid is an absolutely imperative program. You also said, in a response to one of Senator Young’s question, that Medicaid 

is a program where ‘‘the States know best how to care for their Medicaid population.’’ 

I agree that every State’s role in the Medicaid program is significant, which is 

why I want to protect State flexibility when it comes to this program. Thirty-one 

States—including my home State of Ohio—have made the decision to expand Medicaid coverage under the Affordable Care Act (ACA). 

Ohio’s Governor John Kasich, in a letter to Senator Hatch just last week, wrote 

‘‘we strongly recommend that States be granted the flexibility to retain the adult 

Medicaid coverage expansion and Federal matching percentage.’’ 

Governor Kasich’s letter also said that those States that have opted to expand 

Medicaid are experiencing significant positive results. In Ohio, high-cost ER utilization has gone down, health status has improved, and most enrollees have found it 

easier to keep or find work. Further, thanks to ACA’s Medicaid expansion, Ohio was 

able to extend coverage to 700,000 previously uninsured Ohioans. 

Do you support the flexibility provided to States under the ACA to expand Medicaid? 

Answer. State flexibility is an important component in making Medicaid more 

workable for patients. Every State has different demographic, budgetary, and policy 

concerns that shape their approach to Medicaid and Medicaid expansion. That is 

one of the reasons I devoted so much time to working to help identify creative solutions, and why I believe a one-size-fits-all approach is not workable for a country 

as diverse as the United States. 

Question. As a cabinet-level advisor to the President, how will you advise the 

President on any bill that would limit a State’s flexibility to expand Medicaid—like 

Ohio did—as provided for under the ACA? 

Answer. I look forward to faithfully executing whatever law that Congress passes 

and the President signs, if I am confirmed. Furthermore, I am committed to ensure 

that the Medicaid program is well administered, effective, and available for eligible 

beneficiaries and that the States/Governors are given the flexibility to pursue innovative approaches that fit the needs of their States. 

Question. As part of the Medicaid program in Ohio, Governor Kasich has led efforts to engage providers, payers, community organizations, and employers and encourage them to work with the Medicaid population and provide a ladder out of poverty. As a result, more than 70% of the expansion population in Ohio reports that, 

since getting covered, it has been easier for them to keep or find a job. 

One program in particular, CareSource’s Life Services pilot program provides supports and mentoring to help individuals achieve physical and behavioral health and 

economic stability. The CareSource Life Services program could serve as a national 

model for lifting individuals out of poverty. 

As Secretary of Health and Human Services, how will you work to support and 

expand funding for programs like Life Services? 

Answer. I understand that some enrollees in CareSource’s Medicaid managed care 

product have access to a program called Life Services which provides services and 

supports to help the enrollees obtain and keep jobs. Although I understand this Life 

Services program is a benefit of the managed care plan and not part of an Ohio 

Medicaid 1115 waiver demonstration, I would be interested to explore with you and 

others how such programs might be integrated or associated with a Medicaid waiver. This kind of development shows why waivers are an important tool for States 

221 

to innovate within the Medicaid program, as they have for many years prior to the 

ACA becoming law. 

MEDICARE NEGOTIATIONS/DRUG PRICES

Question. Last week when you testified in front of the HELP Committee, you were 

also asked how we should address the high cost of prescription drugs. 

You avoided answering questions from many of my colleagues by saying that, as 

Secretary of HHS, your job will be to ‘‘administer’’ programs and not ‘‘legislate.’’ 

President Trump supports the elimination of the noninterference clause in Medicare Part D. He would like to have the Centers for Medicare and Medicaid Services 

(CMS) negotiate directly with drug manufacturers to get the best deals on prescription drugs for our Nation’s seniors. 

If Congress passes legislation supported by the President that gives the Secretary 

of HHS the authority to negotiate and this legislation is signed into law—would you 

use this administrative authority to negotiate better prices on behalf of the more 

than 40 million Part D beneficiaries? 

What are your ideas on effective ways to reduce out-of-pocket prescription drug 

costs for Medicare beneficiaries? 

Answer. We all share concern when prescription drug prices are too high for anyone to access the drugs they need. This especially concerns me as a doctor. If confirmed, I look forward to using tools Congress provides to lower health-care costs. 

In addition, we need to continue to build on the gains towards affordability allowed 

by the Generic Drug User Fee Act and find additional ways to facilitate more efficient generic entry. This starts with making sure that we are giving generic sponsors clear guidance so that they can prepare approvable applications on the first try. 

If I’m confirmed, I’m committed to working with the FDA (and Congress, if appropriate) to find additional efficiencies and administrative steps that can help facilitate appropriate generic entry. 

FAIR PAY/HOME-CARE WORKERS

Question. The majority of the home-care workforce—or those individuals who provide services to older Americans and individuals with disabilities who receive homeand community-based services through Medicaid—is made up of female workers. 

This workforce is primarily paid through Medicaid and, on average, States pay 

these workers an average of just $13,000 a year. This means that those women caring for the disabled and elderly are often forced to rely on Medicaid themselves. 

In order to provide the highest level of quality care to our most vulnerable Americans—the elderly and those with disabilities—do you agree that those home-care 

workers providing this care full time should be paid more than $13,000 a year by 

their State Medicaid program—‘‘yes’’ or ‘‘no’’? 

Answer. I agree it is important to provide those who care for our most vulnerable 

total compensation that reflects the important work they do. In many cases, this 

compensation may include more than wages and could, depending, e.g., on housing 

prices, be significantly more than the number given. 

Question. Past leadership at CMS committed in writing to exploring Federal actions under its current authority that could work with States to strengthen and support home-care workers. In a meeting with Finance Committee Staff last week, you 

expressed an interest in building off of the work of the prior administration. 

Will you commit to continuing this work to ensure fair pay and advancement opportunities for the home-care workforce. Describe how you would go about achieving 

this goal. 

Answer. If confirmed, I would be pleased to work with you to explore such options. 

One potential issue is to ensure that such workers are not somehow considered 

State employees and therefore subject to unique requirements and diversions from 

income that relate to that labor workforce. Another longer term situation is to empower patients, as the ultimate recipient of these services to make choices regarding 

providers of these services that leads to a competitive market for higher performing 

workers who satisfy customers. 

222 

INFANT MORTALITY/TOBACCO

Question. Ohio has one of the highest infant mortality rates in the country. In 

2015, our State ranked 42nd in the Nation for infant mortality, and even worse for 

African American babies. 

We don’t know exactly why Ohio does so poorly when it comes to infant mortality, 

but one thing that we do know is that health complications caused by preterm 

births are the leading causes of infant mortality. We also know that a major factor 

in premature births is tobacco use, and Ohio’s smoking rate among pregnant women 

is nearly twice the national rate. 

In addition to providing coverage to an additional 20 million Americans, the Affordable Care Act also strengthened Medicaid coverage of services that help tobacco 

users to quit. Local groups have taken advantage of these provisions in their fight 

against infant mortality. 

Medicaid covers nearly 50 percent of births in this country. Do you support the 

current requirement that State Medicaid programs provide pregnant women with effective tobacco cessation services without cost sharing? 

Answer. The science is pretty clear that tobacco use during pregnancy is risky for 

both moms and babies. States should have maximum flexibility to prioritize critical 

health risks such as smoking during pregnancy. When it comes to Medicaid requirements, I hope to return a lot of control to States, and if confirmed, I will be reviewing such requirements and their efforts in order to develop policy recommendations 

for reform. 

Question. How will you work with Congress to maintain this requirement so that 

all pregnant women—regardless of their income—has access to tobacco cessation 

services? 

Answer. The science is pretty clear that tobacco use during pregnancy is risky for 

both moms and babies. Availability of cessation programs is important. I look forward to faithfully executing whatever law that Congress passes and the President 

signs, if I am confirmed. Regardless, I commit to work as HHS Secretary to ensure 

that the Medicaid program is well administered, effective, and available for eligible 

beneficiaries and that the States/Governors are given the flexibility to pursue innovative approaches that fits the needs of their States. 

INFANT MORTALITY

Question. As I mentioned in the hearing and in my question above, the infant 

mortality rate among African American infants in the State of Ohio is among the 

worst in the United States. The overall rate of infant mortality in Ohio is 42nd in 

the Nation. I have introduced legislation to improve prevention efforts nationwide 

by improving Federal reporting of infant and childhood deaths, putting the power 

in the hands of the Secretary of HHS to generate the metrics by which these 

incidences are reported. 

As Secretary of HHS, how would you work to ensure adequate funding for the 

issue of infant mortality, and which metrics and protocols would you use to improve 

reporting of infant mortality cases across the country? 

Answer. Infant mortality is a serious concern for our Nation. While many of the 

underlying factors that contribute to infant mortality are poorly understood, we 

know that certain health behaviors, including alcohol consumption and tobacco use 

during pregnancy, have contributed to higher rates of infant mortality in the United 

States. Access to prenatal care is also vitally important. 

If confirmed as Secretary of HHS, I would work to examine the range of HHS programs, including research to prevent infant mortality, programs to prevent child 

abuse and neglect, efforts to increase access to health services for low-income pregnant women and infants, childhood vaccination initiatives, home visitation programs, and other initiatives across the Department to ensure these resources are 

used more effectively to address this issue and, if necessary, seek additional funds. 

Regarding metrics used to report infant mortality, I agree that measurement is 

extremely important as we tackle this problem. I intend to work with the Congress 

and within the Department to bring more consistency and accuracy to how we measure infant mortality. 

223 

MEDICARE PART D/DIR PAYMENTS

Question. As you know, community pharmacies serve on the front lines as healthcare providers and play an integral role as part of the Medicare Part D benefit. In 

recent years, however, pharmacies have faced increasing uncertainty in their ability 

to serve Medicare beneficiaries due to the increasing use of post-claim adjudication 

price concessions and fees imposed by pharmacy benefit managers, called Direct and 

Indirect Remuneration (DIR) fees. 

CMS has recognized issues with how DIR fees are reported by part D plan sponsors, how these fees impact pharmacy business, and the resulting challenges they 

create for Part D beneficiaries. To respond to these issues, CMS proposed guidance 

(Proposed Guidance on Direct and Indirect Remuneration and Pharmacy Price Concessions) to standardize the timing of how these fees are reported on September 29, 

2014. This proposed guidance would help pharmacists better serve Part D beneficiaries by providing greater clarity about their reimbursement when medications 

are dispensed and would benefit beneficiaries in that they would be able to make 

more accurate comparisons in plan selections. 

Will you commit to supporting the finalization of such guidance? Are there other 

things you would do to ensure pharmacies have the information they need—in real 

time—to best serve their beneficiaries? If so, what are they? 

Answer. If confirmed, I will look forward to working with you to consider how to 

resolve this pending guidance issue. Incidentally, I understand that on January 19, 

2017, CMS released a fact sheet with information about recent trends in drug costs 

and Direct and Indirect Remuneration (DIR) under Medicare Part D. 

EPSDT

Question. Identifying and treating conditions early in life—during childhood—before they become expensive long-term liabilities, is not only the right thing to do, 

but also cost effective. In 1967, Congress added a guaranteed benefit for children 

in the Medicaid program called Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. 

To this day, EPSDT continues to guarantee that children in the Medicaid program 

are appropriately screened and given the necessary treatments they need to thrive. 

If Medicaid were turned into a block grant—and existing Federal standards were 

cut back—EPSDT would be at serious risk, and child health would be put in jeopardy. 

Are you committed to maintaining EPSDT as a guaranteed benefit for children 

in the Medicaid program? 

Answer. Children are, and will continue to be, a high-priority population within 

the Medicaid program. States are well-positioned to determine the most appropriate 

ways to ensure access to the highest quality care for children, which includes diagnosis and screening procedures and the illnesses and conditions they uncover. 

Question. What are the most important metrics in evaluating the success of the 

EPSDT program? 

Answer. From a clinical perspective, successful diagnosis and screening procedures are determined by how well they identify illnesses and conditions. Successful 

treatment of those illnesses and conditions is best evaluated by the extent to which 

the patient’s care goals are achieved. 

Question. If confirmed, how will you use your authority to make sure EPSDT remains an effective program in ensuring children’s health through Medicaid? 

Answer. I look forward to working with States interested to advance initiatives 

designed to improve the quality of care provided to all Medicaid members, especially 

children. 

Question. Through the creation of the EPSDT benefit, Medicaid solidified dental 

services as a necessary component of coverage for low-income children and adolescents. Similarly, Congress recognized the need to include dental coverage as a requirement in the second iteration of the Children’s Health Insurance Program 

(CHIP). The ACA then built on these two programs, and now pediatric dental coverage and preventive oral health services are included in many private insurance 

packages. Despite these advances, tooth decay remains the most common chronic 

condition among children. 

224 

How would you ensure that any major health reform efforts appropriately 

prioritize children’s oral health, both in terms of benefits and affordability? 

Answer. If confirmed as Secretary, I would hope to work with you to revisit the 

current CMS’s ‘‘Oral Health Strategy’’ for children (https://www.medicaid.gov/medicaid/quality-of-care/downloads/cms-oral-health-strategy.pdf). I would also aim to 

provide States with flexibility in their Medicaid programs to provide both coverage 

and access to these services. Lastly, there may be opportunities to encourage innovation in both the coverage and payment for these services as well as the actual 

technology and even the relevant public health education strategies. 

MEDICAID PAYMENT PARITY

Question. On average, Medicaid pays providers about 70 percent of what a Medicare provider receives for the same service. The only difference is the age of the patient being served. There are 45 million children enrolled in Medicaid and as you 

noted in your hearing, and inappropriately low Medicaid payments impede the ability of providers to accept more patients—both pediatric and adult—covered through 

this program. 

Along with Senator Murray, I have worked to introduce the Ensuring Access to 

Primary Care for Women and Children Act in past Congresses, legislation that 

would solidify parity between Medicare and Medicaid reimbursements for primary 

care. 

In today’s hearing, you mentioned that only one in three providers accepts Medicaid patients. You cannot deny that lower Medicaid reimbursements is a contributing factor to this issue. 

This is a platform in which the HHS Secretary can take a stance and move legislation forward. Do you believe that a child’s care should be valued at only 70 percent of that of an adult? 

Answer. A child’s care should not be valued at only 70 percent of that of an adult. 

The current Medicaid payment system is an inelegant combination of base rates set 

by States, supplemental payments to providers, and other Federal and State funding sources for care to the Medicaid or uninsured populations. 

Question. If confirmed, how will you work to improve access to care under Medicaid by adequately and equitably reimbursing physicians that treat Medicaid patients? 

Answer. I agree that adequate Medicaid reimbursement is essential to ensuring 

care for some of our most vulnerable citizens, and I look forward to working with 

Congress to accomplish this important objective. 

LEAD

Question. Dr. Price, do you believe that there is no safe level of lead in children’s 

blood? 

Answer. Science should guide our conclusions in this area. If confirmed, I look forward to working with you to ensure safe environments for America’s children. 

Question. The CDC very recently lowered its reference level for public health 

intervention for elevated childhood blood lead levels from 5 to 3.5 micrograms per 

deciliter. 

Lead is a neurotoxin, and exposure to it can have devastating lifelong consequences for children. Ohio is one of 29 States receiving funding from CDC for a 

State-wide lead poisoning prevention program. In 2014, almost 6,000 children under 

age six in Ohio, or 3.85% of those tested, had elevated blood lead levels. 

If confirmed, will you keep the CDC’s lowered lead reference level? 

Answer. If confirmed, I pledge to work with our public health specialists at CDC 

and throughout the Department to learn more about the impact of lead poisoning 

and communicate the dangers to families and communities. 

Question. At the end of 2016, CMS committed to developing and improving a targeted blood lead screening policy to ensure more children eligible for EPSDT benefits are tested. Can you commit to continuing this work and improving coordination 

across Federal agencies to enhance our lead screening and treatment policies and 

achieve better outcomes? 

225 

Answer. If confirmed, I commit work to improve coordination across Federal agencies to enhance our lead screening and treatment policies to achieve better outcomes. 

Question. What additional actions would you have HHS take to reduce the number of American children with elevated blood lead levels? 

Answer. If confirmed, I pledge to work with our public health specialists at CDC 

and throughout the Department to learn more about the impact of lead poisoning 

and communicate the dangers to families and communities in order to reduce the 

number of American children with elevated blood lead levels. 

TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF)

Question. As part of welfare reform, Congress restructured the Temporary Assistance for Needy Families—or TANF—program as a fixed block grant. Evidence 

shows that one effect of turning TANF into a block grant program has been that 

States are spending less and less on TANF programs and instead using these Federal dollars to support gaps in State budgets. This change has resulted in more 

Ohioans who struggle to support their families with earnings below the poverty 

level. 

What does that say about other proposals to block grant programs like Medicaid? 

Do you think that the block grant approach should be a model for other safety net 

programs? 

Answer. While this would ultimately be a matter for Congress to decide, I have 

long supported States finding their own solutions in addressing unique or complex 

situations in their States. 

Question. In November 2015, the State of Ohio asked HHS for a TANF waiver 

that would have (1) removed the distinction between ‘‘core’’ and ‘‘non-core’’ hours, 

(2) increased the vocational education training limit from 12 to 36 months, (3) increased the job search and job readiness time limit from 6 to 12 weeks and removed 

the 4 consecutive week time limit, and (4) removed the 16 hour monthly cap on good 

cause hours credited towards work participation (while maintaining the 80 hour annual cap). HHS never acted on this request. 

Given that this application has the support of Governor Kasich, if confirmed as 

HHS Secretary, would you grant this waiver to the State of Ohio? 

Answer. In 2012, GAO responded to a congressional inquiry about an ACF Information Memorandum inviting States to apply for waivers to the TANF work requirement. GAO concluded that the Information Memorandum was a rule that must 

be submitted to Congress and the Comptroller General before taking effect. If confirmed as HHS Secretary, I will enquire about the status of this matter and the 

waiver request from the State of Ohio, and provide a response if one has not previously been sent. 

MEDICARE OBSERVATION STATUS/3-DAY RULE

Question. Instead of privatizing Medicare or raising the eligibility age, we should 

be discussing ways to make Medicare stronger for our Nation’s seniors. One way to 

strengthen the program—which you brought up in today’s hearing—is to enable 

beneficiaries better access to skilled nursing facilities after hospitals stays by revisiting the 3 day rule. 

In order for Medicare Part A to cover skilled nursing facility care, a beneficiary 

must be admitted to a hospital for 3 days under inpatient status. I have heard from 

too many Ohioans whose skilled nursing facility care was not fully covered by Medicare because their hospital stays were classified as ‘‘observation’’ rather than inpatient. 

My Improving Access to Medicare Coverage Act, which I plan to reintroduce this 

Congress, which would enable time beneficiaries spend in the hospital under observation to count toward the 3-day requirement for Medicare coverage. 

If confirmed, will you work to administratively correct this billing technicality 

that adversely impacts Medicare beneficiaries? If you are unable to do so administratively, will you work with me to pass this legislation to correct the deficiency in 

current law? 

Answer. If confirmed, I will be pleased to work with you to further consider the 

necessity of the 3 day rule and its pros and cons. I will endeavor to work with CMS 

226 

to identify what more can be done with regard to the observation status issue as 

well. And if the best path forward involves legislation, I would be pleased to work 

with you on that as well. 

BIOSIMILARS

Question. Last year, a number of my colleagues and I sent a letter to then President-elect Trump, encouraging him to work with us on reducing prescription drug 

prices for all Americans. Specifically, we highlighted the need to promote innovation 

and foster competition in drug development. 

I have introduced legislation in the past that would help achieve this by shortening the patent exclusivity period for expensive, brand-name biologic drugs and 

allow biosimilars to enter the market sooner. Biosimilars, which are equivalent in 

safety and efficacy to their reference biologics, have the capacity to reduce prescription drug costs, yet physicians must be willing to prescribe them and patients need 

the information necessary for them to be confident in taking them. 

As a physician, do you believe physicians and patients understand what biosimilars are and how they work? Do you believe the patients and physicians see 

biosimilars as a safe, effective, and less-costly alternative to biologics? 

What do you believe to be the FDA’s role in educating patients, providers, and 

other stakeholders about biosimilars? How will you, as Secretary of HHS, support 

and encourage the robust uptake of biosimilars in the United States? 

Answer. As a doctor, I appreciate your concern that health-care providers and patients be informed when making health-care decisions. It is important that the FDA 

provide clear and timely guidance as it carries out its responsibilities with respect 

to biosimilars. I understand that this is particularly important given that the number of biosimilars available to consumers is expected to increase and the potential 

that these products have to increase consumers’ health-care options. 

COST-SHARING

Question. More than 25 years ago, Congress implemented protections to ensure 

that Medicare beneficiaries are treated and billed fairly by their providers in response to growing concerns that patients charged more than the standard 20% Part 

B coinsurance were opting out of critical care due to high out-of-pocket costs. However, while you were in Congress, you backed legislation that would have weakened 

these protections, allowing Medicare providers to enter into private contracts with 

seniors and people with disabilities to determine cost sharing amounts. 

Do you maintain your position that these patient protections should be undone 

and will you continue to advocate for permitting doctors who serve seniors to charge 

them more than 20% over what Medicare pays, your concern being that those limits 

compromise access to care for seniors? 

Answer. If there are any program changes in this area, they should be voluntary 

for both patient and physician. 

Question. Do you believe that Medicare doctors should be allowed to charge patients whatever they choose? 

Answer. If there are any program changes in this area, they should be voluntary 

for both patient and physician. 

Question. What would you say to fixed-income seniors who receive unexpected additional costs simply so that physicians can be paid more than the agreed-upon insurance coverage limit? Is this not putting patients above profits? 

Answer. Our goal is to ensure all Medicare recipients are able to obtain the highest quality health care. If there are any program changes in this area, they should 

be voluntary for both patient and physician. 

STATE HEALTH INSURANCE ASSISTANCE PROGRAMS (SHIPS)

Question. The State Health Insurance Assistance Programs (SHIPS) are the only 

source of one-on-one Medicare counseling for seniors and people with disabilities. In 

2015, over 7 million people with Medicare received help from SHIPs, including 

375,000 Ohioans using the Nation’s best-ranked SHIP program in the country. Since 

1992, counseling services have been provided via telephone, one-on-one in-person 

sessions, interactive presentation events, health fairs, exhibits, and enrollment 

events. Individualized assistance provided by SHIPs almost tripled over the past 10 

years. 

227 

This modest program is operated in every State and U.S. territory, and has been 

significantly under-funded for years despite the growing demand for services by our 

Nation’s seniors and individuals with disabilities. 

Will you pledge to support increased funding for SHIPs as the country’s Medicareeligible population continues to grow in the President’s proposed budgets? 

Answer. If confirmed, I will fairly consider the needs and work of the SHIPs in 

light of a growing Medicare population, as well as consider other ways to support 

them to make them even more efficient. SHIPs and others like them play an important role in making sure patients are actual health-care consumers. This is a virtuous cycle because it facilitates putting the patient at the center of both health care 

and health-care coverage decision-making. 

DRUG PRICING

Question. In December, President Trump told Time magazine, ‘‘I’m going to bring 

down drug prices. I don’t like what has happened with drug prices.’’ 

Do you agree with President Trump? If confirmed as Secretary of HHS, will you 

work to bring down drug prices? 

Answer. Yes. We all share concern when prescription drug prices are too high for 

anyone to access the drugs they need. This especially concerns me as a doctor. If 

confirmed, I will ensure that CMS looks for ways to ensure that it uses the authorities and tools it has at its disposal to ensure drug prices in the Medicare program, 

in both part B and part D, are manageable for beneficiaries. 

Question. Given the significant burden prescription price tags have on individuals 

and taxpayers, what do you see as the best market-based solution to combat prescription drug price gouging? 

Answer. In addition, we need to continue to build on the gains towards affordability allowed by the Generic Drug User Fee Act and find additional ways to facilitate more efficient generic entry. This starts with making sure that we are giving 

generic sponsors clear guidance so that they can prepare approvable applications on 

the first try. If I’m confirmed, I’m committed to working with the FDA (and Congress, if appropriate) to find additional efficiencies and administrative steps that 

can help facilitate appropriate generic entry. 

Question. Do you believe that Americans deserve more information about when 

and how prescription drug prices rise so that they can make the most informed decisions for their families? 

Answer. Yes. I support empowering patients by putting more information in their 

hands so they can make health care consumer choices that make sense for them and 

their families. 

OFFICE OF REFUGEE RESETTLEMENT

Question. The Secretary of HHS responsible for overseeing the Office of Refugee 

Resettlement at HHS. This office is in charge of providing for the basic needs of refugees when they first arrive in the United States, including victims of human trafficking, torture survivors, individuals who are granted asylum, and those who are 

resettled here after helping our troops abroad because it is no longer safe for them 

in their home country. 

If confirmed, what will you do to ensure these necessary services are provided despite a significant lack of funding for this program? What are your plans for this 

office? 

Answer. The law is clear when it comes to administering services for refugees, 

survivors of torture, and other populations who receive assistance through ORR. If 

I am confirmed, I will work to effectively and efficiently administer this Office. 

Question. Will you advocate for additional resources for this office, given the current refugee crisis across the globe? 

Answer. Should circumstances on the ground change, and current resources are 

found to be insufficient, I will inform Congress and work with them on finding solutions. 

Question. How will you work with our partners around the globe to ensure a safe 

and smooth transition for refugees coming into the United States? 

228 

Answer. Should I be confirmed, it would be my expectation to work with the U.S. 

Department of State, as well as our partners around the globe, to ensure a safe and 

smooth transition for refugees coming into the United States. 

CENTER FOR MEDICARE AND MEDICAID INNOVATION (CMMI)

Question. You’ve stated that you support innovation and see potential in CMMI. 

Would you support continued testing through CMMI in its current form? 

Answer. CMMI is a program providing significant opportunity for testing new 

models for health-care financing and delivery. I defer to the Congress regarding the 

funding of the Innovation Center and any ACA repeal and replacement legislation. 

If confirmed, as HHS Secretary—and if the Innovation Center remains funded—I 

will ask CMS to pursue models that will lower health-care costs and improve quality 

for Medicare and Medicaid beneficiaries. 

ACCOUNTABLE CARE ORGANIZATIONS (ACOS)

Question. Many hospitals, physicians, nursing facilities, and others have invested 

significant resources to participate in ACOs and bundled payment systems. Ohio is 

home to some of the largest ACOs, by membership, in the Nation. 

How would you respond to the concerns of ACO administrators and providers that 

there may be delays or disruptions in their innovative models due to a repeal of the 

ACA? 

Answer. If confirmed, I am committed to working with all providing health care 

to incentivize innovative models for care financing and delivery. 

Question. Do you support the continued implementation of the current voluntary 

models—ACOs and bundled payment models? 

Answer. In general, yes. I look forward to reviewing all models, if confirmed. As 

a physician, I appreciate the goal behind the creation of the ACO model: better patient care. As a legislator, I would agree their successes have been modest to date, 

and there are some challenges they face as well. ACOs are a tool in the toolbox to 

help ensure high quality, low cost health care for beneficiaries. They are not a silver 

bullet to all of our country’s delivery system challenges. If confirmed, I plan to work 

with the CMS Administrator to ensure that we learn from ACOs’ successes and 

challenges to date as we chart the path forward. 

For certain populations, bundled payments make a lot of sense. And they can 

often lead to both better health outcomes and reduced costs. But it is important we 

not get fixated on one of those two outcomes. That is, I support making certain that 

we deliver care in a cost-effective manner but we absolutely must not do things that 

harm the quality of care being provided to patients. 

What we ought to do is allow for all sorts of innovation. Not just in this area. 

There are things that haven’t been thought up yet that would actually improve 

health-care delivery in our country and we ought to be incentivizing that kind of 

innovation. And in finding our way to those innovations, we ought to remember we 

are not talking about science experiments in a lab or a computer simulation, but 

about experiments involving real patients’ lives. 

PAMA IMPLEMENTATION

Question. In 2014, Congress passed the Protecting Access to Medicare Act 

(PAMA), which included a provision to change the way labs are reimbursed under 

the Medicare program by moving away from the Clinical Laboratory Fee Schedule 

(CLFS) and toward a more market-based payment methodology. 

We are concerned that CMS’s regulations implementing this provision, finalized 

in June 2016, contain a reporting deadline that is difficult for the laboratory community to meet. In addition, many of our community-based and regional laboratory 

constituents serving the Medicare program have expressed significant concerns over 

requirements from the regulation that make reporting accurate data a concern, and 

requirements from the regulation that result in the exclusion of market data from 

the hospital outreach laboratory community. Lastly, we have concerns over CMS’s 

definition of an ‘‘applicable lab’’ in the final regulation. We believe the current definition would result in very few labs having to report their data. 

The Office of the Inspector General has also raised each of these issues—the 

timeline, accuracy, exclusion of hospital labs, and lack of required reporting—as potential flaws in the regulation in their September 2016 report, which addressed 

229 

PAMA implementation. In fact, the OIG reported that only 5% of labs will be required to report payer data, excluding 95% of the market and thereby potentially 

skewing the market rates. 

In order to fulfill the goals of PAMA, it is critical that the market data collected 

and assessed by CMS represents the entire laboratory market, consistent with the 

statute, to ensure both equitable and successful implementation of the law. Understanding that this regulation is on a short time-line, given that CMS is set to finalize a new fee schedule in 2017 for implementation in 2018, what would you do to 

address the concerns listed above and ensure the new market-based payment methodology and payment processes for clinical laboratory tests are not unduly burdensome on community-based labs or potentially detrimental to patient access? 

Answer. I appreciate your concerns regarding the implementation of PAMA. Certainly, we should strive for accuracy in this market data collection process. I look 

forward to following up with CMS staff and agree that community-based labs should 

not be unduly burdened and thus limiting patient access. 

Question. Will you commit to revisiting the definition of ‘‘applicable lab’’ to ensure 

equitable and successful implementation of the law, accurately reflecting the entire 

market? 

Answer. As you know, section 216(a) of the Protecting Access to Medicare Act of 

2014 (PAMA) added section 1834A to the Social Security Act (the Act), which requires revisions to the payment methodology for clinical diagnostic laboratory tests 

paid under Medicare, including reporting requirements for laboratories. 

CMS finalized a low expenditure threshold to reduce the reporting burden on 

small laboratories. Under the final rule, CMS will generally exclude a laboratory 

from being an applicable laboratory, and thus from having its private payor data 

reported, if it is paid less than $12,500 under the CLFS during a data collection 

period. CMS expects that 95 percent of physician office laboratories and 55 percent 

of independent laboratories will not be required to report. Additionally, I understand 

CMS-imposed reporting requirements at the TIN level will be less administratively 

burdensome for the laboratory industry as compared to requiring data to be reported at the NPI level. 

MEDICAID AND FAMILY PLANNING SERVICES

Question. Two-thirds of births from unintended pregnancies in the United States 

are paid for by Medicaid or the Children’s Health Insurance Program (CHIP). In 

2010, these unintended pregnancies cost a total of $21 billion dollars, including $824 

million in Ohio. 

We know that publicly funded family planning allows families to prevent unwanted pregnancies, and it is estimated that investing in family planning services 

would have saved public funding of unintended pregnancies by a total of $15 billion, 

including $607 million for Ohio. That’s striking—almost 75 percent of the money 

that would otherwise be spent could be saved through more robust, fully funded 

family planning programs. 

Do you acknowledge the effectiveness of investing in contraception and the need 

to continue the Medicaid State option to expand family planning services? 

Answer. If confirmed, I would work as HHS Secretary to ensure that the Medicaid 

program is well administered, effective, and available for eligible beneficiaries and 

that the States/Governors are given the flexibility to pursue approaches that fit the 

needs of their States. That being said, I would be hesitant to develop policy on the 

basis of financial cost of life. 

Question. How will ensure that family planning services, included access to preferred contraception methods, will remain available to all women, as you committed 

to do in today’s hearing? 

Answer. Women should have the health care that they need and want. The system we ought to have in place is one that equips women and men to obtain the 

health care that they need at an affordable price. As we work towards a replacement for the ACA, I expect this will be one of the topics of discussion. 

FEDERAL RESEARCH

Question. As chairman of the House Budget Committee, you stated in your FY17 

Budget Resolution that ‘‘the Federal Government has a role to play in supporting 

breakthrough research.’’ As a medical doctor, you must understand the importance 

230 

not only of funding research to find better cures for your patients, but also of funding the training of the next generation of doctors and researchers. 

If confirmed, how do you pledge to protect and advocate for the government’s critical Federal research initiatives? 

Answer. As a physician, I am keenly aware of the progress that has been made 

and still to be made through important research initiatives that are fully or partially funded by the Federal Government. Implementing the recently passed 21st 

Century Cures Act will be a priority in coming months and years, including 

leveraging the significantly increased funding for the NIH. NIH plays a leading role 

in so many public-private initiatives, and if confirmed, I look forward to working 

with leaders at the NIH to advance their important mission and our administration’s efforts to promote innovation on behalf of the American people. 

SYRINGE EXCHANGE PROGRAMS

Question. Like many communities in Ohio, your district in Georgia has been hit 

by a significant increase, a 4,000 percent increase, in opioid-related deaths in the 

last 5 years. Simultaneously, we are also seeing an increase in hepatitis C infections 

and HIV infections among those who inject opioids and share syringes. One of the 

clearest examples of this connection is the HIV outbreak in Scott County, Indiana, 

the home State of Vice President Pence. In response to this crisis, then-Governor 

Pence declared a public health emergency and changed Indiana’s policy to allow 

State dollars to support Syringe Exchange Programs or SEPs. 

The Centers for Disease Control and Prevention (CDC), Institute of Medicine, and 

many other scientific bodies have stated unequivocally that SEPs are highly effective in stopping the spread of HIV/AIDS and Hepatitis C. Cleveland has one of the 

longest standing SEPs, and as a result has seen a decrease in the rate of new HIV 

infections as a result of intravenous drug use. In response to progress like this, Congress partially lifted the restrictions related to the use of Federal funds for SEPs 

in 2015. In fact, I note that your wife, who serves in the Georgia House of Representatives, has also worked to expand access to needle exchange programs. 

In the past, you have voted against funding for needle exchange programs. Has 

your position changed? 

Answer. As I mentioned in the hearing, I recognize that the opioid epidemic is 

real and that substance abuse disorders are plaguing many Americans. It is important that we as a nation make sure that every single individual has access to the 

kind of mental health and substance abuse care that they need. I have a broad and 

open mind and welcome proposals to our Nation’s mental health and substanceabuse related crises, particularly those solutions that are evidence-based. If I am 

privileged to serve as the HHS Secretary, I will follow the policies adopted by the 

Congress and signed into law by the President. 

Question. Do you support continued availability of Federal funds for SEPs, based 

on local public health department determination of need? Why did you oppose it in 

the past? 

Answer. The opioid epidemic is real and substance abuse disorders are a serious 

concern for communities across the country. It is important that we as a nation 

make sure that every single individual has access to the kind of mental health and 

substance abuse care that they need. I recognize that we may not always agree on 

the solutions, but we have a duty to those who are suffering to work together to 

find the best answers to these severe problems. I welcome proposals to our Nation’s 

mental health and substance-abuse related crises, especially those that are well supported by evidence. Funding decisions ultimately rest with the Congress, which 

holds the power over the purse. If I am privileged to serve as the HHS Secretary, 

I will follow the policies adopted by the Congress and signed into law by the President. 

Question. If confirmed as Secretary of HHS, how will you work with States to ensure they have the resources and support necessary to continue and open new 

SEPs? 

Answer. It is important that we as a nation make sure that every single individual has access to the kind of mental health and substance abuse care that they 

need. All levels of government need to engage and collaborate to identify effective 

solutions to these problems. 

231 

ANTIBIOTIC RESISTANCE

Question. The emergence of this superbug is extremely serious and illustrates 

both how quickly infectious pathogens can spread across the world and the need for 

international cooperation in detecting newly emerging health threats. 

Do you agree that a dedicated effort to improving surveillance, data collection and 

research efforts is needed to prevent such rapid spread and evolution of antibiotic 

resistant bacteria? 

Will you advise President Trump to continue President Obama’s National Strategy for Combating Antibiotic-Resistant Bacteria (CARB initiative)? 

How will you ensure that the threat of antimicrobial resistance remains a high 

priority for HHS and its affiliates the National Institutes of Health (NIH), Food and 

Drug Administration (FDA), and CDC? In your opinion, how should the United 

States work with other nations to combat these threats? 

Answer. I share your concern regarding the need to take seriously the public 

health threat posed by antibiotic resistance. I appreciate the important role HHS 

can play in combatting this public health threat, from identifying resistance and 

educating the American people about it, to helping to advance innovative, new 

therapies to treat emerging infections. If confirmed, I look forward to continuing to 

work in this area as part of HHS’ public health mission. 

POWDERED CAFFEINE

Question. In 2014, Logan Stiner—who was a senior at Keystone High School in 

LaGrange, OH—died just 3 days before his high school graduation from ingesting 

too much powdered caffeine. For the last several years, I have worked with Logan’s 

family to raise awareness about the dangers of powdered caffeine and encourage the 

FDA to take meaningful action to limit access to powdered caffeine. 

Right now, children and teenagers can buy this potentially deadly chemical in 

bulk from domestic and international retailers by simply going online and clicking 

a button—without their parents even knowing about it. Further, companies are trying to find creative new ways to reach consumers and to dodge States like Ohio that 

have already passed laws cracking down on this dangerous substance. 

The FDA advises consumers against using powdered caffeine and has called upon 

manufacturers to more accurately label these products. But these actions by the 

FDA do not go far enough. As Secretary of HHS, which has jurisdiction over FDA, 

how will you ensure that the Department’s affiliates, particularly the FDA, are effectively educating and protecting consumers about the products available to them? 

Answer. FDA plays a valuable role in providing the American public with timely 

information about FDA regulated products. I appreciate the importance of FDA informing individuals and families about whether or how to use these products. If confirmed, I will ensure that FDA is fulfilling its statutory responsibilities consistent 

with its public health mission. 

MEDICARE ADVANTAGE STAR RATINGS PROGRAM

Question. As you know, CMS uses a star rating system to display the quality of 

Medicare Advantage plans. High performing plans receive quality bonus payments. 

CMS also has an audit and appeals process by which to periodically evaluate plans 

on specific measurements. 

Over the past several years, there have been several circumstances we are aware 

of where plans are penalized in their star-ratings based on deficiencies found in an 

audit. We have heard from a plan based in our home State of Ohio that was penalized by the interaction between the audit and appeals policies and the star-ratings 

program. 

If you are confirmed, can you commit to taking a deeper look at the interaction 

of these two policies and the potentially negative effect on plans, on beneficiaries, 

and on innovative care delivery? 

Answer. Yes. If confirmed, I would be pleased to work with your office and CMS 

to ensure that the Medicare Advantage stars system reflects quality and the Medicare Advantage sanctions system reflects program audit performance, as well as explore whether and how these policies can be made to work in concert rather than 

against each other. 

232 

CANCER MOONSHOT

Question. During last year’s State of the Union address, President Obama announced the Cancer Moonshot initiative, an ambitious project aimed at improving 

cancer prevention, diagnosis, and treatment at twice the rate of current progress of 

clinical cancer research. The 21st Century Cures Act re-committed to this critical 

initiative through the inclusion of funding for the next 5 years of the program. 

Academic and clinical centers in Ohio are playing important roles in the execution 

of this initiative, through partnerships like that that exists between The Ohio State 

University’s Comprehensive Cancer Center and Columbus’s Richard J. Solove Research Institute with Tampa’s Moffitt Cancer Center to form the ORIEN partnership. This initiative is particularly focused on inclusion and retention of minorities 

in cancer-specific clinical trials, an important diversity metric to improve clinical 

care for all Americans. 

As Secretary of HHS, how will you work to facilitate collaborations between researchers and clinicians to improve cancer care under the goals outlined by the Cancer Moonshot? 

Answer. If confirmed, we will make treating and helping to cure cancer a priority 

and there likely will be overlap with the Cancer Moonshot goals. Implementing the 

recently passed 21st Century Cures Act will be a priority in coming months and the 

administration will accelerate efforts to promote innovation in many areas—including the prevention, diagnosis and treatment of cancer. 

TUBERCULOSIS

Question. Globally, tuberculosis is now killing more people than HIV/AIDS, with 

a death toll of nearly 5,000 per day. In 2015, the United States experienced the first 

national increase in TB cases since 1992, with 9,557 total cases. And in 2013, CDC 

identified drug resistant TB as a serious public health threat. 

CDC provides critically important support to local health departments to address 

the TB epidemic, and it supports crucial TB research. CDC also provides crucial 

support to the global fight against drug resistant TB. 

Despite these sobering statistics and impressive work done by the CDC, funding 

for CDC’s domestic TB program has remained stagnant since FY 2005 at $135 million. As a result, the CDC has stated that are our national response to TB ‘‘has 

stalled.’’ 

If confirmed, will you implement the U.S. National Action Plan for Combating 

Multi-Drug Resistant Tuberculosis, and will you support increased Federal funding 

for the U.S. response to this deadly, airborne infectious disease? 

Better TB drugs and diagnostics are being developed, thanks to U.S. ingenuity, 

and these new tools can help us stop this epidemic. What will you do, if confirmed 

as Secretary of HHS, to advance these drugs and diagnostics and provide support 

to the communities working to develop new treatments? 

Answer. As a physician, I recognize and share your concern regarding the public 

health threat posed by tuberculosis, particularly drug resistant tuberculosis. If confirmed, I look forward to working with CDC officials in their efforts to combat the 

spread of tuberculosis. 

LOW-INCOME HEATING ASSISTANCE PROGRAM (LIHEAP)

Question. As you may know, the LIHEAP program plays a key role in helping lowincome families stay warm in the winter and avoid dangerous heat in the summer. 

It is a program that is critical to nearly 450,000 households in Ohio that otherwise 

would be forced to choose between keeping warm or going hungry. 

If confirmed, will you commit to maintaining the program as currently structured? 

Answer. If I am confirmed, I will implement the program dutifully in as effective 

and efficient manner as possible. 

Question. Nationwide, nearly 7 million of our Nation’s poorest and most vulnerable households rely on the program. Will you commit to maintaining and possibly 

even supporting an increase in the program’s annual appropriation? 

Answer. If I am confirmed, I will implement the program dutifully in as effective 

and efficient manner as possible. Should circumstances on the ground change, and 

233 

current resources are found to be insufficient, I will inform Congress and work with 

them on finding solutions. 

NUCLEAR MEDICINE

Question. Diagnostic nuclear medicine procedures help millions of Medicare beneficiaries detect life altering illnesses, such as heart disease and cancer, each year. 

The quick turnaround on nuclear testing, when used appropriately, helps improve 

the quality and efficiency of care by helping to reduce inappropriate or unnecessary 

procedures. Despite these positives, CMS continues to treat the diagnostic radiopharmaceutical drugs used in nuclear medicine procedures as supplies—not drugs— 

and, as a result, they are not appropriately reimbursed under this system. 

Physician and industry groups have been working for years to try to address this 

issue. If confirmed, will you work with stakeholders to develop superior payment 

models to these drugs and nuclear medicine procedures are appropriately reimbursed? 

Answer. I share your concerns and look forward to working with you, if confirmed. 

THERAPY CAPS

Question. As you know, the therapy cap exceptions process expires in less than 

a year—on December 31, 2017. We have all heard from constituents whose therapy 

needs exceeded the cap and their conditions have deteriorated, necessitating more 

expensive medical intervention. 

As Secretary of HHS, how will you support the repeal of these arbitrary and discriminatory limits and maintain access to rehabilitation therapy that Medicare 

beneficiaries clearly need? 

Answer. Rehabilitative therapy is a vital component of recovery for many patients. 

Arbitrary limits on its use are not a wise decision for patient-centered care. If confirmed as Secretary, I will look into this issue and seek to understand the competing 

objectives and issues motivating the current CMS policy. Part of the frustration 

with the current health care system is rules like this that do not make sense to 

many people. However, that is not surprising when one considers that Medicare 

Parts A, B, C, and D have each developed in silos and that even payment for particular types of services sometimes reflect silos within the silos. It may be that other 

approaches to therapy provide greater quality care at reduced cost with more respect for the individual needs of each patient in consultation with their doctor. If 

confirmed as Secretary, I would hope to break down these silos and encourage approaches based on a broader perspective. 

Question. Given the problems associated with monitoring the therapy cap, is CMS 

capable of achieving a timely uniform and defensible streamlined, responsive, and 

transparent process for manual medical review of Medicare records by Medicare administrative contractors? 

Answer. We will strive to do so. Any time there is manual review of anything in 

an organization with the scale of Medicare, it is a recipe for something to go wrong. 

If confirmed as Secretary, I would be pleased to work with you to confirm whether 

the staffing and other resources needed would be up to the challenge you describe. 

ADDICTION TREATMENT

Question. If confirmed as Secretary of HHS, how will you prioritize the prevention, treatment, and recovery from mental and substance use disorders in States 

like Ohio? 

As our country continues to explore potential reforms to our health care delivery 

systems, what will you do to prioritize access to behavioral health services? 

Answer. Mental and substance abuse disorders continue to be a serious challenge 

felt in communities across the Nation. I firmly believe, that it is absolutely vital 

that substance abuse disorders and other mental health problems are treated. If 

confirmed, I will work closely with you and the other members of Congress to ensure that the Substance Abuse and Mental Health Services Administration fulfills 

its duty of treating those who are in addiction recovery while working to prevent 

people from becoming addicted in the first instance. 

234 

PHARMACISTS

Question. The Pharmacy and Medically Underserved Areas Enhancement Act recognizes pharmacists as healt-care providers in underserved areas in order to expand 

access to care. In areas with a shortage of primary care providers, pharmacists may 

play a key role in helping patients manage their diseases to avoid Emergency Department visits and hospitalizations. These services are especially important for patients with multiple chronic conditions who may be taking several medications at 

a time. 

If confirmed as HHS Secretary, would you support this approach as a way to increase care in rural and underserved areas? 

Answer. We ought to step back and say, ‘‘What are we doing wrong?’’ as one out 

of every eight physicians no longer sees Medicare patients. Therefore, if confirmed 

as Secretary, I would be open to all options to address the impact of the ongoing 

physician shortage in rural areas. Paying pharmacists in underserved areas to engage in certain medical services could work well in those States where pharmacists 

have such licensure and a setting appropriate to the services, where primary care 

doctors continue to be involved in care, and where there is a patient and consumer 

demand for such services. 

QUESTIONS SUBMITTED BY HON. ROBERT P. CASEY, JR. 

MEDICAID AND CHIP

Question. You have proposed eliminating the Patient Protection and Affordable 

Care Act, an action that would end the expansion of Medicaid to millions of people 

and would result in an addition $1.1 trillion being cut from State budgets. This action would throw millions of people into the realm of the uninsured, including hundreds of thousands with disabilities. They would no longer have access to such services and treatments as behavior health care, mental health treatment, and preventative services. The services provided by Medicaid expansion have greatly improved 

the quality of life for millions of citizens, particularly those with disabilities. 

Do you propose those individuals return to being uninsured? Do you propose that 

their health care, including mental health treatments, be discontinued? Does your 

plan mean you support returning hundreds of thousands of people with disabilities 

into the category of the uninsured? 

Answer. Our goal is to ensure access to affordable, quality health care for all citizens. 

Question. If your plan is implemented, many people who will lose Medicaid coverage will be people with disabilities who depend on Medicaid for services that are 

unavailable through private insurance; services such as personal care services, respite care, or intensive mental health services. These health, personal care, and preventative services allow individuals to live in the neighborhoods of their choice, be 

independent, work, and participate in their communities. Many of these people, capable, able people, will be forced into institutions if they lose access to these crucial 

services. They will lose their independence and we will pay more tax dollars for 

their care. 

How is this a good outcome for these people and for America? 

Answer. Changes to the ACA should not be done in isolation. Our goal is to ensure access to affordable, quality healthcare for all citizens. This, of course, includes 

people with disabilities who depend on Medicaid. I note that community integration, 

beneficiary autonomy in decision making, and person-centered planning are central 

tenets articulated in CMS’ approach to Home and Community Based Services and 

the HCBS Settings Rule with a compliance date in March 2019, and I support each 

of those principles. It is also important to note that many residential, disabilityspecific settings have long provided a safe and integrated community alternative to 

institutional placement for individuals with disabilities, and appropriate weight 

should be given to the preferences of families and individuals with disabilities because they are in the best position to decide what type of setting best meets their 

individualized needs and circumstances. 

Question. Federal flexibility in Medicaid has allowed Pennsylvania to take extra 

steps to ensure that children with extensive health care needs have access to Medicaid, in what’s referred to as Family of One program. This program, in addition to 

235 

the Medicaid expansion for parents, has improved the economic security of families 

in Pennsylvania. The State’s budget relies on the Federal share in order to support 

these Medicaid programs. However, the budget you authored in the House last year 

would have cut Medicaid funding by $1 trillion dollars, about one-third over a 10- 

year period. 

Given that half of Medicaid enrollees in this country are children, how will you 

ensure that children and families aren’t harmed by cuts in Medicaid funding 

through block grants? 

Answer. Changes to the ACA should not be done in isolation. Our goal is to ensure access to affordable, quality health care for all citizens. 

Question. As a physician you know that Medicaid covers a broad range of services 

to address the diverse needs of the populations it serves. In addition to covering the 

services required by Federal Medicaid law, many States elect to cover optional services such as prescription drugs, physical therapy, eyeglasses, and dental care. Coverage for Medicaid expansion adults contains the ACA’s ten ‘‘essential health benefits,’’ which include preventive services and expanded mental health and substance 

use treatment services. Medicaid provides comprehensive benefits for children, 

known as ‘‘EPSDT,’’ that are considered a model of developmental pediatric coverage. EPSDT is especially important for children with disabilities because private 

insurance, which is designed for a generally healthy population, is often inadequate 

to their needs. 

Unlike commercial health insurance and Medicare, Medicaid also covers long-term 

care, including both nursing home care and many home and community-based longterm services and supports. More than half of all Medicaid spending for long-term 

care is now for services provided in the home or community that enable seniors and 

people with disabilities to live independently rather than in institutions. Given that 

both EPSDT for kids and long term services and supports are not generally covered 

in commercial health plans, I fail to see how people will not be worse off if the structure or financing of the Medicaid program is restructured in the ways that you and 

other administration officials have suggested. 

Can you guarantee that under a block grant, per capita cap and/or an HSA structure that all of these vital services will be covered for the millions of Americans who 

count on them? 

Answer. My work in the Congress has been to improve Medicaid and provide additional flexibility. If I have the privilege of being confirmed as Secretary I would look 

forward to the opportunity to work with States and Congress using the tools and 

authorities given by Congress in legislation to ensure the highest number of people 

get access to the highest quality care. 

Question. Forty percent of Pennsylvanian children rely on Medicaid and CHIP, 

which serves our State’s most vulnerable children: children living in or near poverty; infants, toddlers and preschoolers during key developmental years; children 

with special health-care needs; and children who have been place in foster care due 

to neglect or abuse. Medicaid’s comprehensive, pediatrician-recommended services 

under EPSDT—Early and Periodic Screening, Diagnostic and Treatment services— 

are critical for their health and to ensure that they hit key development milestones. 

In recent years, there is clear evidence of the long-term return on investments in 

Medicaid. Children enrolled in Medicaid are healthier as adults and more likely to 

graduate from high school, attend college, resulting in greater economic success. 

Do you support the EPSDT benefit package for children which ensures that America’s most vulnerable children receive the services they need to thrive? Are you willing to protect these benefits by not allowing States to waive this important benefit? 

Answer. Every State has different demographic, budgetary, and policy concerns 

that shape their approach to Medicaid and Medicaid expansion. That is one of the 

reasons I devoted so much time to working with States to help them to identify creative solutions, and why I believe a one-size-fits-all approach is not workable for a 

country as diverse as the United States. If I am confirmed, I will work with CMS 

as they take a look at waivers that are pending and appropriate for my input and 

will have to make a decision at that point. 

Question. Your 2016 budget proposal would have block granted Medicaid and 

would have eliminated many critical patient protections. With our current Medicaid 

structure, children have a right to the full array of services they need, from critical 

health screenings for cancer treatment to services for children with autism or mental health needs. For many children, this coverage can be the difference between life 

236 

and death. Medicaid as currently structured also enables children with disabilities 

to live up to their potential, be successful in school, and have the opportunities to 

be full citizens. 

Do you support the continuation of Medicaid’s requirement to cover a comprehensive array of services for children through the Early Periodic Screening Diagnosis 

and Treatment (EPSDT) program? Will you commit to ensuring that HHS will actively enforce the requirement to provide screenings, diagnosis, and treatment for 

children with disabilities or with potential disabilities? 

Answer. Our goal is to ensure every single American has access to the coverage 

they want for themselves or their children and dependents. I think the conversation 

and focus in these topics has been the question of coverage rather than true access 

for too long. By that I mean that Americans might have an insurance card and yet 

not be able to afford care or it might not be available to them for other reasons. 

Question. Many people with disabilities want to work and can do so with the services only available through Medicaid, to help them work. These services include supported employment for people with mental health disabilities or personal care attendants for those with intellectual or physical disabilities. Without these services, 

many people with disabilities will be unable to work. 

How will you ensure that a person with a disability, mental health, intellectual, 

physical, sensory, or any other type of disability as defined by the Americans with 

Disabilities Act, has access to the services currently available through Medicaid? 

Answer. I look forward to faithfully executing whatever law that Congress passes 

and the President signs, if I am confirmed. I commit to work as HHS Secretary to 

ensure that the Medicaid program is well administered, effective, and available for 

eligible beneficiaries and that the States/Governors are given the flexibility to pursue innovative approaches that fit the needs of their States. 

Question. As economies evolve, professions change and while new types of jobs 

emerge, certain types of jobs are reduced or eliminated and workers must make 

transitions. This happens to people across the workforce, but it happens almost 

twice as often to workers with disabilities. 

Do you support taking away people’s Medicaid coverage because they lose their 

jobs? How will you ensure that people with disabilities who become unemployed are 

able to retain Medicaid benefits? 

Answer. Medicaid is a vital safety-net program, and it is our goal to strengthen 

it. If confirmed, I look forward to faithfully executing laws to strengthen the Medicaid program that Congress passes and the President signs. 

Question. In 1999, in the Olmstead decision, the U.S. Supreme Court agreed that 

individuals with significant disabilities have the right, under the Americans with 

Disabilities Act, to access services in the community rather than only in an institutional setting. Since the Olmstead decision, the U.S. Department of Health and 

Human Services has employed its authority over Medicaid waivers to encourage 

States to expand home and community-based services and to shift away from overreliance on institutional care. 

Will you continue this longstanding Federal policy? If no, why not? If yes, what 

steps will you take? 

Answer. I support encouraging the use of home and community-based services if 

the services are appropriate, the individual does not oppose the treatment, and the 

services can be reasonably accommodated. 

Question. Since the Olmstead decision, Congress has authorized several programs 

to incentivize States to meet their obligations under the Olmstead decision by increasing Federal dollars for providing community-based services. These programs 

include the Money Follows the Person program, the State Balancing Incentive Program, the Community First Choice State Plan option, and the Home and Community Based Services option. These programs are implemented and managed through 

the Department of Health and Human Services. 

Is it your view these programs should continue? Why or why not? 

Answer. I support ensuring that individuals are able to receive services in community-based settings. 

237 

Question. You are a vocal proponent of passing Federal laws to change Medicaid 

from a program that includes an open-ended Federal financial commitment to fixed 

block-grant payments to the States. 

Would this change end the Federal oversight and incentive programs that have 

helped State systems transform into systems that allow individuals with significant 

disabilities to live in the community? How would you ensure that any changes in 

Medicaid would not move people with disabilities back into nursing homes and other 

institutional settings that are linked to significantly poorer quality of life, physical 

and mental health outcomes, and longevity? 

Answer. We are committed to supporting high-quality health care for all Americans, including individuals with disabilities. If confirmed, I look forward to working 

with you to achieve these goals. 

Question. In 2011, the Department of Health and Human Services promulgated 

a rule to ensure that Medicaid funds designated for services in home and community-based settings were not used to fund services in segregated, institutional settings. For example, the second floor of a building used to provide inpatient hospital 

care could not be considered a community-based setting. That rule has been championed by the disability community as critical to afford people with disabilities the 

chance to live independent and fulfilling lives in their own homes and communities. 

Do you support the continuation of this rule? Do you commit to ensure that HHS 

assertively enforces it? 

Answer. Community integration, beneficiary autonomy in decision making, and 

person-centered planning are central tenets articulated in the Home and Community Based Services (HCBS) Settings rule you refer to, and I support each of those 

principles. It is also important to note that many residential, disability-specific settings have long provided a safe and integrated community alternative to institutional placement for individuals with disabilities, and appropriate weight should be 

given to the preferences of families and individuals with disabilities because they 

are in the best position to decide what type of setting best meets their individualized needs and circumstances. States must come into compliance with the final rule 

by March 17, 2019, and I plan to work with States during this transition period to 

ensure continuity of services for Medicaid participants and minimize any disruptions to them and the service systems they currently rely on. 

Question. With an additional 16 million people gaining access to Medicaid since 

its expansion and a total of 75 million people covered by the program, Medicaid continues to be a critical, State-based health care program. In order to provide effective, 

high-quality care, States need dedicated funding for the full Medicare-eligible population as well as sufficient Federal funding that reflects actual State costs and increases in health-care costs. 

As Secretary of HHS will you ensure that State-funding for health care is adequate and reflects the actual costs of caring for each State’s Medicaid population? 

Answer. States are not just regulatory partners in the Medicaid program but also 

co-funders. As we look to provide them with more flexibility but also continue to provide Federal funds, I agree it is important States meet their funding commitments 

and the Federal Government oversee and check that is the case. 

Question. Medicaid provides care to some of the Nation’s most vulnerable and 

complex populations. In order for States to continue to provide high-quality and effective care, adequate and sustainable funding is required. 

As Secretary of HHS, will you work to prevent disruption and ensure adequate 

and sustainable funding for Medicaid? 

Answer. If confirmed, as Secretary I will work to prevent disruption and ensure 

adequate and sustainable funding for Medicaid. In fact, it is just this goal that is 

at the root of many improvements I have offered in my career. 

Question. During the hearing in the Finance Committee, you gave your commitment that you would ‘‘absolutely’’ support an extension of the Children’s Health Insurance program, and even expressed support for a longer extension of the program, 

beyond the typical 5-year authorization. Yet Gene Sperling wrote in the New York 

Times on Christmas Day that—‘‘Mr. Price’s own proposal, which he presented as the 

chairman of the House Budget Committee, would cut Medicaid by about $1 trillion 

over the next decade. This is on top of the reduction that would result from the repeal of the Affordable Care Act, which both Mr. Trump and Republican leaders have 

championed. Together, full repeal and block granting would cut Medicaid and the 

238 

Children’s Health Insurance Program funding by about $2.1 trillion over the next 

10 years—a 40 percent cut.’’

Do you deny that you have advocated for these changes to Medicaid and CHIP? 

You also said during the hearing that there were elements of the budget that you 

did not support. Which parts do you not support? 

Answer. In the past, as a member of Congress, I have advocated policies that 

would strengthen our health-care programs so that they remain solvent for the sake 

of future generations. 

Question. During the hearing, you claimed we were looking at CHIP and Medicaid 

in a silo, instead of looking at the entire range of what the policy will be with respect to health insurance programs. We do not have anything to compare CHIP and 

Medicaid to, because this administration cannot provide a clear plan that is a viable 

alternative to the Affordable Care Act, the CHIP program and Medicaid. 

What will those policies be, and how will they provide better options for the children and individuals with disabilities who rely on CHIP and Medicaid? 

Answer. If confirmed, I look forward to working with you to ensure there are better options available. 

Question. In your answer to Senator Alexander’s question at the HELP Committee 

hearing, you stated, ‘‘folks at the State level know their populations better than we 

(in Washington) ever could know them.’’ The bipartisan, consensus-driven National 

Association of Medicaid Directors advocated for continuing the State Innovation 

Model (SIM) out of the Center for Medicare and Medicaid Innovation. The SIM has 

fueled 35 States (led by both Democrats and Republicans) to improve their local 

health-care systems. 

Given your desire to move decisions and innovation to the local level, as HHS secretary would you continue to support CMMI’s State-level initiatives? 

http://medicaiddirectors.org/wp-content/uploads/2016/12/Key-Considerations-inAffordable-Care-Act-Repeal-and-Replace-Initiatives.pdf 

Answer. CMMI is a program providing significant opportunity for testing new 

models for health-care financing and delivery. 

Question. In reference to your reply to Senator Alexander, 16 States who have expanded Medicaid have Republican leadership. As of January 19th, at least 5 Republican governors have publicly advocated to retain the Federal-State Medicaid expansion partnership. 

Given that several local leaders—including Republicans—favor retaining this program, what is your plan as HHS secretary to honor the wishes of State leadership, 

preserve this program, and avoid adverse consequences to States? 

http://www.politico.com/story/2017/01/gop-governors-republicans-obamacare233576 

Answer. If confirmed, I look forward to working with Congress and Governors to 

ensure access to affordable, quality health care for all citizens. 

Question. In the past, you have stated support of expanding State waiver authority for the Medicaid program. Do you support efforts to evaluate the impact of these 

waivers in terms of access to care, quality of care, and costs of care? 

Answer. It is my strong belief that we need to look at all possible outcomes of 

policy changes. 

Question. In 2015, your budget proposal would have repealed the Affordable Care 

Act, reduced Medicaid spending, and cut the Supplemental Nutrition Assistance 

Program—all told, up to $519 billion in cuts to needy families—yet your proposal 

would have increased defense spending higher than the administration requested, 

gathering criticism from other Republicans. 

Are you only concerned with increased Federal spending when it benefits families 

and children? 

Answer. In my time in Congress, I have been concerned with increased Federal 

spending at all levels. 

Question. In your conversation with Senator Warren and Senator Kaine during 

your appearance at the HELP committee, you cited access to care as your critique 

for the Medicaid program. You stated that Medicaid recipients have access to insurance, but they do not have access to the care they need. Yet the Government AcVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00242 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
239 

countability Office has stated that ‘‘Medicaid enrollees report access to care that is 

generally comparable to that of privately insured individuals and better than that 

of uninsured individuals.’’ The report does cite more challenges with accessing specialty and dental care. 

Do you agree with the GAO’s assessment? If so, what strategies would you suggest to increase access to specialty and dental care for Medicaid recipients? If you 

don’t agree with the GAO’s assessment, please outline your plan to increase access 

to Medicaid-eligible Americans. 

Answer. As a doctor who has actually treated thousands of Medicaid patients, I 

do care deeply about the Medicaid program and the access of Medicaid patients to 

actual care, not just a card they can carry with them. I know from personal experience the difficulties Medicaid patients face, and I receive letters about it all the 

time. My plan is to work with States to ensure they have the flexibility to make 

high quality care truly available. 

Question. It is true that Medicaid faces challenges, including low payment rates 

and barriers to interstate care which limit access and must be improved. Greater 

consistency of national data could significantly improve Medicaid’s ability to serve 

children and other beneficiaries and drive quality improvement. Access to certain 

services, such as pediatric mental health services is a pressing concern. 

What would you do as Secretary to drive improved outcomes in child health across 

States? 

Answer. Ensuring children have access to the health care they need is undoubtedly a top priority. If confirmed, I look forward to working with you to increase access to affordable health plans for families and children as well as taking the necessary steps to strengthen American families. 

Question. A major focus of Congress and the administration has been on pursuing 

delivery system reforms that improve quality and reduce costs. The Federal Government over time has focused more on the needs of children in these reforms, but 

Medicaid for children still lags behind Medicare in supporting improvements in care. 

What steps will you take to promote increased emphasis on reforms targeting the 

unique needs of children? 

Answer. Our goal is to make certain that every single American has access to the 

coverage they want for themselves and their children; and we must ensure that the 

individuals and children who lost coverage under the Affordable Care Act are able 

to access quality health care. If confirmed, I look forward to working with you on 

this effort. 

Question. To ensure kids continue to receive the critical care they need under 

Medicaid, any potential restructuring needs to consider children’s unique health 

care needs and the impact of limiting our investments into their future and the Nation’s as a whole. Any reforms must ensure children’s funding is stable, clearly defined, protects current services, and begins to remediate shortages in critical areas, 

such as mental and behavioral health services. 

How will you ensure that Medicaid continues to deliver essential services tailored 

to the unique needs of children? 

Answer. If confirmed, I look forward to working with you to prioritize a nation 

of healthy children through increased access to affordable health plans for families 

and children, as well as taking the necessary steps to strengthen American families. 

MEDICARE

Question. Do you support converting Medicare’s successful Independence at Home 

(IAH) demonstration into a nationwide program? Do you support the inclusion of licensed mental health professionals on the primary teams for home-based team care? 

Answer. If confirmed, I look forward to working with you on this issue. As a general matter, I believe we ought to allow for all sorts of innovation. Not just in this 

area. There are things that haven’t been thought up yet that would actually improve 

health-care delivery in our country and we ought to be incentivizing that kind of 

innovation. And in finding our way to those innovations, it is important to remember many of these experiments involve real patients’ lives. 

Question. The Medicare program requires that to receive telehealth services, a patient must be in a rural area and at an eligible originating site that currently does 

240 

not include the patient’s home. Do you support making a rural Medicare beneficiary’s home as an eligible originating site for the use of telehealth services? 

Answer. This is certainly something that we will take under consideration. Telehealth holds great promise, particularly for rural areas experiencing physician 

shortages and for patients with limited mobility. At the same time, allowing a beneficiary’s home to qualify as an eligible originating site could create significant Program Integrity challenges. If confirmed, I will certainly direct CMS to take another 

look at this issue to ensure we are doing everything we can to maximize beneficiary 

access to care with appropriate safeguards against fraud. 

Question. Do you support the continuation of the new Merit-based Incentive Payment System as presented in the final rule on the Medicare Access and CHIP Reauthorization Act (MACRA)? 

Answer. The recent CMS MACRA final rule approached the first year of the Quality Payment Program as a transition year, and took steps to address physician concerns regarding the burdens associated with program participation. I think significant challenges remain with respect to provider burden, and, if confirmed, I plan 

to direct the CMS Administrator to ensure that the program is structured to achieve 

its quality and budgetary goals, while ensuring that patients and the providers who 

care for them are at the center of our reform efforts. 

Question. In both the Medicare and Medicaid programs, we are witnessing increased participation in managed care plans. Yet in 1995, you objected to managed 

care as ‘‘the antithesis of our society,’’ citing that managed care threatens the doctor-patient relationship. 

As HHS Secretary, what plans do you have to monitor the quality and effectiveness of Managed Care plans offered in Medicare (through Medicare Advantage) and 

Medicaid programs? 

Answer. If confirmed, I will not pick winners and losers among different plans or 

methods of health-care delivery. It is my intention to fairly and accurately monitor 

the quality and effectiveness of our entire care system, including managed care 

Medicare and Medicaid plans. The facts on the ground will determine our plan 

ahead. 

Question. In September 2011, DHHS released a new policy that implements the 

recommendations of the Memorandum on Hospital Visitation. The rules updated the 

Conditions of Participation (CoPs). The policy states that hospitals receiving Medicare or Medicaid payments should allow patients to designate visitors, regardless of 

sexual orientation, gender identity, or any other non-clinical factor. The HHS policy 

has enhanced hospital visitation rights of same-sex couples. 

Assuming no legislative changes are made, as HHS Secretary, will you continue 

to support and enforce these existing rules? 

Answer. It is essential that health-care services be available to all people with the 

highest level of quality, affordability, and respect for their human dignity. As a physician, I believe that patients should be at the center of health care. This policy allows patients to designate their visitors, regardless of their identity, and I believe 

patients should have that authority. 

Question. In 2012, the Center for Medicare and Medicaid Innovation under Provision 5590 of the ACA funded the Medicare Graduate Nurse Education Demonstration project to address the primary care provider shortage, including the Hospital 

of the University of Pennsylvania. In Philadelphia alone, the project has produced 

703 advanced practice nurses, the majority of whom have assumed primary care 

roles, a 78% increase since before the project launched. 

As HHS Secretary, do you plan to continue to support novel reimbursement models to address the Nation’s shortage of primary care providers? Would you consider 

expanding the successful Graduate Nurse Education demonstration project to other 

sites? 

Answer. I remain committed to ensuring that every American receives access to 

the care that he or she needs. Funding decisions, however, ultimately rest with the 

Congress, which holds the power over the purse. If I am privileged to serve as the 

Secretary of Health and Human Services, I will implement the policies agreed upon 

by the Congress and signed into law by the President. 

Question. There is universal agreement on the need to improve patient care and 

reduce costs. One way to do so is for the Federal Government to continue to promote 

241 

the growth of health information technology and electronic health records. One success in this space over the past several years has been the development and growth 

of the Direct Exchange network, which has allowed for millions of health care record 

exchanges over the past several years. 

Will you as HHS Secretary continue to support the expansion of Health IT and 

the use of networks such as Direct Exchange working with HHS–ONC to encourage 

and ensure the safe and interoperable exchange of medical records? 

Answer. Electronic information sharing, as supported by interoperable health information technology (IT) systems, impacts overall care and the patient experience. 

Patients and providers often rely on the fast exchange of relevant, trustworthy information across health IT systems. Methods to improve flexibility and patient engagement, and clear the way for increased health IT interoperability should be examined as we work to improve health-care delivery. I look forward to continued discussions with you regarding various means to improve the current health IT infrastructure. 

FOSTER CARE AND CHILD WELFARE

Question. You have hardly any record on child welfare issues. The largest Federal 

investment in child welfare is made through title IV–E of the Social Security Act, 

which reimburses States for activities associated with foster care, and it is managed 

by the Department of Health and Human Services. While foster care is a critical, 

often life-saving intervention, we should be moving toward a system that not only 

supports children who can no longer remain safely with their families, but one that 

also helps stabilize struggling families so that they can keep their children when 

it is possible to do so safely. This focus on prevention is not only often in the best 

interest of children, but also in the best interest of State budgets, and States that 

have started shifting to a prevention-focused model have seen lower downstream 

costs associated with foster care, homelessness, health care and criminal justice. 

This is an especially critical issue right now, at a time when we are seeing foster 

care caseloads increasing as a result of the opioid epidemic. 

Do you agree that we must make investments in services aimed at helping vulnerable families? 

Answer. Yes. The family is the foundation of society. It is critical that we build 

and sustain strong families by providing assistance when necessary for those struggling with addiction and mental health issues so that we prevent child neglect and 

violence against children. 

Question. The Department of Health and Human Services is the lead Federal 

agency responsible for addressing child abuse and neglect, including prevention, foster care, reunification, and adoption when children cannot return home. As was discussed during your hearing, the new administration is proposing to block grant 

Medicaid, which is the primary source of services to help families involved in the 

child welfare system. This system is experiencing additional strain as a result of the 

opioid epidemic, which has shattered many families across the Nation. 

Have you considered the potential implications of block-granting Medicaid for 

families in the child welfare system? 

Answer. I look forward to working with the Congress to ensure that all children 

have access to the coverage, regardless of family situation or personal circumstance. 

Question. Will you commit that, if confirmed as Secretary of Health and Human 

Services, you will take action to guarantee parents coverage of and access to mental 

health and substance use disorder services, to prevent child abuse and neglect and 

help reunify families? 

Answer. Substance abuse disorder is a problem and the opioid epidemic is real. 

As I mentioned in the hearing, this is a rampant crisis that is harming families and 

communities across the Nation. This harm includes the potential for abuse and neglect that you mention. I also said, and I firmly believe, that it is vital that substance abuse disorder and other mental health problems are treated. If confirmed 

I will work closely with you and other members of Congress to ensure that the Substance Abuse and Mental Health Services Administration (SAMHSA) fulfills its duty 

of leading public health efforts to advance behavioral health and reduce the impact 

of substance abuse and mental illness on America’s communities. 

Question. According to the Substance Abuse and Mental Health Administration, 

there are 21.6 million people that have a substance use disorder, with just 9.3 perVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00245 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
242 

cent receiving treatment. According to research by Richard G. Frank, the Department of Health Care Policy at Harvard Medical School, and Sherry Glied, Dean of 

the Wagner School of Public Service at NYU, repeal of the Affordable Care Act will 

take $5.5 billion from the treatment of low-income individuals with mental and substance use disorders—11 times the funding that Congress just provided through the 

21st Century Cures Act. 

Do you think such a reduction in both mental health and substance use treatment 

funds through a repeal will have an impact on the child welfare system and foster 

care numbers? 

Answer. Changes to the ACA should not be done in isolation. I remain committed 

to ensuring that every American receives access to the mental health and substance 

abuse care that he or she needs. If I am privileged to serve as the Secretary of 

Health and Human Services, I will implement the policies agreed upon by the Congress and signed into law by the President. 

Question. The Affordable Care Act included a provision to allow children aging out 

of foster care to continue their health coverage through Medicaid up to age 26. 

Block-granting or capping Medicaid would essentially end this guarantee. 

Do you believe we should end this right to health coverage for former foster youth? 

Answer. This would be a part of the new legislation that Congress will be voting 

on, so that decision is in Congress’s hands. If confirmed, I will work to ensure that 

HHS appropriately implements the statutes within its purview. 

Question. Currently, when families adopt children with special needs from foster 

care, those children are guaranteed Medicaid coverage through the age of 18. This 

is an important support for these children and their adoptive families. 

If confirmed as Secretary of Health and Human Services, what assurances can 

you give to these children and their adoptive parents that their health-care needs 

will continue to be met? 

Answer. The life and health of children with special needs is of great importance 

to me, as it has been when I practiced medicine and while I have been in Congress. 

I offer every assurance to children and their adoptive parents that I will do all I 

can, if confirmed as HHS Secretary, to ensure their needs continue to be met to the 

best of the Department’s ability. 

ETHICS OF PROVIDING HEALTH CARE TO PEOPLE ON PUBLIC PLANS

Question. You have been a member of a fringe physician group, the American Association of Physicians and Surgeons (AAPS), which espouses a number of very dangerous ideas, including perpetuating debunked myths about vaccines and claiming 

that it is ‘‘immoral’’ for doctors to provide care to people who rely on publicly funded 

health plans such as Medicare, Medicaid, and CHIP. 

Were you aware of these positions published by AAPS before joining the organization, and do you support those positions? 

Answer. My initial membership in AAPS was based on their successful opposition 

to destructive health policy changes promoted in the early 1990s. 

THE OPIOID EPIDEMIC

Question. According to the recent Facing Addiction: Surgeon General’s Report on 

Alcohol, Drug, and Health, ‘‘Substance misuse and substance use disorders are estimated to cost society $442 billion each year in health-care costs, lost productivity, 

and criminal justice costs.’’ The National Survey on Drug Use and Health (NSDUH) 

reported in 2015 that 21.5 million people in the United States, over 8 percent of 

the population, had a substance use disorder. The Center for Disease Control and 

Prevention reported over 52,000 drug overdose deaths in 2015. Of the millions of 

people struggling with a substance use disorder, only about 10 percent receive substance use disorder treatment in a given year. 

If confirmed as Secretary of Health and Human Services, what actions will you 

take to address the needs of Americans struggling with substance use disorders, especially those who are seeking treatment? 

Answer. Substance abuse disorder is a problem and the opioid epidemic is real. 

As I mentioned in the hearing, this is a rampant crisis that is harming families and 

communities across the Nation. This harm includes the potential for abuse and neglect that you mention. I also said, and I firmly believe, that it is absolutely vital 

243 

that substance abuse disorder and other mental health problems are treated. If confirmed, I will work closely with you and other members of Congress to ensure that 

the Substance Abuse and Mental Health Services Administration (SAMHSA) fulfills 

its duty of leading public health efforts to advance behavioral health and reduce the 

impact of substance abuse and mental illness on America’s communities treating 

those who are in addiction recovery while working to prevent people from becoming 

addicted in the first instance, and explore other means available to HHS to assist 

those struggling with substance use disorders obtain treatment and to prevent addiction. 

Question. If confirmed as Secretary of Health and Human Services, will you commit to supporting, and as a Cabinet member advising the President to support, continued funding for opioid crisis grants, as administered by SAMHSA? 

Answer. I remain committed to ensuring that every American receives access to 

the mental health and substance abuse care that he or she needs. Funding decisions, however, ultimately rest with the Congress, which holds the power over the 

purse. If I am privileged to serve as the Secretary of Health and Human Services, 

I will implement the policies agreed upon by the Congress and signed into law by 

the President. 

Question. If confirmed as Secretary of Health and Human Services, will you commit to supporting, and as a Cabinet member advising the President to support, 

funding for the Substance Abuse Prevention and Treatment Block grant to preserve 

the critical safety net for Americans who require substance abuse treatment but 

who are uninsured? 

Answer. Access to mental health and substance abuse care is absolutely vital. If 

I am privileged to serve as the Secretary of Health and Human Services, I will implement the policies agreed upon by the Congress which holds the power of the 

purse, and signed into law by the President. 

Question. If confirmed as Secretary of Health and Human Services, would you 

commit to supporting, and as a Cabinet member advising the President to support, 

funding requests for the National Institute of Mental Health and the National Institute on Drug Abuse to develop better treatments for substance use disorders? 

Answer. I remain committed to ensuring that all Americans maintain access to 

the mental health and substance abuse disorder treatments; however, funding decisions ultimately rest with the Congress, which holds the power over the purse. If 

I am privileged to serve as the HHS Secretary, I will implement the policies adopted 

by the Congress and signed into law by the President. 

Question. Integrated primary care and mental health care is one promising strategy to improving outcomes for Americans with substance use disorders. If confirmed 

as Secretary of Health and Human Services, will you support demonstration programs—which as Secretary you would have the ability to direct—to integrate primary and behavioral health care, through the Center for Medicare and Medicaid Innovation? 

Answer. CMMI is a program providing significant opportunity for testing new 

models for health-care financing and delivery. If confirmed, as HHS Secretary, I 

plan to work closely with CMS to ensure that CMMI—after appropriate consultation 

with Congress, the States, health-care stakeholders, and Innovation Center staff— 

tests innovative models that reduce costs and improve quality for Medicare and 

Medicaid beneficiaries. 

Question. A key challenge to effectively addressing the opioid epidemic in the 

United States is a shortage of qualified providers. The Affordable Care Act included 

a provision to establish a National Healthcare Workforce Commission, yet this Commission has never met. 

If confirmed as Secretary of Health and Human Services, would you commit to 

supporting, and as a Cabinet member advising the President to support, a congressional appropriation to convene this commission so we can understand the root 

cause of mental health provider shortages and develop evidence-based strategies to 

address them? 

Answer. As I mentioned in the hearing, it is important that we as a nation make 

sure that every single individual has access to the kind of mental health and substance abuse care that they need. I look forward to working closely with you and 

the other members of Congress to ensure that the mental health profession is adequately, if not robustly, staffed for this and the future generations. 

244 

COVERAGE

Question. On January 7, 2009, you penned a commentary in the Wall Street Journal that advocated for ‘‘access to coverage for all Americans and coverage that is 

truly owned by patients.’’ Yet under the policy proposals you have authored, according to the Congressional Budget Office, ‘‘the number of people who are uninsured 

would increase by 18 million in the first new plan year.’’ After repeal of Medicaid 

expansion and exchanges, 32 million Americans would be uninsured by 2026. 

How do you reconcile your position in 2009 with the analysis by the CBO in 2017? 

Answer. I disagree with the conclusion drawn by CBO. If there are any changes 

to Medicaid, they should not be done in isolation. 

Question. You introduced the Medical Freedom Act of 2015, which would repeal 

the requirement that insurers offer dependent coverage until the age of 26. HHS 

estimates this provision has affected 2.3 million young adults. 

If confirmed, what is your plan to protect the health and well-being of young 

adults under the age of 26? 

Answer. This would be a matter for Congress to determine through legislation. 

If confirmed, I will work to ensure that HHS appropriately implements the statutes 

within its purview. 

CHILDREN

Question. Oftentimes, changes in the larger health-care landscape take place, for 

example in the Medicare program, without a full examination of how these changes 

could potentially impact children, even inadvertently. 

As you look at health-care changes at the national level as Secretary, how will 

you ensure that children’s unique health-care needs are taken into account? 

Answer. I look forward to working with Congress to ensure that children will not 

be inadvertently impacted by potential changes to the health-care system. 

LIHEAP

Question. The Low-Income Home Energy Assistance Program (LIHEAP) provides 

short-term aid to vulnerable populations for heating or cooling assistance, crisis assistance or weatherization assistance. Without this support, many low-income participants would quickly fall behind on their bills and face shut-off of essential energy 

services. The program effectively utilizes a partnership between the Federal Government, State government and the private sector. 

LIHEAP protects the most vulnerable in our society. According to the Campaign 

for Home Energy Assistance, in Pennsylvania in 2014, 35% of households receiving 

LIHEAP were elderly, 30% were disabled, and 18% had children under 5. You were 

a member of the Task Force on Poverty, Opportunity, and Upward Mobility that 

drafted the ‘‘A Better Way’’ plan that proposed to combine LIHEAP with 10 other 

social program grants to create a large block grant to States. Should such a plan 

come to pass, it would eliminate a dedicated fund for utility crisis assistance. In addition, your recent budget took across the board cuts from safety net programs and 

highlighted LIHEAP as one of several ‘‘duplicative anti-poverty programs.’’ While 

the Department of Energy also oversees an energy program (the Weatherization Assistance program), this program provides grants to States to improve the weatherization and energy efficiency of low-income homes. Thus, serving a different, though 

just as important, service from LIHEAP. 

Can you explain why you think LIHEAP is a duplicative anti-poverty program 

and which other programs in particular you think are providing the same services? 

Answer. One of the main goals of the ‘‘A Better Way’’ plan was to match povertyfighting programs with the needs of those on Federal Aid more effectively so that 

it is easier for them to get back on their feet. Using block grants, rather than dedicated grants, gives States and communities more freedom to use the funds where 

they are most necessary. 

Question. According to the National Energy Assistance Directors Association, 

States have been forced to reduce the number of households served by LIHEAP from 

8 million to the current level of 6.7 million due to Federal cuts to the program. This 

equates to 1.3 million eligible households nationwide that did not receive assistance. 

245 

LIHEAP is a critical safety net program to support the elderly and families as 

the country recovers from the economic recession. Families should not have to 

choose between heating their homes and putting food on the table. You have previously voted in the House of Representatives against increasing funding for 

LIHEAP. 

Do you support increasing funding for LIHEAP? If not, why do you not support 

it? 

Answer. If confirmed, I will administer LIHEAP as effectively and efficiently as 

possible. If once in office, and should circumstances on the ground change and current resources are found to be insufficient, I will inform Congress and work with 

them on finding solutions. 

Question. Will you support maintaining the funding at the current level of $3.3 

billion in the President’s final recommendations for FY 2017 and proposed FY 2018 

budget? 

Answer. If confirmed, I will administer LIHEAP at the levels passed by Congress. 

TAX ISSUES

Question. Do you think the President should disclose how much he stands to benefit from the repeal of the net investment income tax prior to signing the repeal of 

the Affordable Care Act into law? 

Answer. This is a matter for the President. 

Question. With respect to subsidizing the cost of health care, please explain why 

an annually disbursed refundable tax credit is superior to a monthly insurance premium support credit. 

Answer. There are many health-care scholars who have promoted the superiority 

of a credit versus a subsidy, as it may provide greater flexibility and options for patients. 

QUESTIONS SUBMITTED BY HON. DEBBIE STABENOW

CONTINUOUS COVERAGE

Question. Last week we held a forum and asked folks from around the county to 

share their stories and help inform the debate around repeal of the ACA. One of 

the women on the panel, Holly Jensen, was a small business owner insured with 

a plan she selected on the marketplace. Holly was living with undiagnosed depression, anxiety, and obsessive compulsive disorder that was getting worse by the day. 

It got to the point that she withdrew from her community, her work, and was really 

struggling. She was unable—understandably—to make her monthly premium payments. Luckily, because of Medicaid expansion, she was able to get the treatment 

she needed a few months later and is doing well today. Her small business is back 

up and running. However, she did not maintain coverage continuously, as your plan 

and many others require. 

If the continuous coverage requirement were in place, Holly would re-enter the 

health insurance market and could be labeled with a pre-existing mental health condition, correct? How do you believe this problem is best addressed? 

Answer. I believe it is important that we as a nation make sure that every American has access to the kind of mental health care and health coverage that best 

meets their need. Additionally, it is imperative that all Americans have access to 

affordable coverage and that no one is priced out of the market due to a bad diagnosis. This is a matter for the legislative branch, however, and if confirmed, I will 

work to ensure that HHS (appropriately) implements the statutes within its purview. 

MATERNITY COVERAGE

Question. As I mentioned today, prior to the ACA, the vast majority of plans on 

the individual market did not offer maternity coverage. You said today that women 

would likely opt not to purchase one of those plans if they were pregnant or planning to be. However, over the course of a health plan year, couples and families 

make many decisions about their health-care future, sometimes including whether 

or not to have a child. 

246 

Given this fact, do you believe that all health plans should be required to cover 

maternity and newborn care? 

Answer. My hope is to move in a direction where insurers can offer products people want and give them the coverage they want. That, of course, can and would in 

many cases include maternity and newborn care. Getting to that kind of system requires changes that will inevitably involve working with Congress and considering 

the tradeoffs of various proposals to achieve our shared objective of the best and 

highest quality care being available to Americans. And note that I refer to care because ultimately, having maternity or other coverage is not meaningful if one cannot 

access the care they need or the quality of care leaves them worse off. So we must 

work towards both coverage and care. 

QUESTIONS SUBMITTED BY HON. MARIA CANTWELL

LONG-TERM CARE

Question. Do you share my view that patients should be able to age in their 

homes and communities instead of in nursing homes and other institutional/inpatient settings, so long as the patient chooses this option and it is clinically appropriate? 

Answer. Our health-care system should be able to accommodate the choices of patients, in consultation with their physicians, regarding the ideal setting for their 

care. 

Question. Do you agree with me that home- and community-based care is, in general, far less costly and more convenient for patients compared to institutional care 

in nursing homes? 

Answer. Home- and community-based care is often less costly and more convenient as compared to institutional care in nursing homes. Our goal ought to be the 

right care in the right setting and the best care possible for Medicaid patients and 

all Americans. Too many Medicaid beneficiaries lack access to care. 

Question. Do you support incentives for States to transition or ‘‘rebalance’’ their 

Medicaid long-term care population from nursing homes to home- and communitybased care? 

Answer. If confirmed, I will work to provide States the flexibility to pursue innovative approaches that fit the unique needs of their citizens. 

Question. Are you aware that, under the Affordable Care Act’s Balancing Incentive Program (section 10202), the State of Georgia was approved for $57 million to 

transition Medicaid beneficiaries from institutional long term services and supports 

(LTSS) settings to home-and community-based settings (HCBS), and, as a result of 

that investment, Georgia has been able to shift more than 10 percent of its longterm care costs from high-cost nursing homes to low-cost home and community care, 

according to reports submitted to CMS and Georgia’s program application? 

Answer. Each State has different needs, and I believe CMS needs to work with 

States to ensure that, consistent with those needs, the Medicaid program provides 

the best possible coverage to their residents. It is not surprising that providing 

States with flexibility to tailor their Medicaid program leads to good results in general. 

Question. Do you support the Balancing Incentives Program in the Affordable 

Care Act? 

Answer. I am committed to ensuring that Medicaid is available for eligible beneficiaries, and working with CMS to make sure that States are able to make the most 

use of available resources to serve their citizens with the highest quality care, if I 

am confirmed. 

Question. If you do support this program, or if you at least agree with its intent 

and goals, will you commit to working with me and my staff to expand Federal incentives for States to ‘‘rebalance’’? 

Answer. Yes, I will look forward to working with you and your staff to explore 

proposals you have in mind and otherwise consider how best to provide States with 

flexibility to provide the highest-quality care for Medicaid beneficiaries. 

247 

Question. Do you believe that, if executed well, ‘‘rebalancing’’ programs such as 

Balancing Incentives can improve the care experience for patients and reduce State 

Medicaid costs? 

Answer. The experience of our system is that while many different States may 

face the same problem, the approach that is most likely to succeed may depend on 

the particular State and other details specific to the circumstances. 

BASIC HEALTH PROGRAM

Question. The Basic Health Program (section 1331 of the Affordable Care Act) is 

a State option that is providing health insurance and access to care to more than 

750,000 working low-income individuals in New York and Minnesota. States that 

have taken advantage of this voluntary program are seeing lower costs for beneficiaries, higher enrollment, and net State budget savings, compared to not implementing the program. Through the Basic Health Program, States are price-makers, 

not price-takers. 

Do you support the Basic Health Program as a way to empower States to negotiate a better deal on health insurance for their citizens? 

Answer. I support the efforts of States to innovate and find solutions for their citizens with respect to health care, in the area of insurance and otherwise. 

Question. Will your Department and CMS commit to funding and administering 

the Basic Health Program as required under current Federal law? 

Answer. If confirmed as Secretary of HHS, my role will be to administer the laws 

of the land as they originate from the Congress, including those relating to the 

Basic Health Program. 

Question. If Congress repeals the Affordable Care Act, will you commit to ‘‘not 

pulling the rug out’’ from the 750,000 low-income individuals who are benefitting 

from the Basic Health Program? 

Answer. In working through the current situation and options for the future, I 

am committed to working towards solutions that provide meaningful access to care, 

not just insurance but actual care, for all, including—of course—these individuals. 

Question. In other words, will you use your administrative discretion as HHS secretary to not rescind funding for State Basic Health Programs, unless a rescission 

of that funding is explicitly required by a change to the statute? 

Answer. If confirmed, I will follow the directions of Congress as contained in appropriations and other law regarding funding for health-care programs. 

DELIVERY SYSTEM REFORM

Question. Washington State and the Pacific Northwest have led the way in pioneering nationally recognized innovations in the delivery of health care—whether it 

is the Qliance Direct Primary Care medical home model, Group Health Cooperative’s highly popular integrated coverage and care model, the Everett Clinic’s price 

transparency initiatives, Boeing’s Accountable Care Organizations, or dozens of others. Despite their innovations, health-care providers in my State are paid nearly 

$2,000 less (per Medicare enrollee, per year) than the national average, based on 

CMS spending data compiled by the Kaiser Family Foundation. I would argue that, 

due to our current volume-based system, my constituents are paid less specifically 

because they are efficient and because they do a good job of keeping patients 

healthy. 

Should the Federal Government reward such high-value health care providers, as 

long as we clearly define and agree upon metrics for what constitutes ‘‘high-value’’ 

care? 

Answer. I look forward to faithfully executing the laws Congress passes pertaining 

to health-care provider reimbursement. 

Question. Does the current fee-for-service system encourage unnecessary healthcare spending? If so, can you please explain specifically how this system encourages 

unnecessary health-care spending, including in which specialties of medicine? 

Answer. The current system encourages unnecessary spending since too many of 

the decisions providers and patients make are determined by a distant Federal bureaucracy and not based on the value of care that is provided to patients by their 

248 

health-care providers. If confirmed, I look forward to executing laws that reduce unnecessary health-care spending. 

Question. As a physician, do you share my view that clinicians should focus more 

on keeping their patients healthy and less on paperwork? 

Answer. Clinicians should focus more on keeping their patients healthy and less 

on paperwork. Unfortunately, it does not seem that is the current trend. 

Question. As a physician, do you share my view that the current fee-for-service 

system requires significant paperwork, including substantial time spent on coding 

and billing for each individual procedure or service rendered? 

Answer. Clinicians should focus more on keeping their patients healthy and less 

on paperwork. Unfortunately, it does not seem that is the current trend. 

Question. You voted for the bipartisan Medicare Access and CHIP Reauthorization 

Act (MACRA) when it was considered on the House floor. Will you commit to working with Washington State health-care providers to help them succeed in Medicare’s 

new Quality Payment Program, as outlined in regulations by CMS, including Advanced Alternative Payment Models? 

Answer. If confirmed, I commit to work closely with the CMS Administrator to 

make sure we implement MACRA in a way that is easy to understand, minimizes 

burden, and is fair to all affected providers. 

Question. Will you commit to fund and administer Medicare’s Accountable Care 

Organizations, including the Medicare Shared Savings Program under section 3022 

of the Affordable Care Act, and will you commit to helping health-care providers 

participate in these models, should they choose to do so? Will you commit to not 

taking any administrative action that would make it more difficult for Medicare 

beneficiaries or health-care providers to participate in this voluntary program? 

Answer. As a doctor, I appreciate the goal behind the creation of the ACO model: 

better patient care. As a legislator, I would agree their successes have been modest 

to date, and there are some challenges they face as well. ACOs are a tool in the 

toolbox to help ensure high quality, low cost health care for beneficiaries. They are 

not a silver bullet to all of our country’s delivery system challenges. If confirmed, 

I plan to work with the CMS Administrator to ensure that we learn from ACOs’ 

successes and challenges to date as we chart the path forward. 

Question. Will you commit to fully fund approved grants under the Center for 

Medicare and Medicaid Innovation (CMMI), and will you continue to fund and administer future payment initiatives under CMMI, consistent with the legislative intent of Congress in the Affordable Care Act? 

Answer. If confirmed, I will work to ensure that HHS (appropriately) implements 

the statutes within its purview. 

Question. Do you share my view that, given Congress’s significant ongoing investment in the delivery of health-care services, the Federal Government should fund 

research into health-care quality? Will you commit to not taking administrative actions that would weaken the work of the Agency for Healthcare Research and Quality (AHRQ) within HHS? 

Answer. I appreciate your concerns about health-care quality. I also appreciate 

the fact that health-care research may address patient safety, care management and 

methods to broaden access to health-care services, among other issues. Health-care 

studies also help to inform the discussion on ways to improve the quality of care 

and reduce costs. As you know, Congress will ultimately make the decision on 

whether to fund the Agency for Healthcare Research and Quality (AHRQ). Nonetheless, if confirmed, I look forward to working with you to more carefully examine 

AHRQ and determine how it may best drive positive patient-centered solutions in 

healthcare. And if confirmed, I will work to ensure that HHS (appropriately) implements the statutes within its purview. 

HEALTH CARE LEGISLATION

Question. I have authored bipartisan legislation (S. 2259 in the 114th Congress) 

to make it easier for rural health-care providers to participate in the Medicare 

Shared Savings Program by allowing CMS to adopt a broader beneficiary assignment method than is provided under current law. Will you commit to providing me 

and my office responsive and accurate technical assistance on this legislation? 

249 

Answer. I look forward to working with you on this issue and sharing both feedback and assistance regarding the important policy issues in beneficiary assignment 

for the Medicare Shared Savings Program. 

Question. I have authored bipartisan legislation (S. 2373 in the 114th Congress) 

to require Medicare to cover an essential preventive product, compression therapy 

items, for beneficiaries who experience swelling from lymphedema. Will you commit 

to providing me and my office responsive and accurate technical assistance on this 

legislation? 

Answer. As you know, CMS has a detailed process for making determinations regarding whether items and services are reasonable and necessary, if they can be 

considered eligible for Medicare coverage given other restrictions and prohibitions. 

From time to time, Congress sees it fit to make its own determination regarding 

specific items or services. If confirmed, I would be pleased to work with your team 

to provide information on the Medicare coverage process and potentially relevant 

considerations. 

Question. I have cosponsored bipartisan legislation (S. 3129) to preserve patient 

access to outpatient therapeutic services in Critical Access Hospitals and other rural 

hospitals. Similar legislation has been signed into law the last 3 years. Will you 

commit to working with me, my staff, and bill sponsors and cosponsors, on this 

issue? 

Answer. If confirmed, I look forward to working with you and others in the Congress to see that critical access hospitals are best enabled to serve rural populations 

well. 

Question. Will you commit to providing me and my office responsive and accurate 

technical assistance on any future legislation I author or on which I seek assistance? 

Answer. Federal agencies play a significant role in the legislative process, often 

including providing technical assistance. Such technical assistance can involve situations where the agency provides feedback but clarifies that the assistance does not 

reflect the views or policies of the agency or administration. If confirmed, I will endeavor to work with you in this way as appropriate to ensure proposed legislation 

is consonant with the existing statutory and regulatory scheme. 

WASHINGTON STATE’S SECTION 1115 MEDICAID WAIVER

Question. On January 9, 2017, CMS approved Washington State’s proposed Medicaid waiver (‘‘Medicaid Transformation Project, No. 11–W–00304/0’’) under section 

1115(a) of the Social Security Act. In securing agreement on this waiver, Washington State health officials and CMS spent countless hours over more than a year 

in good-faith negotiations. This approved waiver will help Washington State pursue 

a smarter and more innovative Medicaid program that reflects changes in healthcare delivery, technology, and the preferences of patients. 

Will you commit to honor this approved waiver and not take any administrative 

action to rescind, weaken, or de-fund its components? 

Answer. It would be inappropriate at this point to comment on any specific waivers under consideration at CMS, but, if confirmed, I would work with the CMS Administrator to ensure that CMS uses its waiver authority to provide much needed 

flexibility to States to innovate within the Medicaid program. 

GRADUATE MEDICAL EDUCATION

Question. The vast majority of Washington State counties are Health Professional 

Shortage Areas (HPSA’s) according to HHS’s HRSA. Do you agree with an established body of research illustrating that there are physician shortages in the United 

States, especially in primary care specialties and in rural communities? 

Answer. Access to care is a critical issue in many parts of the country, particularly for primary care in rural areas. The underlying physician shortage is sometimes worsened by government policies. If confirmed, I look forward to the opportunity to address these physician shortages, particularly as they relate to the Medicare and Medicaid programs. 

Question. Do you agree with previous congressional intent that the Federal Government, through Medicare and other programs, has a strong role to play in graduate medical education (GME) policy and funding? 

250 

Answer. I have always been a strong supporter of efforts to support medical education. Congress has used the Medicare program from its inception to invest in future generations of doctors. Regardless of what we do in Washington, health care 

should always be about that one to one relationship of a patient to a doctor. That 

relationship of course requires a doctor. And so I am hopeful we can continue to find 

ways to remove disincentives to the practice of medicine and its rewards as well as 

support the profession in other ways. 

Question. Was your own surgery residency funded by Medicare? 

Answer. Both my wife and I were residents at Emory University. I completed my 

residency in 1984. The Medicare program has paid for some portion of GME at participating hospitals since its inception in 1965. 

QUESTIONS SUBMITTED BY HON. MARK R. WARNER

AFFORDABLE CARE ACT

Question. In December 2016, the Congressional Budget Office issued a report noting that it would define as insurance coverage only ‘‘a comprehensive major medical 

policy that, at a minimum, covers high-cost medical events and various services, including those provided by physicians and hospitals.’’ The ACA established a set of 

services, known as Essential Health Benefits, that all insurance policies must include to make sure patients have appropriate health coverage. 

What would you advise the President define as ‘‘coverage’’ under a Republican 

ACA replacement plan? 

In a repeal-and-replace scenario, will coverage obtained by individuals provide 

adequate financial protections against high medical costs? 

Will you advocate for insurance policies under the Republican replacement plan 

that provide meaningful coverage so that insurers could not once again: (1) charge 

higher premiums to women, people with pre-existing conditions, or others for reasons such as their profession or the industry in which they work; (2) drop or severely limit benefits such as maternity care and prescription drugs, which insurers 

must currently cover as ‘‘essential health benefits;’’ (3) reinstate annual and lifetime 

limits on coverage; or (4) charge deductibles, co-payments and co-insurance without 

limits? 

Will you commit to safeguarding the consumer protections that the Affordable 

Care Act put in place? 

Answer. This is a work in progress. If confirmed, I would appreciate your 

thoughts on how best to address these matters. It is important that any system 

have safeguards so that no one loses access to care due to a bad diagnosis. Additionally, credible coverage is important. Patients should be provided an array of options 

so they may select the one best for themselves and their family; and consumer protections are integral to any patient-centered system. 

DRUG PRICES

Question. The rise in prescription drug costs is squeezing American families as 

well as Federal spending. We need to address this now. In your testimony to the 

HELP Committee last week, you agreed that we need to work in ‘‘a bipartisan way 

(to address the) root causes of drug prices, (and) to make sure that drug pricing is 

reasonable.’’ But you refused to commit to specific policies. President Trump has 

said that we should allow Medicare to leverage its power as a payer, and negotiate 

drug prices with pharmaceutical companies. 

Do you agree with President Trump that Medicare should negotiate drug prices? 

Answer. The issue of drug pricing and drug costs is one of great concern to all 

Americans. You have my commitment to work with you and others to make certain 

that Americans have access to the medications that they need. If confirmed, I look 

forward to focusing on how we can make health care more affordable, including prescription drugs. I share your concern regarding the importance of individuals and 

families being able to afford the prescription drugs they need. 

DRUG PRICE AND VALUE

Question. While we are moving towards paying for value in many areas of 

healthcare, in the drug space we have largely lagged behind. In the past year, we 

251 

have seen some insurers and drug manufacturers pilot value-based arrangements 

that hold the manufacturer accountable for how their product performs in the real 

world on an agreed upon set of metrics. In 2015, I led a letter with my colleagues, 

Senator Kaine, Senator Nelson, Senator Shaheen, and Senator Heitkamp, to the 

Centers for Medicare and Medicaid asking them to examine the potential of using 

value-based arrangements in Medicare and other public programs. 

Will you commit to working with me to identify potential regulatory policy barriers that should be reviewed in order to continue to move towards reimbursement 

for value rather than volume in the drug space? 

Answer. If confirmed, I look forward to working with you and others to ensure 

that we are moving toward a health-care system defined by high-quality, patientfocused care. I appreciate how reimbursement—and other regulatory policies impact 

physician behavior. If confirmed, I will ensure that HHS is a good steward of taxpayer dollars, with the goal of delivering the highest-quality care through its healthcare programs, including the Medicare program serving our Nation’s seniors. 

GABRIELLA MILLER/NIH

Question. Gabriella Miller, a 10-year old girl from Leesburg, VA who suffered 

from pediatric brain cancer, became an extremely impressive activist on behalf of 

childhood cancer awareness before her untimely death. Her work led to the passage 

of the Gabriella Miller Kids First Act, and NIH has been moving forward to implement this law and expand pediatric research. 

Will you prioritize pediatric cancer research and implement the Gabriella Miller 

Kids First Research Act? 

Answer. I am always inspired by the courage cancer patients bring to their fight 

against this devastating disease. This is particularly true when the patients are 

some of the youngest amongst us. It underscores why we must cure cancer. The NIH 

plays a pivotal role in supporting cutting-edge biomedical research across our country, including key efforts related to pediatric research, and I recognize that we must 

make progress on this front for the adults and children fighting cancer. If confirmed, 

I look forward to continuing HHS’s important work to advance cancer research and 

bring forward innovative treatments as part of our shared goal of defeating cancer. 

CYBERSECURITY/INTERNET OF THINGS

Question. The declining cost of digital storage and Internet connectivity have 

made it possible to connect an unimaginable range of products and services to the 

Internet, with medical devices at the forefront of this trend. However, in many 

cases, manufacturers have brought insecure devices to market, with few incentives 

to design the products with security in mind, or to provide ongoing support to address vulnerabilities. For example, we have seen cases where an implantable device 

lacked meaningful authentication methods, leaving it susceptible to unauthorized or 

malicious commands sent remotely. 

The FDA has taken important steps to addressing cybersecurity in the ‘‘Internet 

of things.’’ This includes promulgating post-market guidance, working closely with 

cybersecurity researchers, and engaging manufacturers to promote development of 

more secure devices. Will you commit to continue and build on these efforts? 

Answer. The safety of American citizens will always be a top priority of the HHS 

and ensuring the security of medical devices against the threat of hacking is critical 

to that end. If I am confirmed, the FDA will continue and improve upon its efforts 

to strengthen cybersecurity within the medical device industry as well as other related industries. 

BAN ON CDC GUN RESEARCH

Question. Since 2013, Americans have died from incidents involving firearms and 

automobiles at almost identical rates. Over the last two decades, the Federal Government has spent $240 million a year on motor vehicle safety research, and motor 

vehicle deaths plummeted nearly 25 percent from 2004 to 2013 thanks to data supporting new policies. CDC has done virtually no research into gun-related injuries 

and deaths after an appropriations rider was added that prohibits the CDC from 

‘‘participating in advocacy or promotion of gun control.’’ Roughly 100,000 Americans 

injured or killed each year by guns, including over 2,000 in 2016 from accidental 

shootings alone. The original author of the appropriations rider, Representative Jay 

Dickey (R–AR), has declared he regrets it and would like to see the CDC able to 

252 

research violence and injury related to firearms. To make smart policy, it’s necessary to have accurate information and data. 

If confirmed, would you direct CDC staff to interpret the appropriations rider in 

a reasonable way, so that CDC could in fact conduct unbiased research on the relation of firearms to public health? 

Answer. The CDC performs an important role in helping to understand and communicate public-health issues. If confirmed, I will work to faithfully ensure that the 

Department and its operating divisions fulfill their statutory responsibilities. 

RURAL HOSPITALS

Question. Rural hospitals, serve older, sometimes more economically disadvantaged populations challenged by less access to primary, dental, and mental health 

care than their urban counterparts. Rural hospital leaders from across Virginia continue to share with me their concerns with efforts to repeal the Affordable Care Act. 

The ACA lowered the percentage of uninsured by 8 percentage points in rural counties, decreasing bad debt for providers in these areas, and providing them with some 

financial breathing room. Yet despite this progress, the Virginia Hospital Association estimates that 43% of rural hospitals in Virginia operate at a financial loss. 

Should there be supports included in an ACA replacement proposal to ensure 

these safety net providers can afford to keep their doors open to serve these vulnerable patients? 

Answer. Our goal is to ensure access to affordable, quality health care for all citizens. This of course includes individuals who access care at rural or critical access 

hospitals. And so the best metric in the end is one that measures the extent of access to actual care, not just coverage, and the quality of that care as determined 

by patients working individually with their doctors. I look forward to working on 

this important issue with you, if confirmed. 

Question. Last week, CBO reported that in the first year after a repeal of the ACA 

marketplace subsidies would take effect, about half of the Nation’s population would 

live in an area that would have no insurer participating in the individual market, 

increasing to three-quarters of the population by 2026. You have emphasized ‘‘access’’ to coverage but the report suggests repeal in its effects will eliminate choice, 

competition, and access in rural communities, reversing much of the progress we’ve 

made to reduce the number of the uninsured, as well as reducing uncompensated 

care. 

What advice would you give President Trump on addressing the bad debt issues 

these rural hospitals would face post-repeal? 

Answer. Changes to the ACA should not be done in isolation. Our goal is to ensure access to affordable, quality health care for all citizens. 

HOME INFUSION

Question. While I supported the 21st Century Cures Act when it passed in December, I remain concerned about a provision which caused the misalignment of effective dates of two important policies. The act included a provision Senator Isakson 

and I fought hard to include that would pay for services associated with allowing 

Part B to reimburse for Medicare patients to receive infusion drugs at their home 

starting in January 2021. However, a provision which was used to help pay for such 

payment, a cut to the reimbursement rates for Part B Durable Medical Equipment 

(DME) home infusion drugs, had an effective date of January 2017. This leaves a 

4-year gap where home infusion services will not be adequately reimbursed. While 

I work with my colleagues in Congress to fix this issue, I hope that the Centers for 

Medicare and Medicaid Services (CMS) will make every effort to ensure Medicare 

beneficiaries continue to have access to these lifesaving medications. 

Can you commit to report back on actions CMS and HHS can take to protect 

beneficiaries from losing access to life-saving care? 

Answer. Yes. I look forward to working with you to find approaches to this issue 

that ensure access to the highest quality care. 

TELEHEALTH

Question. I’ve worked with bipartisan members of the Finance Committee to expand the use of telehealth, especially in Medicare, and I was glad that at your hearVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00256 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
253 

ing last week you called telehealth an ‘‘exciting innovation for rural and underserved areas.’’ 

As Secretary, will your Department work with my staff and others to find ways 

to fully leverage HHS’s existing authority to lower barriers for telehealth and remote patient monitoring in Medicare? 

Answer. I share your interest in promoting telehealth. Telehealth can provide innovative means of making health care more flexible and patient-centric. Innovation 

within the telehealth space could help to expand access within rural and underserved areas. If confirmed, I look forward to continued discussions on telehealth, including on the best means to offer patients increased access, greater control and 

more choices that fit their medical needs. 

SUBMITTED BY HON. DEBBIE STABENOW, A U.S. SENATOR FROM MICHIGAN

DPCC FORUM ON HEALTH AND HUMAN SERVICES 

NOMINEE TOM PRICE 

THURSDAY, JANUARY 19, 2017 

OPENING STATEMENT OF HON. DEBBIE STABENOW, 

A U.S. SENATOR FROM MICHIGAN 

Senator STABENOW. Well, good afternoon. We so appreciate all of you being with 

us, and I want to thank all of my colleagues for being here and for their hard work. 

Senator Murray will be joining us; she has been involved in helping to create the 

success of today, as well as Senator Warren. Senator Kaine of course is here, and 

Senator Hassan. It’s very important for us to have an opportunity to hear from all 

of you as we are reviewing and making decisions on who will head the Health and 

Human Services Department for our country. 

And Senator Murray has joined us; welcome. Let me just start by saying that on 

all of these issues this is not personal to any nominee, this is about differences, fundamental differences, and ideas and policies and what helps people, what hurts people. I mean these are very important debates, and your voice, your opinions are very 

important to all of us. 

So you’re here at a critical time, and we know that just last week Republicans 

in both the House and the Senate pulled the first thread that will unravel potentially the entire health-care system, voting to adopt a budget resolution that would 

allow for repeal of the Affordable Care Act, and we don’t know what comes after 

that. If this happens, according to the Congressional Budget Office, 32 million people, including many of you on this panel today, would lose health insurance coverage 

and individual market premiums would double in the next 10 years, according to 

the budget office. 

Unfortunately, the damage would not end there. Another 52 million adults, including 1.7 million in my own home State of Michigan, could become uninsured due 

to pre-existing conditions. Forty-eight million people could lose mental health parity 

protections, which makes sure that diseases are treated above the neck, as well as 

below the neck. We could be sent back to a time when being a woman was a preexisting condition, when insurance companies would cut you off when you hit an annual or lifetime limit on coverage, even if you needed more care. 

One hundred and five million Americans no longer face bankruptcy when they get 

sick because those caps have been eliminated, and that is a good thing. The Medicare trust fund has been extended by 11 years, preserving future benefits, and 11 

million seniors have saved an average of $2,000 because what has been called the 

‘‘donut hole,’’ this gap in coverage, has been phased out; it’s now closed so there is 

continuous coverage. 

I could go on with the numbers, but the most important thing is not the numbers. 

The most important thing is how all of this effects your families, our families, our 

children, our parents, our grandparents. 

254 

If confirmed by the Senate, the Secretary has tremendous power. His or her decisions in office will affect all of us. His or her voice will strongly influence the President’s decision to promote, sign, or veto legislation. 

We have heard mixed messages. Our President-elect campaigned on not cutting 

Medicare or Medicaid. Just over the weekend he said we would have insurance for 

everyone. We would certainly welcome the opportunity to see that plan, we do welcome it. But at the same time, just this fall, Congressman Price said he expects 

Medicare to be overhauled ‘‘within the first 6 to 8 months’’ of President Trump’s administration. He also believes, ‘‘the age of eligibility needs to be increased,’’ and 

that, ‘‘the better solution is premium support,’’ which is another word for vouchers. 

When it comes to covering pre-existing conditions, he has indicated that he 

thought that was, ‘‘a terrible idea.’’ So this is important, this is about ideas and policies and values and perspectives, and we are very grateful that all of you are here. 

We had asked the Chairmen of the two committees responsible for the nomination 

if we could in fact have a panel of all of you, of others, to share voices at the formal 

confirmation hearing. That was rejected, and so we’re doing a public forum to give 

you an opportunity to share your thoughts. 

So thank you again, and before introducing our panelists, our terrific ranking 

member from the Health, Education, Labor, and Pensions Committee, Senator Murray, is here, if you would like to say a few words. 

OPENING STATEMENT OF HON. PATTY MURRAY, 

A U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Well, I won’t talk long because I really do want to hear from 

all of you, it’s so important, and I want to thank Senator Warren and Senator Stabenow for putting this together, because, as all of you know, we did have a hearing 

yesterday. 

I was disappointed we couldn’t ask more questions of the nominee himself. We 

were only given one round. There is a lot to be concerned about. 

Congressman Price has a long record of making decisions I would not make, taking away affordable health care, going after people who depend on Medicaid. He is 

a politician who has worked hard to undermine reproductive rights, seniors who rely 

on Medicare—the list goes on—and this is a cabinet secretary who will oversee the 

lives of literally every family in this country. 

So we have a responsibility to hear from those families in this country and the 

impact this department will have on them. So I really appreciate your doing this, 

and I look forward to all of your testimony. 

And I just want to give a shout out to our Democrats, both here and on my committee, who really did an excellent job, both with this hearing and the DeVos hearing, in really, in the very limited amount of time we had, showing some of their 

record. 

So, thank you all very much for being here. 

Senator STABENOW. Thank you so much. Senator Warren, who has played such 

an integral role as we have been bringing forth public voices on the nominees, is 

here. Thank you. 

Senator Warren? 

OPENING STATEMENT OF HON. ELIZABETH WARREN, 

A U.S. SENATOR FROM MASSACHUSETTS 

Senator WARREN. So, thank you very much, Senator Stabenow, for your leadership in pulling this together so we get to have these people’s hearings, and I also 

want to say ‘‘thank you’’ to Senator Murray. She really is our leader, and the one 

who is keeping us in this fight on the nominees, and the fight to protect what it 

is that we stand for here. 

And I welcome our newest member, Senator Hassan, who is also on the committee, and Senator Kaine. So we have a bunch of people who are in there fighting. 

255 

You know, President-elect Trump has spent the past few weeks filling his cabinet 

and putting together his team for how he wants to run his administration. The decisions that he makes will have tremendous consequences on the lives of everyone in 

this country, and when it comes to the Secretary for the Department of Health and 

Human Services, President Trump’s choice will have an enormous effect on the lives 

of everyone in this room and everyone in this country. 

They will help determine whether millions of Americans continue to have access 

to medical care, whether contraception or cancer screenings or flu shots must be 

covered by your health insurance, whether Medicare and Medicaid are protected for 

the 100 million Americans that rely on this program. In short, the hiring decisions 

that President-elect Trump is making tell us about the values of the incoming 

Trump Administration. 

Now, unlike many of President-elect Trump’s nominees, who have little or no experience as they take over their various departments, Congressman Price has a lot 

of experience in health-care policy, and that is why we are so worried. His record 

makes clear that he has some very radical, scary ideas about how to change health 

care in America. Congressman Price once described the ACA’s ban on discriminating 

against individuals with pre-existing conditions as ‘‘a terrible idea.’’ He has voted 

10 times to defund Planned Parenthood, which provides lifesaving cancer screenings 

and treatment for sexually transmitted diseases to millions of people a year. He has 

proposed privatizing Medicare and increasing the eligibility age for coverage, and 

he has championed massive cuts to the Medicaid program that will leave millions 

of people either uninsured or with fewer benefits. 

Twenty-four Senators, led by Senator Casey of Pennsylvania, sent letters to Senator Hatch and Senator Alexander, asking them to include witnesses in Congressman Price’s nomination hearings, witnesses who could talk about what the impact 

of his radical policy proposals would be on the lives of real people. 

Now, I am sorry that the Republicans refused to hear your voices, but I am deeply 

grateful that you came here today to make sure that your voices are heard anyway. 

I am grateful to my colleagues who are doing everything they can to amplify your 

voices, and to make sure that as the United States Senate considers its sacred obligation on advice and consent of the nominees in front of us, that we remember, most 

of all, that we are here to serve you. So thank you for being here. 

Senator STABENOW. Thank you so much. 

We have been joined by Senator Hirono from Hawaii, and with the indulgence of 

the rest of our distinguished Senators who are here, I think I’ll move to hearing 

from our guests and then move to questions, if that is all right with everyone. 

So let me first take home State advantage here, our prerogative, by introducing 

Anne Serafin from Ferndale, Michigan. She lives with Multiple Sclerosis and is covered by Medicare. 

Anne and her husband also supported Anne’s mom for the last decade, and after 

years of financial stress were able to get her mom into a nursing home, with the 

cost of her care covered by Medicaid, and we greatly appreciate hearing your story. 

We’ll introduce everyone and then we will come back to you. And I am going to 

turn now to Senator Warren for our next guest. 

Senator WARREN. That’s right. I have the privilege of introducing Kanisha Hans, 

who is here today with us to talk about the impact of the Affordable Care Act on 

her personally. 

I just want to add that Kanisha discovered her passion for advocacy by volunteering in political campaigns, good for you, candidates for local office. 

Today Kanisha lives in Boston, and she works in a Cambridge tech start-up. She 

graduated from Boston University in 2015 with a B.A. in Political Science and a 

minor in Public Health. 

She is taking off time from work to be here today, and we are very grateful that 

she is willing to share her story, which underlines the critical protections that the 

Affordable Care Act gives us for women’s health care. 

So thank you very much for joining us today, Kanisha. 

Senator STABENOW. Kanisha, welcome. 

Now we have also been joined by Senator Blumenthal from Connecticut; welcome. 

256 

Alyce Ornella from Harpswell, Maine. So you’ve come a little bit, how is the snow 

up there right now? Much colder; okay. 

Alyce and her husband were self-employed when they were able to get health insurance coverage through the ACA exchange. Alyce’s plan provided free pre-natal 

care, including prenatal tests while she was pregnant with her son, Sam. When Sam 

was unexpectedly born with serious birth defects, her plan covered all of his intensive care and surgery costs, and Sam now receives care through Medicaid, which 

has covered every test and exam that he has needed, and we wish him well, we hope 

where is Sam? 

Oh, well we want to see Sam. 

Okay, is that who I met earlier, with the terrific sweater on? 

Okay, we need to have him come back. 

So welcome, we’re so glad to have him, and close to home, riding the Metro in 

I think today to avoid all the traffic, Diane Fleming. Diane is 75 years old, lives 

in Washington, DC, went on Medicare at age 65, 5 years ago was diagnosed with 

thyroid cancer. Medicaid has covered the bills from the four surgeries, radioactive 

iodine treatment, CT scans, sonograms, MRIs, and needle biopsies she has needed 

to treat her cancer. 

We are very grateful to have you here to hear from your story and have you elaborate as well. 

And I know that Senator Brown is hoping to join us. I know I just left him a while 

ago in the Finance Committee. 

So, Holly, he wanted to introduce you, but I know he is going to join us if he can. 

Holly is from Cleveland, Ohio. Self-employed as a non-profit consultant in Cleveland, runs her own LLC., was able to access mental and behavioral health services 

through Medicaid, and has been able to go on—I’ll let you tell your story about what 

you have been able to actually receive in terms of help as a result of that, but we 

are so pleased you are here as well. 

And Senator Bob Casey from Pennsylvania has just joined us. So I am going to 

ask Anne if you could share your story. We ask everyone to take no more than 5 

minutes to start so that we can have an opportunity to ask questions as well, but, 

Anne, thanks so much for you and your husband being here. 

STATEMENT OF ANNE SERAFIN, PANELIST FROM 

FERNDALE, MI 

Ms. SERAFIN. Good afternoon. My name is Anne Serafin. I live in Ferndale, Michigan, and I am 66 years old. I just want to say, I’m reading this statement, so it 

may not convey the real passion I feel about this issue. But please know how important this is to me. 

I’ve had personal experience with Medicare since I was 40 years old, when I was 

diagnosed with multiple sclerosis. 

As you may know, MS is a neurological condition, which varies in severity and 

it’s very unpredictable. My particular version resulted in functional quadriplegia. As 

a result, I am unable to walk, but I can stand up with personal assistance and a 

grab bar. I can use my right arm, in a limited fashion, but have no use of my left 

arm. Fortunately my vision, speech and cognitive abilities have been spared. 

At the time I was diagnosed, I was a marketing professor at University of DetroitMercy. The University placed me on disability, and a year later my application for 

Social Security disability benefits and Medicare was approved. Thanks to strong 

union support, the University picked up my secondary health insurance until I 

turned 65. 

Within a few years, new MS medications started coming onto the market, and my 

neurologist and I chose Copaxone. The price started out at about $8,000 a year, but 

is now $84,000 a year. After ten years, it became apparent that Copaxone was not 

working, so I tried several other medications, including Acthar Gel. 

In the ’70s, this cost $50 a month, but when the drug company realized it could 

benefit many people with MS, it shot up to $30,000 a month. Because it was off 

label, my insurance would not cover it. The National Organization for Rare Diseases 

helped for two months, but I could not afford to continue after that. 

257 

I am currently on Gilenya, with a co-pay of $38 per month. Without Medicare or 

secondary insurance, this one drug would cost about $75,000 a year, which is nearly 

our total household income including our Social Security benefits. I have a handout 

that can show you if you’d like to see it about how prices have shot up for all MS 

medications. 

Disability is costly even beyond medications. Making our home accessible, purchasing an accessible vehicle, the scooter I drive, and hiring personal assistance; it 

gets expensive. This is why my 68-year old husband continues to work part time 

as a self-employed writer, while also serving as my primary caregiver. His monthly 

insurance costs were $900 before he turned 65. 

We rejoiced when he was able to get Medicare and have that number come down 

to $200 for supplemental insurance. Without Medicare, I would have had to decide: 

do I eat, or do I get my meds? Without Medicare, I would have to pay an astronomical cost for private insurance, if I can get coverage at all. 

While I was dealing with my own health issues, my aging parents needed increasing care and support. My father was a U.S. Army veteran who served as a paratrooper in World War II. He helped liberate Normandy with his D-Day combat 

jump. He was also an independent artist and relied on Medicare and the VA hospital for his health care. Even though my dad worked until his death at age 91, 

my husband and I needed to financially support my parents to keep them in their 

home. This is what they wanted, to age with dignity. We’re Greek, and Greeks take 

care of their own. 

I also have experience with Medicaid, which my mother relied on for the last 3 

years of her life. My husband and I took care of her financially before she passed 

away at 98 this past October. Until my dad passed, my mother had Medicare with 

supplemental insurance. But my parents had no savings and no assets—we had 

bought them a condo and took over the mortgage payments. When my mother’s dementia worsened to the point that she needed full-time care, we had to place her 

in a nursing home. I could not care for her complex needs; I needed help for my 

own care. 

Even a bare-bones nursing home would’ve been too much for us at $6,000 a 

month. She received $1,190 a month in Social Security and widow’s VA pension benefits. It was only because of Medicaid that she was able to get the help that she 

needed at the end of her life. Without Medicare and Medicaid, things would have 

been very different for my family. I don’t know how I could have cared for my mother on top of managing my own care. My family would have lost our home and all 

our savings trying to keep up with the bills. 

So many families are squeezed like ours, having to afford care for their aging parents and their own care or childcare at the same time. But with support, we don’t 

have to suffer just being alive. 

I can’t cook for myself, I can’t get myself out of bed, but I can still contribute. 

Because of these public programs, I can be productive and be involved in things that 

are important to me. This includes being here with you in Washington, talking with 

legislators, and volunteering as an advocate with Michigan United, Caring Across 

Generations, and the MS Society. All because of the support I get from Medicare. 

If these programs are cut, people will face more catastrophes than ever before. 

People are panicking. If these services are cut, it will have a huge, huge, huge impact on the lives of many people. Congress needs to know that. Thank you for listening. 

Senator STABENOW. Thank you so much, Anne. We really appreciate it. Kanisha 

Hans, welcome again. 

STATEMENT OF KANISHA HANS, PANELIST FROM 

BOSTON, MA 

Ms. HANS. Hi my name is Kanisha Hans, and I am from Boston, Massachusetts. 

I am 23 years old and an Indian immigrant, and a recent college graduate. Thank 

you to Senator Warren and all the Senators here who have invited me today to 

share my story about how important the affordable care act and access to reproductive health-care providers like Planned Parenthood cannot be repealed without devastating impacts on the health and well-being of millions of people. 

258 

Like the vast majority of American women, I rely on birth control. And like millions of young people I rely on my parent’s insurance plan for my health-care coverage. Both have allowed me to pursue a college education and ultimately secure 

and maintain employment. When I was 15 years old I needed a birth control prescription for debilitating periods I was having that caused me to pass out during 

class. Being from a reserved Indian family I didn’t feel comfortable discussing my 

situation at home. So I told a friend whose mother brought me to Planned Parenthood. My doctor at Planned Parenthood prescribed me birth control and helped me 

to afford it. This was one of the first times I felt like someone was listening to me 

about my own health-care needs. Remembering the caring and non-judgmental services provided to me, I saw Planned Parenthood again when I needed to change birth 

control methods due to other health concerns. 

Unfortunately my insurance failed to cover the high cost of the specific type of 

birth control that I needed. Forcing me to use a prescription that didn’t suit me and 

even exacerbated my symptoms. Luckily, I was eventually able rely again on a doctor I trusted at my local planned parenthood to manage my condition. There they 

were able to cover the cost of my long acting reversible contraceptives at a cost that 

I could afford. This was before the Women’s Preventative Benefits in the ACA and 

I was charged $100 instead of $1,000. This was critical for me because I would have 

been unable to afford the method that was best for my health while I was also pursuing an undergraduate degree and balancing other living expenses like tuition and 

rent. 

Unfortunately, I know many women and many students who were priced out of 

this privative care. But today thanks to the Affordable Care Act these same barriers 

no longer exist like they once did for me. 

Six years ago the passage of health-care reform was a historic step for women of 

all ages. Thanks to the Affordable Care Act, I’ve joined the 55 million women nationwide who benefit from no co-pay for birth control and expanded insurance coverage. What’s more important is that women like me are able to afford the right 

of birth control for our bodies or conditions with no out of pocket cost and in consultation with our doctors. 

Beyond just birth control I now join millions of young people getting access to 

needed health-care coverage as a result of being able to stay my parents insurance 

until age 26 and I am not forced to pay more because I am a women or because 

I have a preexisting condition. I am grateful to have a job and while I am not financially dependent on my parents I am able to stay on their health care. So by staying 

on my parents plan I am both able to stay healthy and pay my student loans on 

my own every month. Hopefully someday I will also be able to pursue a graduate 

degree and pay that off as well. 

This winter I was able to go back to Planned Parenthood to get a new IUD. After 

the results of the election I became fearful that I wouldn’t be able to afford this care 

anymore. Tom Price has a history of working to reduce access to care and leading 

the Federal health care agency. I am concerned he is out of touch of the healthcare needs of patients like myself. To be clear without Planned Parenthood and the 

Affordable Care Act I would not have been able to afford the birth control I needed 

to manage my condition. If Congressman Tom Price is successful in rolling back the 

ACA I will be forced to pay for care I need, charged more because I am a women 

and could even lose my health insurance all together. He isn’t looking out for me 

and he isn’t looking out for women, men, or young people. And he isn’t looking out 

for the well-being of Planned Parenthood patients. He cannot be trusted with my 

health or the health of this country. Thank you. 

Senator STABENOW. Thank you very much. We have been joined by Senator Jeff 

Merkley from Oregon. Welcome, and, Alyce, I believe Sam has entered the room. 

Yes, welcome, Sam. Sam has the coolest sweater on, you have to see Elmo. Hi, Sam. 

He is living proof of the importance of affordable access and health care. 

Senator KAINE. He can have my seat if I can have the sweater. 

Senator STABENOW. Yes, just not for a while. Yes, welcome. 

STATEMENT OF ALYCE ORNELLA, PANELIST FROM 

HARPSWELL, ME 

Ms. ORNELLA. Yes, thank you. I hear myself echoing. Three years ago my husband 

and I were expecting our first child. At the time we were self-employed as small 

259 

business owners and we couldn’t afford the high cost of health insurance. This was 

before the ACA. When the Affordable Care Act was passed we found an affordable 

plan on the market place. Suddenly all of my prenatal care was covered, my pregnancy was completely normal and uneventful. Just as everyone hopes the plan we 

signed up for through the marketplace covered advance testing for genetic conditions and all my results came back clear. But then the unexpected happen as tends 

to happen. No one wants to face the devastation of their baby being born with life 

threatening medical problems but that is exactly what happened to us. 

Our son Sam was born with multiple congenital birth defects, none of which could 

be detected before he was born. He was rushed by ambulance teams to the Maine 

Medical center in Portland. When he was just 2 days old the pediatric surgeons performed surgery there to save his life. The medical bills in his first month alone 

toped $100,000. Within his 2 years of life Sam has been seen by nearly a dozen specialist and has gone through 20 tests and procedures to ensure that his health remains stable. 

Later in his infancy Sam was approved for SSI benefits which meant he also became covered by Medicaid—the transition to that coverage was seamless I only 

needed to make sure his pediatrician put in an authorization for his medication and 

specialist. He was able to continue seeing the same specialist that he’d seen since 

birth and his Medicaid coverage has fully provided for every test and exam he’s 

needed. Knowing that Sam can receive all the care his doctor’s want for him has 

greatly lessened anxiety we’ve felt regarding his multiple conditions. His access to 

testing has enabled us to confirm positive side changes in his conditions which has 

allowed him to go off certain medications sooner than expected. 

Sam is now a thriving happy 2 year old who seems like any kid his age. I’ve been 

able to return to work part time since he is doing so well. Sam’s health will still 

require a team of pediatric specialists to ensure care for him throughout his childhood. 

The protections the Affordable Care Act has provided ensure that we have been 

able to get him the tests, medicine, therapies, doctor visits that he needs to stay 

healthy. The Affordable Care Act ensures that he can never be denied coverage. And 

that our family is not charged exuberant premiums fees and high deductibles because of his medical needs and means he will never face lifetime limits in coverage 

for the conditions he has had since he was born. The Affordable Care Act has been 

critical to how well he is doing today. 

Due in part to our fears regarding the ACA repeal my husband and I have given 

up self-employment so that we can attain more security regarding health-care coverage in the future. My husband has recently accepted a job that will take him away 

from home more than we are used to but comes with a solid employment based 

health-care coverage for our family. This is our priority now that the new administration and Senate Republicans have made the ACA repeal their first goal. However 

I cannot rest assured that Sam’s long-term future will be as secure if we lose the 

provisions for no denial pre-existing conditions. I fear the return of yearly or lifetime 

limits on coverage. And high risk pools. What if my husband loses his job? What 

will health-care access look like for Sam 5 or 10 years from now? What will be available to him when he is an adult looking for coverage as a person who was born with 

multiple medical conditions and has a complex medical history? No one should face 

financial ruin because they need medical help and no one should be forced to go 

without the medical care they need. 

It would be irresponsible to our representatives in Washington to pull the rug out 

from under millions of people around the country who have health care because of 

the Affordable Care Act. I know how it would affect my son’s life if that were to 

happen and it would be devastating for him and our family. 

Senator STABENOW. Thank you so much for sharing your testimony and for 

sharing Sam. It is a blessing to see him acting so well, like a normal 2-year-old. 

Oh, before I forget, welcome, Senator Sheldon Whitehouse, joining us from the 

Great State of Rhode Island. So, Diane, welcome. 

STATEMENT OF DIANE FLEMING, PANELIST FROM 

WASHINGTON, DC 

Ms. FLEMING. Good afternoon, everyone. It is such a pleasure, and thank you for 

allowing us to be here. My name is Diane Fleming. I am a 75-year-old young adult. 

260 

I live in Anacostia neighborhood which is ward eight, 10 minutes from the Capital 

here. I am a retired member of the International Association of Machinists. And I 

am here today on behalf of the alliance for retired Americans. I am pleased to be 

surrounded by others who are fighting to protect our hard earned Medicare benefits. 

I worked for United Airlines for 35 years as a reservation and ticket agent. But 

when the airline went bankrupt I lost most of my pension. So you know that is a 

little less money. Luckily, my job provided me with health care coverage until I was 

65 and went on Medicare. 

Five years ago I was diagnosed with thyroid cancer. Since then I have had four 

surgeries, radioactive iodine treatment twice, the cancer has recurred and I will 

need to have surgery again. After being diagnosed with the thyroid cancer I’ve had 

CT scans, sonograms, MRIs to detect the target areas, little biopsies, and most of 

these procedures are very expensive. We are talking $1,000 to $3,000, to $3,000 for 

one thing. I have also had to have blood work regularly to check the levels. And 

I don’t know how I would have been able to afford all of these treatments and test 

done without Medicare to cover the bills. 

In addition to the cancer, I suffer from glaucoma, which is hereditary through my 

family, and I need daily drops. 

Medicare has help to make sure I receive treatment every 4 months to check the 

eye pressure. While others have private Medicare advantage plans. I chose the traditional Medicare. It has made my cancer a lot more bearable, enabling me to focus 

on getting better rather than going bankrupt. I know I speak for millions when I 

say no cuts to Medicare and no privatization. With premium support of vouchers 

a person with my pre-existing condition, with my age, I probably wouldn’t be able 

to get insured, and if I could it would be very costly. So I need the guaranteed coverage that Medicare offers. Not a coupon or voucher. Those things don’t work anyway that I could not afford. Millions of older Americans are able to enjoy their retirement without astronomical medical expenses because of Medicare. 

In the age of small or nonexistent pensions, minimal retirement savings, and skyrocketing prescriptions, Medicare is literally a lifesaver. My sister just had to go on 

a medication, and a 28-day supply is $30,000. So without Medicare she would not 

be able to do this. I retired at age 62, but I was lucky that United did provide health 

coverage and I was able to continue with that until I turned 65. So most Americans 

don’t have that. We must make sure that Donald Trump keeps the promise not to 

cut Medicare so medical expenses don’t bankrupt millions of seniors and their families. 

Since November the President-elect and Republican support on Capitol Hill have 

taken steps towards dismantling and cutting our earned Medicare benefits. President-elect Trump has named house budget committee chairman Tom Price of Georgia to be the Secretary of U.S. Health and Human Services. Representative Price 

has spent years trying to privatize and cut Medicare in the past. I wonder what he 

is cutting out of his area. Representative Price has promised to cut and change 

Medicare into a voucher program. As Secretary, Price will have significant control 

over Medicare including RD plan and policies affecting the price of prescription 

drugs. His views are out of touch and he is just not a very sensitive person. We 

Americans have paid for decades and we continue to pay. Money comes out of my 

monthly Social Security checks to cover Medicare. 

So Representative Price and the President-elect will be working closely together 

with House Speaker Paul Ryan. He has tried to do this over and over again. If 

Speaker Ryan’s plans were to become law, seniors would become deeply hurt. We 

simply cannot afford to wait until we are 67 to go on Medicare and the privatization 

that the speaker calls for. The members of the Alliance will fight Donald Trump, 

and thank all of you all, fighting Paul Ryan and Price every step of the way. We 

need to guarantee the benefits that Medicare offers, not coupon care that leaves seniors like me hanging out to dry. Thank you very much. 

Senator STABENOW. Thank you very much. We are pleased to be joined by Senator 

Baldwin; welcome. And we are so pleased now to hear from Holly Jensen. Welcome 

again. 

261 

STATEMENT OF HOLLY JENSEN, PANELIST FROM 

CLEVELAND, OH 

Ms. JENSEN. Thank you so much and good afternoon. I am Holly Jensen, and I 

am 32 and from Cleveland, and I am honored to tell you how the ACA and Medicare 

saved my life. I own a small business that helps nonprofits with communications 

and fundraising. I am a really hard worker and I love what I do. Most of my business comes from referrals from causes I support and I am proud to say that I am 

good at my work. This is my first business card, I still am proud of it and am excited by it. Part of the gig economy comes with the risk. If I don’t produce I don’t 

get paid. I don’t get paid sick days. I don’t get paid vacation days. So when the Affordable Care Act passed, it was huge relief. 

I had never had my own insurance before. I had been living before undiagnosed 

with anxiety, depression, and OCD. It began to severely impact my life. Tasks that 

normally took an hour began to take all day and things began to feel insurmountable. I remember one project I was excited about working with the Compassionate 

Communications Center for Ohio and was going to go down from Cleveland to Columbus to meet with the board to discuss their Middle East peace activism. As I 

was preparing my disorder was beginning to spiral out of control and pretty much 

fell apart. I had to cancel this trip that I was really looking forward to at the last 

minute. This is one example of the way my untreated disorders were effecting my 

life. It was horrible and really embarrassing. My increasing inability to function 

dealt not only a blow to my bank account but also my livelihood and self-respect. 

I withdrew from my community and the arts world, which often involved organizing 

small business owners such as myself. My once active life became small and empty. 

I felt like I was slipping out of society. 

However, the most painful act of being untreated was seeing my relationship with 

my loved ones crumble. Including my mom who is my best friend in the world. She 

just turned 65 in August. I hope she doesn’t mind me saying that. Sorry, mom. She 

is going through the process of Medicare and is having tests that she has never had 

before. So my mother lives three blocks from me, and my brother lives one block 

from me. And at this point weeks would go by without me as much as answering 

a text message from them. So it was getting scary. And about a year ago I hit rock 

bottom. I couldn’t keep up with my premiums or any bill. And it was winter in 

Cleveland and I don’t have a car, so I slug through the snow and sleet to the free 

medical clinic in Cleveland. At this point I didn’t have anywhere else to turn. Asking for help took a really long time and was incredibly humbling. When I got there 

my mind was so rattled that I didn’t even know how to begin filling out the paperwork. A women there walked me through it, helped me through it, and treated me 

with respect and efficiently helped me re-figure out my life. Ta-da; this is my ticket, 

my golden ticket. 

On that day, I felt like a person who deserved to care. And even before the process 

of receiving treatment started, that glimmer of hope meant so much. It meant I 

wasn’t a disposable person. And it took so long to ask for help, if I would’ve been 

turned away, I really might have lost hope entirely. And if they’d said I needed regular employment to access Medicaid, I definitely would’ve continued going in a 

downward spiral. Requiring employment for Medicaid would’ve been like telling me 

you’ll throw me a life preserver after I stop drowning. 

My psychiatric care has given me the foundation on which to rebuild my life. I 

take medications, such as this, and I have weekly counseling therapy sessions that 

help me heal and grow. I also do an enormous amount of work on my own to make 

sure that I keep up my progress. This care not only saved my life, it gave me back 

my life. Thanks to Medicaid, I’m becoming the professional I want to be again. But 

more important, I’m becoming the person I want to be. 

I have faith in growing my business, not just struggling to keep it alive. I’m back, 

actually working with [the] compassionate Communications Center of Ohio, doing 

psych redesign and branding, and I really love working with all of my clients. And 

once again, organizing and participating in arts events in my community and I’m 

volunteering at my local recovery clubhouse, applying my communication and development skills to help them to continue to support the community. I’m reconnecting 

with my friends and loved ones. Perhaps most important, [I’m] restoring my relationship with my mom. It feels good to pay my bills, but it feels even better to be 

part of something. 

262 

Mental and behavioral health is no joke. Without Medicaid, I know I would have 

eventually depended on emergency care, taxpayer funded rehab, and the legal system. I would’ve cost taxpayers much more than the expense of my basic care now. 

My goal is to continue healing, regain my earning potential, get my private health 

coverage, and happily support Medicare and Medicaid in my tax dollars. Despite my 

relatively high tax rate for self-employed people, I would be proud to support these 

life-saving and tax dollar saving programs. And I know I’m not alone. We cannot 

afford to discard and destroy the ACA and Medicaid for millions of people like me 

who would be turned away. For me, that would’ve meant discarding me exactly 

when I needed support the most. Thank you for allowing me to share my story. 

Senator STABENOW. Well, thank you so much. Hi, we’ve been joined by my friend 

and colleague, the great Senator of Michigan, Gary Peters. You have the full Michigan delegation here, Anne. You have all of us here with you. So, let me begin. We 

want to give all of our colleagues the chance to ask a question. 

I have to say that listening to all of you, whether it’s talking about maternity 

care, I remember the fights in the Finance Committee when colleagues did not believe that that should not be in the central service and it makes me smile to hear 

you talk about maternity care and to see Sam and to have each of you talk about 

things that so many of us fought so hard for. But, I do want to particularly, Holly, 

thank you for being here, as the author of the mental health parity provisions in 

the ACA because of my own family’s situation. I want to thank you for your courage, 

because we have done less research over our country’s history on the organ called 

the brain, we’re finally doing that. But, whether it’s a chemical imbalance in the 

brain, like my dad had, and was finally diagnosed as bipolar. And once that happened and he got the mediation he needed, he went on to live a very effective life. 

So, I saw what it was like when he didn’t and when he did. And, a tremendous difference. So, I have always felt that, and I know my colleagues have, that whether 

its diabetes and you’re checking your sugar, or whether it’s a chemical imbalance 

in your brain, we want to have the same view in terms of access to care. And not 

have a stigma, depending on which part of our body the disease is in. So, I just want 

to thank you for your courage and for speaking out for millions of people; one out 

of five people in our country are struggling with a disease that involves behavior 

health. And so, thank you very much for doing that. 

Anne, I wanted to ask you a question, actually a couple of questions. You were 

talking about your prescription drug costs. When we look at these numbers, unbelievable, $50/month to $30,000/month or $8,000/year, was it, to $84,000/year. I 

mean, these are astronomical increases, and there’s a whole range of things, dealing 

with cost of medicine that we need to tackle still in this country for sure. But, I 

wonder if you might speak about where you would be right now without Medicare, 

speak a little bit more about that. So, costs, what that would mean to you. And if 

we saw Medicare turn into some kind of a voucher, no matter what we call it, being 

in support of a voucher, where it wasn’t guaranteed coverage and guaranteed prescription drug coverage, how would that work for you? 

Ms. SERAFIN. Well, first of all, without Medicare, I would have to get insurance 

and because of my preexisting condition, I would not be able to get insurance. Second, without Medicare, I think my husband and I would’ve ended up on Medicaid 

because we would’ve been bankrupt. I mean, we have a small nest egg, which we 

have, as I’ve shared before, used a substantial portion of to help out my parents. 

That would’ve been gone. The costs are just prohibitive; we couldn’t have done that. 

$6,000, $8,000, $84,000/month and actually, the MS—— 

Senator STABENOW. A month? So, it’s $84,000/month? 

Ms. SERAFIN. No, sorry; that was a year. 

Senator STABENOW. Oh, a year, okay. Either way it’s a lot of money. More than 

most people make a year. 

Ms. SERAFIN. It’s a lot of money, but the Acthar Gel is $30,000/month. 

Senator STABENOW. All right, thank you. We have many colleagues I want to 

make sure have a chance to ask questions. So, thank you, for now and, Senator 

Warren. 

Senator WARREN. Thank you, and thank you all again for being here. You know, 

yesterday at the hearing for Congressman Price to be Secretary of HHS, I asked 

him about the cuts that he has proposed to Medicare and Medicaid. You know, he’s 

already proposed $449 billion in cuts to Medicare and over $1 trillion in cuts to the 

Medicaid program. And so I asked him if he would commit to follow through on 

263 

Donald Trump’s promise, ‘‘I won’t cut Medicare or Medicaid.’’ And, there was a lot 

of dancing back and forth, but the bottom line is, no, he would not commit, which 

I’m suppose should not have been a surprise. But what I just want to do, as briefly 

as I can, is to just focus in, just a little bit, down the line and put a face to that. 

What it means to put those kind of cuts into the system. So, if I can, let me start 

with you Ms. Fleming. You used to work at United Airlines, as I understand. How 

many years did you pay into the Medicare system? 

Ms. FLEMING. [Mic did not pick up.] 

Senator WARREN. And how long have you worked there? 

Ms. FLEMING. Thirty-nine years. 

Senator WARREN. Thirty-nine years that you paid into the Medicare system. So, 

when Congressman Price proposes cutting $449 billion out of the Medicare system, 

I just want to ask, that’s going to put more out-of-pocket costs on you. Does that 

sound fair to you? 

Ms. FLEMING. [Mic did not pick up.] 

Senator WARREN. Nice question. Where else is it we so much need to spend $449 

billion that you can spend more out of pocket so that money can go somewhere 

else—like tax cuts for rich people. Ms. Jensen, can I ask you—just because I want 

to be clear about this. One of the things that Medicaid does is make sure you get 

access to mental health services. If you lose that access, what happens to your life? 

Ms. JENSEN. Um, that would entirely change my life. I wouldn’t be able to afford 

the services I need. My medications alone right now run about as much as my rent. 

And I know that weekly counseling or therapy sessions would really be out of reach. 

It would threaten not only the growth of my business but the existence of my business. Basically no Medicaid, no business. That would kind of be the end of one of 

my dreams. And, untreated disorders—my untreated disorder, I know I would retreat from society. I would retreat from my loved ones. I would not be a productive 

citizen. I would probably get in trouble and cost the taxpayers some money. Mental 

and behavioral health is no joke. There are fatal consequences, and it’s a matter 

of life and death for a lot of people—including me. 

Senator WARREN. Thank you. Thank you. And Ms. Serafin—I know that you have 

dealt with both systems, both Medicare and Medicaid. For just 1 minute, I’d like 

to focus on the Medicaid part of that. Your mother, after your father passed, your 

mother declined, needed full time care. And she was supported by Medicaid during 

that period of time. She was able to be in a facility that could take care of her. If 

Medicaid hadn’t been available to you—if there had been a trillion dollar cut to 

Medicaid, what would have happened to you and your husband? 

Ms. SERAFIN. Well, physically I could not take care of anyone else, I can hardly 

take care of myself. So, we would have had to hire someone or we would have had 

to move because our home was not accommodating for another person with a disability. Second, the care my mother received in the nursing home was so personally 

gratifying; I could sleep at night. My mother was a really strong woman, she could 

have been a CEO. She was born in the wrong era. But as a daughter, as mothers 

and daughters often do, we didn’t always see eye to eye on everything. And people 

in the nursing home loved her—they loved her feisty manner, they loved the things 

that she would say. And I would think, ‘‘Oh god, I would never say that.’’ But they 

thought she was wonderful. 

Senator WARREN. My mother was like that too. 

Ms. SERAFIN. I could sleep at night. I could feel good because I so cannot do things 

as it is for myself, and there were loving people who would go to her and say, ‘‘I 

love you, Anita,’’ and it just made my heart feel that wonderful feeling. 

Senator WARREN. That’s the face of Medicaid. And one more on Medicaid. And 

that is Sam. Right, Ms. Ornella? 

Ms. ORNELLA. Yes. 

Senator WARREN. Sam is the happy face of Medicaid. If there’s $1 trillion in cuts 

to Medicaid, and Sam is not able to get help through Medicaid, what happens to 

Sam? 

Ms. ORNELLA. We barely qualified for Medicaid as it was, so if there are any cuts 

to it, we would have been in that group of people who I believe wouldn’t have qualified on the financial basis. Medicaid has provided him to be able to go to his kidney 

264 

doctors and to keep his status check on his kidneys, which is what we think his 

long-term issues are going to be. Medicaid has been there to cover tests for swallowing, for swallowing functions, for all the different parts of his body that are affected by his disorder. So, my fear is that if we do get employer based coverage, anything can happen in life—what if my husband lost his job and then we didn’t qualify 

for Sam to get Medicaid anymore? How would we deal with that double whammy 

of losing employer coverage and then not qualifying for Medicaid for a medically 

complex child? 

Senator WARREN. Thank you. I’m very grateful to all four of you for putting a face 

on what Medicare and Medicaid mean. I suggested yesterday to Congressman Price 

that if he is confirmed to be the head of HHS, that he cut out the statement of Donald Trump, ‘‘I will not cut Medicare or Medicaid,’’ and tape it above his desk and 

look at it every single day—because you are what that’s all about. You are the reason we must not cut Medicare and Medicaid. Thank you, thank you for being here. 

Senator STABENOW. Thank you so much, that is so true. Senator Kaine? 

Senator KAINE. Well thank you, Senator Stabenow, and to my colleagues for doing 

this. Thank you for sharing your stories, these are very important. 

Kanisha mentioned the words, ‘‘kind of afraid of what might happen,’’ and I just 

kind of jotted that down. There’s about 66 million Americans who are really disappointed about what happened in November, but there’s a subset of people who 

are really personally very, very afraid. And I think the job of us, the job of those 

of us who are disappointed is to have the backs of those who are afraid. 

People are afraid because they might lose their healthcare. People are afraid because they’re worried about rollback of marriage equality. People are afraid because 

they’re worried that they might be deported. People are afraid for a lot of reasons. 

And it gives me a lot of motivation to try to have the backs of folks who have legitimate concerns and fears. And coming and sharing your stories is important. 

Congressman Price poses particular challenges to us because you can kind of look 

in vain in his record to see support for virtually anything that’s a part of the healthcare coverage safety net. He wants to turn Medicaid into a block grant program and 

is against ESGIA, voted repeatedly against it, called it ‘‘socialized medicine.’’ Most 

programs cover more than 800,000 Virginians. 

He wants to repeal the Affordable Care Act. That’s a program that helps millions 

of Virginians, if you add up all pieces of it together. He wants to change Medicare 

into a premium support program that would raise costs, by CBO estimate, of 1.3 

million Virginian seniors. And he wants to defund Planned Parenthood which is the 

primary health care provider of choice for tens of thousands of Virginians. If you 

look at everything that’s in the coverage space, that’s in the access space, he is opposed to it. And so that’s what makes him so problematic as a next HHS Secretary. 

On my webpage I put up a little thing, kaine.senate.gov/ACAStory, and a week 

ago I asked Virginians to share stories much like you shared today. We have more 

than a thousand submissions of stories just like yours. 

I’m going to ask one question based on a theme that’s emerging from the stories 

that I have not been paying much attention to but both Alyce and Holly, you mentioned it in your testimony. The ACA makes it easier to be self-employed and start 

your own business compared to what we had before. And if we can get over the rush 

to repeal that’s injecting so much uncertainty into this question of, ‘‘will we be able 

to count on this or should we go back and work with an employer provided plan?’’ 

The ACA has turned into this motivator for entrepreneurial spirit and start-up 

businesses and innovators. Exactly the kind of thing we want to do, so, separate 

and apart from all the health care benefits, which are fantastic—that’s reason 

enough to fight for them—the ACA has also given people who have a dream to start 

their own business, to start their own nonprofit the ability to do it, and have health 

insurance if they do it. 

It’s interesting, Senator Stabenow, the number of stories I’ve gotten on my 

website of people who have come up to me and mention this aspect of the Affordable 

Care Act, even though sometimes that’s not the story they’re telling me. Something 

about their child who has a special need, but they’re telling me they’re able to have 

health insurance as an entrepreneur, as a small business owner, as a startup or 

nonprofit because of the ACA. 

So I’m seeing this really positive economic effect and I imagine that again, that 

was in Alyce and Holly’s stories. It might not have been the main theme of the 

265 

story, but it was an element in both your stories. And I think that’s something we 

have to fight to protect. I’d be interested in hearing your thoughts. 

Ms. ORNELLA. I’ll just give an example. Before the ACA was passed, my husband 

and I, who were both self-employed, went without insurance, because in Maine the 

quote for what was available to us, and we were two adults under the age of 35, 

was $1,200 a month. And that was a huge part of our income. We’ve not ever been 

people who have made a lot of money so we went without insurance. And then when 

we were able to sign on to the ACA plan we paid $200 a month. 

So, for that reason, we were able to continue our small business activities for 

longer than we would have otherwise and we supported ourselves for a number of 

years that way. Obviously priorities change when you have a child and if you have 

a child that has complex medical needs you start to assess whether or not you can— 

especially when there’s talk of repealing the ACA and protections for people with 

preexisting conditions you start to rush into thinking, ‘‘I need to work for someone 

else now.’’ 

Senator KAINE. But if we stabilize this and get over this rushed, this foolish rush 

to repeal—— 

Ms. ORNELLA. Yes. 

Senator KAINE. We have something that we think we need in place for people like 

you, the chance again to say, ‘‘Hey I want to be my own boss and start my own 

business.’’ 

Ms. ORNELLA. Oh yes, absolutely. 

Ms. JENSEN. I’ve actually never had health insurance from my employer. I went 

without it for a long time until the ACA and eventually Medicaid. It is absolutely 

essential to my business. My well-being is the cornerstone of it. It’s more important 

than my credit line, it’s more important than tax rates. Nothing gets done when I’m 

unwell. And we can’t claim to support small businesses if we don’t support small 

business owners. Yes, my business would probably not exist without Medicaid at 

this point to be honest. And in the larger picture, I worry about how that will 

dampen America’s innovation and entrepreneurship. If it becomes an unbearable 

risk to start your own business, guess what? We’re losing a lot of small business 

owners in America. 

Senator KAINE. Thank you. I appreciate it. 

Senator STABENOW. Thank you so much. And, Senator Kaine, I have heard the 

same thing from so many people who have been able to go into small business and 

their life’s dream because they’ve been freed from that chain of having to be somewhere with insurance from their employer. So thank you so much for that. I know 

Senator Merkley has to leave at 1 and, to just briefly say something, we will let 

you jump in here to do that. I am going to step away to ask a question at the Finance Committee of Mr. Mnuchin—we’re beginning a second round—and I will stop 

back, so we’re doing our version of Beam Me Up, Scotty, as we’re running back and 

forth between everything—but, Senator Merkley? 

Senator MERKLEY. Inaudible 1:12:33–1:13:13. I think it’s vetted in the issue of 

Medicare, Medicaid, and ACA. We have a health-care system that’s just, when you 

need care, when you have that disease, that accident, you know you can access it, 

and then you pay more and you get the care that you need. So I just wanted to 

share that comment. [Inaudible comment] . . . have questions for Sue. Thank you 

for sharing your testimony. We need a health-care system. It gives peace of mind 

to Americans, not distress of whether you’ll be able to get care, not go bankrupt, 

and that’s what we’re fighting for. Thank you. 

Senator HASSAN. Well, thank you. I want to thank Senator Stabenow more—you 

really were the driving force in organizing this. I also just really want to thank all 

five of you for being able to be here to tell us your experiences, because change occurs when people are willing to stand up, especially in a democracy, and not only 

talk about ideas, but talk about real life experiences so that policy makers understand what the impact of their ideas and philosophies are and really can be informed as we work to make sure that things work for the American people. I am 

struck by the themes that your combined testimony have raised for today’s panel, 

and I hope for everybody who’s watching and listening cause I think we really see 

and heard from you a wide range of experiences that really talks about the individual peace of mind, the physical health, and the economic health that comes with 

accessible, affordable, high quality health care. I want to touch on a particular subVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00269 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
266 

set of what I’ve heard, just because I think given Congressman Price’s, nominee 

Price’s, record is important. But before I do that, a special shout out, Alyce, to you, 

we have something in common having had kids with special needs and it has its 

challenges but it has its good rewards too, so, thank you for what you’re doing to 

raise Sam. 

Ms. ORNELLA. Thank you. 

Senator HASSAN. You’re Welcome. And, Kanisha, I wanted to talk to you a little 

bit more about your experience. First of all, given Congressmen Price’s record of repeatedly voting to defund Planned Parenthood, you talked about how important 

Planned Parenthood had been to your care at critical times in your life. Can you 

just tell us a little bit more about what your experience as a patient at Planned 

Parenthood was like and how it impacted your ability to do what you wanted to do 

with your life? 

Ms. HANS. Sure. So, when I went to Planned Parenthood when I was in high 

school; it’s because I had no other place to go. And now I go to Planned Parenthood 

by choice because I trust them with my health care. I’ve mentioned before I had 

a medical condition that went undiagnosed for a while. I’d gone to several different 

doctors before, and Planned Parenthood was the first one to diagnose me with my 

condition and was able to treat me. And thanks to title X funding, I was able to 

afford my care, and that’s why I keep returning to Planned Parenthood, because I 

trust them. 

Senator HASSAN. I take it would also concern you to know that Dr. Price voted 

as a Congressmen against a District of Columbia law that would prohibit employers 

from discriminating against employees with the decisions they make about their reproductive health and birth control. Is that something you’re aware of and does it 

concern you? 

Ms. HANS. Yes it does concern me. I’m 23 years old and I am employed so I am 

worried about getting kicked off my parent’s insurance, and if I do go on my employer’s insurance, it’s not my boss’s business about my health care and it is something 

that is very concerning, and having grown up most of my adult life with the Obama 

administration, I never imagined I would have to worry about this. And it’s kind 

of really throwing me for a loop. 

Senator HASSAN. Right; well, thank you. I too am going to have to leave; this is 

what happens. Senator Kaine, you can sit right here. 

Senator KAINE. I do have other questions, but I wasn’t planning on sharing. I may 

have to go too. I’ll keep it rolling. 

Senator HASSAN. What I hope you all know, again, is how grateful we are to you 

for telling your stories. Each and every one of you has been willing to talk about 

something that used to be very hard to talk about, and particularly Holly, as I just 

ended my term as Governor of New Hampshire, and I’m dealing with an opioid crisis, as many States are. We also know that behavioral health challenges and substance use disorder sometimes co-occur, and so the importance of people with behavioral health challenges and/or substance misuse speaking up for themselves, the 

same way it’s important for women who need access to strong and good reproductive 

health care speaking up for themselves, for people with disabilities, or parents for 

people with disabilities, the willingness to speak up about the need to be included 

is just critical, and in a democracy, where every single one of us counts, you guys 

have done us all proud today reminding us of that, so thank you so much, and let’s 

keep at it because this rush to repeal is so misguided, and with regard to Congressman Price’s nomination, I hope very much, at the very least, that he will understand and reflect on your testimony should he become confirmed. Thank you. 

Senator HIRONO. Senator Kaine, you have one question to ask? 

Senator KAINE. I do, I do, thank you, Senator Hirono. I’m so glad that we got into 

the reproductive health issue. This week, there was an amazing announcement, and 

it didn’t get enough attention and that’s the unwanted pregnancy rate in the United 

States, it’s at its lowest ever since history has been able to record that rate. What 

a great thing. The Affordable Care Act and the fact that Planned Parenthood has 

not been defunded is one of the reasons—two of the reasons why unwanted pregnancy rates has come down. This is not really a question, it’s an editorial comment. 

I am stunned at the number of individuals who take policy positions that would suggest they’re very much against unwanted pregnancies who want to repeal the Affordable Care Act. I’m stunned at institutions that have taken an anti-ACA position 

who are institutions that would suggest production of the unwanted pregnancy rate. 

267 

I can’t imagine anybody in society who would look at the reduction of unwanted 

pregnancy and say that’s a bad thing. I think virtually everybody in society, regardless of politics, political party or political at all, regardless of region, regardless of 

race, regardless of anything, would look at reductions in unwanted pregnancy and 

say ‘‘that’s a good thing.’’ And yet some of the people who are the most claiming 

to be forward are the ones trying to undo the very health-care safety that has been 

able to bring down the rates of unwanted pregnancy. If they are successful in that, 

the unwanted pregnancy rates will go back up. That’s one of the many things I have 

a hard time figuring out. And I will turn it back to my colleague, Senator. 

Senator HIRONO. Thank you now that everybody has left, not you folks, but 

Mahalo for being here, and you know that we were joined by so many of our Senate 

colleagues today to hear your stories, and I know you understand that we are in 

the midst of confirmation hearings for many of President-elect Trump’s nominees, 

and so I know you understand why people are going in and out. 

We have a nominee for HHS Secretary who wants to privatize Medicare, who 

wants to dismantle Medicaid, who wants to defund Planned Parenthood, and you 

have come in today to tell us your own experiences and stories about how these programs have literally saved your families, saved you and allowed you to go forward 

and thrive. So, I will join my colleagues in fighting tooth and nail against the 

voucherizing of Medicare and the privatizing of these kinds of programs that really 

are the lifelines for millions of people in our community. 

I think that finally, with the potential demise or repeal of the Affordable Care 

Act and voucherizing of Medicare and the huge cuts to Medicaid, the defunding of 

Planned Parenthood, it is finally, I think, sinking into our country what these kinds 

of actions would mean to them. 

I was a member of the United States House of Representatives when we were 

working on the Affordable Care Act, and I remember, sadly, how many people on 

Medicare, including people from the state of Hawaii who were on Medicare, who 

came to me and called me and said, ‘‘Don’t touch Medicare but don’t pass the Affordable Care Act.’’ These seniors are going to find out that with the repeal of the Affordable Care Act, they will end up paying more for drugs because the Affordable 

Care Act was the prescription drug donut hole. They will not be able to access the 

kind of preventative care that allows them to age in place and maintain their lives 

with the repeal of the Affordable Care Act. 

This is sad, that so many people who came forward to say that we shouldn’t pass 

the ACA will be among the millions who will be hurt with the repeal of the ACA. 

So, we have a President-elect who recently said that ‘‘my health-care plan will cover 

everyone.’’ Did you . . . he said that. There will be health care for everyone. How 

do you all think that is supposed to happen? How is that supposed to be implemented with Secretary Price at the helm? Anybody? It’s more than just a rhetorical 

question. 

I would like you all to say that on the record what you all think will happen to 

President-elect Trumps pledge that his health care plan will cover everyone. 

Ms. JENSEN. It does not seem logical to me if he is making that statement and 

he is nominating or choosing someone who, in what touches me personally, says he 

does not believe that preexisting condition should be considered as an accommodation or a protection, and I’m thinking of my own child who was born that way. He 

didn’t acquire them through any of his own choices in life, or anything that he did. 

There’s millions of children and individuals who are in way worse position than Sam 

is. So how does that add up if you say you want to have coverage for everyone but 

then the person you pick to be in charge is already excluding individuals before 

their record is of exclusion. I don’t understand how that makes sense. 

Senator HIRONO. Thank you. With the other people who have come forward, 

would you like your comments to this question to be on the record? 

Ms. FLEMING. Yes, I’d like to comment. Obviously, the President-elect has not 

really looked at Representative Price’s record in voting the things that he has voted 

against, so I think that hopefully, he will take a look at his record in what he has 

done in the past and give him some new ideas that this is not good in what you’re 

planning to do. 

Senator HIRONO. Ms. Serafin? 

Ms. SERAFIN. I think that if he is chosen, he will decimate Medicare and Medicaid 

as we know it. I believe that his stance will be ‘‘you can go out and figure out how 

268 

to take care of yourselves on your own. We’ll give you the costs, we’ll give you the 

money for whatever else we need the money for.’’ It will be chaos, I believe it will 

be complete chaos. 

Ms. HANS. Yes, I would like to go in everyone else’s comments in that I don’t 

think the President-elect has really done his homework in who he’s been nominating 

and that’s been made very clear by Tom Price’s record. And it doesn’t seem like Tom 

Price doesn’t really care about the health of the citizens of the United States. And 

therefore, it makes no sense that he should be at the helm of HHS. His record has 

consistently shown that he doesn’t care about people who rely on these health programs the most. 

Senator HIRONO. Ms. Jensen, would you like to add to this? 

Ms. JENSEN. Yes, I would. Thank you for the opportunity. I very much agree, it’s 

like Trump hasn’t met Price. For instance, one of the ideas thrown around about 

employment requirements for Medicaid seem counter intuitive for me. I feel like it’s 

the law makers’ job to represent the caring majority, not the minority of the 

wealthy, and I feel like we’re going in that direction. Yes, and I don’t know how 

we’re supposed to reconcile these two entirely exclusive plans that we have on the 

table. Yes, I believe that lawmakers need to work to protect the vulnerable, nurture 

small business, and save the taxpayers money. 

Senator HIRONO. Thank you. Senator Blumenthal, we can proceed to you with 

your question. 

Senator BLUMENTHAL. Thank you Senator. Thank you all of you for being here 

today. Your stories, as Senator Warren said, have really given us a face and a voice 

to this somewhat abstract issue to many Americans. People take their health for 

granted until they don’t have it and then it becomes the most important thing in 

the world as each of you know from your personal experience. All of us know it because we’ve all had bad health, it’s not like wealth gives you immunity, but it enables you to do a lot of preventive care, and that’s what I want to focus on is the 

prevention. Cause just as we ignore the economic impact of small businesses as 

Holly has said so well, we also ignore the increased cost of health care if preventive 

steps aren’t taken. At a very early age, Sam’s age, to forestall diabetes and obesity 

and smoking and even opioid prevention because preventing addiction is so much 

more cost effective than treating it later. You mentioned, Anne, that the cost of your 

medicine is $75,000 a year; do I have that right? 

Ms. SERAFIN. It would be, for the one drug I talked about, it would be $84,000 a year. As it is now, the Gilenya I’m on is $6,000 a month, so that is $72,000 a 

year. 

Senator BLUMENTHAL. So, you can see just the cost of that one medication and 

your medical cost may not be preventable in the same way but we can really save 

a lot of money through prevention and we can bring down the cost of medication. 

One area that I think perhaps in this conversation that has not been emphasized 

is the effects and the goals of the Affordable Care Act in restraining and diminishing the growing cost of health care. That was one of the objectives, not just create 

more demand for it and put more money into the health-care system, but also try 

to make it more efficient and effective. So I don’t know whether any of you any have 

observations on that aspect of it, I would welcome. 

Ms. HANS. Yes, I think that a lot of people have kind of lost sight that that was 

the goal of the ACA: when more people have coverage, it actually drags cost down. 

When people don’t have coverage, they keep putting off care. I know—I personally 

had to put off care because I couldn’t access it, and when you keep delaying care, 

it’s more costly in the end. And in the end, the taxpayers are still paying for it, 

they’re just paying a lot more. 

Ms. FLEMING. My view is that preventive care is necessary. This is a good thing, 

we’re becoming a healthier society with this, and if you eliminate some of the preventive care, the early exams that you can have, which we cannot do before, because 

of the cost, you can really target if there is an issue, you can target right away and 

take care of it which in the long run will cost us a lot less than someone that has 

to have really severe care, so the preventive part of it is from early childhood all 

the way up, to us older folks. Thank you. 

Ms. ORNELLA. I’ll just quickly add with Sam’s conditions, he requires regular monitoring to ensure that no further problems arise or if they do, they are caught in 

a timely manner. So I don’t know if we want to consider that, I guess we’d consider 

it because by doing monitoring, which can range from minor tests that cost a few 

269 

hundred dollars to tests that cost a few thousand dollars, it’s heading off any problems be exacerbated but, you know, especially with a young child that cannot really 

communicate what’s going on in their body, so being able to access that kind of care 

is important to maintaining a stable health condition. 

Ms. SERAFIN. I just want to add that the disease modifying drugs that are there 

for multiple sclerosis are there to retard any advancement. So even though they are 

costly, hopefully they’re actually lessening your chances of developing a more severe 

disease and more costly problems. 

Ms. JENSEN. And I’d like to add specifically for mental health and behavioral 

health, preventative care in that world is kind of a new frontier. I definitely had 

that attitude of ‘‘I can handle this. I can do this. I can dig my way out of this.’’ I 

didn’t want to ask for help. Maybe that’s a very American thing: ‘‘I can do it myself.’’ 

And that is what the preventative care is coming up against a lot of times. And I 

would say that education about mental health and behavioral health, the idea that 

was raised before that mental health and behavioral health are part of health care. 

So education about that could be very effective. And also reducing the stigma, even 

by covering these things we do a little bit to reduce the stigma. You’re saying, you’re 

a person worth care. You’re not disposable, you’re not discardable. And also reducing 

the stigma about asking for help which I hope I can do in a tiny way today. 

Senator BLUMENTHAL. Just so you know Holly, for, I think it’s more than 8 years, 

there’s been a law on the books that requires, it’s called, parity. In other words insurance companies are required to cover mental health care in the same way that 

they cover physical healthcare. That’s a matter of Federal statute but there was a 

delay in adopting regulations to implement the statute. That delay occurred under 

both the Bush and Obama administrations and I was involved in helping to advocate that law. We did it in Connecticut which is my State, and then that law became 

a model for the Federal statute but only recently has it been implemented and even 

now it’s not fully enforced. So my colleague Chris Murphy and I, we’re both from 

Connecticut, we’ve both advocated that there be enforcement of that statute in part 

to deal with the stigma that you mentioned which is still a major obstacle. 

Ms. JENSEN. You can’t ask for help if you don’t think there’s anyone out there 

to help you. 

Senator BLUMENTHAL. Well said. Thank you all. 

Senator HIRONO. Thank you, Senator Blumenthal. I’m going to ask Senator Casey 

to wrap up, but before I do that I want to thank all of you once again. You represent 

millions and millions of affected people in our country and I think our voices, and 

I say ‘‘our’’ because you know we are with you, need to be heard. As we say in Hawaii, ‘‘Mahalo nui loa.’’ And thank you, Ms. Jensen, for pointing out the importance 

of mental health services because, as Senator Blumenthal has pointed out and many 

of us know, there has been a lack of parity as to the treatment and the access to 

care for the mental health side which can be just as debilitating if not more so than 

physical injuries, so, Senator Casey, thank you very much. Mahalo. 

Senator CASEY. Senator Hirono, thank you very much, and Senator Blumenthal 

and all those who are here. I’m the last one; because I am, I won’t ask questions. 

I just wanted to make a comment about your testimony, maybe a comment about 

the process, and give you the last word if you so choose. We’ve been here a while. 

One thing I want to say at the outset is, both Alyce and Diane, I’m using your 

first names even though we don’t know each other, I don’t know who to commend 

more on multitasking with Sam, but that’s a pretty good tag team. I don’t know if 

you practiced that this morning but it sure looked seamless. But we’re grateful for 

your testimony. 

I want you to know something and I say this in a very serious way, not just as 

a way to say thanks for making the trip here. We live in a society where on an hourly basis it seems, the lives of movie stars or athletes or even politicians or wealthy 

people, depending on what category someone’s in, their lives are always chronicled, 

always on the news, always a subject of interest and debate and coverage so to 

speak. Every once and awhile the lives of real people are put up with the same degree of prominence but frankly not enough. And in this debate, right now it’s more 

than just a debate, it’s a fight. 

Chapter 1 is stopping the repeal of the Affordable Care Act, and that’s a fight 

we’re in right now. Chapter 2, in my judgment, would be if they’re successful in 

Chapter 1, fighting like hell to make sure whatever they replace it with, and no 

one’s been able to find it—we might want to hire a private investigator to find it 

270 

in the replacement bill, but it doesn’t seem to have surfaced yet; I’m hoping it 

does—but to fight like hell to make sure that whatever is in the replacement bill 

is substantial enough to meet all of your needs and the needs of lots of other people. 

But your stories are not stories that are customarily on display in Washington; 

yours are the stories of people that have lived quietly triumphant lives. You’ve had 

to triumph over things that I’ve never had to worry about and a lot of people in 

this building have not had to worry about. Not everyone, but a lot of us haven’t had 

those same worries. So in your own way, in a very quiet way, you’ve been triumphant in a way most of us haven’t been able to appreciate. And that story that you 

told is both inspirational but also instructive and even instrumental. And I say that 

because the process. If you take your stories out of the debate, years ago when we 

were trying to pass the ACA and I was here and played a role in that, but even 

more so now if you took your stories out of this debate to stop repeal and to make 

sure we get the right result down the road, we lose. 

Because if it’s just a bunch of Senators rattling off numbers—and they’re great 

numbers to talk about: 20 million people insured and all of that. We’ve got to keep 

using numbers; they’re important. But what is indispensable in winning this battle 

is how often we tell your story, how often we excerpt from it in a floor speech, and 

how often we use a 20-second sound bite in an interview or back home or on the 

road or in debates in committee. All of those stories are going to be indispensable 

to that. 

So this isn’t just a nice thing to do today. You’re contributing to the effort to win 

the battle. Your stories are persuasive, numbers once and awhile can help you persuade, your stories are persuasive. So it’s up to us to make sure that we keep telling 

your stories, and stories like yours all across the country. So you’re playing a big 

role in this debate and in so many ways that’s doing something for your country. 

You’ve come here to talk about your life which isn’t easy to do. And politicians 

like me, we talk a lot and we talk about issues but rarely we don’t talk about our 

own personal lives. That is much more difficult than what we do every day. To tell 

a story, to admit that things weren’t going well in your life or that the struggles 

you had or that the suffering you or your family endured. That’s not easy to do for 

anyone and we appreciate you doing that. 

So that effort, that sacrifice, that commitment to going beyond yourself is very, 

very meaningful to the debate. So I hope you understand that and that you don’t 

ever get dispirited in this fight because we need you very much in this fight and 

you’ve already been willing to sign up and not only put your hand up but walk towards the goal that we’re trying to achieve. 

Holly, one of the best lines today is yours: ‘‘It feels good to pay my bills, but more 

so to be part of something.’’ And not just the kind of care that saved your life but 

gave your life back. So the measure of our success will be how often we can put 

your stories on the record in the interview. So I just want you to know how much 

we appreciate you. Secondly in the process, today I’m going back and forth between 

the hearing from the Finance Committee—we have Mr. Mnuchin for Treasury Secretary. That’s what we’re doing today, we’re asking him a lot of questions about 

tough topics like mortgage foreclosures and things like that. But we’re going to finish that hearing today; obviously it’ll go for a while more, and we’ll vote on that 

nomination. 

But we’re kind of in the middle of the Representative Price nomination. I’m on 

both committees that he testified in front of, but only the Finance Committee will 

be where the vote is. So he’ll appear there in front of our committee where we’re 

doing Treasury today, and that’s where the vote will be. And because of your testimony today, you’ve given me more, I won’t use the word ammunition, but you’ve 

given more information for us to be able to present in questions or comments in that 

hearing on Representative Price. 

And obviously we can’t just do a good job in these hearings, we have to do a lot 

more on the road back in our States. So that’s the process and we’re going to continue to fight very hard to give meaning and value and really to validate what 

you’ve told us today. 

This is critically important, that we preserve all these protections. And absent any 

other comments, we can wrap up, but I just want to give you the last word. You 

traveled and took time to be here, so if anyone wants to make any final comments, 

and then we’ll gavel out with the gavel. We actually have a gavel; I’ll do that. 

271 

Ms. SERAFIN. Thank you for this opportunity. It has helped me personally to be 

able to share this story and feel like I’m part of what’s going on and it’s helped me 

to live with the next 4 years. 

Senator CASEY. Ann, thank you very much. We’re grateful. Anybody else? 

Ms. FLEMING. I just want to thank everyone. It’s good to put faces to it all with 

you all as well and I think one of the things that’s missing is the eye to eye contact 

that you’re, you know, going to implement something but you can’t look me straight 

in the face or straight in the eye and tell me what you’re going to take away and 

not give me anything else. This is good to be able to, the empathy that you have 

and that you have all presented in front of us today, which I don’t see that happening in the next round of people. There’s no compassion—where is it? It’s missing. 

So thank you all. 

Senator CASEY. We’ll do a better job on our end. If we’re in the middle of a debate, 

figuratively speaking and sometimes literally, we say, ‘‘Well, I know you don’t like 

what I said, but answer Diane’s question. How can you help her? How can you make 

sure she doesn’t have a circumstance that’s unimaginable and will have the help 

that she needs?’’ 

Ms. FLEMING. I wanted to say, I live right across the bridge, so any time, just 

give me a call. 

Senator CASEY. You’re close. 

Ms. FLEMING. I’ll come in. 

Senator CASEY. Thanks. Anybody else? 

Ms. HANS. Yes, I would like to echo Diane’s comments. It was really great meeting 

everyone. After everyone’s questions and comments, I feel hopeful, and I haven’t 

since November. 

Senator CASEY. Good; thank you. Well, absent any other comments, I get to—this 

is really amazing that I get to hit this gavel. I just want to make it official. We 

are adjourned. 

Anna Isis-Brown 

Caring Across Generations activist 

Los Angeles, CA 

January 2017 

Attn: Members of Congress and fellow Americans 

Every member of my immediate family has benefitted from the Affordable Care Act 

(ACA). I am a 30-year-old newly-wed. I applied for individual health insurance in 

2010, before the ACA went into effect. At the time, I was working full-time at a university bookstore, but the job did not offer me health insurance. I was denied coverage due to my pre-existing conditions—which included various allergies, minor 

dermatologic issues (eczema, acne), and depression. I went without an Epipen (a 

lifesaving emergency medication for my most severe food allergies) and stopped taking my antidepressant medication for the 2 years that followed because I didn’t have 

health insurance. I have health insurance through my employer now, but it is very 

important to me to know that if I ever lost my employer-sponsored health insurance 

in the future, the ACA would protect me from being excluded from the individual 

insurance market again. 

Last year, at age 60, my father was diagnosed with two types of skin cancer. He 

lost his job about 2 years before the diagnosis. After he lost his job, he paid for 

COBRA for a while, but its high cost became completely unaffordable for him. He 

didn’t seek treatment for the suspicious-looking patches of skin on his face, ears, 

and back because he was frankly afraid to find out what they were and how much 

they would cost to treat. He eventually applied for insurance through the Arizona 

state exchange, on the assumption that it would be cheaper to pay for the plans 

available on the exchange than it would be to keep paying for COBRA. When he 

finally applied to the exchange, he learned that, due to his income and Arizona’s 

Medicaid expansion, he was actually eligible to get coverage for free. With his new 

coverage, he finally got a diagnosis and treatment. His doctor told him that without 

treatment, his face could have been disfigured by the basal cell carcinoma, and if 

the patches of squamous cell carcinoma had just spread unchecked, they could’ve 

become much more serious. My dad is still with us today because his cancer was 

caught and treated early enough. 

272 

My sister is 27 years old and has a mental health condition. She works full-time 

as the General Manager of a movie theater that is part of a small local chain. Until 

December 2016, her job did not offer health insurance. They just began offering her 

a plan last month, and she is now on it. For about the past 2 years, she purchased 

her health insurance through the California state exchange. The ACA allowed her 

to have coverage she could afford, and get treatment for her mental health conditions, when her company didn’t offer any coverage. 

My husband also works full-time as the Operations Manager for a small company 

in the film industry here in Los Angeles. He is the company’s only full-time employee. The company does not offer health insurance. Until we got married in August 2016, he purchased his health insurance through the California state exchange. 

For about a year, when his income was lower, he got a small subsidy to help pay 

for the insurance. The ACA is the only option for many working people whose jobs 

simply do not offer insurance. 

The ACA has made a difference in each of our lives, and for that, I am very grateful. 

I have such a sense of security knowing that, whatever happens in my career path 

in the future, I will always be able to get the Epi-pens that have saved my life once 

already. I am grateful for my time with my father, knowing that he was able to access the care he needed to treat his cancer before it got too advanced, and that he 

will be able to treat it again if it ever returns. And I felt enormous peace of mind 

that my sister and husband have been able to get the coverage they needed when 

they couldn’t obtain it through their employers. In a time when many people need 

more help, it is not right to be offering less and to get rid of the only affordable 

option that many have. The ACA has been a lifeline for my family, as I’m sure it 

is for so many others. 

Carol Gloor 

Savanna, IL 

In 2015, after several years of chronic pain, MRI’s, and cortisone injections, I was 

finally told I needed to have my left hip replaced. I have always been an active person and the gradual loss of the ability to walk long distances was devastating to 

me. Thanks to Medicare, I had my hip replaced over a year ago. The hospital bill 

alone was over $50,000, not counting the cost of the physical and occupational therapy which followed. Medicare paid for most of it, my supplemental insurance paid 

for some, and I paid the balance. I am one of the lucky ones in that I have supplemental insurance and some liquid assets, but without Medicare I could never have 

afforded the operation. Being well and my quality of life would have come at the 

cost of my savings and my assets. I am sure there are many others in the same 

situation looking for assistance. Instead, some people want to take that away from 

the people who need it most. I am hiking again and volunteering in many ways to 

make my community and my state a better place. Thank you, Medicare. 

Kim Thomas 

Raleigh, NC 

My name is Kim Thomas. I’m a home care worker from Raleigh, NC. I became a 

home care provider after caring for my terminally-ill mother. As a home care worker, I assist with activities of daily living—such as toileting, bathing, mobility, meal 

preparation, and medication reminders—that make it possible for seniors and people with disabilities to live at home with dignity and independence. I have a true 

passion for caregiving. I became a Certified Nursing Assistant. I obtained my LPN, 

with special certifications and training in Alzheimer’s/Dementia care, Diabetes care, 

all stages of cancer, Parkinson’s, end-of-life care, wound, and respiratory care. I 

have a genuine love for seniors and the elderly—that’s why I work as hard as I do. 

And I work hard. I work about 100 hours a week or more. I work 16-hour shifts 

Monday through Saturday and three 14-hour night shifts each week. I don’t receive 

paid time off, holidays, vacation, sick time, health insurance, or retirement benefits. 

And still, my wages are so low, $8 or $9 per hour, that I struggle to get by. 

Though my job is all about taking care of people, I found it hard to take care of 

myself before the Affordable Care Act. I have diabetes and had a hard time finding 

coverage because of this pre-existing condition. 

273 

I used to go to the Emergency Room and pay $100 a visit for diabetes medication. 

But I wasn’t getting the care I needed to stay healthy and work hard for my family. 

I determined to find insurance coverage. 

After weeks of research and rejections, I was able to get a ‘‘high risk’’ plan for $479 

per month with huge deductibles. 

Not long after that, I got really sick. I was vomiting and had diarrhea for more than 

24 hours. I clearly needed to go to the hospital. But I was scared of using my insurance plan—scared they would take it away from me. I finally crawled across the 

floor to call 911. 

Doctors at the hospital determined my gallbladder had erupted and I needed surgery. But I kept telling the hospital staff that I couldn’t stay there because I 

couldn’t afford it. And when I called in to work, they asked me if I was ‘‘really sick’’ 

and suggested I get a second opinion. 

I was in the hospital for 5 days. I came home to a $3,000 hospital bill and a note 

from my insurance company that my premium was being raised to more than $800 

per month. I had to let my life insurance plan go, because I couldn’t afford both. 

I sometimes missed car insurance payments—and I need my car to get to work. 

When the Affordable Care Act went into effect, I decided to visit HealthCare.gov and 

see if I could do better than $800 per month. I visited the website, then spoke with 

an agent who told me they could have me insured starting January 1 for $73.28 

per month. Now, I get my diabetes medication at the pharmacy for $4, instead of 

haphazard $100 ER visits. 

Without the Affordable Care Act, I wouldn’t be able to manage my diabetes and be 

as healthy as I am. If it goes away, I am scared of the impact it will have on my 

life, including my ability to work and support my family. When every dime goes to 

medication or insurance premiums, you can’t afford your other bills. 

I can’t believe someone would want to take this healthcare away from the American 

people. As a home care worker, it’s not just me who depends on Obamacare and 

other programs such as Medicaid, it’s my consumers, too, who receive Medicaid coverage. Medicaid is largest provider of long term care coverage in the country and 

more specifically home and community based care. Many of my consumers would 

be unable to remain in their homes or get the life-saving care they need if it were 

not for Medicaid. In fact, one of my consumers had a massive stroke and lost his 

ability to speak. Without Medicaid coverage, he would be unable to afford his medications—putting him at risk for another stroke. 

If I lose my health coverage, if I’m no longer covered because of a pre-existing condition, if I have to go back to paying $800 per month for health insurance, it will 

cause chaos in my life. If the Medicaid program is cut and if I no longer have a 

job or my hours are reduced and my consumers don’t have access to the care they 

need, it will not only cause chaos in my life, but chaos in their lives as well. 

The Affordable Care Act and Medicaid have changed my life and the life of my consumers for the better. It has made me healthier and able to work hard to support 

my family. Please don’t take that away. 

Michael Lostutter 

Bloomington, Indiana 47401 

January 6, 2017 

My wife Mary and I are both age 64, we have been married 43 years. We grewup in rural Indiana. We had one child, a daughter who passed away in 2010. She 

was a traumatic brain injury survivor due to an auto accident in 1996. We were 

her caregivers for 14 years as she was permanently disabled due to her injuries, 

confined to a wheelchair. 

Mary and I both worked longer than we were married, her mostly part-time at various jobs, myself from several full time positions finally retiring as the administrator 

of a multi-employer pension plan. 

Prior to our daughter’s demise, we had no plans to retire early or otherwise as we 

had our daughter’s economic future as our primary consideration. After her unexpected death, our world changed as did our expectations for the future. We decided 

to retire early. 

274 

Working full time provided Mary and I with group health insurance however, at retirement the employer sponsored group plan was no longer available. COBRA coverage also was not available due to the size of the employment group. 

The Affordable Care Act (ACA) with it requirement to insure without regards to preexisting conditions allowed us to secure affordable coverage at age 62. We have 

maintained coverage through 2016, as I have now become eligible for Medicare and 

Mary likewise will be eligible in February. 

The ACA has allowed us to enjoy our early retirement. It also, has allowed deserving younger folks the opportunity to replace us in the workforce improving their 

lives as well. 

Mikki Chalker 

Binghamton, NY 

Most people do not realize what a godsend the ACA has been for people with disabilities. Until the ACA, many people with disabilities were doomed to poverty. Private insurance was unaffordable, or simply unavailable. My daughter suffered a 

traumatic brain injury at birth, leading to severe spastic cerebral palsy, a lifelong 

condition which will require lifelong care. Until the ACA, private insurance simply 

would not cover her. People like my child, who need insurance to be able to live, 

were doomed to stay under the limits of poverty for life in order to qualify for Medicaid and Social Security. Removing the pre-existing conditions barrier allows my 

13 year old daughter, and others like her, to have insurance and yet still become 

tax-paying citizens with full independent lives. 

Also, Medicaid and the waiver services it provides have allowed millions of people 

to live and thrive in the comfort and dignity of their own homes. Medicaid waiver 

services have allowed my daughter to receive nursing care at home which makes 

a difference in how often she is hospitalized. It also means that we can have the 

equipment to give her the care she needs at home—wheelchairs, lifting equipment, 

suction machines, mobility aids, and bathing aids. My daughter needs almost 100 

percent assistance with daily living activities. Having insurance to provide these 

means she lives at home, not in an institution. With me providing that care at home 

with help from a nurse means she is hospitalized less, improving not just her health 

and daily life, but also saving untold thousands in hospital care and additional medical costs. Most importantly, it allows her to be a 13-year-old girl, with hopes and 

dreams and ambitions, not just a patient, not just a body in a nursing home or institution. I can’t imagine going back to life with less access to these services. Not only 

does my daughter deserve better, she deserves more. 

These are not small things in our lives. I am grateful for the work of Caring Across 

Generations that allows me to share how critical the ACA has been for my life and 

my daughter’s life. 

Mina R. Schultz 

Fairmont, WV 

When I was 25, I was finishing my graduate program at the University of Missouri 

and preparing to enter the Peace Corps. I had student insurance, but it would end 

upon graduation, and I would have about 9 months without coverage before my 

Peace Corps service began. I didn’t give it much thought; I was young, healthy, 

didn’t go to the doctor much. My parents foresaw the gap in coverage and told me 

about a new law that would allow me to stay on their coverage until I turned 26. 

I said, sure, sign me up. Didn’t really matter to me, but why not? So I joined their 

plan. 

The pain started in April 2011, about a month before graduation. I wrapped my 

knee, iced it, and took a break from running for a while so it would heal. After graduation I was planning on taking a temporary job in rural Montana, to pay the bills 

until my Peace Corps service started. I was still having pain, and not wanting to 

end up in the middle of nowhere Montana with a torn ligament, I scheduled an 

MRI. I will never forget the MRI techs telling me, ‘‘You’ll be glad you came in.’’ I 

was sure I had torn something. I was on my parents’ insurance at the time. 

I will never forget the phone call, when the doctor said, ‘‘Ms. Schultz, it appears 

you have a tumor.’’ 

275 

The tumor was osteosarcoma, an aggressive bone cancer usually found in children 

and adolescents. I endured 5 surgeries, including a total knee replacement, and 9 

rounds of chemotherapy (each involving 3 doses of chemo, so 27 doses all together) 

over the course of a year. Most of my treatment was inpatient, though I also received at-home physical therapy and IV services. Just one of my post-chemo injections cost thousands of dollars. Because I had taken that insurance, most of my 

treatment was covered, and my parents avoided bankruptcy. I would not have qualified for charity care. I don’t know how we would have afforded my lifesaving treatment had I chosen to forego coverage because I was 25 and thought I was healthy. 

I think about it every day. 

Now I am an enrollment assister in rural north-central West Virginia. I help my 

community members navigate the Health Insurance Marketplace, expanded Medicaid, and the ACA in general, because I believe everyone has the right to the access 

and care that I received when I was sick. No one should have to experience what 

I did, but especially no one should go bankrupt because they want to survive an 

illness. I try to explain this to people on a daily basis, that it is a responsibility to 

get coverage to protect yourself from the exploding cost of health care in our country, because you truly never know when something catastrophic might happen. I 

carry coverage so that I can cover my own costs and remain a contributing member 

of society. While I am coming up on 5 years cancer free, I have secondary conditions 

as a result of treatment, and take medications to manage my health. Because of my 

previous diagnosis and resulting side effects, I would be considered uninsurable 

without the ACA requirement to cover those of us with pre-existing conditions. 

I am a contracted worker. I purchase my own insurance through the Marketplace 

exchange and receive a subsidy to help me afford this coverage. Because of the 

threat to the law, I am having to look for a new job, one that will offer me benefits 

so that I can’t be denied coverage, and hopefully one that won’t cap my benefits. 

I love my current job, but I won’t be able to afford high risk pool coverage should 

the ACA be repealed and replaced. I take pride in being able to cover my own expenses, and I fear that I will have to rely on my community to care for me if I no 

longer have the ACA to protect me. I’m just trying to do my best, but I feel like 

my congressmen and women are trying to take away my autonomy by taking my 

care. I thought government was supposed to protect its people. Please protect me 

by keeping the ACA in place, so I can continue to have access to the care I need 

to maintain my health and contribute to my community. 

Risa Morimoto 

Caring Across Activist 

New York, NY 

January 2017 

Attn: Members of Congress and fellow Americans 

Without Medicare, Medicaid, and the Affordable Care Act, health care would be 

much more difficult for my family. Like many others, my family is pressed between 

providing care for our parents and for ourselves too. These programs are what make 

it possible for all of us to access the different kinds of care that we all need. 

My mother had just turned 65 when she had a stroke in 2001. She was covered by 

Medicare and spent 3 months receiving care in the hospital. Ten years later, she 

was diagnosed with Parkinson’s disease and needed 24/7 care. She refused to go into 

a nursing home and insisted that she be cared for in her own home. 

Until her stroke, my mother was a hardworking small business owner—she opened 

up the first Japanese restaurant in Long Island. When she got sick, we had to sell 

her business, the thing she had worked so hard on for most of her life, and that 

was difficult for all of us. That left her with her house, but she didn’t have many 

assets beyond that. We are Japanese, and taking care of our parents is a very big 

deal in Japanese culture. My brother and sister and I did our best. At the time, 

we weren’t aware that my mother was eligible for Medicaid, and we could not afford 

to pay out of pocket for in-home help. Even with taking turns, after 10 years, my 

siblings and I were both completely burned out from our own full-time work and 

full-time caregiving. It really started to tear our family apart, both financially and 

emotionally. 

Now she is covered by Medicaid, and we’ve been able to hire aides through the community-based Medicaid program. My mother is eligible to receive 106 hours of inhome care per week, but Mom is very particular about who spends time in her home 

276 

with her. We were able to hire Japanese caregivers, which helped us transcend 

some of these cultural and language barriers and made her feel much more comfortable. Living with the effects of a stroke and Parkinson’s for 16 years shows what 

a strong person my mother really is, and my siblings and I are happy we get to 

support her. It’s not easy—she cannot really do anything without assistance, but she 

knows she wants to be in her home where she is most comfortable and everything 

is familiar. Community Medicaid is what keeps her safe and comfortable at home, 

keeps her out of a nursing home, and we know it saves the state money. 

My brother moved into my parents’ home, and my sister lives next door. I make 

the trip out to Long Island every weekend from my home in New York City to help 

out. Even with the three of us sharing the responsibility of caring for her, we could 

not do it if it weren’t for the caregivers who come to her home to take care of her. 

This is what allows my brother and sister and I to continue our full time jobs and 

maintain our own lives as well as pitch in to help with Mom. Without these aides, 

she would lose everything and I have no idea where she would live. 

My husband and myself are small business owners, and insurance has never been 

easy or inexpensive for us without the benefit of receiving coverage through an employer. So when the Affordable Care Act was announced, we thought this would finally be something where we’d have a real option for substantial health care. Before 

the ACA, we had health insurance through Freelancers Union. I was always trying 

to cobble something together for both of us, or thinking we’d have to just rely on 

a catastrophic plan. Last year was stressful and frustrating—mid-year our insurance company cut my doctor and hospital out of the network. One example is that 

my husband and I needed to get physicals and blood work in September so I had 

to find a new doctor who turned out to be one of the worst doctors we had ever been 

to. The doctor’s office mistakenly sent our bloodwork to the wrong lab (even though 

we explicitly told them they had to go to Quest Lab to which they answered they 

knew). 

Even though they said they would fix the error, they didn’t. Their mistake cost us 

$500. I don’t know why our doctor and hospital dropped our insurance coverage midyear, and while I understand that there have been some problems since the ACA 

rolled out, I don’t believe the answer is throwing it all out. The solution is to improve it and make it stronger. Getting more people covered through the ACA will 

help stabilize it. Having coverage that we can afford through the ACA is a huge relief. I have a close family friend who for many years could not afford insurance. 

When he finally had to drop his coverage, he was diagnosed with leukemia shortly 

afterwards. He lost his house, his business—everything. I get such peace of mind 

knowing that my coverage provides preventative care, and knowing that if some unexpected emergency arises, we will be covered and we will be okay. 

My family has been able to afford the care we need because of Medicare, Medicaid, 

and the Affordable Care Act, and I think we as a country can do even better to 

make sure that everyone is able to get the care they need. Cuts and defunding these 

programs would make things much more difficult for many Americans—and no one 

says that it should be easy, or that the government should do it all, but where we 

can make things better, why wouldn’t we? I am proud of these programs that help 

people get the help they need. 

I am happy to be an advocate for better care with Caring Across Generations as 

part of the Caring Majority, and to be able to tell my family’s story. Supporting 

these programs is bigger than politics—it is about people’s lives. This is a moment 

when we need to take steps forwards, not backwards. I hope Congress does what 

the majority actually wants—it’s their job. 

Rita Morris 

Birmingham, Alabama 

I am Rita Morris of Birmingham, AL and proud daughter of Mrs. Katie. I thank 

you in advance for your valuable time in allowing me to share my personal experience as a family member and consumer of nursing home care with Medicaid. At 

some point in our lives we will be a caregiver or in need of a caregiver. I ask of 

you today to consider your family as I share a glimpse of ours. I ask that you recognize your partnership with us. As Mother’s caregiver of 14 years, an only child, wife, 

cancer survivor and mother, my hope was for quality of life, quality of care and 

peace of mind for all of us. Nursing home care directly affects our loved ones as well 

as our families. My mother became a widow at the age of 45; I was 16. Out of necesVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00280 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
277 

sity I quickly learned about our family finance needs and importance of health care. 

Years later as a Registered Nurse, I was well aware that health care is driven by 

federal and state regulations. When my Mother was diagnosed with vascular dementia, her life and our family’s life changed. At that time, I was a stay at home 

mom with a child in kindergarten. Our journey started at that time. We had many 

partners in caring for Mother along the way—the Grace of God, family, friends, 

faith, Medicaid, Medicare, Social Security, and many wonderful health care providers—but our journey would have been completely different if not for Medicaid. 

As Mother’s dementia advanced, her physical, mental and spiritual needs increased. 

She was able to live in her home for 2 years with assistance, in our home for 1 year 

with sitters, for 4 years in specialty assisted living, and for 7 years in a nursing 

home. After 4 years in assisted living, the dementia had progressed and she required pureed food and more care. When this occurred, we were no longer eligible 

for assisted living. The next transition was to the nursing facility. I researched the 

regulations (OBRA) for nursing homes and Medicaid before we moved in. We were 

prepared. The rules and regulations of Medicaid, Medicare, and Social Security are 

clear in purpose and process. They served our family as intended and were greatly 

needed. 

In 2007 we were told that Mother could possibly live 6 months in the nursing home. 

We recognize and respect that the decisions for our federal funded health insurance 

programs are in the hands of our legislative partners. Medicaid was the most lifeenriching benefit that Mother received at her most vulnerable time. She moved into 

the nursing facility in August of 2007. Her financial assets were depleted, her dementia had advanced, and she required care around the clock. Dementia symptoms 

were not limited to the hours of 8 am to 5 pm; they were around the clock for 24 

hours. I completed the Medicaid application with the online form and directions. I 

submitted the form personally to our local office and received a follow-up call 3 

weeks later. She moved into the nursing home in August 2007 and was approved 

by Medicaid retroactively in October 2007. 

As a cancer survivor, my biggest fear was that I would no longer be there to care 

for her. I often asked myself: Who would care for her in my absence? My hope was 

to be able to care for her as she did for me, my father, and my family: simply with 

love. Her focus was always on us; she did not focus on finances, insurance or direct 

care. Medicaid provided Mother with the 24 hour a day care that she needed, the 

necessities that she required, and a state surveyor to monitor the care and assure 

that the facility was in compliance with the regulations. As an only child, I had 

peace of mind knowing that in the event of my absence, her care would be paid for 

and she would get the care she needed, with protection and oversight. 

As a result of the necessities and protections Medicaid provides, my Mother lived 

an additional 7 years with respect, dignity, and quality of care and quality of life. 

Her wishes were simple. She used to say, ‘‘I don’t want to be the one someone would 

see and say ‘that poor thing’ ’’ and ‘‘I don’t want to be a burden on you.’’ She was 

never in a situation of being neither ‘‘that poor thing’’ nor a burden. In those 7 years 

she was admitted to the hospital only one time for a fractured hip. She had no skin 

breakdown, limited contractures, and was treated in her own bed for pneumonia 

and urinary tract infections over the years. She was provided care by loving caregivers, and she was loved by many. The staff of the two sister facilities that she 

called home became our extended family. 

I was able to be a partner, assist in her care, be an involved mother in after school 

activities, help my son with his homework, and serve as room mom at his school. 

I was able to be present in our home as wife and mother in our family commitments. Our one income family was able to provide for our immediate needs and to 

save for our son’s college needs. This was not always easy, but it was our new ‘‘normal’’ and we did the best we could. The stress of caregiving is tremendous. It takes 

a village to raise our children and it takes a village to care for our vulnerable loved 

ones of all ages and needs in all settings. The nursing home setting had a profound 

impact on our family. Long-term care is the most precious, personal and spiritual 

time for transitions in roles and in preparation for the final transition to Glory. 

I would like to take a moment to share with you a glimpse of what our lives could 

have been without our Medicaid partner. In 2007 the potential of living 6 months 

could have been a reality. We would have had two options if we had to leave the 

assisted living without Medicaid. One would have been to care for Mother in our 

home, a home with a then 13 year old still needing to be driven to school and activities, increased homework, wife to prepare meals and provide 24 hour care during 

a time that Mother was still walking and wandering. The focus was caring for MothVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00281 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
278 

er and family. When Mother was in our home, she found it to be stressful living 

with us before she chose to move to the assisted living. She wanted to be with 

friends her own age in her own ‘‘home.’’ In our home, she had the constant reminder 

of her losses and her dependence on us. We required sitters in my absence along 

with medical equipment. If we continued to care for Mother in our home, she may 

not have received the highest quality of care that she deserved and she may never 

have achieved a high quality of life. 

Our second option without Medicaid would have been to pay privately for the nursing care that she needed 24 hours a day. As an estimate in 2007, the private rate 

for the nursing home was $5,000 per month or $60,000 a year. Over a period of 7 

years the total would have been a minimum of $420,000. Our family would have 

required loans to meet those needs. We were and still are a one income family. We 

would have done everything needed to care for Mother. However, as parents to our 

only child, we also had to anticipate his college needs. This would have been an 

overwhelming situation and limited at best. 

These are two very different options both affecting our family and most importantly 

the quality of care and the quality of life that Mother would have experienced. 

There would have been no peace of mind for any of us with either of these two options. In closing I would like to express my thanks to you and to ask for your continued support of Medicaid as an essential way to meet our medical needs and financial support not only for our loved ones, but for families as well. As the generation 

before us, we have contributed to our Social Security and have anticipated having 

Medicare and Medicaid in place as our needs arise. It has been a privilege and an 

honor to walk with Mother as her partner on this journey. Mother’s last transition 

occurred on September 1, 2014 when she was called home to Glory. As my husband 

and I walked with Mother out the front door in the early hours we left with no regrets. It was well with my soul. I hope that our experience with Medicaid can relay 

the profound impact that the decisions made with a vote can have on the lives of 

those you serve. The photo of my hand with Mother’s reflects my commitment of 

love and care and her fragile dependence and trust. 

With our Medicaid partner, Mother was afforded quality of care and quality of life 

while I was afforded the peace of mind to continue to serve in my proudest role, 

Daughter. 

Sincerely, 

Rita Morris 

Daughter of Mrs. Katie 

Susan Flashman 

Mt. Rainier, MD 

My name is Susan C. Flashman, and I have been on Social Security since I became 

disabled following brain surgery in 2011. And 2 years later I was eligible for Medicare coverage. My husband, Richard A. Bissell, has been on Medicare for 12 years. 

We are both retired and live on a fixed income made up of Social Security and our 

retirement pensions from our years of Union employment with the International 

Brotherhood of Electrical Workers. We pay monthly for our Medicare coverage, as 

well as our supplemental insurance offered through our UNION. 

Because we have Medicare coverage, we have been able to repair injured and worn 

parts of our bodies through surgery. The repairs have helped us to maintain an active life with minimal pain. Following my brain surgery, and as soon as I was well 

enough, I could have a breast biopsy performed to make certain that a mass seen 

during my annual mammogram was not the start of cancer. 

This peace of mind following brain surgery was priceless. Since then, Medicare has 

helped to pay for the repair of my left wrist, and my broken toe. Both important 

to keep me living a full and independent life. In this same manner, my husband 

had surgery to repair a torn rotator cuff in his shoulder. Without such surgery, the 

pain would have incapacitated him. 

The importance of Medicare to us is that we can stay healthy enough to continue 

to contribute to our community in voluntary activities, as well as maintain an independent life in our own home. In doing so, we do not burden our families, or the 

long-term care system. 

279 

If we were unable to have Medicare help maintain our health through regular doctor’s visits and medical tests, we might become less healthy more quickly as we age. 

The enormous cost of health care for those who are no longer able to earn additional 

funds is critical. 

If Medicare were to become part of the insurance business, I am afraid that I and 

every subscriber would have to hire a lawyer to be certain that these companies fulfilled their legal obligations of coverage. I have personally encountered this type of 

dilemma following my brain surgery. In order to receive the benefits I deserved from 

a catastrophic medical insurance plan, I had to rely on legal counsel. What is even 

worse than having to fight for what is due, is to have to fight when you are least 

able. The insurance industry counts on this to help reach their profit margin. 

While we were working, we contributed to Social Security and Medicare and now 

the Congress thinks privatizing care for seniors should be profitable. Hogwash! 

It is time to expand Social Security—so that everyone in this country has the basics 

they need to live a decent life, not just those lucky enough to have inherited wealth. 

Sincerely Submitted by Susan C. Flashman on January 16, 2016. 

Lezrette Hutchinson 

Bronx, NY 

My name is Lezrette Hutchinson. I live in the Bronx, NY, and I am 60 years old 

and a mother of three. Thank you for convening a public forum to give voice to 

American families who would be harmed by proposals that would make people with 

Medicare and Medicaid pay more for their care. Please accept this letter as formal 

comment for the forum record. 

In 1999, after years of working at New York’s Board of Education, I was diagnosed 

with sarcoidosis. Sarcoidosis is an inflammatory disease that affects my lungs, 

which makes me depend on oxygen. With little information about the disease, I became extremely ill. 

Two years later, I became homeless for a time after a fire burned down my home. 

The side effects of the disease and my medications made me depressed. This was 

because I didn’t know where to go for proper treatment, and I was prescribed the 

incorrect medications. I was unable to go to work nor to take meaningful part in 

my children’s lives as they grew into adulthood. 

My health turned around once I found a sarcoidosis clinic at Mount Sinai Hospital, 

which accepts both my Original Medicare and fee-for-service Medicaid coverage. 

After receiving the care I desperately needed, I was able to become an activist and 

participate in a support group for those with sarcoidosis. Later, I joined the board 

of my medical center to implement changes that my fellow advocates and I knew 

would improve patients’ quality of life. I also attended a recreational support group 

called the 50s-plus Program, and then joined the Workgroup for People with Medicare and Medicaid, part of the Duals Coalition of New York’s Medicare Rights Center. 

If I didn’t have my original Medicare, I would need to find a plan that would cover 

me best, knowing that I have a serious, rare disease. I would need to make sure 

I found a way to continue to receive the care I need with the right doctors who can 

service my chronic disease. This would be a challenge for me since not many doctors 

specialize in my illness, and if I couldn’t continue to see them my illness would take 

a turn for the worse. 

With my current income, by the time I pay my rent and bills, I do not have much 

left. If my Medicare costs increased that would be a big financial hardship for me. 

Thanks to my Medicare and Medicaid, I am provided with affordable, vital services 

that enhance my life. I would love to continue to get the quality of care that I am 

getting now. Yes, I am ill but I don’t want that to stand in my way. I recently found 

out I am going to be a grandmother and I want to take part in my grandchild’s life 

and make up for the years I was unable to be in my own children’s lives due to 

my illness. 

Theresa Maguire 

Queens, NY 

280 

My name is Theresa Maguire. I live in Queens, NY, and I am a mother of two and 

recently became a grandmother. Thank you for convening a public forum to give 

voice to American families who would be harmed by proposals to repeal the Affordable Care Act (ACA) and undo the Medicare and Medicaid guarantee. Please accept 

this letter as formal comment for the forum record. 

On December 28, 2010, I received a fully favorable (100% disabled) decision in connection with my Social Security Disability Insurance Benefits application. At 57 

years old, I had been a grammar school teacher consecutively for the previous 26 

years. I am disabled from Chronic Interstitial Cystitis (IC) with Hunner’s Lesions. 

I also have Pelvic Floor Dysfunction, Pudendal Nerve Involvement, hypertension, 

tachycardia, IBS, and anxiety. 

Since 2010, I have been treated by Dr. Robert Moldwin for my IC condition and its 

related issues. Dr. Moldwin is one of the leading specialists in the United States 

for IC and is the author of ‘‘The Interstitial Cystitis Survival Guide.’’ He has played 

a primary and pivotal role in my treatment. I first saw Dr. Moldwin in May of 2010 

and I continue to visit his practice generally on a weekly/bi-weekly basis. 

In June of 2010, Dr. Moldwin ordered me to begin bladder installations. Each installation lasts approximately 1 hour and consists of 15 steps. I must undergo these 

treatments on a semi-weekly, and often weekly, basis. On several occasions, the installations will puncture one of my Hunner’s lesions which causes five or more 

hours of steady bleeding. During this time, I am forced to stay in or near a bathroom and drink copious amounts of water. With time, the bleeding subsides. In addition to the installation procedures, I receive ‘‘internal nerve block injections’’ into 

the walls of my pelvis. I also endure ‘‘internal physical therapy.’’ This is to assist 

with the pain associated with my conditions. 

All efforts at relieving my pain thus far have been only temporary in nature. After 

suffering from the pain and devastating change of lifestyle brought about by my condition, I began to see a mental health specialist in October of 2010, and my treatment with her has been ongoing since. My pain is moderate to severe, and occurs 

on a daily basis. This is exacerbated by my particularly small bladder which causes 

further pain. This also causes my frequency of urination to increase along with the 

increased pain. 

I wake up multiple times a night. I live with fatigue, loss of sleep, and bladder 

spasms, among other symptoms. My experience of pain or other symptoms is severe 

enough to interfere with attention and concentration on a frequent basis, and I am 

incapable of even a low stress job. I can only sit continuously for 20 minutes, stand 

for 20 minutes, and total sit, stand, or walk less than 2 hours in an 8-hour period. 

My condition dictates bathroom visits that can be 20 times in a 24-hour period. Urinating is a burning painful experience for me a majority of the time. I suffer the 

inability to sit at times due to the excruciating pain of my condition. I have a prescription from my neurologist that allows me to be in a kneeling position in the car 

when I cannot transfer to a sitting position due to temporary paralysis of my pelvic 

floor. All together, I need 10 prescription medications, 5 to regularly manage my 

conditions and an additional 5 for bladder installations. 

I had to wait 2 years to receive Medicare. For those 2 years, I needed to pay COBRA 

premium payments. The burden of my illness exacerbated and strained my ability 

to meet even the simplest daily tasks. Furthermore, the emotional and psychological 

strain and stress of medical insurance payments and medical co-payments while 

waiting for Medicare was enough to push me over the edge. Since I was a teenager, 

I worked diligently as a tax-paying citizen and continued to do so my entire adult 

life. Here I was at 57 years old sinking with a monetary situation that added to 

my already debilitated medical condition. If I were to get sick now, I would have 

the ability to shop for other, potentially less expensive, insurance options than that 

COBRA coverage through New York State’s health exchange—thanks to the Affordable Care Act (ACA). 

Since I began receiving Medicare, I have been privileged with being treated by the 

same doctors as prior to my Medicare coverage, and I have been comfortably reassured with my present Medicare coverage that I can continue to receive the cutting 

edge treatments available to me. I pay $104 per month for Medicare (which is deducted from my Social Security Disability Benefit), and I do not have any other 

medical insurance coverage. I cannot take on the burden of paying for additional 

coverage. I receive a Social Security Benefit of $1,550 per month, and I receive a 

disability insurance check for $775 per month. My out-of-pocket co-pays for 2016 

were slightly more than $3,215 in addition to my Medicare premiums. 

281 

I hope my story conveys the fragile, debilitating situation one is put in when one 

can no longer function as a productive member of society and can therefore no 

longer earn a living. Medicare needs to remain with its benefits, at the very least, 

intact. I cannot endure the thought of elected officials dictating changes in Medicare 

that determine not only my quality of life, but my life itself. I deserve to have a 

fighting chance, and I need my Medicare benefits to remain stable to be granted 

that fighting chance. With your help, your actions, your foresight, and your good 

consciences, you can save lives. I hope all members of Congress will step up to the 

challenge and battle for what is a human right—the right to decent medical benefits 

for the disabled. 

PREPARED STATEMENT OF HON. RON WYDEN, 

A U.S. SENATOR FROM OREGON

The American public heard a lot of promises about health care from the new administration. No cuts to Medicare or Medicaid. Nobody hurt by ACA repeal. ‘‘Insurance for everybody . . . much less expensive and much better.’’ Congressman Price’s 

own record undercuts those promises, and this morning I’ll get to those issues. 

But first I’m going to start with questions about ethics and undisclosed assets. 

Congressman Price owns stock in an Australian biomedical firm called Innate 

Immunotherapeutics. His first stock purchase came in 2015 after consulting Representative Chris Collins, the company’s top shareholder and a member of its board. 

In 2016, Congressman Price was invited to participate in a special stock sale called 

a private placement. The company offered the private placement to raise funds for 

testing on an experimental treatment it intends to put up for FDA approval. 

Through this private placement, Congressman Price increased his stake in the company more than 500 percent. He has said that he was unaware he paid a price 

below market value. 

That claim doesn’t pass the smell test. Company filings with the Australia Stock 

Exchange clearly state that this specific private placement would be made at belowmarket prices. The Treasury Department handbook on private placements says they 

are ‘‘. . . offered only to sophisticated investors in a nonpublic manner.’’ Congressman Price also said last week that he directed this stock purchase himself, departing from what he said was his typical practice. 

Then there’s the issue of what was omitted from the Congressman’s notarized disclosures. Congressman Price’s stake in Inna te is more than five times larger than 

the figure he reported to ethics officials when he became a nominee. He disclosed 

owning less than $50,000 of Innate stock. At the time the disclosure was filed, by 

my calculation, his shares had a value of more than $250,000. Today his stake is 

valued at more than half a million dollars. Based on the math, it appears that the 

private placement was excluded entirely from the Congressman’s financial disclosure. This company’s fortunes could be affected directly by legislation and treaties 

that come before Congress. 

It also appears Congressman Price failed to consult the House Ethics Committee 

following trades of several health care stocks, as they were directly related to two 

bills he introduced and promoted. Even if some of those trades were not made at 

his direction, he would have been aware of them as soon as he filed his Periodic 

Transaction Reports with the House of Representatives. 

Set aside the legal questions. It’s hard to see how this can be anything but a conflict of interest and an abuse of his position. 

Finally, one of the most important questions on the Finance Committee’s biographical questionnaire is whether nominees have been investigated for ethics violations. Congressman Price has been the subject of two investigations stemming from 

fundraising practices. This too was not disclosed. 

I believe this committee needs to look into these matters more thoroughly before 

moving ahead with this nomination. 

Let’s turn now to policy, starting with the Affordable Care Act and the scheme 

known as ‘‘repeal and run.’’ The secret Republican replacement plan is still hidden 

away, but already the administration is charging forward with a broad executive 

order endangering people’s health care. As the Budget chairman, Congressman 

Price is the architect of repeal and run. 

282 

If his repeal bill became law, 18 million Americans would lose their health-care 

plans in less than 2 years. In one decade you’d go from 26 million people without 

insurance to 59 million. Repeal and run would raise premiums 50 percent in less 

than 2 years. Costs would continue to skyrocket from there. The market for individuals to buy health insurance would collapse. No-cost contraceptive coverage for millions of women—gone. By defunding Planned Parenthood, nearly 400,000 women 

would lose access to care almost immediately. Hundreds of thousands more would 

lose their choice to see the doctors they trust. 

The Price plan takes America back to the dark days when health care worked 

only for the healthy and the wealthy. 

Congressman Price’s other proposals don’t offer much hope that the damage will 

be undone. By the Trump rubric of ‘‘insurance for everybody,’’ ‘‘great health care 

. . . much less expensive and much better,’’ the Congressman’s plans get a failing 

grade. 

In another bill, the Empowering Patients First Act, the Congressman Price 

brought back discrimination against people with pre-existing conditions such as 

pregnancy or heart disease. It gave insurers the power to deny care and raise costs 

on people with pre-existing conditions if they didn’t maintain coverage. In effect, the 

bill said insurance companies could take patients’ money and skip out on paying for 

the care they actually need. 

His bill also gave insurers the green light to reinstate lifetime limits on coverage 

and charge women higher rates just because they’re women. It gutted the tax benefits that help working people afford high-quality health-care plans. It slashed the 

minimum standards that protect patients by defining exactly what health plans 

have to cover. All this from a proposal called the Empowering Patients First Act. 

It’d be a stretch to find a bill with a more ironic title, considering how much power 

it handed to giant insurance companies. 

If there’s a theme developing, it’s that the Congressman’s proposals push new 

costs onto patients. The massive cuts to Medicare proposed in Congressman Price’s 

budget are another prime example. In my view, the Congress has a duty to uphold 

the promise of Medicare—the promise of guaranteed benefits. 

Congressman Price advocated privatizing Medicare and cutting it by nearly half 

a trillion dollars. After his nomination, he said he wants to voucherize Medicare 

within the first 6 to 8 months of the administration. 

He also supports ‘‘balance billing.’’ That means seniors could be forced to cover 

extra charges above what Medicare pays for the services they receive in the doctor’s 

office. So in this case, it’s extra costs pushed onto elderly people who live on fixed 

incomes. 

Congressman Price has also called for block granting and capping Medicaid, a 

plan that would shred the safety net for millions of America’s most vulnerable patients. 

Medicaid insures 74 million people. More people rely on Medicaid to help pay for 

nursing home care and home-based care than any other program. The program pays 

for nearly half of all births and covers millions of children. It’s a critical source of 

mental health care and substance use treatment, which is vital at a time when communities nationwide are battling the opioid epidemic. But Congressman Price’s most 

recent block grant proposal cut Medicaid by a trillion dollars. 

Setting that huge cut aside, there’s also a concerning pattern to the way some 

lawmakers look at programs that have undergone this kind of transformation. At 

first it’s a block grant, a few years later it’s declared a slush fund, and then it gets 

slashed to the bone. 

Unfortunately, that pattern has also defined Congressman Price’s approach to 

other areas that would be within his jurisdiction as Secretary. His budget called for 

trillions of dollars in cuts to programs that support millions of vulnerable people— 

everything from job training to housing assistance to child nutrition. He also voted 

no on the reauthorization of the Violence Against Women Act when it sailed through 

the House on a bipartisan basis. 

As I wrap up, I want to return to health care. The Congressman and many others 

say patients should be at the center of care, and nobody would dispute that idea. 

When I look at Congressman Price’s proposals, I don’t see the patient at the center 

of health care. I see money and special interests at the center of health care. 

283 

His plans would tell vulnerable Americans that their health care will go only as 

far as their bank accounts will take them. The well-to-do might be able to afford 

Congressman Price’s proposals and the costs they push onto patients, but millions 

of working Americans cannot. 

Congressman, I thank you for joining the committee today and I appreciate your 

willingness to serve. I look forward to your testimony. 

MEMORANDUM FOR FINANCE COMMITTEE MEMBERS 

From: Senate Finance Committee Staff 

Date: January 23, 2017 

RE: Nomination of Dr. Thomas E. Price 

This memo describes the Senate Finance Committee staff review of the 2013, 

2014, and 2015 tax returns, and other documentation of Dr. Thomas E. Price in connection with his nomination to be the Secretary of the Department of Health and 

Human Services (HHS). 

Background 

Finance Committee staff conducted a review of Dr. Price’s Senate Finance Committee (Committee) Questionnaire, tax returns for 2013, 2014, and 2015, and financial disclosure statements. As part of this review, a due diligence meeting was held 

with the nominee and his legal representation on January 16, 2017. His accountant 

participated via telephone. In addition to the due diligence meeting, staff submitted 

multiple rounds of written questions to the nominee. 

At the conclusion of this process, three issues have been identified that have been 

deemed appropriate to bring to the attention of committee members. 

Senate Finance Committee Questionnaire—Ethics Investigation and Late 

Property Tax Payments Omitted 

All nominees referred to the committee are required to submit the Senate Finance 

Committee Statement of Information Requested of Nominee (‘‘Questionnaire’’). 

Part D. Legal and Other Matters, Question 1, asks nominees: ‘‘Have you ever 

been the subject of a complaint or been investigated, disciplined, or otherwise cited 

for a breach of ethics for unprofessional conduct before any court, administrative 

agency, professional association, disciplinary committee, or other professional 

group?’’ 

In his response, submitted December 21, 2017, Dr. Price responded, ‘‘No.’’ However, in 2010, the Office of Congressional Ethics (OCE), an independent office of the 

House of Representatives, conducted an investigation into Dr. Price’s 2009 fundraising activities. OCE voted 4–0–1 to refer the case to the House Ethics Committee, 

which, after conducting a second investigation, ultimately found no wrongdoing in 

2011. 

In written questions submitted to Dr. Price on January 6, 2017, committee staff 

requested an explanation for the omission of the ethics investigation. Dr. Price stated it was an inadvertent omission and that the majority of activities investigated 

related to his authorized campaign committee, rather than him personally. The information pertaining to this investigation has been and continues to be available on 

the web page of the House Ethics Committee. 

Part F. Financial Data, Question 10, asks nominees: ‘‘Have you paid all Federal, 

State, local, and other taxes when due for each of the past 10 years?’’ Dr. Price responded, ‘‘Yes.’’ However, upon examining Washington, DC and Nashville, Tennessee real estate tax records, Committee staff determined late tax payments had 

been made in relation to rental properties owned by Dr. Price, totaling $1,583.45 

for late payments made over the past 7 years. 

In written questions submitted to Dr. Price on January 6, 2017, Committee staff 

requested an explanation for the omission of the late tax payments. Dr. Price stated 

that, regarding the DC property, he believed that ‘‘late fees and penalties derived 

from not receiving timely property tax notices.’’ Regarding the Tennessee property, 

the nominee noted that ‘‘notices regarding property taxes for this rental property 

. . . were either not being received or being wrongly mailed to the tenant at the 

property and not reaching the nominee and his spouse.’’ 

284 

1Treasury Reg. § 1.167(a)–5, T.C. Memo. 1982–51, Meier v. Commissioner. 

Depreciation of Land Value and Miscellaneous Employment Deductions 

Committee staff received 2013, 2014, and 2015 tax returns from Dr. Price on December 21, 2016. In addition to the written questions submitted on December 28, 

2016 and January 6, 2017, Committee staff spoke with Dr. Price’s accountant on 

January 9, 2017. Following the due diligence meeting with Dr. Price, Committee 

staff then submitted an additional round of written questions to the nominee on 

January 16, 2017. 

Improper Inclusion of Land Value in Depreciation Calculations 

Taxpayers who own rental property are generally allowed to deduct depreciation 

expenses associated with the wear and tear of those buildings. Taxpayers are not, 

however, allowed to include the value of land in the depreciable amount. 

Dr. Price owns rental condominiums in Washington, DC and Nashville, Tennessee, and claimed depreciation expenses associated with those properties for years 

2013, 2014, and 2015. It appears these values included depreciation for the value 

of the land. According to property tax records, the land value of Washington, DC 

condominium was listed as $95,640, and the land value of his Nashville condominium was listed as $30,000. 

Under current tax rules,1 these values are not allowable for depreciation expenses. Committee staff asked for clarification on this issue in the due diligence 

meeting with Dr. Price and sent written follow-up questions on January 16, 2017. 

In his response to the committee, received on January 23, 2017, Dr. Price’s accountant stated he had taken the position that the land had a fair market value 

of zero. However, given the lack of another valuation besides the property tax assessments, Dr. Price has committed to address the discrepancy by filing a Form 

3115 to adjust the depreciation and account for the improper deductions on his 2016 

tax returns, though adjustments may be spread out over 4 years. 

Absence of Documentation of Employment Deductions 

In 2013, 2014, and 2015, Dr. Price claimed miscellaneous employment deductions, totaling $19,034. Dr. Price, and his wife, also a medical doctor, both list their occupations as ‘‘PHYSICIAN’’ on the second page of their Form 1040s. Neither Dr. Price 

nor his wife actively works as a physician, though Dr. Price has noted he has maintained his medical license. Committee staff requested substantiation and further explanation of the deductions in written questions submitted December 28, 2016. 

Committee staff spoke with Dr. Price’s accountant on this matter on January 9, 

2017, and again during the due diligence meeting on January 16, 2017. In those discussions, Dr. Price’s accountant noted that Dr. Price and his wife, Elizabeth, would 

compile a variety of expenses, including vehicle expenses, and discuss with the accountant what portion of those expenses would be appropriate to deduct as employment expenses, frequently settling on an amount equal to roughly 60 percent. 

Though the Prices no longer actively work as physicians, their accountant believed 

that the deductions were appropriate, and were reflective of expenses incurred by 

Mrs. Price. After the January 16, 2017, due diligence meeting, staff suggested that 

in the absence of full documentation of the deductions, that the returns be amended. 

In a response, received January 23, 2017, Dr. Price’s accountant noted that proper 

documentation could not be located. Dr. Price’s 2013, 2014, and 2015 tax returns 

will be amended to remove the $19,034 of deductions. Since Dr. Price was subject 

to the Alternative Minimum Tax (AMT) in each of those years, the changes will not 

result in any change to tax liability. 

Asset Values 

In separate financial disclosure filings to the House of Representatives, to the 

committee, and to the public through the Office of Government Ethics (OGE) Form 

278, the nominee reported ownership of stock in an Australian pharmaceutical company—Innate Immunotherapeutics Ltd. The nominee purchased these shares in two 

tranches: one in 2015 valued at $10,000 at the time of purchase, but was valued 

at between $15,000 and $50,000 on December 20, 2016, the date of filing. A second 

tranche was purchased in August 2016 of 400,613 shares, through a private placement offering, and was listed on the committee questionnaire as being valued between $50,000 to $100,000, which was based upon the purchase price. An analysis 

done by multiplying the number of shares by the market price on December 20, 

2016 demonstrates a value higher than that reported by the nominee. The nominee 

285 

noted that the amounts reported to the committee were a good faith valuation. The 

nominee agreed to recalculate the value of the shares based on the market value 

at the time the committee Questionnaire was completed. The revised value of the 

second tranche was between $100,000 and $250,000 when filed. 

The nominee and committee staff also agreed that the tranche of shares acquired 

in August 2016 was not accounted for on the OGE Form 278, and the nominee told 

staff that income attributable to his holding in the company reported on OGE Form 

278 was incorrect. The nominee noted that it is unclear how information related to 

his holding in this stock was misstated on the published form. The nominee agreed 

to contact OGE to correct the form. 

Senate Finance Committee—Bipartisan Vetting Process 

January 24, 2017 

The Finance Committee has a long, bipartisan tradition of engaging in a very thorough process for vetting nominees. It has served the committee well and it has 

served the country well. 

It has several steps. First, we review the paperwork, consisting of the committee 

questionnaire, financial disclosure (OGE Form 278), ethics agreement, ethics letters, 

and 3 years of tax returns. Frequently, there have to be several rounds of written, 

follow-up questions before the paperwork is satisfactorily reviewed. 

Next, we have three staff meetings; one to complete the due diligence review (financial), one to discuss policy with the chairman and ranking member’s staff, and one 

with the staff of committee members. Only after all of these steps have been completed do we notice a hearing, seven days prior to the hearing’s date. 

The two nominations that we are considering so far each raise issues that have 

taken some time to review. In the case of Mr. Mnuchin, he has very complicated 

financial affairs, with partnerships embedded within other partnerships. It took 

some time just to get a good understanding of his financial affairs. In the case of 

Dr. Price, it has been difficult to value his stake in an Australian drug company. 

In fact, Dr. Price revised his committee questionnaire just yesterday, January 23, 

2017, to correct inaccurate information about the ownership of this stock. 

Below is an overview of the dates of meetings, materials received, rounds of questions asked, and responses received between committee staff and the nominees 

through the bipartisan vetting process. 

Mr. Steven T. Mnuchin 

Materials Submitted 

• December 16: Tax Returns • December 19: Questionnaire; Interim OGE Form 278 • January 10: Revised Questionnaire; OGE Ethics Materials; OGE Form 278 • January 15: 2nd Revised Questionnaire 

Meetings 

• January 13: 1st due diligence (financial) • January 17: 2nd due diligence (policy) • January 17: 3rd due diligence (Committee Member staff) 

Rounds of Questions 

• December 23: Initial Tax Compliance 

» Responses received: December 30, January 4, January 6 

• January 4: Follow-up Tax Questions and due diligence matters 

» Responses received: January 6, January 9, January 13 

• January 10: Follow-up Tax Questions and due diligence matters 

» Responses received: January 12, January 18 

• January 13: Tax and Non-tax follow-up questions, following 1st due diligence 

meeting 

» Responses received: January 18 

The Honorable Thomas E. Price 

Materials Submitted 

• December 21: Questionnaire; Tax Returns 

286 

• January 11: OGE Ethics Materials; OGE Form 278 • January 23: Revised Questionnaire 

Meetings 

• January 16: 1st due diligence (financial) • January 17: 2nd due diligence (policy) • January 17: 3rd due diligence (Committee Member staff) 

Rounds of Questions 

• December 28: Initial Tax Compliance 

» Responses received: January 4 • January 6: Due diligence matters 

» Responses received: January 12 • January 10: Additional Tax Compliance 

» Responses received: January 12 • January 16: Tax follow-up questions, following 1st due diligence meeting 

» Responses received: January 23 • January 17: Non-tax follow-up questions, following 1st due diligence meeting 

» Responses received: January 22 

The Washington Post, January 23, 2017 

HHS NOMINEE’S MIX OF INVESTMENTS, DONATIONS, LEGISLATION

KEEPS RAISING QUESTIONS

By Kimberly Kindy and Amy Goldstein 

Representative Tom Price, the Georgia Republican nominated by President Trump 

to lead the Department of Health and Human Services, is under increasing scrutiny 

for a trifecta of financial, campaign and legislative activities that some longtime ethics lawyers describe as ‘‘extremely rare’’ and revealing ‘‘an extraordinary lack of 

good judgment.’’ 

In recent years, Price has repeatedly traded stock in dozens of health-related companies while pushing bills that could have benefited many of them. At the same time, 

he has been uncommonly reliant on campaign contributions from the health-care industry, accepting more than $700,000 from physicians, hospitals, drug companies 

and insurers during his 2016 run for a seventh congressional term, according to the 

Center for Responsive Politics. 

‘‘I haven’t seen anything like this before, and I’ve been practicing and teaching 

about securities law for 30 years,’’ said Richard W. Painter, who was chief White 

House ethics lawyer for President George W. Bush from 2005 to 2007. 

Given that Price has some influence legislatively over the health-care sector, his volume of trades in related companies is unusual, according to a former chief counsel 

to the House and Senate ethics committees. In the past few years, more lawmakers 

have moved away from investing in individual stocks, opting instead for mutual 

funds, Treasury bills or municipal bonds as investments. 

‘‘They are allowed to do this type of trading, but I would advise against it,’’ said 

Rob Walker, who served in the bipartisan counsel positions from 1999 to 2008. ‘‘The 

level of scrutiny he is facing goes along with the territory of making these kinds 

of investments.’’ 

Price’s investments and donations coincide with a pattern, dating back to his years 

as a state senator, of strenuously promoting legislation that advances the interests 

of the medical profession. An orthopedic surgeon for 20 years before he entered politics and still an active member of the American Medical Association, he has sought 

as both a Georgia legislator and congressman to make it more difficult for patients 

to win medical malpractice lawsuits and to limit certain damage awards in such 

cases. 

‘‘Whether it be liability or any policy issues about how health care is delivered, how 

it is paid for, how it is accessed, it is doctors all day every day,’’ said longtime critic 

Mark Taylor, a Democratic lieutenant governor in Georgia during most of Price’s 

tenure in the state Senate and first years on Capitol Hill. 

And while Price speaks often of pursuing a patient-centered health-care system, he 

rails against what he calls an excessive federal role in health care, voting at one 

point against an expansion of the Children’s Health Insurance Program. ‘‘The desire 

287 

of those on the left to gradually move every American to Washington-controlled bureaucratic health care is so strong they will stop at nothing,’’ he said before casting 

that vote in 2007. 

In Congress, he has been one of the most ardent opponents of the Affordable Care 

Act, sponsoring the only bill to repeal the sprawling health-care law that passed 

Congress. Then-President Barack Obama vetoed it early last year. 

Price’s investment and legislative records are central themes that Democrats plan 

to pursue in his confirmation hearing Tuesday before the Senate Finance Committee. During a ‘‘courtesy’’ hearing last week before a different Senate panel, he 

faced sometimes-heated interrogation by Democrats over the timing of stock purchases and the extent of his involvement in them. 

The nominee has said he would divest financial interests in any companies that 

could pose a conflict of interest for him as HHS secretary. But some lawmakers, as 

well as the advocacy group Public Citizen, are calling for an investigation by the 

Office of congressional Ethics. They also have filed complaints against Price with 

the Securities and Exchange Commission. 

A congressional probe would cease if he were to become HHS secretary. An SEC investigation would continue. 

An HHS spokesman reiterated Monday that Price had no knowledge of any trades 

in his financial portfolio, with the exception of those in one company. The spokesman declined to provide the name of Price’s broker or to share a copy of his written 

agreement with the investment firm. Price’s legislative office did not respond to repeated requests for comment over several days. 

If confirmed, the 62-year-old congressman, who chairs the House Budget Committee, would run one of the biggest federal agencies and its $1.1 trillion budget. 

Supporters suggest a doctor best understands what the nation’s health-care system 

needs, with Senator Orrin G. Hatch (R–Utah) describing Price as ‘‘very upfront and 

very straightforward, very honest, and somebody who really understands the healthcare system of this country.’’ 

Price has largely defended his investment activities by saying his broker made nearly all of the stock purchases without his knowledge. Brokers cannot make securities 

trades for clients without their expressed permission in writing, and Senators Patty 

Murray (D–WA) and Ron Wyden (D–OR) sent a letter Friday asking Price for such 

proof. Aides in their offices said Monday that he has not responded. 

And regardless, said Painter, now a law professor at the University of Minnesota, 

‘‘It’s a pretty weak defense since he could have gone online at any time and seen 

the trades that were being made on his behalf.’’ 

Representative Louise M. Slaughter (D–NY), the co-author of the 2012 Stop Trading 

on Congressional Knowledge (STOCK) Act, shares that sentiment. The law passed 

after media reports on the close ties between lawmakers’ stock portfolios and legislative actions. It requires that trades be publicly reported within 45 days instead of 

annually—the sole reason Price’s stock activity last year has come to light in the 

midst of his confirmation. 

‘‘The weakest link here is this notion that some broker bought all these things without his knowledge,’’ Slaughter said. 

A spokesman for the Trump transition countered on his behalf last week, although 

Phil Blando addressed only the issue of campaign fundraising. ‘‘Any effort to connect 

campaign contributions to Dr. Price’s policy positions is an increasingly stale and 

desperate Democratic talking point,’’ he said. 

Of particular concern to Slaughter and her Democratic colleagues is Price’s largest 

stock buy last year—between $50,000 and $100,000—in an Australian biomedical 

firm, Innate Immunotherapeutics. Price acknowledged last week that this purchase, 

and several smaller ones made in the company in 2015, occurred without a broker’s 

aid. He told members of the Senate Health, Education, Labor and Pensions Committee that he learned of the company from Representative Chris Collins (R–NY), 

who serves on Innate’s board, and then did his own research on it and the multiple 

sclerosis drug it was developing. 

The 2016 investment was done through what’s known as a ‘‘private placement offering’’ made by a company to a select group of potential investors. Price contended 

that he received no insider information ahead of time. 

288 

Price’s denial didn’t satisfy Murray, who also pressed him on the timing of the 

trades. They coincided with final negotiations on the sweeping 21st Century Cures 

bill, aimed in part at helping to accelerate clinical trials and approval of drugs like 

Innate’s. 

Simon Wilkinson, Innate’s chief executive, told The Washington Post that about 640 

investors purchased stock through the special offer. The company did not directly 

approach Price, he said. 

According to David Blake, an Australian securities analyst, the shares the lawmaker purchased in the special offering are now worth between $337,500 and 

$675,000—a 575 percent increase. 

Another trade in the spotlight involves Zimmer Biomet, a major manufacturer of orthopedic and dental implant devices. 

CNN was the first to report financial disclosure records showing that Price bought 

between $1,001 and $15,000 worth of Zimmer Biomet shares last March. A week 

later, he introduced legislation to delay a new payment model that industry analysts 

said could have serious financial implications for the company. 

The HHS regulation carried ‘‘tremendous risk and complexity for patients and 

health-care providers,’’ Price said when he introduced his bill. ‘‘Rushing its implementation would be unreasonable and potentially detrimental to patients and their 

quality of care.’’ 

Federal Election Commission records show Price received $2,000 in campaign donations from the company’s political action committee in November 2015 and June 

2016. 

In a statement, Zimmer Biomet spokeswoman Monica Kendrick said it ‘‘did not support’’ Price’s legislation and was unaware of his investment in the company. She 

said the company had long backed efforts such as the payment model Price sought 

to block. 

Price also purchased stock in three pharmaceutical companies in the months leading 

up to his introduction last June of a bill that would have provided the businesses 

with massive tax breaks for their manufacturing and production activities in Puerto 

Rico, records show. Amgen, Eli Lilly and Bristol-Myers Squibb gave a combined 

$20,000 to his 2016 reelection campaign, according to filings with the Federal Election Commission. 

The bill ultimately did not pass the House. Blando stressed last week that Price had 

‘‘no say or input into these trades’’ and that to insinuate a connection ‘‘is insulting.’’ 

Overall, Price is far more reliant on donations from health professionals than other 

lawmakers in comparable positions in the House. Since he was first elected to Congress in 2004 from an affluent, conservative district in northern Atlanta, they have 

given more than $3.5 million in campaign contributions, more than any other donor 

sector, according to data from the Center for Responsive Politics. 

In contrast, the previous chairman of the House Budget Committee, Speaker Paul 

D. Ryan (R–WI), has received $1.3 million in contributions from health professionals 

since 1998. 

While Price resembles many House Republicans in his zeal for dismantling the 

ACA, his focus on medical malpractice lawsuits is distinctive. 

Starting in 2009, he has four times introduced the Empowering Patients First Act, 

with the most recent three bills seeking to repeal the ACA. All would have weakened patients’ hand in medical malpractice cases by setting $250,000 caps on noneconomic damages, creating clinical guidelines to protect doctors from liability or 

both. And he sponsored two separate bills aimed at creating such guidelines for use 

in malpractice lawsuits. 

None got out of House committees. 

Julie Tate, Alice Crites, and Matea Gold contributed to this report. 

(289) 

COMMUNICATIONS

AMERICAN ASSOCIATION OF HIP AND KNEE SURGEONS (AAHKS) 

OFFICE: 847–698–1200 • FAX: 847–698–0704 • WEB: aahks.org 

9400 W. Higgins Road, Suite 230 • Rosemont, IL 60018–4976 

The Honorable Orrin Hatch The Honorable Ron Wyden 

Chairman Ranking Member 

U.S. Senate U.S. Senate 

Committee on Finance Committee on Finance 

219 Dirksen Senate Office Building 219 Dirksen Senate Office Building 

Washington, DC 20510 Washington, DC 20510 

Dear Chairman Hatch and Ranking Member Wyden: 

The American Association of Hip and Knee Surgeons (AAHKS) strongly supports 

the nomination of Congressman Tom Price, MD as Secretary of the United States 

Department of Health and Human Services (HHS). AAHKS is the foremost national 

specialty organization of 2,900 physicians with expertise in total joint arthroplasty 

procedures. The mission of AAHKS is to advance hip and knee patient care through 

education and advocacy, and we look forward to working with federal officials to improve our health care system. 

Prior to entering public service, Congressman Tom Price practiced medicine as an 

orthopaedic surgeon. He spent nearly two decades in private practice caring for patients and their families. Dr. Price’s experience as a physician gives him a critically 

important perspective on the real-world impact of health policy including the importance of access, coverage, the doctor-patient relationship, clinical decision making 

and challenges of navigating a complex health care environment. Most importantly, 

we have confidence that as a physician, he will seek to put patients first in his role 

as HHS Secretary. 

Dr. Price was also an educator. He was an assistant professor at Emory University 

School of Medicine and Medical Director of the Orthopedic Clinic at Grady Memorial 

Hospital, a public hospital serving the greater Atlanta area. His contributions to the 

education of resident physicians under his tutelage are a testament to his commitment to secure a healthy future for all Americans. 

AAHKS respectfully urges the Senate to confirm Dr. Price’s appointment as 

Secretary of HHS. 

Sincerely, 

William A. Jiranek, M.D. Michael J. Zarski, J.D. 

President Executive Director 

ASSOCIATION OF WEB-BASED HEALTH INSURANCE BROKERS (AWHIB) 

Introduction 

The Association of Web-Based Health Insurance Brokers (AWHIB) appreciates the 

opportunity to provide comments on the nomination of The Honorable Thomas Price 

to be Secretary of the Department of Health and Human Services. AWHIB is a 

trade association of web-broker entities (WBEs) that have signed agreements with 

the Centers for Medicare and Medicaid Services (CMS) and are currently leveraging 

the Federally Facilitated Marketplace’s (FFM) direct enrollment application programming interfaces (APIs). Our members include brokerage firms that sell health 

insurance online directly to consumers, private health insurance exchanges, and 

technology companies that support individual agents and brokers. AWHIB seeks to 

290 

collaborate with consumers, issuers, regulators, lawmakers, and other industry 

groups to continually develop technologies and enrollment strategies that provide 

Americans with the greatest access to health insurance products and services. 

AWHIB members have played a significant role in enrolling consumers in individual 

market health insurance policies. During the plan year 2016 annual open enrollment period, AWHIB members alone facilitated nearly 1 million initial enrollments 

and active reenrollments, or over 12% of initial enrollments and active re-enrollments by consumers in the Federally-facilitated Marketplace states and states using 

the Federal platform. This amount is in addition to the hundreds of thousands of 

off-exchange individual market enrollments facilitated by AWHIB member companies. Our web broker technology is used by tens of thousands of independent health 

insurance agents nationwide, and AWHIB member companies have partnerships 

with the world’s largest health insurance brokers, tax preparation firms, and health 

insurance technology firms, including Jackson Hewitt; Tax Act; Mercer; Buck 

(Xerox); Lockton; Bankrate; NFP; SummaCare Inc.; HealthSpan Inc.; HealthSpan 

Integrated Care Inc.; H&R Block; Walgreens; Working America; CUNA Mutual 

Group; Benaissance; Direct Health; and Assurex Global. 

AWHIB offers its support for Congressman Price to be the next Secretary of HHS 

based upon his significant experience in the House of Representatives, including his 

role as Chairman of the House Budget Committee during the 114th Congress, as 

well as 20 years as a practicing orthopaedic surgeon. If confirmed by the Senate, 

AWHIB looks forward to working with Secretary Price to improve the health of all 

Americans. 

Principles for Stabilization and Reform of the Individual Health Insurance 

Market 

The nation’s individual health insurance market is at a critical juncture as it enters 

its fourth year following the full implementation of the Affordable Care Act. AWHIB 

recognizes that the Administration, along with many members of Congress, intend 

to take steps to modify and/or replace many of the elements implemented under the 

Affordable Care Act, including potentially the health insurance Exchanges. As key 

players in assisting consumers make an informed choice of insurance products, 

AWHIB’s members want to offer their perspectives and recommendations regarding 

the individual health insurance market for consideration by an incoming Secretary 

of HHS. 

To promote the availability of coverage, AWHIB recommends that an incoming Secretary consider the following six key tenets to help guide changes to the individual 

health insurance market: 

• Expand Consumer Choice of Enrollment Venue—Provide consumers with choices 

on how to enroll in health insurance and support multiple channels for enrollment, including private sector channels. Private health insurance exchanges 

and WBEs have enrolled consumers in health insurance products prior to the 

ACA, and as part of the ACA both on and off the exchanges. They also have 

extensive third party partnerships with retailers, tax preparation firms, unions, 

employers and other organizations that could be leveraged to reach consumers 

‘‘where they are.’’ Despite this experience, private sector enrollment channels 

have been highly underutilized by the Exchanges to date. 

• Provide for Versatile Eligibility Determination Regardless of Enrollment Channel—Whether the ACA Exchanges continue or are replaced, Federal and state 

governments should provide simple and versatile approaches to render eligibility determinations, such as a standalone eligibility service (SES), that can 

interact with a variety of enrollment channels. This would enable health insurance enrollment efforts to leverage a variety of private and public sector based 

enrollment channels. 

• Promote Innovation—One of the core strengths of private health insurance exchanges and WBEs is their ability to use technology innovations to meet the 

needs of their consumers. While AWHIB recognizes the need for robust consumer protections, WBEs and private exchanges also need flexibility to take full 

advantage of innovation. To achieve this balance, Federal and state governments should focus on defining the overall policy aims, while permitting flexibility for innovation within defined policy guardrails. 

• Strengthen Support for Continuous Coverage—Improve the health of the insurance risk pool by implementing enrollment policies emphasizing continuous coverage. This includes improving the administration of special enrollment periods 

291 

and making changes to the annual open enrollment process. If the individual 

mandate is removed, AWHIB supports guaranteed renewability and other incentives to further continuous coverage. 

• Use Refundable Advanceable Tax Credits to Further Insurance Accessibility— 

Base tax incentives for health coverage on refundable advanceable tax credits 

rather than tax deductions. Refundable advanceable tax credits are versatile 

and can be used by consumers to lower the cost of monthly health insurance 

premiums, making health insurance accessible to more consumers than tax deductions and non-refundable credits. 

• Improve the Overall Health of the Insurance Market—Implement policies that 

would support a more healthy insurance market that is sustainable for health 

insurance carriers and affordable for consumers. Congress and HHS should consider implementing risk mitigation strategies such as a revised reinsurance program or national high-risk pool, as well as allowing for greater availability and 

incentives for health savings accounts. 

Near-Term Changes to Strengthen the Current Exchange Market 

Based upon the above principles, AWHJB recommends the following near-term actions should the ACA Exchanges remain in place for the near term or an indefinite 

period of time: 

• Implement Enhanced Direct Enrollment for the FFM for PY 2018—Federallyfacilitated Exchanges and state Exchanges that use the Federal enrollment 

platform permit WBEs to enroll consumers into Exchange coverage using a socalled ‘‘direct enrollment process.’’ However, the current process is not consumer 

friendly and requires the consumer to be redirected to HealthCare.gov before 

being redirected back to the WBE website to select a plan. This experience is 

jarring and confusing to the consumer, rendering it nearly non-functional. 

HHS has proposed to replace the current direct enrollment process with an enhanced direct enrollment process, which would permit the consumer to complete 

the Exchange application and select a plan on the WBE platform, however, has 

not firmly committed to a timeframe for fulfilling those original intentions. 

AWHIB strongly recommends that HHS implement enhanced direct enrollment 

for PY 2018, as this would permit WBEs to significantly increase the number 

of consumers that could enroll in coverage through the Exchanges. Furthermore, this could also be used to support eligibility determination for refundable 

advanceable tax credits under future replacement plans. 

• Strengthen Special Enrollment Periods—To improve the health insurance risk 

pools, HHS should require full verification of eligibility for special enrollment 

periods. In addition, Congress and HHS should shorten the 3-month grace period for non-payment of premiums by consumers receiving advance premium tax 

credits, and prevent such consumers from taking advantage of enrollment rules 

to drop and reenroll in coverage. These changes would help to stabilize the individual market, providing greater predictability for carriers and reducing the potential for adverse selection. 

Long-Term Changes if the Role of Public Exchanges Is Altered Significantly 

If the public exchanges’ role in facilitating consumer shopping is significantly altered or replaced, consumers will still need tools to help them understand, compare, 

select and enroll in available health insurance products. WBEs and private exchanges are well positioned to fill this void as a private sector alternative to the 

public exchanges, as they already provide consumers with online shopping platforms 

designed to help consumers understand, compare and select available health insurance products. Furthermore, they have extensive experience, having served as an 

additional channel for consumers to shop for and enroll in public exchange coverage 

(specifically with respect to Federally-facilitated Exchange), and as a shopping and 

enrollment portal for off-exchange health insurance products. 

AWHIB recommends the following changes to promote broad access in a reformed 

market: 

• Promote Consumer Choice in Enrollment Venue—AWHIB recommends that consumers be able to shop for and enroll in health insurance coverage in any online 

portal that meets Federal or state requirements, including a public exchange, 

WBE/private exchange or carrier portal. This will provide consumers with 

greater choice according to which type of portal best suits their needs, as each 

type of portal may provide value to different types of consumers. 

292 

• Implement Refundable Advanceable Tax Credits—As noted above, AWHIB recommends that tax incentives in a reformed marketplace be structured as refundable advanceable tax credits, as this will enable consumers to use their tax 

credits to lower the cost of health insurance premiums. Refundable advanceable 

tax credits help make health insurance more accessible for consumers than tax 

deductions. 

• Seamlessly Verify Tax Credit Eligibility—If tax credits are refundable and 

advanceable, consumers need to know whether they are eligible for the tax credit when shopping for a health plan. To support broad access to insurance, HHS 

should provide WBEs, private exchanges and carriers with access to a standalone eligibility service (SES). With SES, a WBE, private exchange or carrier 

would be able to submit tax credit application data to the Federal government 

(IRS or HHS on behalf of IRS), and then receive an official Federal eligibility 

determination—all through back-end web-services. As a result, the consumer 

could obtain a tax credit eligibility determination as part of the WBE, private 

exchange or carrier’s consumer shopping and enrollment experience, making it 

easier for consumers to access health insurance coverage. 

• Transact Enrollment Directly With Carrier—Permit WBEs and private exchanges to enroll consumers directly with the health insurance carrier, unless 

otherwise specified by a state. ACA enrollments are currently processed through 

the Exchange, even if plan selection takes place on a WBE/private exchange or 

carrier shopping platform. A more efficient and seamless process would allow 

for WBEs, private exchanges and carriers to enroll consumers directly with the 

carrier, with the carrier transmitting enrollment information with HHS for purposes of tax credit administration once the consumer has effectuated enrollment 

with the carrier. 

• Maintain Guaranteed Renewability; Implement Incentives for Continuous Coverage—Should the individual mandate be eliminated, maintain guaranteed 

reewability provisions in order to encourage consumers to maintain coverage 

and avoid enrolling in coverage only when needed. Also implement clear disincentives for incurring gaps in coverage, including late enrollment fees or waiting periods for consumers who do not maintain continuous coverage and otherwise qualify for a special enrollment period. Such measures would help to mitigate adverse selection and support risk pool health in place of an individual 

mandate. 

• Improve the Overall Health of the Insurance Market—Consider changes to improve the overall health of the insurance market, including risk mitigation 

strategies such as revised reinsurance, risk adjustment, risk corridor, and/or 

national high-risk pool programs. Also consider options to promote a broader 

range of health insurance products, including the expanded availability of 

health savings accounts. 

Conclusion 

The individual health insurance market is at a critical moment—one that will require strong leadership from HHS. AWHIB believes that short-term action is needed 

to help bring greater stability to the market and offers specific recommendations if 

broader reforms are undertaken. AWHIB looks forward to working with Congressman Price to improve the health of all Americans if confirmed by the Senate as the 

next Secretary of HHS. 

LETTER SUBMITTED BY STEVEN P. BRASCH, M.D. 

January 26, 2017 

Senate Committee on Finance 

Dirksen Senate Office Bldg. 

Washington, DC 20510–6200 

Dear Senators: 

I hereby file my OPPOSITION to the confirmation of Representative Tom Price for 

Secretary of Health and Human Services. 

Because of many of Dr. Price’s views on matters of public health, the ACA, medical 

and social services to the poor, underserviced, gay, and disenfranchised citizens of 

America, I believe he is poorly qualified to serve as our next Secretary of HHS. 

293 

Please contact me if you have any questions. 

LETTER SUBMITTED BY LESLI CHOAT, MT (ASCP) 

January 24, 2017 

U.S. Senate 

Committee on Finance 

Dirksen Senate Office Bldg. 

Washington, DC 20510–6200 

I would like to express my opposition to the Nomination of Tom Price for HHS Secretary. 

My health care career has spanned 32 years and I continue to function as STD 

Counseling and Testing Coordinator in an STD program. I was working in health 

care before HIV and hepatitis C (HCV) were identified. I am a scientist who has 

seen the great strides the United States and the world have made to test and treat 

for HIV, HCV and other infectious diseases. I saw so many die in the beginning of 

the AIDS epidemic and I am proud to see so many live healthy lives with the advances we have made in HIV care. I serve on my local HIV planning group to advance HIV prevention and care in my community. I support Planned Parenthood 

and the services they provide to so many that have no other access to health care. 

I see HCV as a looming public health threat that must be addressed. My voice 

should be heard as a citizen who works every day on the front lines of American 

Public Health! 

I oppose Representative Tom Price as HHS Secretary. I do not feel Tom Price has 

the expertise or background knowledge to run such a vital department overseeing 

so many branches of American health care. Representative Price has spent the last 

8 years undermining efforts aimed at providing health care and social services to 

communities both living with, and vulnerable to, HIV/AIDS and other health conditions. These actions include voting to repeal the Affordable Care Act (ACA) multiple 

times, pushing for the privatization Medicare, supporting to defund Planned Parenthood, pledging cuts to social service and safety net programs—all while demonstrating a hostile voting record on lesbian, gay, bisexual, transgender and queer 

(LGBTQ) issues. Throughout the recent hearing before the Senate Committee on 

Health, Education, Labor and Pensions (HELP), Price made several indications to 

continue a trend to dismantling existing systems, without details of a replacement 

that sustains access to health care and social services. 

At a time when we are at the forefront of new and exciting science to deliver better 

antiretroviral therapies for HIV, breakthroughs in cures for HIV, and pathways for 

making TB treatments shorter and more tolerable, the nomination of Tom Price 

threatens to impede the progress of both scientific research and its implementation. 

Upon confirmation, I feel Tom Price will, as promised, oversee the dismantling and 

overhaul of health care systems that are responsible for delivering many of these 

medical advances to people in the United States, particularly those communities impacted by health, social, and economic disparities as well as stigma. 

HHS is not just the department that oversees our health care system, but also governs our public health, research, and regulatory agencies, such as the Centers for 

Disease Control and Prevention (CDC), National Institutes of Health (NIH), and the 

Food and Drug Administration (FDA). The recent revelation of ethics violations and 

refusal to clearly answer questions on these issues during the Senate HELP hearing 

clouds my trust in Price to ensure the sanctity and impartiality of these agencies. 

Trust in HHS leadership is needed in prioritizing pressing public health challenges 

and countering emerging threats such as Zika, Ebola, drug-resistant TB and antimicrobial resistance through robust R&D, proactive epidemiology, pharmacovigilance, and accelerated research and response. 

Price’s worrisome background as a member of the American Academy of Physicians 

and Surgeons—an organization that promotes and endorses the theory that HIV 

does not cause AIDS, despite a substantial evidence base to the contrary—puts into 

question his capabilities to end an epidemic. Health conditions like HIV thrive on 

stigma. Price has only perpetuated stigma and marginalized vulnerable communities by voting against bills that afford protections to the LGBTQ community. With 

attention needed for other neglected populations, such as prisoners impacted by HIV 

and HCV, it becomes less likely under a Price-led HHS that key populations will 

be able to access needed health care and treatment. 

294 

With Price’s support of the repeal of ACA and efforts to defund Medicaid, the hopes 

and vision of providing health care that include ending the HIV epidemic and curbing HCV transmission among the poorest and most vulnerable Americans will vanish. 

Sincerely, 

Lesli Choat 

LETTER SUBMITTED BY RICHARD AND JILL CLAYBOUR

January 25, 2017 

U.S. Senate 

Committee on Finance 

Dirksen Senate Office Bldg. 

Washington, DC 20510–6200 

Honorable Chairman and Members of the Committee: 

We are private citizens writing to beg that you oppose confirmation of Tom Price 

as the new Secretary of Health and Human Services. 

His history of support for views with little or no foundation in science, his apparent 

willingness to leave needy sick citizens without health care and a reasonable transition to a supposed ‘‘much better’’ program are in themselves sufficient reasons in 

our eyes to disqualify him. We are shocked, however, at the continued revelations 

of his conflicts of interest and believe that in no way should these matters be swept 

under the rug. At a time when Americans have sent a clear signal of their distrust 

in Washington, we look to you to make sure that our leaders are setting an example 

of probity and conformance to the highest ethical standards. 

Thank you for your consideration. 

Sincerely, 

Richard and Jill Claybour 

LETTER SUBMITTED BY ROBERT K. DARROW

U.S. Senate 

Committee on Finance 

Dirksen Senate Office Bldg. 

Washington, DC 20510–6200 

January 27, 2017 

Senators: 

I am writing to you as a 32-year survivor, thriving and living with AIDS, and in 

opposition to President Trump’s nomination, Tom Price, for Secretary of HHS. Tom 

Price’s questionable fitness to head a multi-agency cabinet-level department charged 

with the health of U.S. residents can simply be ascertained from his own record as 

a Congressional representative to parts of Atlanta’s northern suburbs—a district 

and metro area with extremely high rates of HIV and a flourishing opioid epidemic. 

Despite the abundance of epidemiological data illustrating the impact of the HIV 

epidemic in his own district and in the southeastern United States, Representative 

Price has spent the last 8 years undermining efforts aimed at providing health care 

and social services to communities both living with, and vulnerable to, HIV and 

other health conditions. These actions include voting to repeal the Affordable Care 

Act (ACA) multiple times, pushing for the privatization of Medicare, threatening to 

cap and block-grant Medicaid, supporting to defund Planned Parenthood, pledging 

cuts to social service and safety net programs—all while demonstrating a hostile 

voting record on lesbian, gay, bisexual, transgender and queer (LGBTQ) issues. 

Throughout the recent hearing before the Senate Committee on Health, Education, 

Labor and Pensions (HELP), Price made several indications to continue a trend to 

dismantling existing systems, without details of a replacement that sustains access 

to health care and social services. 

295 

At a time when we are at the forefront of new science to deliver better antiretroviral 

therapies for HIV, breakthroughs in cures for HCV, and pathways for making TB 

treatments shorter and more tolerable, the nomination of Tom Price threatens to 

impede the progress of both research and implementation. Upon confirmation, Tom 

Price will, as promised, oversee the dismantling and overhaul of health care systems 

that are responsible for delivering many of these medical advances to people in the 

United States, particularly those communities impacted by health, social and economic disparities as well as stigma. 

Before the ACA, hundreds of people every year were waitlisted for the AIDS Drug 

Assistance Program (ADAP). People living with HIV (PLHIV) would need an AIDS 

diagnosis to be eligible for Medicaid. Pre-existing conditions would also disqualify 

many PLHIV from gaining insurance. While the ACA is not perfect, thousands of 

PLHIV have been transitioned onto insurance through marketplaces and have become eligible for Medicaid benefits. This has provided many with access to comprehensive health care for the first time, with profound effects on public health and 

prevention outcomes. Much of the success we’re seeing in increasing viral suppression rates and reducing the number of diagnoses annually will be put in jeopardy 

if the ACA is repealed without replacement. Without replacement and stewardship 

by the incoming Secretary of Health and Human Services, access to treatment, prevention and other services will remain out of reach for many of these communities. 

HHS is not just the department that oversees our health care system, but also governs our public health, research, and regulatory agencies, such as the Centers for 

Disease Control and Prevention (CDC), Indian Health Services (IHS), National Institutes of Health (NIH), and the Food and Drug Administration (FDA). The recent 

revelation of ethics violations and refusal to clearly answer questions on these 

issues during the Senate HELP hearing clouds any trust in Price to ensure the 

sanctity and impartiality of these agencies. Trust in HHS leadership is needed in 

prioritizing pressing public health challenges, ensuring drug and device safety, and 

countering emerging threats such as Zika, Ebola, drug-resistant TB, and antimicrobial resistance through robust R&D, proactive epidemiology, pharmacovigilance, and accelerated research and response. 

Price’s worrisome background as a member of the American Academy of Physicians 

and Surgeons—an organization that promotes and endorses the theory that HIV 

does not cause AIDS, despite a substantial evidence base to the contrary—puts into 

question his capabilities to end an epidemic. Health conditions like HIV thrive on 

stigma. Yet, Price has only perpetuated stigma and marginalized vulnerable communities by voting against bills that afford protections to the LGBTQ community. 

With attention needed for other neglected populations, such as prisoners impacted 

by HIV and HCV, it becomes less likely under a Price-led HHS that key populations 

will be able to access health care and treatment. 

Now more than ever, ending the epidemics of HIV, TB, and HCV requires a combination of bipartisan federal and state leadership, evidence-based policies, and adequate resources in proper alignment to deliver the promise of biomedical and public 

health advances. Efforts to lower drug prices for HIV and HCV while sustaining 

U.S. leadership in R&D for TB and other neglected diseases remain inevitable challenges to the successor of HHS and the Trump administration. Tom Price, however, 

remains a concerning and unqualified candidate to lead HHS given a track record 

that only marginalizes communities, raises questions on his ethics and integrity to 

run an expansive $1 trillion department, and putting forth policy proposals that 

seek to fast-track the loss of lifesaving health care for 18 million Americans. Ending 

the epidemics remains impossible by destroying access to health care and treatment. 

With Price’s support of the repeal of ACA and efforts to defund Medicaid, the hopes 

and vision of providing health care—including ending the HIV epidemic, curbing 

HCV transmission, eliminating TB—among the poorest, sickest, most disenfranchised, most vulnerable Americans will vanish. 

Respectfully, 

Robert K. Darrow, executive director emeritus 

The Philadelphia Center—Shreveport 

LETTER SUBMITTED BY ANGELA WILSON GYETVAN

January 19, 2017 

U.S. Senate 

296 

Committee on Finance 

Dirksen Senate Office Bldg. 

Washington, DC 20510–6200 

Dear Committee Members: 

I am writing in regards to the Full Committee Hearing for the Nomination of Tom 

Price to serve as Secretary of Health, held January 18, 2017. 

I object to Mr. Price’s nomination on the following grounds: 

(1) Potential ethics violations: There is evidence that Mr. Price invested in at 

least one health-care company, then introduced legislation favorable to the 

company after he made the investment. At the very least, this is a violation 

of House ethics rules. At the most, it is insider trading—and must be investigated before any confirmation. 

(2) Conflicts of interest: Price holds positions in multiple healthcare companies, 

and must divest or put those holdings into a blind trust prior to any confirmation. He also has ties to the tobacco industry—smoking is the leading cause 

of preventable death!—and has consistently voted against tobacco regulation 

as a result. 

(3) Non-support for social safety net and general lack of compassion: Price supports the roll-back of Medicare and Medicaid, the repeal of the Affordable 

Care Act, and blocked the expansion of the Children’s Affordable Health program. He even voted to block medical treatment if a Medicare co-pay is not 

available: a position that is directly opposed to the Hippocratic Oath he took 

when he became a doctor. 

(4) Track record on women’s and LGBTQ rights: Price supports overturning Roe 

v. Wade and has voted against legislation that prevents discrimination based 

on sexual orientation. 

The Health Secretary needs to be a representative for all of us. Mr. Price is not that 

person. 

Thank you. 

Angela Wilson Gyetvan 

HUMAN RIGHTS CAMPAIGN

1640 Rhode Island Ave., NW 

Washington, DC 20036 P 202–628–4160 

F 202–423–2861 http://www.hrc.org/ 

Written Statement of David Stacy 

Government Affairs Director 

I submit this testimony on behalf of the Human Rights Campaign’s 2 million members and supporters. As the nation’s largest organization advocating for the civil 

rights of lesbian, gay, bisexual, transgender, and queer (LGBTQ) people, I raise severe concerns regarding the ability of Representative Tom Price to serve and represent the health and well-being of all Americans as Secretary of the Department 

of Health and Human Services (HHS). Representative Price has developed a lengthy 

public record attacking LGBTQ people and every hard-fought victory that we have 

achieved as a community in recent years. He has used his position as a Congressman elected to represent Georgia voters as a national platform to deny federal 

rights—including protection from violence—for LGBTQ people nationwide. 

Representative Price has consistently voted against critical pieces of legislation that 

would protect LGBTQ people including the Employment Nondiscrimination Act 

(ENDA), the Matthew Shepard and James Byrd, Jr. Hate Crimes Prevention Act, 

and the 2013 reauthorization of the Violence Against Women Act (VAWA). Beyond 

these votes, Representative Price has publicly spoken against equality, regularly 

partnering with groups known for promoting anti-LGBTQ views—using the privilege of his position to spread intolerance and misinformation. He has even argued 

that legislation like ENDA, designed to protect vulnerable workers and promote 

equal opportunity, would have ‘‘remarkably negative’’ consequences and should be 

evaluated for the medical and health-care costs of ‘‘promoting a homosexual lifestyle.’’ I must clarify that the real impact of nondiscrimination provisions on health 

297 

and well-being of LGBTQ people are remarkably positive, to use Representative 

Price’s descriptor. 

We know that systemic discrimination in employment, housing, health care, and 

education increases the risk of poverty and compounds the health disparities already facing our community. Fear of discrimination deters many LGBTQ people 

from seeking necessary and important preventative health care, and when they do 

enter care, studies indicate that the respect that LGBTQ people receive is not consistent with the respect that all patients deserve. Recent studies have shown that 

transgender people are particularly at risk for discrimination—especially in the 

health-care setting. One third of transgender people seeking care reported experiencing discrimination, harassment, assault, or even denial of care simply because 

of their gender identity. One in four transgender people avoided care altogether 

fearing discrimination. Nondiscrimination provisions provide individuals and families with the security they need to lead full and productive lives. They also increase 

access to insurance coverage and reduce incidents of arbitrary denial of care based 

on bias. 

It is critical that healthcare facilities treat every patient with respect, recognize patients’ gender identity, and provide equal access to gender appropriate facilities 

while providing treatments. This basic standard of care is embraced by major medical establishments and organizations including the American Academy of Pediatrics 

and the American Counseling Association. These groups have made it clear that this 

access is not just an issue of civil rights, but also public health. However, Representative Price has directly attacked transgender people’s rights to access appropriate 

facilities calling this most basic right ‘‘absurd.’’ This dismissal of basic rights and 

welfare is deeply disturbing. 

Since joining Congress, Representative Price has failed to adequately represent the 

nearly 10,000 LGBTQ Georgians living in his district. He has consistently refused 

to recognize them as deserving constituents and has failed to represent even their 

most basic needs to Washington. Representative Price’s repeated choice to place his 

personal anti-LGBTQ ideology ahead of this significant portion of his own Congressional district calls into question his ability and true willingness to serve all Americans as Secretary of HHS. This role demands a public servant dedicated to improving health-care coverage and outcomes for all people, not a culture warrior with an 

outdated and dangerous agenda. 

We are also concerned by Representative Price’s longstanding opposition to the Affordable Care Act (ACA). The ACA is a critical tool to combat the stark disparities 

facing our community by expanding access to coverage and ensuring that everyone— 

regardless of who they are or who they love—has access to the care they need. The 

federal government has published regulations implementing the nondiscrimination 

provision of the ACA to explicitly protect individuals on the basis of gender identity 

or sex stereotyping. These protections are critical for some of the most vulnerable 

members of our community. This rule also makes clear to providers that transgender patients must be treated consistent with their gender identity, including 

with respect to facilities and patient rooms. The regulation also prohibits the categorical exclusions in insurance coverage that have plagued the transgender community for so long and have put basic transition related care out of the reach of 

so many. 

Because of the ACA, many LGBTQ people have access to comprehensive health-care 

coverage for the first time. This security and assurance of quality care without discrimination can be life changing. Representative Price’s clear commitment to dismantling the ACA and his hostility towards nondiscrimination provisions generally 

could seriously undermine the health-care outcomes for our community for years to 

come. 

Finally, as Secretary of HHS, Representative Price will be charged with leading one 

of the world’s largest medical and health research organizations—overseeing the 

Centers for Disease Control and Prevention as well as the National Institutes for 

Health. He will also lead administrations and sub-agencies like the Substance 

Abuse and Mental Health Services Administration (SAMSHA) that has published 

cutting edge research impacting the LGBTQ community including a report addressing the well-established medical harms of so-called ‘‘conversion therapy.’’ However, 

Representative Price has done little throughout his career as a Congressman or as 

a physician to prove his commitment—or even belief—in evidence based science. 

Representative Price is a longstanding member of the Association of American Physicians and Surgeons, a fringe organization that publicly questions well-established 

298 

public health concepts including childhood vaccination and the safety or abortion. 

Perhaps most troubling for our community is the organization’s suggestion that HIV 

does not in fact lead to AIDS. Although Representative Price has stated that he does 

not personally hold this view regarding HIV/AIDS, his continued association with 

an organization that is so clearly anti-science is deeply disturbing. As Secretary of 

HHS Representative Price will be called on to be a research visionary, committed 

to science and to pursing answers to the nation’s most complex health questions 

with dedicated compassion. Absolutely nothing in Representative Price’s record 

shows that he is up to this job. 

LEADINGAGE

2519 Connecticut Ave., NW 

Washington, DC 20008–1520 P 202–783–2242 

F 202–783–2255 http://leadingage.org/ 

January 24, 2017 

Dear Senator: 

LeadingAge is a nonprofit aging services association. Our 6,000+ members and partners include nonprofit organizations representing the entire field of aging services, 

39 state partners, hundreds of businesses, consumer groups, foundations, and research partners. Among our members, we count more than 2,000 nonprofit nursing 

homes, either as free-standing nursing homes, or as a component of a multi-level 

community. According to GAO, nonprofit nursing homes tend to have higher staffing 

ratios and are more likely to be higher quality as rated by the CMS 5-star system. 

CMS recently issued a final rule implementing new requirements for participation 

for nursing homes in the Medicare and Medicaid programs. This 105-page rule adds 

new requirements, mandates previously voluntary provisions such as corporate compliance programs, and revises requirements currently in effect. 

As you consider the nominations of Representative Tom Price for Secretary of HHS 

and Seema Verma for Administrator of CMS, we urge you to address the following 

concerns. 

LeadingAge strongly supports high quality for nursing homes and transparent 

standards. Our community based, nonprofit providers are a vital element of the 

post-acute and long-term care continuum, and are often recognized as exemplars of 

person-centered care and quality. We support many aspects of these new regulations, including the focus on person-centered care. In fact, prior to the enforcement 

date of the new regulations, our members were actively engaged in the process of 

integrating the components of Compliance and Ethics, and Quality Assurance Process Improvement (QAPT) into their day-to-day operations. 

However, we are gravely concerned about the broad scope of these new regulations 

(stated by CMS to be the most significant changes to nursing home regulation since 

1991), as well as the incredibly short time frame by which providers must comply. 

We submitted extensive comments to CMS during the regulatory comment period 

on the content of the regulations including a particular concern about having sufficient time to implement. We are also participating as stakeholders in the various 

meetings and calls conducted by CMS. To date, the agency has not been responsive. 

Specifically, we have particular concerns about the following aspects: 

(1) Workforce: Many sections of the regulations require new staffing or changes 

to the training and competencies of existing staff. Some of these went in to 

effect November 28, 2016 less than 2 months after the final rules were published. Providers were expected to comply immediately with the requirements, 

but given little guidance as to these competencies. This left insufficient time 

for providers to develop the necessary skills training and assessments to comply with the new requirements. And lastly, many rural communities have a 

workforce shortage and simply do not have sufficient numbers of workers to 

employ to meet these regulations. 

(2) Delayed Guidance: CMS normally develops written guidance explaining the 

regulations, provides definitions and instructions for implementation, and 

identifies resources for training. However, it has failed to do so for many of 

the new policies and procedures that went into effect in November, or for the 

new systems that must be in place later this year. 

299 

(3) Guidance Going Beyond Regulatory Language: Where draft guidance has 

been shared with stakeholder groups, there is considerable concern that this 

guidance goes well beyond the scope of the actual regulations and thus creates 

a whole new set of compliance requirements for enforcement that are not defined in regulation. Guidance that exceeds the regulations but is enforced like 

regulations should not be enforceable. 

(4) Timing: As stated above, the extremely short time frames required for compliance create impossible burdens for many providers, particularly for those 

smaller and rural providers. The risk is therefore that many of these vital 

community-based homes will close, rather than face severe enforcement penalties. When these homes close, the negative impact on the community is 

widespread: Vulnerable residents often are displaced and providers—who are 

often the primary employer in that community—lose their jobs. 

Implementation of broad regulations that impose unrealistic time frames, fail to recognize the negative impact in a challenging workforce environment, and for which 

guidance and resources have not yet been thoroughly considered or shared with the 

very providers who will be expected to comply, can only set up providers for failure. 

This will negatively impact patients and communities for years to come. 

We ask for a thoughtful evaluation of these new regulations and a realistic time 

frame by which providers are able to comply. 

Thank you for your consideration. 

Sincerely, 

Katie Smith Sloan 

President and CEO 

LeadingAge 

LETTER SUBMITTED BY DEBBIE MURZYN

January 24, 2017 

Dear Senate Finance Committee: 

I oppose the nomination of Tom Price for the Secretary of Health and Human Services. I request that you oppose President Trump’s pick and challenge his nomination. Tom Price’s questionable fitness to head a multi-agency cabinet-level department charged with the health of U.S. residents can simply be ascertained from his 

own record as a Congressional representative to parts of Atlanta’s northern suburbs—a district and metro area with extremely high rates of HIV and a flourishing 

opioid epidemic. Despite the abundance of epidemiological data illustrating the impact of the HIV epidemic in his own district and in the Southeastern United States, 

Representative Price has spent the last 8 years undermining efforts aimed at providing health care and social services to communities both living with, and vulnerable to, HIV and other health conditions. These actions include voting to repeal the 

Affordable Care Act (ACA) multiple times, pushing for the privatization Medicare, 

threatening to cap and block-grant Medicaid, supporting to defund Planned Parenthood, pledging cuts to social service and safety net programs—all while demonstrating a hostile voting record on lesbian, gay, bisexual, transgender, and queer 

(LGBTQ) issues. Throughout the recent hearing before the Senate Committee on 

Health, Education, Labor and Pensions (HELP), Price made several indications to 

continue a trend to dismantling existing systems, without details of a replacement 

that sustains access to health care and social services. 

At a time when we are at the forefront of new science to deliver better antiretroviral 

therapies for HIV, breakthroughs in cures for HCV, and pathways for making TB 

treatments shorter and more tolerable, the nomination of Tom Price threatens to 

impede the progress of both research and implementation. Upon confirmation, 

Tom Price will, as promised, oversee the dismantling and overhaul of 

health care systems that are responsible for delivering many of these medical advances to people in the United States, particularly those communities impacted by health, social and economic disparities as well as stigma. 

Before the ACA, hundreds of people every year were waitlisted for the AIDS Drug 

Assistance Program (ADAP). People living with HIV (PLHIV) would need an AIDS 

diagnosis to be eligible for Medicaid. Pre-existing conditions would also disqualify 

300 

many PLHIV from gaining insurance. While the ACA is not perfect, thousands of 

PLHIV have been transitioned onto insurance through marketplaces and have become eligible for Medicaid benefits. This has provided many with access to comprehensive health care for the first time, with profound effects on public health and 

prevention outcomes. Much of the success we’re seeing in increasing viral suppression rates and reducing the number of diagnoses annually will be put in jeopardy 

if the ACA is repealed without replacement. Without replacement and stewardship by the incoming Secretary of Health and Human Services, access to 

treatment, prevention and other services will remain out of reach for many 

of these communities. 

HHS is not just the department that oversees our health care system, but also governs our public health, research, and regulatory agencies, such as the Centers for 

Disease Control and Prevention (CDC), Indian Health Services (IHS), National Institutes of Health (NIH), and the Food and Drug Administration (FDA). The recent 

revelation of ethics violations and refusal to clearly answer questions on 

these issues during the Senate HELP hearing clouds any trust in Price to 

ensure the sanctity and impartiality of these agencies. Trust in HHS leadership is needed in prioritizing pressing public health challenges, ensuring drug and 

device safety, and countering emerging threats such as Zika, Ebola, drug-resistant 

TB, and antimicrobial resistance through robust R&D, proactive epidemiology, 

pharmacovigilance, and accelerated research and response. 

Price’s worrisome background as a member of the American Academy of 

Physicians and Surgeons—an organization that promotes and endorses the 

theory that HIV does not cause AIDS, despite a substantial evidence base 

to the contrary—puts into question his capabilities to end an epidemic. 

Health conditions like HIV thrive on stigma. Yet Price has only perpetuated stigma 

and marginalized vulnerable communities by voting against bills that afford protections to the LGBTQ community. With attention needed for other neglected populations, such as prisoners impacted by HIV and HCV, it becomes less likely under 

a Price led HHS that key populations will be able to access health care and treatment. 

Now more than ever, ending the epidemics of HIV, TB, and HCV requires a combination of bipartisan federal and state leadership, evidence-based policies, and adequate resources in proper alignment to deliver the promise of biomedical and public 

health advances. Efforts to lower drug prices for HIV and HCV while sustaining 

U.S. leadership in R&D for TB and other neglected diseases remain inevitable challenges to the successor of HHS and the Trump administration. Tom Price, however, 

remains a concerning and unqualified candidate to lead HHS given a track record 

that only marginalizes communities, raises questions on his ethics and integrity to 

run an expansive $1 trillion department, and putting forth policy proposals that 

seek to fast-track the loss of lifesaving health care for 18 million Americans. Ending 

the epidemics remains impossible by destroying access to health care and treatment. 

With Price’s support of the repeal of ACA and efforts to defund Medicaid, 

the hopes and vision of providing health care—including ending the HIV 

epidemic, curbing HCV transmission, eliminating TB—among the poorest, 

sickest, most disenfranchised, most vulnerable Americans will vanish. 

Thank you for your time. 

Debbie Murzyn 

NATIONAL CENTER FOR LESBIAN RIGHTS (NCLR) 

1100 H Street, NW, Suite 540 

Washington, DC 20005 

January 25, 2017 

The Honorable Orrin Hatch The Honorable Ron Wyden 

Chairman Ranking Member 

U.S. Senate U.S. Senate 

Committee on Finance Committee on Finance 

104 Hart Senate Office Building 221 Dirksen Senate Office Building 

Washington, DC 20510 Washington, DC 20510 

The Honorable Lamar Alexander The Honorable Patty Murray 

Chairman Ranking Member 

301 

1http://www.rightwingwatch.org/post/rep-tom-price-fears-negative-health-and-economic-impacts-of-gay-rights-bills/. 2https://www.facebook.com/reptomprice/posts/10154118633590421. 

3http://www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF. 

U.S. Senate U.S. Senate 

Committee on Health, Education, Labor, 

and Pensions 

Committee on Health, Education, Labor, 

and Pensions 

455 Dirksen Senate Office Building 154 Russell Senate Office Building 

Washington, DC 20510 Washington, DC 20510 

Dear Chairman Hatch, Ranking Member Wyden, Chairman Alexander, and Ranking 

Member Murray: 

The National Center for Lesbian Rights (NCLR) writes to oppose the nomination of 

Representative Tom Price as Secretary of Health and Human Services (HHS). We 

have grave concerns that Representative Price will not work toward HHS’s goal of 

enhancing and protecting the health and well-being of all people. 

It is imperative that the person chosen to lead the Department of Health and 

Human Services demonstrate a commitment to health-care access and science-based 

public health and health-care policy. This important federal official must also be 

free from discriminatory or hostile attitudes toward minority and vulnerable groups, 

and administer our critical health-care programs free from ideological bias. Representative Price’s record as a legislator casts serious doubt on his ability to perform 

this role. 

Representative Price’s Opposition to LGBT Equality 

Representative Price has espoused negative views of LGBT people, who have only 

in recent years begun to achieve critical protections for our health and relationships. 

In 2013, on a conference call, Representative Price was asked if Congress should be 

required to consider the ‘‘fiscal impact’’ of legislation involving LGBT people because 

of the supposed health and economic costs of LGBT people’s so-called ‘‘lifestyles.’’ He 

stated that was ‘‘absolutely right,’’ and that ‘‘the consequences of activity that has 

been seen as outside the norm are real.’’ 1 Representative Price is also a member 

of the Association of American Physicians and Surgeons, which supports conversion 

therapy and calls transgender identity a pathology. 

In May of 2016, the Departments of Justice and Education issued guidance to 

schools on title IX clarifying that the law protects transgender students and requires that they be treated consistent with their gender identity in schools. Representative Price responded with a Facebook post that the guidance was ‘‘absurd.’’ 2

Such an attitude calls into question his ability to enforce essential health care nondiscrimination protections. In a 2015 national survey,3 3% of transgender people 

who had gone to a doctor or a hospital had been turned away because of who they 

are. In that same survey, 23% of transgender people nationally said they had avoided getting care when they were sick or injured because they were afraid of that kind 

of discrimination. Section 1557 of the Affordable Care Act (ACA) prohibits discrimination in health-care programs or activities on the basis of race, color, national origin, sex, age, or disability. This is the first time that federal law has broadly prohibited sex discrimination in health care. Health insurers, hospitals, clinics, and any 

other entities that receive federal funds are covered by this law. Prior to section 

1557, there were no broad federal protections against sex discrimination in health 

care or health insurance. The regulations implementing this important provision 

that were issued last year state that prohibited sex discrimination includes discrimination based on gender identity and sexual orientation. These critical protections 

would not exist if the ACA had not been enacted or were repealed, as Representative Price has repeatedly voted to do. Representative Price’s plan to replace the 

ACA, the Empowering Patients First Act, did not include a similar prohibition on 

discrimination in health care programs on the basis of sex. 

Representative Price has also co-sponsored the ‘‘First Amendment Defense Act,’’ considered by many to be the most sweeping anti-LGBT bill in Congress as it would 

establish sweeping new religious accommodations that would seriously harm legal 

rights and protections for millions of Americans and permit unprecedented types of 

discrimination against LGBT individuals, same-sex couples, and others. Its aim is 

to enable a wide range of ‘‘persons’’—defined in the bill to include government employees, recipients of government grants and contracts, and even for-profit businesses—to violate constitutional or statutory law so long as the violation is based 

on a sincerely held religious belief about marriage or sexual relationships. 

302 

4https://www.congress.gov/crec/2007/05/22/CREC-2007-05-22-pt1-PgH5560.pdf. 

5https://www.nlchp.org/documents/ID_Barriers. 6http://williamsinstitute.law.ucla.edu/wp-content/uploads/Durso-Gates-LGBT-HomelessYouth-Survey-July-2012.pdf. 7https://www.congress.gov/crec/2010/12/15/CREC-2010-12-15.pdf. 

8https://tomprice.house.gov/press-release/price-responds-scotus-marriage-ruling. 

In 2007, Representative Price offered an amendment to Federal Housing Finance 

Reform Act that required all adults in a household to present specific forms of identification before they could receive assistance through affordable housing grants.4

Such a law presents a significant barrier to homeless persons because they often 

lack these types of identification.5 Given that homelessness has become a critical 

issue for those in the LGBT community,6 we cannot support a nominee who actively 

works to build barriers to safe shelter for those in need. 

We are further concerned by Representative Price’s record of opposing the repeal of 

Don’t Ask, Don’t Tell,7 legislation that would ban employment discrimination on the 

basis of sexual orientation, and LGBT hate crimes protections, as well as his continued opposition to the Supreme Court’s recognition that the Constitution requires 

equal protection of LGBT people, including with respect to marriage.8

Representative Price’s Opposition to Reproductive Health Care 

Representative Price’s consistent opposition to reproductive health care for women 

also raises serious concerns. Despite access to birth control being widely recognized 

as one of the most important public health achievements of the 20th century, resulting in improved health and safety for millions of women, Representative Price has 

consistently opposed the publicly funded family planning network, the title X program, the contraception benefit under the Affordable Care Act, and the Medicaid 

program’s family planning freedom-of-choice provision, while seeking to bar Planned 

Parenthood from receiving critical federal funding even for health care services entirely unrelated to abortion and despite the dependence of millions of low-income 

women on those services. 

Representative Price has co-sponsored legislation that would define life at conception, which would outlaw abortion entirely, along with several of the most effective 

and widely used forms of birth control, and prohibit in vitro fertilization. Representative Price also sponsored legislation in Georgia that would require health-care providers to give medically inaccurate information to patients seeking abortion. 

Ideological opposition to contraception and abortion, and the use of misinformation 

to reduce access to these essential reproductive health-care services, renders Representative Price unfit to hold the position as the head of our nation’s public health 

care infrastructure. 

Representative Price’s Opposition to Protecting Access to Healthcare 

As a member of Congress, Representative Price has proposed a ‘‘replacement’’ for 

the ACA that would strip coverage from millions of Americans, including LGBT people and their families. Under Representative Price’s plan, LGBT people would lose 

not only nondiscrimination protections (described above) but also health-care coverage they can only afford because of the law. 

Representative Price’s alternative legislation would allow insurers to dramatically 

raise premiums for some people with pre-existing medical conditions, including HIV/ 

AIDS, which would have a dramatic impact on gay and bisexual men. His plan 

would also fully repeal the Medicaid expansion, a provision of the ACA that extended Medicaid coverage to people making less than approximately $16,000 per 

year. Because of employment discrimination that pushes many LGBT people into 

unemployment or low-wage jobs that do not offer health insurance, LGBT people are 

disproportionately likely to need alternatives such as Medicaid. Representative 

Price’s ACA alternative would also decimate federal funding for HIV/AIDS treatment. 

For the foregoing reasons, we oppose the nomination of Representative Tom Price 

to lead the Department of Health and Human Services. 

Sincerely, 

National Center for Lesbian Rights 

303 

LETTER SUBMITTED BY MARILYN D. QUINN

January 24, 2017 

Re: The potential appointment of Tom Price to be Secretary of HHS 

Dear Committee Members, 

As a citizen and a woman who will soon be 70, I want to tell you what I think about 

the nomination of Congressman Tom Price for Secretary of HHS and some of the 

health-care issues that are important to me, my family, my friends, and to all Americans. I was able to watch some of his hearing, and I have read some of his statements concerning health care and health insurance. 

(1) Obamacare: 

My 36-year-old working daughter was finally able to get health insurance due 

to Obamacare. As a resident of New York State, she was also able to pick her coverage from a state-endorsed exchange. I tried to help her get insurance before 

Obamacare, I called health insurers who would have charged twice the amount she 

finally paid for a policy after passage of the ACA. She also has a pre-existing condition (asthma), and her employer does not offer health insurance. 

We are afraid of a future without the ACA. I believe that the ACA was damaged by two actions during its enactment: (1) the removal of the coverage mandate and (2) the removal of the ‘‘public option.’’ These would have created a bigger pool of insured and would have provided insurance for those who are too poor 

to pay the coverage fees. These two provisions were killed by the Republicans 

(and a few misguided Democrats under pressure from people with the wrong information). 

I say, ‘‘Fix it.’’ Don t kill it. 

This country would be spending less on health care if it considered it to be a right 

for all American citizens, as it is in many other nations. I believe that singlepayer Medicare for all would create the kind of broad pool necessary to keep costs 

down for patients and providers alike, as it does in most other developed countries. 

Imagine how much less time and money it would take for the government and the 

nation’s medical offices to administer the policies. Imagine how much less it would 

cost if everyone had access to affordable preventive care. I keep hearing that the 

potential problem with ‘‘single payer’’ is the ensuing difficulty for many doctors and 

hospitals to make more money off their patients. (Why not reward those who successfully improve their patients’ lives or fill the needs of the under-served and those 

who are unlucky enough to live in impoverished urban deserts?) 

I believe firmly also that many of the people I know who would love to change jobs, 

or love to move to another state for work or study, or want to start their own business, perhaps by working from home as entrepreneurs, would also benefit by having 

a policy that is affordable and portable. My best friend started a business in Europe where health care was available for everyone, regardless of employment, place 

of domicile, and income. 

Too much time, stress, and money go into the intricacies, changes, and details 

regarding insurance, which consume and direct the courses of our lives. This is a 

waste for all citizens and ultimately for our government. 

It is advantageous for citizens to learn the truth about all of this. People should 

know that if they help pay for the health care of everyone else, not just themselves, 

both the country and themselves will benefit. 

(2) Access to affordable contraception and legal abortion: 

I need only point out how these benefits to women have saved many lives and improved the health of women and their families. Pregnancy and childbirth wreak 

many changes on a woman’s body, some of them deadly. Illegal abortion, of course, 

is dangerous. The protection of the right to a safe abortion should not be weakened 

by those who follow religious dogmas or unscientific views of pregnancy and the 

medical procedures used in modern America. I know women who suffered great indignities in the 1960s (e.g., transport in the trunk of a car) and dangers (e.g., inserting sharp objects into the vagina or ingesting poison) before the passing of Roe v. 

Wade. Women will always be willing to do these things in order to control their destinies. 

For many years, I have been protecting access to clinics and doctors who bravely 

give women the service they need to reduce their family’s size, or to complete a colVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00307 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
304 

lege education, or to take a job that would be impossible without affordable quality 

childcare. This country was founded on freedom of and from religion. We need 

to respect that right, which formed the basis of our country’s beginnings. Someone’s 

religious beliefs should not be used to deny another woman even minimal access to 

these basic needs. The lives of individual women and of their family members 

should be respected no matter how much their religious belief differs with 

regard to definitions of life, personhood, female versus male, sexual preferences and activities, and health conditions. There is no 100% effective form 

of birth control, but many of them work well enough to permit modern women sexual fulfillment, wider career choice, and a healthier body for starting a family when 

she is ready and willing. 

One other aspect of reproductive choice should be included in the work of the HHS. 

The United States must cooperate with organizations and help other nations 

in need of assistance to provide contraception, childcare, health care, and 

safe abortion access. When women have these benefits, they become more economically productive, better mothers, and better able to counter the actions of autocratic or theocratic governments. The world’s environment would also benefit from 

the amelioration of the effects of overpopulation, the resulting pollution, and increasing warfare over necessities for life. 

Thank you for listening. I was one of those many, many individuals, along with my 

husband and daughter, who marched in Washington on January 21st. If I must, I 

will return, and I will march, write, and put my money toward keeping women’s 

healthcare and reproductive choices free from misinformed or misogynistic people in 

power. I will speak out against anyone who tries to take away any person’s right 

to affordable health care and reproductive choice. 

Sincerely, 

Marilyn D. Quinn 

LETTER SUBMITTED BY STACEY RAVANESI

To: Senate Finance Committee 

Date: January 24, 2017 

I am in deeply concerned about the nomination of Representative Tom Price (R–GA) 

for Secretary of Health and Human Services (HHS). As a matter of fact I am intensely opposed to his nomination. I strongly request the Senate Finance Committee 

to challenge his nomination to helm an agency that plays an exceedingly important 

and complex role in ending the certain epidemics in the United States and around 

the world. Individuals impacted by HIV, tuberculosis (TB), hepatitis C (HCV), and 

other infections; their families and their communities could face serious and often 

deadly consequences if someone with Representative Price’s agenda leads this vital 

multi-agency cabinet-level department. 

Representative Price’s questionable suitability to head HHS and be ultimately responsible for policies that directly affect the health of U.S. residents can simply be 

ascertained from his own record as a congressional representative to parts of Atlanta’s northern suburbs—a district and metro area with extremely high rates of HIV 

and a flourishing opioid epidemic. Despite the abundance of epidemiological data illustrating the impact of the HIV epidemic in his own district and in the Southeastern United States, Representative Price has spent the last 8 years undermining 

efforts aimed at providing health care and social services to communities both living 

with, and vulnerable to, HIV and other health conditions. These actions include voting to repeal the Affordable Care Act (ACA) multiple times, pushing for the privatization of Medicare, threatening to cap and block-grant Medicaid, supporting to 

defund Planned Parenthood, pledging cuts to social service and safety net programs—all while demonstrating a hostile voting record on lesbian, gay, bisexual, 

transgender, and queer (LGBTQ) issues. Throughout the recent hearing before the 

Senate Committee on Health, Education, Labor, and Pensions (HELP), Price made 

several indications to continue a trend to dismantling existing systems, without details of a replacement that sustains access to health care and social services. 

At a time when we are at the forefront of new science to deliver better antiretroviral 

therapies for HIV, breakthroughs in cures for HCV, and pathways for making TB 

treatments shorter and more tolerable, the nomination of Representative Price 

threatens to impede the progress of both research and implementation. Upon conVerDate Sep 11 2014 21:12 May 16, 2018 Jkt 000000 PO 00000 Frm 00308 Fmt 6601 Sfmt 6621 R:\DOCS\30005.000 TIM
305 

firmation, Representative Price will, as promised, oversee the dismantling and overhaul of health-care systems that are responsible for delivering many of these medical advances to people in the United States, particularly those communities impacted by health, social, and economic disparities. 

HHS is not just the department that oversees our health-care system, but also governs our public health, research, and regulatory agencies, such as the Centers for 

Disease Control and Prevention (CDC), Indian Health Services (IHS), National Institutes of Health (NIH), and the Food and Drug Administration (FDA). The recent 

revelation of ethics violations and refusal to clearly answer questions on these 

issues during the Senate HELP hearing clouds any trust in Representative Price to 

ensure the sanctity and neutrality of these agencies. Trust in HHS leadership is 

needed in prioritizing pressing public health challenges, ensuring drug and device 

safety, and countering emerging threats such as Zika, Ebola, drug-resistant TB, and 

Gonorrhea, infant mortality increases from infections such as congenital Syphilis, 

and antimicrobial resistance through robust R&D, proactive epidemiology, pharmacovigilance, and accelerated research and response. 

Representative Price’s worrisome background as a member of the American Academy of Physicians and Surgeons—an organization that promotes and endorses the 

theory that HIV does not cause AIDS, despite a substantial evidence base to the 

contrary—puts into question his capabilities to end an epidemic. Health conditions 

like HIV thrive on stigma. Yet Price has only perpetuated stigma and marginalized 

vulnerable communities by voting against bills that afford protections to the LGBTQ 

community. With attention needed for other neglected populations, such as prisoners impacted by HIV, HCV, and TB; it becomes less likely under a Price-led HHS 

that key populations will be able to access health care and treatment. 

Now more than ever, ending public health epidemics requires a combination of bipartisan federal and state leadership, evidence-based policies, and adequate resources in proper alignment to deliver the promise of biomedical and public health 

advances. Efforts to lower drug prices while sustaining U.S. leadership remain inevitable challenges to the successor of HHS and the Trump administration. Representative Price, however, remains a concerning and unqualified candidate to lead HHS 

given a track record that only marginalizes communities, raises questions on his 

ethics and integrity to run an expansive $1 trillion department, and putting forth 

policy proposals that seek to fast-track the loss of lifesaving health care for 18 million Americans. Ending the epidemics remains impossible by destroying access to 

health care and treatment. With Representative Price’s support of the repeal of ACA 

and efforts to defund Medicaid, the hopes and vision of providing health care among 

the poorest, sickest, most disenfranchised, most vulnerable Americans will vanish. 

The practice of slashing proven best public health practices from the most helpless 

Americans is shameful and morally horrendous, while also stigmatizing populations 

that have been historically marginalized throughout American history. Therefore, I 

am begging please do NOT confirm Representative Price for Secretary of HHS. 

Thank you. 

Stacey Ravanesi 

LETTER SUBMITTED BY INDU SUBAIYA, M.D., MBA 

CEO, Health 2.0 

350 Townsend Ave. 

San Francisco, CA 94107 

U.S. Senate 

Committee on Finance 

Dirksen Senate Office Bldg. 

Washington, DC 20510–6200 

January 30, 2017 

Honorable members of the Senate Finance Committee: 

My name is Indu Subaiya, M.D., MBA, and I am Co-Chairman and CEO of Health 

2.0, the largest health care innovation conference and network in the world. I submit this letter to oppose Tom Price’s nomination for Secretary of Health and Human 

Services. 

306 

We know that the ACA reduces barriers to health care for millions of Americans, 

but what many don’t know is that it also fuels a vibrant segment of the private sector, the health technology innovation economy. 

In a decade of working alongside thousands of health-care innovators globally, and 

in chapters in over 40 U.S. cities from Nashville to Boston, Dallas to Chicago, we 

have never seen our health-care system adapt so beautifully to reward private enterprise while saving lives and taking care of our most vulnerable without the heavy 

hand of government. 

Dr. Price appears to be a well-intentioned, educated man, but he has been out of 

both the practice of medicine and a transforming health-care industry for too long 

to lead us in this dynamic market. Appointing him to architect a replacement plan 

for the ACA would be like hiring a dinosaur to build a space station. 

What health care needs today is a pragmatic voice who can put pedal to metal on 

the progress that’s begun, who can work on reforming the ACA dispassionately with 

business leaders, entrepreneurs and patients represented in equal proportions, and 

who understands the health care innovation economy. 

But Dr. Price is far too polarizing in his politics to be taken seriously by the diverse 

and moderate mainstream on both sides of the aisle. Those of us fixing health care 

on the ground have blasted silos, left partisanship at the door and figured out how 

to advance a common interest. Ask Republican Governor Charlie Baker, Republican 

former Head of the ONC, Dr. David Brailer, Chelsea Clinton of the Clinton Foundation, Mark Bertolini, CEO of Aetna, Bernard Tyson, CEO of Kaiser all of whom 

we’ve warmly welcomed on stage at Health 2.0 not just as speakers but as partners 

in the work of transforming health care. 

Dr. Price on the other hand has never reached out to our community, and he’s had 

a decade to do so. Instead he has represented the Association of American Physicians and Surgeons, seen as a fringe group promoting self-interest, technophobia, 

and a ‘‘doctor knows best’’ philosophy. That era in medicine is over. The era of 

shared decision-making, data transparency, evidence-based medicine and providers 

as partners in care and innovation is here. Our era needs a Secretary of HHS who 

will command the respect of the brightest lights in the health care innovation economy and Dr. Price is just not that person. 

What do I mean by the innovation economy in health care? I am not referring to 

the old generation of electronic medical record companies (EMR) that indirectly received incentives under the HITECH act. I’m referring to the more than 4,000 new 

companies and many more thousand jobs that were created in response to the ACA’s 

imperative to make health care more accountable for its outcomes. These companies 

have applied the best of American business and technological ingenuity to support 

doctors in their workflow and decision-making, to promote collaboration among caregivers, to avoid redundancy in testing, to improve patient safety and to allow patients to take more responsibility for their health and care. 

As a sector, they’ve raised over $19.8 billion in venture capital since 2011 because 

investors could bet on the momentum of a system aligning around the best interests 

of patients for the first time in history. What happens when you leave the doctor’s 

office or hospital has always mattered to individuals and families; but now it made 

business sense. 

All this capital isn’t just lining the pockets of Silicon Valley startups. Economic development corporations in New York City, Massachusetts, Detroit, and Louisiana 

are making long-term, strategic investments in the health technology innovation 

economy to attract innovative companies to set up shop in their cities to provide 

badly needed solutions and to be powerful engines of job growth. 

That’s great you say. We’ll keep this thriving and virtuous economy alive, we’re just 

going to get rid of the individual mandate, some nasty corporate penalties and poorly run exchanges that limit choice and raise premiums for patients and we’ll handle 

pre-existing conditions with hiving off those patients into separate pools. But that’s 

a fool’s errand. 

It was precisely because the ACA widened the tent of coverage that new private sector markets were created. It was precisely because of exchanges that Americans 

woke up to the fact that you need to take responsibility for your health and spend 

your pre-deductible dollars wisely, and private sector businesses rose to the occasion 

to build tools to educate consumers on managing health-care expenses and decisionmaking. 

307 

Overstretched health systems also see innovative technology as a way to do more 

for patients with less overhead, to reach people in rural areas and at home cheaply 

and effectively, to refer repeat visitors to the ER to a lower cost option in the community. Hospitals like Massachusetts General in Boston, Cedars Sinai in Los Angeles, Dell Medical Center in Texas, UPMC in Philadelphia and New York Presbyterian in New York City all have either started their own or participated in 

health technology innovation programs to test new models of care delivery in partnership with the entrepreneurial community in health care. 

It was the ACA’s imperative to take care of a wider and more diverse population 

that created demand for new products to address the social determinants of health 

that are killing our small towns: caregiving burden, mental health, substance abuse, 

food insecurity, health literacy, social support for the elderly and so much more. 

These social ills normally depend on inefficient government programs. But thanks 

to the ACA, for the first time entrepreneurs have paying customers for solutions to 

these issues. Customers like public health departments, community clinics and hospitals. At the national conference we run on health innovation, the session on ‘‘Community Health’’ normally draws a handful of do-gooders. This past year you couldn’t 

get in the room if you tried; it was packed with entrepreneurs. The ACA had created 

a market for doing well by doing good. 

The train of progress toward a healthier America and a more efficient health-care 

system has left the station. If confirmed, Dr. Price would waste time trying to run 

after it only to get run over by it. We have better Republican candidates to choose 

from who have worked shoulder to shoulder with patients and innovators, who’ve 

been part of the transformation of American health care on the ground, not in DC 

and not in the ivory tower. 

Don’t appoint him because you are comfortable with him as a congressman and a 

doctor. Neither role prepares him for this job. Don’t appoint him because the AMA 

endorsed him. The AMA is a friend to the innovation community but it speaks for 

a minority of physicians. You have already heard from thousands of doctors who 

aren’t involved in politics who oppose this nomination. Take your time and don’t 

rush this vote. Let’s fix what’s broken together without taking a wrecking ball to 

progress. On behalf of those of us with real experience making positive change in 

the trenches of health care, I ask you to vote ‘‘no’’ on Tom Price. 

Thank you for your consideration. 

Sincerely, 

Indu Subaiya, M.D. MBA 

CEO, Health 2.0 

TREATMENT ACTION GROUP (TAG) 

90 Broad St., Suite 2503 

New York, NY 10004 

Tel 1–212–253–7922 

Fax 1–212–253–7923 http://www.treatmentactiongroup.org/ 

January 24, 2017 

U.S. Senate 

Committee on Finance 

Dirksen Senate Office Bldg. 

Washington, DC 20510–6200 

Dear esteemed members of the Senate Finance Committee: 

Treatment Action Group (TAG) submits this statement for the record in strong opposition to the nomination of Representative Tom Price (R–GA) for Secretary of 

Health and Human Services (HHS). We urge critical community action and implore 

the Senate Finance Committee to challenge his nomination to helm an agency that 

plays an exceedingly important and complex role in ending the HIV, tuberculosis 

(TB) and hepatitis C (HCV) epidemics in the United States and ultimately around 

the world. 

TAG is an independent, science-based research and policy think-tank fighting for 

better treatment, vaccine and a cure for HIV/AIDS, TB, and HCV. We work closely 

and interface extensively with U.S. health care, research, and regulatory institutions to support expanded access to health care, centralize community engagement 

and ethically accelerate vital research. 

308 

Tom Price’s questionable fitness to head a multi-agency cabinet-level department 

charged with the health of U.S. residents can simply be ascertained from his own 

record as a Congressional representative to parts of Atlanta’s northern suburbs— 

a district and metro area with extremely high rates of HIV and a flourishing opioid 

epidemic. Despite the abundance of epidemiological data illustrating the impact of 

the HIV epidemic in his own district and in the Southeastern United States, Representative Price has spent the last 8 years undermining efforts aimed at providing 

health care and social services to communities both living with, and vulnerable to, 

HIV and other health conditions. These actions include voting to repeal the Affordable Care Act (ACA) multiple times, pushing for the privatization of Medicare, 

threatening to cap and block-grant Medicaid, supporting to defund Planned Parenthood, pledging cuts to social service and safety net programs—all while demonstrating a hostile voting record on lesbian, gay, bisexual, transgender, and queer 

(LGBTQ) issues. Throughout the recent hearing before the Senate Committee on 

Health, Education, Labor and Pensions (HELP), Representative Price made several 

indications to continue a trend to dismantling existing systems, without details of 

a replacement that sustains access to health care and social services. 

At a time when we are at the forefront of new science to deliver better antiretroviral 

therapies for HIV, breakthroughs in cures for HCV, and pathways for making TB 

treatments shorter and more tolerable, the nomination of Representative Tom Price 

threatens to impede the progress of both research and implementation. Upon confirmation, Representative Price will, as promised, oversee the dismantling and overhaul of health-care systems that are responsible for delivering many of these medical advances to people in the United States, particularly those communities impacted by health, social, and economic disparities as well as stigma. 

Before the ACA, hundreds of people every year were waitlisted for the AIDS Drug 

Assistance Program (ADAP). People living with HIV (PLHIV) would need an AIDS 

diagnosis to be eligible for Medicaid. Pre-existing conditions would also disqualify 

many PLHIV from gaining insurance. While the ACA is not perfect, thousands of 

PLHIV have been transitioned onto insurance through marketplaces and have become eligible for Medicaid benefits. This has provided many with access to comprehensive health care for the first time, with profound effects on public health and 

prevention outcomes. Much of the success we’re seeing in increasing viral suppression rates and reducing the number of diagnoses annually will be put in jeopardy 

if the ACA is repealed without replacement. Without replacement and stewardship 

by the incoming Secretary of Health and Human Services, access to treatment, prevention and other services will remain out of reach for many of these communities. 

HHS is not just the department that oversees our health-care system, but also governs our public health, research, and regulatory agencies, such as the Centers for 

Disease Control and Prevention (CDC), Indian Health Services (IHS), National Institutes of Health (NIH), and the Food and Drug Administration (FDA). The recent 

revelation of ethics violations and refusal to clearly answer questions on these 

issues during the Senate HELP hearing clouds any trust in Representative Price to 

ensure the sanctity and impartiality of these agencies. Trust in HHS leadership is 

needed in prioritizing pressing public health challenges, ensuring drug and device 

safety, and countering emerging threats such as Zika, Ebola, drug-resistant TB, and 

antimicrobial resistance through robust R&D, proactive epidemiology, pharmacovigilance, and accelerated research and response. 

Representative Price’s worrisome background as a member of the American Academy of Physicians and Surgeons—an organization that promotes and endorses the 

theory that HIV does not cause AIDS, despite a substantial evidence base to the 

contrary—puts into question his capabilities to end an epidemic. Health conditions 

like HIV thrive on stigma. Yet Representative Price has only perpetuated stigma 

and marginalized vulnerable communities by voting against bills that afford protections to the LGBTQ community. With attention needed for other neglected populations, such as prisoners impacted by HIV and HCV, it becomes less likely under 

a Price-led HHS that key populations will be able to access health care and treatment. 

Now more than ever, ending the epidemics of HIV, TB, and HCV requires a combination of bipartisan federal and state leadership, evidence-based policies, and adequate resources in proper alignment to deliver the promise of biomedical and public 

health advances. Efforts to lower drug prices for HIV and HCV while sustaining 

U.S. leadership in R&D for TB and other neglected diseases remain inevitable challenges to the successor of HHS and the Trump administration. Representative Tom 

Price, however, remains a concerning and unqualified candidate to lead HHS given 

309 

a track record that only marginalizes communities, raises questions on his ethics 

and integrity to run an expansive $1 trillion department, and putting forth policy 

proposals that seek to fast-track the loss of lifesaving health care for 18 million 

Americans. Ending the epidemics remains impossible by destroying access to health 

care and treatment. With Representative Price’s support of the repeal of ACA and 

efforts to defund Medicaid, the hopes and vision of providing health care—including 

ending the HIV epidemic, curbing HCV transmission, eliminating TB—among the 

poorest, sickest, most disenfranchised, most vulnerable Americans will vanish. 

In summary, we urge the Senate Committee on Finance to challenge the nomination 

of Representative Tom Price as he is unqualified and unfit to lead HHS in a critical 

juncture to end the HIV/AIDS, TB, and HCV epidemics. Should you have any questions or concerns in regards to our statement of opposition to the nomination of Representative Tom Price for HHS Secretary, please contact TAG policy staff Kenyon 

Farrow at (202) 236–3274 or via email at kenyon.farrow@treatmentactiongroup.org, 

and Suraj Madoori at (917) 530–5996 and suraj.madoori@treatmentactiongroup.org. 

Thank you. 

Mark Harrington 

Executive Director 

Treatment Action Group 

LETTER SUBMITTED BY ELIZABETH VALLANCE

January 25, 2017 

U.S. Senate 

Committee on Finance 

Dirksen Senate Office Bldg. 

Washington, DC 20510–6200 

To the committee members: 

I write in strong protest of the nomination of Tom Price to head the Department 

of Health and Human Services. 

Nothing in Representative Price’s record suggests that he is fit to hold this position. 

Nothing in his record suggests an understanding of the public health issues faced 

by people of limited incomes, by the elderly, by people with AIDS or addiction problems, by people in minority communities including the LGBTQ community. He has 

repeatedly fought efforts to provide women’s health through Planned Parenthood, 

has fought to cut desperately needed social services and safety-net programs which 

are effective and solvent, including (they work, though he disdains them) the Affordable Care Act, Medicare, and Medicaid. 

My mother was a proud nurse practitioner in a public clinic in Appalachian Pennsylvania for many years before she died (of cancer—we need that cancer research!) 

in 1997, and her stories of the many women (anonymous of course)—young women, 

poor women, women without health plans, women who were alone and frightened 

by symptoms they couldn’t understand, many with their male partners, women new 

to the area who had no other resources—were extremely moving tales of gratitude 

for the compassionate care they received. It was clear to her, and it is clear to me, 

that providing professional health care was critical to the health of these women 

and the well-being of their families, their children, and the community. Surely all 

existing programs can be improved upon, and I would welcome genuine improvements—in accessibility and efficiency—in any of them. But Representative Price has 

offered no solutions, only his intentions to reduce important national programs without a clue as to what might replace them. The women my mother treated in those 

years before the Affordable Care Act were fortunate to have that clinic, but that was 

not typical and her clinic couldn’t reach everyone. 

Donald Trump seems bent on destroying much of what we as a nation have so 

painstakingly created over the past decades, programs that might begin to bring 

this country a bit higher in the lists of international rates of healthiness and longevity. The Programs under HHS are the most crucial to this slow progress we have 

made. HHS needs a leader who understands, respects, and wants to improve on 

them, not someone whose only interest in the job seems to be to wreck the department and its critical programs. 

310 

There are thousands of FAR better candidates out there, responsible health-care 

and health-policy professionals whose commitment to the health and well-being of 

our citizens is clear. Reject this terrible choice and let’s find someone more qualified 

than Tom Price to head the programs that the health and well-being of so many 

millions of Americans depends on. 

Thank you for your consideration, 

Elizabeth Vallance, 

Citizen and voter. 

Æ