[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]





                    OBAMACARE IMPLEMENTATION AND THE
                     DEPARTMENT OF HEALTH AND HUMAN
                      SERVICES FY16 BUDGET REQUEST

=======================================================================

                                HEARING

                               before the

                      COMMITTEE ON WAYS AND MEANS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 10, 2015

                               __________

                          Serial No. 114-FC05

                               __________

         Printed for the use of the Committee on Ways and Means



[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]










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                      COMMITTEE ON WAYS AND MEANS

                     PAUL RYAN, Wisconsin, Chairman

SAM JOHNSON, Texas                   SANDER M. LEVIN, Michigan
KEVIN BRADY, Texas                   CHARLES B. RANGEL, New York
DEVIN NUNES, California              JIM MCDERMOTT, Washington
PATRICK J. TIBERI, Ohio              JOHN LEWIS, Georgia
DAVID G. REICHERT, Washington        RICHARD E. NEAL, Massachusetts
CHARLES W. BOUSTANY, JR., Louisiana  XAVIER BECERRA, California
PETER J. ROSKAM, Illinois            LLOYD DOGGETT, Texas
TOM PRICE, Georgia                   MIKE THOMPSON, California
VERN BUCHANAN, Florida               JOHN B. LARSON, Connecticut
ADRIAN SMITH, Nebraska               EARL BLUMENAUER, Oregon
LYNN JENKINS, Kansas                 RON KIND, Wisconsin
ERIK PAULSEN, Minnesota              BILL PASCRELL, JR., New Jersey
KENNY MARCHANT, Texas                JOSEPH CROWLEY, New York
DIANE BLACK, Tennessee               DANNY DAVIS, Illinois
TOM REED, New York                   LINDA SANCHEZ, California
TODD YOUNG, Indiana
MIKE KELLY, Pennsylvania
JIM RENACCI, Ohio
PAT MEEHAN, Pennsylvania
KRISTI NOEM, South Dakota
GEORGE HOLDING, North Carolina
JASON SMITH, Missouri
ROBERT J. DOLD, Illinois

                       Joyce Myer, Staff Director

                  Janice Mays, Minority Chief Counsel



























                            C O N T E N T S

                               __________

                                                                   Page

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

                                WITNESS

The Honorable Sylvia Burwell, Secretary, U.S. Department of 
  Health and Human Services......................................     5

                       SUBMISSIONS FOR THE RECORD

A Submission of The Honorable Earl Blumenauer....................   120
Act No. 2015-279.................................................   123
Foster Family-based Treatment Association (FFTA).................   130
William Jefferson Terry, Sr., M.D., Member, American Urological 
  Association, American Medical Association, and Medical 
  Association of the State of Alabama............................   138

 
                    OBAMACARE IMPLEMENTATION AND THE
                     DEPARTMENT OF HEALTH AND HUMAN
                      SERVICES FY16 BUDGET REQUEST

                              ----------                              


                        WEDNESDAY, JUNE 10, 2015

                     U.S. House of Representatives,
                               Committee on Ways and Means,
                                                    Washington, DC.

    The Committee met, pursuant to call, at 10:05 a.m., in Room 
1100, Longworth House Office Building, Hon. Paul Ryan [Chairman 
of the Committee] presiding.

    [The advisory announcing the hearing follows:]

ADVISORY

FROM THE 
COMMITTEE
 ON WAYS 
AND 
MEANS

                                                CONTACT: (202) 225-3625
FOR IMMEDIATE RELEASE
Wednesday, June 3, 2015
No. FC-05

                   Chairman Ryan Announces Hearing on

                    Obamacare Implementation and the

                     Department of Health and Human

                      Services FY16 Budget Request

    Chairman of the House Committee on Ways and Means Paul Ryan (R-WI) 
today announced that the Committee will hold a hearing on Obamacare 
Implementation and the Department of Health and Human Services FY16 
Budget Request. The hearing will take place Wednesday, June 10, 2015, 
in Room 1100 of the Longworth House Office Building, beginning at 10:00 
a.m.
      
    Oral testimony at this hearing will be from the invited witness 
only. However, any individual or organization may submit a written 
statement for consideration by the Committee and for inclusion in the 
printed record of the hearing.
      

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

      
    Please Note: Any person(s) and/or organization(s) wishing to submit 
written comments for the hearing record must follow the appropriate 
link on the hearing page of the Committee website and complete the 
informational forms. From the Committee homepage, http://
waysandmeans.house.gov, select ``Hearings.'' Select the hearing for 
which you would like to make a submission, and click on the link 
entitled, ``Click here to provide a submission for the record.'' Once 
you have followed the online instructions, submit all requested 
information. ATTACH your submission as a Word document, in compliance 
with the formatting requirements listed below, by the close of business 
on Wednesday, June 24, 2015. For questions, or if you encounter 
technical problems, please call (202) 225-3625 or (202) 225-2610.
      

FORMATTING REQUIREMENTS:

      
    The Committee relies on electronic submissions for printing the 
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the Committee relies on electronic submissions for printing the 
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included in the body of the email. Please exclude any personal 
identifiable information in the attached submission.
      
    3. Failure to follow the formatting requirements may result in the 
exclusion of a submission. All submissions for the record are final.

    The Committee seeks to make its facilities accessible to persons 
with disabilities. If you are in need of special accommodations, please 
call 202-225-1721 or 202-226-3411 TDD/TTY in advance of the event (four 
business days notice is requested). Questions with regard to special 
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    Note: All Committee advisories and news releases are available 
online at 
http://www.waysandmeans.house.gov/.

                                 

    Chairman RYAN. The Committee will come to order. We know 
that the Secretary is on a tight timeline today with a hard 
deadline at noon. That is why the Ranking Member and I just 
discussed that we will limit Members' questions to 4 minutes so 
as to accommodate as many Members as possible in the 
questioning. But first let me start off by thanking our 
witness, Secretary Burwell.
    I understand that you have to get going, so we are going to 
move this as quickly as we can. We were supposed to have this 
hearing earlier in the year, but events overtook us. So here we 
are today. I understand that the majority of your remarks are 
going to be about the budget. That is all well and good. But it 
shouldn't surprise you, Secretary Burwell, that we are a little 
more interested in talking about ObamaCare, especially given 
the President's remarks this week.
    I hope he gives you a medal for this job, because defending 
this healthcare law is no easy task. I think any objective 
observer would say that this law is on the fritz, by the law's 
own standards. The whole point of ObamaCare was to make health 
care more affordable. But premiums aren't going down, they are 
going up, way up all over the country. Insurers are proposing 
double-digit premium increases. In Maryland it is close to 30 
percent; Tennessee, 36 percent; South Dakota, 42 percent.
    Tax season was like a bad dream before. Now it is a total 
nightmare. People could never afford these plans on their own, 
so the law gave subsidies to some people. Well, now two-thirds 
of the people who got them had to pay the IRS back, on average 
over $700. That is not the kind of money that people just have 
laying around.
    And for all of this hassle, for all of this, what are we 
getting for it? The argument was that if people had insurance 
they would go to the doctor instead of the emergency room. But 
now even more people are going to the emergency room.
    So whatever the Supreme Court decides later this month, I 
think the lesson is absolutely clear: ObamaCare is just flat 
busted. It just doesn't work. And no fix can change that fact. 
We are not talking about a ding or a dent or a fender-bender or 
a flat tire. The whole law is a lemon. Its very linchpin, its 
central principle, is government control. That means higher 
prices, fewer choices, and lower quality.
    So the answer isn't just to tighten a few screws and 
everything will be fine. The answer isn't just to tweak it here 
and tweak it there and we will all be okay. The answer is to 
repeal and replace this law with patient-centered reforms.
    And the truth is, I don't have to convince this 
Administration that the law is broken. I know that you know it 
is broken, because you keep trying to fix it. For several years 
now, HHS has delayed parts of the law, and sometimes, in some 
cases, they have rewritten it on the fly.
    We know the most egregious example, the subsidies. The law 
says that people who buy plans on State exchanges can get 
subsidies. It doesn't say anything about Federal exchanges. And 
yet, HHS has sent millions of subsidies out the door, putting 
millions of people at risk.
    More and more it seems the Administration isn't so much 
implementing the law as they are improvising it. We have 
already seen the evidence of the Administration using one 
account to pay for multiple programs--programs that Congress 
never funded. That is one of the main reasons that we are 
holding this hearing today. It is Congress that wields the 
power of the purse. And more and more the Administration is 
acting like a purse snatcher.
    So again, my kudos to you, Secretary Burwell, on a very 
difficult assignment. But the American people, they deserve 
better. They deserve a healthcare system that puts the patient 
first. They deserve lower prices. They deserve more choices. 
They deserve higher quality. And the Committee is going to do 
all it can to make those things happen.
    And with that, I would like to yield to the Ranking Member.
    Mr. LEVIN. Welcome.
    You know, I am glad we are having this hearing. And 
obviously the Republicans want to focus on ACA, and I think 
that is a good idea, because what is busted is not ACA, but 
your attacks on it, endless attacks, never coming up with a 
single comprehensive alternative in all these years.
    So you sit as armchair critics while millions of people 
have insurance who never had it before. Millions of kids have 
insurance who would not otherwise have had it. People who have 
preexisting conditions no longer are canceled or can't even get 
insurance. The doughnut hole is gone. Millions of people in 
lower income categories are now insured through Medicare, 
millions and millions and millions. Cost containment is 
beginning to work. It is beginning to work. The increase in 
costs, that rate is going down.
    And so you are livid because it is getting better. That is 
why you are livid. And I am not surprised at your fervor. We 
will be glad to take it on. We will be glad to take it on.
    And I think you just need to understand what this 
experiment is all about. It was combining increased access to 
Medicare, to Medicaid, with an increased reliance on the 
private insurance sector. That is really what this is all 
about, an experiment.
    And you talk about government control? More and more people 
are getting insurance through the private sector. And the 
States that are denying their citizens further coverage under 
Medicaid are essentially telling people: Well, get lost when it 
comes to health coverage. Get lost.
    And you have a governor, Mr. Chairman, who is running 
around this country talking about the evils of health care, 
when millions of people are benefiting from what happened.
    So you decided to turn this from budget to ACA. Welcome. 
Welcome. Your frustration is millions and millions and millions 
of people are benefiting, have health care when they did not 
before.
    So, Madam Secretary, I think they have thrown down the 
gauntlet. I don't feel sorry for you. I think you love this job 
and you like being the person who is administering this 
experiment in greater health coverage after 70, 80 years of 
nothing being done in this town or throughout this country. So 
I happily welcome you because I think you are a very happy 
warrior.
    I yield back.
    Chairman RYAN. I would like to recognize the happy warrior 
now for your opening statement. The floor is yours, Secretary 
Burwell.

  STATEMENT OF THE HONORABLE SYLVIA BURWELL, SECRETARY, U.S. 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Secretary BURWELL. Thank you. Chairman Ryan, Ranking Member 
Levin, and Members of the Committee, thank you for the 
opportunity to discuss the President's budget for the 
Department of Health and Human Services.
    I believe firmly that we all share common interests and 
therefore we have a number of opportunities to find common 
ground. And we saw the power of common ground in the recent 
bipartisan SGR fix, and I appreciate all of your efforts to get 
that work done.
    The President's budget proposes to end sequestration, fully 
reversing it for domestic priorities in 2016, matched by equal-
dollar increases for defense funding. Without further 
congressional action the sequestration will return in full in 
2016, bringing discretionary funding to its lowest level in a 
decade, adjusted for inflation. We need a whole-of-government 
solution, and I hope both parties can work together to achieve 
a balanced and commonsense agreement.
    The budget before you makes critical investments in health 
care, science, innovation, and human services. It maintains our 
responsible stewardship of the taxpayer's dollar. It 
strengthens our work, together with Congress, to prepare our 
Nation for key challenges both at home and abroad.
    For HHS, the budget proposes $83.8 billion in discretionary 
budget authority. This is a $4.8 billion increase, which will 
allow our Department to deliver impact today and lay a strong 
foundation for tomorrow. It is fiscally responsible, which in 
tandem with accompanying legislative proposals would save 
taxpayers a net $250 billion over 10 years. In addition, it is 
projected to continue slowing the growth of Medicare by 
securing $423 billion in savings as we build a better, smarter, 
healthier delivery system.
    In terms of providing all Americans with access to quality, 
affordable health care, it builds upon our historic progress in 
reducing the number of uninsured and improving coverage for 
families who already had insurance. A recent example of this 
progress is the 10.2 million Americans who are currently 
enrolled in health insurance through the marketplaces in 2015.
    The budget covers newly eligible adults in 28 States, plus 
D.C., with expanded Medicaid, and an improved access to health 
care for Native Americans. To support communities throughout 
the country, the budget makes critical investments in health 
centers 
and our Nation's health workforce, particularly in high-need 
areas. 
To advance our common interests in building a smarter, better, 
healthier delivery system, it supports improvements to the way 
care is delivered, providers are paid, and information is used.
    To advance our shared vision for leading the world in 
science and innovation, the budget increases funding for NIH by 
$1 billion to advance biomedical and behavioral research, among 
other priorities. It invests $215 million for the Precision 
Medicine Initiative, which will focus on developing treatments, 
diagnostics, and prevention strategies tailored to the 
individual genetic characteristics of individual patients.
    To further our common interests in providing Americans with 
the building blocks of healthy and productive lives, this 
budget outlines an ambitious plan to make affordable, quality 
childcare available for working families. To keep Americans 
healthy, the budget strengthens our public health 
infrastructure with $975 million for domestic and international 
preparedness, including critical funds to implement the Global 
Health Security Agenda. It also invests in behavioral health 
services, including more than $99 million in new funding to 
combat prescription opioid and heroin abuse, dependence, and 
overdose.
    Finally, as we look to leave our Department stronger, the 
budget invests in our shared priorities of addressing waste, 
fraud, and abuse, initiatives that are projected to yield $22 
billion in gross savings for Medicare over the next decade.
    We are also addressing our Medicare appeals backlog with a 
coordinated approach. We are pleased that the Senate Finance 
Committee last week passed bipartisan legislation, and we look 
forward to working with this Committee on it. I also want to 
assure you I am personally committed to responding promptly and 
thoroughly to the concerns of Members of the Committee.
    I want to close by taking a moment to say how proud I am of 
the HHS employees, from their work combating Ebola, to 
assisting unaccompanied children at the border, the commitment 
that they show day to day, day in and day out, as they work to 
help their fellow Americans have those building blocks of 
healthy and productive lives.
    I look forward to working closely with you to advance our 
common interests on behalf of the American people. Thank you.
    [The prepared statement of Secretary Burwell follows:]
    
    
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    Chairman RYAN. Thank you.
    Let me first start off by saying where we agree with the 
Administration we work with the Administration. This week's 
action on trade is a perfect example. But on this healthcare 
law we could not be more opposed to what the Administration is 
doing. We really think this is doing a great harm to the 
healthcare system and to the people we all represent.
    So let me start by just addressing the big elephant in the 
room. Any day now the Supreme Court, as you well know, because 
your name is Burwell in King v. Burwell, is about to rule, and 
if the Court rules against the Administration then millions of 
people will be stuck with a government-designed health 
insurance that they cannot afford.
    So, I mean, the big question is, then what? What about the 
people who are going to lose their subsidies and possibly their 
coverage? Is the President going to dictate to us how to fix 
this flawed law or is the President, is the Administration 
going to be willing to work with us to give families greater 
freedom in choosing the health care that works best for them?
    Secretary BURWELL. With regard to the question of the 
courts, I think you know we believe that we are implementing 
the law as it was written, as the statute is written, as it was 
intended, as CBO has scored it for all these years, as recent 
articles have reflected, that those who were part of writing 
the law indicate that it should be. The idea that citizens in 
the State of New York should receive Federal subsidies that 
taxpayers contribute to and citizens in the State of Texas 
should not is not what we think the law intended----
    Chairman RYAN. I understand your opinion on what the Court 
ought to do, but it stands to reason that there is a pretty 
decent chance that they may not go your way. So the question 
then is, then what?
    Secretary BURWELL. So if the Court does decide and if the 
Court would decide for the plaintiffs, and the idea that the 
Court would say that subsidies in the Federal marketplace are 
not eligible, those States that are part of the Federal 
marketplace, that those citizens can't have those subsidies, if 
the Court makes that decision we are going to do everything we 
can, and we are working to make sure we are ready to 
communicate, to work with States, and do everything we can. But 
the critical decisions, if the Court says that we do not have 
the authority to give subsidies, the critical decisions will 
sit with the Congress and States and Governors to determine if 
those subsidies are available.
    Chairman RYAN. So here is the question I am trying to get 
at. Is the President going to stand up and wave, I have a one-
page bill, I have a one-sentence fix, take it my way or the 
highway, is that going to be the Administration's position? Or 
is the Administration going to be willing to work with Congress 
to find a way to give people more healthcare freedom? That is 
the question I am trying to get at.
    Secretary BURWELL. With regard to the question of 
healthcare freedom, I think it is important to reflect, the 
marketplace is a market. It uses private insurers. People that 
sign up in the marketplace are not on, so they have many 
choices. As a matter of fact, in the marketplace this year 
there were 25 percent more plans. That is more choice. That is 
more competition. That is why 8 in 10----
    Chairman RYAN. Let me ask it this way, because I want to be 
kind to everybody's time. Let me ask it this way. If the 
plaintiffs prevail, if the King side wins, and then the 
exchanges are deemed unconstitutional, not legal in the 
Federal-exchange States, and the individual mandate is 
effectively struck down for those taxpayers in those States, is 
the President going to say reinstate the individual mandate? I 
have to tell you; it is not real popular. And we here, at least 
on this side of the aisle, aren't eager to reinstate the 
individual mandate. We would like to free people from some of 
these mandates.
    I would say that the Administration has kind of been a 
little two-sided on this particular issue, mandates, where you 
have delayed the employer mandate twice. That goes away as 
well.
    So is the Administration going to take the position 
Congress must just reinstate this thing in all these 37 States, 
reinstate the individual mandate, reinstate the employer 
mandate, my way or the highway, or is the President going to be 
willing and flexible to work with Congress to fix this mess and 
negotiate with Congress? That is what I am trying to get at.
    Secretary BURWELL. So I think it is actually very 
important, though, with regard to the decision before the 
Court, the decision before the Court is who receives subsidies 
and whether or not those subsidies can be given in States that 
have a Federal marketplace versus a State marketplace.
    Chairman RYAN. Yes, we understand that.
    Secretary BURWELL. That is the decision, and that is the 
only decision before the Court right now.
    Chairman RYAN. Okay, so should----
    Secretary BURWELL. And with regard to what happens if that 
decision occurs----
    Chairman RYAN. Yes.
    Secretary BURWELL [continuing]. Three things occur. The 
first thing that occurs is, for the people----
    Chairman RYAN. Secretary Burwell, we know what will occur. 
We all know this. The question is, what will the Administration 
do? Will they stand up with one piece of paper and say, ``My 
way or the highway,'' or will they work with Congress to 
address the situation?
    Secretary BURWELL. The problem that occurs if the Court 
decides against us is that they have made a decision that the 
subsidy isn't available.
    Chairman RYAN. You are not going to answer the question, 
are you?
    Secretary BURWELL. No, the answer is, the problem that gets 
created is subsidies aren't available. They aren't available 
for millions of Americans. They lose their insurance. It drives 
up costs in the individual market. To solve that problem the 
critical decisions are going to sit with the Congress or 
States.
    Chairman RYAN. Okay. Right. So for a bill to become a law, 
it goes through the House, the Senate, then the person at the 
other end of Pennsylvania Avenue, the President, signs that 
bill into law. Is the President going to come out and say, 
``Only my way or the highway,'' one-sentence, one-page fix, or 
is that President of the United States going to be thinking 
less about digging in and defending his law as exactly written, 
or is he going to be willing to actually deal with the issue, 
which is affordable health care for millions of people who are 
losing their health insurance? Is he going to work with 
Congress to address this situation or is he going to put 
concrete around his ankles and say, ``It is my law or 
nothing?'' That is the question I am trying to get at.
    Secretary BURWELL. So the President and we have said, the 
Administration has said all along, with regard to improvements, 
and we believe that there are improvements that can be made, we 
look at three things and a fourth underlying: Affordability, 
access, quality, and the issue of how it affects the deficit 
and our economy. We will look at anything and have that 
conversation.
    Chairman RYAN. Okay.
    Secretary BURWELL. With regard to the specifics that you 
raised, I do think it is important, the issue of the individual 
mandate. That is related to a very fundamental part of the 
system, which is preexisting conditions. And it is our 
experience, at least in my conversations across the country, 
that most Americans believe that you shouldn't be kept out of 
insurance or banned. If I have a child that has a condition, 
that is born with a particular condition, that I shouldn't 
spend my time worrying that that child will never get insurance 
once they go off mine.
    Chairman RYAN. You are kind of going off topic. I am going 
to cut you off there. We both know that there are ways of 
dealing with those problems without having to impose an 
individual mandate.
    Let me leave it there, in the interest of everybody's time.
    Mr. Levin.
    Mr. LEVIN. Well, I am not surprised at the tone, but I 
really think it is so counterproductive. Chairman, you talk 
about two-sidedness. The two sides, when you say you worry 
about the millions who will lose their insurance, when it is 
your allies who brought the suit that would deprive them of 
insurance. You talk about concrete, having feet in concrete? 
That is exactly where you have been in terms of ACA. Your feet 
have been in concrete while you have brought up bill after bill 
to try to destroy ACA. And when you say will the President be 
my way or the highway, that is precisely what has been your 
approach to ACA. Precisely. You have never sat down with us to 
say, how could we make some changes? Instead, you have been out 
to destroy ACA. And you say, where is the President's plan, 
when the President believes the Court will and should uphold 
the law. All you have done is issue op-eds.
    Chairman RYAN. And bills.
    Mr. LEVIN. And bills, contrary, contradictory bills. So you 
don't have any plan. Like you haven't had a plan for 60 years. 
So you can keep going after the Secretary and she will keep 
trying to spell out.
    I will ask you, and I finish, how many people have been 
receiving subsidies, Madam Secretary?
    Secretary BURWELL. Some 7.3 million people have received 
subsidies that are in the marketplace right now.
    Mr. LEVIN. So when you shed tears about 7.3 million, 
remember--or about the law--it is 7.3 million.
    What has been the average subsidy?
    Secretary BURWELL. Two hundred and seventy-two dollars per 
month is the average subsidy in terms of those that are in the 
marketplace that are subsidized. That is the 7.3 million. So 
10.2 million people are currently in the marketplace overall. 
About 85 percent of those receive subsidies. The average 
subsidy is $272 per month, which is what results in the 
affordability.
    Mr. LEVIN. And just quickly tell us, how many people have 
received additional care through expansion of Medicaid?
    Secretary BURWELL. The question of the total number, 
because there are people in terms of the expansion itself, 
about 10 million people are the estimates in terms of those 
States that have expanded.
    Mr. LEVIN. So add those two together and we are talking 
about individuals with families, and the Republicans come here 
and castigate you and this President. The shoe should really be 
on the other foot.
    I yield back.
    Chairman RYAN. Mr. Johnson.
    Mr. JOHNSON. Thank you, Mr. Chairman. I hardly know how to 
follow that.
    I guess I am supposed to thank you for being here. But I 
have to tell you, I am not in agreement with much of what you 
are saying. And let me just ask you, we are trying to get the 
health care back in shape, and it sounds to me like you want to 
go your way and not try to work with us. And let me just ask 
you if there are any proposals that HHS supports that will 
reduce costs for consumers without setting price controls or 
imposing other restrictions that will reduce access to care?
    Secretary BURWELL. Yes, there are a number of things that 
are part of our budget and that we are currently implementing 
that are reducing costs. We know that since the passage of the 
Act, the trajectory of Medicare----
    Mr. JOHNSON. But it looks to me like everything is going 
up.
    Secretary BURWELL. Well, Medicare spending, if we look at 
what it was projected to be in terms of the previous 10 years 
up to 2008 to where it has been since 2009 through 2014, we 
saved $300 billion. With regard to per capita healthcare costs 
in the country, in 2011, 2012, and 2013 the cost growth is the 
lowest that it has been in 40 years. So that is taxpayer 
savings. That is also savings for providers.
    Mr. JOHNSON. Well, the insurance rates are going up, not 
down, and everybody is paying more for it.
    Secretary BURWELL. So insurance rates before the Affordable 
Care Act were going up often in the individual market well 
above double-digit numbers. And so what we have seen since the 
implementation is, while those rates are still continuing to go 
up, they are going up at a much lower rate.
    Mr. JOHNSON. Okay. Let me just change subjects for a second 
and ask you about an effort that my colleague, Lloyd Doggett, 
and I have been after for a number of years, and that is ending 
the use of Social Security numbers on Medicare cards. As you 
know, that finally became law earlier this year as part of the 
Medicare Access and CHIP Reauthorization Act. So let me ask 
you, is HHS already implementing that, and how fast do you 
think you will be able to issue cards without Social Security 
numbers on them?
    Secretary BURWELL. First, let me say thank you. Having put 
this in the budget when I first arrived at OMB, I thought, as I 
told you in our call, it would take years. So thank you for 
your leadership and effort on this. We were pleased and I 
personally was very excited.
    So right now we are putting together the work plan to do 
that. We haven't established the exact timetable, but as soon 
as it was passed, the next day, we asked the team for the work 
plans. We want to do it as quickly as possible in ways that 
will serve the consumer. As you know, there are a lot of 
Medicare consumers. We want to make sure that we are not 
disrupting them or their services, but we very quickly want to 
do it because, like you, we believe this is an important part 
of privacy and security.
    Mr. JOHNSON. Well, I thank Lloyd Doggett for helping me 
with that. But how easy do you think you can make it for 
seniors to get a new card?
    Secretary BURWELL. I think that is the part, in terms of 
understanding the timing, because we want it to be easy for 
seniors and we want to make sure they understand. One of the 
things we don't want to do by making this improvement is create 
confusion. So figuring out the way that we can enter in the new 
people coming in very quickly with their cards, but we want to 
carefully plan for those with the existing cards, because we 
don't want to have a confusing situation. So that is what we 
are working to do, and we look forward to staying in touch with 
you and your office about how we do that.
    Mr. JOHNSON. Thank you, ma'am.
    Thank you Mr. Chairman.
    Chairman RYAN. Thank you.
    Mr. Rangel.
    Mr. RANGEL. Thank you, Mr. Chairman. And I want to thank my 
colleague, Mr. Johnson, for not drinking all of that Kool-Aid 
that you had in the back against ObamaCare, and bringing 
forward something constructive that the people outside would 
know that we are trying to provide health care is very healthy.
    Chairman RYAN. Try the Kool-Aid.
    Mr. RANGEL. I can't try that Kool-Aid, because I was a 
former altar boy, and I went to school and learned all the 
religions. And I just thought that the right thing for 
Americans to do was to believe that health care was a part of 
the pursuit of happiness. It doesn't even seem like a political 
thing if a kid is sick and someone says that you can't have 
health care. It should pain us as human beings if a person goes 
to a doctor and finds out that the child has an illness but he 
can't get insurance. Maybe we can find a Good Samaritan on the 
side of the road. And we know that most people, middle class 
people, have insurance, but that poverty sometimes restricts 
people from getting this.
    It just seems to me that instead of tearing down a system 
where you know in your hearts people are getting health care, 
that you would say, ``I don't like the way you have done it, 
Mr. President. I don't like the way you Democrats have done it. 
Let us help you to do it better.'' But to take some sense of 
pride that the Supreme Court will just strike down the 
opportunity for people to get just basic health care to me is 
not just mean-spirited----
    Chairman RYAN. Will the gentleman yield?
    Mr. RANGEL. I don't think so, Mr. Chairman, because you are 
on a roll now, and I don't want to have you become a nice guy 
at this point in time, because I am glad that you have 
rehearsed the attack that you intend to do. And I don't care 
who the Secretary is, if you are on the side of giving 
assistance to people that can now go see a doctor, that can now 
prevent going into intensive care because they have had 
preventive care, that can now get insurance, that they couldn't 
have insurance, from a political point of view, I wouldn't want 
to be in your shoes explaining it.
    Of course, those that are already covered, it is no problem 
there. I have mine, Jack. You get the best that you can. But I 
don't care what religion you believe in and even if you don't 
believe in any, it seems like compassion should override 
partisanship. And if we don't like what is before us, we should 
work hard to repair and to fix it and to improve it.
    And so, you know, I am 85 years old. If I have to decide 
what moral side I am going to be raising issues on, I can't 
find a better one than this. And it goes without saying, if you 
are crippled, if you are blind, if you are disabled, if you 
want help, and if money and insurance is what is keeping you 
from getting it, you cannot give a better political home run 
ball to the American people to decide a basic question, which 
side are you on?
    And so I am glad that politically my party would never put 
me in this position. The only position I would rather be in is 
where you are sitting, Madam Secretary, to be able to see that 
you are on the right side of the issue. You can see that people 
don't really want to discuss the millions of people that are 
being helped and we are not talking about. We are talking about 
life and death in the true sense of the word. And if someone 
had a conscience that when a doctor said, ``I wish you had seen 
me earlier,'' and they said, ``I wish I could have, but I 
didn't have insurance to do it, Doctor,'' or how many cases we 
have in intensive care saying, this woman, this man would never 
have had to be here if it was detected earlier and we have a 
mechanism for all of this.
    Chairman RYAN. The time of the gentleman has expired.
    Mr. RANGEL. Well, thank you, Mr. Chairman. I will turn back 
the balance of my time.
    Chairman RYAN. Okay, that is good.
    Mr. RANGEL. There was another minute there, but you cut 
that off.
    Chairman RYAN. We are doing 4 minutes so that we can get to 
Members of the other dais here. I would just ask Members, if 
you have a question, ask it earlier on so that the Secretary 
has a chance to respond.
    The gentleman from Texas is recognized.
    Mr. BRADY. Thank you, Mr. Chairman.
    And, Madam Secretary, health care is about patients, not 
politics. So I was really pleased to hear you answer Mr. Ryan 
that if the Court rules against the IRS in this case the 
Administration will do everything we can. Can you give us some 
guidance here? Will the President sign legislation other than 
merely extending the subsidies to the Federal exchange?
    Secretary BURWELL. With regard to the question of 
legislation and the Affordable Care Act, that has been a 
question and a comment. And where we have been is when there is 
repeal of fundamental elements----
    Mr. BRADY. But on going forward, I appreciate looking 
backward, but going forward, if the Court rules for the 
plaintiffs, will the President sign legislation other than 
extending subsidies to the Federal exchange?
    Secretary BURWELL. So the President has and I think will 
continue to sign legislation that we believe improves 
affordability, quality, access, and takes care of the deficit 
issues of the country.
    Mr. BRADY. So the answer is, and thank you for saying what 
I hear you say, the President will sign legislation other than 
simply extending the subsidies to the Federal exchange. Are you 
saying that is correct?
    Secretary BURWELL. The SGR bill that we just recently 
signed includes very important provisions that actually extend 
the Affordable Care Act's effort to do delivery system reforms.
    Mr. BRADY. But as you know, that is not on the Supreme 
Court case. Specific to that, asking your guidance, the 
President will sign legislation----
    Secretary BURWELL. Specific to the Supreme Court case----
    Mr. BRADY [continuing]. Other than merely extending 
subsidies?
    Secretary BURWELL. Specific to the Supreme Court case, if 
the question is the Supreme Court case, I want to return to 
what the Supreme Court case is saying.
    Mr. BRADY. No, we are looking for your guidance in a 
bipartisan way. So your answer is, yes, the President will sign 
legislation other than extending the subsidies to the Federal 
exchange.
    Secretary BURWELL. With regard to the question of the 
Supreme Court case, that is an issue about subsidy. That is all 
that is about.
    Mr. BRADY. And your guidance to us would be----
    Secretary BURWELL. If your question is, are we willing to 
consider things that would improve or enhance affordability, 
quality, and access, we are open to those things.
    Mr. BRADY. So yes.
    Secretary BURWELL. With regard to the Supreme Court case, 
though, I think it is very important for me to be clear. That 
is about one item. That is about one item.
    Mr. BRADY. The subsidy. I am very well aware.
    Secretary BURWELL. And that is the subsidy.
    Mr. BRADY. I just want to make sure, again, as we look to 
work together to put patients ahead of politics, you are 
saying, yes, the President would definitely sign legislation 
other than extending the subsidies to the Federal exchange. The 
answer is clearly yes.
    Secretary BURWELL. I want to distinguish between the 
question of how one resolves the problem that gets created. 
That doesn't have anything to do with any other parts of the 
Affordable Care Act.
    Mr. BRADY. But no, no, no. This is such an easy question. 
It can be, yes, the President will sign other legislation, or, 
no, he will sign only that legislation.
    Secretary BURWELL. Congressman, I think it is very hard for 
me to answer a question about hypothetical legislation.
    Mr. BRADY. No, it is actually not hypothetical. As we know, 
the Court is going to be ruling. Not hypothetical. If they rule 
for the plaintiffs, guiding us, you are saying the President 
would sign other legislation, he will not, as Mr. Ryan said, he 
will not say, ``My way or the highway.''
    Secretary BURWELL. With regard to fixing, improving the 
Affordable Care Act, these are two different issues. The 
subsidy issue----
    Mr. BRADY. No, no, Madam Secretary, I don't mean to 
interrupt. I am really seeking your guidance. So the answer, 
though, to finalize it, is yes.
    Secretary BURWELL. My answer, Congressman, is we will 
review any legislation we get that has to do with the 
Affordable Care Act based on four things.
    Mr. BRADY. But I am asking about signing. So the answer is 
no?
    Secretary BURWELL. With regard to legislation that we sign, 
we will look at any piece of legislation and we will judge it 
by four things: Access----
    Mr. BRADY. So would the President sign legislation to 
extend those subsidies temporarily while Republicans and 
Democrats and the President work toward a long-term solution?
    Secretary BURWELL. With regard to the subsidies, as I have 
said, the critical decision is with Congress. If the Congress 
writes legislation that makes sure that those subsidies are 
available, that is something that would fix the issue.
    Mr. BRADY. The answer is yes. Yes, he would sign 
legislation other than extending it, correct?
    Chairman RYAN. Time.
    Secretary BURWELL. Congressman, I apologize, but when you 
say ``other,'' I want to make sure----
    Chairman RYAN. The time of the gentleman has expired.
    Mr. McDermott.
    Mr. MCDERMOTT. Mr. Chairman, thank you.
    Ms. Burwell, it is really nice out in Seattle. I am not 
sure you made the right choice coming back here to work.
    Secretary BURWELL. I am in the wrong Washington, is that 
what you are telling me?
    Mr. MCDERMOTT. I listen to this, and we are all talking 
about if the President does this and whatever. But let's talk a 
specific, because I think that we haven't heard a specific come 
out of the Republicans since the bill was passed. They have 
never put anything on the table.
    Now we have a bill, 1016, put in by Senator Johnson from 
Wisconsin, and it is his solution if the bill fails. And as I 
read it quickly, it repeals the individual mandate, it repeals 
the employer mandate, and it says that the States can continue 
the funding down, and the standard of benefits that people get 
are not the national standards, but whatever the State of 
Mississippi or Alabama or Georgia or Texas or one of these 
States that has not had an exchange, whatever they set as a 
benefit.
    We know it will be lower, because it already is. They won't 
cover people in Medicaid. So they clearly don't care about the 
level of health care.
    But explain to me how you would respond to 1016.
    Mr. PRICE. Will the gentleman yield? Will the gentleman 
yield?
    Mr. MCDERMOTT. No, I am not going to yield. I am going to 
let her explain.
    Mr. PRICE. Will you take back the disparagement of the 
citizens of the State of Georgia?
    Mr. MCDERMOTT. She has the right to explain what the 
President would think of a particular piece of legislation that 
has been put forward as a serious thing by a Senator in the 
U.S. Senate.
    Secretary BURWELL. So with regard to the Johnson piece of 
legislation, that piece of legislation, from our perspective, 
is repeal, because it gets rid of preexisting conditions, it 
stops the funding for preventative services, it undoes that 
people up to 26 would be covered, and it actually takes away 
subsidies from all over time.
    And so with regard to that particular piece of legislation, 
that is a bill that, from our perspective, is repealing. And we 
have spoken to the issue of something that repeals the 
Affordable Care Act is something that the President will not 
sign.
    Mr. MCDERMOTT. So in answer to Mr. Brady's question, will 
the President sign a bill that we pass, if we pass this bill, 
will the President sign that?
    Secretary BURWELL. As I have said, this bill, in its 
current form, is repeal, and the President has said that he 
will not sign something that repeals the Act.
    Mr. MCDERMOTT. Is there any place that you see where there 
is a proposal on the table by any Member of the House or Senate 
that looks at this point as though it deals with protecting the 
ACA in general and fixes the one specific problem?
    Secretary BURWELL. We have not seen anything.
    Mr. MCDERMOTT. And you have looked at all the legislation 
and read all of the press releases and everything else?
    Secretary BURWELL. At this point we have not seen something 
that addresses the specific issue of the question. Although I 
think there is also the issue, I think we are all very focused 
on the loss scenario. At some point I think it actually is 
important to focus on the win as well in terms of how we all go 
forward if there is a win.
    Mr. MCDERMOTT. Tell us about the costs of health care. We 
hear the Chairman say the President promised that there would 
be a reduction in premiums. Now, would you explain why that is 
a little bit misleading in that certainly everything is going 
up in the society, but they are not going up as much as was 
predicted. I would like you to talk about that.
    Secretary BURWELL. That is correct. And as we have seen, 
the premium increases that occurred in the individual market 
and even in the employer-based market, we are seeing smaller 
increases in those premiums than we saw before. And so while 
there are increases, the increases that we were historically 
seeing that were driving costs for individuals, for employers, 
and in terms of Medicare and the costs to the government, that 
is what we have seen shrink and slow.
    Chairman RYAN. Thank you.
    Mr. Tiberi.
    Mr. TIBERI. Thank you, Mr. Chairman.
    Thank you, Secretary Burwell.
    The recent SGR repeal and Medicare reform bill that passed 
a couple months ago included a bipartisan bill that I sponsored 
to require binding bids from suppliers participating in the 
durable medical equipment and supplies competitive bidding 
program. The provision, supported by my Democrat colleagues, 
removes bad actors from the program, something I don't have to, 
I know, go over with you, and ensures that seniors get quality 
medical equipment.
    In a compromise with the Administration, the law requires 
that CMS implement the provision not earlier than January 1, 
2017, but not later than January 1, 2019. I think that 2019 is 
a very generous timeline to implement the bill and would hope, 
with your leadership, that we could move it closer to the 
January 1, 2017 timeline.
    Because at the end of the day, as you know, again, there is 
bipartisan support for this concept. My good friend Bill 
Pascrell is all over this issue as well. We think that this 
will ultimately help separate the good from the bad and 
ultimately help our seniors. So your leadership would be 
critically important to moving that closer to the beginning 
than the end.
    Secretary BURWELL. So it is related to Mr. Johnson's 
question too. As soon as the bill passed, which was such a very 
important bill--I don't think I need to articulate to this 
Committee all the important things we have worked to put 
together so that we are specific and we do try to meet and beat 
deadlines. We have been able to do that on some bipartisan 
legislation in behavioral health that was supported both in the 
House and the Senate in terms of beating deadlines we were 
given, and where we can, we are going to try to. Thank you for 
your support in helping to do that. If we need further support 
and help I will come and ask.
    Mr. TIBERI. Thank you.
    Secretary BURWELL. But it is something that is a priority.
    Mr. TIBERI. Thank you.
    The other issues, Madam Secretary, are intellectual 
property rights, incentivizing the creation of innovative new 
medicines that improve people's lives and supporting good U.S. 
jobs. We are talking about trade this week.
    I want to ask you specifically about India. Over the past 
couple of years, India's intellectual property climate has 
unfortunately deteriorated pretty significantly and the U.S. 
IP-intensive industries have suffered, including 
pharmaceuticals, and they have expressed significant issues 
with respect to the Indian market.
    Most notably, courts in India have issued compulsory 
license, as well as denied or revoked several patents for 
popular medicines held by U.S. companies, citing an Indian law 
that many believe diverges from India's international legal and 
international trade commitments.
    Have the compulsory license and denial, revocation of 
patents on medicines been part of any of HHS discussions with 
its Indian counterparts? And I know this is kind of a question 
that might have come out of left field based upon what you 
prepared today, but would you agree it would be ill-advised for 
any U.S. Government employee to undermine the policy of the 
United States to promote strong international property rights 
in foreign markets? And if you aren't prepared to answer that, 
would you mind looking into it and getting back to us as we 
have this trade debate this week?
    Secretary BURWELL. Yes, I am happy to get back to you. The 
USTR would probably lead in any of those conversations that 
were in that space. So I think what I will do is coordinate 
with the USTR so that we get back to you together.
    Mr. TIBERI. That would be great.
    Secretary BURWELL. Because I think you probably know those 
conversations----
    Mr. TIBERI. Yep.
    Secretary BURWELL [continuing]. With the governments are 
being led by the USTR. We give our policy and programmatic 
input to them and they lead.
    Mr. TIBERI. Great.
    Secretary BURWELL. So we will make sure that one of the 
two, either HHS or the USTR, gets back to you.
    Mr. TIBERI. Thanks so much. I appreciate your leadership.
    I yield back.
    Secretary BURWELL. Thank you.
    Chairman RYAN. Thank you.
    Mr. Neal.
    Mr. NEAL. Thank you, Mr. Chairman.
    Madam Secretary, the opioid addiction issue is pronounced 
now across my congressional district, and there are all sorts 
of stories now that indicate a nationwide trend. And I am 
curious about the response of your Department, the agencies 
that you oversee, and I would also like to ask specifically 
about prescription drug misuse.
    Secretary BURWELL. Yes.
    Mr. NEAL. I would like to know about the evidence that you 
are coming across on that basis.
    Secretary BURWELL. So with regard to the issue that you 
have raised, thank you for raising it. In our budget there are 
99 million additional dollars to implement an evidence-based 
strategy on the problem.
    Let's just quickly touch on the problem. When we think 
about the problem, as you articulated, in your district, across 
the country, opioid and overdose deaths have exceeded the 
number of deaths from car accidents or any other accidental 
death. In the year 2012, there were 259 million prescriptions 
for opioids. That is more than one for every adult in the 
country.
    Mr. NEAL. Would you say that again? How many prescriptions?
    Secretary BURWELL. There were over 250 million 
prescriptions in 2012 for opioids. That is how many 
prescriptions there were. That is more than the number of 
adults in our country. So that was one prescription for every 
adult in the country in terms of where we are in the magnitude 
of the problem.
    Let's go to the solution. We have worked and worked with 
States and worked with the Congress. There are a number of 
bills up on the Hill right now. There are three basic areas on 
which we need to focus.
    One is prescribing. A big part of the problem, as you can 
see from that number, is prescribing. What we need to do there 
is we need to provide new prescribing guidelines for pain and 
pain medication that will help the problem. But also, in the 
prescribing States, States need to do what are called 
prescription drug monitoring plans. They are almost in all 50 
States and they are the means by which a physician has the 
opportunity to look up and see that a controlled substance was 
already given to you, and control it that way. It works the 
same way with pharmacists. So prescribing is number one.
    Number two is the use of naloxone, which is a very 
important drug that actually stops death when there is an 
overdose, and making sure that first responders have access. 
That is a very important part of that picture. Nick Kristof 
even had a piece out about it this week.
    Number three is the issue of medicated assisted treatment 
combined with behavioral issues and making sure that we do 
treatment for those who are addicted.
    So those are the three things. The $99 million additional 
funding in our budget cuts across CDC and SAMHSA as we do this. 
We are doing this in conjunction with States. I have been in 
Massachusetts with your Governor, doing a joint event with your 
Governor. This is a bipartisan, bicameral, and statewide issue, 
whether it is Governors or both sides of the legislative body 
and both sides of the aisle. And certainly your colleague from 
Kentucky is leading in this effort in the House.
    So that is our plan. That is what we are trying to do.
    Mr. NEAL. And it is noted that in some places in New 
England heroin is selling for $3.50 a bag on the streets of 
some of our old industrial cities. And I have House bill 1821 
that I would invite Members to take a hard look at. Senator 
Markey has a companion bill in the Senate.
    What specific actions should Congress be taking along these 
lines to assist you in noting, as you have, that there are now 
more deaths from overdose than from automobiles?
    Secretary BURWELL. So on the heroin point, we know that the 
second two elements, the nonprescribing elements of the 
strategy, we will work on.
    With regard to the places where we believe we need help 
from Congress to implement that strategy, one is in the area of 
buprenorphine, which is another drug that helps in this, and 
the question of prescribing. So we believe that that is an 
important place. The second place is in making sure people are 
trained with the guidelines.
    Chairman RYAN. Thank you.
    Dr. Boustany.
    Mr. BOUSTANY. Thank you, Mr. Chairman.
    Welcome, Secretary Burwell.
    Last fall the Administration proposed a child support 
enforcement rule, and former Chairman Dave Camp, along with 
Senator Hatch, sent a letter expressing concern about this. And 
the issues that were raised were that the Administration in 
this area was usurping the authority of Congress to write law 
and was, in effect, writing law.
    And this has been a repetitive theme. I think Chairman Ryan 
raised this issue with regard to certain issues relating to 
ObamaCare. But we have seen this with immigration, with 
ObamaCare, other areas of the law, TANF waivers. So why, 
especially in this area where this Committee in a bipartisan 
way has been willing to work with the Administration on these 
child support policies, why does the Administration choose to 
trample on the Constitution and Article I powers in an area 
where we want to work together? I just don't get it.
    I mean, I understand there is always tension where we 
disagree. I get it. And that is a fight that we are seeing 
being played out in the courts. But why in an instance where we 
do have willingness to work and cooperate on this important 
issue area?
    Secretary BURWELL. We would look forward to the opportunity 
to work in this space. In terms of that particular rule, there 
were some very important things that I know you are familiar 
with, the fact that some of these things were done in the 
1990s. So people have to do paper applications with regard to 
child support. And so a lot of the rule was about things like 
improving the ability to use technology and other things, and 
improvements and simplifications to the rule.
    If there are specific policy areas that are of concern, we 
are listening to those comments that have come in. I think you 
know we have not finalized the rule. And we would welcome the 
opportunity to work on the issues and the substantive areas.
    Some of the things that have been mentioned in the release 
that happened yesterday are in areas where the States have 
advised us--in the State of Texas--in terms of we are following 
what the States have asked us to do in terms of things like 
using money for people to do job training, which is an issue 
that is important in a number of the States.
    Mr. BOUSTANY. Well, Chairman Ryan and I introduced 
legislation yesterday dealing with this in order to protect our 
constitutional right to write law. I know there is companion 
legislation in the Senate by Senator Hatch and Senator Cornyn. 
But we want to put the Administration on notice that this body, 
the legislative branch, writes law and that the executive 
branch executes. And we are getting tired of it, especially in 
an area where we have some agreement. Just be put on notice 
that we are going to continue to assert our constitutional 
prerogative.
    On a different issue, the employer mandate has not been 
implemented. There are a lot of complications with it. We know 
how complicated it is. We have heard testimony in the past on 
this. And I know it does not apply to small businesses, those 
with 50 or fewer full-time equivalents. But those individuals 
would still be subject to the individual mandate.
    Why has the Administration been reluctant to assist these 
kinds of small businesses? I questioned Secretary Lew when he 
was before this Committee earlier this year with regard to 
health reimbursement accounts, and there was a move, I think, 
for a 6-month reprieve on really onerous penalties for small 
businesses, but 6 months. I just don't get it.
    I have legislation that would actually make it more 
effective for small businesses to use these health 
reimbursement accounts, which are completely legal under ACA, 
but yet for some reason your agency and the Administration have 
decided to close the door on these. I don't get it. Shouldn't 
we be helping small businesses and their employees at a 
troubled time?
    Secretary BURWELL. We agree with you and want to try to do 
more. In the budget right now, the budget proposal that is 
before the Congress right now for fiscal year 2016, we actually 
have proposed expanding the tax credit. It is available for 
those up to 25 employees. We want to move it up to 50, to 
expand the access to tax credits that they can get. It sounds 
like similar kinds of ideas in terms of getting folks the 
access they need to the help they need----
    Mr. BOUSTANY. Well, health reimbursement accounts are very 
effective, and it is a simple solution.
    Chairman RYAN. The time of the gentleman has expired.
    Mr. BOUSTANY. Thank you, Mr. Chairman.
    Chairman RYAN. Mr. Doggett, are you ready?
    Mr. DOGGETT. Thank you, Mr. Chairman.
    Thank you, Secretary Burwell, for being here.
    It seems to me that the focus of this hearing and the focus 
of all of our work should be on how we can make this healthcare 
system work better and deliver services and insure more 
families instead of speculating about some Court decision.
    As you know, Madam Secretary, I have a number of concerns 
about the way this law has been implemented, particularly in 
Texas. I am concerned about the fact that two out of three of 
our Texans who are market eligible for these marketplaces are 
not yet enrolled.
    And I think there are things that your office can do for 
more effective implementation. I would encourage you strongly 
to do the same kind of cost-benefit analysis that you did at 
OMB, and that is to look at these contractors and see if they 
are delivering on their services. As you know, I have a number 
of queries to you about those. I would hope to focus on how we 
can make it better and how we can make the implementation 
better.
    But when I hear you accused of being a purse snatcher, it 
does get my attention. You know, the easiest thing for this 
Court to do, and I think the right thing, is to not ignore the 
other 900 pages of the law and focus solely on four words. And 
if it is necessary to have a legislative fix, deleting four 
words solves the entire problem and allows this law to work the 
way the Congress intended for it to work.
    There are many other ways to address this problem, and in 
fact, apparently, some States are beginning to look at the 
possibility that the best way to fix the law, should the Court 
render the wrong decision, is to simply create their own 
exchange.
    It is also extremely impressive to me that of all the 
proposals that have come in here at the last minute of 
Republicans to deal with the possibility of an adverse Court 
decision, how many of those proposals attempt to include as 
much of the hated ObamaCare as possible--preserving the right 
of young people up to age 26 to participate in their family's 
health insurance program, attempting to maintain exchanges and 
so on.
    If today we are asking you about how to make improvements 
to reach more people in our laws, that would be a reasonable 
thing, instead of the polemics that are going on here. Indeed, 
I think it is probably historic. I could not find another 
circumstance in which Members of the House and Senate ask a 
court to deny thousands, indeed, millions of people across the 
country an opportunity to get a Federal tax credit, to say 
please deny--in Texas, our two Senators--please deny our 
constituents $206 million every month in Federal tax relief, 
but let them keep paying taxes to finance the same kind of tax 
credits for people in California.
    Or someone from Wisconsin--since Chairman Ryan joined the 
same brief in the Court--who says, please have my constituents 
continue to pay taxes to fund tax credits in Connecticut, but 
deny thousands of people tax credits in Wisconsin.
    It is an unusual situation, to say the least, that that 
kind of approach would be taken.
    I believe we need to look for improvements in the law, to 
strengthen the law, but that the idea of denying relief to 
people who are receiving it right now is to take away from them 
Federal tax assistance and to take away from them the 
opportunity to get the insurance that is working for their 
family.
    To say that it is a lemon to provide families the relief 
with insurance for preexisting conditions that they never had 
before, something that is lifesaving in many cases, is truly a 
misstatement about the work of this legislation. Thank you very 
much.
    Chairman RYAN. Thank you. The time for the gentleman has 
expired. Mr. Roskam is recognized.
    Mr. ROSKAM. Thank you, Mr. Chairman. Secretary, thanks for 
your time today. There are two issues that I would like to use 
our couple of minutes together on. They are related. It is the 
discussion around cost-sharing reduction payments and then also 
the basic health program. So just to set the table, the cost-
sharing reduction payments, the issue is whether the 
Administration has the authority to spend out of an account 
that hasn't been appropriated.
    As you know, Chairman Ryan and Chairman Upton wrote to you 
and Secretary Lew on February 3. Your response back at a staff 
level, look, I mean, it was sort of predictable. It restates 
the obvious in terms of a number of truisms about the 
Affordable Care Act. And then it says go talk to the lawyers at 
the Department of Justice because there is pending litigation. 
A little bit of a cute response in my view. But it is your 
play. Now, where there is no litigation pending and the issue 
is exactly the same is on the issue of basic health programs. 
So it wouldn't be satisfactory to say you have to check with 
Justice. Because they are not involved in any litigation 
because there is no litigation between us at this point in 
time.
    So here is my question. The law is really clear that you 
can't spend money that hasn't been appropriated. There is no 
ambiguity about that. The Constitution is clear. The GAO states 
this. Many, many, different entities say that money cannot be 
spent absent an appropriation. And, yet, there are a number of 
States that are announcing that, you know, Minnesota was a 
State that says they are going to be implementing the program.
    New York has announced that they will operate the basic 
health program starting in January of 2016. New York has 
estimated that they will receive $2.5 billion, B, billion. How 
is this possible since the money has never been appropriated? 
In other words, what extra-constitutional authority are you 
invoking that allows you to spend money that has not been 
appropriated?
    Secretary BURWELL. With regard to the issue of 1311 and 
where that is, I think 1311 is about States that want to choose 
and try to do things in ways that seek flexibility. And that is 
what we try to do is work with States when they do that.
    With regard to the authority, both for the cost-sharing and 
the issue of 1311, in the budget appendix, pages 1046 and 1047, 
is the place where we believe these authorities lie.
    Mr. ROSKAM. But there has been no appropriation, you will 
acknowledge that, won't you?
    Secretary BURWELL. With regard to the authorities there, 
what we believe is the authorities for the APTC are the 
authorities because that is what the money----
    Mr. ROSKAM. But you are conflating two concepts. You are 
conflating authorization, which I am not arguing with, and 
appropriation. There has been authorization. But there has been 
no appropriation. So how do you appropriate money that hasn't 
been appropriated?
    Secretary BURWELL. But programs that are tax credits aren't 
a part of our discretionary budget every year. In terms of 
discretionary programs, I mean, the Earned Income Tax Credit, 
other 
tax programs and tax credits are not a part of the 
discretionary process.
    Mr. ROSKAM. So just to follow up, would you be willing to 
come in and give a briefing to me and also to Chairman Tim 
Murphy, who chairs the Oversight Subcommittee at Energy and 
Commerce, to clear up these things when we have more time 
together?
    Secretary BURWELL. Congressman, we would look forward to 
the opportunity to try to clear this up and have the right 
people come and discuss these issues.
    Mr. ROSKAM. Thanks very much. I have just one other quick 
point. You mentioned in your opening statement that there was 
$22 billion in fraud savings, which is okay, not great. The 
problem is, and Mr. Lewis and I found this out together, along 
with all the Members of our Subcommittee, Medicare, by 
Medicare's own admission, is wasting $1 billion a week, every 
single week in fraudulent and erroneous payments.
    So $22 billion over the decade is okay. But it is like 
turning it off halfway through the year and then letting 9.5 
years go by without doing anything. So I think we really need 
to up the game. I yield back.
    Chairman RYAN. Thank you. Mr. Thompson.
    Mr. THOMPSON. Thank you, Mr. Chairman. Thank you for having 
the hearing. And thanks for helping to subsidize my California 
constituents and their health care. I appreciate that.
    Madam Secretary, thank you very much for coming out. I just 
want to say that I hear a lot from my constituents as well 
about the ACA. I hear from people who are pleased that the 
preexisting conditions is no longer an issue for them, that 
their 26-year-old can stay on their policy, that they have 
access to quality preventive care, which I know for a fact will 
save us all money in the long run. But I also hear them say 
that they recognize there are problems with the ACA. And they 
want us to work together to fix those problems.
    I don't know how it could be a lot different than in other 
parts of the country. My experience has been that folks want 
access to quality affordable health care. And we do have a 
responsibility to figure out how to make that happen. And I 
appreciate your effort in that regard.
    So I am all for fixing, making tweaks, making adjustments. 
Congresswoman Black and I are going to introduce legislation 
today, as a matter of fact, that falls into that category of 
making a tweak, making a fix. And we are going to introduce a 
bill that would ease the reporting requirements for employers 
offering coverage for their employees. And it would require 
that the exchanges use the most recent tax data to ensure that 
individuals and families will not have a large tax bill at the 
end of the year.
    As I am sure you know, Covered California in my home State 
of California, requires that the most recent tax data be used. 
And it has worked well. It has been beneficial. I am just 
wondering if you have any thoughts on requiring the more recent 
tax data to determine eligibility for subsidies, especially for 
auto renewals, and making that apply to all the exchanges?
    Secretary BURWELL. I think it is in our interest. And what 
we want to seek to do is get the most up-to-date information 
that we can possibly have which is why we encourage people to 
come in and update throughout the year. And we continue to do 
that.
    With regard to the specifics of this piece, I think we 
would have to look at the legislation. I am not sure if it sits 
with Treasury or with us. But we would work together to 
understand. Because I think what we want is actually to have 
the most up-to-date information. And that information for some 
people is an evolving and changing piece of information. For 
those who are self-employed, their incomes change throughout 
the year. And we do have means by which they can come in and 
update it. And we try to encourage them to do that.
    So, the most up-to-date information that we can implement 
is something that we do support. And so with regard to the 
specifics of the legislation, we would like to have the 
opportunity to look at it and understand between us and 
Treasury where we could be.
    Mr. THOMPSON. Thank you. I also had some questions 
regarding the RACs and the appeal process that I understand 
from your staff we are going to work together outside of the 
Committee hearing to deal with. So I appreciate that 
commitment. I am assuming it is shared by you.
    Secretary BURWELL. Yes, it is. And I would also use this 
just as an opportunity again to mention the piece of bipartisan 
legislation that Senate Finance just passed this past week on 
this issue, in terms of the strategic approach to help us get 
to a place where we can reduce that backlog of appeals. There 
are administrative things we can do. But we do need some 
statutory help. And Senator Hatch and Mr. Wyden have led an 
effort on that side. We are hopeful we can work with all of you 
too.
    Mr. THOMPSON. Great. And then Mr. Boustany had some 
questions about the HRAs. And we are working together on that 
legislation. I hope that we can have the help of your agency in 
making sure that this is the best legislation possible.
    Chairman RYAN. Thank you.
    Secretary BURWELL. We will work with you.
    Mr. THOMPSON. Thank you. I yield back.
    Chairman RYAN. Dr. Price is recognized.
    Mr. PRICE. Thank you, Mr. Chair. Madam Secretary, with 
respect, many of us here and many across the land sincerely 
believe that the principles that you outlined that all of us 
hold dear, accessibility, and affordability, and quality are 
all being harmed by the current path that we are on.
    And I want to highlight some of the problems in the system 
that are, I believe, we believe, harming patients and in many 
cases destroying the ability of those working as hard as they 
can to care for those patients. One of them is the Electronic 
Health Record and Meaningful Use.
    CMS is now dictating to physicians what must be documented 
and how it must be documented, without regard to what is truly 
important and necessary for taking care of patients. It is 
wasting money. It is wasting time. It is wasting resources. 
And, sadly, it is wasting the expertise of physicians, leading 
to further disgust on the part of physicians, many leaving 
practice. In fact, I know two individuals who said this was the 
last straw and they quit, at an age where they could be able to 
practice for years and years.
    There are positive solutions if we allow for flexibility 
and respect to those providing the care. ICD-10 is another 
example of CMS making it more difficult for physicians to care 
for patients. In some cases, in small and rural practices, as 
we have discussed, it will drive physicians out of business. So 
access is destroyed for those patients in those areas.
    The United States inappropriately combines and confuses 
clinical data, that is what is happening medically with a 
patient, with billing data, under the guise of wanting more 
information and saying that everybody else in the world is 
doing it. Well, the fact is that the United States will be the 
only country to use all 87,000 codes, the only country to use 
it in an outpatient setting, the only country to use it in a 
billing process, and the only country to put the cost on the 
shoulders of the physicians and those providing the care. This 
happens on October 1. If past is prologue, sadly, it holds real 
potential to be a significant disaster, further harming doctors 
and patients. I urge, I urge CMS to delay any penalty for 
coding errors for at least 2 years. It is only reasonable given 
the magnitude of the change coming.
    Durable medical equipment and a caring provider is 
oftentimes the only thing that stands between a patient's 
quality of life and hospitalization or illness, exacerbation, 
or even death in the instance of the provision of oxygen. Yet, 
CMS has put in place a system of what they call competitive 
bidding, what you call competitive bidding. It doesn't work. It 
is harming patients. And it is driving folks who have been 
wonderfully providing care and service in communities all 
across this Nation out of business, further harming those 
patients. I urge, I plead with CMS to allow, at least allow a 
pilot demonstration to show there is a much better way to save 
money and also provide services to patients.
    Sadly, Madam Secretary, the President continues to 
shamelessly condemn and attack those standing up for patient-
centered health care. As recently as yesterday, he ignored 
reality and cynically mocked those striving for positive 
solutions. We know that he has a pen and a phone. What he 
doesn't seem to have is the knowledge or the humility or the 
concern or the desire to work together on behalf of those 
struggling to provide care and those receiving the care.
    Madam Secretary, I urge you, I urge you and your team to 
join with us in an open-minded way to end the oppression of 
meaningful use, to provide for flexibility with ICD-10 so that 
more practices aren't destroyed, to allow for a pilot program 
to demonstrate that competitive bidding is hurting patients and 
that there is a much better way, and to give physicians the 
freedom to care for patients.
    If you are sincere in your desire for accessibility and 
affordability and quality, that would lead to your action 
working with us. And I look forward to that and hope that we 
will be able to move in a positive direction. Mr. Chairman, I 
yield back.
    Chairman RYAN. Thank you. Mr. Larson.
    Mr. LARSON. Thank you, Mr. Chairman. And thank you, Madam 
Secretary, thank you for your service. Hailing from the great 
State of Connecticut, we are so proud of the advances of the 
Affordable Care Act. And it is great to have a Governor that is 
hands on in terms of its implementation and all the progress 
that we know that has been made and will continue to be made 
under this Act.
    Mr. Chairman, I would like to submit for the record a 28-
page report entitled ``The Language of Healthcare 2009,'' by 
Frank Luntz. Mr. Chairman, is there an objection?
    Chairman RYAN. No objection.
    [The submission of The Honorable John Larson follows:]
    
    
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    Mr. LARSON. No objection. And I think that, I have a great 
deal of respect for Mr. Luntz as well. He and Stan Greenberg, 
another pollster and someone who spends an awful lot of time on 
the science of language, in looking at, in detail, what people 
should say around subject matter areas, have studied this 
debate. Now, this is particularly of interest to me because it 
passed, you know, this was recommended in 2009. And, basically, 
Mr. Luntz describes the 10 rules for stopping the Washington 
takeover of health care. And it is informative even to this 
debate today.
    For example, one of the things he says, that arguments 
against the Democratic healthcare plan must center around 
politicians, bureaucrats, and Washington, not free markets, tax 
incentives, or competition, is interesting. So we will hear a 
lot on that. It also goes on to underscore, you simply must be 
vocal and passionate on the side of the reform. The status quo 
is no longer acceptable. If the dynamic becomes President Obama 
is on the side of reform and Republicans are against it, then 
the battle is lost and every word of this 30-page document is 
useless.
    He goes on to say this, and this is the whole point, it is 
not enough just to say what you are against. You have to tell 
them what you are for. It is okay and even necessary for your 
campaign to center around why this healthcare plan is bad for 
America. But if you offer no vision for what is better for 
America, then you will be relegated to insignificance at best 
and labeled obstructionist at worst. What Americans are looking 
for in health care is what your solution is, what it will 
provide. The words of more access, more treatments, and more 
doctors are sure winners. I agree with Mr. Luntz there. And 
that is what this subject should be about, for us providing 
more access.
    Madam Secretary, may I ask you, are you aware of any 
Republican legislative proposals that reduce the number of 
uninsured in this country by more than 60 million and make sure 
that we continue to provide all the benefits of addressing 
preexisting conditions, keeping your children on the plan, and 
making sure we focus on prevention?
    Secretary BURWELL. I have not seen a proposal that does 
that.
    Mr. LARSON. I thank you, Madam Secretary. And with that, 
submitting this full report for the record, I think it is worth 
everybody's reading. And we ought to get back to what this 
Committee should be doing. And that is to put Americans first 
and put Americans on the road to having the best access, more 
access, more accessibility, and more availability to health 
care. Thank you.
    Chairman RYAN. Thank you. Time for the gentleman has 
expired. We are now going to enter into the two-to-one phase, 
two on 
our side, one on the Democrats side, to keep it equal. Mr. Bucha
nan.
    Mr. BUCHANAN. Thank you, Mr. Chairman. And thank you, Madam 
Secretary. I appreciate you taking the time this week to give 
us a call, give me a call and make time for a chance to visit. 
My biggest concern, you made four points. At the top of the 
list, I was Chairman of the Florida Chamber. We had 137,000 
businesses we represented. Most of them were 50 employees or 
less. So we have a lot of small businesses. But the biggest 
issue, and it is before the ACA, it goes back 15 years, is 
affordability. And there was an expectation or hope that we 
could bend the curve on affordability. There is no question 
people who get the subsidies, they benefit. There are over a 
million in Florida. But there are many just above that line, 
the poverty line that don't get the subsidies.
    And I want to talk on two bases first. Small business, 
their cost of trying to provide health care has gone up 20 to 
30 percent in the last 3 or 4 years. I just talked to another 
person the other day who has 130 employees, and it went up 30 
percent. But throughout Florida, throughout our region, we are 
not seeing any reduction or anything in terms of affordability 
from that standpoint. And many times, last week we had a town 
hall meeting, we had one woman, or a couple weeks ago, we had 
one woman who said it cost $2,000 a month to get health care. 
She can get it for less. But then she has to pay some kind of a 
$10,000 penalty in terms of her health care if she has a claim. 
What is your thought on the affordability, where we are at as 
it relates to people who don't get subsidies?
    Secretary BURWELL. When we think about the affordability, I 
think we think that some progress has been made. And as you 
appropriately reflect, what we were seeing before is we were 
seeing rising deductibles and we were seeing growth. And we 
have seen a slowdown in the premiums. The things that we have 
seen slow down, is we have seen a slowdown in premium growth 
across a number of categories. We have also seen Medicare 
savings that I mentioned earlier, over $300 billion in terms of 
where we are in our Medicare pricing.
    The other thing that is indicative is that we have seen the 
per capita healthcare costs grow. As a Nation, because we have 
so many people retiring and coming into Medicare, the overall 
costs of health care are probably going to go up because we 
have more elderly. So we do focus deeply on that per capita----
    Mr. BUCHANAN. Well let me just mention, because we are 
short on time, we are not seeing the discounts, per se. I would 
love to have you come to Florida and talk to a lot of small 
businesspeople. We are not seeing those. We are not seeing any 
kind of discounts. Most of it is 20 to 30 percent increases. In 
the last couple of years, they were hopeful but they are not 
seeing it. And then, unfortunately, a lot of the costs get 
pushed to the employee.
    Secretary BURWELL. That is right.
    Mr. BUCHANAN. And so, many of the employees that were maybe 
picking up a couple hundred bucks a month, now they are paying 
$500 to $600 out of their pocket. If they don't get a subsidy, 
many of them are being gutted. We like to talk up here a lot 
about the middle class. But this is, a lot of this is putting 
the middle class at risk in terms of healthcare costs. And what 
is your thoughts on that?
    Secretary BURWELL. I think this is why one of the things we 
need to focus on now deeply is delivery system reform. And that 
is the idea of better, smarter, healthier. And by that, it is 
both about quality and I think we have to be careful when we 
talk about this topic because people hear it and we need to 
make sure we preserve quality and improve quality. Why in our 
country do we have some of the lowest levels of quality 
offerings for health care? It is about improving quality and 
affordability.
    And right now, one of the things that we did, in January we 
committed that the Federal Government, that Medicare payments, 
30 percent of them by 2016, 50 percent by 2018 will be based on 
value instead of volume as a part of working on this overall 
issue. Because we want to hear what you are hearing and that is 
important to us. And so that is a part of why we think this is 
so important.
    Mr. BUCHANAN. Let me close with the idea, because I have a 
few seconds, I hope we can focus more on affordability, all of 
us. Because it is bankrupting a lot of people that don't get 
subsidies. That is the reality in Florida for small business 
and individuals. So the focus needs to be on affordability, 
finding a way to bend the curve on healthcare costs. Thank you, 
Madam Secretary.
    Secretary BURWELL. We look forward to the opportunity to 
actually work with you on some of these delivery system reform 
issues.
    Chairman RYAN. Thank you. Mr. Smith.
    Mr. SMITH OF NEBRASKA. Thank you, Mr. Chairman. And thank 
you, Madam Secretary, for being here today. There is limited 
time and a lot to cover here. As you know, as we spoke earlier 
about the consumer operated and oriented plan programs which 
were the alternative to the public option, I would argue, 
perhaps, these are somewhat quasi-public options, intended to 
be low-cost, government-subsidized healthcare plans. And to 
date, I believe HHS has awarded $2 billion in Federal loans to 
establish the plans.
    One plan, as you know, CoOpportunity, which served over 
100,000 people in Nebraska and Iowa, was seized by the State of 
Iowa and has since been liquidated. Folks who were on the plan 
have been left confused and frustrated and, again, looking for 
other plans. And I sent a letter on January 23 asking specific 
questions. I did receive a response on May 21. I would like to 
request unanimous consent to submit both of these letters for 
the record.
    Chairman RYAN. Without objection.
    [The submission of The Honorable Adrian Smith follows:]
    
    
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    Mr. SMITH OF NEBRASKA. Thank you. Now, quickly some 
questions. CoOpportunity received approximately $146 million in 
Federal loans. Will any of those dollars be paid back to the 
Federal Government?
    Secretary BURWELL. With regard to that, that is a question 
I will follow up on.
    Mr. SMITH OF NEBRASKA. Okay. I appreciate that.
    My understanding is Iowa and Nebraska were told they could 
not suspend enrollment within CoOpportunity and have it remain 
a qualified health plan. Yet, Tennessee was later allowed to do 
so. Do you know why that policy changed?
    Secretary BURWELL. So, per our conversation, I actually did 
follow up with CMS. And we didn't have the record of that 
request in any way coming in. So I would love for our team to 
be able to follow up and understand if there was 
miscommunication. Because, based on your comment, it was 
something that was concerning to me when you mentioned it. And 
I went and followed up. So if we can work with your staff to 
understand what your staff understands happened, that would be 
helpful.
    Mr. SMITH OF NEBRASKA. Okay. Recent reports claim only one 
co-op didn't have an operating loss in 2014. Is that accurate?
    Secretary BURWELL. I would have to go co-op by co-op.
    Mr. SMITH OF NEBRASKA. Okay. Are there any concerns about 
possible liquidation of any of the other plans in the near 
future or not so distant future?
    Secretary BURWELL. With regard to the co-ops, because they 
are all new businesses, they are start-ups, like the small 
businesses that we were just talking about before, you know, we 
are going to have failures in terms of the co-op system. That 
was a part of what was set up in terms of the original $5 
billion that the Congress gave, but then through sequester and 
other means went to $1 billion.
    So I think that there will be co-ops that will have 
challenges and issues. I think we are working closely with the 
States and State insurance departments to make sure that we get 
in front of them and do the kinds of things that we attempted 
to do in the CoOpportunity situation, which was make sure as 
much as possible and where it was appropriate we would engage 
in supporting communication, offering a special enrollment 
period, and working with the State insurers to use our and any 
authorities we had to make sure that those consumers were taken 
care of.
    Mr. SMITH OF NEBRASKA. Okay. Will any of the consumers who 
lost coverage from the failed co-op be penalized by the 
individual mandate?
    Secretary BURWELL. I do not know how many are not still in 
the system. But I will check and will follow up on that. My 
understanding is no, but I want to confirm that before----
    Mr. SMITH OF NEBRASKA. In that vein, I have introduced H.R. 
954, which would exempt anyone who has lost health insurance 
from the failed co-ops from the individual mandate. Could the 
Administration support that approach and that piece of 
legislation?
    Secretary BURWELL. What I would love to do is have the 
opportunity to see if that is something that has already 
happened or not and then review the bill.
    Mr. SMITH OF NEBRASKA. Okay. Now, in the bigger picture of 
obviously large sums of money being offered to these consumer- 
operated and oriented programs, what is the likelihood of those 
dollars being paid back?
    Secretary BURWELL. With regard to the loans that have gone 
out?
    Mr. SMITH OF NEBRASKA. Correct.
    Secretary BURWELL. I think with regard to a number of the 
co-ops, that will happen in terms of the successful co-ops and 
those that are gaining traction and working. As I said, there 
may be some that are not. And we will get back to you on that 
specific question.
    Mr. SMITH OF NEBRASKA. It seems to me also that the various 
States relevant to this issue might have a different approach 
for paying the claims that were submitted by--how on top of 
this are we? Because it is, in Nebraska, there is a fall back 
and, yet, it hurts more people. I apologize. My time has 
expired.
    Secretary BURWELL. State insurance law, as you know, is a 
big part of how that gets determined. But we try to work with 
and support the States with different options.
    Chairman RYAN. The time for the gentleman has expired. Mr. 
Blumenauer.
    Mr. BLUMENAUER. Thank you, Mr. Chairman. Madam Secretary, I 
appreciate your reluctance to deal with hypothetical 
legislation that hasn't yet been written to deal with a legal 
decision that hasn't yet been rendered. I think that is 
prudent. But if this occurrence takes place by the Court, it 
seems to me that it would not be rocket science, as some of my 
colleagues have mentioned, to make relatively minor changes, to 
conform statutes to the intent and text of the bill and move 
forward. I think the Committee could take one weekend and fix 
it and move on.
    I would like to shift gears slightly. We have had an 
ongoing series of conversations, it has been 6 years since a 
provision I authored was approved unanimously by this 
Committee, not just by part of it, unanimously by this 
Committee, dealing with end-of-life care. That provision, 
despite a kerfuffle and certain rhetorical flourishes, remained 
in the legislation. Unfortunately, it fell victim to the 
reconciliation process. And 6 years later, we are still trying 
to achieve those objectives.
    Although the world has moved on, in a best-selling book by 
Atul Gawande, Bill Frist, and Billy Graham, all agree that this 
is necessary. You recently received a letter from 65 notable 
national organizations calling on you to have Medicare 
reimbursement for advanced care planning. As you know, the AMA 
did the coding. It is all teed up, ready to go. We thought the 
Administration was going to be there. And, yet, it lingers.
    Published, peer-reviewed research shows that advance care 
planning leads to better care, better patient and family 
outcomes, fewer unwanted hospitalizations. The list, as you 
personally know, is compelling for this service. Is the 
Administration prepared to finally move forward and authorize 
it?
    Secretary BURWELL. With regard to this, as I think you just 
mentioned, the AMA has given us the guidance and the coding. 
And we are in the process of reviewing that. As we indicated in 
a recent rulemaking, indicated in our preamble, that is 
something that we are working on and reviewing the current 
coding.
    Mr. BLUMENAUER. So it has been 6 years since Congress 
embraced it. The Committee approved it unanimously. We have had 
the research clear, the IOM dying in America. I am trying to 
understand what it is that is so hard to figure out whether or 
not this is part of the legacy of the Obama Administration, 
which has done some good things with health care. This seems to 
be a really terrific thing that is really simple, that would 
make a huge difference in people's lives. Private insurance is 
moving. What is it that is hanging this up? Why can't we just 
get to yes?
    Secretary BURWELL. Congressman, as we have said and in our 
conversations and our team's conversations with you, this is an 
issue we are going to continue to work on. Because we want to 
make sure if we move that we do make the progress that we would 
intend to make.
    Mr. BLUMENAUER. Well, I find it mystifying that the rest of 
the world is aligned. This is one of the few things that this 
Committee agreed to unanimously and that we see the difference 
it makes in human lives. And the Administration continues to 
study. And I really hope that this could be part of the legacy 
and that it is part of the 2016 reimbursement.
    I find it frustrating beyond my ability to express. I am 
happy to walk, I have walked the plank for this Administration 
on things before. And this is really troubling.
    Chairman RYAN. Thank you. Time for the gentleman has 
expired. Ms. Jenkins.
    Ms. JENKINS. Thank you, Mr. Chairman. And thank you, Madam 
Secretary, for being here today. I want to echo the comments of 
Chairman Ryan and others on the Committee regarding the Supreme 
Court's decision later this month on the constitutionality of 
this President's healthcare law. Many Kansans are poised to 
lose their subsidies, which is the only thing that makes their 
insurance somewhat affordable. Many of my constituents will be 
facing increases over 30 percent next year, which, in addition 
to the loss of their subsidies, will make their insurance 
unaffordable.
    And I am extremely frustrated because I had an exchange 
with your predecessor, Secretary Sebelius, 3 years ago on 
February 28, 2012, when she was a witness here before the 
Committee. And on that day, I expressed my concern that I did 
not see anything in the President's healthcare law that would 
allow Federal subsidies to flow through non-State-based 
exchanges. And I told her the Administration didn't have the 
authority to allow these subsidies to flow through federally-
facilitated exchanges, even though the IRS at 
the time was telling Congress that the distinction didn't 
matter. Because in the law, there is no mention of the term 
federally-facilitated exchanges.
    Even though Secretary Sebelius promised me that HHS would 
give me a detailed answer in writing defending her 
interpretation of the law, she never did. And, obviously, this 
issue didn't go away. And now the Supreme Court will finally 
weigh in on it. And I am equally concerned when you suggest 
that the decision before the Supreme Court is just about the 
subsidies. Because it isn't. We have research here from the 
American Action Forum which talks about all of the positive 
outcomes from a decision by the Supreme Court against the 
Administration. Over 11 million individuals freed from the 
individual mandate, over 260,000 businesses freed from the 
employer mandate, hundreds of thousands of new jobs, 1.2 
million workers added to the labor force.
    With limited time, what I would like to do is turn my 
attention to a different topic. I have introduced legislation 
the past 3 years, along with my colleague, Representative Kind 
from Wisconsin, to repeal a provision in the healthcare law 
that allows folks to go to their doctor to get a note in order 
to purchase over-the-counter medicines with their HSAs or FSAs. 
And this presents patients with a maze of government redtape 
that they must navigate in order to purchase over-the-counter 
medicines, whose use saves the healthcare system money.
    Additionally, it presents physicians with the bizarre 
scenario of unnecessarily seeing patients in order to prescribe 
over-the-counter pain relievers or allergy medicines. This 
provision makes care less affordable, more confusing, clogs 
doctors' offices, and makes patients less likely to use over-
the-counter medicines. So, Madam Secretary, I was just 
wondering if you think that this is good policy and if you 
would support us in repealing this provision?
    Secretary BURWELL. As I have articulated, one of the things 
we are focused on is this idea of how we can improve quality 
and move toward affordability. The specific piece of 
legislation, I am sorry, I am not familiar with, I am not 
familiar in terms of the issue that I think you are trying to 
resolve. And so this is one I would want to understand. I also 
do want to return to where you began.
    Ms. JENKINS. Okay. But, in theory, would you support this 
if we could convince the Chairman to mark up the bill and move 
it over to the Senate? We have done that once. It has already 
passed with bipartisan support out of this Committee and out of 
the House once before.
    Secretary BURWELL. Congresswoman, I would want to look at 
the substance of the issue before I could comment specifically 
on that. It is not one, I am sorry, I am familiar with.
    Ms. JENKINS. Okay. All right. Thank you, I yield back.
    Chairman RYAN. Thank you so much. Mr. Paulsen.
    Mr. PAULSEN. Thank you, Mr. Chairman. Madam Secretary, 
thanks for being here. In the limited amount of time, I want to 
address a couple of things. In Minnesota, unlike many States, 
we had a pretty low uninsured rate prior to the President's 
healthcare law kicking into effect. You know, we had a high-
risk pool for people who had preexisting conditions. It has 
been in existence since 1976. And it certainly wasn't perfect 
but it worked pretty well. That high-risk pool was closed to 
make way for the new State exchange program that was set up.
    And now a lot of the headlines, similar to what we have 
heard from some of our colleagues and concerns about premiums 
rising, headlines over the last few weeks in Minnesota that 
have appeared in some of our papers, show the experience under 
the new exchange and the President's healthcare law has been 
affecting their pocketbooks, right? And so it got here, you 
know, eight Minnesota healthcare plans propose premium hikes 
from 11 to 74 percent.
    We have another story here, Blue Cross and Blue Shield of 
Minnesota, which is the largest insurer in the individual 
market, which you mentioned earlier about the individual 
market, having the marketplace work, they announced proposed 
average increases of 54 percent. So certainly this is a 
pocketbook issue for families, for individuals, for small 
businesses alike. And that is why I really do hope, regardless 
of the court decision and how that goes, that we will be able 
to work with the Administration on addressing some of these 
affordability costs. Because I think when you are talking about 
premiums, this goes to the heart of affordability, as opposed 
to talking about, you know, per capita healthcare costs being 
lowered in Medicare and other areas like that.
    So just some commentary there, that I hope that cooperation 
will be coming forward. Because we need that. We need that on a 
host of issues if we are going to solve some of the challenges 
rather than just digging in and just protecting every provision 
of the law as it is intact right now. And I will just mention 
this. You know, my interest with medical devices and medical 
technology, which we talked about last week, is very important 
in my State. And America has been a leader in developing these 
technologies and cures. And innovation happens at a really 
rapid pace. But often the regulatory process does not keep 
pace. And I don't think it is acceptable that American-made 
technology is available to citizens in other countries and it 
is not available to our patients here at home.
    And the number one concern that I hear now from patient 
groups, from doctors, from investors in new med-tech companies, 
from manufacturers isn't the FDA. The biggest hurdle they now 
face is CMS and the lack of certainty surrounding coverage and 
coding and reimbursement. And these decisions take 2 or 3 
years. And that is after the devices have already been 
approved. And they have already been approved. And this creates 
a lot of uncertainty for manufacturers and doctors that want to 
utilize the best available technology for their patients.
    So I guess my question is, you know, what can HHS do to 
oversee CMS, right, which is under your authority, to make sure 
that we are bringing certainty to the coverage, to the coding, 
and to the reimbursement process for medical technology that, 
quite honestly, can lead to less invasive procedures and a 
whole host of areas of health care that can actually save 
money? It is definitely an impediment right now.
    Secretary BURWELL. On the issue of the DME and CMS, we want 
to continue to work and would like to work. What we are trying 
to do is get that balance between making sure, we have all 
talked a lot about healthcare costs and growing healthcare 
costs, so making sure that the evidence-based decisions in 
terms of CMS saying they will pay for it.
    FDA determines its safety. And then CMS determines if we 
will pay, if, you know, the benefits are such that it should be 
a part of a payment scheme. And we will continue to move things 
through quickly. But we will also continue to try to figure out 
the ways that we balance it. If there are places and things 
that people, that you have ideas about faster, that is 
something that we would welcome in terms of what you are 
hearing from the companies.
    The other thing I think it is important to touch on is the 
premium issue. What has been in the news recently is actually a 
part of the ACA's effort to make sure that we have transparency 
and downward pressure on premiums. What has been in the news 
recently is any premium increase that is above 10 percent has 
to be reviewed. It has to be reviewed by State insurers. And so 
what you are seeing in the space right now in many of the 
articles, I am not sure of all the headlines you read, but a 
number of those headlines are about the fact that these are now 
their first submission. And last year we saw this come down 
because the review process works. Because there are 
conversations like this in public, that it creates downward 
pressure on those premium increases.
    So it is a part of the process. And it doesn't reflect the 
whole base. Most insurers are saying that the majority of their 
people that they think will enroll next year in 2016 will have 
premium increases less than 10 percent. So we agree with you on 
the importance of that downward pressure.
    Chairman RYAN. Thank you. Mr. Kind.
    Mr. KIND. Thank you, Mr. Chairman. Madam Secretary, thank 
you for being here. Obviously, there is a lot of attention and 
focus on King v. Burwell and where that Court ultimately comes 
down. But in your opinion, how quickly or easily could this 
Congress, if it wanted to, enact legislation language to fix 
that overnight if it is an adverse decision from the Supreme 
Court?
    Secretary BURWELL. I think I would hesitate to say how 
quickly the Congress could act.
    Mr. KIND. Assuming there is a willingness.
    Secretary BURWELL. But I think the question of, the issue, 
if it is ruled that it is about the subsidy, that that is a 
relatively simple solution that one can do legislatively with 
regard to subsidies for those that are in the Federal 
marketplace.
    Mr. KIND. I come from a State, Wisconsin, I am very proud 
of, but I have never seen a greater act of fiscal malpractice 
by the current Governor than what has been perpetrated the last 
few years in his denial of the Medicaid expansion money. And 
his budget this year is proposing over $300 million of cuts to 
our university system. But if he took the Medicaid expansion 
money over the next 2 years, that would bring into the State 
$350 million over the next 2 years.
    It just seems to be basic math. And his denial of that is 
not only denying people who are tough to cover to begin with, 
but also denying getting that money into the State where it can 
do some good in Wisconsin. I know you especially and HHS have 
been working very closely with many other Republican Governors 
throughout the Nation to figure out a path forward on waivers, 
and modifications, and other things. I would encourage you to 
continue those lines of communication. Because we need help in 
Wisconsin.
    He also rejected the ability for us to form our own 
exchange. So we are in that box right now looking at the 
Supreme Court. And we could have done it the Wisconsin way and 
created our own health insurance exchange. He chose not to. So 
if we do get an adverse decision, 166,000 Wisconsonites would 
lose their premium tax credits. And my guess is insurance then 
would be rendered unaffordable to them too. So there is a lot 
riding on this decision. And, hopefully, you will be able to 
continue to work with the States and convince them to do the 
right thing, especially in Wisconsin where we need help. But I 
also appreciate your focus, your sustained focus not only on 
delivery system reform, but payment reform, getting to a 
quality-based reimbursement system.
    And I agree with my colleague, Mr. Buchanan, that more 
needs to be paid to cost containment. And there is some good 
news. You have set up the new network on quality collaboration 
throughout the Nation. And I hail from the land of integration, 
coordination, quality measurements, best practices, value-based 
medicine and so forth. But in your estimation, how quickly can 
we pivot now from fee-for-service volume to a quality-based 
reimbursement system?
    Secretary BURWELL. When one considers that Medicare dollars 
are a large portion, we believe that we can move to 50 percent 
by 2018. The goal for 2016, being 30 percent, was where we 
started out. Because, obviously, I won't be here, we needed to 
set a goal, an achievement that would be there while we serve 
out. So we think that you can get to 50 percent of Medicare, at 
the point at which 50 percent of Medicare is based on value. 
And what we are trying to do is make that pass by this network. 
So I am meeting with the insurance, the CEOs, as well as CEOs 
of companies, because those are the other payers.
    In New York State, Medicaid has committed to doing the same 
thing we are. So I think the path that we have Medicare on is 
close to the trajectory for the Nation in terms of moving 
toward more value-based----
    Mr. KIND. You mentioned New York. Why do you think more 
States aren't taking up this challenge and converting Medicaid 
to that type of payment system too?
    Secretary BURWELL. I think that more States are interested. 
And in our conversations with States, I think a number of 
States are not wanting to have the public commitment. And so a 
number of States are a part of that network.
    And across all States, I can look around and have talked to 
Governors from a number of your States that are willing and 
thinking about this because they believe getting the value-
based payments in Medicaid, which is a large expense for the 
States, is a very important thing. So I think there are more 
States that are interested but are not at the point of public 
commitment.
    Mr. KIND. Thank you. Thank you, Mr. Chairman.
    Chairman RYAN. Thank you. We are now going to move to 3 
minutes per person in order to try to fit in as many people as 
possible. Mr. Marchant.
    Mr. MARCHANT. Thank you, Mr. Chairman. Secretary Burwell, 
in the period of time in which the Affordable Care Act was 
being adopted, probably the most unpopular aspect of it and 
most debated in my district were the IPAB panels. Many names 
were given to those panels. And then last week, I think, I was 
able to cast a vote publicly that would abolish that panel. 
Yet, there is talk about strengthening the panel. There is talk 
about expanding the panel. Could you give us an explanation of 
what this talk is all about and what the purpose of it is?
    Secretary BURWELL. With regard to the changes in our budget 
around IPAB, it is to strengthen and increase the Medicare 
savings. Because as we have all discussed, healthcare costs and 
the issue of healthcare costs, Medicare being a core element of 
that, are very important.
    What we are hopeful of, and in the budget, the $423 billion 
of Medicare savings that is specific in specific ways, that we 
can all have a discussion about, I know there are those who 
disagree with us about the balance we have of provider and 
beneficiary approaches to getting that money. But I think what 
we believe is that IPAB as a tool, and a tool that the Congress 
would still engage with, because you all would approve anything 
that was suggested by IPAB, Congress would have the opportunity 
to give it a thumbs up or a thumbs down, is an important tool 
to keep the pressure on all of us.
    Because I think we all know, Medicare expenditure is a 
tough issue. It is a very tough issue for everyone in terms of, 
even the issues we are talking about, about payments for DME or 
other things, that is what drives those costs upward. And so we 
believe it is a tool in the toolbox. We actually, in our 
budget, are depending though on specific issues that the 
Congress could review.
    And right now, IPAB would not kick in, in the President's 
budget it would be 2019. If you don't do any of the changes 
that we would do, it would be 2022. And that obviously is in 
another Administration.
    Mr. MARCHANT. And so why has the President not named anyone 
to the panel?
    Secretary BURWELL. With regard to the issue of panel 
members, it is something that we believe we should do in 
consultation with the Congress. And so that has been a place 
and I think it is because, as you were expressing, making sure 
if you were going to name a panel, there is appropriate 
congressional input.
    And the other thing is at this point, now that we see the 
numbers, and we have made improvements in terms of the Trust 
Fund's viability over, you know, increased by many years, the 
need is not for now. And it would be in another Administration. 
So the question of us naming the panel now----
    Mr. MARCHANT. So the President will not name a panel in his 
Administration?
    Secretary BURWELL. At this point, with regard to where we 
are in the budget, we have not yet done it.
    Chairman RYAN. The time of the gentleman has expired. Mrs. 
Black.
    Mrs. BLACK. Thank you, Mr. Chairman. And thank you for 
being here, Secretary Burwell. Mr. Chairman, I ask unanimous 
consent to insert this report from the Treasury Inspector for 
Tax Administration in the record.
    Chairman RYAN. Without objection.
    [The submission of The Honorable Diane Black follows:]
    
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

   

                                 
    Mrs. BLACK. The Affordable Care Act requires the exchanges 
to determine if applicants were offered health insurance by 
their employer. And if they were offered that comprehensive and 
affordable coverage, then those individuals are not eligible 
for the premium tax credit.
    The Treasury Inspector General recently reported in this 
report, stated that neither the Federal nor the State exchanges 
were able to verify most individuals' attestation that they 
were not offered health insurance by their employer. And this 
is happening despite the fact that the burden and the costly 
reporting requirements have been placed upon our employers. 
What is it that HHS is doing to ensure that people who receive 
these credits actually legally are eligible for them?
    Secretary BURWELL. So much of our, this is the APTC that 
you are referring to, correct?
    Mrs. BLACK. That is right.
    Secretary BURWELL. So with regard to that, we have a data 
matching process that we are doing. And it checks both 
immigration status, as well as income status. And that is one 
of the processes we are doing to make sure that people who are 
eligible, and we release numbers, I think you probably saw last 
week where over 100,000 people came off the rolls because we 
weren't able to verify the information.
    And so that is a process, it is a process last year that 
took a longer period of time. And now we have improved to a 90-
day period of time.
    Mrs. BLACK. So let me quickly go to the other part of this 
which involves the IRS. Because in their application, that is 
the individual's application for this coverage, individuals are 
asked if their employer offered them health insurance. And the 
exchanges then are required to provide the applicant's response 
to this question along with the information related to the 
employer to the IRS in a monthly data report.
    The Treasury found that neither the CMS nor many of the 
State exchanges were able to submit this information until well 
after the 2015 filing season was complete. So it appears that 
two of those State exchanges have still not provided that 
required information. This is just one example of the numerous 
delays from CMS when it comes to Obamacare.
    So healthcare.gov alone took over $1 billion to build. And 
yet it is apparent that these systems are still not fully 
functioning based on this report. So CMS undertook this mammoth 
project without effectively planning for the development or the 
oversight. And this has led to hundreds of millions of dollars, 
these are taxpayer dollars, that are being wasted.
    So my question is, can you outline the oversight that is 
being conducted to ensure that the legal requirements that were 
set up by the law are actually met and the systems are properly 
developed to protect our taxpayer dollars?
    Secretary BURWELL. Congresswoman, I want to check because 
this report, I think, as you all probably know, there have been 
over 50 audits of the Affordable Care Act, and I want to make 
sure that I am focused on the right one.
    With regard to the one you are speaking about, if it is the 
one that I think it is, we are now in a place where the 
information is going from the Federal marketplace to the IRS on 
a monthly basis. And, you know, with all of these audits that 
we have received from both IGs and the GAO, we continue to work 
through their suggestions. And I think it is that one. But we 
will follow up, and if it is not the case, we are now in a 
monthly reporting----
    Mrs. BLACK. I would really appreciate your following up. 
Because it is related to this report. Thank you very much.
    Chairman RYAN. Thank you. Mr. Pascrell.
    Mr. PASCRELL. Thanks, Mr. Chairman. And thank you, Madam 
Secretary. I am pleased that during your confirmation process, 
you expressed support for improving the safety of medical 
devices--a few of us have brought that up--by incorporating the 
FDA's new, Unique Device Identifier, the UDI, to assist in 
health insurance claims. Myself and Chairman Brady have talked 
about this in the past.
    I am asking you today, despite this widespread support, 
that--some in the CMS, I am putting it mildly, have resisted 
this important public health and patient safety effort. So we 
need the tools. Could you commit to work with the Committee 
this summer to move the policy forward?
    Secretary BURWELL. I do commit. And I think we have made 
some progress by having FDA and CMS working together on 
something that will actually be more implementable. So we are 
working on it. And your comments and the Chairman's comments 
and others are something that I recognized when I came in. And 
so we have been working on it, but would look forward to 
working with the Committee further.
    Mr. PASCRELL. Thank you. Let me shift a gear a little bit 
here. You would think that if my colleagues on the other side 
cobbled together all of the time they spent trying to undermine 
the ACA, they would have been able to come up with an 
alternative to this law. They can't find anything good to say 
about anything. So in this Committee alone, we have had over a 
dozen hearings just on issues related to the individual and 
employer mandate. Many Members, in good faith I am sure, 
brought this up today. Not to mention nearly 64 votes to repeal 
or undermine the ACA. Make no mistake about it. That is what 
this is about. And how many have we had on this elusive 
Republican alternative I keep hearing about? Zero.
    The reality is that this Act is working. It has problems. 
Medicare has problems. Medicaid has problems. This is a very 
imperfect world, Madam Secretary. More than 10 million 
Americans have health coverage through the marketplaces. 
Eighty-five percent receive tax credits to help with the cost 
of coverage. So while we 
are waiting, I am interested in the answer to one question. Has 

the ACA impacted employer-sponsored insurance offering take-up 
rates? And does the ACA maintain the financial incentives for 
employers to cover and to offer coverage? That is my question.
    Secretary BURWELL. This past week, we have seen a piece of 
work by the Urban Institute with regard to the number of 
employer-base. The statistics that we have, certainly CBO's 
changes to its numbers, most recent changes to its ACA numbers, 
have to do with the fact that they now have lowered the number 
of people they think will switch from the employer-based market 
to the marketplace.
    And the Urban Institute numbers that came out this week 
said that there actually, on a percentage basis, has been a 
slight, very slight, so I would call it basically the same, no 
decrease, but the same. It is a slight tip up, but not 
numerically, I think, significant. Actual maintenance of those 
in the employer-based market. And so there has not been a 
decrease.
    Mr. PASCRELL. Thank you very much, Madam Secretary. I yield 
back, Mr. Chairman.
    Chairman RYAN. Thank you. Mr. Young.
    Mr. YOUNG. Madam Secretary, thank you for being here today. 
The President after the G-7 summit this week said the 
Affordable Care Act is working. I mean, part of what is bizarre 
about this whole thing is we haven't had a lot of conversation 
about the horrors of Obamacare because none of them have come 
to pass. And he continued, somewhat oblivious, seemingly, to 
some of the things I am hearing in my own district, saying, 
``It hasn't had an adverse effect on people who already had 
health insurance.''
    You know, I am frustrated. And I know many Hoosiers are 
frustrated by some of the adverse impacts they have 
experienced, from diminished coverage options, to lack of 
accessibility in their own communities for care. A lot of 
people are being squeezed when they go into the exchanges with 
price increases on premiums. And then there are the penalties, 
of course, the mandate taxes that exist if they can't afford to 
buy health insurance.
    And so I just want to humanize this a little bit for you. 
Because I know you are quite conversant in the statistics and 
the goings on of much of this healthcare law. Patsy, from my 
district in Jeffersonville, Indiana, her premium went up $135 a 
month. She no longer has access to the family physician that 
has cared for her for over 25 years. Brandon, from Greenville, 
signed up for health care his family can't use because his 
family's deductibles are too high. And they make just enough 
that they don't qualify for assistance. Jason, from Georgetown, 
Indiana, had to seriously consider paying the individual 
mandate tax because he couldn't afford to pay the increased 
premiums on the exchange and didn't qualify for an exemption. 
Debra, from New Albany, had her monthly premium skyrocket to 
$800 a month, more than her mortgage payment.
    So these are just illustrative of what are larger problems 
in every State across the country, every congressional 
district. And, you know, to use the President's own words, 
these horror stories haven't come to pass. They are coming to 
pass. They are in existence right now. And I just want to know 
what you believe, Madam Secretary, I should tell my 
constituents who are trying to comply with this law? Are they 
merely collateral damage?
    Secretary BURWELL. With regard to the examples and stories, 
I think they are important. And they are important to combine 
with the numbers in terms of what we know, that, you know, 16.4 
million people in our country are no longer uninsured. And the 
stories, I hear those stories and respect those stories. But 
having traveled 22,000 miles and having been out amongst 
people, I heard the story from the woman in Texas who said you 
want to know how to treat MS? I will tell you how to treat MS. 
You get sick enough to go to the emergency room, and they will 
treat you. And now she said I will know how.
    Mr. YOUNG. So in the near term, what do we do? I am sorry 
for interjecting but time is short. What do we do for these 
Hoosiers who don't qualify for a hardship exemption?
    Secretary BURWELL. I think, first of all, we need to make 
sure they have exhausted that remedy. And, please, we are----
    Mr. YOUNG. I have made sure they have. Our office has.
    Secretary BURWELL. And have worked through us. The other 
thing, on a number of the examples that you talked about, there 
is the issue of coverage to care and helping people understand 
how to select the right plan. The plans on the marketplace are 
very varied. There are many in terms of the questions of 
deductibility and that sort of thing.
    Chairman RYAN. Thank you. Thank you. Mr. Renacci.
    Mr. RENACCI. Thank you, Mr. Chairman. And thank you, Madam 
Secretary, for being here. Earlier on, you said the 
Administration is looking for fixes and improvements for the 
ACA. And I want to run through just a couple of them that I 
think would, it is disingenuous if you don't help make some of 
those fixes.
    One of them deals with seasonal employees, the definition 
between seasonal workers and seasonal employees. I am not sure 
if you are aware of the conflict with that definition and some 
of the difficulty it is causing people in my district but also 
across the country.
    The other is the readmission, hospital readmission program. 
This program was aimed at reducing unnecessary hospital 
readmissions called the Hospital Readmission Reduction Program. 
The goal of the program was really something that I would 
support and probably many of my colleagues support. In fact, it 
is estimated that nearly $18 billion per year is wasted on 
avoidable readmissions of Medicare patients alone. However, the 
implementation of this program has been problematic, especially 
for those hospitals serving low-income populations.
    Evidence suggests that economically disadvantaged patients, 
especially patients eligible for both Medicare and Medicaid, 
are much more likely to be readmitted within 30 days of 
discharge regardless of physicians' efforts to educate them on 
proper post-discharge care.
    Do you believe the readmission program criteria can be 
improved by adding clear adjustments for dual eligible status 
as well as for other planned readmissions such as those 
following trauma?
    Secretary BURWELL. So I agree with you on the issue of 
socioeconomic status and the difficulties that that can cause. 
We actually had a proposal and a rulemaking and a proposed 
rulemaking and a suggestion of how to make some of those kinds 
of changes. The remarks we received back were an important 
issue, but not the right way to go about it.
    The Congress, thankfully, has also given us money to 
actually do this specific study of how we can work through this 
issue. We look forward to working with you on how we correct it 
because we had a proposal that others didn't. We believe it is 
an important issue. When I analytically understand how we can 
account for that but at the same time do what your beginning 
point was, which is we know we have more readmissions than we 
should, both in terms of quality and price, I will discuss it 
in more detail. And so getting to that is something we would 
like to do. We have tried to propose it. We clearly didn't get 
it there.
    Mr. RENACCI. Thank you. I have Ensuring Beneficiary Equity 
in Hospital Readmission Program, H.R. 1343, a bill that I have 
introduced which does have bipartisan support that I would hope 
the Administration would consider and support.
    Also, on seasonal employees, I have STARS Act, H.R. 863, 
really to clarify the conflicting definitions between seasonal 
workers and seasonal employees, which is causing compliance 
problems for both employers and individuals. Interactions 
between seasonal, seasonality, the employer mandate and the 
individual mandate, really create opportunities for accidental 
noncompliance resulting in significant tax penalties for 
American workers and businesses alike.
    So that is another issue I would hope that we can work on. 
Because these are issues clarifying and fixing, as you said, 
fixing or improving the current law. So I thank you, and I 
yield back.
    Chairman RYAN. The gentleman yields back. I understand that 
the Secretary has a hard stop. I regret the fact that not every 
Member will be able to ask questions of the witness at this 
moment. I would like to invite any Member, particularly those 
who did not have the opportunity, to give us--the Committee 
their questions in writing. We will submit them to the 
Secretary, to the witness, and I ask the Secretary to respond 
in a very timely manner to these questions from the remaining 
Members.
    Secretary BURWELL. I would be happy to. I would be happy to 
and I think a number of you have my cell number, so feel free.
    Chairman RYAN. With that, to honor your time, your 
deadline, the hearing stands adjourned. The Committee stands 
adjourned.
    [Whereupon, at 12:03 p.m., the Committee was adjourned.]
    [Submissions for the Record follow:]
    
    
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