Transcripts For CSPAN3 Centers For Medicare Medicaid Services Administrator Seema Verma... 20240713

Subcommittee hearings on investigations will come to order. We are hearing a hearing called sabotage. The purpose is to examine the efforts to ensure quality and Affordable Health care. The chair recognizes yourself for five minutes for an opening statement. Its no secret that the Trump Administration has worked to sabotage health care in this country. On his very first day in office, President Trump issued an executive order directing all federal agencies to dismantle the Affordable Care act, both, to the maximum extent bylaw. Ever since then, the Trump Administration has worked tirelessly to undermine the aca, and other Critical Health programs at every turn. In her role, this seema verma has been behind many of the efforts to undermine the Nations Health care. Despite her role in this, is the first time administrator has appeared to testify and an oversight hearing, and we have many questions regarding the administrations actions. Since for double care act was signed into law more, than 20 Million People gained affordable High Health Care coverage, but now under President Trump, this administration is determined to take us in the wrong direction. Last year, we saw the number of uninsured people in this country increase for the First Time Since the aca was passed, about 1. 9 were insured last year, compared to the year before, including half 1 million more children. Further, the Kaiser Family foundation estimates that Health Insurance premiums are 16 higher this year than they would happen if the Trump Administration has not worked to undermine the aca. We know the Trump Administration has taken numerous steps to sabotage the aca. Theyre chipping away at critical protections guaranteed by the law. They are allowing states to increase consumer costs, reduced their coverage, and undermine protections for those with preexisting conditions. They are promoting junk insurance plans that do not provide essential Health Benefits and leave patients on the hook, when they need coverage of the most. Theyre making it more difficult and expensive for individuals to find quality coverage on the Health Insurance marketplace. And, to top it off, their rooting for the aca is collapse, by declining to defend the law and the texas forces United States lawsuit. We will likely here today that obamacare sort of our problems, but while the Nations Health care law may not be perfect, its important to understand what would happen if the Trump Administration succeeded in dismantling the aca entirely. 21 Million People could lose their Health Insurance. Up to 133 million americans with preexisting conditions could be denied coverage or charge higher premiums. Those lucky enough to keep their coverage of the aca could once again face lifetime caps on coverage and could lose coverage for things like prescription drugs and maternity care. Women could be charged more than men for their Health Coverage. And 60 million seniors and disabled americans on metal care will have to pay more for Preventative Care prescription drugs. Yesterday, cmf announced that ac premiums will drop. Thats good news. However, lets think about how many more people would be covered now and how many more lower premiums could be if after the repeated acts of sabotage at the hands of this administration. The aca is succeeding despite the Trump Administrations efforts to tear it down. Time and time again, this administrations actions on health care have gone squarely against their duty to promote High Quality Health Care and the well being of children and families in need. Under this administration, thousands of children and families have lost coverage of basic Health Services, and this administrations actions have hurt those with disabilities, rural americana, veterans, women and young people of color. The Trump Administration have tried to make philosophical arguments for why they are doing these things. But the numbers dont lie and at a time when we are facing Critical Health challenges, like the Opioid Epidemic and high rates of infant mortality, its unconscionable that this administration is working to reverse the problems that weve made. They will have to answer, and administrator verma will have to explain why she and this administration are actively trying to take their health care away. With that, the chair will recognize the Ranking Member Mister Guthrie for an opening statement. Thank you for holding this, and i will like to welcome administrator verma for her first appearance before the committee. She oversees numerous federal programs cms will impact 145 million americans. And she represents more than 100 trillion dollars of the budget, emphasizing a Critical Role the agency plays in the Nations Health care system on how to illustrate how we cannot possibly cover all of the role of her work in a single hearing. And thank you for your commitment to promoting competition, after that work youve accomplished thus far. I was pleased to see the announcement of premiums decreasing in 2020. A far cry from the double digit premium increases weve seen in past years. Ive also heard from my constituents on how cms is patient over paperwork initiatives will provide focusing on the quality of care provided to patients rather than the burdensome administrative tasks. Im also glad that we are strengthening the oversight of Nursing Homes in recent months. This committee examine the care in Nursing Homes after instances abuse, neglect in standard care occurring in Nursing Homes across the country. Another critical issue is the Opioid Epidemic. This has been at the forefront of the fight for the Opioid Crisis. Our investigative in legislative work led to the support act for patients and communities act. This was signed into law one year ago tomorrow. While there is much to be done both logistically, to support act in responsibilities and helping to address the Opioid Epidemic. Many of the initiatives ive described share bipartisan support. This is why the title for this hearing, sabotage, the Trump Administrations attack on health care is over the top. No one can reasonably categorize the cms effort to protect populations in Nursing Homes are sabotage. Moreover, the democrats will spend a lot of time today criticizing cms recent actions relating to demonstrations, and innovation labors. I find it disingenuous to lay cmss commitment to strengthen its partnerships with states to promote innovation and sabotage. I do, however, want to discuss areas where i think well cms take additional action in the future. At the beginning of flu season, and that will potentially be one of the worst flu seasons weve ever seen. This subcommittee held a hearing. In 2018 examining the efforts to respond to seasonal influenza, and while scene was not a witness, we did learn that we were working to use medicare data to compare the effectiveness of flu vaccines. I have some questions about this, and i hope we can hear another hearing on flew preparedness as soon as possible. I have questions for cmss about the efforts to the inevitability of health care data. I appreciate the, work that same as has done to implement the cure act, but as i said in my letter to cms with congressman trader this summer, im concerned that a recent proposal is not adequately protecting health care data. Thank you again for being here today. I look forward to your testimony, and i will yield my time to the congresswoman from indiana. Welcome administrator verma. Seema verma and her family our constituents of mine back home in indiana, and we actually have been friends for a couple of decades. We worked together in merit Stephen Goldsmith office where she was focused on Health Policy in the late 90s. That innovation was recognized also by former indiana governor mitt sandals, who asked seema verma to work with him and ensure that health care was working for patients in indiana. This was a indiana popular bipartisan Medicare Program. Healthy indiana plan requires small number contributions what are called power accounts, that focus as incentivizes Preventive Care to drive down costs. We are very proud that seema verma stepped up at the invitation of the president to take the innovation and her incredible dedication to the health of americans here in washington d. C. We thank you for your work. I yield back. The chair recognizes the chairman of the full committee mr. Pallone for the purposes of an opening statement. I think the chairwoman. Todays hearing continues this ongoing work to bring oversight and accountability to the Trump Administrations relentless attack on Peoples Health care, whether be attacks on the Affordable Care act, medicare or medicare. Since day, one the Trump Administration has engaged in a concerted effort, i heard what my colleague said that he does not think that this administration is sabotaging anything but, the problem that i have here is, if someone is on the right, ideologically and says, look, the government should not be involved in health care, should not angle involved with Health Insurance, people are on their own. If you said that i would say, okay, i understand, you want to get rid of all the Health Insurance, you want to get rid of this, while this is not the governments role. The problem i hear my colleagues on the other side, including the president suggests otherwise. That they want to have cover, they want to have people have Health Insurance. I dont see that. I think, if you look at this practically and not ideologically, it is clear that fewer people have Health Insurance, that theyre essential benefits are being cut back, not being covered, so to suggest that somehow theyre not responsible for that i think its not true, they are responsible. Its a concerted effort to cut back on peoples Health Insurance. Their benefits, and will cover today. Half our witness today is the administrator for the centers for medicare services, cms, seema verma, who is the administrators a point person on this. She has a difficult record to defend, and thanks to the communications policies, the number of uninsured americans increased by 2 Million People from 2017 2018, rising to 27. 5 million uninsured. Between december 2017 and this june, more than 1 million children, lost Health Coverage through medicare or the childrens Health Insurance program. These are bipartisan programs. Why system annotation making it more difficult for people to get coverage and particular children. These are disturbing trend and, unfortunately they, could get worse if cmf and the Trump Administration are successful and pushing their harmful policies. The Trump Administration is actively supporting a lawsuit that would overturn Affordable Care act. The Health Insurance away from americans and would allow Insurance Companies to discriminate against people with preexisting conditions. The administration has expanded dock insurance plans that are not required to cover essential Health Benefits, like hospitalisation, prescription drugs, and Emergency Care services. The Trump Administration has also placed extremely burdensome and sometimes illegal hurdles in front of Medicare Beneficiaries. These roadblocks are closing pain for low income families. As 1 million children lost health care between december 2017 engine this year. These numbers show that the Trump Administration policies to drive people off medicaid, tied them up and red cape, or scare them into not even applying for insurance in the first place are working. I am deeply concerned by the Trump Administrations ongoing attempts to impose illegal work requirements, waivers on Medicare Beneficiaries. These requirements are not only costly, but a clear violation of both medicare statute and longstanding congressional intent. These legal actions have been rightfully defeated and the courts. The Trump Administration refuses to give up, and the Trump Administration is also not given up in the ongoing attempts to sabotage the health care millions of americans who threw the aca. These proposals have been so extreme, that even administrative amash has raised a red flag. And an internal nima nadal, and im quoting, cause coverage losses, and market disruption. The middle concluded that 1. 1 million americans will lose their coverage. I have requested it that miss seema verma provide the analysis discussed and that memo. If the Trump Administration is pursuing a policy that would have harmful impact on the american, people we need to know what the analysis shows. Up to date, ive not received a one page response that answers and in my questions. Under the leadership, cms has followed the Trump Administration and stonewalling legitimate congressional oversight requests, and im appalled by the family, nonresponsive letters that weve received from cms many times past the deadline. As a road unelectable to secretary azar and missed verma last week, obstruction of congressional oversight is acceptable and if it continues, it may necessitate the use of additional measures including compulsory processes. I appreciate you being here today. That says a lot, that you are here, and i dont want to take away from that. The stonewalling of our oversight requests have to end. With that, i yield back. The chair recognizes the Ranking Member of the full committee for five minutes. Good morning. Thank you for being here, we appreciate it, weve enjoyed working with you on minutes issues. Im glad you are here. Cnns is largest administrator of Health Benefit programs and the United States. 25 million americans will receive their benefits by cms, either big job and we appreciate you. That includes medicare, medicaid and chip. Republican leadership, has extended chip for five years and then six years, we have 14. We have for ten years, fully locked in childrens Health Insurance and a lot of democrats have not voted against this, almost every step of the way. I dont want to get into this part but its unfortunate because there are issues that we need to focus on. Together i think about the meetings ive had with the president , you and others, i have seen president s who have leaned and to get drug prices down. I wish you could be here during our markup, when every democrat was holding up posters about what President Trump said about drug prices. Well we may have some disagreements about the policies, they were the president advocates last week when we were dealing with drug costs. The chairman are working shoulder to shoulder with this administration to protect consumers from surprise billing. What i ran into in my part of the world is people are so concerned about the high costs of health care, and the Affordable Care act, weve had our debates about what the best policies are there, it did not deliver as promised to bring down premiums 2500 bucks. In fact, i cant find anybody in my district that has seen that level of reduction. But what they have seen is increase and deductibles and copay. s insurance by name, is not insurance by function if deductible oracle pace are so high you cant afford to access the care. So, there are issues there. In terms of the Affordable Care act. Things that we supported in the Affordable Care act, including protecting people with preexisting conditions, letting your children stay on until theyre 26, theres a whole host of things. We did a lot of work together, and it was reference earlier today about the support act. I helped steer through that process, will open session where members of congress could come and make their case. Tomorrow marks the one year anniversary. I just left a meeting in the senate with the first lady and secretary azar, celebrating what we had accomplished together as a congress and almost unanimously as i recall. To address this horrible scorch of opioids. When it comes to first times, were glad to hear, the other firsttime would be to have a hearing in this committee on medicare for all. We were talking about my colleagues were talking about how the Trump Administration is chipping away at aca, i would argue that their president ial candidates are taking a chainsaw massacre approach to it because they want to throughout the whole thing and go with a government run system that wipes out medicare, medicaid, the a, all private Health Insurance and theyre having a fight over how to pay for it, or to talk about how to pay for it. Working americans lose their insurance under their plan and ive asked for a hearing before this committee since the first of this congress and weve yet to have one on their medicare for all proposals. Theres a lot of debate here and areas that we should be working on a. I will yield now to the Ranking Member of health secretary, doctor burgess. Id like to do something that i dont normally do, which is quote from the washington post. And the health tool to article by page cunningham States Obamacare premiums will become more affordable next year, despite the dire predictions by democrats to the trump ministration would destroy the insurance and market places. She goes on to say they improvements are striking, considering the democrats has been the last few years blasting the Trump Administration for peeling away obamacare regulations. Quoting alex azar, President Trump who was supposed to be sabotaging the law has been running it better than the guy who wrote it. Quoting President Trump himself, once we get rid of the individual mandate and made it better, obamacare doesnt work but it works adequately now and we had that choice to make. Politically, its not a good thing that i did that but it was the right thing to do for a lot of people he said in july. I will just submit this entire article for the record. Objection. Gentleman yields back. Now numbers Opening Statements be made part of the record without objection. I now like to introduce our witness for todays hearing, honorable seema verma, administrator for centered for medicare and medicaid services, department of health and Human Services. You are aware that the committee is holding investigative hearing and we are doing so, we are the practice of taking testimony under oath. Death any objections . No. The witness responded no. You are entitled to be accompanied by council today . No. The witnesses bonded no. If he would then please rise and raise your right hand so that you may be sworn in. It is where that the testimony youre about to give is the truth, the whole truth, and nothing but the truth. You may be seated. Let the record respect the witness responded in the affirmative. You are now under oath and subject the penalties set forth and title 18, section 101 of the u. S. Code. Now a five minute summary of your opening statement. You are now recognized. Thank you. Chair degette, Ranking Member guthrie, and members of the subcommittee, thank you for the invitation to discuss the efforts for centers for medicare indicate services to transform and improve the United States Health Care System. When i came to cms, our goal was to improve quality, lower costs and improve the health care experience, and only for the beneficiaries of our programs but for all americans. In 2017, this administration inherited a chaotic and declining individual Health Insurance market. The relief promised by proponents of the Affordable Care act never materialized. Quite the opposite. Premiums and states using the federal exchange more than doubled through 2016 to 2017, the final year the Previous Administration oversaw the program. Issues were fleeing the market and we were scrambling to prevent bear counties. Over just two and a half years as administrator, im happy to report that our market based reforms have delivered lower premiums on the exchanges for the First Time Since the law started. Yesterday, we announced that for 2020, the average premium for a benchmark silver plan will drop by 4 in states using the federal exchange platform. This is on top of it increases we saw last year, in some cases, the decline in premiums is substantially higher, with six states experiencing double digit percentage decreases, including a 20 drop and delaware, 15 and north dakota, and a 14 drop in oklahoma, on top of this, more issues are entering the market and the number of states but just a single monopoly is declining. Only two states will have a single issue or in 2020, compared to five this year and ten last year. This is success despite this progress, it was inevitable that obamacare is affordability prices would eventually increase the number of uninsured, and that is with the latest census data shows. In fact, 85 of that 1. 9 newly uninsured in 2018 occur among people with incomes higher than 300 of the federal Poverty Level. These are people who do not qualify for large aca subsidies and represent a new class of uninsured, those that cant afford obamacare premiums. Our work to lower premiums has not stopped with the exchanges. Under the president s leadership, we have strengthened medicare, seen similar success and medicare. Medicare beneficiaries have more choices with about 1200 more medicare vantage plans available in 20 2010 and 2018. The average monthly premiums are the lowest they happen in 13 years, and in medicare partly, the low as they have been in seven years. Across the board, in medicare and the exchanges, premiums are low. All of our work at cms focuses on making health care more accessible to the American People. Were using every lever to tackle longstanding issues and problems in the Health Care System. Were executing on our vision to transform care by putting patients first and focusing on 16 shooting and initiatives grounded in empowering patients, and unleashing innovation. Cms its committed to moving to a competition of value and moving patients the choice and control they want the, affordability they need and the quality they deserve. Well my written testimony provides more details, i will highlight a few of our efforts. We are empowering patients with the decisions they need, an efforts underway under Price Transparency and ensuring the beneficiaries medical records can travel with them while keeping the data private and secure. We are addressing issues that drive up health care costs, express images of cross after becoming administrator of cms, one of my first actions was to launch the patients over paperwork initiative. Across our problems, we have made changes to our regulations and guidance. Last week, released a proposed rule to modernize and clarify the regulations and interpret the law. Our policies will say providers an estimated 4. 4 million hours a year, previously spent on paperwork but savings projected to be approximately eight billion dollars over the next ten years. Were also working to bring our programs into the 21st century. Last year, the administration launched the my healthy Data Initiative to meet the needs of a number of tech savvy beneficiaries. This includes releasing two new cross calculator tools and the first redesign of medicare planned finder and a decade. As part of mildly data, blue button two point oh is already getting Medicare Beneficiaries the ability to connect their claims data to tool developed by innovator. We have launched several historic to improve rural health, transform our efforts and to foster innovation throughout the Health Care System, bringing new technology to our beneficiaries. Were also focused on transforming the Medicare Program around three pillars, flexibility, integrity and accountability. Our goal is to restore the state partnership and allow states to resume their role as laboratories of innovation. We are proving Ground Breaking waivers, and Holding States accountable for results, including through our new medicare scorecard, youre time has expired. We are putting patients first as we move forward with providing all americans to an axis of health care options. Now members can ask questions and i will recognize myself for five minutes. Administrator, as i stated and as you mentioned in your statement we saw the number of uninsured people in this country increase last year for the First Time Since the aca was passed about 1. 9 Million People, is that correct . That is correct and. About half of those people were children, is that right . I dont think that number is right. What is the right number. Its about 400,000. In the texas versus United States skates, thats the case that the administration has requested that the aca be struck down, is that correct . That is correct. Any day now the court will rule and if the court rules the way the administration has asked, in the entire ac will be invalidated. Is that correct . That is correct. Okay. If the aca was invalidated, about 21 Million People will lose their Health Insurance. Is that correct . I think what yes or no will work. No. How many people lose their Health Insurance at the aca with struck down, to you know . The president has made clear that we will have a plan in action to ensure okay, im going to get to that in a moment, but the aca was struck down, isnt it true 12 nine people would lose their Health Insurance . The president know, yes or no. How many people lose their insurance . The president has made clear. Okay, you refused to answer that. Let me ask you this. If the aca was struck down, then also the provision of the preexisting conditions would be struck down, since part of the aca, is that right . The president has made clear that we will do everything we can to ensure that americans with preexisting conditions maintain the protection they have today. Let me just say then, since youre not answering my question, the aca, if it was struck down, this is what would happen. 21 Million People who are in short under the aca will lose their insurance. That includes 12 Million People on medicaid and 9 Million People who have aca protection. Theyre currently 133 Million People with preexisting conditions who, under the aca get protections. Now, theres alaska this. Im sure you look at the same answer, but theres 2. 3 million Adult Children under the age of 26 who, because of the aca, are able to stay on their parents insurance. Ill ask you this. If the aca was struck down, with those 2. 3 million Adult Children still have insurance. The president has made clear that we will maintain what works and we will try to address the problems that we are having with the aca. So, did the Administration File some kind of a motion in the texas case to say that the preexisting conditions should be maintained . Yes or no. Individuals who have preexisting conditions today do not receive a subsidy that they dont have the protections today. I can give you an example. You dont think the aca is protecting people with preexisting conditions . If you cant afford your Health Insurance and you have a preexisting condition, you dont have protection. But about the Adult Children . The Trump Administration file emotion with the court to say they should still be able to stay on their parents insurance until age 26. Yes or no . The president has made clear that we will have a plan in action to make sure that americans have access to affordable coverage. We do not have that today. There are Many Americans today that are not getting a subsidy i understand your position. Youre not answer my question. If the aca was struck down, brig people with preexisting conditions, the Adult Children, all the provisions of the aca will be reversed. So youre telling me, administrator, that the Trump Administration has told people they will be protected. Can you produced for me right now the Trump Administrations plan to protect the people . Can he produce it right now please . The 55yearold couple making 66,000 dollars thats not my question. Excuse me. They have a copy of the plan that will replace the aca . Yes or no. I will not get into any specifics. Youre not going to answer the question. Okay, the terrible yield back if you will recognize the Ranking Member for five minutes. Thank you administrator. They want to finish your comments you are making. Thank you. A 55 year old couple making 66,000 dollars a year in nebraska could face an annual premium of over 31,000 dollars, and thats on top of a 12,000 dollar deductible. That same situation and colorado, that premium will be 32,800 dollars. In new jersey, the premium would be almost 16,000. Were talking about people having to spend a third to half of their income on premiums. That doesnt include the deductibles. If those individuals and that couple have a preexisting condition, they dont have any protections today. I was going to talk about the lowering premiums, but youre going from an already pretty high premiums that increases the aca, we have made an effort and put into place lowering. What challenges remain to further lowering premiums . One of the things we need to do is focus on lowering the cost of care. Theres been so much discussion about throwing more money at the problem, having more government control, but what we are focused on ends is lowering the cost of health care. Many of the initiatives that we have at cnns, weather around drug pricing or getting rid of administrative burdens that are getting in the way of doctor spending time with their patients and increasing costs on whether its focusing on efficiencies in the states system by making sure that patients have access to the record, we are focusing on access that will lower the cost of care for americans. If we do that, more people will be able to afford health care. I want to switch a little bit, there question is, they understand the purpose but it doesnt adequately reflect the quality that they produced in the hospitals. I know they decided to change the hospital starvation and so my question is that some stakeholders request star readings from Hospital Compare website. What is the plan to use the current methodology to update star ratings. Can you provide an estimate for the facts of this . Forceful, start with, as we are focusing on lowering health care costs, we think that Price Transparency is very important. Along with that, equality transparency is important. Thats where the hospital star ratings are about. I appreciate your comments and theyre concerned that hospitals have raised about their methodology, and weve made it clear that we want to work with them to make sure that americans have access to quality information that will give them the best understanding of what kind of hospital and issues that hospital may have, so we are dedicated to working with them. In the meantime, we want to be able to use what we have because we think its important for patients to have that information. Thank you. Last week, we had a markup on a drug pricing bill here and the big concern i have had, and one of the great things has been bipartisan was that what we have moved here, and when i talk to people back home that things are working and moving forward, its a blockbuster drugs that are coming out, the blockbuster procedures, and the bill that was estimated at ten to 15 remedies would not come forward because of the impact of the bill, and they were a couple of members that the ten to 15 would be something that he would have to sacrifice for being able to negotiate lower drug prices. One said that if we have these blockbuster cures, weekend for them, than what good are they . Essentially, the beloved better than the cures. My comment, was lets come with the black buster cures and figure out how to yours and figure out how to find them. One of the things is value based, arrangements and another certain things it is dark law and other things they get in the way of the value based arrangement. Can you talk about value based arrangements for dealing with expensive curious . Thanks for the question. I think we are seeing the advent of new high cost drugs. Weve seen drugs price that half 1 million dollars, 1 million dollars, 2 million dollars. Those are providing hope for so many patients because of these new medications being able to cure diseases and can actually prevent some downstream costs for the Health Care System over the long term. They can reduce costs. That being said, i dont think that our system is set up to handle this. We played the average sales price, about four and a half percent with the sequester. But its an add on pavement. If you think about that, out of the system can handle it. We do need to think about okay, youre time has expired. I now recognize the gentlewoman from illinois. Your testimony before us, you say that, quote the individual market was in a state of crisis because of the aca. But in reality, it is you and the Trump Administration who have done everything you can to sabotage the aca and reverse the historic gains and Health Coverage. So lets go over some of the record over the past three years. Your record on his first an, office the president signed an executive order directing federal agencies to undermine the aca, quote, to the maximum extent permitted by law. Days later, they pulled the funding for out region advertising for the final days of 2017. Enrollment have reduced enrollment by half 1 Million People. You cut the number of days people could sign up for coverage by half. You spent tons meant for promoting the enrollment on a Public Relations campaign to undermine the law. Hhs changed its, making it more difficult to obtain coverage for open enrollment. You caught the Outreach Advertising budget by 90 , which resulted in as many as 100 fewer people gaining access to coverage. You ordered the Regional Directors to stop participating in open enrollment events. In 18 cities, including my hometown of chicago, you terminated contracts for in person assistance who guide applicant through the aca enrollment process and was designed to help them sign up for insurance, and those are now gone. You slashed funding for non profit navigators that helped people shop for better coverage and you stopped making cost sharing reduction payments to insurers. Even though it was warned that failure to make these payments would increase premiums by 20 and add nearly 200 billion dollars to the national debt. Time again, this administration, including you and President Trump himself have used inflammatory rhetoric to spread false floods and misinformation about the aca. Though you have slashed funding for aca enrollment outrage, you have certainly pushed taxpayer funds elsewhere, according to a press report. You personally approved the awarding of millions of dollars of federal contracts who polished your brand and travel with you throughout the country. This calls into question your stewardship of Critical Resources to give people coverage. Administrative administrative arena, it is your tenure thats focused on undermining the aca. Premiums will go down in 2020 but imagine how much more money americans could have saved if you were uplifting the ac and helping them get coverage. President trump has said that their only plan is to let obamacare fail. You have gone further than that. You are actually sabotaging the law. You have led the effort, administrator verma. You say we have heard for ten years now, actually since the passage of the aca that republicans want to repeal and replace the law, now youre telling us, if theres a Court Decision, very soon that overturns the Affordable Care act that you have a plan. Where is the plan . Do you have a plan that you can presented to us, or is this another high in the sky promise that, weve heard for many years . The chair recognizes the gentleman from texas for five minutes. Thank you for the recognition. Just a point. For 20 7 18, and involved 81,000 individuals. There was a group of 17 navigators that enrolled more than people, crossing the taxpayers 5000 dollars per enrollee. To contrast, the agents brokers are able to enroll people at a much more Cost Effective rate, before this before. Will the gentleman yield . No. Let me just ask you this. Which is the more Cost Effective way of enrolling people . Its a navigator agents and brokers . To answer that, agents and brokers. What we have found in the Navigator Program is that when we look at the numbers, we found that the Navigator Programs were not meeting their goals. That in fact, despite the spending, they were actually enrolling less than 1 of all the enrollments. When we did the math, sometimes we were spending 5000 dollars per person for these Navigator Programs. We felt there was a better way. They have demonstrated their advertising budget and even after that, enrollment went down. We saw for more Cost Effective way in all of our contracts, and we focused on finding new and Cost Effective way of enrolling people, like digital at, and those have been proven to be effective. Under our administration, premiums are lower, there are more choices, we have a 90 satisfaction right at our call center for open enrollment, which does not happen. It only happened under our tenure. Because of the changes weve been able to use those savings to lower the user fees. We found that before, and i hope to do it again. Thats an incredible figure about the call centers. And the implementation came up in october of 2013. I did not take the special deal, i went through health care that glove and that interaction took four months to actually accomplish, and was one of the most miserable experience at ever been through. So thank you for improving the Customer Experience at that end up people not caring about the politics, but just need the deliverable. It sounds like you are working hard on that. Thank you for your commitment. We will be working on the next version of the bill, over the next coming months and we really want to involve you and your office. Some of these fantastic therapies that are coming down, where a single shot can cure some significant diseases. We have to have a way of advertising that cost over a long period of time. We look forward to your help as the committee develops the cure, if no one can afford to take it. Let me just ask you this. On prior authorization, i made a lot of comments from my physician colleagues about this. What do you do to make your patience over paperwork. How are you trying to reduce this . Thats an issue that i hear a lot about from providers on the front line. We did a National Listening tour, and i will say that was one of the number one issues that physicians are complaining about. With could cost, as part of our patients over paperwork initiative, weve heard from both sides about as. I can tell you that i have a bunch of individuals that are working on how we can figure out how to ensure that we have three of our protections in place for integrity. We want to make sure that evidence based treatment is being provided. But the process can be burdensome, and can get in the way of providing care. We can create delays in. Care you can expect to see some action on that. Weve had a lot of discussion, on the issue of infant mortality. A good hearing the other day with david nelson, where i trained, talking about his experience. Are there any tools they do not have that will be helpful . This is something i started my career on. Working on the area. Weve had a conference on this issue, some of the things that were working on a streamlining eligibility. Working your time has expired. We now recognize the chair for five minutes. Thank you. I just want to pick up on the statement the questions you said about the administration to decision to ask the courts to strike down the aca. The republican lawsuit that is seeking to declare the entire aca invalid. Obviously, if the District Court ruling is upheld, this verma he will be responsible to the largest coverage loss in u. S. History. Over 20 million americans will lose their coverage, raising consumer costs and making lifesaving health care unaffordable. As i said in my opening, and everybody on the right said thats fine because we dont want the federal government to do anything, thats not what i hear from trump or my republican colleagues. They say they want to provide Health Insurance, even though they are sabotaging everything. I was not here but i want to know, that the president have a plan and what is the plan . It sounds like theres a secret plan that he doesnt want to reveal. Can you just tell us, what is the president plan. What is the plan . Im not going to get in any specifics of the, plan but i will say that the President Health care agenda has been an action for day one. Im not asking about that. I disagree that he has had a plan so far, other than to sabotage the aca. What im asking is, if the Court Strikes down the aca in this lawsuit, what happens then . What is he going to do next . What is his plan to deal with the reality that all these people will not have Health Insurance . We have planned for a number of different scenarios, but we need to hear from the courts. The president has made his commitment clear that he wants to make sure that people with preexisting conditions have protections are not giving me any details other than saying that he is going to give us something. I think that the gentleman, yield. In the court. The administration ask for the entire poll of Affordable Care act, they asked for the entire thing to be struck down. They didnt ask for the certain portions of the aca to be retained. This is my problem, and i want to move on. My problem is, again, at the administration, if the president is on us and said, look, i want to get rid of the acl, have anything, else i dont think people the federal government should be involved in health, care you on your own. If that youre ideology, i dont agree with, it but i understand that we are coming from. I think its so deceptive to suggest that somehow, were going to cover everyone, and were going to do Something Better but not give us anything, in your giving us anything. Let me go back to my other issue with that i mentioned before about not being responsive. In june i sent you letters suggesting, oh, im going back to the snow. You finalized the marketplace rule that changed the formula for aca subsidies, despite your own objections to the policy, and i appreciate your objections. In fact, an internal memorandum to secretaries are, dated august 2018, you wrote that, i quote, i recommend not moving forward with this policy and that it would cost coverage losses and market disruption. You cautioned that is the policies under consideration are adopted, and i quote, Exchange Enrollment would decline by 1. 1 million. You wrote that these could result by potentially in states with no subsidize covers available. My question is, do you still believe that this policy would likely result in families losing coverage . I think we have several policies in that memo. I am comfortable with the final rule on where we came out. And i think that the evidence is clear that premiums are lower. We have more choices available on the exchanges, so the actions that we have taken have resulted in americans having more choices about their health care, and lower premiums for the first time. I understand that. In june, i sent you in the secretary letters requesting the underlying analysis discussed in the memo and the analysis of those policies. Last week, i sent you and secretaries are followup letter reiterating my request. I requested a complete response to my letter by october 30th, but so far, as ive said, i received one half page respond to answers not of my questions. Not a single document. Your response has been unacceptable. Congress and the American People have a right to know what the analysis shows. Would you committed to providing those documents to my letter by october 30th . Cms hes a sub agency, were under hhs and all the documentation of requests are handled by hhs, so i would refer your question to the agency. Thats a really poor. Excuse youre chair has expired. We now recognizes mr. Mckinley for five minutes. Administrator, i think we are you an apology for the youve been treated here. I have i go home every weekend, and i talked to the people, West Virginia is a red state. I wasnt in the end of the weekend before, a red state. And i was in boston for meeting up there. And i heard the same thing from people on the street, when we will talk to the waitresses about whats going on in washington, and they talked about the tone, the accusatory languages, the lack of civility, and today, i think its hit a new point by this word sabotage. Its already been used for two times today, as if some involved in a dictionary theyve been wanting to use to stir up things. People are appalled by this, and they want us to work together, to accuse you in this administration the way they have, i apologize for that. Let me ask you a couple of questions, however. And that is, in West Virginia, inapp alaska, we are decimated with the Opioid Crisis. Were trying to find ways of can there be something we set up, so im going to weigh with the sand box you want to play and. What are the ways that we can provide additional funding for non opioid rehabilitation treatment, because we have the incentives offer using opioid, but what about some of the other not operate . Can you come back to when he put together your role theres, nothing about that theyre not popular treatment, and i hope that we can do that. Can we work together, administrator, on that . Sure, cms has worked with state Medicaid Programs and approved 26 state medicaid, with permit states to expand services for care for substitutes disorder and institutions for mental duties. And weve been working to implement all of the sections of the support act that relate to see a mess. In relation to your question, i will have our office of legislation reach out to you im not going to track this administrator, are going to trust the Previous Administration. We just have a difference of opinion, but we can talk to each other. What we asked under the Obama Administration was, where the rehabilitation for the medicaid, medicare agreement. 28 days, with they come up . But no one has ever gone back to us on that. So im curious, administrator, to have an opinion . This is a trick question. 28 days, its not enough for rehabilitation someone deep and drugs . At like to consult with our agency experts, and i will have our departments of legislation wouldnt you be suspicious . Weve had to deal with this pretty severely, where we have 52 deaths per 100,000 and West Virginia, which is leading the country on. Thats every Rehabilitation Center i go to asks me that question. Where did the 28 days come up with . Ive asset under the Previous Administration, and asking at now under can we consider a Pilot Project that maybe goes for 120 days, 480 days to find out . The impression i am getting under both administrations edwards looking for quantity of the people they treat, that quality. We put someone a treatment for 120 days, i think the outcome its going to be far better than 28 days. After you can get back to me on another time, is that fair to say . Thats fair to say. We will have our legislative focus reach out to you. Thanks for your question. I apologize for the way the pin treated in this committee so far. I yield back my time. Gentleman yields, back we recognize the gentleman for five. Minutes thank you for being. Here in arkansas, one of the 18,000 recipients lost coverage, after a requirement in that state. In New Hampshire, 17,000. Both states, youve suggested a large number were working or eligible for exemptions, but they lost coverage or would have lost coverage because of that tape. ,. . ,. ,. . It do not respond to the concerns of that . Community engagement requirements are about improving the lives of people can you point me to one study that says that a work requirement makes people healthier . One. Ive worked as a medicare problem maam, one. I asked secretaries are this question. There are many studies to talk about how employment has a positive impact on Health Excuse me, no. That is once again, secretaries, are asked this question to him eight months ago, he gave the exact same answer. You guys run Health Care Programs in this country. Im certain you understand the difference between correlation and causation. After people may work, work does not make people healthier. You are imposing policies on millions of people across the country, can you show me one study that shows that that is a good policy . I spoken to many people is that it . No none of those individuals im reclaiming my time maam. Lets talk about adrian mechanical, who lost his coverage because of the work, is medication is going to cross it has drawn, so we did the anyone widow left out of the pharmacy, its best to ignore preventable pain and suffering, he failed. He almost cost him to miss a few days of work, and he got fired. The work requirements causing to loosen the job, and its healthier. Do you consider that a success . I think its premature to draw the success premature for miss maralago . The program was in effect for ten months. What i will say, 80,000 people lost their health care, how many more people have to lose their health care before you can make a determination . Community engagement as halfway out of paris. Show me the data. She will be the day that list people out of poverty there are data is that show that when we look at a and looking at somebodys Health Status. Youre not going to spin me for the next five minutes. You talked about the financial aspects of health care, are you aware of how much kentucky is spending on its work requirements . A legend for you its 190 million dollars. You know if the per capita annual spending his . 2000 dollars. Those are the people they serve. Im reclaiming my time. He contract that was made for your pr and advanced services was here in this hearing. Are you aware that one of the items is for a confidant who was scheduled to receive 425,000 dollars . All of the contracts that we have at sea mass are based on promoting the promotion of cnn has and for two reasons one is to be require specialized expertise that we do not have. The expertise of the right but at that same cost its 2000 kids or 200 kids are eligible in four chip in kentucky what have those Better Health Care Communications person underneath within cms dozens not hundreds. Or have access to health care. What is a better solution of those taxpayer dollars . The use of our contract started to promote the programs in place. At the expense of those two undercuts . Those are consistent with the Previous Administration is done. Those contracts that we have in place are consistent with how the agency has use resources within the past. Theyre focused on promoting their work. One of the things they want to do. The chair now recognizes the gentleman for virginia for five minutes. The to finish your answer. Well as trying to say is that the contract we have in place or about promoting the work of the agency. One of the things that i wanted julie king to see at cms was that the American People understand the things that we are doing. We have a historic number of initiatives and 16 initiatives and support that the American People understand that we do not have expertise in house at the time. The other thing that these contractors are for is we have something that we cannot do inhouse. Thats one reason or we create some short term health. My job at the agency is to set the initiative and set the agenda and its up to other Staff Members to determine whether that work could be done in the house or need to hire contractors. In relationship to chip, wouldnt you agree that the healthy kids act was a major step forward . Absolutely it was. Its very important that the access very important to their development. Would you be surprised to learn that the other premiers of this committee and particular those on the other side of the aisle . That would be very concerning. I understand. Also i, find it interesting that im cleaning up some stuff here. They have remained a 2. 6 million more people are employing from the insurance today then before President Trump took office. Are you aware of that . Yes, i think our agencys success and the success of the administration that their premiums are lower without exchanges and without medicare. There are more choices for people in medicare and the exchanges more than what we have been came into office with. Weve heard a lot today about sabotage and the gentleman from West Virginia, mr. Mckinley talking about the fact that sabotage has been used and that as colleagues on the other side of the aisle that when you grind a bill such as obamacare, and you compare 3033 times the words of the secretary appears, 974 times the words the, secretary shall appear and off the top of his head, doctor bridges indicated that 162 times that they kept going out and shall determine the secretary shall determine and will have to double check that because i sent off the top of his head. Wouldnt you think it would be unfair to say that the law had been sabotaged and the congress that was passed specifically by democrats and no one in the house voted for it. If it was sabotaged, if it was sabotage because of a huge powered to the branch of government they would find themselves within the Administrative Branch of government for a difficult possible outcome if there was sabotaged it was sabotage and its initiation into the passage of that bill. Would you agree with me on that . I agree, and the results speak for themselves. Results are that premiums are lower. Premature going up, hundred percent in some cases, some 200 in some cases. This is for the first time that weve actually seen premiums go down. They went out last year. Theyre going down again. We put out over 12 reassurance waivers and, in some cases, using double digit increases. 30 . For all the work that we are doing, or dont know how we measure that, but to me that looks like success. Yes maam. Now, lets get to Something Else i need to talk about. Earlier this year, it came to my attention thats the plan to include ventilators and the competitive acquisition plan. In june, we let it later expressing concern about that decision. I support the goal of Insurance Financial responsibility in health care, but im not convinced that this method is appropriate in every situation. Until we know that access to the critical piece of equipment will not be compromise, and i think we should be making fundamental changes. I just got your letter, arrived late yesterday afternoon in response to that letter, where you said were not going to do it on invasive, but heres the problem i have. I have a rural district, as does my friend mr. Wells. What happens is that, if you go to this cost only issue, in those rural areas, were going to make somebody drive for five minutes to an hour, i remember talking to one of my suppliers were lady lived on top of one of the two highest peaks in virginia and he took her oxygen up there to her and make sure that she had what she needed to her ventilator surprise. Noninvasive. Shes not coming down the mountain, politically not in the wintertime to get what she needs if not a low cost suppliers only located in the town, and if it becomes a point where they have to get to bristol, youre talking about even more time. Just to get down the mountain. Its going to take a lot of time. I would ask you all to really take a look at that because im afraid that, enable district, our folks are not going to get served. Time has expired. The chair recognizes the woman from california, mysteries for five minutes. This administration has made clear that they will not protect people with preexisting conditions, or protect access to Affordable Health care for americans. They continue to repeal the aca, first through legislation, and when that failed, through the courts. In lieu of complete repeal, theyve done everything they can to chip away at the protections that it provides. Repealing the protections harms patients, but helped Insurance Companies to make greater profits. It gives him powers to deny and delay care for people who really need it. As a physician, i took an oath to do no harm and trying to take affordable coverage away from millions of americans flies in the face of that oath. I practiced medicine before the passage of the Affordable Care act, and i saw what that meant for patients. Let me tell you a little bit about what that was like. In fact, even when i was in medical school, during my medical School Graduation at harvard medical school, my whole family, i have a big family, they came from everywhere, and we were in my tiny little apartment we were getting ready for my ceremony, and my little sister crossover in excruciating pain, shaking, we were so very concerned that she refused to go to the Emergency Department. It wasnt because she was going to miss my graduation, shouldnt want to be a burden to us for that, but primarily should not have Health Insurance. She cannot afford it. She was so afraid, so chic this endured it. Thats what families do throughout our country. They endure this pain. She was 22. Now she could have been on her parents Health Insurance. The second story is, a man, 55 years old from palm springs with hiv positive status. Before the Affordable Care act, infections, after infections, life threatening, very concerned. He was not going to live past 58 or something, and now because of the Medicaid Expansion, hes happy, hes living well, he finally can get the care and the medications and everything that he can have, and he is living the life that hes always wanted. Its like that young mother of two who came into my Emergency Department with the chief symptom of a lump in my breath, and im thinking, a lump in your breast . Why you coming during the holidays for a lump in your breast. She didnt have any primary care. Shouldnt have insurance. She knew it was growing, it was the size of eliminated, irregular inform, was painless. Her sister forced her because they knew what they were afraid of. And sure enough, it was mostly cancer. I was able to connect with post Emergency Department care. And because of the Affordable Care act, that preventative mammogram is now coverage. A nasty potentially had cancer metastasize through her body. Thats what we are angry. Its for those patients that we are standing up. Its for the American People who are scared that we are going to go back to a time when they are going to be denied and delayed, that theyre going to endure pain, that theyre going to potentially lose their lives and leave their children behind, that theyre going to sell for infections and thats why we are pressing you and this administration for those questions. Because, this administration is encouraging the Supreme Court to strike down the aca in its entirety. All of it. There is no defensive court to protect people with preexisting conditions. There is no defence in court for the young people to stay on their parents Health Insurance, theres no defence of the Medicaid Expansion, theres no defence of protection or prevented of care that helped my constituents, my patients and my family. There is no defence for the American People in those protections for them. And to make matters worse, you have no plan. You cant produce a document, you cant give us a detail. Youre skirting the issues and all were getting is only spin and talking points. The American People deserve better and i yield back my time. I now recognize the young lady from indiana for five minutes. Thank you and thank you for being here today. The stories that you have heard from my colleagues i assume in the role for the last three years youve mentioned that you have been having a roundtable discussion and that wasnt what i originally was going to ask you. I want to save a little time for it with you. Can you share very briefly how you do stay connected with patience and people you are trying to serve . I appreciate that. Weve done a National Listening tour and talk to people all over the nation. Can you share who these people are . The type of people you talk to. In the examples that were used previously, im scared for those people to because they dont have a subsistent they often cannot afford Health Insurance under obama care. Obamacare structure is so expensive, for the middle class that they cant afford Health Insurance. Thats why were seeing increases in the number of shores. Premiums have gone up and this is stabilize the market and they are going down. They are still too expensive and they do not have a subsidy f you do have a preexisting condition, you do not have protections today and this is why this administration is trying to advance efforts in that every american has access to affordable coverage. Thank you i want to pivot and focus of over the role of technology and the Health Care System. Medical error is the third leading cause of death and the United States and responsible for claiming over 400,000 lives and millions of dollars are wasted on tests and procedures. We know that patients are up to date with medical information at their fingertips. A colleague of mine across the aisle introduce the medical health care record act and a directed to cms secure records by cms through the blue button two point oh program. Propose cms around virility impatient pooled to be published before the end of the year, requiring medical care plans first to offer their planned rolling through access for data and their mobile application of choice that you mentioned for more and more patients enter text abby and want this type of access. I remain concerned about the promotion or awareness of the cms Blue Button Program thats been approved it with apps for the beneficiaries. The recent survey so that 100 Medicare Advantage members are familiar that the blue button with the program is knowing how important this is, what more can be done to reach these roles . Its complicated to get through your websites and process to find the blue button. And yet, people want to have their medical records in their hands. Can you talk to us about what your plans are to improve access to our own medical records . I appreciate the question. I agree with you, that we can do more to make sure that they understand whats available. The issue of patient records and if youll indulge me for a second a tell you a story will give you a sense of the issue of patient access. Anyone who is traveling and they were headed home and heading to d. C. , when my husband had a cardiac of it and had major seizure. My daughter called me on the phone to the paramedics and they said youre husband is not breathing and we need to understand his health history, is there anything in the south history. How long ago was this . About two years ago, in 2017. So, at that time, obviously im in a panic but i did not have that information. My family didnt have that information. My husband was in no condition to tell us about his health and i scrambled for about two hours and the time that it took me to get my kids and to get by husband to try to find this information. In the end, the hospital had to do a number of tests as they couldnt figure out what was wrong. Luckily, he is okay and he survived something that less than 1 of people survive. Hes very lucky but what i left the hospital, i asked the staff there, could i have a copy of all the tests that you performed so i have a complete medical record to get back to his doctors in indiana. Unfortunately, all they can give me it was a cd rahm. After our federal government spent 36 billion dollars on Electronic Health records all i got was a cd rome which only had a record of one test. That really spoke to me about the issues that patient veto have access to their complete medical records and they need to understand the issues a place. Can i interrupt. Are you going to dedicate more people to this to fix this . This is one of our main priorities. We have several roles to make sure ensures or providing point state education and we are giving incentive payments to physicians to make sure theyre providing data to their patients. The chair now recognizes the gentleman from New Hampshire for five minutes. Thank you for being here today. A quick yes or no question before we start. I understand yesterday secretary castor said the reason that hes not concerned about the Court Decision ending the aca overnight is that he is rely or on an appeal to the Supreme Court, is that your position . Is that why you dont want to have the plan tell us that today . We have a number of different scenarios. Are you expecting what the secretary speaking to his eyes going to take some time for the court to resolve and we have planned for a variety of different scenarios. Including an appeal to the Supreme Court . Correct. I am confused today by her testimony. Particularly by the testimony of our colleagues. Ive been in congress for seven years, i voted 55 times not to repeal the Affordable Care act. Because our college were so persistent about week after week and month after month of going over and over again to repeal the Affordable Care act in its entirety. Now, this administration is in court asking to repeal the Affordable Care act in its entirety and you sit here today singing the praises of the Affordable Care act and ill proud you are of your work to bring down the rates. At the same time, youre cutting access for 400,000 children that had their testimony heard the sport. I want to move to a particular important part of my constituents. Which is the issue of preexisting conditions and youll recall before the Affordable Care act america this could be to die their Health Insurance coverage if they had any kind of preexisting conditions. Think about it with my family ill start with the beginning of the alphabet. Asthma, allergies, all simmers, cancer, diabetes. The list goes audit ought. In fact, over 50 of americans have a deniable condition. And New Hampshire, thats 54 of our citizens which have a deniable condition. And yet, your administration and in fact your own actions with the short term limit Duration Health plans by the way, a classic rushing to d. C. Short term limited Duration Health plans. They have threatened families with preexisting conditions and in fact, youve encouraged stage to promote plans through their waivers in order to sister circumvent dispels benefits and protections for preexisting conditions. I was very proud to lead Bipartisan Legislation and passed the house protecting americans with preexisting conditions. Last may and it will ensure that people with preexisting conditions are covered. But let me ask you, do you believe that allowing individuals to be discriminated against or after coverage declined to preexisting conditions as moving america in the right direction for their health care . Yes or no . None of the actions we have taken do anything to undermine the protection. Encouraging junk plans that do not cover americans with preexisting conditions. We heard the testimony right here. We had families right in front of us and they had no idea and there is no requirement that they be warned of that and in the next three months and within the year there could be reupped multiple times. Your testimony is not actually truthful to us today. I regret that. According to a 2019 study by the Kaiser Family foundation. Half of america and, as i mentioned, have a declined condition. Did your agency conducted analysis to evaluate the effects of the implementation . Of your guidance of these families and access to the Affordable Health insurance . Yes or no . Which guidance referring to . The guidance that you provided about the junk health plans. Did you analyze the impact on American Families that had preexisting conditions . Yes or no . On the issue of the 13 32 guidance that we had with states. I can tell you they had an enormously difficult time. Quick question. A double digit rate increase did you analyze what would happen to families with preexisting conditions, yes or no . The way the guidelines work is that we give direction to states about how they can develop plants. Im asking if your office analyzed the impact of your guidance, yes or no . We would have to review the proposals. Can you provide that to this committee . Youre analysis . Every proposal that comes in under 13 32 is analyzed around the guardrails around congress. Could you provide that analysis to this committee and my time is up . Yes or no . Yes or no . Will you provide that analysis to this committee . The chair now recognizes the gentleman from South Carolina mr. Duncan for five minutes. Thank you madam chairman. I verma will let you at finish the question. Let me start with our limited duration plans. These were open before obamacare started over three months and we extended the period of time. We also make sure when we strengthen these protections which are not in place under the Previous Administration that they no longer understood what kind of plan and what will the limitations war with these plants. There are so many plans that cant afford coverage under obamacare and under 200 . I gave you some examples of a couple in nebraska theyre, 55 years old, the premiums they would have to pay are anywhere between a third to half of their income. Short Term Limited Duration plans are lifelines and provide coverage at rates that are perhaps 60 lower than what they could find under obama care. It provides an alternative and many people are in between jobs that cannot afford obamacare and this is his and this is an alternative. This is what we are doing to ensure that protection is in place and that they are clearly articulating a limitations of what they may not cover. Thank you for that i apologize for some of my colleagues of troop the way theyve treated you today. We had multiple conversations regarding these issues and the process in this region. The topics include inconsistency and military penalties incitations and facilities urging forward and especially hit. We touched on the need for a specific data to be provided for abuse reporting roles. Another thing out appreciate you looking into is the red consumer alert icon that could be placed next and Nursing Homes. Theres incidents of abuse and that compare website. This initiative goes but cms needs to fully solve the reporting issues before we go negatively, these facilities online and in the Southeast Region will go in a tight spot. Can you in your staff please comment or commit to revisiting the issue of this icon being implemented . We had this strategy in strengthening the oversight and the enforcement and increasing transparency inequality over one of the things that weve done is help clarify the jeopardy guidelines. I agree with you, theres been inconsistency and house ems and state agencies up implemented the guidance. That is why we have created a new performance standard system so we can monitor what is going on in the local level to ensure that we have consistency and how we are clarifying the immediate jeopardy in cases of abuse and neglect. In terms of the icon, there is about 85 of Nursing Homes that have been captive by this and only alerts those that weve had cases of neglect and if theres other types of issues that have come up there is a high level of areas of abuse but those areas we only use the icon in a repeat offender. This impacts many Nursing Homes and Nursing Homes that provide a high quality care and there are some out there that think its important to say that the American People have the information they need to make decisions that work best for them. Well be watching some of how they impact the office facilities. I want to touch base on mueller thing and thats the Exchange Program and section 13 oh three of the Affordable Care act. Weve talked yesterday about the issues and the ruling of the finalization that supposed to be and hhs his hands. Roaming begins november 1st let me get clarification on this, work and many of our colleagues designed this asking for secretary azar to prove that. I want to submit that if we can into the record and i also want to urge my colleagues in another matter today if you like to sign on to that they are urging. Without objection, the letter will be put in. I want to add a letter from the care providers that have urged this to take action as well for the record. Will review that letter. Its important that this role get finalized. It was proposed november of 2018 and thats almost a year later. Can you speak to the work that cms as not been in this role. I know its in azars hands but in the next ten seconds . We share your commitment to get that finalized. We will be doing everything we can to bring that to fruition. If any colleagues want to sign off of that letter secretary azar by closing business in the contest and i yield back. The chair will admit the second letter thats been referenced. We now recognize miss castor in florida for five minutes. Thank you. The Trump Administration is me numerous policy changes that increase the cost on families across this country. Increase Health Insurance premiums and erode coverage for preexisting conditions. Preexisting conditions like cancer and diabetes. We all help but this fight was over but will continue to have to work to make sure that families who have preexisting conditions get their coverage. You stated earlier in your testimony that the Trump Administration policy has stabilized costs. There is no evidence of that. I recent study by the five Family Foundation estimates that 2019 premiums are 16 higher than the otherwise would be due to the Trump Administrations actions. The court under your own agency has established the various sabotage policy of the Affordable Care act as increased based on families who are not up for tax credits. One of the most egregious policies that is increased cost is the expansion of the Health Insurance plan. The Short Limited Duration plant. What has happened after the Trump Administration and the gop who failed to repeal the Affordable Care act and dramatically cut Health Services under medicaid be turned to the very insidious plan to put it outreach enrollment. Week in the Health Insurance pool by eliminating those and allowing those junk insurance plans to roll out to the detriment of families that we represent. Those plans do not have to cover preexisting conditions and go under hospital and dont have to carry prescription drugs and when secretary azar was here, madam administrator, we asked him specifically are you aware that these plans can exclude coverage and decline would offer coverage to individuals with preexisting conditions, yes or no and he responded yes, thats correct. Do you agree with those insurance plans dont have to cover preexisting conditions. Those plans provide more ups flexibility. Are you saying you agree then that they dont have to cover preexisting conditions. This is very dangerous. Were about to enter in another enrollment period. Under the Affordable Care backed and the dates start november 1st. Run through . December 18th. So, be careful consumers and families across the country. If you go online any type in im looking and shopping for Health Insurance, sometimes what will come up will be one of those jump insurance plants. The federal trade commission is already had to act and shut down some of these fly by night Health Insurers calling the bait and switch scheme. When youre shopping for your Health Insurance and be careful. A lot of these companies are going to market a plan that says we will cover you, will cover your preexisting condition and find out is not covered. In fact, the congressional budget is in the report that short term plans have large coverage gaps can expose consumers to catastrophic costs. Especially for folks with preexisting conditions. For example, i will get that involved in a plaid that was diagnosed with Breast Cancer which face between 40 what douse it at 111,000 dollars it out of pocket costs. Thats from the cbo. One of the other affects has been to current navigators across the country. Theres a lot of information coming out that navigators are in fact if you go to the Family Foundation and the Government Accountability Office Report from the past few months. They will say, hhs is peddling false information and these navigators are brokers and foreign but navigators to not have allegiance to insurance and they have enough to consumer. They will often help go through all their affordable option and so its really unwise to a live in a navigators at bark it youre owed plants and cut outreach and all these things undermining the Health Insurance goal for families. I chair now recognizes the Ranking Member walden from oregon. Thank you for being here. We appreciate your leadership in the agency and through these discussions. I wanna talk about the navigators because in the cms report from 2016 which is before the Trump Administration, for 2017 they received 62. 45 per million a federal grants and 21 individuals which i understand that right equates to 767 dollars per person which is the math if you dont buy the total number and rolled forces the total amount spent. According to cms and the Obama Administration, 17 navigators with 100 and people each cost of 5000 dollars per and 78 failed to achieve their aroma nichols. This is from the cms information that is from 2016. Where when did you become administrators . March 2017. In 2017, cms and now that it would start working for navigators based on their ability to meet their own goals. That sounds like pretty standard practice. We have a duty to taxpayers make sure our programs are costeffective. As a result, sea ms reduced the program by 10 million from 39 organizations in 2018 on. Why do that . We did that because the Navigator Program was not producing the types of results we wouldve expected to see. My goal is to make sure that consumers using health care doug of im call centers have a great is koreans. We felt that we won a program is new it requires a lot of investment in terms of outreach. Without looking at the Affordable Care act and they are reviewing the types of investment they are made. You see from the Previous Administration that they doubled their advertising budget to 100 million dollars. It actually went down so you knew those types of things were ineffective. The same thing with the Navigator Program, when we did the math didnt add up and it was 5000 dollars per person. What we try to do was a vested most Cost Effective ways and more of those types of things. I think our results have been effective and we had 90 of Customer Satisfaction for people that use their call centers. Weve seen the dire predictions of that going down. We had minor fluctuation which i think could be attributed to the trump economy and things are moving so good that people dont necessarily let me ask you that. Im sorry to interrupt you but on the very point, how many more people are not covered by private insurance is the result of this economy . Because of the Strong Economy overseeing is that people are relying on program this much. We are seeing some of the individuals that are subsidized and theyre having trouble affording Health Insurance. That the increase and the number of uninsured years are actually closer to 300 and 400 above the Poverty Level. That that shows us that they cant afford Health Insurance premiums because of the way obamacare was structured. People that are subsidized were saying there movement go up at the other population overseeing problems. This is kind of the middle class. Not clean subsidy that cant afford alvin showrooms that they are stuck with. Youre trying to give off and statements. My states ive gotten away from certain political acquired its. Short Term Limited Duration plants and association plans. Those are efforts at the administration to give you alternatives because we know the middle class cannot afford expensive obamacare. Were trying to provide more choices. We let the American People decide what benefit plan is going to work best for them, not a one size fits all government probe which is expensive. We take americans should make those decisions. We had a debate on the floor on these issues and a number of my friends on the other side of the idle said he was directing the navigators to a whole bunch of things which went out to rural areas. I think we followed up with a letter recently, that told me that the system is broken with the navigators. They would have amendments go to all of these different things. Is that system important . I also think, if you look at open enrollment for the Medicare Program every year and what we do its a system of volunteers. Are there agencies for medicare . We use our ship volunteers. They do it incredible job of getting people through the enrollment process and theres better ways and more Cost Effective ways. My time is expired thank you chair. They now recognize lady from new york miss clark for five minutes. Thank you madam chair. I think our Ranking Member for the administrator verma Hubert Humphrey said quote, the test of Government Law is how they treat those out are in the dawn of light, to children. This is even inscribed of all that went through the front door of hhs. On their watch, its safe to say that this administration has failed that moral test. This administration inherited historically low rates among children. But banks to this administration sabotage the health care, those rates have gone up from 3. 6 million uninsured in 2016 to 4. 3 million uninsured children in 2018. Youve said that you want to preserve medicaid for those who truly need it. Our low income children among those which need medicaid . This is a yes or no question . As a mom of two children. I think having Health Insurance is very needed for their development. The New York Times is reporting that since 2017, more than 1 million children have lost coverage in medicaid and chip. The Census Bureau on you watch and the childrens rate increase to 5. 5 and largely because the deadline in coverage of the medicaid and chip. They agree with the five news of the administration own Census Bureau, that yes or no . Yes or no. Its not a yes or no question. You either agree with the census or you dont. Do you agree with . It i believe it is accurate. You previously claim that the children who lost medicaid have transitioned into private coverage. But if that were true wed see an increase in the Inter Private coverage. However their own peril says that thats not the case and there has been no increase and the number of children covered under the private insurance. Administrator vermont can you explain why the rates of children and road in medicaid are going up by coverage is also been flat. If you look at the inter children which are continually concerned about and the biggest draw as her family earning above 14 of the Poverty Level. Whats happening is that under the trump economy its the best thing weve had 50 years. I dont want to hear youre talking points. The New York Times talked about the consensus thing which the family didnt know that he had been kicked off medicaid for a respiratory virus. They have the number of children with more frequent fellow biloxi checks to any state. Data shows if the 50,000 children in texas were kicked off medicaid, more than half regained their coverage in the 12 months. Which means, these children were dropped erroneously. In tennessee, tens of thousands of children lost coverage because of incomplete work. Until recently, tennessee used an application that could be to 47 pages slog that medicaid expert called daunting. I administrator burma, the Program Technology is it apart but would you agree, the Program Integrity requirement should not be weaponized to kick children off of medicaid . Yes or no . I think its important that children have coverage first of all. In terms of Program Integrity, unfortunately, were seeing that there are major problems and medicaid eligibility. Were hearing cases all the time. I understand your concern. But there should be far more concerned about the decline or the increase in the number of children. Who are uninsured. You talk about being a parent, what about low income children across this nation thats a responsibility you want to preserve medicaid million children have lost medicaid that it had years and the numbers dont lie and they are clearly going in the wrong direction and you have cleared the most vulnerable ones among them. You have failed the American People and with that madam chair i yield back. We inaudible now recognize the gentleman from york mister tonko for five minutes. Thank you madam chair. Administrator verma, cms has provided the availability of short Term Limited Duration insurance plans that are not required to comply with the comprehensive consumers of the Affordable Care act. These plants under the protection with preexisting conditions increased costs and leave American Families with less financial protection and more exposure. I want to follow up with representative castor. Isnt it true that these plans are allowed to exclude coverage for preexisting conditions . Short Term Limited Duration. Yes or no. It depends on the plan. It depends on the plan. Is it true they are about to exclude coverage, yes or no . Limited duration plans are more flexibility. I have five minutes. There are different types. Im asking if these plans are allowed to exclude. Limited duration have the flexibility. It is a yes. It depends on how theyre structured. Not all of the plans will do that. Are they allowed to . Youre not answering the question. They have the appropriate protections in place. Youre eating up the clock. Im asking you if theyre allowed for preexisting conditions . They have flexibility around. I believe thats a yes answer. Administrator verma is, a true that people on these plans could be charged higher premiums based on their Health Status . Gender . Age . Cbo said that it could be 60 lower than the Affordable Care act. Can they charge higher premiums without limit based on their Health Status . They have the flexibility. Thats a yes. Thats why the prices there. I dont use any more time. With the charging of more based on their Health Status. Are you concerned about the failure of these services. Administrator burma is a true that plans cant refuse to cover essential Health Benefits like hospitalisation . Which currently care . Prescription drugs and Mental Health care and prevented of care . Yes or no . I was talking to a family. Yes or no. Yes or no its my time . Is it true that these reviews with the benefits. Their different plans are offered under short Term Limited Duration. Again, the question is that can they refused to cover essential Health Benefits . They have the flexibility. Yes they, have flexibility. These plans by color some of the benefits. Im concerned of what might happen should people get sick or have this plan. Verma isnt it true that these cant impose lifetime an annual limits on coverage if they are not subject to cost during these limits . If there are more affordable options available under obama care people would not have to make compromises. Unfortunately, premiums have gone up so much. Please, im asking for a yes or no. Isnt it true that these plans can impose lifetime annual limits on coverage . Yes they can. Okay, thank you for the s. These plants seem to have very little use with health care or dont want to be one sickness away from bankruptcy. That is why the aca was passed to. Make sure people had comprehensive coverage who were not one illness away from bankruptcy. Administrator verma, what people with these people supposed to do when they make Vital Health Care service which are not covered . What do they do and they have such their income on their premiums. Another ten to 12,000 dollars on the high deductibles and what the administration is trying to do is to provide choices where there are any and theyre forced to pay half of their income or third other income on premium and a deductible they cant afford Health Insurance in the short Term Duration plans which give them a different option. Its better than having no insurance at all in the absence of no solution. Under affordable premiums need to be something for people. I believe that these to cystics will be able to afford something with these subsidies to provide an encouraging statistic. I would ask that you put Children First and with that i yield back. The time is expired. They now have the lady from Washington State Cathy Mcmorris rodgers. Thank you madam chair. I give the administrator a chance that he didnt get the answer the last question since you are being cut off repeatedly. Thank you i appreciate that. First of all, obamacare as become affordable for so many families. Through the middle class they cant afford the premiums and theyre not getting a subsidy they have no archie native. Short Term Limited Duration plans provide an alternative. I was talking to a family where the husband lost his job and to kids in high school and they could not afford they couldnt afford premiums under obama care. They looked at the short Term Limited Duration plan and met their coverage needs and review the benefits that was not going to work for their family. They were able to provide this plan and they could be 60 lower than whats on the exchanges. They gave them an alternative and they did not need it for a long period of time. Its important that we get alternatives and acts as a solution and were trying to do something for the American People for, the middle class americans i cant afford obamacare. I want to say thank you for your leadership i, want to thank you for your commitment for making sure that we keep the promise especially for those of medicare and our seniors that are dependent upon the medicare. For those on medicaid and some of the most vulnerable in our country. I want to say thanks for the work that youre doing and i want to applaud the work that youre doing to ensure that we continue to lead the world and innovation and thinking about how we ensure that we have a Health Care System that is going to provide access and quality at an affordable price for everyone. The flexibility is so important and theyre offering of plans is so important and these individuals and what they need. Medicare and medicaid are critical safety nets and we must keep fulfill the promise that we have made to those that are dependent upon medicare medicaid. I am committed to making sure that those with preexisting conditions have the confidence and the certainty that they will always have quality access to Affordable Health care. A son with special needs, disabilities and to dub during the debate of obamacare, i was concerned about the impact it was going to have on those with disabilities within medicaid. According to the Kaiser Family foundation, they have reported that more than 450,000 individuals with Development Disabilities are on a waiting list today for medicaid. In this country, 450,000 individuals with disabilities. When during the debate when i said i was concerned about people with disabilities being put on a wade list for medicaid i was laughed at. Today, in Washington State, 15,000 individuals with disabilities are on the waiting list. This is Washington State which expanded medicaid to the furthest degree possible. We have hundreds and thousands of people with disabilities are waiting for care. I cochair the world Health Coalition and visited hospitals and Health Care Facilities all throughout my district in eastern washington. Its heartbreaking when i hear from providers that are having trouble keeping their doors open because of the low reimbursement rates and the high population of medicare and medicaid. Washington tate as the highest level of a thundered 30 of the Poverty Level are covered under medicaid. The threshold is even higher for children in 210 of the federal poverty line. We need to make sure we are protecting the current beneficiaries because they need to have that certainty. I want to ask you, can you talk to me about what youre trying to track those that are on the waiting list . How do you ensure that the populations for the most vulnerable in our communities are actually getting the care that we have promised to them . I share your commitment to the vulnerable population of the Medicaid Program. Any of these individuals have no place to turn and medicare is the safety net that is so critical to improving their lives and the quality of care and their day to day lives. One of the things that is very concerned about this program and integrity within the Medicaid Program is were seeing some alarming data that is showing these states are necessarily putting the right people on the program. We have some high cases and problematic eligibility systems that are putting people that dont belong. We will be taking action to make sure that we can ensure that the people in the Program Actually are part of the program. If we dont do that were failing. The chair now recognizes the chain chair lady from dare delaware. Thank you administrator verma for coming today. It is critically important because cms is tact with overseeing the implementation of the Affordable Care act and the labor of law and thousands of delaware eons as millions of americans to be protected and not be denied coverage based on a preexisting condition. They are removed from their Parents Health plan at the age of 26. Just to name a few. One of the significant reasons they came to congress was to protect because i know it cave hope to so many people. Particularly people with preexisting conditions. Unfortunately, delaware is and rolling in the changes to travel from 2016. I was not a surprise when you factor in the administrations decision to number one shorten significantly the enrollment period. Number two cut the Navigator Program by 84 causing many people to be confused and not have the help and support they need to navigate which sometimes it is incredibly difficult system for anybody in the private or public sector. Three, cut outreach floods by a lot while big 90 . A program that doesnt have the long devotee of a medicare or the name recognition. With less time to apply, fewer resources to do it you can understand why people believe that this action is a deliberate attempt to unilaterally repeal the aca. Administrator verma, after cutting the federal funding in the enrollment in Health Care Dog of you reported as saying that this decision affects cms commit to exchanges to their most Cost Effective use and better support of consumers through the enrollment process. Id like to focus on to parts of your statement, one supported consumers during the enrollment process and secondly the Cost Effectiveness. According to the former senior adviser, who previously oversaw the aca program. The outreach and part Marketing Programs i had been dramatically scaled back and they were costeffective. Ive been informed there is data on how federal dollars should be effective in order to reach americans with house insurance. Specifically a july 2018 Government Accountability Office Report on hhs outreach enrollment efforts in the individual marketplace. Sites and hhs study from the most effective forms of advertising for midterm enrollees. In march, along with 29 of my colleagues on this committee reached for the study because we wanted to really fully understand and get to the bottom of what the aca marketplace Outreach Strategies were actually working. After a followup we received a letter and wrote another letter and received a letter back which unfortunately did not give us a direct answer. I laugh unanimous consent to submit records. Objection ordered. Who is straighter verma, my colleagues want to understand how cms can most effectively help our constituents and role in the aca compliant Health Coverage. This one really is a yes or no question. Will you commit to releasing any of all documents with this data created from 2016 on related from Market Outreach efforts for the Affordable Care act . So that we on the committee and particularly in our oversight role can have the information and understand that rationale, yes or no . All document requests are headed by health and Human Services so i would refer you requests to the department. The letter that we set was sent to the department . It would be great to also have your commitment. Im assuming you had to make decisions so therefore you had that information or and you made that decision so itll be great to have that information so you can have these decisions again which will support the turning over of that information. All document requests are made by the health and services i refer youre quest. I have my ten seconds left. I will just say for, many years ive got to serve just like you and deputy secretary of health and social services state. Its important that people have confidence and faith in these institutions. The way we answer questions exhibits that confidence and faith. Just answer the questions, just work with us. We all want to see people the time has expired. Will now go to mr. Bucshon for five minutes. Thank you for the work youve done here at cms. Its a Difficult Agency to lead as i would imagine but i want to thank you for a recent proposal as a longterm advocate from the stark law and the proposed real reform. And the regulatory structure with the Service Model and the care and coordinated care with these positions and provide more efficient care for other patients. They will move to a value based carried bottles the law will remove the regulators that hold positions from entering into coordinated payment models and will lead to Better Outcomes to patients. Id like to bring the provisions of the proposed rule by cms. There are concerns as you know, the proposed rule will Place Authority in the hands of cms staff. The same medicare rates for devices that will expand disparity between the medicare reimbursement and the availability and the devices from the beneficiaries. In particular, to think the developer of a free medical device with the family robust sales and the medicare market will review the regulations and the calculation with reasonable uncertainty that might be set by medicare. One of the things we try to do and around keep will provide more transparency and will understand what they will face in terms of coverage decisions and also reimbursements. We tried to propose some regulations i will give more flexibility so we can look at the private market pouring in and what they may expect to be reimbursed and the private market is part of our decisionmaking. I appreciate that. Do you think that in this space the medicare feet would be on the medicare price . It depends on the particular product. Our goal with equipment is to ensure that our beneficiaries have access to the equipment and that we have the committed competitive environment. Thank you very much. I appreciate your consideration on these issues as you work towards getting to that rule. Its a little bit in the weeds but important on the issue as it relates to Medicare Beneficiaries and the other medical problems within the correlation. As you know, we are required to keep these patients in a safe treating range and the concern is, that this years proposal includes a 20 reduction and the international nation which is a test of anti regulation and thats being reduced for about 20 and being reduced for the third year in a row. Id like to ask if we can hit the pause button and reconsider that freezing the reimbursement will figure out whats a sustainable path forward. That will help ensure the Medicare Beneficiaries will take care of what they need. I hope we can take a look at that and revisit that. Finally, i want to thank you for your letter that your office said in response the bipartisan letter. On september 27th with regarding the see why 20 position fee and the schedule proposed rule with concerns of the agency and the payment of adjustment to the evaluation manager and the component of global clothes even though the agency proposed an update that they value for standing alone office visits. Asked the agency work to finalize the rule and i appreciate your ongoing employment and collaboration on that issue. I have 48 seconds left and Everything Else that you feel like you have unable to say during the hearing that you might want to some tell the American People and how they works. I appreciate the opportunity to be able to answer some of the questions that have been proposal we are not time. I have the numbers on the people in medicaid that have declined their as what were seeing on the shore. We look at the Medicaid Program and its natural to see fluctuation and enrollment. As the economy does better, we can expect to see lower it roman and we see that in the Clinton Administration and the report on this as well and because were in a booming trump economy with the lower unemployment and were going to see that impact with the Medicaid Program. This abyss tracey it is committed to addressing children and making sure all kids of access to coverage. Ill be submitting other questions for the record i yield back. We now recognize the chair from carolina mr. Cardenas. Its such an approach important program. One of the games under the Affordable Care act was the increase coverage of the Medicaid Expansion. 12 Million People gained coverage for essential Health Care Services thanks to this expansion. It continues to be one of the most Important Health care in this country. Studies of made clear, that they have greatly benefited americans who gained coverage for the Census Bureau and the ucla and Medicaid Expansion is substantially reduced among those who stood to benefit the most. They estimated that due to the Medicaid Expansion in the states, there were over 19,000 fewer american deaths in the first four years alone and the failure of other states to not expand medicaid resulted in an estimated 15,000 additional american deaths over the same period. Demonstrator verma, were you aware of that particular research . Im aware of it. Thank you. Other studies show the Affordable Care as well as inaudible in the midst of the Opioid Crisis its increased access to medication thats insisted of treatment for opioid addiction. My question to you administrator verma, is a true Substance Abuse in this treatment is a top Health Priority for hhs . I believe it is yes. Thats good to hear. In fact, hhs a stated that the number one strategy to combat the crisis is access, better prevention, treatment and recovery services. As we know, medicaid as one in trickle for increasing that access to those services and expand those states. The american back field as quote medicaid is in the front reliance that provides more confidence of Substance Abuse in the commercial and there might be opportunities to extend medicaid successes and expand medicaid which will help even more patience. Do you agree that the they provide comprehensive care for americans and expanding medicaid will help warm American People suffering from addiction . A couple of things. The Medicaid Program, cms as peru 26 states and how many states in the union . 50 states in the union. Just over half. Just a one set of applied and they will prove that so we have tried to ensure that with Substance Use there are options available to them in more places to receive treatment. They have provided that service are they doing better than the states are not complying . These waivers that we started probably late 2017, so were still a value waiting those. Do you see when you can have them for congress. When is 2018 . These are five year waivers so well see when they start their waiver. Thank you so much. The Trump Administration is looking for the acas demise last in the court to strike down the entire law. But if that happens, Medicaid Expansion will be reversed. Therefore 12 million American People with induce coverage are lost overnight. Administrator verma, if they get their way in the texas versus non isis lawsuit, went up into those people that will have themselves will coverage . Were voting for all americans tough coverage in the Affordable Care act. A lot of them cant afford obamacares coverage. I asked specifically about that lawsuit would happen. The president been very clear he wants to make sure that people with preexisting conditions would have protection. We want to make sure that all americans would have that. Reclaiming my time and thats not the answer to the question i specifically asked. I like to state for the record that the Trump Administration and administrator verma are paying lip service to the caring about American People with these issues. It is clear, not taking the steps to encourage the best thing the state can do to immediately improve the lives of millions of american residents in the states. That it should be expanding medicaid. Im out of time madam chair and i yield back. The chair now recognizes the chairman from montana mister jean forte. Congress moved medicare reimbursement including tel a stroke services. Do you think tell a health would be useful and effective in other scenarios including four world hospitals like i have in my district. Tonight a specialist in the Small Community . Absolutely. I think thats one of the things are trying to focus on in the Medicare Program and part of the reason why we have some concerns about the proposals so that everybody can be put in the Medicare Program. Unfortunately, the problem is off to slow to respond in the technology that. Being said, pardon a Administrative Administration is in Rural Communities and weve also provided Remote Communication Technology to the entire program so are beneficiaries can access care. I wanna dig into this a little more. The government is on the prolific ways of health and Virtual Care Technology within the d. O. D. And i ages and matches nasa. One quarter of 1 of medicare fee for Service Beneficiaries is in 2016. Meanwhile, the government has grants, projects through fcc and others. We know that some grants may be the punitive across hhs and its often difficult for Health Care Providers and patients to understand how they can better access to a Health Services. With limited Resources Available from those options, its important we spend all these funds wisely. Can you help us understand how these different entities across the government coordinate policy to all of that . The federal funding opportunities and best practices to go to health . What are the things of going on at the health and Human Services is the health committee. Weve had bringing together all of the agencies under hhs. To focus specifically on health as part of these discussions were, talking about how can we expand Health Services. To make sure not only people in those communities but in urban communities can access those services. Terribly theres opportunities to exist to prefer and improve court nations further . Absolutely. Are you aware of the National Tell a Health Strategy and if not, should there be one . There is a focused effort on this and Rural Communities to make sure that the but the problem is even with all the services are not cooperating with access. They are focused on that as well and detail the health is a great example of this technology which can go a long way to improve access and improve health care and outcomes. Which would like to improve on that issue. Its an attention for us given the state of montana have a lot of space and not many practitioners they dont have specialists. Its important to bring to those Rural Communities that will maintain viability of these hospitals i appreciate what cmf is done and the federal government and they have access to High Quality Health Care and will focus on leverage and Lessons Learned that have access to most to have it and rural areas which should prioritize efforts to expand Health Access and realized the potential it has to provide and seniors with access to a reliable Quality Health care. I have a minute left, is there, anything else that you like to tell the American People that has been addressed today . I like to focus some of our efforts around rural health. Its an important area, or concern about the hundred hospitals that of closed only 40 of rural hospitals are at a negative margin. This is why weve taken action with the reimbursement in rural areas. We are also working on something for Rural Communities. We think about how they could read is either system that have been made at a local level in washington which is an opportunity for them to rethink the structure and move even more value. Are excited to continue our work and committed to Rural Communities across america. Out of thanks for you work at cms and thank you for your work and i yield back. The chair now recognizes the gentleman from illinois mr. Rush for five minutes. I want to thank madam chair and welcome is trader verma, administrator verma, i said new a letter asking to me a very important question. Why are there so many inaudible seniors in our neighborhoods . The poor parts of my district seems like there is a sinner on each and every corner. I want to thank you for responding to my letter. Im cautiously optimistic about the goals to reduce this unfortunate a kidney in Kidney Disease under the minority community. Madam chair, i have unanimous consent to hold my letter to see a mess and to offer their response into the record. Without objection. Administrator verma, would you describe in detail the goals that you have outlined in your response which will ensure these communities in particular i would have access to care and education on treatment that may require better care on inaudible thank you for your question. Its an important area that has the executive order and the goal of that is multifaceted. We need to improve the quality care and make sure that people are living with Kidney Diseases in that care. So we need to do is make sure that the transplants of the ability to have a transplant to cure that diseases available. We know that theres a lot of things to get in the way of having more organs be available. The president have asked us to take action on the issue. Secondly we want to do is make sure that were paying doctors for the quality and the outcomes that they achieve. Whether things want to focus on is giving People Living we Kidney Disease more options. That they dont need to go into a Dialysis Treatment Center at could have a whole base. Miss verma, i want to know about your centers and those inaudible thought those patients that is really good. Please have your assets on the analysis of the center epidemic and the majority communities around the nation. I think thats what this executive order focuses on. We want to make sure that people have options that are not force in the Dialysis Center and can see that car at home. So you dont have an answer to my question. The executive order at large focuses on that. Let me ask you another question then. Im concerned about hospitals closing in my district. And in similar situations across the nation. Do you have any data on closing of hospitals in the minority income across the nation . You want to understand the impact do you have any data on the number of hospitals that have been closed in my district with low income and minority District Across the nation within the last five years . I dont have data with me today but i can give it to you that we can bring your office and provide anything that we have available to your office. Do you know that there is an increase in the number of hospitals that are closing in low and minority income communities. I dont know that information but i will work with my team lead. Can you come up with any idea of why hospitals are count closing up in my economy. And what the data reveals of this epidemic . We want to make sure people across the nation have access and are you back. I will be happy to work with you on that. Church gentlemen yields back and we now recognize mr. Carter for five minutes. I appreciate it and for being here very much. Something you want to respond to . I want to thank you. Ive been working for now two and a half years and i appreciate your work and i want to especially tell you how much i appreciate the proposed rule changes earlier concerning rebates and the our fees. And i want to temper your remarks but i was devastated that they did not that we are not going to get through and will continue to work towards that. I for one believe that i certainly believe within these will be eliminated. One thing that i dont think needs to be limited is the 3 40 program. Its used for a purpose but i do think it needs to be updated and it needs to be tightened up in that program there follows the program and can be better. Then what it is now if we simply make some changes to it. We studied the last congress about the 3 40 be program at one of the things that we cited was the discounts that are going to be the recipient or the governor entity for the drug and the Medicaid Agency and could be both the state medicaid and the drug medicaid plan or the medicaid manage plan and i wanted to ask you whether they are primary jurisdiction over these programs seeing that jurisdiction of medicaid. What are we doing about that . Sure. I want to address the fees. We are very concerned about the small pharmacies and want to make sure our policies ensure a competitive marketplace. The agency to continue to work on that issue are particularly concerned about the metrics that are possible for some of these policies. We continue to do what we can under the law. As you all know, or try to address the legislatively as well. I think our colleagues on the other side for insisting on that as well. In regard to the 3 40 be program we wont get into that but we are concerned about the double discounts. Some of the proposals that we made will result in our seniors paying less. Were concerned about that but i also add that the president s budget in the 3 40 d in the 3 40 b program will be put back so i would ask that you take a look at that. It would be helpful in forming the program and ensuring that they are paying less with their medication and also ensuring we support safety institutions. Absolutely. I dont need to be redundant but as i said earlier, im not opposed to the program. It just needs to upgrade and we need to make it even better and we can make it better. Lets shift over to your oversight of hospital training in the organization and thats a responsibility and its understanding that you have a new Pilot Program there that is dealing with the increase of the agencys oversight an organization and inspecting those hospitals . We do have this and one of the things that we have concerns about is the organization thats reviewing safety and quality in hospitals. We have also heard some concerns that these organizations are consulting and dollars on the same entities. Were taking a look at that, we want to make sure that the public can count on the credit asian and that they have the information that they have at the hospital at their fingertips. Thats a conflict of interest if theyre consulting and crediting. Is the Pilot Program in place . You just have an rfp for it . Theres two different issues. Its around the credit issue any conflicts of interest. The other issue of in places looking at the Pilot Program to join reviews and we have our oversight and the Incredible Organization as we do the review of the hospitals at the same time and were not to be getting that. Well see how that goes. Out of thank you for all your work and especially for the work from the da are because as you say, particularly for small pharmacies what we need in this country is devastating so i i thank you and i yield back. I want to thank our witness for her participation in todays hearing. I want to remind members that the Committee Rules they have ten Business Days to submit additional questions for the record to be answered by the witness will appear before the subcommittee. The administrator verma, i agreed promptly to these questions should they be received at with that the subcommittee is adjourned. Thank you