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68-055 PDF 2011

SETTING FISCAL PRIORITIES IN HEALTH CARE 

FUNDING 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED TWELFTH CONGRESS 

FIRST SESSION 

MARCH 9, 2011 

Serial No. 112–17 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

JOE BARTON, Texas 

Chairman Emeritus 

CLIFF STEARNS, Florida 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

Vice Chair 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

BRIAN P. BILBRAY, California 

CHARLES F. BASS, New Hampshire 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BILL CASSIDY, Louisiana 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

CORY GARDNER, Colorado 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

HENRY A. WAXMAN, California 

Ranking Member 

JOHN D. DINGELL, Michigan 

Chairman Emeritus 

EDWARD J. MARKEY, Massachusetts 

EDOLPHUS TOWNS, New York 

FRANK PALLONE, JR., New Jersey 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

CHARLES A. GONZALEZ, Texas 

JAY INSLEE, Washington 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

JOHN BARROW, Georgia 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

SUBCOMMITTEE ON HEALTH

JOSEPH R. PITTS, Pennsylvania 

Chairman 

MICHAEL C. BURGESS, Texas 

Chairman Emeritus 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

TIM MURPHY, Pennsylvania 

MARSHA BLACKBURN, Tennessee 

PHIL GINGREY, Georgia 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

BILL CASSIDY, Louisiana 

BRETT GUTHRIE, Kentucky 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

JOHN D. DINGELL, Michigan 

EDOLPHUS TOWNS, New York 

ELIOT L. ENGEL, New York 

LOIS CAPPS, California 

JANICE D. SCHAKOWSKY, Illinois 

CHARLES A. GONZALEZ, Texas 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

HENRY A. WAXMAN, California (ex officio) 

(II) 

(III) 

C O N T E N T S 

Page 

Hon. Joseph R. Pitts, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 2 

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

Hon. Frank Pallone Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 4 

Hon. Michael C. Burgess, a Representative in Congress from the State of 

Texas, opening statement .................................................................................... 6 

Hon. Henry A. Waxman, a Representative in Congress from the State of 

California, opening statement ............................................................................. 8 

Hon. John D. Dingell, a Representative in Congress from the State of Michigan, opening statement ....................................................................................... 9 

Prepared statement .......................................................................................... 10 

Hon. Fred Upton, a Representative in Congress from the State of Michigan, 

prepared statement .............................................................................................. 132 

WITNESSES

Ernest J. Istook, Distinguished Fellow, The Heritage Foundation ..................... 11 

Prepared statement .......................................................................................... 13 

Answers to submitted questions ...................................................................... 135 

John C. Goodman, President and CEO, National Center for Policy Analysis .... 16 

Prepared statement .......................................................................................... 18 

Answers to submitted questions ...................................................................... 136 

Joseph F. Vitale, New Jersey State Senate ........................................................... 30 

Prepared statement .......................................................................................... 32 

SUBMITTED MATERIAL

Letter of March 8, 2011, from 10 public health commissioners to House 

and Senate leaders, submitted by Mr. Engel ..................................................... 56 

Letter of January 24, 2011, from the National Governors Association to Congressional leadership, submitted by Mr. Lance ................................................. 63 

Letter of March 1, 2011, from Chris Christie, Governor, State of New Jersey, 

to Mr. Upton, submitted by Mr. Lance .............................................................. 68 

Letter of March 9, 2011, from Sarah Audelo and Jen Heitel Yakush, CoChairs, Sex Education Coalition, to subcommittee members, submitted by 

Mrs. Capps ............................................................................................................ 74 

Statement of the American Nurses Association, dated March 8, 2011, submitted by Mrs. Capps .......................................................................................... 78 

Letter of September 16, 2009, from Mr. Barton, Mr. Burgess and Hon. Kay 

Granger to colleagues concerning JPS School-Based Health Clinics, submitted by Mrs. Capps .......................................................................................... 80 

Statement of Senator Tom Harkin, submitted by Mr. Waxman ......................... 88 

Statement on behalf of Jeffrey Levi, Executive Director, Trust for America’s 

Health, submitted by Mr. Pallone ...................................................................... 102 

Letter of March 8, 2011, from Alan Weil, Executive Director, National Academy for State Health Policy, to Mr. Pallone ...................................................... 124 

‘‘The Pitts Proposal to Block Mandatory Funding in the Affordable Care 

Act,’’ report dated March 2011, submitted by Mr. Pallone ............................... 128 

(1) 

SETTING FISCAL PRIORITIES IN HEALTH 

CARE FUNDING 

WEDNESDAY, MARCH 9, 2011 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON HEALTH, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:33 a.m., in room 

2322 of the Rayburn House Office Building, Hon. Joe Pitts (chairman of the subcommittee) presiding. 

Members present: Representatives Pitts, Burgess, Shimkus, Rogers, Murphy, Blackburn, Gingrey, Latta, McMorris Rodgers, Lance, 

Cassidy, Guthrie, Barton, Pallone, Dingell, Engel, Capps, 

Schakowsky, Gonzalez, Baldwin, Weiner, and Waxman (ex officio). 

Staff present: Clay Alspach, Counsel, Health; Howard Cohen, 

Chief Health Counsel; Brenda Destro, Professional Staff Member, 

Health; Paul Edattel, Professional Staff Member, Health; Julie 

Goon, Health Policy Advisor; Todd Harrison, Chief Counsel, Oversight/Investigations; Debbee Keller, Press Secretary; Ryan Long, 

Chief Counsel, Health; Carly McWilliams, Legislative Clerk; 

Monica Popp, Professional Staff Member, Health; Krista 

Rosenthall, Counsel to Chairman Emeritus; Heidi Stirrup, Health 

Policy Coordinator; Tom Wilbur, Staff Assistant; Jimmy Widmer, 

Health Intern; Phil Barnett, Democratic Staff Director; Stephen 

Cha, Democratic Senior Professional Staff Member; Alli Corr, 

Democratic Policy Analyst; Tim Gronniger, Democratic Senior Professional Staff Member; Purvee Kempf, Democratic Senior Counsel; 

Karen Lightfoot, Democratic Communications Director, and Senior 

Policy Advisor; Karen Nelson, Democratic Deputy Committee Staff 

Director for Health; Mitch Smiley, Democratic Assistant Clerk; and 

Lindsay Vidal, Democratic Press Secretary. 

Mr. PITTS. The subcommittee will come to order. Just a word 

about this morning’s proceedings. Because we have a joint session 

of Congress today at 11:00, we will begin our hearing at 10:30 with 

members’ opening statements and then recess shortly before 11:00 

for members to move to the Capitol for the session at 11:00. We 

will reconvene our hearing immediately following the joint session 

at 12:15 and start with our introductions of witnesses, their 5- 

minute statements followed by the members’ questions under the 

5-minute rule. The chair will recognize himself for an opening 

statement for 5 minutes. 

2 

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH 

OF PENNSYLVANIA 

The title of this hearing is ‘‘Setting Fiscal Priorities in Health 

Care Funding.’’ And that is exactly what we must do: Assess and 

prioritize all of the things that we need to do and would like to do 

and then make difficult funding decisions with limited amounts of 

money. 

Today, we will address five areas of the health reform law and 

determine if these funding streams are needed, if these programs 

are funded at the most responsible levels, and if they should be 

mandatory or discretionary. 

Section 4002 of PPACA establishes a Prevention and Public 

Health Fund ‘‘to provide for expanded and sustained national investment in prevention and public health programs to improve 

health and help restrain the rate of growth in private and public 

sector health care costs.’’ The section authorizes the appropriation 

of, and appropriates to the fund from the Treasury, the following 

amounts: $500 million for fiscal year 2010; $750 million for 2011; 

$1 billion for 2012; $1.25 billion for fiscal year 2013; and $1.5 billion for 2014, and for fiscal year 2015 and every fiscal year thereafter $2 billion. 

The Secretary has full authority to use this account to fund any 

programs or activities under the Public Health Service Act that she 

chooses, without Congressional oversight. 

On June 18, 2010, HHS announced $250 million in Prevention 

and Public Health Fund dollars would go ‘‘to support prevention activities and develop the Nation’s public health infrastructure.’’ On 

September 27, 2010, HHS announced another $320 million in 

grants from the fund to expand the primary care workforce. And 

on February 9, 2011, HHS announced an additional $750 million 

from the fund for various prevention activities, including preventing tobacco use, obesity, heart disease, stroke and other diseases, and increasing immunizations. 

The goals of these three disbursements from the fund are laudable, and there is no doubt that we must focus on preventing disease. But we must remember that this funding is over and above 

the amount that Congress has decided should go to these activities 

and the amount that Congress has already appropriated for these 

activities. It is also disbursed at the sole discretion of the Secretary. 

Last Thursday I asked Secretary Sebelius whether she needed 

further Congressional approval to spend the money from the 4002 

fund, and she answered no. I then asked her if she could fund activities above and beyond the level Congress appropriated, and she 

stated yes. This should concern every Member that we have a created a slush fund that the Secretary can spend from without any 

Congressional oversight or approval. 

By eliminating this fund, we are not cutting any specific program 

or activity. We are reclaiming our oversight role of how federal taxpayer dollars should be used. 

[The prepared statement of Mr. Pitts follows:] 

3 

PREPARED STATEMENT OF HON. JOSEPH R. PITTS

The subcommittee will come to order. 

The Chair will recognize himself for an opening statement. 

The title of this hearing is ‘‘Setting Fiscal Priorities in Health Care Funding.’’ 

And that is exactly what we must do: Assess and prioritize all of the things that 

we need to do and would like to do and then make difficult funding decisions with 

limited amounts of money. 

Today, we will address five areas of the health reform law - and determine if 

these funding streams are needed, if these programs are funded at the most responsible levels, and if they should be mandatory or discretionary. 

Sec. 4002 of PPACA establishes a Prevention and Public Health Fund ′′to provide 

for expanded and sustained national investment in prevention and public health 

programs to improve health and help restrain the rate of growth in private and public sector health care costs.′′ 

The section authorizes the appropriation of, and appropriates to the fund from the 

Treasury, the following amounts: $500 million for FY2010; $750 million for FY2011; 

$1.00 billion for FY2012; $1.25 billion for FY2013; $1.50 billion for FY2014; and for 

FY2015 and every fiscal year thereafter $2.00 billion. 

The Secretary has the full authority to use this account to fund any programs or 

activities under the Public Health Service Act that she chooses, without Congressional oversight. 

On June 18, 2010, HHS announced $250 million in Prevention and Public Health 

Fund dollars would go ′′to support prevention activities and develop the nation’s 

public health infrastructure.′′ 

On September 27, 2010, HHS announced another $320 million in grants from the 

Fund to ′′expand the primary care workforce.′′ 

And on February 9, 2011, HHS announced an additional $750 million from the 

Fund for various prevention activities, including preventing tobacco use, obesity, 

heart disease, stroke, and other diseases, and increasing immunizations. 

The goals of these three disbursements from the Fund are laudable, and there is 

no doubt that we must focus on preventing disease. 

But, we must remember that this funding is over and above the amount that Congress has decided should go to these activities and the amount that Congress has 

already appropriated for these activities. It is also disbursed at the sole discretion 

of the Secretary. 

Last Thursday I asked Secretary Sebelius whether she needed further Congressional approval to spend the money from the 4002 fund, and she answered no. 

I then asked her if she could fund activities above and beyond the level Congress 

appropriated, and she stated yes. 

This should concern every Member that we have a created a slush fund that the 

Secretary can spend from without any Congressional oversight or approval. 

By eliminating this fund, we are not cutting any specific program or activity. We 

are reclaiming our oversight role of how federal taxpayer dollars should be used. 

Mr. PITTS. At this time I will yield 1 minute to the gentleman 

from Texas, Mr. Barton. 

Mr. BARTON. Thank you, Mr. Chairman. 

I want to welcome especially Dr. Istook and Dr. Goodman. They 

are both personal friends of mine, and Mr. Istook is a former Congressman. 

This is a very important hearing, Mr. Chairman, because we are 

coming to find out every day more and more things about the 

health care law that should be of concern to every American citizen. The ability of the Secretary of HHS without any oversight or 

any authorization of the Congress to spend such sums as necessary 

which could total into the billions of dollars is something that 

should concern everybody in this room, and this hearing to look 

into that part of the law and then look at some of the other specific 

sums that are authorized, if we are really going to get spending 

under control, this is ground zero for starting it. 

4 

So I appreciate you holding the hearing. I appreciate all three 

witnesses for being here. And again to Dr. Goodman and Mr. Istook 

personally, welcome to the committee. 

Thank you, Mr. Chairman. 

Mr. PITTS. The chair thanks the gentleman and yields the remaining time to Mr. Latta from Ohio. 

Mr. LATTA. Thank you, Mr. Chairman, for holding this hearing 

today on fiscal priorities for health care spending. As we continue 

to discover more and more details of the ramifications of 

Obamacare, I am extremely troubled by the fact that this bill put 

in place programs and spending that bypass Congress and gives 

full control to the Administration. 

There are several programs that have been identified in 

Obamacare that are duplicative government programs as well as 

mandatory spending programs. I have grave concerns about these 

duplications and the fact that the programs contained in section 

2953 are of this nature. I am very supportive of the discussion 

draft before us that will convert the appropriation of payment in 

this section of $75 million for each of the fiscal years 2010 through 

2014 into an authorization. Congress needs to be the one that determines funding for these programs and determines if in fact they 

are duplicative and determine this through the normal appropriations process. Making this change could potentially save $375 million over 5 years. We must get our fiscal house in order and there 

are many more savings by further repealing Obamacare. 

This past month, the Congressional Research Service updated an 

October 2010 report that appropriations and fund transfers in the 

Patient Protection and Affordable Care Act. The new report found 

that unbeknownst to almost every Member of Congress, that 

Obamacare contains $150 in direct implementation spending to bypass this Congress’s normal appropriation process. 

Thank you, Mr. Chairman, and I yield back. 

Mr. PITTS. The gentleman’s time is expired. The chair yields for 

5 minutes for opening statement to Ranking Member Pallone. 

OPENING STATEMENT OF HON. FRANK PALLONE JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. Thank you, Mr. Chairman. 

Here we go again, same song, different verse, another hearing 

that continues the Republican hollow agenda of round-the-clock 

complaints of Democrat legislation without a glimmer of their own 

innovation or substance. The American people can do the math. 

Ten weeks, zero jobs bills from the GOP. Months after the election, 

Republicans continue to put partisan politics ahead of Americans’ 

top priority, which is jobs. 

But I should say, I welcome the opportunity to talk about health 

care reform and health security. I am very proud of the benefits it 

will bring to millions of hardworking Americans nationwide and for 

the families that live in every single Congressional district of the 

members of this committee. So while I welcome an honest discussion about reform, the issues raised today border on the absurd, in 

my opinion. The Republicans couldn’t be more hypocritical with 

their seeming concern about the use of mandatory funding for some 

5 

of the programs in health care reform. This hearing isn’t about 

funding streams, it is simply an effort to dismantle the health care 

reform law block by block by cherry-picking policies they don’t care 

for without offering any solutions in return. The truth of the matter is, the last time Republicans were in charge, they embraced 

mandatory health care funding and they used it regularly in bills 

that passed through the Energy and Commerce Committee. The 

Medicare Modernization Act of 2003, I am sure we all remember 

that bill. It passed in the middle of the night after a 3-hour vote 

was held open on the floor, and that bill was chockfull of mandatory goodies. There was the $1.5 billion to fund start-up administrative costs for implementation of MMA and there was an unlimited appropriation to fund the transitional drug assistance program 

and there were a few hundred million in change for a health infrastructure program and another billion for emergency health services, all mandatory funding. 

Then you can fast-forward a couple years and the committee once 

again decided to use mandatory funding for billions of dollars 

worth of programs throughout the so-called Deficit Reduction Act 

of 2005, and I could spend my whole 5 minutes on that but I am 

going to spare you that one. 

The fact is that key programs under the jurisdiction of the Energy and Commerce Committee are and continue to be funded 

through mandatory spending authority. It is the way to ensure an 

adequate and sustained funding stream to ensure the success of 

important programs. And for the Republicans who cry foul because 

we happened to utilize this tool in the Affordable Care Act is simply not credible, and it continues to amaze me how the Republicans 

cry States’ rights, States’ rights at every turn and then undermine 

that same principle with gusto. They want to eliminate all the 

funding for State health exchange grants to tie the States’ hands 

and you are not only going to throw an unfunded mandate on them 

but in effect you are ceding States’ powers to the Federal Government and telling HHS to step in and tell States what insurance exchange model will work best for them. That wasn’t our policy. We 

wanted State innovation in the health care reform bill, and we urge 

our Republican colleagues to rethink their misguided proposal. 

As much as I disagree with the basis of this hearing, I am 

pleased to welcome my good friend, State Senator Joe Vitale, who 

is from New Jersey, who has testified before us several times on 

health care reform, and he will talk about how health care reform 

will help millions of New Jersey families and how New Jersey already benefited from more than $3 million in critical funding from 

the Prevention and Public Health Fund. 

So at this time I would like to yield 1 minute to the gentleman 

from New York, Mr. Engel. 

Mr. ENGEL. I thank my friend for yielding, and I agree with your 

sentiments. 

Mr. Chairman, this hearing calls to mind the classic line from 

Yogi Berra, ‘‘It’s de ́ja` vu all over again.’’ This hearing really isn’t 

about the difference between mandatory and discretionary funding, 

this hearing is really another veiled attempt to undermine the Affordable Care Act and prevent 30 million Americans from accessing 

affordable health coverage. According to the Majority, the AffordVerDate Nov 24 2008 14:01 Oct 06, 2011 Jkt 037690 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 F:\112-017 SETTING FISCAL PRIORITIES-PDF MADE\112-17 SETTING FISCAL PRIORITIE
6 

able Care Act was ‘‘unusual in that it created mandatory spending 

on programs that would otherwise be considered discretionary.’’ It 

seems my friends on the other side of the aisle have a short memory. The Republican Majority mandated open-ended spending on 

new programs in the Medicare Prescription Drug Improvement and 

Modernization Act and the Deficit Reduction Act, both of which 

have resulted in billions of dollars spent outside of the appropriations process and worst of all were unpaid-for federal mandates. No 

jobs created by the Majority, just tax breaks for the rich and big 

corporations, blowing a hole in the deficit and again and again and 

again, day in and day out, attempts to repeal the health care law, 

which is already helping millions and millions of Americans. 

I yield back. 

Mr. PALLONE. Whatever time I have left I yield to Ms. 

Schakowsky. 

Ms. SCHAKOWSKY. Let us take a look at FactCheck.org. This ridiculous idea that somehow there is a dirty little secret, as our 

former colleague, Mr. Istook, said in the bill—what it is really 

about is what he said, pulling out Obamacare weed by weed. This 

is another attempt to repeal the legislation that will help 30 million Americans. 

I look forward to having this conversation with Mr. Istook. 

Mr. PITTS. The gentleman’s time is expired. The chair recognizes 

the vice chair of the committee, Dr. Burgess, for 3 minutes. 

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BURGESS. I thank the chair for the recognition. 

So here we are just 2 weeks shy of the anniversary date of that 

big signing ceremony down at the East Room of the White House. 

We all remember how the Vice President characterized that morning. 

But this bill does represent, this law now represents a fundamental change in the relationship of the government with the people. We have gone from government with the consent of the governed to now the government telling the governed what they 

should get and when they should get it. Remember President 

Obama when he was running in 2008? He made two promises. One 

was if you like what you have, you can keep it, and the other was, 

we have to control costs, that way more people can buy insurance. 

Actually not bad ideas. What happened to, if you like what you 

have, you can keep it? Well, apparently that is gone by the wayside, and what the American people told us in the difficult summer 

of 2009 was, we are scared to death you are going to screw up what 

we have, please don’t do that, and the other part of that equation 

was, could you do something to help us with costs because we are 

dreadfully concerned about the costs of health care. Turns out with 

the signing of this law, we screwed up what was working and we 

exploded the cost. 

Now, I do understand the difference between an authorizer and 

an appropriator. I have been an authorizer during my short Congressional tenure. Mr. Istook when he was here was an appropriator. My first field trip out to the NIH, I was taken to all of these 

big beautiful buildings, all named after appropriators. I said where 

7 

is the building named after the authorizer; there aren’t any. But 

I do understand the very fundamental nature of what we do as an 

authorizing committee. It is our heritage, and our strength comes 

from carefully investigating and carefully vetting those expenditures that we then pass off to the appropriators to eventually write 

the check, and the oversight function that occurs at the authorization level is something which cannot be minimized. We have gone 

through almost a year of this. In fact, we went through the first 

10 months before we had a single oversight hearing from any of the 

relevant federal agencies over just what was going on with the implementation of this. 

Now, look, we are hearing today about the problems with the fed- eral budget. February, $223 billion overdraft. February, I might remind people, is the shortest month of the year. That means that 

is as good as it going to get this year, $223 billion overdraft, and 

what do we get for it? Do you see new clinics, do you see new 

schools? No, what you see is an overdraft, and it gets worse because as this thing is implemented, we go on to subsidies to middle-class families in the exchange to help them buy health insurance and the answer there is a tap with a high-pressure line into 

the federal Treasury. That $223 billion deficit is something for 

which we all wax nostalgic after that kicks in in this bill. 

The mandatory spending which we are all talking about needs to 

be brought back under the control of this committee and be authorized. You don’t have to be against something just because you want 

to label it ‘‘mandatory.’’ It simply means you want to have the correct amount of Congressional oversight. 

Let me yield at this point to the gentleman from Kentucky. 

Mr. GUTHRIE. Thank you, Mr. Chairman, and I thank the gentleman for yielding. 

You know, we are all working on jobs. Everywhere you go, you 

hear people and businesses are sitting on the sidelines not investing because they are not sure how much their employees are going 

to cost them because of the expense that is coming because of this 

bill, and also we need to address spending so American people and 

businesses can have money to create jobs. And every day families 

across this country are sitting around trying to figure out what to 

spend their money on, and I believe Congress should follow suit. 

Unfortunately, during the annual appropriations process, 

Congress’s equivalent of a family budget, a number of federal programs are off-limits because they are created as mandatory spending and not discretionary. These programs are subject to the same 

scrutiny or evaluated for effectiveness in order to earn their continued funding. 

The new health care law created an unprecedented number of 

these mandatory programs. One that we will discuss today is an 

authorization of a mandatory spending program for graduate medical education. While I support graduate medical education and believe we need more residency physicians, particularly primary care, 

I support shifting this program to an authorization. This program 

should not be protected and prioritized over other similar programs. This change is not only fiscally responsible but good policy. 

Thank you, Mr. Chairman, and I yield back the balance of my 

time. 

8 

Mr. PITTS. The chair thanks the gentleman and yields 5 minutes 

to the ranking Member, Mr. Waxman. 

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Mr. WAXMAN. Thank you, Mr. Chairman. 

What the Republicans are conjuring up today is a completely contrived issue about funding for the Affordable Care Act that is entirely false and misleading. Don’t fall for it. Republicans are trying 

to turn back the clock on the Affordable Care Act, a law that reduces the deficit by over $210 billion in the next decade, expands 

the health care coverage to 32 million people, closes the Medicare 

drug doughnut hole, provides free preventive care under Medicare 

and strengthens the Medicare trust fund, and it prohibits predatory, abusive behavior by insurance companies. It addresses public 

health challenges that confront our Nation such as obesity and 

health disparities through support of the public health infrastructure. 

This hearing is about having appropriate resources to fund the 

Affordable Care Act. The Republicans tried to repeal that law but 

they weren’t successful, so now they are trying to defund it in another way. 

Every member of this committee has a history of voting for both 

mandatory and discretionary spending. In fact, a Republican-led 

Congress passed legislation that included over $400 billion of mandatory spending that was not paid for in the Medicare drug bill. 

It is a fundamental part of the responsibility of an authorizing 

committee like Energy and Commerce that has jurisdiction over 

programs like Medicare, Medicaid and CHIP to determine where 

mandatory funding is needed to ensure a program’s sustainability. 

Similarly, assuring funding to implement and support the Affordable Care Act is critical to its viability and success. 

The legislative proposals being discussed today are marked by 

irony and hypocrisy. For example, one proposal repeals the monies 

for the States to establish their exchanges. Just last week we had 

a hearing where Republicans argued the need for State flexibility 

under health reform and discussed the fiscal constraints that face 

States today. This proposal would take away monies that allow the 

States to do the work necessary to design a health insurance exchange that meets the needs of their residents. 

Our members have been discussing the need for expanding the 

health care workforce, especially primary care physicians to serve 

the growing demands for service. According to his testimony, Dr. 

Goodman agrees. It is ironic that one of the Republican proposals 

cuts support from our health care workforce. In a third proposal, 

they claim that education programs aimed at decreasing teen pregnancies should not have a stable funding source. However, Republicans, including Representative Istook, fully support mandatory 

funding for abstinence-only programs and have voted numerous 

times for such programs. 

Well, I look forward, I suppose, to hearing from our witnesses 

and seeing where this bill will go. I want to apologize ahead of 

time. I will need to leave this committee to attend another hearing 

9 

in another subcommittee. I want to yield my 1 minute to Ms. 

Capps and then take back my time after that to yield further to 

Mr. Dingell. 

Mrs. CAPPS. Thank you, Mr. Waxman. 

I will add that today’s hearing is another effort by this subcommittee to do everything it can to repeal the Affordable Care Act 

and avoid the issue Americans care most about, which is jobs. But 

unlike previous efforts that just ignored job creation altogether, today’s hearing is on legislation that will flat out hurt our economy 

and keep people out of the workforce. 

For example, the school-based health center construction grants 

will enhance the health of children and their families but also stimulate the economy of local communities with new construction jobs. 

Similarly, the teaching health centers program not only expands 

primary care services to those who need it most but also trains new 

providers with the expertise needed to serve these expanding populations. The Republican majority has placed both of these programs 

on the chopping block. Let us be clear: These proposals take away 

funding from shovel-ready projects in our communities and they 

keep qualified applicants away from the primary care workforce. 

I know many of our colleagues will say that our budget requires 

us to make tough calls. It is not being tough to go after kids and 

the underserved. These aren’t tough calls; they are bad calls. 

I yield back the balance of my time to Mr. Waxman. 

Mr. WAXMAN. Thank you very much. I want to yield 1 minute to 

the distinguished chairman emeritus of our committee, Mr. Dingell. 

OPENING STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MICHIGAN 

Mr. DINGELL. Thank you very much for that. I appreciate your 

courtesy. 

Today’s hearing is a wasted opportunity to have a substantive 

conversation as to how this committee can work together in a bipartisan fashion to further improve our health care system. I understand that the Majority has concerns about the reform. So do 

we. But we have also heard repeatedly about how the health care 

reform law will destroy State budgets, kill jobs, drive up health 

care costs and overwhelm Medicare and Medicaid. But I see nothing that they are putting on the table to address these problems. 

And while my colleagues take great joy in extolling the problems 

of the health care reform law, they have not brought forward a single substantive suggestion for improvement. We can see clearly 

from the five discussion drafts before us today that the Majority 

has no intention of working with the Minority to improve the 

health care reform law. 

I have long said that no law is perfect. The last perfect law that 

came into the hands of men came on stone tablets off the top of 

Mount Sinai in the hands of Moses, and I believe that we are going 

to find that the draft legislation that you have submitted to us or 

will be submitting to us is going to be bad legislation, and indeed, 

you are letting the perfect be the enemy of the good. 

It is my sincere hope that this committee will work together to 

improve this bill and not blindly tear it down. Further, I hope that 

10 

the next hearing before this subcommittee will take some time to 

deal with the real problems in health reform and not the politics. 

Thank you. 

[The prepared statement of Mr. Dingell follows:] 

PREPARED STATEMENT OF HON. JOHN D. DINGELL

Thank you, Mr. Chairman. 

Today’s hearing is yet another example of the Majority’s strong commitment to 

improving the Affordable Care Act. 

Rather than bringing substantive suggestions as to how we can work today to improve our health system, the Majority comes to the table once again with a sledgehammer and a long list of myths about what health reform will do. 

The Majority continues to warn about the dangers and deficiencies in the health 

reform. It is their misguided belief that the health reform law will destroy State 

budgets, kill jobs, drive up health care costs, and overwhelm Medicare and Medicaid. 

And while my colleagues seem to take great joy in extolling the problems with 

the health reform law, they have yet to bring a single, substantive suggestion for 

improvement. You can see clearly from the five discussion drafts before us today 

that the Majority has no intention of working with the Minority to improve the 

health reform law. 

The process of drafting good legislation is a difficult one, but as Members of Congress it is our responsibility to draft legislation that will improve the lives of our 

constituents and communities. A straight repeal of the funding for these public 

health programs is not in the interest of American families, it is not in the interest 

of public health, and it is not in the interest of State budgets. 

I have long said that no law is perfect, and I strongly believe that as you draft 

legislation you cannot let the perfect be the enemy of the good. I hope to work with 

my colleagues to improve this bill and not blindly tear it down. I hope that the next 

hearing before this subcommittee will deal with the substance and not the politics. 

Mr. PITTS. The gentleman’s time is expired. The opening statements are concluded. We will recess for the joint session at 11:00. 

The joint session may end early, so I would urge the members to 

return 15 minutes after the close of the joint session. So we will 

recess until approximately 12:00 or before if we can do that. 

The committee is in recess. 

[Recess.] 

Mr. PITTS. The time of recess having expired, the subcommittee 

will come to order, and I would like to welcome the three witnesses 

at this time. Note that your written testimony will be entered into 

the record and we will ask you to summarize, each of you for 5 

minutes. 

Let me introduce two of the witnesses, and then I will ask the 

ranking member to introduce the third witness. First of all, the 

Hon. Ernest Istook serves as a Distinguished Fellow at the Heritage Foundation. Prior to joining Heritage, Mr. Istook served the 

people of Oklahoma’s 5th district for 14 years, and he was a member of the House Appropriations Committee. Secondly, Dr. John 

Goodman is with us. He is the president and CEO of the National 

Center for Policy Analysis. Dr. Goodman is an expert on consumerdriven health care reform. He received his PhD in economics from 

Columbia University. Welcome. 

And I will turn to the ranking Member to introduce his witness. 

Mr. PALLONE. Thank you, Mr. Chairman. 

I already mentioned that Senator Joe Vitale, he has testified before our subcommittee on at least two occasions in the last Congress, I believe, and he was the chairman of the health committee 

11 

in the State senate. He continues to be a senior member of the 

health committee. And he doesn’t actually live in my district but 

a majority or a good portion of his State senate district is in my 

congressional district. He is a friend, but beyond that, I would say 

most people in the State would consider him the number one expert on health care in New Jersey, so good to see you. 

Mr. PITTS. Thank you, and welcome. 

Now the chair recognizes the gentleman Mr. Istook for 5 minutes 

for his opening statement. 

STATEMENTS OF ERNEST J. ISTOOK, DISTINGUISHED FELLOW, THE HERITAGE FOUNDATION; JOHN C. GOODMAN, 

PRESIDENT AND CEO, NATIONAL CENTER FOR POLICY 

ANALYSIS; AND JOSEPH F. VITALE, NEW JERSEY STATE SENATE 

STATEMENT OF ERNEST J. ISTOOK 

Mr. ISTOOK. Thank you, Mr. Chairman, and of course, you have 

my written testimony. We are here talking of course about the authority for funding and the actual appropriations that were made 

within what is known both as the Patient Protection and Affordable Care Act, or PPACA, and also known as—— 

Mr. PITTS. Is your mic on? 

Mr. ISTOOK. Let us try it now. 

Mr. PITTS. That is better. 

Mr. ISTOOK. I will begin again, if I may. 

Thank you, Mr. Chairman, for having us here. We are here of 

course talking about the funding approaches within the health care 

legislation that was passed last year, formally known as the Patient Protection and Affordable Care Act, PPACA, also known to 

many of us as Obamacare because of President Obama’s crucial 

role as the driving force. 

This legislation was so unwieldy and complicated that even now 

people are discovering things that they didn’t realize about the legislation, and I compare it to the ability to hide a lot of needles inside a haystack that contains 2,700 pages, and people are at different times finding the challenges presented by that. Although 

original estimates said that the bill created 159 new government 

agencies, the Congressional Research Service later concluded the 

actual number of new agencies, boards and so forth is currently unknowable because so many of those are given the authority to 

sprout off new entities in return. 

The new law attempts to bypass the normal appropriations process, which is another feature that makes it more difficult to deal 

with it, and for we who believe that the bill should be repealed, 

and if not repealed, then defunded, that presents special challenges 

because so many advanced appropriations were made. Advance appropriations are actual appropriations for future fiscal years. The 

comparison is to think in terms of writing checks. If you say I am 

not going to write any future checks for something, you are trying 

to defund it. However, if there is already a series of postdated 

checks out there, you have not defunded it. And I realize that is 

the subject of a major political battle that we have in Washington. 

12 

And of course, that violates the typical Congressional process of 

appropriations. I spent 14 years as a Member of the House Appropriations Committee, several of those years as a subcommittee 

chairman. Typically, the normal process is, you create enacting legislation, so-called authorization bills that authorize spending and 

then the second half of the process is that appropriations are made 

in the amount that they deem to be proper at the time. 

Now, I am not aware personally of any occasions where we have 

had advance appropriations not just for one fiscal year in the future, not just for two fiscal years in the future but for three, four, 

five, six, seven. In fact, the legislation actually contained funding 

actual appropriations spread out over ten different appropriations 

and fiscal years. 

Now, what happens when you do that is, in essence you make 

an attempt to handcuff the current elected Members of Congress. 

You can just as easily decide spending levels for a future fiscal 

year, say, 2079. You could pass a bill now that seeks to control 

what spending is going to be 5 years, 10 years, 50 years in the future but it would not be good practice. 

The people who should make the key funding decisions for the 

current time are the people who are elected to serve and represent 

the public at this particular time. So I am glad that you are looking 

at legislation to pull back funds previously appropriated to PPACA, 

or Obamacare, which in essence is putting a stop-payment order on 

these postdated checks. But it is important that this be done both 

through the authorizing process and through the appropriations 

process where there is also authority to repeal these existing appropriations and to pull them back. 

Defunding is a very routine policy tool for Congress and for the 

White House. So is funding at levels below what is authorized. As 

noted by the Congressional Research Service, Congress is not required to provide funds for every agency or purpose authorized by 

law. One of our founding fathers, James Madison, said it is the 

power over the purse, which is the most complete and effectual 

weapon with which any constitution can arm the immediate representatives of the people. However, if the decisions were made by 

the last Congress, by the prior representatives of the people, then 

you don’t have the same power that James Madison said was essential as a safeguard of the public purse. 

I should mention that the White House also routinely proposes 

not funding programs which have been authorized or funding them 

at beneath authorized levels. If we intend for a policy to bind future generations, we should follow the supermajority process that 

would actually enshrine that in the Constitution but we should not 

accept that a simple act of Congress today should be elevated to 

handcuff a future Congress not that the last Congress should handcuff the current Congress. 

Thank you, Mr. Chairman. 

[The prepared statement of Mr. Istook follows:] 

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Mr. PITTS. The chair thanks the gentleman and recognizes Dr. 

Goodman for 5 minutes for an opening statement. 

STATEMENT OF JOHN C. GOODMAN 

Mr. GOODMAN. Thank you, Mr. Chairman, members of the committee. My name is John Goodman. I am president of the National 

Center for Policy Analysis. 

I would like to begin by saying there are serious structural problems in the Affordable Care Act and they are so serious that even 

if the critics weren’t around, the Congress is going to have to go 

in and make major structural changes to this bill. Let me just draw 

your attention to a few of them. 

First, people are going to be required to buy an insurance plan 

whose cost is going to grow at twice the rate of growth of their income. You don’t have to be a mathematician or an accountant or 

an economist to know that if you have to buy something whose cost 

is growing at twice the rate of growth of your income, eventually 

it is going to crowd out everything else that you are consuming. 

That is an impossible path. It wasn’t created by President Obama 

or by Congress, but the bill, the Affordable Care Act, locks us onto 

that path and takes away a lot of the ability that people need in 

order to get off of it and move to a lower-cost health care system. 

Secondly, there is a bizarre system of subsidies in the act under 

which people at the same income level get radically different 

amounts of help from the Federal Government depending upon 

whether they are on Medicaid, whether they are in an employer 

plan or whether they are in an exchange. For example, a family at 

an income level of $30,000 a year in the health insurance exchange 

will get more than $16,000 of help from the Federal Government. 

That same family at work gets the current tax break which is a 

little over $2,000. I think this huge discrepancy of subsidies is one 

of the why the job market is not responding better than it is right 

now. There is enormous uncertainty right now on the employer side 

but eventually this is going to be very, very disruptive and eventually I think everybody who is average income or below average income is going to lose his employer-provided health insurance. The 

numbers are just so large and the incentives are just so great. They 

will either go into Medicaid or they will go into an exchange, or the 

subsidized plans, if we follow the Massachusetts example, will pay 

little better than Medicaid rates. Essentially you can think of it as 

Medicaid Plus. 

Number three, in the exchange itself we are creating perverse incentives for insurers. They will have to take all comers for the 

same premium. They will try to attract the healthy and avoid the 

sick. After people enroll, they have an incentive to overprovide to 

the healthy because those are the ones they want to keep. They 

want to attract more just like them. They will have an incentive 

to underprovide to the sick because they didn’t want them in the 

first place and they certainly don’t want to attract any more just 

like them. I think this is one of the worst features of the bill and 

it is the one that has been the least talked about in Congress and 

outside Congress. 

On the other side of the exchange from the buyer’s point of view, 

the incentives are also perverse. In Massachusetts, people are 

17 

going bare while they are healthy. They get sick, they enroll, they 

pay premiums for a few months, get their health care, get their 

bills paid and then they drop coverage again. So far, we are only 

talking about a few thousand people although the number is growing every year. In a State like Texas where we are signing up people for Medicaid in the emergency room, this would be absolutely 

disastrous. 

Number five, we have promises that we can’t possibly keep. This 

bill will insure between 32, 34 million additional people if the economic studies are correct. These people will try to consume twice 

as much health care as they have been consuming. In addition, almost everybody else is going to be pushed into a plan where benefits are more generous than they are now. There is a whole long 

list of preventive services that have to be made available with no 

deductible, no copayment. Bottom line, we are going to have a huge 

increase in demand for care. The bill has no provision for increasing supplies. We are going to have a huge rationing problem, and 

that is going to be very, very bad for anyone whose plan pays below 

market rates, and who are those people? That is everybody in 

Medicare, everybody in Medicaid and maybe everybody who is getting subsidized insurance in the health insurance exchange. 

And finally, we have impossible benefit cuts for seniors. We are 

paying for more than half the cost by cutting spending on Medicare. What are we talking about? Well, for someone reaching the 

age of 65 this year, the reduction in Medicare spending will be 

about $35,000 in present value terms. That is equal to about 3 

years’ worth of benefits. For a 55-year-old, the day that President 

Obama signed the bill, they lost $60,000 in spending, and for 45- 

year-olds, it is $100,000 in spending. Where are all these dollars 

coming from? I heard on TV this morning they were going to come 

from eliminating waste, fraud and abuse. Well, that is ridiculous. 

Where it is going to come from is in reduced payments to doctors 

and hospitals and other providers. According to the Medicare chief 

actuary, by the end of this decade Medicare will be paying doctors 

and hospitals less than Medicaid. Senior citizens will be behind 

welfare mothers in terms of their attractiveness to physicians. In 

3 years, most of you will be flooded by phone calls from constituents telling you they can’t find a doctor. I think it is a very, very 

serious problem and one that Congress has not yet addressed. 

The appropriations process is not the only way to deal with this 

but Congressional oversight is certainly a beginning. 

[The prepared statement of Mr. Goodman follows:] 

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Mr. PITTS. The chair thanks the gentleman and recognizes Senator Vitale for 5 minutes for an opening statement. 

STATEMENT OF JOSEPH F. VITALE 

Mr. VITALE. Thank you, Mr. Chairman. Good afternoon, Chairman Pitts and members of the Subcommittee on Health. My name 

is Joe Vitale. I was elected to the New Jersey State Senate in 1998 

and had the distinct pleasure of serving with your colleague, Congressman Leonard Lance. In fact, he is my Congressman. Congressman Pitts, Congressman Pallone and Congressman Waxman, 

thank you for the invitation to testify regarding proposals that 

would defund critical pieces of the Patient Protection and Affordable Care Act. 

I want to limit my testimony to how PPACA will benefit New 

Jersey citizens and how the act has already begun to do so and 

how defunding elements of reform will only serve to undermine access to our State’s uninsured citizens. In addition, I will cover some 

ground on how the federal and State health care partnerships have 

already made a significant difference in the wellbeing of hundreds 

of thousands of New Jerseyans. New Jersey was recently awarded a $1 million health exchange 

planning grant. The State department of banking and insurance 

awarded nearly $250,000 of that money to the Rutgers University 

Center for State Health Policy, which is a nonpartisan evidencebased think tank, to hold shareholder sensing meetings. The center 

will provide it gathers through these meetings and to provide to 

the State and other stakeholders including legislators. With the remaining funding, the department has planned to hire consultants 

to inform policymakers of aspects of an exchange such as design, 

development and oversight. In short, an exchange designed specific 

for New Jersey will contemplate and deliver a well-thought-out 

mechanism where hundreds of thousands of currently uninsured 

New Jerseyans will gain access to affordable and sustainable 

health care coverage. It is my belief that a properly financed and 

implemented exchange as made available through PPACA is smart, 

efficient and a sustainable way to access the appropriate care. 

The public health initiatives are the single-most proven method 

of controlling health care costs. Vaccinations, workplace safety, infectious disease control, safe food handling, prenatal care and family planning are just a few examples of how population-based prevention and public health programs are the most effective investment Congress can make to control future health care costs. 

One example through PPACA is where New Jersey received 

$350,000 for an HIV prevention grant. With these funds, we have 

tested an alternate means of confirming HIV that replaces a more 

expensive test at a fraction of the cost. Defunding public health initiatives will have a devastating consequence for all the people we 

serve. 

Of all the components of PPACA that are being considered for 

defunding, rolling back expansion of school-based health centers 

may be the most shortsighted. Five years ago, I worked with the 

Visiting Nurse Association of Central New Jersey to create a nontraditional school-based health services program in the suburban 

middle-class town in which I live. Children enrolled in the program 

31 

are able to see a visiting advanced practice nurse within the school 

nurse’s office. APNs are licensed and able to diagnose and recommend treatment. Prescriptions are called in to the student’s 

pharmacy so that they are ready for their parents to pick up on the 

way home. Children are treated faster, return to their classroom 

sooner and parents miss less work that many times adds up to less 

income and employee productivity. At the request of parents, the 

Visiting Nurse Association now provides annual sports evaluations 

for their students. School-based health centers require a relatively 

small investment and provide an enormous return on that investment. 

Through PPACA, New Jersey has received several grants to address primary care workforce shortages. Defunding programs 

aimed at addressing these critical shortages for me may be the 

most reckless. The primary care workforce shortages impact every 

State and will reach critical levels as access to health care coverage 

is expanded. It takes 10 years to produce a physician and 8 years 

to produce an advanced practice nurse. In New Jersey, we already 

aggressively addressing this issue but we cannot go it alone and 

PPACA will make an enormous difference. A loan redemption program has been created to encourage nurses to pursue nursing faculty careers. PPACA dedicated $800,000 to this program and will 

help ensure that New Jersey’s health care system can handle the 

increased demand. 

Through PPACA, New Jersey Department of Labor was awarded 

$150,000 workforce development primary care grant and has received $10,560,000 to increase the number of resident physicians 

trained in family medicine, general internal medicine and pediatrics. Defunding primary care workforce development will cripple 

health care delivery in States that do not already have existing 

health care workforce development programs in place. 

As one of the original authors and ongoing supporters of New 

Jersey’s SCHIP program, I can tell you firsthand just how effective 

federal and State partnerships can be. Currently, New Jersey enrolls over 600,000 children in SCHIP and in Medicaid, an additional 600,000 parents and adults without children in SCHIP and 

in Medicaid as well. Many also contribute to that insurance. 

I will close by saying that most of us elected officials enjoy some 

of the best health insurance that taxpayer dollars can subsidize. I 

think it is fair and right that we extend that same generosity to 

millions of Americans who may never have that same opportunity. 

Thank you. 

[The prepared statement of Mr. Vitale follows:] 

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Mr. PITTS. The chair thanks the gentleman. Thanks to all the 

witnesses for their testimony and we will now turn to questioning. 

The chair recognizes himself for 5 minutes for questioning. 

Mr. Istook, regarding State exchange grants with unlimited mandatory expenditures and the size of the appropriations really at the 

discretion of the Secretary with such sums, in your years as an appropriator and legislator, have you ever seen Congress grant an 

Administration official an unlimited tap into the U.S. Treasury? 

Mr. ISTOOK. No, Mr. Chairman. I can recall no such instance, 

and furthermore, I think it violates what the Constitution intends 

when it says no spending shall be made except by appropriations 

from the Congress, and to leave the amount at the discretion of any 

public official, whether it be the Secretary of HHS or anyone else, 

I think is not in keeping with the constitutional intent. 

Mr. PITTS. As our national debt currently sits at over $14 trillion, 

each citizen is individually responsible for roughly $45,000 of debt. 

We also heard news earlier this week that in February, the shortest month of the year, the Federal Government ran its single largest monthly deficit in U.S. history, $223 billion. In analyzing this 

law, we have found 2,000 ‘‘the Secretary shall’’ statements. With 

these facts in mind, do you think it is appropriate to give a single 

Administration official an unlimited tap into the U.S. Treasury? 

Mr. ISTOOK. No, sir, I do not believe that is an appropriate thing 

to do, just as it would not be appropriate for you to entrust all of 

your personal finances and investment to some individual and 

leave out your own discretion and control over them. 

Mr. PITTS. Now, section 4002 of PPACA creates a fund to provide 

funding for programs authorized by the Public Health Service Act 

for prevention, wellness and public health activities. From the period fiscal year 2012 to fiscal year 2021, there will be $17.75 billion 

deposited in that fund. Who has the authority, Mr. Istook, on how 

to determine how these funds are spent? 

Mr. ISTOOK. Under the statute, that authority appears to rest 

solely with the Secretary of Health and Human Services. 

Mr. PITTS. And so the Secretary can spend this money without 

any further Congressional action. Is that correct? 

Mr. ISTOOK. Yes. Because it is already appropriated, the Secretary is given discretion to decide how it has been spent. Then 

Congress does not need to take further action to authorize the Secretary to do that but it would need to take further action to stop 

the Secretary from spending that fund freely as they may see fit. 

Mr. PITTS. Does the program’s appropriations sunset at any 

point? 

Mr. ISTOOK. I do not find any sunset in the legislation. If it is 

there, I am sure somebody else would point it out to us. 

Mr. PITTS. So the HHS Secretary will receive a $2 billion annual 

appropriation for this program in 2030, in 2040 or in perpetuity regardless of the effectiveness of the program or the need for these 

funds? 

Mr. ISTOOK. So long as the Secretary doth live. That appears to 

be the case. 

Mr. PITTS. All right. Let us to go to Dr. Goodman. As a general 

proposition, do you believe the massive health care law signed by 

48 

President Obama responsibly sets federal spending priorities in the 

health care field? 

Mr. GOODMAN. No, I do not. Just my back-of-the-envelope cal- culations suggest that for every $2 of spending, only $1 is actually 

paid for, and if Congress has to restore the spending for seniors, 

that means only one of every $4 of promises is actually paid for. 

So there is a commitment here to spend an enormous amount of 

money and no one can tell me where the money is going to come 

from. 

Mr. PITTS. All right. Senator, in your testimony you argue that 

the massive new health care law does not expand government’s 

role in the health care arena. Are you aware that PPACA adds 20 

million Americans into the government-run Medicaid program? 

Mr. VITALE. Yes. 

Mr. PITTS. Are you aware the health care law creates at least 

159 new agencies, boards and commissions? 

Mr. VITALE. I am not aware of the total number but I will take 

your word for it, Mr. Chairman. 

Mr. PITTS. Are you aware that the Secretary of HHS has the 

power to prevent doctors and hospitals from contracting with insurers if they fail to meet new federal guidelines and standards? 

Mr. VITALE. Yes, and I agree with her. 

Mr. PITTS. Are you aware that the Secretary of HHS can dictate 

the benefits, the network requirements, the medical loss ratios, the 

actuarial value and the other terms of every health plan in America including new requirements on plans that Americans have and 

like today? 

Mr. VITALE. Someone should, and the responsibility rests with 

her. 

Mr. PITTS. Thank you. I am sorry I am out of time. 

I yield 5 minutes to the ranking member, Mr. Pallone, for questioning. 

Mr. PALLONE. Thank you, Mr. Chairman. 

I wanted to ask a question of Senator Vitale. Forty-eight States 

and D.C. receive grants for the purpose of planning and establishing an exchange. In addition, six early innovator grants were 

awarded to develop an array of models for exchange information 

technology systems that can be used by other States. So about $296 

million has gone out to States for these grants related to the exchange. Now, the Republicans criticize again and again that they 

do not want a federal solution for health reform but the fact is, if 

a State does not or is unable to establish a State exchange, the 

Federal Government would establish one for them. So these planning and establishment grants provide the necessary support to ensure States are able to work with their stakeholders. You know, if 

it is an active exchange, it negotiates with insurers to leverage the 

best quality choices for best prices or it is an open exchange that 

invites all insurers to offer products that consumers can be aware 

of or choose from. These grants basically make all this possible and 

make for good exchanges. 

So I wanted to ask you, Senator, if Congress were to repeal this 

provision providing for grants for the States for exchanges, does 

New Jersey have the money to do this work on its own, and what 

is the fiscal situation in New Jersey that relates to that? 

49 

Mr. VITALE. Well, I don’t believe that we have the money to do 

it on our own, and I think earlier in my testimony I described the 

level of federal-State partnerships that have always been successful 

when run properly and really in good coordination have always 

made sense. Having a one-size-fits-all exchange model that would 

be implemented by the Federal Government I don’t think would 

work in New Jersey, but be that as it may, in terms of the dollars 

and cents, we don’t have the resources to not only design but also 

implement the exchange, and of course, our condition economically 

is as bad or worse than most other States, the worst recession since 

the Great Depression. And so our resources are limited and already 

the governor has decided that he is going to eliminate and reduce 

programs to the uninsured, to the Medicaid recipients in our State. 

So I don’t see how it is in New Jersey or any other State, for that 

matter, unless they find a pot of gold and can come out from underneath this recession without the partnership of the Federal Government. 

Mr. PALLONE. I appreciate that. Let me ask you about the prevention and the public health investment fund because again we 

are trying to provide Americans with better choices about prevention. Both Democrats and Republicans keep talking about prevention as a way to provide better quality care and save money, and 

I think if you talk about where we are today before this act, the 

health care reform goes into place, you know, be more apt to describe the situation as sick care rather than wellness care, and that 

is why we created this prevention fund to provide Americans with 

options to keep themselves healthy instead. 

There are over 530 organizations that support the prevention 

and public health fund because it has already shown it can deliver 

on the promise of creating a better pathway to prevention. So many 

people on both sides of the aisle have supported prevention because 

it holds a promise to reduce health spending, and I know this has 

been important to you both improving health and reducing spending. 

My question, Senator, again is, New Jersey has received over $15 

million in grants from the fund. It supported activities such as quit 

lines, HIV prevention, other important activities. Are you able to 

comment on how prevention and public health fund awards like 

these help to complement your own state efforts, and is this an investment that is worth making because obviously the Republican 

option is to eliminate it? 

Mr. VITALE. Well, I think everyone in this room will agree that 

we want to have smart public health opportunities and options for 

every American, but the States can’t go it alone, but we also know 

that it makes smarter financial sense to address these issues early 

on in terms of prevention not only in terms primary care, spending 

money in the beginning of life prevention and not at the back end 

of life but also on all the public health initiatives that the Federal 

Government and the State government by itself certainly lowers 

cost, lowers the instances of contagious disease and infections and 

the variety of things that happen to people in the public health 

field and so reducing those costs is paramount and it makes financial sense. You know, we have to spend so much more not wellness 

but on sickness, as you said earlier, as opposed to spending it up 

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front. It makes sense to spend it now and do it in a way that is 

appropriate and provides the greatest bang for the buck. 

Mr. PALLONE. I appreciate that. I don’t want us to be fooled by 

these arguments about mandatory versus discretionary spending in 

this fund. Seventy-one percent of Americans favor increased investment in community health and disease prevention. I think it is 

tragic that we are even considering striking the fund, given what 

it can do. 

Thank you, Mr. Chairman. 

Mr. PITTS. The chair thanks the gentleman. The gentleman’s 

time is expired. The chairman recognizes the vice chairman of the 

committee, Dr. Burgess, for 5 minutes for questions. 

Mr. BURGESS. Thank you, Mr. Chairman. 

Dr. Goodman, did you want to respond to that last question? 

Mr. GOODMAN. Yes. I agree with Congressman Pallone that both 

Republicans and Democrats are out there saying that by spending 

money on preventive care we will save money overall but it is just 

not true. There are an enormous number of studies of this issue. 

They overwhelmingly show that preventive medicine by and large 

does not save money, that yes, you will save money if you catch a 

disease in its early stage with one person but to get to that person 

you have to spend money on 10,000 other healthy people, and it 

turns out that there are very few preventive procedures that actually save money. I think the political reason why we hear so much 

about preventive medicine is, it is the only thing you can do for 

healthy people, and most people are healthy. So it makes political 

sense to talk about spending money on preventive care but it is not 

a way to overall health care costs. Pregnant women at risk, smoking cessation advice, immunizations, they will pay for themselves 

but giving free checkups to the elderly, that will never save money. 

Mr. BURGESS. Interesting observation. And we do appreciate all 

of you being here. Let me just say that again. 

Mr. Vitale, let me ask you a question. In your testimony, you 

talk about the rollback of the funding of the country’s school-based 

health centers and maintain that in fact that is shortsighted. I 

don’t know, you may be being a little tough on the President but 

let us explore this a little bit. In the law as it is now, section 

4101(a), the mandatory funding that we are talking about today is 

actually for school-based clinic construction, correct? Is that yes? 

That is a yes. The clerk will note that is a yes. 

Mr. VITALE. Yes. 

Mr. BURGESS. What about the money for the doctors and nurses 

that are going to be in the clinic? Is that mandatory or discretionary? 

Mr. VITALE. I am not sure. 

Mr. BURGESS. Well, 4101(b) is discretionary. Do you know the 

dollar amount that President Obama requested in his latest budget 

that he sent up here to the Hill just a little over a month ago? 

Mr. VITALE. For which part? 

Mr. BURGESS. For the staffing of the school-based clinics. 

Mr. VITALE. I am not aware of it but any staffing would be helpful. If the money doesn’t in that proposal, then it is what it is, but 

what is important to recognize is that whether it is for bricks and 

51 

mortar or whether it is for individuals to serve in those capacities 

is vitally important. 

Mr. BURGESS. Well, the actual dollar figure requested by the 

President was zero, so I think maybe you are stating the President 

was shortsighted with that budgetary amount. I don’t know. I will 

leave that up to you. 

But what good are the bricks and mortar if you don’t have the 

doctors and nurses there to receive the children, the patients when 

they come in to be seen? How are you going to have a child seen 

at a school site if there is no doctor or nurse in the clinic? 

Mr. VITALE. Well, the elements of reform in PPACA and what we 

do in New Jersey is to encourage primary care workforce development so primary—— 

Mr. BURGESS. Yes, encourage it by not funding it in the discretionary part of the President’s budget, and that is a discrepancy 

and that is one of the things—you know, the Secretary couldn’t answer the question when I asked her why it was that it was constructed like that. I am going to accept that it was a drafting error 

on the part of the Senate. I am going to accept the fact that this 

bill was a poorly constructed product that was rushed through on 

the Senate Floor to get the Senators out of town before a snowstorm hit on Christmas Eve. We all accept that. They never got to 

a conference committee because we know that 2 weeks later Scott 

Brown gets elected, they lose the 60-vote margin. Nancy Pelosi said 

there is not 100 votes for this damn thing over in the House, and 

it took 3 months to twist enough arms and crack enough skulls to 

get it passed, and that is precisely the reason why, because it 

doesn’t deliver on the promise that was intended. 

Now, another aspect is, what are the duplicative aspects of this? 

You had a stimulus bill that passed in February 2009, $3 billion, 

I believe, for community health centers. Was there not enough to 

scrape together for the $50 million that would fund the schoolbased health clinics in this program? Did the Congress have to 

fund it twice to get to your level of satisfaction? 

Mr. VITALE. Well, you know, I would certainly welcome and support legislation that you could introduce that would fund those programs and put those doctors and nurses in those buildings. 

Mr. BURGESS. Well, oK. There is the other part of the problem, 

last month, a $223 billion overdraft by the United States Congress. 

If you multiply that out over the 10-year budgetary window, that 

is almost $27 trillion. That is twice what the debt limit is going to 

be expanded later this year. That is twice what the debt limit already is, and that is irrespective of any money collected in taxes. 

So that is the problem. There is no money there, and that is an 

important concept. 

Let me just ask you a question. Governor Christie, did he sign 

on a letter asking for relief of maintenance of effort to the Congress? 

Mr. VITALE. Yes, he did. 

Mr. BURGESS. And was he correct or incorrect in that? 

Mr. VITALE. He was incorrect, sir. 

Mr. BURGESS. I believe he was correct, and again, the answer is, 

$223 billion overdraft, it is unsustainable. 

52 

Mr. Chairman, thank you. I hope we have time for a second 

round because I have some questions of the other witnesses, and 

I will yield back. 

Mr. PITTS. The chair thanks the gentleman. The gentleman’s 

time is expired. The chair recognizes the ranking member emeritus 

of the committee, Mr. Dingell, for 5 minutes for questions. 

Mr. DINGELL. Mr. Chairman, I thank you for your courtesy to 

me, and I want to welcome our panel, particularly my old friend, 

Mr. Istook. I am delighted to see you here. 

I am troubled about the committee and what it is doing. I am 

very much troubled that instead of trying to improve the legislation, we are concentrating on trying to repeal it. At the same time, 

I note that those who would repeal the legislation and who are trying to impede the implementation of this legislation are coming forward with no suggestions as to alternatives and no differences that 

they would make because of either amendments or replacement 

legislation. 

This is a yes or no question, old friend. You have great familiarity with the differences between mandatory and discretionary 

funding and the importance of both, and I know my colleagues 

have concerns that they have expressed about mandatory spending 

under the Affordable Care Act but I would point out that the majority of the members on the other side of the aisle have voted for 

this kind of funding when it suits their purposes, particularly in 

the instance of the Medicare Part D or the Medicare Prescription 

Drug Improvement and Modernization Act. There was a lot of funding of this particular kind, and a similar situation in which many 

of the members on the other side of the aisle also voted for the 

SCHIP program in the Deficit Reduction Act. 

Would you agree, old friend, that mandatory appropriations are 

from time to time a necessary part of legislating and particularly 

so in the case of the Medicare Prescription Drug Improvement and 

Modernization Act and in the Deficit Reduction Act? Yes or no. 

Mr. ISTOOK. One, I always appreciate your courtesy, Mr. Dingell. 

The challenge is, there are different types of mandatory appropriations. They have been used in different mechanisms. I have never 

seen them used in the same way that they are here. For example, 

in the prescription drug benefit bill, you had an existing program 

which receives permanent appropriations, namely Medicare, and 

there is an expansion of its scope rather than a creation of a new 

mandatory stream of funding. 

Mr. DINGELL. But we are following a precedent long established 

in many differences. 

Mr. ISTOOK. I don’t see it in the manner it is done here. 

Mr. DINGELL. Now, as a former Member, you served here with 

distinction, do you agree that Medicare and Medicaid programs are 

essential cornerstones of the health care system in this country? 

Mr. ISTOOK. I think they certainly have become cornerstones 

upon which people depend. Is it necessary, especially for Medicaid, 

to be its current scale? I don’t believe so. 

Mr. DINGELL. And those bills that we have been discussing have 

been funded by mandatory appropriations over the years. 

Well, I want to thank the panel for being here. I notice I have 

a minute and 27 seconds and I just want to maintain that I conVerDate Nov 24 2008 14:01 Oct 06, 2011 Jkt 037690 PO 00000 Frm 00056 Fmt 6633 Sfmt 6633 F:\112-017 SETTING FISCAL PRIORITIES-PDF MADE\112-17 SETTING FISCAL PRIORITIE
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tinue to appeal to my friends on the Majority. Let us work together 

to get a good piece of legislation made better and to meet the concerns that are expressed by all of us here about different components of this legislation. I have heard that the Members on the 

other side want to repeal it. I think that would be extraordinarily 

unwise, and I would hope that they would join us in trying to improve our Nation’s public health, to save our health care system, 

to see to it we have the money in the system that we need and that 

we have a workable program that will head off the appalling increase in cost which we see going forward on a continuing basis 

under the old system, and I thank you for your courtesy, Mr. 

Chairman. 

Mr. PITTS. The chair thanks the gentleman. The gentleman’s 

time is expired. The chair recognizes the gentleman from Ohio, Mr. 

Latta, for 5 minutes for questions. 

Mr. LATTA. Thank you very much, Mr. Chairman. I appreciate it. 

And to our panel, thanks very much for being here. I really appreciate it. It is always enlightening to get the testimony from you all. 

Dr. Goodman, if I could maybe start with you. It is kind of interesting, because I know that this has been discussed a lot during 

the debate on the health care legislation. On page 7 of your testimony you were talking about Massachusetts and what has happened up there. It is interesting that you stated that people remain 

uninsured while they were healthy and get insurance after they 

are sick. Then they receive care and their medical bills are paid, 

they drop their insurance coverage again. And I guess some of the 

questions I would like to ask is first of all, what is the enforcement 

mechanism they have in Massachusetts or lack thereof to try to 

change this or get people to be on insurance all the time? 

Mr. GOODMAN. Well, the Massachusetts model has a fine, and 

the general Massachusetts approach was copied. I do agree with 

President Obama on this. The federal model did in large part come 

from Massachusetts, and it is a strange model because, you know, 

in other health care programs that we have, we don’t let people 

game the system. In Medicare Part B, in Medi-gap insurance and 

prescription drugs, you don’t let people just go until they get sick 

and then sign up for the same price everybody else is paying. There 

is a penalty if you do not sign up when you are eligible, and yet 

in Massachusetts, people can wait until they can sick, they can 

sign up at any time. There is a 12-month open season. They pay 

a small penalty when they are not insured but the penalty is small 

compared to the cost of insurance so the real incentive there and 

the real incentive under the Affordable Care Act is go bare while 

you are healthy, pay the fine and wait until you get sick and then 

sign up for the most generous—and if you are really sick, you will 

sign up for the most generous of the options that you have. 

Mr. LATTA. Do you know what that penalty is, out of curiosity? 

Mr. GOODMAN. In Massachusetts? I don’t remember. But under 

the Affordable Care Act, it will be less than $1,000 a person. 

Mr. LATTA. This might be a rhetorical question then, because I 

already know what the answer is. Who makes up that difference? 

Mr. GOODMAN. Well, the cost of care falls on everyone else, and 

if you allow people to game the system, stay outside when they are 

healthy, let them join when they are sick for the same premium 

54 

everybody else pays, premiums have got to rise. Everybody else has 

to pick up that difference. And through time costs just get higher 

and higher and higher as people are allowed to game the system 

in that way. 

Mr. LATTA. Thank you. 

Congressman, a question for you. As a former appropriator, you 

know, when you look at this, and you stated in your testimony but 

is it right that Congress should really abdicate its responsibility by 

saying that we are going to have these going out year after year 

after year in these mandatory’s instead of us looking at every year? 

As Dr. Burgess pointed out, we had a $233 billion shortfall in the 

month of February. You know, should that be abdicated by Congress? 

Mr. ISTOOK. No, neither in the case of Obamacare nor for that 

matter in the case of Medicare or Medicaid should we have unrestricted, open-ended appropriations or permanent appropriations 

rather than putting things upon a defined budget that is defined 

by what Congress is able to provide what the Nation can afford at 

a particular time. So this is a common problem with any form of 

mandatory appropriation whether it be the permanent appropriations that go out, for example, to Medicare or the different process 

that was used here, passing a series of annual appropriations for 

consecutive years. Either way, you are not matching your current 

resources with what you are trying to provide, and that of course 

is what leads to deficits such as the $1.6 trillion that we have for 

this current fiscal year. 

Mr. LATTA. Thank you very much. 

If I could, I would yield the remainder of my time to Dr. Burgess. 

Mr. BURGESS. Thank you. 

Dr. Goodman, you mentioned in your testimony that the mandate is going to become ever more costly. You already alluded to 

the amount of money the deficit is for February of this year and 

what future projections are. How expensive is that going to be for 

the taxpayer in the years ahead? 

Mr. GOODMAN. Well, I don’t have an estimate off the top of my 

head but it is going to be very expensive and it is going to be more 

expensive and it is going to be more expensive than I think the 

Congressional Budget Office has estimated, and the reason is because of these different subsidies that I have talked about. It is 

going to be foolish for modern income employees to try to get insurance from an employer. They are all going to find their way into 

the exchange, and the subsidies in the exchange are paid for by the 

federal taxpayer. So I think the Congressional Budget Office was 

estimating maybe 17 million people would go over into the exchange. Douglas Holtz-Eakin, former director of the Congressional 

Budget Office, thought it might be twice that many, but it could 

be much higher than that. I think eventually everybody who can 

get a better deal will be in the exchange. 

Mr. PITTS. The gentleman’s time is expired. The chair recognizes 

the gentleman from New York, Mr. Engel, for 5 minutes for questions. 

Mr. ENGEL. Well, thank you, Mr. Chairman. I would like to first 

ask unanimous consent to introduce for the record a letter from the 

public health commissioners from 10 of our Nation’s biggest cities, 

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which provides great examples of the ways the fund is being used 

in our Nation’s cities. 

Mr. PITTS. Without objection, so ordered. 

[The information follows:] 

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Mr. ENGEL. Thank you, Mr. Chairman. 

Mr. Chairman, Republicans have decided that this is the week 

to talk about mandatory spending in the Affordable Care Act. This 

has probably confused many Americans who thought that Congress 

was going to focus on creating jobs and reducing the deficit. 

I want to welcome our three panelists. I want to welcome Congressman Istook back. But let us examine the issue of the Affordable Care Act mandatory spending provisions. One of our colleagues, Michelle Bachmann, on Meet the Press last weekend said 

that using mandatory funding was ‘‘gangster government’’ and she 

said that this mandatory funding was the bill’s, and again I quote 

her, ‘‘dirty little secret.’’ Congressman Istook, you said to 

FactCheck.org that this assessment was fair because these appropriations were, and I quote you, ‘‘not trumpeted loudly by sponsors 

of the measure.’’ So I am going to ask you in a minute to comment, 

but let us review the history here. 

For example, let us look at the prevention and wellness fund. 

This is a critically important fund to provide stable funding for our 

public health infrastructure. The fund will support State and community efforts to prevent disease and make our Nation healthier. 

Over 530 organizations have supported this fund because investing 

$10 per person per year on community-based prevention could save 

this Nation more than $16 billion annually. I have never considered this a ‘‘dirty little secret.’’ I am proud of it. I have tried to 

trumpet it loudly. It was in just about every document we ever produced, every draft on the House and Senate side, every explanatory 

fact sheet and every full CBO score. So let me read to you from our 

fact sheet: ‘‘Provides $15 billion in mandatory spending to support 

prevention and wellness activities.’’ Does that sound like we are 

trying to keep this a secret? Even FactCheck.org concluded that 

‘‘No secret. Bachmann gets it wrong.’’ And the Washington Post 

said, ‘‘This is bordering on ridiculous,’’ and concluded that there is 

no bombshell beyond the bombast. 

But let us take this chance to learn more about the fund. I would 

like to first ask Senator Vitale, according to Healthcare.gov, organizations in New Jersey have received nearly $15 million in prevention and public health grants from tobacco cessation programs to 

HIV prevention, to public health infrastructure to primary care 

training. Senator, you mentioned in your testimony the idea of 

bringing primary health care services to people in their behavioral 

mental health setting. I am told that people with serious mental 

illness die an average of 25 years sooner than the general population, largely due to untreated chronic disease. Can you tell us 

how bringing primary care and mental health together is actually 

an important shift in how we think about prevention? 

Mr. VITALE. Well, thank you for that question, Congressman, and 

you are right. It is an incredibly important way in which to bring 

the care to them. I think that for a long time a lot of policymakers, 

even State legislatures, have overlooked the importance of those 

mental health and substance abuse issues, and in New Jersey we 

have the same issues. And I was a little blindsided and dumbfounded by a comment by my friend, Dr. Goodman, that prevention 

really doesn’t save money. If you talk to any other health care expert in the Nation that is learned as he is, we would get a different 

61 

answer, that that prevention model is incredibly important. It 

means the world to people even in terms of life and death, and so 

I would support those initiatives. They make a whole lot of sense. 

Mr. ENGEL. Thank you. This fund is much more than simply providing more funds for good things. It is about changing the way we 

think about prevention. I can’t think of a better use of tax dollars 

than to institute proven prevention strategies that could save the 

taxpayers money. 

I just wanted to say, Dr. Goodman, I don’t necessarily need a 

reply from you but I was interested when you were talking about 

the Massachusetts bill vis-a-vis the bill that we tried to put in, and 

I think you actually make a point many of us have been saying, 

that the fact of the matter is, it is not fair for someone not to belong and then when they get sick opt in because then everyone 

else’s premium rises. That is why you have to everyone being directed to mandatorily purchase insurance, and I find it really ironic 

that Mr. Romney, who implemented as governor the law in Massachusetts which allows people to first get sick and then opt in is now 

one of the people who is cracking the bill. 

Mr. Istook, I want to give you a chance to respond. You replied 

to an inquiry from FactCheck that Congresswoman Bachmann’s 

‘‘dirty little secret’’ remarks were fair and you said these appropriations were ‘‘not trumpeted loudly’’ by sponsors of the measure. I tell 

you, we trumpeted it loudly and I don’t know why you can say that 

we tried to hide it, but I would like to give you a chance to respond. 

Mr. ISTOOK. If I may, Mr. Chairman? 

Mr. PITTS. Proceed. 

Mr. ISTOOK. Thank you. Actually, particular things have been 

checked both by FactCheck, by the Washington Post and by 

PolitiFact. None of them had any criticism of what I have said on 

this. They had criticism of Ms. Bachmann but not of my characterization. As I said, her characterization I believe was a fair comment and opinion. Just because something is well known to some 

people such as, say, yourself does not mean that it has overall been 

well communicated to the American people. That is why I mentioned that we have a 2,700-page bill that is a huge haystack with 

a lot of needles still being discovered within that haystack, and I 

think the revelations are continuing and that is part of what the 

chairman is seeking to point out during this hearing. 

Mr. ENGEL. Thank you, Mr. Chairman. 

Mr. PITTS. The gentleman’s time is expired. The chair recognizes 

Mr. Lance for 5 minutes for questioning. 

Mr. LANCE. Thank you, Mr. Chairman, and good afternoon to you 

all. I am new to this committee, and it is my honor to meet for the 

first time Congressman Istook and Dr. Goodman. I certainly know 

Senator Vitale. We served together in the State senate for the 7 

years I was in the State senate. I believe Senator Vitale is completing his 14th year in the State senate, and not only is he an expert on health care, he and I served together on the State senate 

budget committee and worked on many issues together. 

As a general matter, the National Governors Association writing 

our leaders, Speaker Boehner and leader Pelosi and leader Reid 

and leader McConnell, in January said that moving forward Congress should not impose maintenance-of-effort provisions on States 

62 

as a condition of funding. This was a general letter and it did not 

relate specifically to the health care bill. It was more in general in 

tone. I want to make that clear. I would like to have unanimous 

consent to introduce that letter into the record. It was signed in a 

bipartisan capacity by the chair and the vice chair of the National 

Governors Association. 

Mr. PITTS. Without objection, so ordered. 

[The information follows:] 

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Mr. LANCE. Thank you, Mr. Chairman. 

And then more recently Governor Christie wrote the chair of the 

full committee, Chairman Upton, on March 1st relating specifically 

to the health care legislation. Governor Christie was unable to join 

the distinguished panel last week that included the Governors of 

Mississippi, Utah and Massachusetts, and as it relates directly to 

the health care issue, the Governor of New Jersey stated that we 

in New Jersey are facing an unprecedented Medicaid shortfall of 

approximately $1.3 billion in State fiscal year 2012 and he goes on 

to state that ‘‘our options to close this gap are severely affected by 

further restrictive maintenance-of-effort requirements in the health 

care legislation. Noncompliance with those requirements could result in our losing $5.4 billion federal funding. Governors need flexibility, not federal mandates.’’ 

To the panel in its entirety, if you would, gentlemen, beginning 

with you, Congressman Istook, address your views regarding the 

maintenance-of-effort requirement, specifically given the fact that 

it seems to me so many governors have suggested that we should 

look at that. And Mr. Chairman, might I place in the record of the 

subcommittee the letter from the Governor of New Jersey to Chairman Upton on March 1st? 

Mr. PITTS. Without objection, so ordered. 

[The information follows:] 

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Mr. LANCE. Thank you. 

Congressman Istook? 

Mr. ISTOOK. Yes. Thank you, Mr. Lance. And having served in 

State government as well as Federal Government, I know that 

often States feel trapped by having gotten into a program and then 

told you have to maintain those efforts even if federal funding may 

be diminished or even if there are major changes in the federal program. A key example right now, the Obama Administration is saving we are trying to provide States some certain opt-out flexibility, 

but what the fine print says is we will only let you do it if we decide you are trying to the same thing that we are trying to do, if 

you are trying to do things our way. It is not really an opt-out. It 

is still another level of control. So I fear that the maintenance-ofeffort requirements have become just another way for the Federal 

Government to dictate to the States they participate in a program 

that they cannot afford. Medicaid is if not the largest certainly an 

enormous budget item in so many States right now and they are 

finding that it is simply unaffordable, and providing some leeway 

on maintenance of effort is an important way to address that. 

Mr. LANCE. Thank you, Congressman. 

Dr. Goodman? 

Mr. GOODMAN. Well, of course, the States are trapped, and all 

the programs that we are talking about here today further trap 

people in the existing health care system. We want lower costs and 

higher-quality care. We have to let people get out of the way we 

have been doing things and try something new. Probably the best 

way that we could spend money on preventive care for low-income 

folks is to pay the market price that minute clinics charge and 

shopping malls and at Walmart for basic preventive primary care. 

At least I could argue that that has a much better chance of getting care to people that anything else that we have talked about. 

In any event, people at the local level need to have these flexibility. 

These kinds of programs don’t give it to them. 

Mr. LANCE. Thank you. 

Senator Vitale, my friend. 

Mr. VITALE. Thank you. Well, you are right, Congressman Lance. 

The governor did sign onto that letter to remove the MOE from 

New Jersey’s obligation, and I will tell you that could be the worst 

thing that could happen to the population. If this happened last 

year and the governor cut out tens of thousands of parents from 

SCHIP, he didn’t go below 133 because that was the maintenanceof-effort level. If he were able to do this year, we would have tens 

of thousands of working parents who go to work every day without 

the ability to have health care and the access to health care that 

we all enjoy. He would also dismantle many of the benefit designs 

and programs in Medicaid to the aged, blind and disabled and to 

the vulnerable populations. So to say that the maintenance effort 

is a way in which it forces the States to provide their care, I know 

that at least in the case of our governor, he will take that opportunity to remove that care and it would be just devastating for that 

population and literally hundreds of thousands of New Jerseyans. 

Mr. PITTS. The gentleman’s time has expired. The chair recognizes the gentlelady from California, Ms. Capps, for 5 minutes for 

questions. 

71 

Mrs. CAPPS. Thank you, Mr. Chairman. I just want to take a 

minute to clarify one item regarding the application process for 

construction funds. Already 350 community clinics or schools have 

applied for funding for construction. Part of that process includes 

the requirement that as they apply for the funds that they demonstrate that they have adequate funding for adequate staffing for 

that facility. 

I want to also welcome our witnesses and thank them for their 

testimony, and in particular, welcome to our former colleague, Mr. 

Istook. 

As you all know, school-based health centers provide comprehensive and easily accessible preventive and primary care health services to approximately 2 million students nationwide, and there is 

no doubt about it, and I know this as many years of being a school 

nurse: Healthier children do better in school. At a time now when 

we are trying to out-compete and out-innovate other countries, we 

do need our kids healthy and in the classroom. 

Now, there is a statement, Senator Vitale, that I would like you 

to respond to and see if you agree with this statement. It is a 

quote: ‘‘School-based health centers have proven that effective preventive and primary care for medically underserved children can 

decrease academic failure rates resulting from poor health.’’ Is that 

something you would agree with? 

Mr. VITALE. It is, Congresswoman, and thank you for being a 

school nurse. We have an example in the town in which I live, and 

I was interim mayor for a few months and I worked with the Department of Human Services and the Visiting Nurse Association of 

Central Jersey to establish a school-based health clinic in six of our 

communities out of 30 schools, six of the most medically underserved schools in our school district, and one of them which had 

very high special-needs population and now several years later 

when I visit and we assess the efficacy of that program, it clearly 

illustrates that those children receive care when they need it up 

front right in the school. Parents get the prescription. They are 

able to write those prescriptions because the advance practice 

nurses now can diagnose and prescribe. Kids get on their medication earlier. They get back to school quicker and they learn faster. 

And we have seen an enormous decrease in the amount of absenteeism for all those children in those six schools where previously 

those absentee rates were much higher. So they are learning better, they are learning faster, and parents who need to take time off 

from work in many ways can’t afford to do that save them money 

as well. 

Mrs. CAPPS. Absolutely. I agree with your testimony. It is eloquent. I also agree with the statement that I quoted, and I wish 

I could take credit for the quote but I wanted to point out that this 

comes from two of my colleagues who are members of this committee, Chairman Emeritus Barton and Mr. Burgess, and they sent 

a ‘‘dear colleague’’ highlighting their support along with their fellow Texan, Congresswoman Kay Granger, their support of schoolbased health centers. And after an endorsement like that one, I 

find it quite puzzling that our Republican colleagues are here trying to eliminate funds for communities across the Nation who want 

to benefit from the school-based health centers. 

72 

Mr. BURGESS. Will the gentlelady yield? 

Mrs. CAPPS. I will yield after I finish my statement and question. 

In fact, the interest in expanding school-based health centers is 

so great that HHS has received 350 applications for this funding. 

Requests come from 44 different States including the Congressional 

districts of nine of our Republican colleagues who are part of this 

subcommittee. So let us be clear. The need is there. While these 

centers benefit all children who have access to them, they are also 

a vital support for low-income Americans and I hope it is clear to 

us all that 40 percent of children treated at school-based health 

clinics either have no insurance or are enrolled in Medicare, SCHIP 

or other public coverage. For some children, school-based health 

centers are the only consistent access to health care that they or 

their families have, and we know there are many millions of other 

children who could benefit from them. With more access to these 

centers, these children could be spending more time learning in 

their classrooms and less time clogging up our emergency rooms. 

And now, Senator Vitale, as a former mayor, which you mentioned, and current State senator, you do understand the economic 

needs of local communities during these tough times. The funding 

for school-based health clinic construction is the perfect shovel 

ready for today. So with so many people out of work, we are trying 

to provide more jobs for the American people. Maybe you can talk 

about what this means to your State of New Jersey. 

Mr. VITALE. Well, we have many of the same challenges as every 

other State, in fact, New Jersey being so urbanized in so many 

areas and where there are so many medically underserved populations, school-based clinics are a perfect way to capture kids that 

are school age. Providing the bricks and mortar or the dollars for 

those bricks and mortar is certainly very important but the other 

elements of the act that would help us to train additional physicians, advance practice nurses, to put those bodies in those clinics 

from time to time are also important elements so we are dealing 

with both the bricks and mortar and those who would be future 

physicians and advance practice nurses. So those developments 

combined certainly make great sense and will make a great deal 

of difference in urbanized communities. 

Mrs. CAPPS. Thank you. 

I wanted to yield time to my colleague, and I would be happy to, 

but I could ask unanimous consent, Mr. Chairman, to insert two 

letters for the record, one from the Sex Education Coalition and 

also one from the American Nurses Association. These groups highlight the importance of personal responsibility education programs, 

and I think for the record we should include the ‘‘dear colleague’’ 

that was sent out by our colleagues. 

Mr. BURGESS. Reserving the right to object until I have a chance 

to respond. 

Mr. PITTS. All right. The gentlelady’s time has expired. 

Mr. BURGESS. I object to the insertion in the record. 

Mr. PALLONE. Mr. Chairman, can I ask why—— 

Mr. PITTS. Would you provide us a copy so we can look at it? 

Mr. BURGESS. I have a copy. The copy is not the issue. I asked 

for a chance to respond. I was denied that chance. I will object to 

the insertion in the record until I am given such chance to respond. 

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Mr. Chairman, I ask unanimous consent for 30 seconds to respond. 

Mr. PITTS. All right. Without objection, go ahead. You can have 

30 seconds. 

Mr. BURGESS. The issue is not whether or not Chairman Barton 

and I support the program. The issue is to have mandatory funding 

for the construction of the clinic and zero funding for the doctors 

and nurses who staff it. The other issue is a $223 billion structural 

debt for the month of February. There are going to be all kinds of 

programs that I supported in the past that we simply cannot fund. 

We simply cannot pay for everything. This is a poor crafting in the 

bill that was signed into law a year ago. We should fix it. It is 

within our scope to do so. Let us make the construction an authorizing program, not a mandatory program, and I will yield back. 

Mr. PALLONE. Does the gentleman withdraw his objection? 

Mr. BURGESS. Objection withdrawn. 

Mr. PITTS. All right. Without objection then, the letters are entered into the record. 

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Mr. PITTS. The chair recognizes the gentleman, Dr. Cassidy, for 

5 minutes for questioning. 

Mr. CASSIDY. I forego my questioning. I wasn’t here to hear the 

testimony. And although I have a great interest in the topic, I don’t 

want to just read something put in front of me. I would actually 

rather digest, and so if I could yield to anyone who wishes to have 

time yielded to them. 

Mr. BURGESS. I would be happy to accept the time from the gentleman from Louisiana. 

Dr. Goodman, we started just a moment ago when I had a few 

seconds yielded to me and we were talking about the costs of the 

subsidies. Now, we had multiple hearings leading up to the passage 

of PPACA a year ago, and one of the things that got me was, we 

never really focused on the cost of delivering care. Now, you have 

been a proponent of patient-powered, consumer-directed health 

plans. Governor Mitch Daniels in Indiana popularized the Healthy 

Indiana program and over the same period of time that Medicare 

and Medicaid expenses, PPO expenses grew by 7 or 8 percent, he 

saw an overall reduction in expenses for State employees of 11 percent over that same 2-year interval. Would you care to comment on 

the techniques used by Governor Daniels to hold down costs in his 

State for the State employees? 

Mr. GOODMAN. Well, sure. Part of the approach is to empower 

patients and give them control over dollars, and that is the reason 

I said earlier, if low-income families could just stop by the minute 

clinic, get their immunization shot, get their flu shot, get a prescription filled, that probably is a better use of money than building a lot of buildings. 

Mr. BURGESS. And what is the barrier to the patients doing that? 

Mr. GOODMAN. The barrier is the government and bureaucracy’s 

control of the money, and it is not patient friendly, and so the system is set up so that it is a relationship between the provider and 

the payer and the patient is just an excuse to bill, and if you want 

real change in the marketplace, then you have to have providers 

competing for patience based on price and on quality, and they are 

not going to do that unless the patient controls the money. 

I wonder if I might respond to Congressman Engel’s point about 

Massachusetts and the mandate there, if I may? 

Mr. BURGESS. Please. 

Mr. GOODMAN. Because I have talked to Governor Romney about 

this. They did it the wrong way in Massachusetts and we did it the 

wrong way in the Affordable Care Act, and if I could just choose 

a number, suppose we are willing to offer somebody a $2,500 subsidy to buy individual health insurance. The way to do it is to offer 

it as a refundable tax credit so that if he buys this insurance, he 

gets his $2,500 for the insurance. But if he doesn’t buy the insurance, then the $2,500 needs to go over into the social safety net. 

So if he goes in for care, he doesn’t have insurance, he is responsible for his bills. If he can’t pay for his bills, we put money over 

there for him. But in doing it that way, you don’t let people game 

the system. You let money follow people. We will never get all the 

people in the insurance system. But the way you make them pay 

their own way is, they pay higher taxes if they turn down your subsidy, and that is the right way to organize the system, and I can’t 

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speak for Governor Romney but I think these days he is leaning 

more toward that approach than trying to force everybody to buy 

a plan that they don’t really want to buy. 

Mr. BURGESS. Thank you. 

Mr. Istook, you were an appropriator during the years that the 

Medicare Modernization Act passed. Would you care to comment on 

some of the discussion we have heard today how the forward funding or advance appropriations occurred in the Medicare Modernization Act? I was too young to remember it or to acknowledge it at 

the time but you were there, a seasoned appropriator. 

Mr. ISTOOK. It was not done the same way. What we have in 

Medicare, whether you are talking about Medicare Part D or any 

other Medicare, you have what is called a permanent appropriation. Now, that is a problem because rather than having a defined 

amount where we spend what we can afford to spend, it is an openended expenditure. So when Medicare Part D was created, it was 

simply changing the definitions of what is covered as opposed to 

providing new appropriations. 

In the case of PPACA, Obamacare, there are a series, and Congressional Research Services devotes I think 16 pages to describing 

specific item after specific item after specific item after specific 

item where they make appropriations for the current fiscal year 

when it happened, fiscal year 2010, where they make appropriations that are explicit to fiscal year 2011, explicit appropriations for 

fiscal year 2012, and so forth all the way up to fiscal year 2019 

scattered over a whole variety of different programs. So it is taking 

singular programs and a great number of them and creating annual appropriations for them not on a permanent basis but for a 

10-year period not changing the definition of something that exists 

that also has permanent appropriations. It is a very different process and very unprecedented in my experience. 

Mr. BURGESS. Thank you. And I will just point out in H.R. 3200 

that passed this committee, the appropriations, the public health 

fund was subject to appropriations. 

I thank the gentleman for yielding. I will yield back. 

Mr. PITTS. The gentleman’s time has expired. The chair recognizes the gentlelady from Illinois, Ms. Schakowsky, for 5 minutes 

for questions. 

Ms. SCHAKOWSKY. Thank you. First I wanted to clarify something about the school-based clinics. The grant application for the 

school-based clinics, which many schools are applying for, is very 

clear. They need to demonstrate that they have the funds to run 

the center but they don’t have the funds to build the center. So this 

is a suggestion where denying construction funds actually would 

deny the clinic and they understand that they have to provide the 

money to run it. 

Mr. Istook, we are kind of getting into the weeds here, but in 

general about this issue of secret funding, you said that FactCheck 

exonerated you but I wanted to just read a quote. You said that 

‘‘it is within the range of fair comment and opinion for Congresswoman Bachmann to say that funding for these and other programs was a secret.’’ So in a way, you are saying that this kind 

of we didn’t know about it, nobody knew about it, this was snuck 

in there is a fair statement. Do you agree with that? 

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Mr. ISTOOK. Well, when the Speaker of the House told people 

that you had to pass the bill so that folks could find out what was 

in it, you know, I think that illustrates that we are finding out bit 

by bit is certainly within the realm of fair comment. 

Ms. SCHAKOWSKY. So even though the debate was very clear, for 

example, on the CHIP program you say that there is something 

very different about the Medicare Prescription Drug Improvement 

and Modernization program which you voted for but in fact $40 billion of what is in the Affordable Care Act goes to the CHIP program just for 2 years, so isn’t that exactly the same thing? 

Mr. ISTOOK. Actually it goes for 2 years and those particular 2 

years, if I recall correctly, are something like adding—what is it— 

2017 and 2019—— 

Ms. SCHAKOWSKY. No, 2014 and 2015, actually, and that is when 

the program goes into effect. 

Mr. ISTOOK. There are other provisions that go up to 2017. 

Ms. SCHAKOWSKY. Well, I wanted to ask you about something—— 

Mr. ISTOOK. So the point there is, if something is supposed to be 

subject to the annual appropriations process, why isn’t it subjected 

to the annual appropriations process by the people—— 

Ms. SCHAKOWSKY. Well, that is what I want to ask you about. 

Funding for the State pharmaceutical assistance program into 

2006, that was 3 years into the future. You voted for that, right? 

Mr. ISTOOK. I am not sure what you are talking about. 

Ms. SCHAKOWSKY. This is what was in the bill, a 3-year appropriation for the State pharmaceutical assistance program, and 

there was also funding for a pilot program for nursing home backgrounds. That was 4 years into the future, and of course, that was 

a good call. But you voted for that. 

Mr. ISTOOK. Ma’am, one, if you have specific provisions you want 

to recite from that bill to see where they are parallel, I would be 

happy to look at that. But secondly, whether you are talking about 

the practice of advance appropriations for appropriations that occur 

1 year or 2 years in the future, there is no comparison with a bill 

that seeks to make advance appropriations 10 years into the future 

which is what we are talking about with Obamacare. 

Ms. SCHAKOWSKY. When you voted for the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, the welfare 

reform, did you know that that bill contained significant mandatory 

appropriations for abstinence education and childcare and development block grant? 

Mr. ISTOOK. When you use the term ‘‘mandatory appropriations,’’ 

it means different things. Does it have express line items for year 

by year for fiscal years? Do you have that information in front of 

you? 

Ms. SCHAKOWSKY. Well, let us ask for the Deficit Reduction Act. 

You missed that vote. But all the Republicans on this committee 

supported it. It contained mandatory spending. 

Mr. ISTOOK. Well, again, you see, the term ‘‘mandatory spending’’ 

is used to cover a lot of different definitions. I am talking about the 

practice of advance appropriations which are defined, and this is 

from OMB, which are defined as one made to become available 1 

year or more beyond the year for which the appropriations act is 

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passed. That is not the same as other categories of so-called mandatory spending. It is certainly not the same as permanent appropriations as they are found, for example, in Medicare. So again, if 

you have something specific you would like me to look at, the line 

item of a legislation, but I find nothing that is comparable to what 

happens—— 

Ms. SCHAKOWSKY. Well, actually that is not true because the 

State pharmaceutical assistance program that you asked about, 

and I was listening to you while staff was telling me, that was unlimited 3 years into the future but absolutely unlimited. There was 

no dollar amount. 

Mr. ISTOOK. If you can recite a—there is—well, then it is certainly not the same thing as what we are talking about if you say 

there was no dollar amount. If you have a citation to a specific section of a law that you want me to look at, I would be happy to look 

at that with you. 

Ms. SCHAKOWSKY. And let us remember also that none of us this 

was paid for, period, that that legislation was not paid for at all, 

and the Affordable Care Act is. 

Mr. PITTS. The gentlelady’s time is expired. The chair recognizes 

the gentleman from Illinois, Mr. Shimkus, for 5 minutes. 

Mr. SHIMKUS. Thank you, Mr. Chairman. Welcome to our panelists. I appreciate you coming. I am going to yield my time to Congressman Burgess for questions. 

Mr. BURGESS. I thank the gentleman for yielding. You know, it 

is almost like a line from that Kevin Costner movie, if you build 

it, they will come, so OK, we are going to build the clinics. We are 

not going to fund the staffing but the requirement is that you have 

to staff the clinic if you are going to apply for the building fund, 

but what happens when the States get into a budget crunch. Who 

could believe that that would ever happen, but it could. The States 

get into a budget crunch and they can no longer afford that. The 

fact of the matter is, we are going to continue to build the clinics. 

That spending is required in the Patient Protection and Affordable 

Care Act. So it is duplicitous to say that hey, it is oK to pay to 

mandate the funding for the building of the clinics because people 

have to demonstrate an ability to staff. In fact, they don’t. If they 

did, why have 4101(b) contained within the bill? 

Again, I will accept Secretary Sebelius’s assertion that she 

doesn’t know why those two sections were put side by side, 4101(a) 

and 4101(b). I accept the fact that the bill was poorly crafted and 

poorly drafted. I accept the fact that even though I opposed H.R. 

3200, it was an infinitely better crafted product than this thing 

that came out of the Senate on Christmas Eve. After all, 3200 had 

a severability clause. The bill that was signed in law contains no 

such clause and in fact if there were a severability clause, we 

might not be having the arguments that we are having down in 

Florida today. 

Dr. Goodman, I wonder if you would—we heard it expressed 

again today that the Patient Protection and Affordable Care Act is 

going to save $142 billion over the lifetime of the bill. I think that 

is preposterous. But you started to talk about the cost of the subsidies for purchase of insurance in the exchange. We have already 

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trapolated deficits into the future. What is going to happen to those 

projections when the subsidies for families earning up to $80,000 

a year, what is going to happen when those subsidies kick in to the 

overall cost of this legislation? 

Mr. GOODMAN. Well, it is going to soar, so we are sort of treading 

water right now. There are a few changes that have been made but 

really everything begins January 1, 2014. That is when the mandates become effective, the subsidies become effective. Overall on 

the employer side, I think companies like McDonald’s and Burger 

King, who employ a lot of workers who only make $10, $15 an 

hour, they are not going to be able to afford family coverage that 

costs as much as $6 an hour, so they are going to have to find a 

way to get their workers over in the exchange, and I don’t know 

how they will do that, maybe treat them all as independent contractors, but they are going to find a way or they won’t survive, 

and then when they get over there, the taxpayer is going to pay 

for not just the premium but going to reimburse those workers for 

a lot of out-of-pocket costs. 

The costs are going to be quite large. Remember, the only way 

we really are paying for most of this is by thinking we are going 

to cut Medicare, but when you all 3 years from now start getting 

calls from seniors saying we can’t find a doctor who will see us, 

then you are going to be under enormous pressure to undo all of 

that spending that is in the bill and then you are going to find that 

you really haven’t paid for this at all. 

Mr. BURGESS. And of course, the Independent Payment Advisory 

Board is beyond our scope today, but it should be the subject of a 

future hearing but that actually has some pretty dire consequences, 

again, wasn’t part of the House bill, 3200, but certainly as part of 

the bill that was signed into law. Have you had any thoughts looking ahead to that Independent Payment Advisory Board and how 

that is supposed to structurally pay for the expansion of all of this? 

Mr. GOODMAN. Yes. And let me just say too that I think we do 

need to reform Medicare and there is a right way to reform it and 

the right way to reform it is to let doctors and hospitals come to 

Medicare and propose different ways of being paid. If they can save 

Medicare a dollar, you ought to be able to let them keep 50 cents 

or 25 cents, and if you did it that way, I think you would solve a 

lot of problems very quickly. But the only way this payment commission is going to be able to control cost is just by squeezing the 

providers. The only thing they know how to do is just squeeze down 

the doctor fees, hospital fees, and as the chief actuary of Medicare 

pointed out, the Medicare rates are going to be down here and everybody else’s rates are going to be going like that, and the difference is going to grow wider and wider through time, and by the 

time we get to the end of the decade, doctors will prefer Medicaid 

patients to Medicare patients. The waiting lines are going to be 

long and seniors will be at the end of the line. 

Mr. BURGESS. What is the implication for the average Member 

of Congress on that day? 

Mr. GOODMAN. You are going to be hearing from a lot of older 

voters and they are not going to happy. 

Mr. BURGESS. I was going to say, are they going to be happy or 

sad? 

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Mr. GOODMAN. They are going to be very sad. 

Mr. BURGESS. I thank the gentleman for yielding his time, and 

I will back the 10 seconds. 

Mr. PITTS. The chair thanks the gentleman. The gentleman’s 

time is expired. The chair recognizes the ranking member of the 

full committee, Mr. Waxman, for 5 minutes for questioning. 

Mr. WAXMAN. Thank you, Mr. Chairman. I would like to draw attention to a statement from Senator Harkin which I first of all ask 

unanimous consent to put into the record. 

Mr. PITTS. Without objection. 

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Mr. WAXMAN. He is chairman of both an authorizing committee 

and appropriations subcommittee, and he says, ‘‘I understand the 

implications of this guarantee that Congress should mandate appropriations for certain programs in the Affordable Care Act that 

are fundamental to its success.’’ So I thought he has a lot to say 

from both sides of authorizing and appropriating. 

The health insurance marketplace was broken, and reforming 

the health insurance market was imperative. We say this frequently, and I would like to ask rhetorically, what does it mean? 

It meant the number of uninsured Americans would have grown to 

66 million by 2019. Those would be unhappy people as well. From 

2004 to 2007, 12.6 million adults, 36 percent of those who actually 

tried to purchase insurance in the individual market, were denied 

coverage. They weren’t happy about that. They were charged a 

higher premium rate or discriminated against because of preexisting conditions. Health insurance premiums more than doubled 

in the last decade and have risen three and a half times faster 

than wages during the same period, and at least 42 States, at least 

75 percent of the insurance market was controlled by five or fewer 

insurance companies. This type of market concentration provides 

little leverage for consumers to fight insurance company abuses 

such as rescissions of health care coverage when someone gets sick 

or denials of medically necessary treatments are insisted on. 

Now, I might just point out that those facts are I guess the Republican plan because they want to repeal the Affordable Care Act, 

which would leave us with the status quo. They would do nothing. 

The Affordable Care Act addressed these problems, and here are a 

few of the examples. They prohibit insurers from denying individuals insurance or charging people more because of preexisting 

health conditions from hangnails to heart disease. They limit outof-pocket spending for health care benefits, prohibit annual and 

lifetime limits by insurance companies, significantly reduce red 

tape, invest in ways to reform the delivery system to provide better 

care at lower costs. 

Senator Vitale, can you describe why health reform is so important, why repealing it would be disastrous for Americans, for the 

economy and for our health care system? 

Mr. VITALE. Thank you, Mr. Waxman. You all have a very difficult time of it here and you made some very difficult decisions 

and very controversial decisions. I can speak from the experience 

of New Jersey and what it means to have a State with 1.3 million 

uninsured mostly working people who get up every day, put on 

their shoes and try to make a living and provide for their families. 

They work for small companies by and large who can’t afford the 

cost of health insurance to provide to their employees, and if they 

can, the contribution by the employee is usually beyond what it is 

that they can afford. So the simple facts are, and setting aside all 

the controversy between what is mandatory and what is discretionary, the fact of the matter is that there are millions of New 

Jerseyans and millions of Americans who are suffering every day 

without an opportunity for what is reliable and dependable and affordable health care. PPACA provides that. It is an imperfect piece 

of legislation, and most legislative initiatives are, and I can speak 

for that firsthand in New Jersey. 

93 

Mr. WAXMAN. Now, if it weren’t there, we would be back to the 

golden age of pre-Affordable Care Act, which I guess is what the 

Republicans would want. 

Now, one of the things they attack in this proposal today are the 

teaching health centers. For years, we provided mandatory funding 

for hospitals under the Medicare program to train medical resident 

trainees. In 2009, we provided about $9.5 billion in mandatory 

funding to train medical residents. Multiple expert bodies including 

MedPAC, the Council on Graduate Medical Education and others 

have called for more training of primary care residents and more 

training in the community because that is where most physicians 

practice today. That is why the ACA provided $230 million over 5 

years to directly fund community-based centers to train primary 

care. 

Now, my colleagues on the other side of the aisle have repeatedly 

called for more workforce efforts. One of the witnesses, Dr. Goodman, has criticized the ACA for not providing enough funding to 

train physicians. Senator Vitale, can you tell us about the importance of funding to training primary care residents in your State? 

Mr. VITALE. Three years ago, I attended a class and I spoke to 

a class at Rutgers Medical School, and there were about 60 students present and I asked by a show of hands how many were 

going forward to primary care. One person raised their hand. So 

the importance is of course—and thank you, Mr. Chairman. The 

importance is of course that we begin to develop this not just those 

who practice in primary care but also those who practice in advanced practice nursing. 

Mr. WAXMAN. Well, I can think of no better use of mandatory 

funds than to provide funding for residents. 

Mr. PITTS. The gentleman’s time has expired. The chair recognizes the gentlelady from Tennessee, Ms. Blackburn, for 5 minutes 

for questions. 

Mrs. BLACKBURN. Thank you, Mr. Chairman, and thank you to 

our witnesses for your patience today, and also for understanding 

that we have another hearing going on downstairs. 

Mr. Vitale, I appreciate that you are here. I was a State senator 

in Tennessee before I came here, and I was a State senator during 

the TennCare era, which was the test case for public option health 

care. Now, I know in New Jersey you have guaranteed issue and 

I think it is 45 mandates—am I correct—that you all have to cover 

in that package? Which is pretty expensive. And the way TennCare 

is set up under an 1115 waiver with CMS, it was between the Governor’s Office in Tennessee and CMS. So in New Jersey, do you all 

have any law on the books that allows the governor to spend State 

money without coming to the legislature? 

Mr. VITALE. Well, there are elements in every—and we balance 

our budget every year by constitutional mandate. There are elements in the budget that is part of the governor’s budget and so 

he is of course free to spend the dollars in his budget appropriation. 

Mrs. BLACKBURN. OK. Let me ask you this, the 45 benefit mandates, that is a big number. Do you think as you are looking at the 

health care situation in your State and others and talking with us, 

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do you think that individuals should have access to health care 

with fewer mandated benefits, State or federal mandated benefits? 

Mr. VITALE. I think we should all have the same benefits available to all of us. 

Mrs. BLACKBURN. So you think one size fits all? 

Mr. VITALE. In most cases, yes. 

Mrs. BLACKBURN. I have to differ with you on that. 

Mr. Istook, let me talk to you about the teaching centers. I found this very interesting. Section 5508 of Obamacare provides $230 

million not simply an authorization but this is for the teaching 

study program yet the President’s budget zeroes out funding for 

children’s hospital graduate medical education. And you are a 

former appropriator so do you think that it is wise to make one 

program mandatory and beef up one and then completely cut out 

another one, especially when you are looking at children’s health 

care? 

Mr. ISTOOK. There is an unfortunate trend that we have seen in 

the President’s budget proposals of substituting mandatory funding 

for discretionary funding, in other words, trying to remove things 

beyond the ability of Congress to control spending. Examples include not only what you cite but when the President says, for example, we are reducing discretionary spending, if you read the 

budget you find that one way is, you take Pell grants and say they 

are no longer discretionary, now they are mandatory. You take 

transportation funding and say it is no longer discretionary, now 

it is mandatory, and they then trumpet a claim that we have reduced discretionary spending. Well, you have done that by relabeling it as mandatory. There is no savings there and it is lousy 

practice as far as accountability. 

Mrs. BLACKBURN. Dr. Goodman, if I could come to you on that 

very point, because the concern of moving things from discretionary 

to mandatory is of great concern to us. As you all have reviewed 

the bill, have you been able to articulate the number of times that 

this has happened in the Obamacare bill and to look at the estimated impact above what we know as the appropriated dollars for 

this one action? 

Mr. GOODMAN. Well, not beyond what the Congressional Research Service report has stated. I just think there are, as my testimony indicated, fundamental flaws in this bill. And in response to 

Congressman Waxman’s critique, behind every flaw that we discuss in this testimony, we said this is the alternative, this it the 

right way to do it as far as general concept is concerned, and if we 

don’t do it the right way, then we are going to continue on a spending path that is simply unsustainable. There is nothing in the Affordable Care Act that fundamentally changes the way we are 

going to pay for health care. It is going to make all the perverse 

incentives that are now there worse than they were before, and the 

price we pay is going to be higher. 

Mrs. BLACKBURN. I found it so interesting last week, and I discussed this with Secretary Sebelius last week. There was a Wall 

Street Journal editorial where you had Ms. Cutter and Ms. 

Daparel, the word was that they were telling people not to worry 

about all the numerous waivers that were there and not to worry 

about the duplications, that this is a way—giving the States a 

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waiver was a way to ease us more to a single payer system, and 

as we have looked at these programs, the personal responsibility 

education program, there is money for that that is made mandatory 

in the Obamacare program but yet the President’s fiscal year budget, 2012 budget, includes $16 billion for programs that overlap. Are 

you all doing any research work on that? And I know my time is 

expired and I will yield back at the end of your response. 

Mr. GOODMAN. Well, let us think about what those waivers are 

about. Two point seven million people have been granted a waiver. 

That contracts with 12,500 people who have the problem everybody 

is talking about, that they have been denied health insurance because of a preexisting condition. Twelve thousand five hundred people now have been signed up for insurance, paying the same premium healthy people pay. That problem is solved. The 2.7 million 

people are people like the workers at McDonald’s who earn $10, 

$15 an hour. The insurance that they are going to have to buy for 

family coverage would be almost $6 an hour. They can’t afford it. 

McDonald’s can’t afford it. That is why they were granted a waiver 

but at the end of the waiver period the problem is not going to go 

away. 

Mr. PITTS. The gentlelady’s time is expired, and the chair recognizes the gentlelady from Wisconsin, Ms. Baldwin, for 5 minutes 

for questions. 

Ms. BALDWIN. Thank you, Mr. Chairman, and before I turn to 

the topic of the hearing, I do want to express my gratitude to you 

and members on both sides of the aisle for advancing H.R. 525 on 

public health veterinarians, which passed last night by the very 

comfortable margin of two votes. So mission accomplished with regard to that piece of important legislation, and I really do appreciate the efforts of members on both sides of the aisle. 

Turning to the subject at hand, many are familiar with the expression ‘‘everyone is entitled to their own opinions but they are 

not entitled to their own facts,’’ and I understand that my Republican colleagues may have differing opinions about the health care 

law that was signed into law last year but there should be no mistake about the facts. The five committee prints that we are looking 

at in this hearing put forth by the Majority will not create jobs. 

These proposals will not stimulate our struggling economy and 

these proposals will not put the middle class of America back to 

work. 

The Republican Majority is playing what I would consider a dangerous game of bait and switch with the American people. Despite 

promises from the new Majority during the midterm elections that 

this Congress would be focusing on creating jobs and bolstering the 

economy, the legislative proposals and the committee prints that 

they have offered us today fail to deliver on this promise. In fact, 

not only do the Majority’s legislative proposals do nothing to create 

jobs or bolster the economy, I think these proposals would actually 

exacerbate the problem by taking away new job opportunities. 

With new investments in the health care law, we took tremendous strides towards expanding, for example, the primary care 

workforce, and we are on a path to train 16,000 new primary care 

providers in the United States. So far, my home State of Wisconsin 

has received $3.8 million for a primary care residency program, 

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and we know how important training primary care physicians is for 

our economy. I mean, these doctors serve as gatekeepers, keeping 

people out of emergency rooms and controlling health care costs. 

The Republican proposal to change the teaching centers development grants program places this investment at risk and could ultimately worsen the health care workforce shortage. I fail to see how 

taking away funding for critical jobs is going to help our economy. 

Another proposal that we are looking at today would repeal funding for grants to States to establish exchanges. These exchanges 

are critical for ensuring that thousands of small businesses and 24 

million Americans have access to new coverage options. The grants 

to States would provide States with the flexibility to create an exchange that meets each State’s needs. Wisconsin has already received $38 million through an early innovator grant. This critical 

funding will spur job creation in my State and improve access to 

quality, low-cost health coverage. 

This Republican proposal raises an important question: Are we 

going to ask cash-strapped States to return the money they have 

already been awarded? Will Wisconsin have to return the $38 million that Governor Walker has already accepted? And I fail to see 

how rescinding money that will create jobs is the right thing to do 

to get our economy back on track. 

Mr. Chairman, the American people, the people of Wisconsin deserve better, and we should be focusing on the greatest need our 

country has right now, which is jobs, jobs and jobs. I would yield 

my remaining time to the gentleman from New York, Mr. Weiner. 

Mr. WEINER. Thank you very much, and welcome, Congressman. 

It is nice to see you back. It is nice to see people who leave this 

place with marketable skills. I am glad at least you do. 

I just want to ask a yes or no question, if I could, in the brief 

time that Congresswoman Baldwin has yielded to me. Congressman Istook, is Medicare a single-payer system? 

Mr. ISTOOK. No. 

Mr. WEINER. Dr. Goodman, is Medicare a single-payer system? 

Mr. GOODMAN. No. 

Mr. WEINER. Senator Vitale, is Medicare a single-payer system? 

Mr. VITALE. I believe it is. 

Mr. WEINER. It is single payer in the traditional way that it is 

used because there is one person writing the checks but that 

doesn’t mean that—right? I mean, basically the Federal Government collects our money in our taxes, in our payroll taxes and then 

reimburses doctors, reimburses clinics, reimburses other—that is a 

single-payer system. It doesn’t mean that Medicare employs the 

doctors, it doesn’t mean they employ the clinics, it doesn’t mean 

they employ the pharmaceutical companies. It is just who passes 

the money along. And in the one second I have left, do you know 

what the overhead and profits is of Medicare? One point zero three 

percent. 

Mr. BURGESS. [Presiding] The gentleman’s time is expired. The 

chair recognizes the gentleman from Georgia, Dr. Gingrey. 

Mr. GINGREY. Mr. Chairman, thank you, and Representative 

Istook, let me associate myself with Representative Weiner in regard to his comments. Thank you for your service and happy to see 

you, and thank all three of the witnesses for your testimony today. 

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I want to start out by saying that the actions of this Administration and the Secretary of Health and Human Services I think border on deception and they leave me with very little confidence in 

both Obamacare and the Administration’s ability to enact the law 

through regulation over these next 3 years. Just last week was the 

latest example. Secretary Sebelius right here in this committee told 

Congressman Shimkus that the Administration was confident that 

she could spend one pot of money, $500 billion worth of money, 

twice, both to pay for Obamacare and increase the solvency of 

Medicare. And then next the Secretary testified that she had used 

her powers as Secretary to slip in an end-of-life provider code into 

Medicare in the dark of night without allowing for public comment. 

And finally, she told our panel and a Senate Finance Committee 

panel a few weeks ago that a major long-term-care program created 

in Obamacare that she is in charge of was totally unsustainable 

but only after direct questioning. No previous announcement to the 

American people or to Congress, and of course, I am referring to 

the CLASS Act. 

With these thoughts in mind, I wanted to ask you, Representative Istook, section 4002 of the Obamacare bill, or the Affordable 

Care Act, created a fund for prevention, wellness and public health 

activities. In the language of Obamacare, it says that these funds 

are for ‘‘sustained and national investment in prevention and public health programs.’’ Are the words ‘‘prevention’’ and ‘‘public health 

programs’’ defined in section 4002? 

Mr. ISTOOK. I am not aware of any definition. I think that is left 

to the sole discretion and judgment of the Secretary. 

Mr. GINGREY. And so conceivably then Secretary Sebelius or any 

Secretary could use these funds for any purpose that they decide 

is prevention, correct? 

Mr. ISTOOK. Oh, yes. They could be extremely broadly defined. 

Mr. GINGREY. Wide, wide discretion on the part of the Secretary 

of HHS. 

Mr. ISTOOK. Right. 

Mr. GINGREY. Let me go to Mr. Goodman. You know, we all remember the Andy Griffith Medicare ads that the Secretary ran last 

year that looked a lot like to me political advertising for the Affordable Care Act, Obamacare. Is there anything that would prevent 

the Secretary from using these taxpayer dollars to pay for similar 

political advertising on provisions in Obamacare in a lead-up to the 

2012 elections, as an example? 

Mr. GOODMAN. I don’t think so, and let me say, those Andy Griffith ads were extremely deceptive bordering on fraud because what 

he talked about were the benefits for seniors under the bill but 

didn’t mention any of the costs, and for every $1 of new spending, 

there are $10 of reductions in spending for seniors. So on net, there 

is going to be a lot less spending on senior citizens. You know, that 

ad made it sound like boy, once seniors find out how this works, 

they are going to like it. 

Mr. GINGREY. Well, I thank you for that response, and I wasn’t 

going to use the word ‘‘fraud’’ but I guess ‘‘bordering on fraud’’ is 

acceptable language in your testimony, and I tend to agree with 

you on that. 

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Dr. Goodman, how much authority does Secretary Sebelius have 

over Obamacare now that it is being implemented by regulation? 

Mr. GOODMAN. You know, I don’t know but every time I learn 

about some new exercise of authority, I am shocked. I have never 

seen so much authority that has been given to a Secretary, nothing 

even close to it, and it bothers me because, you know, there are 

elections, Presidents come and go, Secretaries come and go, and if 

a Secretary has that much power, how do we know what is going 

to happen 8 years from now, 12 years from now? We are no longer 

a government of laws, we are government of people and discretion, 

whims. 

Mr. GINGREY. Mr. Goodman, thank you. 

In the few seconds I have got left, let me shift to Senator Vitale. 

Senator, in your written testimony and what you said to us here 

today, you kind of touted what New Jersey has done in regard to 

the CHIP program and the fact that you cover childless adults, and 

I realize this goes back to Governor Whitman but, you know, and 

you talk about the fact that charity care went way down because 

you expanded this cover, the CHIP program. I think it was, what, 

something like 400 percent of the federal poverty level in New Jersey. Are you aware of the fact that most of these hospitals that provide charity care are not-for-profit, and in that status as not-forprofit they get tremendous tax breaks, and it is their obligation to 

be designated as not-for-profit to provide this charity care? 

Mr. VITALE. May I respond, Chairman? Thank you. 

Well, you are right, but the fact of the matter is that the overwhelming amount of charity care has just really been debilitating 

for our State’s hospitals. It is so overwhelming that they do meet 

their charitable obligation as not-for-profits but to the extent now 

that there are so many uninsured accessing health care in the 

worst and most expensive manner, in the emergency departments, 

has pushed a number of hospitals and into closure in our State, 

and those who are surviving are under increasing pressure from 

those who are uninsured. 

Mr. GINGREY. Mr. Chairman, reclaiming—I realize my time is expired and I appreciate your indulgence. If you could just let me 

make this one comment? I mean, the point I am making is that 

these hospitals, they are designed not-for-profit, and it doesn’t 

mean that these patients are going to the emergency room to get 

their care. Most of these hospitals have outpatient clinics and the 

ability to provide the same level of care that they would be getting 

if they were signed up for SCHIP or in one of these exchanges that 

the good senator is referring to, and I will yield back and I thank 

you for your indulgence. 

Mr. BURGESS. Thank you. The gentleman from New York is recognized for 5 minutes. 

Mr. WEINER. The problem is, they are not paid for. Ultimately, 

they have to pay for it. The bill fairy doesn’t come in and say to 

any kind of hospital we are going to go pay your bills. 

By the way, Dr. Goodman, calling Andy Griffith a fraud is outrageous. He is one of the most beloved Americans. I am just kidding. 

Let me just, Senator Vitale, let me ask you a couple of questions. 

There has been a lot of discussion by the two gentlemen to your 

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right about the inflexibility and the Federal Government control 

that is being taken by this bill. Let me just ask you a couple of 

questions. State insurance commissioners were still kept in charge 

of State insurance policies in the 50 States. Is that correct? 

Mr. VITALE. Yes. 

Mr. WEINER. And didn’t the Affordable Care Act not only do that 

but empower them with additional tools they didn’t have before on 

behalf of the residents of the State? Is that correct? 

Mr. VITALE. That is correct. 

Mr. WEINER. Is it also correct that under the federal Affordable 

Care Act the exchanges if the States so choose are going to be set 

up as State-run, State-governed exchanges? Is that correct? 

Mr. VITALE. That is correct. 

Mr. WEINER. Isn’t it also true that despite the efforts of many of 

my Republican friends and perhaps the gentlemen to your right, efforts to nationalize tort reform were resisted? Isn’t tort reform still 

the purview of the States under this law? 

Mr. VITALE. It is and always has been. 

Mr. WEINER. Isn’t it also true that the expansion of Medicaid between now and 2017 is entirely picked up by the Federal Government? Is that true? 

Mr. VITALE. Yes. 

Mr. WEINER. Isn’t it also true that in 2018, 2019, 2020 and 2021, 

if there are fewer poor people, fewer people bankrupted by health 

care costs, for example, more people working, more people employed, the number of Medicare beneficiaries if your State is successful will go down, will it not? 

Mr. VITALE. Yes, it will. 

Mr. WEINER. And with it will be Medicaid expenses, will it not? 

Mr. VITALE. Yes. 

Mr. WEINER. So in fact, if you are a well-governed State and the 

economy does better, meaning less, God willing, 20 percent of the 

economy is health care, and people are employed more like they 

have been increasingly—more private sector jobs have been created 

under President Obama than under 8 years of President Bush—if 

it continues that way, Medicaid expenses could go down. Is that 

correct? 

Mr. VITALE. That is correct. 

Mr. WEINER. Now, if I can talk to you a little bit about some of 

the things that are required in here and just get your feedback on 

them. One is this notion of standards. The gentlewoman from Tennessee says oh, one size fits all, but let us assume for a moment 

the citizens of New Jersey through their State rights say that we 

are going to have certain health care standards that are robust, we 

want to make sure that our insurance actually covers people, and 

the State of Tennessee says no, we are going to have a scaled-down 

program that has virtually no benefits but lower cost, isn’t it very 

likely that citizens of New Jersey, if they can go to that lower 

standard, the healthy ones will say, Wait a minute, I don’t need a 

lot of insurance, I am going to go to the lower standards—won’t 

there be a race to the bottom, less insurance and ultimately the 

same thing we have now, which is people who are underinsured? 

Wouldn’t that be the effect? 

Mr. VITALE. That will be the effect, yes. 

100 

Mr. WEINER. So the effect of having standards across State lines 

is to make sure there is fair competition between States. 

Next is this notion of mandatory coverage that is enshrined in 

Romneycare. Are you aware that under the mandatory policies of 

Romneycare that with the subsidy, a very similar model that we 

set up, under Romneycare, a grand total of 0.67 percent chose not 

to take the subsidy and buy insurance? Are you aware of that? 

Mr. VITALE. Yes. 

Mr. WEINER. It is a very tiny number because actually this is 

going to come as a surprise, the American people when given a 

subsidy, they want the insurance. 

Now I would like to talk a little bit about Dr. Goodman and Congressman Istook’s solutions. They say why don’t we look at what 

Walmart does and they are able to lower costs if we just give people money, they will go out and buy insurance. Well, if you don’t 

believe in the laws of big markets and you don’t believe in the laws 

of the economy that more people joining together can negotiate for 

lower prices, you can do something. Maybe my father when he retired at 61 with an incidence of prostate cancer was not yet eligible 

for Medicare, he went out as an individual and said I am going to 

try to buy insurance so the insurance company said one of two 

things: One, we don’t want you, you are going to get sick, our business model is paying out as little as possible, or two, they said 

$17,000 to $20,000 a year from my retired father. And the reason 

is very simple. Under Dr. Goodman’s model, we can all be given 

money to go out and spend and people like me and Congressman 

Istook, who is healthy as an ox, he will be able to get insurance, 

but what do you do with the people who the insurance company 

says I don’t want it. Under Dr. Goodman’s model, there are no 

standards, everyone just gets a check. What you are doing is 

deconstructing one of the most powerful models that Walmart uses, 

which is when you get large pools of people, you are able to hold 

costs down. If you don’t believe me, look at how auto insurance 

works. It aggregates risk over the whole pool. You say to each and 

every citizen, go out and buy for yourself, you are resisting the 

ideas of a free marketplace and how it works and works best. And 

I have got news for you, Dr. Goodman. Do you know who is going 

to love your idea? Insurance companies. They love the idea of just 

give the money, we will get some people come in with the money 

but we will get to decide who we want and who we don’t, and you 

ignore the idea that sometimes what you have got to say is you 

know what, let us pool people together, and for those of you who 

are wondering, the idea of expanding Medicare, the boogeyman of 

the single-payer system, is based on that model because we have 

all these citizens, we hold down costs and we aggregate everyone 

together. That is the way the system works correctly. I thank you. 

Mr. PITTS. The gentleman’s time has expired. The chair recognizes the ranking member for a unanimous consent request. 

Mr. PALLONE. Mr. Chairman, I would ask unanimous consent to 

include the testimony of Jeff Levi of the Trust for America’s Health 

and from Alan Weil of the National Academy for State Health Policy, and I would also like to add a facts sheet on your proposal, the 

chairman’s proposal, to block mandatory funding in the Affordable 

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Care Act. This was prepared by Mr. Waxman, our ranking member. I believe you have all of these. 

Mr. PITTS. Without objection, so ordered. 

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Mr. PITTS. In conclusion, I would like to thank our witnesses, 

former Congressman Istook, Dr. Goodman, Senator Vitale, for their 

testimony. I would like to thank them and the members for participating in today’s hearing. I remind the members that they have 10 

business days to submit questions for the record, and I ask the witnesses to please respond promptly to the questions. Members 

should submit their questions by the close of business on March 

23rd. 

With that, this subcommittee hearing is adjourned. 

[Whereupon, at 1:50 p.m., the subcommittee was adjourned.] 

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