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





                       EXAMINING THE POLICIES AND
                           PRIORITIES OF THE
                       U.S. DEPARTMENT OF HEALTH
                           AND HUMAN SERVICES

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

                                HEARING

                               before the

                         COMMITTEE ON EDUCATION
                           AND THE WORKFORCE
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

             HEARING HELD IN WASHINGTON, DC, MARCH 15, 2016

                               __________

                           Serial No. 114-41

                               __________

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


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                COMMITTEE ON EDUCATION AND THE WORKFORCE

                    JOHN KLINE, Minnesota, Chairman

Joe Wilson, South Carolina           Robert C. ``Bobby'' Scott, 
Virginia Foxx, North Carolina            Virginia
Duncan Hunter, California              Ranking Member
David P. Roe, Tennessee              Ruben Hinojosa, Texas
Glenn Thompson, Pennsylvania         Susan A. Davis, California
Tim Walberg, Michigan                Raul M. Grijalva, Arizona
Matt Salmon, Arizona                 Joe Courtney, Connecticut
Brett Guthrie, Kentucky              Marcia L. Fudge, Ohio
Todd Rokita, Indiana                 Jared Polis, Colorado
Lou Barletta, Pennsylvania           Gregorio Kilili Camacho Sablan,
Joseph J. Heck, Nevada                 Northern Mariana Islands
Luke Messer, Indiana                 Frederica S. Wilson, Florida
Bradley Byrne, Alabama               Suzanne Bonamici, Oregon
David Brat, Virginia                 Mark Pocan, Wisconsin
Buddy Carter, Georgia                Mark Takano, California
Michael D. Bishop, Michigan          Hakeem S. Jeffries, New York
Glenn Grothman, Wisconsin            Katherine M. Clark, Massachusetts
Steve Russell, Oklahoma              Alma S. Adams, North Carolina
Carlos Curbelo, Florida              Mark DeSaulnier, California
Elise Stefanik, New York
Rick Allen, Georgia

                    Juliane Sullivan, Staff Director
                 Denise Forte, Minority Staff Director
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                            C O N T E N T S

                              ----------                              
                                                                   Page

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

Statement of Members:
    Kline, Hon. John, Chairman, Committee on Education and the 
      Workforce..................................................     1
        Prepared statement of....................................     3
    Scott, Hon. Robert C. ``Bobby'', Ranking Member, Committee on 
      Education and the Workforce................................     4
        Prepared statement of....................................     7

Statement of Witnesses:
    Burwell, Hon. Sylvia Mathews, Secretary, U.S. Department of 
      Health and Human Services, Washington, DC..................     9
        Prepared statement of....................................    12

Additional Submissions:
    Byrne, Hon. Bradley, a Representative in Congress from the 
      state of Alabama:
        Slides...................................................    37
    Carter, Hon. Buddy, a Representative in Congress from the 
      state of Georgia:
        Letter dated March 22, 2016, from Secretary Burwell......    65
    Chairman Kline:
        Prepared statement of the U.S. Chamber of Commerce.......    67
    Pocan, Hon. Mark, a Representative in Congress from the state 
      of Wisconsin:
        Letter from Brent Nathan Brown...........................    72
    Questions submitted for the record by:
        Allen, Hon. Rick, a Representative in Congress from the 
          state of Georgia.......................................    83
        Bishop, Hon. Michael D., a Representative in Congress 
          from the state of Michigan.............................    82
        Mr Byrne.................................................    81
        Mr. Carter...............................................    82
        Clark, Hon. Katherine M., a Representative in Congress 
          from the state of Massachusetts........................    86
        Foxx, Hon. Virginia, a Representative in Congress from 
          the state of North Carolina............................    77
        Fudge, Hon. Marcia L., a Representative in Congress from 
          the state of Ohio......................................    84
        Heck, Hon. Joseph J., a Representative in Congress from 
          the state of Nevada....................................    79
        Chairman Kline...........................................    76
        Messer, Hon. Luke, a Representative in Congress from the 
          state of Indiana.......................................    81
        Polis, Hon. Jared, a Representative in Congress from the 
          state of Colorado......................................    85
        Roe, Hon. David P., a Representative in Congress from the 
          state of Tennessee.....................................    78
        Mr. Scott................................................    83
        Walberg, Hon. Tim, a Representative in Congress from the 
          state of Michigan......................................    78
        Wilson, Hon. Frederica S., a Representative in Congress 
          from the state of Florida..............................    85
    Secretary Burwell's responses to questions submitted for the 
      record.....................................................    88
 
                 EXAMINING THE POLICIES AND PRIORITIES
                    OF THE U.S. DEPARTMENT OF HEALTH
                           AND HUMAN SERVICES

                              ----------                              


                        Tuesday, March 15, 2016

                     U.S. House of Representatives

                Committee on Education and the Workforce

                            Washington, D.C.

                              ----------                              

    The Committee met, pursuant to call, at 10:00 a.m., in room 
2176 Rayburn House Office Building. Hon. John Kline [chairman 
of the committee] presiding.
    Present: Representatives Kline, Foxx, Roe, Thompson, 
Salmon, Rokita, Barletta, Messer, Byrne, Carter, Bishop, 
Russell, Curbelo, Stefanik, Allen, Scott, Hinojosa, Davis, 
Courtney, Fudge, Polis, Sablan, Wilson, Bonamici, Pocan, 
Takano, Jeffries, Clark, Adams, and DeSaulnier.
    Staff Present: Andrew Banducci, Workforce Policy Counsel; 
Janelle Belland, Coalitions and Members Services Coordinator; 
Kathlyn Ehl, Professional Staff Member; Ed Gilroy, Director of 
Workforce Policy; Callie Harman, Legislative Assistant; 
Christie Herman, Professional Staff Member; Tyler Hernandez, 
Press Secretary; Amy Raaf Jones, Director of Education and 
Human Resources Policy; Nancy Locke, Chief Clerk; Michelle 
Neblett, Professional Staff Member; Brian Newell, 
Communications Director; Krisann Pearce, General Counsel; 
Alexandra Pena, Staff Assistant; Lauren Reddington, Deputy 
Press Secretary; Alissa Strawcutter, Deputy Clerk; Juliane 
Sullivan, Staff Director; Leslie Tatum, Professional Staff 
Member; Olivia Voslow, Staff Assistant; Tylease Alli, Minority 
Clerk/Intern and Fellow Coordinator; Pierce Blue, Minority 
Labor Detailee; Jacque Chevalier, Minority Senior Education 
Policy Advisor; Denise Forte, Minority Staff Director; 
Christine Godinez, Minority Staff Assistant; Carolyn Hughes, 
Minority Senior Labor Policy Advisor; Eunice Ikene, Minority 
Labor Policy Associate; Brian Kennedy, Minority General 
Counsel; Richard Miller, Minority Senior Labor Policy Advisor; 
Alexander Payne, Minority Education Policy Advisor; Veronique 
Pluviose, Minority Civil Rights Counsel; and Marni von Wilpert, 
Minority Labor Detailee.
    Chairman Kline. A quorum being present, the Committee on 
Education and the Workforce will come to order. Good morning, 
everyone, and welcome, Secretary Burwell. We appreciate you 
joining us to discuss the policies and priorities of the 
Department of Health and Human Services.
    From welfare and health care to early childhood development 
and support services for older Americans, the policies your 
department oversees affect the lives of millions of Americans.
    Conversations like this one are vitally important as we 
work to ensure that the Department is acting in the best 
interest of the taxpayers and those in need.
    As we examine what programs and policies are working and 
which ones are in need of improvement, I hope there are a 
number of areas where we can find common ground.
    Of course, there are also areas where we will ultimately 
agree to disagree, and perhaps the most prominent example is 
the President's health care law. As has been the case for 
nearly six years, this flawed law continues to hurt working 
families, students, and small businesses. It is still 
depressing hours and wages for low-income workers, still making 
it harder for individuals to receive the care they need, and 
still driving up health care costs.
    One Emory University professor recently wrote that his 
family's health insurance premium is now their biggest expense, 
even greater than their mortgage. Before the health care law 
went into effect, this man was able to cover his entire family 
of four for less than $13,000. Now, the cost of insuring just 
him and his wife is nearly $28,000. Twice the cost to cover 
half as many people. In fact, paying more for less is becoming 
a hallmark of the health care law.
    Over the years, Republicans have put forward a number of 
health care reform ideas, ones that would expand access to 
affordable care and lead to a more patient-centered health care 
system. We will continue to do so, because we firmly believe 
the President's health care law is fatally flawed and 
unsustainable, and more importantly, because we believe the 
American people deserve better.
    Again, I suspect we will have to agree to disagree, but as 
I mentioned, there are areas where I am hopeful we can find 
common ground.
    Head Start, for example, currently supports nearly 1 
million children at a cost of more than $9 billion annually. It 
is an important program for many low-income families. However, 
concerns persist that it is not providing children with long-
term results.
    We both agree, I am sure, changes need to be made, but so 
far we have different ideas of what reform should look like. 
The Department is in the process of fundamentally transforming 
Head Start through regulations that will have serious 
consequences for the vulnerable families this important program 
serves.
    We, on the other hand, have outlined a number of key 
principles that we believe will strengthen the program based on 
feedback we collected from parents and providers.
    I look forward to discussing where we might be able to find 
middle ground and work together so that these children can have 
the solid foundation they need to succeed in school and in 
life.
    I am also hopeful that we can work together to ensure 
changes to the Preschool Development Grants program are 
implemented as Congress intended. The Every Student Succeeds 
Act reformed the program to help States streamline and 
strengthen early learning efforts.
    To accomplish this goal, Congress moved the program from 
the Department of Education to HHS, which already oversees the 
bulk of early learning programs. As you take on this 
responsibility, Madam Secretary, please know we intend to stay 
engaged with the Department to ensure a successful transition.
    Finally, the Department is also responsible for helping 
States to prevent and respond to child abuse and neglect, 
specifically those outlined in the Child Abuse Prevention and 
Treatment Act or CAPTA. As I am sure you are aware, this law 
provides States with resources to improve their child 
protective service systems, if they make a number of assurances 
concerning their child welfare policies.
    It has come to our attention that some States are making 
these assurances without putting the necessary policies in 
place. Yet, not a single State is being denied Federal funds.
    A Reuters' investigation recently revealed the shocking and 
deadly consequences of this neglect and cast serious doubts as 
to whether basic requirements of the law are being met and 
enforced.
    In light of this tragic report, we wrote to you to better 
understand the Department's process in reviewing and approving 
State plans under CAPTA, and I would like to continue that 
discussion here today.
    It is clear that the current system is failing some of our 
country's most vulnerable children and families, and something 
has to change.
    As you can see, we have quite a bit to cover today. These 
and other issues are vitally important to the men and women we 
serve, and we have a responsibility to ensure that we are 
serving those individuals in the best way possible.
    With that, I will now recognize the ranking member, Mr. 
Scott, for his opening remarks.
    [The information follows:]

           Prepared Statement of Hon. John Kline, Chairman, 
                Committee on Education and the Workforce

    From welfare and health care to early childhood development and 
support services for older Americans, the policies the Department of 
Health and Human Services oversees affect the lives of millions of 
Americans. Conversations like this one are vitally important as we work 
to ensure the department is acting in the best interests of taxpayers 
and those in need. As we examine what programs and policies are 
working, and which ones are in need of improvement, I hope there are a 
number of areas where we can find common ground.
    Of course, there are also areas where we will ultimately agree to 
disagree, and perhaps the most prominent example is the president's 
health care law. As has been the case for nearly six years, this flawed 
law continues to hurt working families, students, and small businesses. 
It's still depressing hours and wages for low-income workers, still 
making it harder for individuals to receive the care they need, and 
still driving up health care costs.
    One Emory University professor recently wrote that his family's 
health-insurance premium is now their biggest expense - even greater 
than their mortgage. Before the health care law went into effect, this 
man was able to cover his entire family of four for less than $13,000. 
Now, the cost of insuring just him and his wife is nearly $28,000. 
That's right - twice the cost to cover half as many people. In fact, 
paying more for less is becoming a hallmark of the health care law.
    Over the years, Republicans have put forward a number of health 
care reform ideas, ones that would expand access to affordable care and 
lead to a more patient-centered health care system. We will continue to 
do so, because we firmly believe the president's health care law is 
fatally flawed and unsustainable, and more importantly, because we 
believe the American people deserve better.
    Again, I suspect we will have to agree to disagree, but as I 
mentioned, there are areas where I am hopeful we can find common 
ground.
    Head Start, for example, currently supports nearly one million 
children at a cost of more than $9 billion annually. It's an important 
program for many low-income families. However, concerns persist that 
it's not providing children with long-term results.
    We both agree changes need to be made, but so far, we have 
different ideas on what reform should look like. The department is in 
the process of fundamentally transforming Head Start through 
regulations that will have serious consequences for the vulnerable 
families this important program serves. We, on the other hand, have 
outlined a number of key principles that we believe will strengthen the 
program based on feedback we collected from parents and providers. I 
look forward to discussing where we might be able to find middle ground 
and work together so that these children can have the solid foundation 
they need to succeed in school and in life.
    I'm also hopeful that we can work together to ensure changes to the 
Preschool Development Grants Program are implemented as Congress 
intended. The Every Student Succeeds Act reformed the program to help 
states streamline and strengthen early learning efforts. To accomplish 
this goal, Congress moved the program from the Department of Education 
to HHS, which already oversees the bulk of early learning programs. As 
you take on this responsibility, Secretary Burwell, please know we 
intend to stay engaged with the department to ensure a successful 
transition.
    Finally, the department is also responsible for helping states to 
prevent and respond to child abuse and neglect, specifically those 
outlined in the Child Abuse Prevention and Treatment Act or CAPTA. As 
I'm sure you're aware, this law provides states with resources to 
improve their child protective services systems - if they make a number 
of assurances concerning their child welfare policies. It's come to our 
attention that some states are making these assurances without putting 
the necessary policies in place. Yet, not a single state is being 
denied federal funds.
    A Reuters' investigation recently revealed the shocking and deadly 
consequences of this neglect and cast serious doubts as to whether 
basic requirements of the law are being met and enforced. In light of 
this tragic report, we wrote to you to better understand the 
department's process in reviewing and approving state plans under 
CAPTA, and I'd like to continue that discussion today. It's clear that 
the current system is failing some of our country's most vulnerable 
children and families, and something has to change.
    As you can see, we have quite a bit to cover today. These and other 
issues are vitally important to the men and women we serve, and we have 
a responsibility to ensure they are serving those individuals in the 
best way possible.
                                 ______
                                 
    Mr. Scott. Thank you, Chairman Kline, and welcome, 
Secretary Burwell. Thank you for being with us. We look forward 
to your testimony.
    Today, we will hear about the President's Fiscal Year 2017 
Health and Human Services' budget proposal and the Department's 
policy priorities. Once again, I commend the Secretary for her 
work to ensure that the budget reflects the priorities of this 
committee, protecting access to health care for all Americans, 
giving all children the chance to succeed, and making sure that 
we meet the needs of families and children affected by public 
health threats when they occur.
    In many areas, I believe we have made great progress on 
these priorities. In the not so distant past, many families 
were left without affordable health care options and many more 
could not have access to basic consumer protections in their 
insurance.
    Double digit increases in prices were routine every year. 
Women routinely charged more for insurance than men. If you 
lost you lost your job and wanted to start a new business and 
you had a preexisting condition, you were essentially out of 
luck. If you were a senior and fell into the Part D doughnut 
hole, you did not get any help, and when we consider the 
Affordable Care Act, thousands of people every day were losing 
their insurance.
    Passage of the Affordable Care Act has given millions of 
Americans access to health care coverage, many for the first 
time in their lives. The ACA has helped slow the growth in 
health care costs, it is closing the doughnut hole for seniors, 
and has encouraged and improved access to mental health 
services and preventive care. Instead of thousands losing their 
insurance, millions more have gained insurance.
    So, I thank Secretary Burwell for her efforts and her 
Department's hard work in implementing the Affordable Care Act. 
I recognize the challenge your department faces in implementing 
this law with limited resources and unlimited attacks.
    Despite these challenges, the ACA has expanded coverage to 
millions and given millions more robust consumer protections in 
their health coverage. The ACA has provided a historic 
foundation for which we are going to accomplish our ultimate 
goal, making sure that all Americans have the opportunity to 
succeed.
    I do not believe that we have reached the finish line yet, 
but I look forward to working with the Department and my 
congressional colleagues to make meaningful improvements as we 
strengthen the law.
    I also pleased that the President's budget has placed a 
priority on giving all children a chance to succeed by ensuring 
robust funding to increase both access to and quality of early 
learning and child care programs. We must invest in high 
quality early learning programs because all children deserve to 
enter kindergarten with the building blocks to success.
    Decades of research have shown that properly nurturing 
children in the first five years of life is essential to 
supporting enhanced brain development, cognitive functioning, 
and emotional and physical health.
    All too often, low-income working families lack access to 
high quality affordable child care in their early childhood 
education, and these children tend to fall behind. Beyond the 
achievement gap, children that do not participate in high 
quality early learning programs are more likely to have weaker 
educational outcomes, lower earnings, increased involvement in 
the criminal justice system, and affordable high quality child 
care is, therefore, not just critical for children, it is also 
critical for working parents.
    Child care is a two generation program. Parents of young 
children need child care to work and go to school, and lack of 
stable child care is associated with job interruptions and job 
loss for working parents. Child care ought to be a national 
priority for America's children and working families.
    Just two programs survived the bulk of the Federal role in 
early education, the Head Start program and the Child Care and 
Development Block Grant. Unfortunately, because of limited 
Federal funding, too few children have appropriate access. This 
unmet need continues to grow. Only four of 10 eligible children 
have access to a Head Start program, and fewer than one out of 
six eligible children receive Federal child care assistance.
    We have decades of evidence that investing in programs like 
Head Start and the Child Care and Development Block Grant 
works. This is the time to invest in these programs and ensure 
that we are giving all children the chance to succeed.
    I also want to commend the Secretary and her department for 
their efforts in response to some of the most troubling health 
crises of our time, the Ebola outbreak, Zika and opioid crisis. 
The Department has been in the forefront of responding and 
keeping Americans safe and healthy, particularly when you talk 
about budgeting, some do not always see the value of investing 
in prevention or readiness activities so that we are equipped 
to deal with a public health crisis.
    Like many Federal programs, in fact, like health care 
insurance itself, you often do not miss it until it is gone. It 
is important now more than ever that we invest in our Nation's 
current and future health and well-being. The President's 
proposal does this with the Cancer Moonshot and other long-term 
investments.
    Lastly, I would like to thank the Department and the 
Secretary for their efforts to respond to the catastrophic 
situation in Flint, Michigan. The research is clear on the 
impact of exposure to lead on young children, the adverse 
effects of lead exposure range from decreased academic 
attainment to increased needs for special education, and a 
higher likelihood of behavioral challenges. These impacts can 
result in a significant decline in earnings, loss of tax 
revenue, additional burdens to the criminal justice system, and 
increased stress on our hospital systems.
    The opportunity for a strong start to a successful life 
will be stunted for Flint's children if they are not given the 
necessary resources, including early intervention and access to 
high quality early learning programs, such as Head Start, to 
help them overcome the lifelong effects of exposure to lead.
    We need to come up with the money to make that possible, 
and make no mistake, we should not expect to fix this crisis 
easy or on the cheap. In fact, it will cost approximately $1.2 
billion to provide long-term comprehensive services to all 
Flint children exposed to lead just in the areas that cover 
programs under this committee's jurisdiction.
    Furthermore, it is imperative that this committee and the 
Department continue to examine how Federal programs can be 
responsive and ensure that every Flint youth is receiving the 
necessary services to mitigate the effects of lead exposure.
    The Department's response so far has been commendable. 
Additional funding for health centers in Flint, Medicaid 
expansion to provide vital health coverage and important health 
screenings, $3.6 million onetime emergency funding to help Head 
Start grantees expand early childhood education, health care 
and nutritional services.
    These are examples of targeted Federal solutions, but this 
committee and this Congress has to do more. The impact of lead 
exposure on young children is long-lasting, and a response must 
have a long-term approach.
    We must use all of the tools available to us, starting with 
prenatal care and screenings of pregnant moms, early literacy 
resources, early interventions to identify special education 
needs, Title I and Title II funding from the Elementary and 
Secondary Education Act, after school programs, at-risk youth 
prevention programs, even investments in college access 
efforts.
    I know with all the Department's leadership, we can 
continue to respond to this crisis, and I am hopeful that 
together we can put forward real solutions and help mitigate 
the damage from the water crisis in Flint, and make sure young 
children there get back on track to a prosperous fulfilling 
life.
    So, thank you, Mr. Chairman, and thank you, Secretary 
Burwell. I look forward to your testimony.
    [The information follows:]

 Prepared Statement of Hon. Robert C. ``Bobby'' Scott, Ranking Member, 
                Committee on Education and the Workforce

    Thank you Chairman Kline, and welcome Secretary Burwell. Thank you, 
Secretary, for being with us and I look forward to your testimony.
    Today, we will hear about the President's Fiscal Year 2017 Health 
and Human Services Budget proposal and the Department's policy 
priorities. Once again, I commend the Secretary for her work to ensure 
that the budget reflects the priorities of this Committee - protecting 
access to healthcare for all Americans, giving all children a chance to 
succeed, and making sure that we meet the needs of families and 
children affected by public health threats when they occur.
    In many areas, I believe we have made great progress in these 
priorities. In the not so distant past, too many families were left 
without affordable health care options and many more did not have 
access to basic consumer protections in their insurance. Women were 
routinely charged more for insurance than men. If you lost your job or 
wanted to start a new business and you had a preexisting condition, you 
were out of luck. If you were a senior and fell into the Part D donut 
hole, you didn't get any help.
    The passage of the Affordable Care Act has given millions of 
Americans access to health coverage, many for the first time in their 
lives. The ACA has helped slow the growth in health care costs, is 
closing the donut hole for seniors, and has encouraged and improved 
access to mental health services and preventive care.
    I thank Secretary Burwell for her efforts and her Department's hard 
work implementing the Affordable Care Act. As I've said before, I 
recognize the challenge your Department faces in implementing this law 
with limited resources and unlimited attacks. Despite these challenges, 
the ACA has
    expanded health coverage to millions and given millions more robust 
consumer protections in their health coverage. The ACA has provided a 
historic foundation on which we can work to accomplish our ultimate 
goal - making sure all Americans have the opportunity to succeed. I do 
not believe that we have yet reached the finish line and I look forward 
to working with the Department and my Congressional colleagues to make 
meaningful improvements to strengthen the law.
    I was also pleased that the President's budget request placed 
priority on giving all children a chance to succeed by ensuring robust 
funding to increase both access to and the quality of early learning 
and child care programs. We must invest in high-quality early learning 
programs because all children deserve to enter kindergarten with the 
building blocks to success.
    Decades of research has shown that properly nurturing children in 
the first five years of life is instrumental to supporting enhanced 
brain development, cognitive functioning, and emotional and physical 
health. But all too often, low-income working families lack access to 
high-quality, affordable child care
    and early childhood education, and these children tend to fall 
behind. Beyond the achievement gap, children who don't participate in 
high-quality early education programs are more likely to have weaker 
educational outcomes, lower earnings, and increased involvement in the 
criminal justice system. Affordable, high-quality child care is not 
just critical for children, it is also critical for working parents. 
Child care is a two-generation program. Parents of young children need 
child care to work or go to school. And a lack of stable child care is 
associated with job interruptions and job loss for working parents. 
Child care ought to be a national priority for America's children and 
working families.
    Just two programs provide for the bulk of the federal role in early 
education: the Head Start Program and the Child Care and Development 
Block Grant. Unfortunately, because of limited federal funding, too few 
young children have access. This unmet need continues to grow - only 4 
out of 10 eligible children have access to Head Start, and fewer than 1 
out of 6 federally-eligible children receive federal child care 
assistance. We have decades of evidence that investing in programs like 
Head Start and the Child Care and
    Development Block Grant works. It is time to invest in these 
programs and ensure that we are giving ALL children the chance to 
succeed.
    I want also to commend Secretary Burwell and her Department on 
their efforts to respond to some of the most troubling health crises of 
our time. From the Ebola outbreak to Zika to the opioid crisis, the 
Department of Health and Human Services has been at the forefront of 
responding and keeping Americans safe and healthy. Particularly when 
you talk about budgeting, some do not always see the value of investing 
in prevention or readiness activities so that we are equipped to deal 
with a public health crisis. But like many federal programs and in fact 
like health care insurance itself, you often don't miss it until it's 
gone. So it's important, now more than ever, that we invest in our 
nation's current and future health and well-being. The President's 
budget proposal does this with the ``Cancer Moonshot'' and other long-
term investments.
    Lastly, I sincerely thank the Department's for their efforts to 
respond to the
    catastrophic situation in Flint. The research is clear on the 
impact of exposure
    to lead on young children. The adverse effects of lead exposure 
range from decreased academic attainment to increased need for special 
education and a higher likelihood of behavioral challenges. These 
impacts can result in a significant decline in earnings, loss of tax 
revenues, additional burdens to the criminal justice system, and 
increased stress on our hospital systems.
    The opportunity for a strong start to a successful life will be 
stunted for Flint's children if they are not given the necessary 
resources, including early-intervention and access to high-quality 
early learning programs, such as Head Start, to help them overcome the 
life-long effects of exposure to lead.
    We need to come up with the money to make that possible. Make no 
mistake - we should not expect the fix to this crisis to be easy or 
cheap. In fact, it will cost approximately $1.2 billion to provide 
long-term, comprehensive services to all Flint children exposed to 
lead. And that cost only covers the programs that fall under this 
Committee's jurisdiction. Furthermore, it is a moral imperative for 
this Committee and the Department to continue to examine
    how federal programs can be responsive and ensure every Flint youth 
is receiving the necessary services to mitigate the effects of lead 
exposure.
    The Department's response has been commendable - additional funding 
for health centers in Flint, Medicaid expansion that will provide vital 
health coverage and important health screenings, and $3.6 million in 
one-time emergency funding to help Head Start grantees expand early 
childhood education, health, and nutrition services. These are examples 
of targeted federal solutions. But this Committee and this Congress 
should do more.
    The impact of lead exposure on young children is long lasting and 
our response must have a long-term approach. We must use all the tools 
available to us, starting with pre-natal care and screenings for 
pregnant moms, early literacy resources, early interventions to 
identify special education needs, Title I and II funding from ESEA, 
after-school programs, at-risk youth prevention programs, even 
investments in college access efforts. I know that with the 
Department's leadership, we can continue to respond to this crisis. I 
am hopeful that, together, we can put forward real solutions to help 
mitigate the
    damage from the water crisis in Flint and make sure the young 
children there get back on track to a prosperous, fulfilling life.
    Thank you and Secretary Burwell, I look forward to hearing from you 
today.
                                 ______
                                 
    Chairman Kline. I thank the gentleman. Pursuant to 
Committee Rule 7(c), all members will be permitted to submit 
written statements to be included in the permanent hearing 
record. Without objection, the hearing record will remain open 
for 14 days to allow such statements and other extraneous 
material referenced during the hearing to be submitted for the 
official hearing record.
    It is now my pleasure to introduce our distinguished 
witness, welcome back to our new environs here. The Honorable 
Sylvia Mathews Burwell serves as Secretary of the U.S. 
Department of Health and Human Services. Prior to joining HHS, 
she served as director of the Office of Management and Budget 
under President Obama and in a whole bunch of other positions 
in the Clinton Administration. This will be the Secretary's 
second appearance before the Committee during her tenure at 
HHS.
    Secretary Burwell, I will now ask you to please stand and 
raise your right hand.
    [Witness sworn.]
    Chairman Kline. Let the record reflect she answered in the 
affirmative. Before I recognize you to provide your testimony, 
let me remind you of our lighting system. It is pretty 
straightforward. It is a green, yellow, red system. The lights 
are right in front of you. As in the past, I have no intention 
of ever dropping a gavel while you are speaking, but I would 
ask that you try not to go on too long so that members have a 
chance to engage in the discussion.
    Members will each have five minutes to ask questions, and 
as my colleagues know, I am not quite as reluctant to drop the 
gavel if they are exceeding the five minutes, and, I would ask 
my colleagues, please do not talk for 4.5 minutes and then ask 
a question that will take her five minutes to respond to.
    We do not have time for that today, because I would advise 
all of you that the Secretary has a hard stop time at noon. We 
are going to try to give everybody the five minutes, but we may 
have to curtail that time if we start running short. So, I 
would appreciate your cooperation.
    Madam Secretary, you are recognized.

 TESTIMONY OF THE HONORABLE SYLVIA MATHEWS BURWELL, SECRETARY, 
 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON, D.C.

    Secretary Burwell. Chairman Kline, Ranking Member Scott, 
and members of the Committee, thank you for the opportunity to 
discuss the President's budget for the Department of Health and 
Human Services today.
    As many of you know, I believe all of us share common 
interests and that we can find common ground. In recent 
legislative sessions, this committee took important steps to 
strengthen our workforce and open the doors to new early 
learning opportunities. Thank you for your leadership in 
passing the Workforce Innovation and Opportunity Act and the 
Child Care and Development Block Grant Act of 2014. We look 
forward to working with you on both of these in the year ahead.
    The budget before you today is the final budget for this 
administration and my final budget as Secretary. It makes 
critical investments to protect the health and well-being of 
the American people. It helps ensure that we can do our job to 
keep people safe and healthy, accelerates our progress in 
scientific research and medical innovation, expands and 
strengthens our health care system, and helps us continue to be 
responsible stewards of the taxpayers' dollars.
    For HHS, the budget proposal is $82.8 billion in 
discretionary budget authority. Our request recognizes the 
constraints in our budget environment and includes targeted 
reforms to Medicare, Medicaid, and other programs. Over the 
next 10 years, these reforms to Medicare would result in net 
savings of $419 billion.
    Let me start with an issue we have been working on here at 
home and abroad, and as we work aggressively to combat the 
spread of Zika. The administration is requesting $1.9 billion 
in emergency funding, including $1.5 billion for the Department 
of Health and Human Services. We appreciate Congress' 
consideration of this important request. This funding will help 
us implement the essential strategies to prevent, detect, and 
respond to this virus, with a focus on reducing the risks to 
pregnant woman.
    I know the rise of opioid misuse, abuse, and overdose has 
affected many of your constituents. Every day in America, 78 
people die of opioid related deaths, and that is why this 
budget proposes significant funding, over $1 billion, to combat 
the opioid epidemic.
    Research shows that early learning programs, as the 
Chairman mentioned, can set a course for a child's success 
throughout their life. That is why over the course of this 
administration, together with congressional support, we have 
more than doubled access to early Head Start services for 
infants and toddlers.
    Our budget proposes a total of $9.6 billion to the Head 
Start program and an investment in child care services that 
would allow us to serve over 2.6 million children. Beyond this 
budget, for the children in Flint, Michigan, we have already 
announced $3.6 million, as Mr. Scott mentioned, in one-time 
emergency for Head Start money.
    With these funds, they can expand early childhood 
education, behavioral health services, and other vital 
nutrition services. Today, too many of our Nation's children 
and adults with diagnosable mental health disorders do not 
receive the treatment they need. So, this budget proposes $780 
million in new mandatory and discretionary resources over the 
next two years to close that gap.
    While we invest in the safety and health of Americans 
today, we must also relentlessly push forward on the frontiers 
of science and medicine. This budget invests in the Vice 
President's cancer initiative. Today, we are entering a new era 
in medical science. With proposed increases of $107 million for 
the precision medicine initiative and $45 million for the 
administration's BRAIN initiative; we can continue this 
progress.
    In order for Americans to benefit from our recent 
breakthroughs in medical science, we need to ensure that all 
Americans have access to quality affordable health care. The 
Affordable Care Act has helped us make historic progress. 
Today, more than 90 percent of Americans have health coverage--
the first time in our Nation's history that has been true.
    The budget seeks to build on that progress by improving the 
quality of care that patients receive and spending dollars more 
wisely. It proposes investments to improve the access to care 
for underserved groups across the United States, including many 
in rural communities, with $5.1 billion in health center 
funding and nearly $14 billion over the next decade for our 
Nation's health care workforce.
    By advancing and improving the way we pay doctors, 
coordinate care, and use health data and information, we build 
a better, smarter system.
    Finally, I want to thank the employees of HHS. In the past 
year, they fought Ebola in West Africa, helped millions gain 
health coverage, and have done the quiet day-to-day work that 
makes our Nation healthier and stronger. I am honored to be a 
part of the team, and as members of this committee know, I am 
personally committed to working closely with you and your staff 
to find common ground to deliver for the American people.
    Thank you.
    [The statement of Secretary Burwell follows:]
    
    
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    Chairman Kline. Thank you, Madam Secretary. That is close 
to a record, seven seconds over five minutes. Well done. Thank 
you very much.
    I mentioned in my opening remarks that we are concerned 
about the recent Reuters' investigation into abuse and neglect 
of children born in families battling drug addiction, and there 
was a law, CAPTA, that falls under your department's 
jurisdiction.
    We sent a letter to you asking for information. The 
Department responded, and we thank you for that, but clearly, 
we still have a problem out there, it seems to me.
    Congress has taken steps to streamline the application 
process, but the application still goes through the Children's 
Bureau at HHS, where they review States' applications and sign 
off that it is adequate before Federal funds are dispersed.
    So, I know you looked at this. Do you feel like that within 
the law, the Department is doing everything it can to ensure 
that States are upholding the law, or is there more that should 
or could be done?
    Secretary Burwell. So, when these issues were raised, some 
of the issues raised in the Reuters' articles, we have gone and 
followed up on the examples that were raised, and right now, 
the State of South Carolina is being put on a performance 
improvement plan. So, specific actions are being taken where we 
have found there is wrongdoing. That is in terms of when things 
are brought to our attention.
    As part of this process of review, we also put in place a 
different process to review what the States are saying. When 
they say they have a plan, in this next year's round, we will 
be asking for more details of those plans, so we can understand 
that the States actually have something that is a workable 
plan. So, we have taken steps in terms of where we understand 
there is something wrong and trying to get in front of it by 
making sure that we do a different process with regard to 
review of the plan.
    The other thing I would just say is it will be an important 
part of the Administration for Children and Families as we 
review their budget.
    Chairman Kline. Okay. That is a change to the practice--
    Secretary Burwell. It is a change.
    Chairman Kline. We will be watching with interest. It does 
seem to us there needed to be a way for the Department to be 
able to confirm that the States are doing what they are 
supposed to be doing, without waiting for somebody to come and 
complain.
    Secretary Burwell. Which is why we have taken that step to 
do it in a more proactive fashion with the proposal, so we will 
look forward to the Committee's support for the Administration 
for Children and Families as a part of the budget process that 
we are able to enforce and do, I think, what the Committee 
rightfully is raising.
    Chairman Kline. Thank you. We just passed and the President 
signed into law the Every Student Succeeds Act. It took six, 
seven, eight, or 12 years or something to get to it and through 
it, but it is done, and it is the law. Under the Act, as I 
mentioned in my opening remarks, the Act now authorizes a 
preexisting program known as the ``Preschool Development Grants 
Program.''
    Your department now has the lead under the law, with 
respect to funding authority and responsibilities. As I 
mentioned, it seemed to us that was clear because you already 
have billions of dollars in preschool funding through $9 
billion in Head Start alone.
    We believe that Congress specifically limited Federal 
interference in State early childhood systems to maximize State 
and local control over the improvement or development of the 
early childhood systems.
    So, given the language of the law and what I think are 
clear protections in the law, what are you doing, where are you 
in the process in effecting that transition from the 
appropriated but not authorized program that was in Education 
and is now authorized and will be appropriated, I am sure, 
program that is in your jurisdiction?
    Secretary Burwell. So, the transition by statute will occur 
in 2017, not in this fiscal year. Right now, we are working 
with our colleagues at the Department of Education to actually 
formulize the relationship between us. We are going to do an 
MOU, a Memorandum of Understanding, to formalize the way we 
incorporate the best practices from Education and their input, 
as we integrate this program into the continuum.
    I think you know at the Department, we have home visiting. 
We have early childhood. We have early Head Start. We have this 
program. We will integrate across that continuum, having the 
Department of Education be a contributor, and we decided to 
formalize the relationship.
    Chairman Kline. I am very pleased to hear that. It is 
because you are involved in all of those programs and you have 
that continuum that made sense to many of us to put this 
program there so it can be managed altogether.
    I am going to try to set the example for my colleagues and 
yield back the balance of my time. Pay attention, please, all. 
Mr. Scott, you are recognized.
    Mr. Scott. Nice try. Thank you. Madam Secretary, much has 
been made about the increasing cost of health care. Can you 
tell us briefly how the increases in health care costs now 
compare to what they were before the Affordable Care Act?
    Secretary Burwell. So, we have some of the lowest levels of 
Medicare growth on record that we have had since the passage of 
the ACA and the implementation. So, that has been a very 
important part. We have seen four of the five lowest years of 
growth in Medicare spending, and that is important for the 
taxpayer and for the Federal budget.
    With regard to employer-based care, and that is the care 
that the vast majority of Americans have in this country, last 
year, the increase in employer-based care was around 4.2 
percent in terms of the premiums. When we look at the period 
from 2000 to 2010, that number was 7.6. So, what we see is a 
decrease in the premium growth costs for those in the employer 
system.
    With regard to the marketplace itself and the individual 
market, last year in the marketplace, the premium increases 
averaged in about the 7 percent range, and what we know is 
before the Affordable Care Act, in the individual market, 
premium increases were regularly in the double digit space.
    So, whether one is looking at employer-based care, 
Medicare, which I know we are all concerned about from a 
taxpayer perspective, or looking at the marketplace itself, 
what you see is slowing in the growth of health care costs. It 
brings us to slowing but still increasing, and that is why I 
believe we need to spend a lot of time on delivery system 
reform and reforming the way we provide quality care at more 
affordable prices. I hope we will be able to talk about that 
some today.
    Mr. Scott. How much more do people with preexisting 
conditions have to pay?
    Secretary Burwell. With regard to the preexisting, and I 
think this gets to the quality portion of what I was just 
talking about, in the system today, and I think everyone in 
this room knows someone who has had cancer or has asthma or 
some other condition, for all of those individuals, they no 
longer need to worry that they will either be cut off from 
their care or not be able to access the care.
    I have had the opportunity to travel around the country and 
meet those people who previously did not have that opportunity. 
Making sure that those with preexisting conditions can no 
longer be discriminated against is a very important part of the 
progress on quality of care that we have seen.
    Mr. Scott. Do the people with preexisting conditions have 
to pay any extra?
    Secretary Burwell. No. They are neither kept out nor do 
they pay extra in terms of what they would pay in their 
premiums.
    Mr. Scott. Can you say briefly how the failure to expand 
Medicaid in some States affects those who have insurance?
    Secretary Burwell. With regard to how that impacts those 
who have insurance, it comes in the form of uncompensated 
costs. So, the work that we have done--we have seen about a 
$7.8 billion reduction in uncompensated costs since the passage 
of the implementation of the Affordable Care Act. The vast 
majority of those benefits are going to the States that have 
expanded Medicaid. What that means is that reduction in 
uncompensated care gets translated through the system, and it 
gets translated through the system to individuals and to 
hospitals and communities.
    We know that now in terms of rural hospital closures, which 
are something many are concerned about, we see more of those 
rural hospital closures in States that have not expanded. This 
is because of the uncompensated care issue. It flows to 
individuals. It flows to communities, and it flows to 
hospitals.
    Mr. Scott. Thank you. Disasters can happen anywhere. If a 
disaster were to happen in one of our districts, we could look 
at how you respond to Flint, Michigan to see how you would 
respond in our areas. Can you say what you are doing in Flint, 
Michigan for that disaster, particularly in Head Start?
    Secretary Burwell. So, the President asked that the 
Department of Health and Human Services lead the Federal 
response, which we are doing. So, we are coordinating the 
response of FEMA delivering water, SBA making sure that loans 
can get through, HUD helping housing get different pipes into 
public housing, and then the work we are doing.
    You mentioned our Medicaid expansion, as well as our Head 
Start work. The Head Start work, we have done a $3.6 million 
addition to expand both coverage and services, and that is 
because a lot of what you do to mitigate lead has to do with 
education and nutrition.
    Our colleagues at USDA are working very closely with us as 
well on the nutrition component, and put in place an ability 
for mothers to use WIC money to do formula that was not water 
based, because obviously that was a problem for those children 
focused on 0 to 6.
    Mr. Scott. Does the Zika request include research?
    Secretary Burwell. Yes, it does, and I hope we will have 
more time to discuss Zika. I just got the report today, and for 
U.S. citizens, there were over 450 million cases, and I hope we 
will have an opportunity to discuss that more.
    Chairman Kline. The gentleman's time has expired. Dr. Roe?
    Mr. Roe. Thank you, Mr. Chairman. Thank you, Madam 
Secretary, for your pushing the rule for the end of life 
counseling. That is a huge thing. I have heard a lot of 
positives about that. I want to thank you for that.
    Just a couple of quick questions.
    Stop-loss insurance regulation, as you know, in the private 
sector, a majority of those plans are basically self-insured 
plans, like we had in the City of Johnson City when I was the 
mayor. We used stop-loss insurance to protect our losses if 
they went above what we calculated they might be.
    Would you commit to the Committee not to regulate stop-loss 
insurance as health insurance because it is clearly not, in the 
future as Secretary of HHS?
    Secretary Burwell. I want to understand exactly what the 
regulations and laws are, I apologize, this is one I am not 
familiar with, I want to look into it, and we will get back to 
you in terms of how we think about that issue.
    Mr. Roe. Okay. Thank you. Just for the record, our increase 
in the marketplace in Tennessee was over 30 percent this year.
    A couple of things on Meaningful Use and electronic health 
records. As you know, physicians are struggling to meet the 
Meaningful Use and full disclosure. The primary care group I 
was in had over 100 physicians, and we have met--1 of the 12 
percent in the country--they have met that, and about 40 
percent of hospitals in Stage 2.
    Why would you go to the penalty phase of Stage 3 this year, 
which I think you are going to do, when 80 plus percent have 
not met Stage 2 yet? So, you know that the doctors, providers, 
hospitals, and physicians are going to be cut; why not just put 
it on pause for a year until they can get the systems to help? 
They are trying. They are out there trying to do this day and 
night, so why not do that? Why not pause for a year?
    Secretary Burwell. I think what we have tried to do is hear 
the concerns that have been expressed, and I think you know in 
the rulemaking that we recently put out, we were working to 
also include the legislation you all recently gave us on MACRA, 
and transferring to that system that we have been given 
legislatively to work through.
    So, working to make sure that we can get to the place where 
we are listening to providers--
    Mr. Roe. That is what I am hearing out in the real world, 
that you are not listening. That is a concern because they are 
going to get the penalty phase this year. So, I appreciate you 
are working on that, but what I think I am hearing out there in 
the real world is we are trying the best we can to comply with 
these things, but there are so many things with electronic 
health records and so forth, and I say this jokingly, but an 
electronic health record, I think, made me a congressman not a 
doctor any more.
    A couple of other things I want to go through very quickly, 
and I wrote you a letter about the breast cancer screening 
guidelines. I appreciate you putting that on hold for two 
years. One of my partners in practice, if he had followed the 
guidelines, one doctor in one practice, 24 patients would have 
fallen through the cracks and not been picked up early: 24 
breast cancers, one doctor.
    The other I want to mention is the PSA screening. The 
United States Preventive Task Force Services, which had no 
urologists and no oncologists, made a recommendation that 
absolutely should not be done, and you, as the Secretary, are 
going to penalize the primary care doctor if they order a PSA 
regardless of the patient's family history, regardless of their 
race, and regardless of their symptoms, essentially.
    So, I want to know--last night, I got a call from someone 
who had a PSA of two, a 59-year-old man, got up to go to the 
bathroom one time at night, went to his doctor. His primary 
doctor had ordered one previously, ordered another one, 
ignoring these guidelines, it was three. He said we better 
check it again in 90 days. It was five point something then. 
Sent to an urologist. This man has prostate cancer at 59. He 
would have been missed by these guidelines and might have died.
    I think these guidelines are going to cost people their 
lives. I think we need to seriously step back and take a look 
at them, at least let the science get worked out before you 
penalize a primary care doctor for ordering a PSA, a test that 
is not perfect, but it is an adjunct to clinical history and 
other things. I would strongly encourage you to do that.
    This was last night. I do not know how you would answer 
that patient's family when that patient would very likely have 
died had they followed these guidelines.
    Another issue I want to just bring up briefly: 
affordability of health insurance. I am in a billion dollar 
health care system at home where I practiced, 60 percent of the 
uncollectible debt in that hospital are people with insurance. 
To make these plans affordable, we have increased the out-of-
the-pockets and co-pays so high, that people cannot pay those, 
just average, normal people, rural America, where I live.
    The last comment, we mentioned this last year. In rural 
America, where I live, what is killing our hospitals in 
Medicare is the Medicare Wage Index, which is very unfair to 
rural areas. We get 0.74 cents to what another place might get 
$1.50. I would like to hear from you on that. I want to work 
with you on that.
    With that, Mr. Chairman, I yield back.
    Chairman Kline. I thank the gentleman. Mr. Hinojosa?
    Mr. Hinojosa. Thank you, Chairman Kline and Ranking Member 
Scott. I support President Obama's Fiscal Year 2017 budget for 
the Department of Health and Human Services because the 
administration's priorities for HHS support the well-being of 
all Americans, and are closely aligned with the needs of my 
congressional district.
    Madam Secretary, it is a pleasure to have you testify 
before this committee, and I want to ask the chairman as a 
member of this committee for unanimous consent that the three 
pages of my opening remarks be included in today's report.
    Chairman Kline. Without objection. I am sorry. I am blaming 
it all on the ranking member here.
    Mr. Hinojosa. Thank you, Mr. Chairman. Madam Secretary, as 
you know, the State of Texas did not expand Medicaid, and that 
has hurt us a great deal. I am pleased to hear of your efforts 
to incentivize these vital programs. In your view, why is it 
important for States to expand Medicaid?
    Secretary Burwell. So, the Medicaid expansion issue, I 
think, has two different elements to it. It has the element of 
the individual, and it is about providing financial and health 
security for the individual.
    In the State of Texas, over 40 percent of those who would 
be eligible are working folks, so for many working people, 
making sure they can have both that financial and health 
security is a very important thing to their individual well-
being.
    Separately, there is the issue of what it means 
economically to hospitals and to the States. We know that in 
the State of Kentucky, what we have seen in terms of an 
analysis by Deloitte as well as the University of Louisville, 
that until 2021, 40,000 new jobs would be created in Kentucky, 
and $30 billion would flow into the State of Kentucky.
    So, it is an economic issue in a broader sense, but it is 
also about the individuals and how their lives can be changed, 
and certainly as you reflect, we have a budget proposal to try 
and keep encouraging States to come in.
    Mr. Hinojosa. Thank you. Parental engagement and 
involvement has been one of the most critical if not the most 
critical part of a Head Start program over the last 50 years. 
This holistic approach ensures that children are ready for 
school. How does this proposed rule for Head Start strengthen 
parental involvement?
    Secretary Burwell. So, Head Start, and I think you know I 
am a Head Start kid, it has been a successful program for many 
years, and certainly not just my professional opinion but my 
personal opinion, but the issue of the intergenerational part 
of this, and Mr. Scott referenced it in his opening testimony, 
is an essential part, and it is essential both to get the full 
benefit of the program, and as we work forward, that is some of 
the changes in the proposed rule.
    It is everything from making it easier--in the current rule 
that is there, one-third of some of the requirements are cut 
out, in trying to get to simplification, to make things easier 
for parents and easier for providers, so they can engage and 
participate.
    As a parent of a 6 and 8 year old, I am very clear about 
the engagement and what it means in terms of children's well-
being, and also having quality places for your children to be 
in terms of your ability to focus on your work.
    So, it is about--
    Mr. Hinojosa. Thank you for that clarification. Thank you, 
Madam Secretary. Helping children and young people who qualify 
for help through DACA, Deferred Action for Childhood Arrivals, 
is very important to my region because I have such a large 
number of students, K-12, who qualify.
    How do the priorities in your proposal help them?
    Secretary Burwell. With regard to the DACA issues, I am 
afraid I will most likely need to defer to my colleagues at 
Justice and DHS, who are much more engaged in those issues.
    With regard to the programs that are available, I think you 
know that the health centers throughout the Department are an 
important part of health care for people who do not have 
coverage or coverage access any other way.
    Mr. Hinojosa. Thank you. Madam Secretary, the ACA has been 
instrumental in increasing access to health care for residents 
in my district and across the Nation. What can communities such 
as mine do to increase participation in ACA's health insurance 
marketplace? What are some of the best practices that you can 
share?
    Secretary Burwell. So, open enrollment, I would just remind 
everyone, November 1 through the end of January next year, and 
preparing for that open enrollment is a very important thing 
because it is about the communities' engagement.
    Having visited communities all over the country, what I see 
are stakeholder groups and groups that have come together. The 
hospitals, the insurers, all kinds of local community groups 
come together and make sure that the information is there, and 
that people have a place to go.
    I have visited in the State of Texas. There is some great 
United Way 2-1-1, you just dial 2-1-1 and you are able to get 
that kind of access.
    Mr. Hinojosa. Madam Secretary, in my district, the 
uninsured was 40 percent before ACA. Today, it is only 18 
percent. So, we have made great progress. Thank you.
    Secretary Burwell. Thank you.
    Chairman Kline. The gentleman's time has expired. Mr. 
Byrne?
    Mr. Byrne. Thank you. Madam Secretary, I want to talk to 
you about the transitional reinsurance program and some current 
concerns that I and others have about the legality of the way 
these funds have been used.
    We are going to put on the screen the actual text of the 
law, that you see there now. I also have here the same legal 
memorandum that my colleague, Chairman Pitts, showed you two 
weeks ago when you testified before the Energy and Commerce 
Committee.
    The nonpartisan Congressional Research Service, which put 
out this memo, analyzed this issue and stated, and I am going 
to quote them, ``Insofar as CMS' interpretation allows the 
entire contribution of an issue in any given year to be used 
only for reinsurance payments such that no part of it is 
allocated for the U.S. Treasury contribution, and that would 
appear to be a conflict with a plain reading of Section 
1341(b)4,'' that is the language up there.
    ``Because the statute unambiguously states that each 
issuer's contribution contain an amount that reflects its 
proportionate share of the U.S. Treasury contribution, and that 
these amounts should be deposited in the General Fund of the 
U.S. Treasury, a contrary agency interpretation would not be 
entitled to deference under the Chevron decision.''
    We have that second piece of language up there now. So, you 
have had two weeks since Chairman Pitts brought this to your 
attention. You had the legal memorandum. I assume you have had 
a chance to go over this with your staff and your counsel.
    [Additional submission by Mr. Byrne follows:]
    
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    You would agree that you did not put $5 billion in the 
Treasury that you were required to. My question now is do you 
know not agree that you violated the law in not putting the $5 
billion with Treasury?
    Secretary Burwell. We believe that our reading of the law 
is accurate and correct. As we put out--
    Mr. Byrne. Can you give me some authorization for that?
    Secretary Burwell. Yes. What we did was we actually put out 
our reading of the law in a Notice of Proposed Rulemaking for 
public comment. We put out our logic. We put out our reasoning 
to the public to review our proposal, not in an interim final 
rule, but in a Notice of Proposed Rulemaking, so we could have 
comments.
    A wide range of groups commented on our rule, as is regular 
practice. No one raised any concerns--
    Mr. Byrne. Madam Secretary, let me take my time back on 
that. Whether they commented or not, the law is plain on its 
face. It does not matter what you think or somebody outside of 
your department thinks if the law is plain, you do not get to 
interpret it any other way, and the nonpartisan Congressional 
Research Service says you directly contradicted the law in the 
way you actually carried it out.
    So, are you saying now that because you put it out in 
comment that you get to interpret it any way you want to, 
despite the plain wording of the statute?
    Secretary Burwell. What I am suggesting is that we believe 
our reading is accurate. The public had an opportunity to point 
out if they thought it was inaccurate. That was not done. We 
believe that our reading of the law is accurate.
    Mr. Byrne. Well, Madam Secretary, let me just say this, the 
nonpartisan Congressional Research Service directly contradicts 
you. They say you read it completely wrong and that you clearly 
violated the law.
    Now, there is a lot of concern in America right now about 
the anger among the electorate. I just came through a primary a 
few weeks ago. The electorate is angry. They are angry because 
people in positions of responsibility like you violate the law. 
You violated the law. The nonpartisan Congressional Research 
Service has said you violated the law.
    Here we are today with some excuse that you put it out for 
comment. The fact that you put it out for comment does not 
relieve you of the responsibility to enforce the law as it is 
plainly written. It is plainly written. There is no wriggle 
room around this.
    The fact that you have had two weeks to look at this and 
you cannot offer me any legal authority for what you did tells 
me that you just decided or your staff decided we are not going 
to put the $5 billion in the Treasury as we are required to do 
by law.
    I can tell you my constituents and the people across the 
United States of America are sick and tired of that. So, if you 
want to provide to this committee at a later date whatever your 
legal staff wants to provide as whatever legal basis for their 
interpretation, that is fine, but telling me you put it out for 
notice and comment does not answer the question as to how you 
get around the clear requirements of this law, and it is not 
just my interpretation that I am going on here, I am going on 
the interpretation of the nonpartisan Congressional Research 
Service.
    I appreciate you telling us what you have told us here 
today, but it is not an answer. I hope you and your legal staff 
after this is over will put something together and send it back 
to us. I yield back.
    Secretary Burwell. Congressman, I would like to reflect 
that what I said was we have put out our legal argument. I 
understand and respect there is a disagreement in the 
interpretation of the law.
    What I was saying is we have articulated why we believe our 
reading of the law is correct, not only have we articulated 
that through communication, we did it in a very public way. We 
believe our reading of the law is correct, and I would also 
reflect that with regard to this, and this particular issue, 
there have been 71 IG and GAO investigations in terms of the 
question that you are raising.
    We are working hard to implement the law. There are thirty 
open, there have been over 100 examinations. With regard to 
what I am hopeful for is that we can get to the place where we 
can have the conversations about how to control costs and 
improve quality in this country in our health care system. That 
is what we are working to do.
    Chairman Kline. Madam Secretary, the gentleman's time 
really has expired. We will not get to any of that if we do not 
try to stay within the five minutes. Mrs. Davis?
    Mrs. Davis. Thank you, Mr. Chairman, and good to have you 
with us, Madam Secretary. I wanted to really go to one of the 
areas where as you said we are trying to create a smarter 
system.
    In that regard, I think there has been some early success 
of the diabetes prevention program. We have seen evidence that 
really is common sense, I think, that if you speak to the need 
for providing better nutrition, exercise training, that you are 
going to see a reduce on the onset of diabetes. We have seen 
that particularly in seniors.
    I just wanted to mention that there is bipartisan 
legislation to expand the diabetes prevention program to 
Medicare. There have been numerous pilots to demonstrate that 
really can have a demonstrable effect on saving lives, as well 
as cutting costs.
    I am hoping that you can take a look at that as well, how 
can we work to expand that. I would love to see all my 
colleagues come together on that legislation, but there may be 
some other tools that we have as well. I hope you will take a 
look at that.
    I want to shift quickly to early childhood, because that is 
an area that you are going to be working heavily in as we go 
forward, and certainly reflected in the legislation, the 
transition is in 2017.
    I know that within that legislation, there is a call to 
expand the length of the school day among other requirements. I 
am wondering what you are doing, what the staff is looking at 
now, how are we going to move forward with that while at the 
same time being certain we are keeping the quality the same or 
at least better, maintaining quality, and certainly finding 
ways that we hit the bar of lengthening but we are not losing 
some of the other ingredients that make up such a successful 
program.
    Secretary Burwell. So, as part of our Head Start rulemaking 
right now, it is an open rulemaking, so with regard to what the 
conclusion will be, it is not something I can comment on. At 
this point in time, we are reviewing a number of comments in 
different places.
    It does get, I think, to a little bit of the chairman's 
comment at the beginning, about making sure we are continuing 
to make strides, so that the benefits of these programs are 
known for the children in the short-term as well as the long-
term, in terms of that third grade level and some of the 
research that we have seen.
    One of the suggestions out of that research that had some 
questions was the question of lengthening of time, that time 
there makes a difference to the child's ability to gain and 
retain what they need in order to build the building blocks, 
especially at that critical point in the third grade where we 
really need them reading in a way that it will take off, 
because then they are using the reading for learning when they 
get to the third grade.
    So, the time issue is related to the quality issue that the 
Chairman had raised earlier.
    Mrs. Davis. I appreciate that. I know that what we do not 
want to see is enrollment have to drop as a result of that. 
That is a big concern.
    The other one is regarding homeless children. In San Diego, 
we certainly have a number of children who come in and out of 
the school year. As you are working on the rulemaking, how can 
we provide for spaces for children who may be in and out of the 
program and be sure we guarantee they have a spot when in fact 
they are present and they need to be part of that program?
    Secretary Burwell. I think it has two elements to it, as we 
continue to think about the issue of making sure there is 
flexibility for those children, but also working deeply on the 
issue of homelessness as well, so that you are addressing the 
problem for those that are, but taking on that issue.
    At the beginning of this year, I became the chair of the 
United States Government's Interagency Council on Homelessness, 
and because of the work that we actually share, this committee 
and the Department, we will be focusing on youth homelessness 
as one of the main priorities.
    We will continue the work on veterans' homelessness because 
great progress has been made, but we want to take that next 
step. So, working on flexibility within the programs but also 
trying to get to the root of the issue, we will engage in.
    Mrs. Davis. Yes, thank you so much. I know in terms of 
stability of young children's lives, it is key they are in a 
program and they can count on that when their families are 
moving and not stable. That is so important to them.
    Very quickly, just on one other issue. In the 
Administration for Children and Families, the plan is to 
provide about $9.5 million in demonstration grants to help 
prevent youth sex trafficking. I am wondering if you could just 
speak briefly to how you expect different States to utilize 
these funds.
    Secretary Burwell. You know, I think this is a place where 
different States are going to use different tools based on 
their problems and their approach to those problems. This is 
also a place where our regional offices are engaging directly 
with the communities.
    Mrs. Davis. Thank you.
    Chairman Kline. The gentlelady's time has expired. Mr. 
Curbelo?
    Mr. Curbelo. Thank you, Mr. Chairman. Madam Secretary, more 
than 4,000 foreign children and adolescents have resettled in 
Miami, Dade County, in Fiscal Year 2015, and 937 more in the 
first quarter of Fiscal Year 2016. Foreign born students add an 
average of $2,720 in extraordinary costs to local school 
districts, above and beyond the per pupil State reimbursements.
    The numbers of refugees, especially Cuban refugees, has 
increased substantially in our community. The estimated number 
was over 4,000 last year and is expected to be on a similar 
pace in the current year. However, this could be an understated 
number because many parents are immigrating without their 
children, and their children join them later once they have 
adjusted their status.
    This presents a problem because the later arriving children 
of refugee parents do not count under refugee data, but they 
still represent major costs to local communities.
    Since school districts are barred from inquiring into 
immigration status, is there a proxy measure for school-wide 
services that can be used to determine the actual impact of the 
significant influx on affected school districts?
    Secretary Burwell. You know, I apologize, but I am going to 
need to defer to my colleague at the Department of Education 
with regard to how those measures would be done in schools. I 
apologize.
    Our role, I think you know, is with the parents as they 
come in terms of the Office of Refugee Resettlement. So, I 
apologize, but we can get that to my colleague.
    Mr. Curbelo. Okay. Let me ask you, what is HHS doing, if 
anything, to address the recent increase in foreign born 
students that are challenging communities like ours? How can we 
help school districts like Miami, Dade County, serve these 
students?
    Secretary Burwell. You know, with regard to our role, I 
think one of the things that we can do is make sure that those 
transitions of the individuals--the Office of Refugee 
Resettlement, which is a part of HHS--the thing that I think we 
can do is make those resettlements as successful as possible.
    Part of that success, I think, is making sure they become 
employed members of communities. At that point, our 
contribution can be making sure they are engaged, employed, and 
contributing members of the community in terms of employment 
and taxes, so that then is a part of the regular system.
    With regard to other issues, again, I will defer to my 
colleague at Education.
    Mr. Curbelo. So, let me ask you also, because this is a 
critical issue for our community, and as you know in the past, 
we have seen over 50,000 or close to 50,000 Cubans resettle in 
the United States, and the Miami, Dade County School District 
and Monroe County Schools, for that matter, obviously carry a 
heavy burden.
    Do you know if funding from the Cuban Haitians Social 
Services Set-Aside--can school districts draw from those funds 
to mitigate some of the impacts on these school districts?
    Secretary Burwell. I am not familiar that they can, but why 
do we not go back and check, and I am happy to get back to you 
on that issue.
    Mr. Curbelo. Well, this is just a critical issue for our 
community, Madam Secretary. I hope to work with you and with 
your department to find ways, to find more support for Miami, 
Dade County. This is another case where a local community faces 
the results or the consequences of what I believe is a flawed 
Federal immigration policy, a flawed Federal refugee policy in 
this case, and I think it is incumbent on the Federal 
Government to help communities like ours solve these problems 
because it is unfair for all of these costs, for all of the 
burden, to fall on local school districts and on local 
municipalities.
    Thank you, Mr. Chairman. I yield back.
    Chairman Kline. I thank the gentleman. Mr. Courtney?
    Mr. Courtney. Thank you, Mr. Chairman, and thank you, Madam 
Secretary, for your outstanding service. Your portfolio is 
about as complex and broad as any in government, and I think 
you are doing an outstanding job. Thank you.
    Secretary Burwell. Thank you.
    Mr. Courtney. In your testimony on page 11 you talked about 
the heroin and opioid component in the President's budget, $1.1 
billion. Again, it is allocated to help law enforcement, 
treatment, prevention, and education, which is what I am 
hearing back home in my district, 28,000 people lost their 
lives to accidental overdoses, as you pointed out, in 2014.
    That is a 14 percent increase from the year before. The 
2015 numbers are not going to be any better, and I know that 
because in Connecticut we saw a 20 percent increase since 2015 
numbers by the Office of the Medical Examiner just a few weeks 
ago.
    Director Botticelli was up in Eastern Connecticut talking 
to folks who are on the front lines on this, and you know, what 
is striking is police and law enforcement are totally engaged 
in doing their job, but they are the first to say you cannot 
arrest your way out of this problem.
    Emergency room providers who are saving lives with Narcan 
are frustrated because there is not enough detox beds and 
treatment beds, so there is a revolving door for a lot of these 
folks who are addicted and have no place to go after they have 
been revived.
    The medical provider community is ready, I think, to talk 
about reforming the prescription overprescribing of pain 
killers.
    What I think is of concern is that again, you just released 
new funding to HRSA, to community health centers, which is much 
appreciated, but there is no request for emergency funding this 
year.
    When you look at Zika and you look at OCO, what Mr. Kline 
and I are going to be voting on, billions in emergency funding 
for our overseas military operations on the Armed Services 
Committee, but when you look at a problem where we are losing 
28,000 people a year--Senator Shaheen and myself have a bill to 
sort of move that push to get resources into this year, which 
is so obviously needed.
    I just wondered if you could just sort of talk about your 
perspective on that, you know, the administration's willingness 
to work with us, who really want to get folks who are on 
standby ready to help with a solution.
    Secretary Burwell. So, the issue of the treatment and 
treatment opportunities, that is the biggest part of the money, 
the $1 billion that we have asked for. It is about treatment.
    I think all of you know in your communities as you visit, 
behavioral health is something that was paid for at the 
community level, and so it has never been built up, and now we 
have a very acute problem with people dying but as your law 
enforcement reflect, every law enforcement I talk to, they tell 
you I am not a social worker or a health worker, so that is why 
it is so critically important that we get funds to move, 
because those funds move to the States and the communities--
    Mr. Courtney. Right.
    Secretary Burwell. To get that treatment. The other parts 
are very important, but without the treatment, we now have a 
bolus of people who are addicted, sadly. I wish that was not 
the case. We need to prevent any more, but we have to take care 
of that which we have.
    Right now, Narcan or preventing an overdose death is not 
the only solution. If people are in medication assisted 
treatment, we can make progress. That is why we are pushing 
hard. We appreciate your leadership and others in terms of 
trying to make sure we get that funding for the treatment. 
Funding will also go to other issues, as to Naloxone, getting 
access to people, because not all--I am sure you hear this in 
your communities--not everybody in terms of first responders 
have access.
    We also have work at FDA. They have approved a nasal 
approach which will be easier for others to use that do not 
have to be a trained first responder to do that.
    So, we will work across, but the money for treatment, which 
I think is what you are focused on right now, is an essential 
part of getting to another place in this crisis.
    Mr. Courtney. So, again, the Senate sort of went partway 
there last week in terms of the Comprehensive Addiction 
Recovery Act, but again, it is authorizing legislation without 
resources, and as Congressman Kildee used to say, ``An unfunded 
authorization is kind of like a get well card to somebody who 
is sick, it does not really fix the problem.''
    Again, that is where I think the HRSA funding that was put 
out last week is getting to the house on fire that is happening 
out there, but again, the budget priorities are totally on 
target, as you said, but the question right now is on timing, 
because this issue is accelerating and intensifying.
    I hope all of us are going to work together because it 
affects every district, rural, suburban, urban. It is hitting 
veterans again because of Service connected injuries. This 
should be an easy one for us to work together on.
    Secretary Burwell. Yes. The fire alarm, this is a seven 
alarm fire and we sent one department. We need seven or eight 
others to get to the real issues and the problem.
    Mr. Courtney. Thank you. I yield back.
    Chairman Kline. The gentleman yields back, without 
mentioning basketball. Ms. Stefanik?
    Ms. Stefanik. Thank you, Mr. Chairman. First, I want to 
echo my friend and colleague, Mr. Courtney's, statements that 
the heroin and opioid epidemic is an issue that I have been 
focused on in my district, and I look forward to working with 
you on that issue.
    Thank you, Madam Secretary, for being here today. Shifting 
gears, I think we can all agree here that we need to make sure 
that our seniors receive the best care possible, and in order 
to do that, we must accept there are differing needs across 
this country.
    The Older Americans Act is an important law that helps 
seniors remain in their homes and out of expensive 
institutional care. As you know, what may work for seniors 
receiving meals or care in urban areas is likely to be 
inadequate to the unique challenges facing rural areas such as 
the district I represent in New York's North country, where we 
have one of the highest concentrations of seniors in New York 
State.
    One of the hallmarks of the Older Americans Act is the 
State and local control provided through the structure of the 
aging network. This is a great example of legislation that 
understands one-size-fits-all does not always work.
    Can you speak to how this structure is important to meeting 
the needs of this Nation's elderly and what we will do to 
continue the successful model?
    Secretary Burwell. Yes, and thank you for your leadership 
in terms of the reauthorization, we think it is important to 
continue. I think what you are reflecting is we need to make 
sure we maintain the flexibility for States because it is in 
very wide variance in terms of what it means to serve that 
community and serve that community well.
    So, we want to continue. We think the reauthorization does 
not need major changes, but some small changes that can help us 
with making sure we are using the best data and evidence that 
we have, which is based on some of our learnings that different 
things are working in different places, and keep that 
flexibility in place.
    I think you know in this budget that is before us, even 
without the reauthorization, we have some funding increases in 
particularized areas, and whether that is protecting against 
elder abuse and how that is done in rural areas versus urban 
areas, protecting in that space as well as some of the food 
programs that you mentioned, but we want to work across the 
spectrum of needs and work with those communities on what their 
priorities are.
    Ms. Stefanik. Great. Thank you for that, and I yield back.
    Chairman Kline. The gentlelady yields back. Mr. Polis?
    Mr. Polis. Thank you, Mr. Chairman. I want to thank the 
Secretary for joining the committee today, and I want to thank 
her and the administration for putting forward a budget that 
reduces our deficit, makes important investments in health and 
education that our country needs.
    I applaud the work of the Department of Health and Human 
Services for working to implement the Affordable Care Act. I 
congratulate on the especially successful 2016 third quarter 
enrollment period and 4.9 million new customers in the Federal 
Exchange.
    Madam Secretary, you have seen firsthand, of course, the 
positive effects of the Affordable Care Act. I know in my home 
State of Colorado, 16.5 percent of people lacked health care 
insurance before the Affordable Care Act, and last year, the 
number fell to 6.7 percent, a historic low.
    I am concerned, however, about how the geographic rating 
areas for each State can skew the cost of health care. My 
constituents in Grand County, for example, face among the very 
highest premium increases in the country. Their premiums went 
up at least 25 percent this year. They pay, by the way, nearly 
twice as much as other Coloradoans for insurance.
    How is the Department helping States to guarantee that 
families and individuals who live in rural mountain communities 
are able to access high quality care at a reasonable cost the 
way the Affordable Care Act intended?
    Secretary Burwell. So, one of the things that is important 
in both the employer-based market as well as the individual 
market is the fact that the Affordable Care Act actually put 
out-of-pocket caps in terms of what people will spend, and that 
is another important benefit getting to quality and 
affordability that we have not touched on, and I think that is 
important.
    With regard to the other issues in terms of the Affordable 
Care Act and the steps it is taking to work on places where I 
think it is fair to say that in our country there are pockets, 
such as that you have described, and in some cases, States, 
such as the State of Alaska, where a market is not working in 
terms of creating the amount of competition either in providers 
or insurance companies to put downward pressure on price.
    I think a part of that is why some of the changes that came 
in the Affordable Care Act that help us with delivery system 
reform and some of the work we are doing in the innovation 
centers to create models that people can use to have that 
downward pressure.
    So, there are two parts to it. It is focusing on specific 
markets themselves where the problems exist, but then overall, 
as a Nation, figuring out the steps we need to take to put that 
downward pressure, and our Accountable Care Organizations, we 
have already seen hundreds of millions of dollars of savings, 
and while the statutory level that you all gave us is very high 
to meet success before one can replicate, we have met that, and 
are now in a phase two of that.
    So, it is about regional and retail strategy, and then a 
strategy across the Nation.
    Mr. Polis. Are there are some States that have rolled out 
single geographic rating areas for their entire State?
    Secretary Burwell. I will have to go and check. I think--I 
will check.
    Mr. Polis. Thank you.
    Secretary Burwell. I do not want to give you an incorrect 
answer, so we will come back on that.
    Mr. Polis. Sure. To transition to Head Start, of course, I 
am a firm believer in the benefits of Head Start for kids and 
communities, and in my district and my State, we also have many 
high quality charter schools that serve at risk kids. Public 
charter schools have the autonomy to offer a unique curriculum, 
many students and parents take advantage of that. In Denver 
Public Schools, about a quarter of the kids attend public 
charter schools.
    You know Head Start grants are given to non-profits, 
community centers, sometimes traditional public schools, but to 
my knowledge, no charter school has received Head Start grants 
and few have applied.
    Can you talk about what your agency is doing to clarify 
guidance and do outreach so that high quality charter schools 
know they are eligible for Head Start grants and understand how 
to meet the Head Start requirements so they can offer those 
services for families?
    Secretary Burwell. Out of our conversation last year, this 
is something that we have followed up on, and are issuing 
hopefully clearer guidance. I think we believe it is possible 
and people can do it, but clearly, I think as you reflect, 
people do not understand that charters can do it, so we are 
issuing guidance to make that clearer, and then we will work to 
implement that so people can know what process they need to do 
to do it, because we think it is quite possible and people can 
do it.
    Mr. Polis. Thank you. I also wanted to briefly address 
transgender health. I have worked closely with my colleagues in 
the Equality Caucus, Representative Takano, Representative 
Pocan, also on this committee.
    HHS proposed a rule to implement the non-discrimination 
provisions of the Affordable Care Act that would prohibit 
discrimination on the basis of gender identity. When can we 
expect a final rule, and are there improvements to the proposed 
form to the final rule, which is so important to the LGBT 
community?
    Secretary Burwell. Because it is an open rulemaking 
process, we will not be able to talk about the specifics of the 
final rule, but a rule that is very important. I think you 
probably know that 1557 we were implementing before, but it had 
been five years.
    Mr. Polis. You will have time to complete that rule, 
correct?
    Secretary Burwell. Yes.
    Mr. Polis. Okay. Thank you. I will have some other 
questions for the record, and I will yield back.
    Chairman Kline. The gentleman yields back. I need to advise 
my colleagues that we are going to restrict the time now to 
four minutes and hope we do not have to go to three minutes. 
The math shows we have too many people and not enough time.
    Mr. Russell, you are recognized for four minutes.
    Mr. Russell. Thank you, Mr. Chairman, and thank you, Madam 
Secretary, for being here today.
    As a returning combat veteran, I had some firsthand 
experience with prescription pain killers. In my case, 
Percocet, but, while it did reduce the pain, it left me with a 
clouded mind. I became concerned about that. I did not like not 
having my faculties, so I quit taking them.
    However, pain management, and not just among our veterans, 
has resulted in perhaps a lot of what is categorized as 
suicides, it might have been accidental death. On a broader 
scale nationally, at least 18 States now have more deaths due 
to prescription opioids than car fatalities.
    Secretary Burwell. Correct.
    Mr. Russell. The fatality rates have increased five-fold 
since 1990. Accidental overdoses are up 360 percent since 1999. 
In 2004, prescription and other over-the-counter drugs were 
responsible for more years of lost potential life than all 
accidents from falls, firearms, drownings, fires, and non-
medication poisonings combined.
    Opioid pain killer prescriptions have increased 800 percent 
from 1997 to 2006, and the data for the next decade will 
probably exceed even further.
    America now has had an increase in these, but I cannot 
imagine they have had an 800 percent increase in pain. Instead, 
America now has seen a health science environment that allowed 
law makers to pass these laws in the first place, and I think 
America has been sold faulty health science and a bill of 
goods.
    So, my question to you, Madam Secretary, in the $1.1 
billion spending program to provide treatment to those exposed 
and suffering this abuse, we have been exposed to prescription 
heroin nationwide, what actions will you be taking to curtail 
the science that suggested these laws be passed in the first 
place?
    Secretary Burwell. The research on pain and pain treatment, 
I think, is an important part of the solution. I think when we 
look at the steps that we need to take to push back on many of 
the statistics you articulated, number one, we need to change 
prescribing practices, because that is how many folks are 
getting the prescription, and then that is sometimes a transfer 
to heroin itself. I think you were referring to both. We need 
to work on the medication assisted treatment, and we need to 
get access to Naloxone.
    With regard to the research issues, at NIH, there are two 
parts to this, and one part is making sure that we are 
researching pain issues as well as the treatment of pain, and 
this is a space where I actually work with my colleague at the 
Department of VA, because they have much of the research and 
are doing some of the advances. As you articulated, it is a 
pool of people, sadly, who have these issues in terms of pain.
    So, we are working on it there. We are working on it at 
NIH, and with regard to FDA, what we are trying to do is speed 
along the process for those that can find drugs that are not 
opioid based in terms of pain, as well as those that are 
tamper-resistant. Those are some of the changes we most 
recently made at FDA.
    Mr. Russell. I would hope rather than chase more money 
after bad practices that we would take these things off the 
market. I think we existed for a long time as a country, we 
fought world wars, we did a lot of other things. America has 
not had an 800 percent increase in pain.
    I would hope that you would devote more effort towards the 
faulty science that has allowed these laws to pass. We are 
creating an epidemic that we are not likely to recover from. I 
do appreciate your efforts thus far. Thank you. Mr. Chairman, I 
yield back.
    Chairman Kline. The gentleman yields back. Mr. Sablan?
    Mr. Sablan. Thank you very much, Mr. Chairman. Madam 
Secretary, you mentioned this would be your last budget 
hearing. I think you should be proud. There are so many things 
in the proposal that would serve Americans greatly.
    I am the only member here who is not representing a State. 
I am going to limit my conversation to one issue. The President 
proposed in his fiscal 2017 budget that the National Medicaid 
program be available to the 4 million Americans who live in the 
insular areas, including my constituents, in the Northern 
Mariana Islands, and thank you, this is a very welcomed 
proposal.
    The people of the Mariana Islands are not as well off as 
the rest of Americans. Our median household income is about 
$20,000, and the national median income is $50,000. Because we 
have so many who are poor, we have many who qualify for 
Medicaid, 15,036 of our total population of 53,000 receive 
medical care through the Medicaid program.
    As you know, Medicaid in the Mariana Islands and the other 
insular areas is not the same as Medicaid elsewhere. There is a 
cap on the amount of Federal Medicaid money that goes to our 
islands, only about $5 million per year to the Marianas.
    The local cost-share of Medicaid is not computed on overall 
income as it is with the rest of America. So our Commonwealth, 
our local government has to pay 45 percent of the cost more 
like one of the richer US states would pay. We are not rich, 
however.
    So, we welcome the additional Medicaid money provided by 
the Affordable Care Act beginning in 2011, about $13 million 
per year. That new money kept our only hospital open when the 
local government had to stop its annual funding for our 
hospital because of the Great Recession and loss of tax 
revenues.
    That Affordable Care Act money is only available through 
2019. What happens then? Does our hospital close? What about 
those now on Medicaid, do they lose coverage? I would like to 
give you the time to please explain to the committee about the 
President's proposal and how we are going to make sure that 
Americans in my district get the same access to health care as 
Americans elsewhere, everywhere else in our Nation?
    Secretary Burwell. So, our proposal is a proposal that we 
hope will address the issue of a cliff and not create further 
cliffs with regard to putting in place a proposal that will 
transfer away from a cap and create matches that are more 
aligned with the matches that other Americans receive, at the 
same time, the proposal includes steps to make sure that there 
are reforms and governance is put in place.
    So, it would happen over a period of time where steps would 
have to be met in order for the changes to occur. It is a 
proposal both about getting out of where we have a cliff and 
the problems that you have described in terms of the need, but 
do it in a way that is also encouraging high quality Medicaid 
performance and program integrity.
    So, the proposal combines those two things. We believe it 
is a reasonable and a very needed proposal, and we should get 
ahead of this issue, and that is why we have it in our budget.
    Mr. Sablan. Thank you very much. It is very needed, not 
just for the Northern Marianas but for Puerto Rico, American 
Samoa, Guam, and the U.S. Virgin Islands. I yield back my time. 
Thank you.
    Chairman Kline. I thank the gentleman. He yields back. Mr. 
Barletta?
    Mr. Barletta. Thank you, Mr. Chairman, and thank you, 
Secretary Burwell, for being here today.
    I was deeply disturbed by a recent Senate report that found 
the Centers for Medicare and Medicaid Services, which is part 
of your department, had billed out roughly $750 million in 
Obamacare subsidies to half a million people who were unable to 
prove their citizenship or lawful presence in our country.
    These tax credits are solely to be used to purchase health 
insurance by United States citizens and those lawfully residing 
here. Instead, they were improperly distributed, and the 
Federal Government will likely never see a cent returned.
    This report was just one of many reports that have recently 
come to light detailing the rapid fraud and waste under 
Obamacare mismanagement that hard working Americans have had to 
foot the bill for.
    I have been working to fight illegal immigration for more 
than a decade now, and I find it extremely troubling that, at a 
time when our national debt is $19 trillion and counting, the 
Federal Government continues to throw money away with no regard 
for the consequences.
    I would have a hard time explaining to families in my 
district, many of whom are struggling to put food on the table, 
as to why they should be helping to pay for the health expenses 
of someone who broke the law to get here and has no right to 
those Federal dollars.
    Secretary Burwell, whose decision was it to prioritize 
illegal immigrants over American citizens?
    Secretary Burwell. So, with regard to the Senate report --I 
take the issues of program integrity and budgets very 
seriously. You probably know, it was during the years that I 
was at OMB that we actually had balanced budgets, close to the 
only time during my lifetime. So I take these issues of program 
integrity very seriously.
    With regard to the Senate report, I think what the Senate 
report reflects and says is that they were not able to 
provide--they did not provide--the documentation, we do not 
know whether they did or did not.
    I think with regard to the program integrity that you 
raised, as one looks at what happened in the first year of the 
Affordable Care Act, and there were about 250,000 people who 
were taken off last year, in terms of changes, both immigration 
and income, 1.6 million people in terms of when we reviewed and 
we were not able to receive the documentation, not knowing 
whether they could or could not, and that was both for 
immigration, the immigration number is about 500, and the other 
number is about--
    Mr. Barletta. Am I correct in that the tax credits are 
used, if somebody cannot produce legal documents at the time, 
the tax credits are used until they can come back, it gives 
them an opportunity to come back and prove their legal status?
    Secretary Burwell. It is a 90-day period which is given by 
statute.
    Mr. Barletta. Right. So, my question is after the 90 days, 
why then did the Federal Government not go back, why did we not 
go back to those people after we gave them the tax credits to 
get the money back of the tax credits that could have been used 
for someone else?
    As the head of an agency that knows what it is like to 
scratch for every penny, please explain to me how the 
administration is going to make up to my constituents and 
ensure that three-quarters of a billion dollars is returned to 
the American taxpayers?
    Secretary Burwell. With regard to that, that is the regular 
tax process. For any of these individuals, what will happen is 
they will owe those in taxes, in terms of reconciling, so the 
IRS in its processes--
    Mr. Barletta. We can count on that money coming back?
    Secretary Burwell. So, what will happen is when they go in, 
this will be reconciled through the IRS process. That is the 
way the enforcement will occur because it is a tax matter, so 
it occurs on the IRS side of the house.
    Mr. Barletta. Thank you, Mr. Chairman.
    Chairman Kline. The gentleman yields back. Ms. Bonamici?
    Ms. Bonamici. Thank you, Mr. Chairman. Thank you, Secretary 
Burwell. Your work covers so many areas that affect the daily 
lives of Oregonians and Americans. I appreciate that.
    I want to thank my colleague and friend, Representative 
Stefanik, for bringing up the Older Americans Act. I want to 
ask you about the Home & Community-Based Supportive Services 
program that funds services like legal assistance, elder abuse 
and prevention, transportation and meal sites, medical 
appointments, referral assistance for seniors and their 
caregivers.
    Now, I am supporting the additional $10 million in the 
President's request as well as many of my colleagues. Why is it 
important to increase funding for the Older Americans Act 
programs, especially the Home & Community-Based Supportive 
Services, given the rapidly rising population of older 
Americans? I do want to save time for another.
    Secretary Burwell. I will just quickly say I think there 
are two elements. It is about what it means for the individuals 
in terms of these programs we know are making a difference in 
terms of supporting people to be able to have care at home, if 
that is what is appropriate for them. So, it is about the 
individual.
    It is also about the economics as well, in terms of the 
success of these programs contributes economically.
    Ms. Bonamici. Keeping seniors in their homes, it is less 
expensive. Thank you. The Oregon Health Science University has 
been working in collaboration with Intel on genome mapping. 
That is especially useful in cancer research. The goal is to 
make personalized genomic analysis faster, less costly, more 
routine.
    What are some of the challenges that research institutions 
face regarding the collection and sharing of information, and 
what opportunities might the Cancer Moonshot provide to 
overcome some of these obstacles in advanced precision 
medicine?
    Secretary Burwell. Some of the limitations are the fact 
that the areas of science do not work together, and you 
actually need an engineer to help deliver through the system. A 
biologist figures out what it needs, but an engineer actually 
delivers the delivery mechanism, and we have not broken down 
those silos as we think about the science. I think it can help 
with that.
    The other thing I think it can help with is data and 
information, because one of the things, and this is part of 
what precision medicine is about, making sure data and 
information can be widely accessed in safe, secure ways. That 
is both about privacy and cybersecurity. That information can 
be used widely and broadly to discover and understand more 
quickly.
    It also in the end will save costs because how one accesses 
information for trials will become easier and less costly, 
which is a very important cost element to drugs.
    Ms. Bonamici. Thank you. I look forward to working with my 
colleagues on those important issues. Finally, I think my 
colleagues brought up the issues with opioid overdose and abuse 
and all the resulting deaths, and we have had an explosion in 
my State as well as the country.
    I applaud your three-pronged evidence-based approach. Can 
you talk a little bit about the prong of improving prescribing 
practices?
    Secretary Burwell. An extremely important part, and the 
Center for Disease Control and Prevention will be issuing new 
prescriber guidelines in terms of the issue of how we can talk 
about these issues and think about these issues.
    One of the problems is many physicians say I do not know, I 
was not trained in this way. We want to get those out and make 
sure people are using those. When you think that over 250 
million prescriptions a year for opioids, we know we do not 
need that many as a country, so prescribing is an issue, so we 
are going to target that as an issue, get out new guidelines, 
and then we need to probably work with the Congress to make 
sure those guidelines are used.
    Ms. Bonamici. Thank you. I know my State just received 
about $2.7 million to expand substance abuse services, 
particularly focused on treating opioid abuse. I know that is 
not enough. We still have more work to do.
    I had a fourth question but the Chairman asked already 
about preschool development grants, and I look forward to 
watching that and hope the transition is seamless as the HHS 
continues to manage those grants.
    I yield back. Thank you, Mr. Chairman.
    Chairman Kline. The gentlelady yields back. Dr. Foxx?
    Ms. Foxx. Thank you, Mr. Chairman. Secretary Burwell, I 
want to follow up somewhat on what my colleague, Mr. Byrne, was 
talking about in his line of questioning, but first I want to 
say I have heard from employers who self-insure that this 
transitional reinsurance fee is particularly burdensome to 
them, depriving them of resources that could be used instead to 
create jobs.
    You asserted that HHS interpreted the law accurately and 
appropriately. You claim that the comment period for the NPRM 
resulted in no objections to the Department's interpretation of 
the law.
    However, most of us believe that the NPRM was drafted in 
such a complicated way that no one could interpret it in the 
way your department did, where you used convoluted language to 
create a loophole to justify your reasoning. Given your dubious 
interpretation of the law thus far--you have heard members of 
this committee, and you will hear us say we think you have 
interpreted it wrong. I agree with Mr. Byrne, you have 
interpreted it wrong. You are hearing directly from members of 
Congress that you have interpreted it wrong.
    I am now concerned that you are going to find a way to 
extend the transitional reinsurance program even though the law 
clearly states that it expires this year. So, could you expand 
in greater detail your legal interpretation of implementing the 
transitional reinsurance program contrary to the letter of the 
law?
    Can you commit to this committee that you will follow the 
letter of the law which states the program must cease 
collections for the program at the end of this year? Do you 
plan to distribute funds after 2016?
    Secretary Burwell. With regard to the question of the 
reinsurance program, I think it is actually important to focus 
on what the substance of this program is about, and the 
substance of this is an issue that we have actually talked 
about in a number of places, which is pressure on costs, and 
you were indicating another space, in terms of this is about 
putting downward pressure on costs by creating an ability for 
the issuers in a new market.
    This is one of the transitional programs, and there are no 
plans to extend it beyond.
    Ms. Foxx. Okay. So, you consider the transition period time 
is over?
    Secretary Burwell. We have no plans to change our 
reinsurance time table that was set out. Risk adjustment is the 
only program that will continue beyond right now.
    Ms. Foxx. Okay. When you say ``we have no plans,'' would 
you be a little more explicit, you will or you will not?
    Secretary Burwell. I am being very clear, we have no plans. 
We just issued our rulemakings - our Proposed Notice, a Payment 
Notice--there is nothing that indicates anything that we do 
other than where we are.
    Ms. Foxx. Alright. Madam Secretary, I have some other 
questions, but Mr. Chairman, in the interest of time and my 
colleagues, I will yield back the balance of my time.
    Chairman Kline. I thank the gentlelady. Mr. Pocan?
    Mr. Pocan. Thank you, Mr. Chairman. Thank you, Madam 
Secretary, for being here today. I am trying to get to three 
subjects in four minutes. I am going to try to go fast.
    Does the name Brent Brown from Wisconsin ring a bell to 
you? This is a gentleman who wrote a letter to the President, 
and I would like to ask unanimous consent to enter this letter 
into the record.
    Chairman Kline. Without objection.
    Secretary Burwell. I do know.
    Mr. Pocan. Yes. A gentleman who had spent his entire life 
savings on health care, he was literally a dead man walking, 
could not get health insurance because he had a preexisting 
condition, and because of the Affordable Care Act, he is alive 
today.
    What is unique about the letter, and I just want to read 
two or three of the paragraphs, this is in his letter, ``I 
probably wore pins and planted banners to display my Republican 
loyalty. I was vocal in my opposition to you, particularly the 
ACA. Before I briefly explain my story, allow me to say this, I 
am very sorry. I understand written content cannot convey 
emotions very well, but my level of conviction has me in tears 
as I write this. I was so very wrong, so very wrong.'' He goes 
on to explain about his preexisting condition and had it not 
been for the Affordable Care Act, he would not be alive today.
    So, I just think that is a wonderful example and story, and 
more importantly, part of his appeal was to try to tell people 
maybe on the other side of the aisle who have been trying to 
repeal this for 63-64 times, you know, maybe it is time to move 
on. I just wanted to mention that.
    One of the issues that came up was about the Affordable 
Care Act when it first came out, that on the employer rolls you 
were going to reduce employees because of the part-time hour 
commitment, do you very quickly have any updates on that, how 
we're doing?
    Secretary Burwell. We have seen no evidence, and we have 
continued the recovery in terms of involuntary part-time 
employment. The involuntary part-time employment increased as 
part of the recession, but we continue to see progress and a 
normal recovery, so there are no analytics that show there has 
been an impact in terms of part-time work.
    Mr. Pocan. Great. Thank you. I know a number of us talked 
about opioid abuse. I would like to talk about something 
different than behavioral health, mental health issues.
    I know that while the opioid issue is really getting a lot 
of attention right now, I think mental health issues, 
especially as someone who is a former legislator, 25 to 30 
percent of the people in the prison system in Wisconsin are 
there for mental health. If they were there because they had 
cancer, people would be in the streets, but that is not how we 
are dealing with this issue and the amount of costs that go 
into it, very supportive of the President's budget and the 
increases he is trying to do.
    I just want to make sure we are keeping the focus on mental 
health as we do this because not just the State government, in 
Wisconsin, that is $250 to $300 million a year just for the 
people who have mental health in the corrections system, but in 
the local jails, local government, et cetera.
    I think it is really sad commentary on how we treat the 
disease and not have enough efforts there, and anything we can 
do would be much appreciated.
    Secretary Burwell. I think the Affordable Care Act together 
with the Mental Health Parity Act are the two most important 
steps we can make as a Nation to get parity in this space.
    Mr. Pocan. Great. The final issue I just want to raise in 
the last minute I have, prescription drugs. One of the issues 
that we have seen is prices are rising again, going up. I 
recently was at our VA, and he was telling me about what he had 
to do for one of his patients, a drug that was $125,000 a dose.
    We know that recently companies like Pfizer are trying to 
do tax inversions so they do not have to pay taxes here and go 
to Ireland, by buying a smaller company, yet at the same time, 
they are not going to charge us the prescription prices that 
they pay in Ireland, which is considerably less than they are 
paying here.
    I would just like to advocate for anything we can do and 
you can do within your department to help us look at that issue 
because I think we may need to work with those folks working on 
inversions, because I think it is a real tragedy that we are 
paying more and more for prescription drugs, including 27 
percent, I think, of mental health is on prescription drugs, 
and we need to do something more.
    Secretary Burwell. High cost drugs is a priority, and there 
are a number of elements in the budget we think would help 
address it.
    Mr. Pocan. Thank you. I yield back.
    Chairman Kline. The gentleman's time has expired. Mr. 
Bishop?
    Mr. Bishop. Thank you, Mr. Chairman. Thank you, Madam 
Secretary, for your testimony this morning.
    On February 19, as part of the Fiscal Year 2017 Medicare 
Advantage Rate Notice, CMS proposed a cut to Medicare Advantage 
employer group waiver plans, otherwise known as Medicare 
Advantage retiree coverage, 3.3 million seniors received their 
Medicare Advantage coverage through this plan.
    In fact, in Michigan alone, there are more than 300,000 
retirees, including labor unions, State and local government, 
and private employer retirees who rely on Medicare Advantage 
retiree coverage.
    These proposed cuts would jeopardize the high quality care 
that they depend on for their health and financial security. 
That is why, last week, my colleague, Representative Debbie 
Dingell, and I, led a bipartisan Michigan delegation letter 
that included 11 of our colleagues in Michigan, to raise 
concerns with regard to the impact these proposed cuts would 
have on our constituents, and we also urged the agency to 
remove the cut to the Medicare Advantage retiree coverage from 
the final rate notice.
    Earlier this month, the UAW Retiree Medical Benefits Trust, 
which provides health coverage to retirees and their dependents 
of the United Auto Workers Union, who formerly worked for the 
Michigan Big Three (GM, Ford, and Chrysler) submitted comments 
to CMS expressing concerns with CMS' proposed cuts to Medicare 
Advantage retiree coverage and the impact these cuts would have 
on their retirees.
    The Trust currently provides coverage to 719,000 people. Of 
this population, 534,000 are covered by Medicare. The Trust 
offers their retirees a choice of plans in which they can 
enroll. At the present time, 161,000 of these retirees have 
selected and are covered by Medicare Advantage plans.
    In comments submitted to CMS, the UAW Retiree Medical 
Benefits Trust expressed concerns that the proposed cuts to 
Medicare Advantage retiree coverage might result in diminishing 
the quality of care available to retirees and the proposal 
would lead to substantial reduction in payment to employer 
group waiver plans, thereby resulting in premium increases and/
or benefit reductions.
    This leads me to my question. I did send you this letter, 
and I appreciate the fact that you have acknowledged receipt of 
that letter. Thank you very much for that.
    Having said what I just said, and the grave concerns they 
represent to in particular my constituents in the State of 
Michigan, can you tell me whether or not CMS considered the 
impact the cuts to the Medicare Advantage retiree coverage 
would have on the 3.3 million seniors who depend on this form 
of coverage when developing the Advanced Notice?
    Secretary Burwell. So, we did, and appreciate that, and 
appreciate the letter you have sent. We are in an open comment 
period, so welcome the comments and the concerns. We did 
consider this issue.
    We actually looked to our experience when we did this 
change in Part D. We did not see the impact that folks are 
saying could happen. We did not see that impact occur. We, like 
you, want to make sure affordability is an important part of it 
in our work, but we try to balance affordability for the 
individual as well as affordability for the taxpayer with the 
Medicare dollars, and feel it is a proposal that meets those, 
but we want to continue to hear the comments and see if there 
is something that would distinguish it from the experience we 
previously had.
    Mr. Bishop. Have you responded to the UAW's concerns?
    Secretary Burwell. Probably because it is a part of the 
comment and the rulemaking process, most likely we took it in 
as a formal comment, but I am not sure how they did it, whether 
it was in the form of a letter or a comment. I do not know 
specifically, but it will most likely be a part of the record 
for the comment period.
    Mr. Bishop. Thank you, Madam Secretary. I yield back.
    Chairman Kline. The gentleman yields back. Mr. Takano?
    Mr. Takano. Thank you, Mr. Chairman. Madam Secretary, it is 
truly a pleasure to hear from you this morning about your 
department's priorities. I am glad to hear about the 
administration's continuing commitment to programs that support 
working families, educate our children, and keep Americans 
healthy.
    First, I would like to ask you about the Department's work 
to support LGBT seniors. As you may know, the Congressional 
LGBT Equality Caucus, of which I am co-chair, has formed an 
LGBT Aging Issues Task Force. We sent a letter to Administrator 
Greenlee asking for ACL to require each State plan to assess 
whether State units on aging are meeting the needs of the LGBT 
community in their area.
    As you know, LGBT elders have poorer physical health, worse 
mental health, lower income, and fewer close ties on average 
than other seniors.
    Can you speak to whether ACL will be rolling out a guidance 
focused on LGBT older Americans, and if not, what will they be 
doing to assist this aging population?
    Secretary Burwell. With regard to this population, which as 
you articulated has a higher level of challenges than other 
parts of our elderly populations as a nation, there have been a 
number of steps that we as an entire department have taken in 
this space.
    I think you are familiar with our LGBT Coordinating 
Committee, which is a part of what has led to another thing 
that will be coming to fruition, which I think is a very 
important part of understanding the problem better, which is 
data collection, a five-year data collection, that will be 
targeted, so we can better understand the specifics of both 
what is happening in terms of the results, but what is causing 
many of the things you talked about in terms of the 
discrepancies that we see among the elderly.
    The third piece that I would actually mention is we have 
created a National Resource Center, specifically focused on 
LGBT issues, for communities to access so they can find out 
information and better serve the community.
    So, we are going to continue to work on these issues, 
appreciate your leadership, and look forward to continuing with 
the things you think we can do more in this space.
    Mr. Takano. Well, thank you, Madam Secretary. I wonder if 
you would be willing to have a meeting with the members of the 
LGBT Caucus to discuss these important issues?
    Secretary Burwell. I am sure that we and our team can 
figure out how we can do that and the best way to get action 
taken.
    Mr. Takano. Wonderful. Madam Secretary, in your testimony 
you mentioned the administration's commitment to growing our 
health care workforce by making continued investments in the 
National Health Service Corps, and graduate medical education.
    Ensuring that we have a robust health care workforce is one 
of my top priorities. In Riverside County, which I represent, 
there are only 34 primary care physicians for every 100,000 
people. Half the number of doctors needed to provide adequate 
access to care.
    Can you share more about the administration's efforts to 
guarantee we have the health care workforce that we are going 
to need?
    Secretary Burwell. So, it has a number of different 
elements. You mentioned one in terms of the National Health 
Service Corps and our emphasis on the National Health Service 
Corps, and building that up, and continuing to add members to 
the Corps.
    In addition, the funding that we do for HRSA, our Health 
Resources Services Administration, is another important part of 
making sure that we are building up a Corps.
    I think the other thing is how we do the policies. Our 
graduate medical education funding proposal, we actually 
shifted to the mandatory side because we believe that funding 
should be a dependable, continual part of funding, so we are 
encouraging people to go into these fields and know they will 
have an ability to have help with their loans.
    The other thing that I would mention is the focus on 
primary care, because we believe that is at the center and core 
of transitioning our system to where people have primary care 
homes.
    So, it is both in policy and funding across the Department 
that we are working on the issue of making sure we have enough 
health providers.
    The other thing is people at the top of their licenses, 
right now, we want to make sure there is more access for nurses 
and others to be able to do certain types of functions, and 
lastly, telemedicine. There are three proposals on that.
    Mr. Takano. Mr. Chairman, I almost made it. I am sorry.
    Chairman Kline. The gentleman's time has expired. Mr. 
Rokita?
    Secretary Burwell. I am sorry. That was me, sorry.
    Mr. Rokita. I thank the Chairman. Thank you for coming, it 
is good to see you. On behalf of the Governor of the State of 
Indiana, Mike Pence, and many of us in the State, thanks for 
working with us on what we call ``HIP 2.0,'' consumer driven 
health care, that I think will be a model to help the 
Department and others around the country really get at cost 
constraints while serving more people. Thank you for your 
cooperation and leadership in that regard.
    Secretary Burwell. Thank you.
    Mr. Rokita. I wanted to talk to you a little bit about the 
budget this morning. I thought I heard in your opening 
statement that you were able to get savings from Medicare and 
Medicaid, or did I misunderstand that?
    Secretary Burwell. There are Medicaid proposals as well as 
Medicare proposals.
    Mr. Rokita. I heard Medicaid and Medicare reforms.
    Secretary Burwell. Yes.
    Mr. Rokita. You did not mean spending reforms or did you 
mean spending reforms? What is the effect of the reforms?
    Secretary Burwell. Savings. The effect is savings, $419 
billion for Medicare, Medicaid, and other areas.
    Mr. Rokita. Over the 10 year window?
    Secretary Burwell. That is right.
    Mr. Rokita. Thank you. In your written statement on page 
two, you say that taken together, there is an estimated savings 
of $242 billion over 10 years. What is the difference in those 
numbers?
    Secretary Burwell. We pay for our child care. We pay for 
the other mandatory issues, so we pay for. That is the savings 
in that space, the entitlement space. We use some of that for 
savings and we use some of that to do things like fund child 
care.
    Mr. Rokita. Thank you. How do you save, in terms of 
Medicaid particularly, how do you save money when I thought 
CBO's January report said Medicare spending will grow by $200 
billion in 10 years, what is your--
    Secretary Burwell. Medicare or Medicaid?
    Mr. Rokita. Medicaid.
    Secretary Burwell. Medicaid spending. With regard to some 
of the proposals in the Medicaid space, one of the proposals, 
and I will have to see if this is one of the ones that scores 
into those numbers, but what we want to do is work with States 
so they can do purchasing for drugs together, help States do 
combined purchasing, which can drive down Medicaid costs for 
them and for us. That one, I have to check to see if it is one 
of the scorable ones, but those are the types of things that we 
are looking at.
    Mr. Rokita. Okay. What do you think about flexibility 
grants or block grants or making finite--instead of an open-
ending fee for service kind of structure--what about taking a 
finite amount of money and saying look, this is what you have 
to spend, State X, find out who really is poor, what the poor 
really need, and how the poor should get it?
    Secretary Burwell. So, I think the question of capping 
Medicaid--the concerns we have with it are front and center 
right now in Puerto Rico, where we have almost 250 cases of 
Zika, we have over 10 cases of pregnant women who have tested 
for Zika, and you have a situation where you have a population 
whose needs were not being met before this started, and then 
you have a situation like Zika layered on top.
    So, having a program that is about the ability to be 
flexible with the needs of the people, to meet the needs, 
what--
    Mr. Rokita. That example is a little extreme. That is what 
a supplemental funding measure could be for, something like 
that. We do not have to--
    Secretary Burwell. I hope that is an expression of support 
for our Zika sup----
    Mr. Rokita. Well, it is an expression that Congress can act 
in emergencies, and you are describing an emergency. You are 
not describing day-to-day, in Puerto Rico. I am running out of 
time, so thank you.
    This is not meant to be a political ``gotcha'' in any way, 
but I clearly remember and see evidence where the President in 
2008 when he was running for office the first time said he 
would be able to lower insurance premiums with his Affordable 
Care Act at $2,500 per family on average.
    Your testimony describes the fact that we have slowed the 
growth in health care costs. What happened? What is different?
    Secretary Burwell. I think in terms of that number, that is 
the projected growth, the amount of the projected growth, the--
    Mr. Rokita. He said lower premiums.
    Secretary Burwell. With regard to the specifics, I 
apologize, I am just--
    Chairman Kline. I am sorry, the gentleman's time has 
expired, and we are rapidly approaching--Ms. Clark?
    Ms. Clark. Thank you, Mr. Chairman, and thank you, 
Secretary Burwell, for not only your testimony today but the 
incredible work that you are doing. I especially want to 
highlight your commitment to addressing the opioid crisis, 
coming from a State like Massachusetts where it has just been a 
devastating effect, we so appreciate your partnership and your 
commitment.
    I specifically want to ask you about adolescents and young 
adults. I have spoken with many experts who treat this 
population. They have been clear that this population needs 
special protocols to be able to tailor the treatment to their 
unique social and biological needs. They are also clear there 
has not been enough emphasis on programming or research in this 
area.
    Can you discuss any efforts that are underway to target 
action towards young adults and adolescents, and if you see 
this as an important area for fighting the opioid crisis?
    Secretary Burwell. So, with regard to the fighting it in 
the here and now, a couple of elements and steps. One is you 
are right, because what happens is--I heard a story this past 
week of a young person at Cornell, an athlete injury, got on 
the opioids, overdosed and is dead.
    So, there is special need especially because of these 
athletic injuries, this gets to the prescribing guidelines, and 
making sure there are alternative approaches to helping these 
students and young people through their pain and their athletic 
injuries. That is one whole category.
    There is another category that we know sadly that while I 
think people think alcohol is an okay alternative for these 
young people, it is not, because I think what we know is that 
is a gateway often to the prescription. Those that are 
participating in those activities are more likely as they get 
older to participate in other activities.
    That is the here and now and things we need to focus on. 
The research that we need to do with regard to the question of 
opioids across the board is a broad part of the research. The 
questions of does it help for long-term pain and acute pain, 
that sort of thing, and making sure we are thinking about young 
people as we do the research is a more longer term issue but 
one we need to focus on.
    Ms. Clark. And one we would love to work with you on. I 
want to quickly get back to Zika. You spoke about some 
startling numbers, even here in the United States. Every day we 
are seeing more of the connection being verified by research 
about the connection and danger for pregnant women. We are also 
seeing countries around the globe that have very restricted 
access to family planning for women saying do not become 
pregnant at this time.
    Can you elaborate on what is being done both here at home 
and abroad to make sure that women have access to a full range 
of health care options?
    Secretary Burwell. So, three fundamental things as part of 
the strategy. Number one, a deep focus on pregnant women 
because of the concerns around microcephaly, and the very 
extreme birth defects that can occur with women who have Zika 
while they are pregnant.
    Number two, communication, making sure we are reaching as 
many people as possible who are either traveling to that region 
or have a partner who has traveled to the region, because we 
know sexual transmission is possible. So, communicating about 
the guidelines as much as we know as quickly as we know.
    And number three is making sure that we are focused on the 
research that we need to do to understand more about the 
disease, including how to do better vector control. This is a 
disease that is spread by a mosquito that can bite four people 
in one setting. It is an indoor mosquito. It can breed in a 
capful of water. It is a very difficult mosquito to control.
    We are continuing to use best practices, but more research 
on the disease, on the vaccine, and the vector need to be done.
    Ms. Clark. Great. Thank you.
    Chairman Kline. The gentlelady's time has expired. We are 
shrinking the available time even more. I am telling my 
colleagues as we are moving towards the hard stop. Mr. Allen, 
you are recognized for three minutes.
    Mr. Allen. Thank you, Mr. Chairman, and thank you, Madam 
Secretary, and thanks for your call, by the way. I am sorry I 
did not get back to you.
    I wanted to just comment on a couple of things. One is you 
mentioned you have lowered the taxpayer growth in Medicare. I 
need some background on that, because I am not seeing that, so 
if you could get that to me.
    The other number that I am seeing is ``totally insured.'' I 
am not seeing that in my district. In fact, a very small 
percentage of my district is insured. In fact, doctors tell me 
at the emergency room that nothing has changed, many people are 
showing up without insurance as before.
    Also, on your comment about you do not pay more for 
preexisting conditions, I met a lady yesterday that told me 
about her son and his condition, and she wanted to know why his 
premiums had gotten so high and his deductible was like 
$10,000. I said well, I will get an answer for you. I need you 
to get that to me.
    Last but not least, the President signed into law, and I 
voted for, the Hyde Amendment, which was an attachment to the 
appropriations bill. How are you monitoring your funding of 
these various claims that no taxpayer funds are being used for 
abortions? How do you monitor that, and what are you doing to 
oversee that?
    Secretary Burwell. With regard to where that would occur, 
it would occur in HRSA, the Health Resources Services 
Administration, which are the clinics that we fund directly, 
and there are stringent guidelines with regard to that, that 
the clinics both know and are educated on, so it is not just a 
matter of telling the clinics, it is a matter of HRSA making 
sure they know and understand what those guidelines are so we 
can follow them.
    Mr. Allen. You are auditing these clinics?
    Secretary Burwell. With regard to the specifics of how that 
goes, I will come back to you.
    Mr. Allen. Okay. Alright. The other thing, we have some 
States that are opting out of the Exchanges. I think Oregon and 
Kentucky is talking about getting out of the State Exchanges 
and going back to the Federal Exchange.
    Do you want to explain why that is going on? I mean our 
governor was criticized because he did not opt to go into the 
State Exchange, because he knew eventually the Federal 
Government was not going to fund it any more. Of course, in 
Georgia, we are required to balance our budget. He did not 
think the funds would be there.
    What is your take on this?
    Secretary Burwell. With regard to either approach, I think 
it is about a State's choice and a decision in terms of whether 
or not they want to do the setup of the piece that will attach 
their consumer to their ability to access it.
    In Kentucky, it is a system that is a well-integrated 
system that helps with and creates efficiencies for both their 
CHIP and Medicaid. I think they decided to do it because it 
creates that. Other States choose not to and use the Federal 
marketplace.
    Either way can work as a system. We just want to work with 
States to do what is their preference as a State.
    Mr. Allen. I yield back.
    Chairman Kline. The gentleman yields back. Ms. Wilson?
    Ms. Wilson. Thank you, Mr. Chair. Welcome, Madam Secretary.
    Secretary Burwell. Thank you.
    Ms. Wilson. Unfortunately, Florida, my State, is one of 19 
States that has failed to expand Medicaid under the ACA. Can 
you speak to why Medicaid expansion is so important for 
communities of color, especially in my home State, and across 
the country?
    Secretary Burwell. So, while we have made great progress in 
terms of communities of color, 3 million uninsured reduction in 
the African American community, 4 million in the Latino 
community, we know that the uninsured rates are still 
disproportionately high. We know that if Medicaid expansion 
occurs, that a disproportionate number of folks that are 
minorities will be covered.
    So, we are excited to continue pushing and pushing hard 
because we think it will have a disproportionate benefit to 
communities of color.
    Ms. Wilson. Our governor has repeatedly rejected expansion, 
citing budget restraints. Can you speak to how Florida and 
other States may actually see budgetary relief under Medicaid 
expansion?
    Secretary Burwell. So, what we know, and the University of 
Louisville together with Deloitte has done a piece of work and 
a piece of research on their work and their expansion, and it 
led to the creation--it would lead to the creation by 2021 of 
40,000 jobs, as well as $30 billion flowing into the State.
    We know we see reductions in uncompensated care for 
hospitals and communities across the State when expansion 
occurs. It is about the individual, but it is also about the 
economic impact.
    Ms. Wilson. How are we assured that our communities of 
color are getting the information they need to successfully 
enroll?
    Secretary Burwell. One of the things we do during open 
enrollment, and I had the opportunity to spend a lot of time in 
your State, have gone to every place from beauty salons to 
barber shops, because we need to meet people where there are 
trusted voices.
    In Texas, actually in all States, we do second Sunday, 
where on Sundays, we work with the faith communities across the 
States to help people get information that is important 
information from trusted voices.
    Ms. Wilson. Just keep up the good work. I yield back.
    Chairman Kline. The gentlelady yields back. Mr. Carter?
    Mr. Carter. Thank you, Mr. Chairman. Thank you, Madam 
Secretary, for being here. Madam Secretary, as you know, I am a 
pharmacist, so I am very concerned about issues, obviously, 
dealing with patients and dealing with them getting their 
medications.
    Specifically, I wanted to ask you about compounding, 
compounding for office use only. I am very concerned about the 
FDA interpreting legislative intent, and certainly this is 
something that comes into play when we are talking about for 
office use only.
    I know the FDA continues to prevent medications to be 
compounded for office use only, and what this causes is for the 
patients to have to go back to the pharmacy, get a specific 
prescription, compound it for them, then go back to the doctor 
to have it applied.
    I am wondering where you are at in that process? Many 
States have already allowed for this to take place. Many States 
have already had regulations and laws in place that allow for 
office use only, for compounds to be made, and for the 
physician to have them there in the office where the physician 
has the ability to apply and use that medication instead of the 
patient having to go get a specific prescription filled for 
them as opposed to having it for office use only.
    I just want to know where we are at in that process.
    Secretary Burwell. So, we do not have any guidance out 
preventing that, so maybe I can follow up with your staff to 
understand, that our team can follow up to understand. We 
welcome the input on the guidance on the issue.
    It does not exist, so right now, compounding should be 
occurring.
    Mr. Carter. Compounding is occurring--
    Secretary Burwell. There is not a problem in terms of any 
guidance or any rules about it right now.
    Mr. Carter. I beg to differ. The problem is you are 
requiring each specific patient to have a specific prescription 
for medication, for a compounded medication. What in the past 
we have been able to do is just to supply--
    Secretary Burwell. In the doctor's office?
    Mr. Carter. Exactly, with a compound that is for office use 
only, in which they can apply that medication.
    Secretary Burwell. It is my understanding that is able to 
be done--if there is something that is happening that is not, 
that is why I would like to follow up because what you are 
articulating is not my understanding. Let's understand.
    Mr. Carter. Absolutely.
    Secretary Burwell. Is it a State issue or something else or 
maybe we are not communicating.
    Mr. Carter. We are looking for guidance from the FDA on 
this, and this is an issue that we are very concerned with 
because again it has to do with patient care. We want to make 
sure that patients are getting the care they need.
    Secretary Burwell. And we would like your input on any 
guidance that we would do in this space.
    Mr. Carter. Okay, thank you. Mr. Chairman, I yield back.
    Chairman Kline. I thank the gentleman. Ms. Adams?
    Ms. Adams. Thank you, Mr. Chair, and thank you, Madam 
Secretary, for being here. I am going to move along quickly. I 
just want to give a shout out to my police department in High 
Point for the work they are doing in opioid abuse, and I thank 
you for your work.
    Let me ask you about the health of our Nation's most 
marginalized young people as it relates to sexual health 
services. A lot of data and research performed by CDC, American 
Academy of Pediatrics, and even your Office of Adolescent 
Health show that far too many young people in the U.S. face 
barriers accessing and receiving adequate health care services 
regarding sexual health education.
    So, can you please speak to existing efforts that HHS is 
leading to ensure that our Nation's youth, especially those 
most vulnerable, have the education, skills, and access to 
sexual education services?
    Secretary Burwell. So, across the board in terms of our 
tools, it is our community clinics that we have talked about. 
It is the CDC, as you mentioned. It is also our funding in 
terms of access through Title X. Those are three different ways 
we do that.
    Also, some of the most vulnerable that you are talking 
about are through our minority health issues as well, so that 
is the other place I would mention that we work on these 
issues.
    Ms. Adams. One follow up. So, what is the administration 
doing to address not only the Southern States that are 
disproportionately affected by HIV disease, but also the rural 
communities that are seeing the majority of the diagnoses?
    Secretary Burwell. There is $54 million in minority health 
for HIV specifically proposed in our budget that we will hope 
will continue these efforts and work with those Southern States 
that have a disproportionate number, like North Carolina.
    Ms. Adams. Okay. Thank you very much. Mr. Chairman, I am 
yielding back.
    Chairman Kline. I thank the gentlelady. Mr. Thompson?
    Mr. Thompson. Thank you, Mr. Chairman. Secretary Burwell, 
thank you so much for the phone call, very much appreciate you 
reaching out.
    I just want to note the current crisis with the opioids, 
there is obviously some impact from infants to the elderly. We 
need to approach this from a broader perspective, this is 
symptomatic. I view it as a broader epidemic of substance 
abuse. It does not matter how large or how small the community 
is, it is present.
    This is kind of an all hands on deck for the Executive 
Branch, Legislative Branch, and all of the partners, we need to 
be working together.
    My question though is regarding access to health care. In 
your testimony, you state that through targeted investments, 
the administration's budget expands access to health care, 
particularly for rural and underserved areas. I represent 
Pennsylvania's Fifth Congressional District. It is the State's 
most rural, largest congressional district, about 24 percent of 
the land mass. I know rural. I know it well.
    As a former health care provider for almost 30 years, 
access requires the presence of providers in our communities, 
first. I do not care how you pay for it or all the other moving 
parts of it. You have to have that access. There has to be a 
presence.
    Really, a tremendous concern considering the fact that more 
than 45 rural hospitals have closed since 2010, and 
approximately 300 others are in danger of closing. I struggle 
to understand how these facts support your conclusion that the 
Affordable Care Act is having a positive effect on the well-
being of employers, employees, providers, health care 
professionals, and most importantly, patients in rural areas.
    Can you expand on your statement in regard to those facts? 
That is a trend line that is not good and it scares me.
    Secretary Burwell. It is a trend line that started before 
the passage of the Affordable Care Act, and it is a trend line 
that has a number of different elements that contributed to it, 
and I think as you articulated, as you described your district, 
the issues of population density, the issue of providers being 
willing to go to places where there is not a lot of population 
density in terms of their choices they make, as well as one of 
the contributors I think we do see is uncompensated care in the 
form of Medicaid expansion.
    So, we do see a difference in the places where it has 
expanded, and the number of hospitals that are closing. We see 
a reduction in that because of the reduction in uncompensated 
care.
    Mr. Thompson. Obviously, I keep my finger on the pulse of 
this because that was my life, working to provide access to 
cost effective care. I see rapid expansion monopolies, that 
compounds it by raising costs, monopolies tend to do that, it 
takes the pressure off for increased quality. I think there are 
a lot of issues going on, and I would say they have been 
compounded since that time.
    Thank you so much. I look forward to continuing the 
discussion offline.
    Chairman Kline. The gentleman yields back. We have rapidly 
run out of time. Let me yield to Mr. Scott for any closing 
remarks he might have.
    Mr. Scott. Thank you, Mr. Chairman. Madam Secretary, I 
thank you particularly for your comments on the Affordable Care 
Act, where we have changed the situation from thousands of 
people every day losing their insurance to millions more being 
covered, and the cost savings, rather than often double digit 
increases to the lowest increases in modern history, showing a 
significant savings over what the costs would have been had it 
not for the Affordable Care Act. And people with preexisting 
conditions with no insurance to being able to get insurance at 
standard rates, and more progress could be made if Medicaid 
were expanded in those States, and those with insurance are 
actually picking up a lot of that cost, because of 
uncompensated care is cost shifted to those with insurance.
    I appreciate your response to the opioid situation. 
Finally, I think we are getting a consensus that early 
intervention and prevention is better than hospitalization and 
jails.
    We put all the money in the criminal justice system, and 
when have you ever heard a dealer tell a customer I could not 
get any heroin today because the police have cracked down, and 
a customer say, oh, my God, my dealer got busted, I cannot get 
any heroin.
    All that money spent on the criminal justice system could 
have been spent on research-based and evidence-based approaches 
that would actually reduce the amount of opioids being 
consumed.
    Appreciate your work with Head Start, homeless youth. We 
did not get into foster care. I do appreciate your request for 
additional resources in foster care to achieve permanent 
placements, to the extent that we can get young people on the 
right track and keep them on the right track, we will have 
fewer problems in the future.
    And finally, I express appreciation for your effective 
response to Zika, and the request you have made, I hope we can 
fund that, and to Flint, Michigan.
    So, thank you for your testimony, and look forward to 
continuing to work with you.
    Chairman Kline. Madam Secretary, I want to thank you also. 
I want to thank you for your testimony, for your service, for 
your engagement with the members here, and for allowing us to 
go three minutes over the closing time.
    There being no further business, the Committee stands 
adjourned.
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    [Whereupon, at 12:03 p.m., the Committee was adjourned.]

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